Severe Acute Respiratory Syndrome (SARS): The International Response

Congressional research reportSep 8, 2003

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Order Code RL32072

CRS Report for Congress

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Severe Acute Respiratory Syndrome (SARS):

The International Response

September 8, 2003

(name redacted)

Foreign Affairs Analyst

Tiaji Salaam

Foreign Affairs Analyst

Foreign Affairs, Defense, and Trade Division

Congressional Research Service ˜ The Library of Congress

Severe Acute Respiratory Syndrome (SARS):

The International Response

Summary

Severe Acute Respiratory Syndrome (SARS), a new highly infectious disease,

was first identified by the World Health Organization (WHO) in February 2003.

While the overall number of confirmed cases is not high by comparison with

statistics for other infectious diseases, the distance and speed with which SARS

spread raised an alarm over the potential risks to international public health.

Containment appears to be working; however, there are fears that another SARS

outbreak could take place during the regular influenza season later in 2003.

The United States was instrumental in the global effort to contain the spread of

SARS. Affected countries responded in different ways. Singapore and Taiwan acted

quickly and encouraged international support in curbing the spread of the virus.

China, on the other hand, has been criticized for down-playing the magnitude of the

problem, particularly in the early phase of the disease. This, some analysts contend,

ultimately enabled the virus to cross borders and in the case of Canada, hemispheres.

This report takes a retrospective look at the global response by WHO and by

those countries most affected. It reveals some of the challenges that may lie ahead

for the global health community, such as global interdependence and transparency,

surge capacity, management of public fear and information disclosure, coordination

of different national responses, and lack of funding. Examining the impacts of SARS

and lessons learned may be useful in the response to future outbreaks or incidences

of new diseases. This report will not be updated.

Contents

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

International Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Overview of the Role of the World Health Organization . . . . . . . . . . . . . . . 2

WHO’s Global Health Alert Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Global Outbreak Alert and Response Network (GOARN) . . . . . . 3

The Global Public Health Intelligence Network (GPHIN) . . . . . . . . . . 3

The Global Threat of SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

WHO’s Response to SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

SARS and International Health Regulations . . . . . . . . . . . . . . . . . . . . . . . . . 6

Overview of the International Health Regulations . . . . . . . . . . . . . . . . . 6

The Fifty-Sixth World Health Assembly . . . . . . . . . . . . . . . . . . . . . . . 7

Country Responses to SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

China and Hong Kong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Taiwan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Vietnam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Singapore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Congressional Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Infectious Disease Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Capacity Building . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Improving U.S. Response Capability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Future Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Global Interdependence and Transparency . . . . . . . . . . . . . . . . . . . . . . . . . 19

Developing Surge Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Public Fear and Information Disclosure . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

National Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Inadequate Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Severe Acute Respiratory Syndrome

(SARS): The International Response

Background

Severe Acute Respiratory Syndrome (SARS), a new, highly infectious viral

disease, was first identified by the World Health Organization (WHO) in February

2003. It is believed to have had its beginnings in China’s Guangdong Province in

November 2002. A respiratory disease that causes flu-like symptoms which may

progress to pneumonia, SARS has an average fatality rate of 15%. Between

November 2002 and July 2003, a total of 8,437 cases and 813 deaths were reported

in 31 countries.1

While the overall numbers are not high by comparison with other serious

infectious diseases, the speed and distance with which SARS spread raised an alarm

over the potential risks to international public health. Containment appears to be

working; however, there are fears that another SARS outbreak might take place

during the regular influenza season later in 2003. This report reviews the global

response by WHO and those countries most affected. It also examines the challenges

that may lie ahead should another outbreak of SARS (or another unknown infectious

disease) occur.2

International Response

Since late February, when WHO first identified the outbreak of what later

became known as the Severe Acute Respiratory Syndrome (SARS), it has played a

key role in the global response to the disease. SARS is a striking example of the

risks to international public health posed by such infectious diseases. It also

highlights the need for appropriate mechanisms of containment, particularly as

global travel has become the primary means of spreading the disease around the

world.

Following its initial assessment, WHO made containment of SARS its main

goal. “Despite the lack of understanding about the disease, its cause, and future

For a full discussion of the medical background to SARS and the U.S. response see CRS

Report RL31937, Severe Acute Respiratory Syndrome (SARS): Public Health Situation and

U.S. Response.

Other sources are examining the SARS outbreak, for example, J.M. Drazen, “SARS —

Looking Back over the First 100 Days,” The New England Journal of Medicine, July 24,

2003.

