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Institute of Medicine (US) Forum on Microbial Threats; Knobler S, Mahmoud A, Lemon S, et al., editors. Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary. Washington (DC): National Academies Press (US); 2004.

Cover of Learning from SARS

Learning from SARS: Preparing for the Next Disease Outbreak: Workshop Summary.

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As the SARS coronavirus spread around the globe, so did its political, sociological, and economic repercussions. Workshop participants described the official reaction to the outbreak in China, examined the political and public health implications of how China acknowledged and confronted the full dimensions of the epidemic on national and international levels, and assessed the immediate and long-term economic impact of SARS. Central to these discussions was the recognition of the extreme pressure SARS exerted on both international and local health care systems and the frightening prospect of future outbreaks of greater contagion or virulence.

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The multinational effort to contain SARS placed unprecedented demands on affected and unaffected countries to accurately identify and report cases in a timely manner, to cooperate with GOARN expert teams of scientists and medical personnel coordinated by WHO, and to sacrifice immediate economic interests (e.g., travel, trade, tourism). Without international legal obligation to report SARS, most countries did so fully. Yet this extraordinary alliance would have failed without the full cooperation of China, the epicenter of the epidemic.

Politics, Tradition, and the Chinese Response to SARS

Workshop participants asserted that China’s problems in dealing with the SARS epidemic were fundamentally rooted in organizational obstacles. Problems cited during the workshop included impediments to the flow of information through the governmental hierarchy, a lack of coordination among fragmented governmental departments, and a political system in which the value of handling problems internally overrides any recognized value of external assistance. Importantly, workshop participants noted that these systemic failings are not exclusive to China and impede the response to public health and other social problems in a large number of countries around the world.

Uniquely, the Chinese tradition of respect for senior scientists in positions of authority may have substantially influenced the behavior of the Chinese Center for Disease Control and of other Chinese scientists who were researching the epidemic (Enserink, 2003). A highly respected Chinese scientist reportedly claimed that Chlamydia infection caused SARS, based on an examination of only two specimens. This may have led the Chinese Center for Disease Control and other Chinese clinicians and scientists to maintain that Chlamydia was the SARS agent, despite other evidence inside China indicating that the agent was viral. Consequently, virologists in a Beijing laboratory refrained from announcing their discovery in early March of the SARS coronavirus, a decision that set back by weeks research on the disease and a more significant public health response in China (Enserink, 2003).

The SARS epidemic also exposed weaknesses in China’s public health infrastructure, including inadequate state funding, lack of effective surveillance systems, and severe shortages in facilities and medical staff prepared for an epidemic infectious disease outbreak. As a forewarning, a workshop participant observed that these same weaknesses are often cited by medical and public health experts when assessing the state of preparedness for infectious disease outbreaks in the United States.4 These statements corresponded with other participants who suggested that, in the case of SARS, the United States was perhaps more lucky than it was prepared.

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In response to the deficiencies highlighted by SARS, the Chinese government established a case reporting structure, strengthened its emergency response system, dismissed key officials who mismanaged the crisis during its initial months, and provided funding for the prevention and control of SARS. Chinese workshop participants also credited the SARS experience for increasing the recognition and understanding of government officials and the public about the importance of infectious disease control and prevention in general.5

Economic Impact

While the most immediate and dramatic economic effects of SARS occurred in Asia, every market in today’s global economy was at some point impacted directly or indirectly by the epidemic. Several agencies and experts have attempted to estimate the cost of SARS based on near-term expenditures and losses in key sectors such as medical expenses, travel and related services, consumer confidence, and investment. One model estimated that the short-term global cost of lost economic activity due to SARS was approximately $80 billion.6 Participants agreed, however, that the true economic consequences of SARS remain to be determined, particularly given the possibility of its return.

An economic model presented at the workshop estimated the impact of SARS on several countries—and in aggregate, on the world. It considered two different scenarios: a short-term shock coincident with a one-time epidemic, and long-term effects typical of recurring outbreaks. The model was not intended to calculate precise monetary effects, but rather to reveal the magnitude of the impact on countries and regions, scaled to their individual economies (see Lee and McKibbin in Chapter 2).

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According to this model, the short-term SARS shock disproportionately affected Hong Kong due to its economic dependence on services (e.g., travel, tourism). Significant short-term losses also accrued in China as a result of a sharp decrease in foreign investment, a trend that could be crippling if perpetuated over several years. In the long term, the expectation of continued outbreaks of infectious disease emanating from China could engulf that entire region of Asia in a permanent “disease transmission shock.”

Paradoxically, workshop participants discussed the global cost of SARS associated with lost economic activity—now estimated to have been around $40 billion, and possibly as high as $54 billion if investors remain cautious about the possibility of future outbreaks—as a potential cost of neglecting to invest in public health infrastructure. Several participants warned of a vicious spiral to be avoided: an economic downturn resulting from SARS or another pandemic which squeezes funding for public health, further weakening the world’s ability to prevent or contain subsequent outbreaks. The message here: an ounce of prevention is worth a pound of cure. It was suggested by several participants that further analyses comparing the anticipated costs associated with strengthening both global and national public health systems of surveillance and response with the anticipated costs of another epidemic SARS (or other disease) outbreak might reveal important results to persuade decisionmakers to make priority investments in relevant public health and research areas.

Impact on Global and Local Public Health Systems

Like many of the emergent diseases of the last decade, the challenge of SARS has cast a glaring spotlight on the need for greater investments in public health infrastructure. The outbreak placed a huge burden on international health systems that were already straining to address AIDS, tuberculosis, malaria, and a host of other conditions. With GOARN, WHO had an established structure to coordinate international resources and personnel and thereby muster surge capacity to address such outbreaks. That network was severely tested by SARS, but the successful containment of SARS through national actions supported by international collaboration confirms the value of this approach in addressing future epidemics (see Abdullah et al. in Chapter 1).

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A key factor underlying the influence of SARS on public health, political, and economic systems was the infection of large numbers of health care workers. Nowhere was the impact of SARS felt more keenly than in the local health care systems of affected areas, where frontline caregivers all too frequently ended up as intensive care patients in need of extended hospital stays or as fatalities. This assault on the well-being of many health care personnel, coupled with the exhausting demands put on those who remained healthy, led Toronto health officials to send out a call to infectious disease professionals in the United States and Europe to come to Canada to bolster their capacity to fight the disease. Additionally, a workshop participant alleged that in Toronto, the closing of outpatient clinics in response to SARS may have caused greater morbidity and mortality than the disease itself. However, other participants argued that without a vaccine or cure for SARS, the isolation of patients and their contacts—including their caregivers—represented the most effective method of containing the epidemic.



During the development of the this report, a Chinese author commented that the recent commitment by the highest level of Chinese government officials to the prevention and treatment of AIDS, after years of little public recognition of the disease or its victims, might in large part be credited to the new awareness by all Chinese of the threats posed by unchecked infectious diseases.


Workshop presentation by Warwick McKibbin, Australia National University, September 30, 2003.

Copyright © 2004, National Academy of Sciences.
Bookshelf ID: NBK92486


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