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evolution, the need was great to introduce a series of emergency measures to contain

SARS outbreaks in the affected areas and prevent further international spread, thus

reducing opportunities for the new disease to establish itself.”3 Although WHO’s

representative in China, Henk Bekedam, reportedly said on June 5, 2003 that the

outbreak of SARS had reached its peak worldwide,4 WHO continues to stress the

importance of sustaining international public health measures against SARS and

working towards eliminating it as a public health threat. The SARS outbreak may

reveal valuable lessons about the effectiveness of WHO’s surveillance and response

systems, and its capacity to respond to similar outbreaks in the future. Examining the

evolution of SARS also demonstrates the chains of transmission and role of the

WHO in responding to unfolding events.

Although WHO led an unprecedented global collaborative effort to contain

SARS, the U.S. Centers for Disease Control and Prevention (CDC) also played a key

role in the global partnership. For more information on the role of the CDC in

relation to SARS, see CRS Report RL31937, SARS: Public Health Situation and U.S.

Response.

Overview of the Role of the World Health Organization

The World Health Organization (WHO), established in 1948, is the U.N.

system’s authority on international public health issues. It assists governments in

improving national health services and in establishing worldwide standards for foods,

chemicals, and biological and pharmaceutical products. WHO concentrates on

preventive rather than curative programs, including efforts to eradicate endemic and

other widespread diseases, stabilize population growth, improve nutrition, sanitation,

and maternal and child care. WHO works through contracts with other agencies and

private voluntary organizations. The United States has been a member of WHO

since 1948.

The WHO policy making body is the World Health Assembly, composed of all

192-member states. It meets annually in May to decide the overall direction of the

Organization and the general program for a specific period, and to adopt the two-year

budget. Decisions are made by majority vote, except for decisions on the budget that

require a two-thirds vote. There is no veto provision. The Assembly elects the

Director General as well as the 32 member states who designate persons to serve on

the Executive Board. The Executive Board meets twice a year to review the work of

WHO in more detail and prepares issues for consideration by the Assembly. Ten to

twelve members of the Board are replaced every year. The United States has been

a member on the Executive Board three out of every four years.

WHO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons

for the Immediate Future. WHO: Geneva, May 20, 2003.

United Nations Foundation, “SARS: WHO Declares Outbreak ‘Over its Peak.’” June 5,

2003. [http://www.unwire.org/UNWire/20030605/34097_story.asp]

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WHO’s Global Health Alert Systems

The Global Outbreak Alert and Response Network (GOARN). In

April 2000, WHO formally established the Global Outbreak Alert and Response

Network (GOARN) which brought together 112 institutions and networks of people

and technical resources to respond to disease outbreaks of international concern.

This global health security network provides not only an operational framework,

drawing on data, expertise, and skill, but also aims to standardize the international

response.5 It relies on its partners and agreed standards of practice in responding to

potential threats, which may include emerging diseases and the intentional use of

biological agents. In four years, between January 1998 and March 2002, GOARN

examined 538 such cases in 132 countries.6

The Global Public Health Intelligence Network (GPHIN). WHO also

relies on the Global Public Health Intelligence Network (GPHIN), which is a

customized search engine that tracks Internet communications. This system proved

to be very useful in picking up telecommunicated alerts in China. The system is also

useful to WHO in clarifying or refuting information that may create disruption or

panic. Other tools include geographical mapping technology and an event

management and tracking system that provides an overview of operations.

The Global Threat of SARS

It was clear that SARS presented a serious global threat. Lack of information

about the cause and evolution of the new disease made its potential impact unknown.

WHO concluded that the virus comes from a strain likely to include frequent

mutations and links to animal species, with implications for the likelihood of

establishing endemicity and underlining the importance of finding the means to

control or contain it. Several factors were deemed critical in this analysis:

The symptoms are non-specific and common;

The symptoms can be severe and some patients require intensive

care for respiratory failure;

! The disease spreads easily from one location to another via air travel

as demonstrated in transmission patterns from the initial outbreak in

Asia to other regions, such as North America and Europe;

! There is no vaccine or treatment yet available and diagnostics tests

are of limited use. A number of antivirals are not effective;

! The causative agent is not well understood, so the potential for

continued spread remains;

! Certain cases may contribute to the rapid spread of infection;

! Hospital staff, who are a vital link to the control of infection, are

disproportionately affected as are other close contacts of the patients;

For more information on the Global Outbreak Alert and Response Network, see:

[http://www.who.int/csr/outbreaknetwork].

WHO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons

for the Immediate Future. WHO: Geneva, May 20, 2003, p. 4.

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The disease requires intensive treatment in isolation and is a burden

on health care systems.7

By comparison to SARS, except in the case of HIV/AIDS, other new diseases

that have emerged in the last few decades have not presented the same combination

of factors that pose such a heavy global risk to international health. Some of these

diseases have not sustained strong human-to-human transmission, others have relied

on food or a vector (such as mosquitos) for transmission, and still others have had an

identifiable, often containable, geographic location.

WHO’s Response to SARS

Once the severity of the disease was recognized, in February and March 2003,

WHO took aggressive action. Examining the factors outlined above and the

chronology of events unfolding in China, Hong Kong, Vietnam, and Toronto, it

identified international travel as a primary means of spreading the virus. It also

concluded at the time that some people might be highly infectious, or “super

spreaders”. Identifying these individuals could be critical to the control of the

disease.8 On March 15, 2003, WHO issued emergency travel recommendations as

a global alert and response to international travelers, health care professionals, and

border authorities. Later in March it recommended screening passengers at airports

coming from areas with recent local transmission and gave advice to airlines on

appropriate procedures if a case was suspected during flight. In April and May, on

several occasions, the WHO issued its most stringent travel advisories recommending

the postponement of all but essential travel to areas considered high risk for SARS,.9

WHO also quickly moved to set up systems for — and increase awareness of

the need for — immediate isolation and quarantine of those with or suspected of

having SARS. In addition, it began the detailed work of contact tracing to find the

source of the spread. These procedures along with simple diagnostics and screening

all contributed to the ongoing containment effort.

The response to SARS placed heavy demands on WHO and its GOARN

partners. Time was very much of the essence. WHO pulled together a

comprehensive network, including mobilizing a response on the ground, providing

resources and supplies, monitoring and reporting, and establishing scientific and

medical collaboration. The WHO issued travel procedures to prevent and manage

probable cases of SARS.10 It established a collaborative multi-center research project

The eight bullet points are drawn from a discussion in Severe Acute Respiratory Syndrome

(SARS): Status of the Outbreak and Lessons for the Immediate Future. WHO: Geneva, May

20, 2003, p. 2-3.

TB and Outbreaks Weekly, “Severe Acute Respiratory Syndrome; WHO points at ‘super

spreaders’ as key to stopping SARS,” April 29, 2003.

WHO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons

for the Immediate Future. Geneva: WHO, May 20, 2003, p. 6.

For more detail, see [www.who.int/csr/sars/travel].

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on SARS and brought together clinicians for SARS diagnosis and treatment.11 It also

developed guidelines, recommendations, and descriptions concerning case

definitions, case management, laboratories, biosafety, blood safety, epidemiology,

mass gatherings, and goods and animals from SARS-affected areas.12

An urgent plan for the operational response to SARS was developed and

implemented. This included providing expertise and supplies in SARS-affected areas

and hospitals, and “in the air” through technology to bring the best minds to the

collaboration required. This plan resulted in:

A global alert

Rapid case identification

Global reporting system and verification

Regular updates and advice

International field support and logistics coordination

Epidemiological and clinical networking

Laboratory network13

Through this network, and daily conference calls, epidemiologists were able to

discuss cases, refine their definitions, examine chains of transmission, track progress,

and increase their understanding of what worked best where. Similarly, individuals

working in the clinical network were able to share experiences with different forms

of treatment, examine the possible reasons for the range of individual responses to

the disease, and develop guidelines for infection control. The network of the

laboratories enabled many scientists to work together to come up with the

identification of the SARS virus.

Scientists have much to learn about SARS, including understanding the

evolution of the disease, designing early detection, prevention and treatment

strategies, and establishing effective surveillance systems. Until then, containment

may remain the most effective control tool. If SARS becomes endemic, the WHO

may find the application of models of response for other infectious diseases, such as

malaria, meningitis and yellow fever useful in combating the disease and developing

therapies and vaccines.14

WHO has issued an appeal for funding to support its surveillance and

monitoring activities in Asia. It hopes to help those hardest hit by the disease

economically, to continue with their efforts to control SARS, and ultimately to

For more information about the WHO collaborative network, see [http://www.who.int/

csr/sars/networkshome].

Links to information under

[http://www.who.int/csr/sars/guidelines].

these

headings

can

found

WHO, “The Operational Response,” April 16, 2003.

WHO, “Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons

for the Immediate Future,” Geneva, Switzerland, May 20, 2003, p. 7.

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eliminate the disease as a global threat.15 The WHO has an annual budget of nearly

$850 million. It relies heavily on its 192 member states for resources and teams of

experts.16

SARS and International Health Regulations

The outbreak of SARS has raised many public health questions, including the

application of international law. According to David P. Fidler, Professor of Law at

Indiana School of Law in Bloomington, the legal implications affect three main areas

— International Health Regulations (IHR); public health measures and civil and

political rights; and principles of state responsibility in responding to SARS.17 This

section will focus on the IHR because of its relevance to WHO.

Overview of the International Health Regulations. In 1951, under

Article 21 of the WHO constitution, member states adopted the International Sanitary

Regulations, which in 1969 became known as the International Health Regulations

(IHR). Amendments were made in 1973 and 1981. The main purpose was to control

the spread of diseases with minimum impact on world traffic through the

development of a global surveillance system, the use of procedures at ports and

airports, and the creation of disease-specific provisions. Some argue that the

regulations have not been effective in ensuring protection against diseases in a world

of increasing trade and travel. Experts maintain that a key reason for ineffectiveness

lies in the limited number of diseases to which the IHR applies. Originally, the

regulation covered six diseases — smallpox, relapsing fever, typhus, cholera, plague,

and yellow fever.18 Today the IHR applies only to the last three diseases. Smallpox

is considered to have been eradicated some years ago. Relapsing fever and typhus had

been so successfully controlled that they were no longer considered a public health

threat. The IHR do not apply to more recent infectious diseases such as HIV/AIDS

and SARS. Member states were therefore under no obligation to report the outbreak

of a new infectious disease nor were they required to restrict trade or travel even if

it would benefit containment.19

In the 1990s, the WHO initiated a revision of the IHR to address the limited

scope of the diseases covered, increase its relevance to the kinds of infectious disease

The Australian, “WHO Seeks $306m for SARS Fight,” May 23, 2003.

Washington Post, “SARS Shows WHO Disease Hunters’ Skills, and Limits,” May 31,

2003. [http://www.washingtonpost.com]

The American Society of International Law, SARS and International Law, April 2003, see

[http://www.asil.org/insights].

WHO, “International Health Regulations.” [www.who.int/csr/ihr/en.]; The American

Society of International Law, SARS and International Law, April 2003.

The American Society of International Law, SARS and International Law, April 2003,

see [http://www.asil.org/insights].

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threats most prevalent or likely today, and to manage the return of old diseases. These

revisions are scheduled to be finalized in 2005.20

In 2001, the World Health Assembly adopted a resolution concerning member

response to international public health emergencies and global health security with

reference to epidemics. In 2002, another resolution made the response more specific,

and included health risks related not only to natural occurrence, but to accidental or

deliberate use of biological and chemical agents.21

The SARS outbreak added momentum to discussions about revising the IHL

that were already well under way. As recently as January 2003, the 192 member

states had been discussing the details of the new framework, with a resolution for

completing the revised regulations. Although the IHR were recognized as being

outdated, the case of SARS highlighted the problems of transparency — China

denied the problem existed for months, and the information provided from Toronto

was criticized by some as incomplete and not timely enough.

The Fifty-Sixth World Health Assembly. Fidler argues that “the SARS

epidemic may encourage WHO member states to accept a more robust international

legal framework for global infectious disease control than has existed historically.”22

At the Fifty-Sixth World Health Assembly in May 2003, the member states adopted

two resolutions relevant to the SARS outbreak, one specifically on SARS, the other

on the revision of IHL.23 The SARS resolution focuses on eleven recommendations

to WHO member states in addressing the SARS outbreak; it also requests the WHO

Director General to take specific actions. None of these are new obligations or

binding on member states as earlier press reports might have suggested. Rather, they

build on the role of the WHO and highlight the need for information sharing and

international cooperation in combating an outbreak such as SARS.24

WHO Executive Board, Revision of the International Health Regulations, EB111.R13,

Agenda Item 5.12, 111th Session, January 24, 2003. Report by the Secretariat, WHO

Executive Board,”Revision of the International Health Regulations,” EB111/4, Provisional

Agenda item 5.12, 111th Session, December 15, 2002.

WHO, Revision Process of the International Health Regulations (IHR).

[http://www.who.int/csr/ihr/revision/en/]. Previous resolutions include: WHA48.13 on new,

emerging, and re-emerging infectious diseases, WHA54.14 on global health security,

epidemic alert and response,EB111.R13 on revision of IHR, and EB111.R6 on the

prevention and control of influenza pandemics and annual epidemics. See Fifty-Sixth World

Health Assembly, Geneva, 19-28 May 2003, A56/48 - Revision of the International Health

Regulations.

The American Society of International Law, SARS and International Law, April 2003.

World Health Assembly, Severe Acute Respiratory Syndrome (SARS), WHA56.29, May

28, 2003; and World Health Assembly, Revision of the International Health Regulations,

WHA56-28, May 28, 2003. For a discussion of these resolutions in international law, see

The American Society of International Law, Developments Involving SARS, International

Law, and Infectious Disease Control at the Fifty-Sixth Meeting of the World Health

Assembly, June 2003. See [http://www.asil.org/insights].

The American Society of International Law, Developments Involving SARS, International

(continued...)

CRS-8

The IHL Resolution takes an important political step in emphasizing the need

for member states to cooperate with other states and the WHO in monitoring and

responding to infectious diseases. Although the SARS outbreak highlighted the

strong need for revision of the IHL, then WHO Director General Gro Harlem

Brundtland also pointed out the difficult balance to be struck in revising the

regulations, such as state obligations to report sensitive health information, protection

of human rights and civil liberties in light of an international health threat, and the

impact on immigration policies and decisions.25 The IHL Resolution does not give

WHO a significant increase in authority in terms of intervention during a potential

public health threat, nor does it give WHO the power to reprimand a state that does

not comply.26 However, the IHL Resolution lays the political groundwork for states

to respond appropriately, much of the encouragement to comply will likely come

from international pressure as the SARS case demonstrated.27

The IHL resolution was adopted as an interim measure until the IHL revisions

are finalized in 2005. The WHO opted for this two-step process rather than insisting

that members immediately approve the incorporation of the resolution into the IHL.28

Some experts suggest that this resolution will encourage WHO collaboration within

countries and also provide momentum for implementation of the measures outlined

in the resolution.29 The U.S. delegation initially asked for a postponement of action

on the proposed resolution, hoping to include it in a broader discussion, but later

conceded when it did not enlist member support.30 Others suggested that this was a

“negotiating tactic” used to avoid too early a commitment by the United States.31

(...continued)

Law, and Infectious Disease Control at the Fifty-Sixth Meeting of the World Health

Assembly, June 2003. See [http://www.asil.org/insights].

Washington Fax, Brundtland Urges Health Security Measures for WHO Member States,

May 21, 2003.

The American Society of International Law, Developments Involving SARS, International

Law, and Infectious Disease Control at the Fifty-Sixth Meeting of the World Health

Assembly, June 2003. See [http://www.asil.org/insights].

Washington Post, “WHO Gets Wider Power to Fight Global Health Threats,” May 28,

2003. [http://www.washingtonpost.com]

Washington Post, “WHO Gets Wider Power to Fight Global Health Threats,” May 28,

2003. [http://www.washingtonpost.com]

ProMed,”Comment on WHA Resolution,” May 28, 2003.

Washington Post, “WHO Gets Wider Power to Fight Global Health Threats,” May 28,

2003. [http://www.washingtonpost.com]

United Nations Foundation, “WHO: Members Vote to Give Agency New Powers in

Outbreaks, More”UN Wire, May 28, 2003. See

[http://www.unwire.org/UNWire/20030528/33949_story.asp]

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Country Responses to SARS

The SARS virus rapidly spread to 30 countries, ultimately infecting 8,437

people, of whom 813 died.32 Each country handled the virus differently. Some

countries, like Vietnam, immediately called for international support. Others, like

China, initially downplayed the severity of the virus within their borders. Although

the United States reported 75 SARS cases it had no SARS-related deaths.33

Countries experiencing five or more SARS deaths are discussed in this section.

Other countries that reported SARS deaths include: France (1), Malaysia (2),

Philippines (2), South Africa (1), and Thailand (2).

China and Hong Kong

Reports of SARS outbreak coverups surfaced in mainland China in April 2003.

Many blamed China for the global SARS crisis, which seems to have started in

southern China. Critics argued that had China been forthright in proclaiming the

extent of the SARS problem, the disease would not have spread throughout the

country, and eventually to other countries.34

In response to international criticism about its complacency and cover-up in

preventing the spread of the virus, the Chinese government took a number of steps

to demonstrate transparency and vigilance in combating the spread of SARS. The

Mayor of Beijing and the Minister of Health were fired.35 Chinese authorities also

quarantined those with symptoms of the disease and those with whom they had

contact, often thousands at a time.36 Entire apartment buildings, markets, hospitals,

universities, and schools were shut down. All schools in Beijing were closed for

nearly three months.37 Chinese authorities banned all tourist visits from the central

part of the country and Tibet.38 China also closed some border crossings, including

WHO, Cumulative Number of Reported Probable Cases of SARS. July 10, 2003.

[http://www.who.int/csr/sars/country/2003_07_11/en/]

For more information on how the United States combated the spread of SARS see CRS

Report RL31937, Severe Acute Respiratory Syndrome (SARS): Public Health Situation and

U.S. Response.

Pomfret, John, “Beijing Told Doctors to Hide SARS Victims.” April 20, 2003. The

Washington Post. [http://www.washingtonpost.com]

Pomfret, John, “Thousands Flee Beijing, Fearing SARS.”

Washington Post. [http://www.washingtonpost.com]

April 24, 2003. The

Eckholm, Erik, “4,000 Quarantined in Beijing as Suspected SARS Cases Climb.” April

25, 2003. The New York Times. [http://www.nytimes.com]

The New York Times, “As SARS Eases, Beijing Classes Resume.” May 19, 2003.

[http://www.nytimes.com]

Maynard, Micheline, “Passport, Mask, Thermometer.”

[http://www.nytimes.com]

May 11, 2003.

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some between China and Mongolia and postponed reopening the Khunjirap crossing

between China and Pakistan.39

Chinese officials enacted new laws to fight SARS. One of China’s most

controversial laws, calls for the imprisonment or execution of anyone found

intentionally spreading the virus. The first person facing punishment under this law

is Dr. Li Song. Authorities charge Dr. Li with vandalism and violating an infectious

disease law.40 Hospital officials argue that he left a hospital knowing he had SARS,

and ultimately spread the virus to his family and more than 100 others in the small

town of Linhe. Dr. Li’s mother, father and wife have died of SARS, while Dr. Li

remains in jail.41

Other laws sought to halt the spread of the virus through fines. Authorities in

the southern town of Guangzhou began fining individuals who spit in public 50 yuan

(about $6 US), a fine that many will find difficult to pay.42 In Shanghai, those found

spitting, as well as throwing away cigarette stubs or fruit peels in public areas, and

dumping garbage and sewage in the wrong places are subject to a fine of 200 yuan

(about $24 US), compared to 50 yuan prior to the SARS outbreak.43

China’s moves to address the spread of SARS have also included financial

assistance. The Chinese Ministry of Finance allocated a total of 440 million yuan

(about $53 million) to reinforce the fight against SARS.44 Provincial and local

governments also offered assistance to those affected by SARS. Assistance included

the distribution of temporary subsidies, disinfectants, protective surgical masks and

soap. One Beijing district, the Dongcheng District, reported that it decided to

provide 420 thousand yuan (about $51 thousand) to its low income residents, and

Chaoyang District allocated 350 thousand yuan (about $42 thousand) towards the

purchase of preventive aids.45 Meanwhile officials in Hong Kong announced a $1.5

billion aid package, which included waiving water and sewage charges for the

China Internet Information Center, “China Temporarily Closes Some Border Ports.” May

12, 2003. [http://www.china.org.cn/english/index.htm]

Kahn, Joseph, “Man’s Virus Infects Town, Killing His Family.” May 15, 2003. The New

York Times. [http://www.nytimes.com]

Supporters of Dr. Li point out a number of inconsistencies in the charges. Although

Chinese officials claim Dr. Li spread the virus throughout Linhe when he walked out of Ba

Meng Hospital on April 8, 2003, SARS was not placed on the mandatory quarantine list

until April 14, six days later. Furthermore, members of Dr. Li’s family contend that he did

not know that he was infected with SARS, and he only left the hospital after complaining

of poor treatment. Dr. Li also reportedly walked out of the facility to care for his parents

who suddenly became ill. The Li family are currently searching for a lawyer.

BBC News, “Spitting ban to combat SARS.” May 14, 2003. [www.bbc.co.uk]

People’s Daily, “SARS Epidemic Increases Personal Hygiene Awareness.” April 28,

2003. [http://english.peopledaily.com.cn/]

People’s Daily, “China Allocates US $6.25 mln on Anti-SARS Measures.” May 23, 2003.

[http://english.peopledaily.com.com.cn/]

People’s Daily, “Beijing Moves to Aid Economically disadvantaged residents in SARS

fight.” April 24, 2003. [http://english.peopledaily.com.cn/]

CRS-11

general public for up to four months, increasing income tax rebates, waiving license

fees for heavily affected industries, guaranteeing $450 million in loans to affected

businesses, increasing medical research spending, and reducing commercial rents for

stores at public housing sites and other government controlled properties.46 The

Chinese Government also reserved $128 million for a Hong Kong marketing

campaign now that the city has been removed from the WHO list of infected areas.47

According to the Chinese Government, the international community donated about

$76.6 million to aid its fight against SARS.48

On June 10, the WHO sent a high-level team, including Dr. David Heymann,

Executive Director for Communicable Diseases at WHO, to China to assess the

current situation and plan a strategy for the future. They proposed steps for

examining and detecting cases, defining procedures for contact tracing, and

responding to local transmissions. WHO was particularly concerned about the

capacity of the Chinese rural health systems to deal with emerging infectious

diseases, from effective monitoring and reporting to adequate hospital care.49

However, it found that surveillance systems in two key rural provinces were

effective.50 China has also surprised many with the speed with which it brought its

outbreak under control. Some studies suggest that the mortality rate may have been

lower, and the cure rate higher, than in other parts of the world. Differences in

incubation period and groups at highest risk may provide clues for fighting the

disease. According to Dr. Heymann, “Long-term containment depends on finding

answers to a long list of scientific questions. China has much to offer the rest of the

world.”51

On June 24, 2003, WHO removed its recommendation that people should

postpone all but essential travel to Beijing, China. Beijing was the last area in the

world to have the travel warning lifted. Beijing, with a cumulative total of 2,521

probable cases and 191 deaths, has had the largest outbreak of SARS anywhere in the

world, followed by Hong Kong with 1,755 cases and 296 deaths, and Guangdong

Province with 1,511 cases and 57 deaths.52

Bradsher, Keith, “Epidemic Spurs Plan to Revive Hong Kong.” April 24, 2003. The New

York Times. [http://www.nytimes.com]

Bradsher, Keith, “Relieved Hong Kong Starts to Shed Masks.” May 25, 2003. The New

York Times. [http://www.nytimes.com]

People’s Daily, “FM Spokeswoman Briefs on Assistance to China for SARS Battle.”

May 9, 2003. [http://english.peopledaily.com.cn/]

WHO, “Update 77 — WHO Officials to Visit China,” June 10, 2003.

WHO, “Update 59 - Report on Guangxi (China) visit, situation in Taiwan, risk of SARS

transmission during air travel.” May 19, 2003. [httpwww.who.int/csr/sars]

WHO, “Update 77 — WHO Officials to Visit China,” June 10, 2003.

WHO, “Update 87 - World Health Organization changes last remaining travel

recommendation — for Beijing, China.” June 24, 2003. [http://www.who.int]

CRS-12

Taiwan

The doubling of SARS deaths53 in Taiwan prompted WHO to send a team to

investigate the island’s SARS situation. The sharp increase in new cases and deaths

surprised some as Taiwan initially appeared successful in curtailing mortality,

avoiding international community transmission, as well as maintaining a relatively

low number of new cases compared to mainland China. The government of Taiwan

took early steps to avoid a massive SARS outbreak, including imposing mandatory

10-day quarantines on all visitors arriving from China, Hong Kong, Singapore or

Toronto; cancelling more than 100 commercial flights; cancelling high school exams

scheduled for the end of May; and monitoring the temperature of visitors to many

public buildings and hotels.54

In May 2003, the President of Taiwan, who has been vocal in his desire to gain

Taiwanese observer status to the WHO55, stated that Taiwanese hospital officials

from Taipei Municipal Hoping Hospital may have tried to cover up a SARS

outbreak.56 In response, Taiwanese authorities fired the superintendent of the

hospital and relocated all 200 patients and 900 employees from Hoping Hospital to

a designated SARS facility while the hospital was being disinfected.57 Shortly after,

the Taipei City Government fined the Hoping Hospital 1.1 million Taiwan dollars

($31,682 US) and four other hospitals 1.5 million Taiwan dollars ($43,202 US) each

for delaying reporting SARS cases to health authorities, and revoked the licence of

the former Jen Chi Hospital superintendent, Liao Cheng-hsiung, accusing him of

covering up a SARS outbreak while serving.58 The Taiwan Minister of Health, Dr.

Twu Shiing-jer, voluntarily resigned on May 16, 2003, taking full responsibility for

the SARS spread.59 Two days later, more than 140 medical employees across the

island reportedly resigned to avoid dealing with SARS patients.60 The medical

workers charged that the government had failed to provide sufficient protective

gear.61

WHO reported 10 SARS deaths in Taiwan on May 6, 2003, and 24 SARS deaths on May

13, 2003.

Luh, Shu Shin and John Pomfret, “Taiwan Bidding to Join WHO.” May 10, 2003. The

Washington Post. [http://www.washingtonpost.com]

Taiwan is not a WHO member, thus it sought China’s consent before sending a team.

Luh, Shu Shin and John Pomfret, “Taiwanese President Suggests Hospital Covered Up

Disease.” May 13, 2003. The Washington Post. [http://www.washingtonpost.com]

Ibid.

Channel News Asia, “Taiwan officials confident of bringing SARS under control despite

55 new cases Friday.” May 23, 2003. [http://www.channelnewsasia.com]

McNeil Jr., Donald G., “Taiwan Health Minister Quits Over His Handling of SARS.”

May 16, 2003. The New York Times. [http://www.nytimes.com]

Culpan, Tim, “Taiwan Posts Daily Record for SARS Cases.” May 21, 2003. The

Washington Post. [http://www.washingtonpost.com]

Connolly, Ceci and Tim Culpan, “U.S. Doctor with SARS Symptoms to Return

Home.” May 23, 2003. The Washington Post. [http://www.washingtonpost.com]

CRS-13

WHO officials believe that lapses in infection control, particularly in emergency

rooms, may have been one of the reasons for the rapid increase in cases.62 Reports

seem to support the assertion that Taiwanese health officials may not have taken

enough measures to limit the spread of the virus both within and among the hospitals.

The Dean of Hoping Municipal Hospital’s Radiology Department reported that,

“Everything went wrong. There is no proper quarantine facility.” It was reported

that hospital staff did not separate SARS patients from non-SARS patients, and did

not ask patients about their medical history. Concern about Taiwan’s ability to

contain the virus was heightened when CDC officials announced on May 23, 2003

that an American doctor sent with the WHO/CDC team to investigate Taiwan’s

recent upsurge in SARS cases was suspected to have become infected with SARS

and was returned to the U.S. to undergo treatment.63 CDC officials added that

Hoping Hospital made the critical mistake of sending SARS patients to other

hospitals for treatment, unwittingly spreading the disease.64

In addition to its collaborative efforts with CDC and WHO, Taiwan bolstered

its quarantine efforts, strengthened its contact tracing capabilities, and improved its

infection control practices. The Government of Taiwan also released a $1.44 billion

U.S. aid package, which sought to assist ailing businesses and families of SARS

victims, establish SARS prevention mechanisms, and create effective SARS contact

tracing mechanisms.65 Taiwan was removed from the WHO list of areas with recent

local transmission on July 5, 2003. Its last probable case was reported on June 19,

2003. To date, 671 people have contracted the virus, of whom 84 have died.

Vietnam

Vietnam, the poorest of the SARS-affected countries, was the first country to

contain the SARS virus. The WHO removed Vietnam from its list of affected

countries less than five weeks after it recorded its first SARS death.66 Vietnam was

hailed as a success story largely because of its rapid response to the health crisis, and

its cooperation with WHO and CDC officials who offered critical technical

assistance.67 According to the WHO, Vietnam was fortunate to have had only one

carrier, who spent less than three days among the general public prior to

hospitalization. This limited the number of contacts that the man made.

WHO, “Update 59 - Report on Guangxi (China) visit, situation in Taiwan, risk of SARS

transmission during air travel.” May 19, 2003. [http://www.who.int]

Altman, Lawrence and Donald G. McNeil, “U.S. Doctor with Symptoms to Fly Home from

Taiwan.” May 23, 2003. The Washington Post. [http://www.washingtonpost.com]

Chung, Lawrence, “Complacency and infighting led to worsening outbreak.” May 23,

2003. The Straits Times website. [http://www.straitstimes.com]

Channel News Asia, “Taiwan’s parliament approves special budget of US $1.44 billion

to combat SARS.” May 23, 2003. [http://www.channelnewsasia.com]

Nakashima, Ellen, “Vietnam Took Lead in Containing SARS.” May 5, 2003. The

Washington Post. [http://www.washingtonpost.com]

WHO, “Update 39 - Optimism in Viet Nam, caution urged when using diagnostic tests.”

April 25, 2003. [http://www.who.int/csr/sars]

CRS-14

Some observers praised the success of the country with less resources than its

SARS-affected neighbors to rapidly contain the virus. One Vietnamese health

official explained that Vietnam’s response contrasted with China’s initial response

in that Vietnam did not seek to downplay the potential impact of the disease and it

welcomed international assistance. France quickly announced that it would offer

more than $100,000 to help sterilize Hanoi French Hospital, where the first SARS

case was detected.68 The WHO and CDC donated masks, gowns and other

equipment; Japan contributed two ventilators and other medical supplies; Doctors

Without Borders sent a medical team; and Vietnamese medical workers were trained

in infection control techniques.69 Vietnamese doctors also voluntarily quarantined

themselves in Bach Mai hospital, the designated SARS hospital, to avoid spreading

the virus to their families and the general community.

The government of Vietnam ordered the establishment of provincial and

municipal steering committees responsible for closing down any entity and isolating

any individual who contracted SARS or was suspected to be infected with the virus.70

It also trained medical workers, customs officers, airline staff and those working in

the tourism sectors.71 The Finance Ministry spent about $2 million on medical

equipment and activities related to SARS prevention72 and targeted a little more than

$1 million for Vietnam’s border provinces tasked with preventing SARS from

leaving or entering Vietnam.73 The Government of Vietnam recently announced that

it intended to spend an additional $3.3 million to prevent SARS from returning.74

Johnny Chen, believed to have carried SARS to Vietnam from China, died of SARS

on March 13, 2003. A little more than a month later on April 28, 2003, the WHO

announced that Vietnam was the first country to have contained the deadly virus. A

total of 63 people contracted SARS in Vietnam, 5 of whom died.75

Asia Times, “Vietnam shows how to beat SARS.”

[http://www.atimes.com]

April 30, 2003.

Nakashima, Ellen, “Vietnam Took Lead in Containing SARS.” May 5, 2003. The

Washington Post. [http://www.washingtonpost.com]

Ministry of Foreign Affairs, “Further precautions taken to ward off SARS.” March 31,

2003. [http://www.mofa.gov.vn]

Ministry of Foreign Affairs, “Deputy Prime Minister asks all provinces to establish SARS

control committees.” April 16, 2003. [http://www.mofa.gov.vn]

Ministry of Foreign Affairs, “30 billion VND for SARS prevention work.” April 8, 2003.

[http://www.mofa.gov.vn]

Ministry of Foreign Affairs, “Further precautions taken to ward off SARS.” March 31,

2003. [http://www.mofa.gov.vn]

Ministry of Foreign Affairs, “Ninety returnees from Beijing to leave isolated centre.”

May 12, 2003. [http://www.mofa.gov.vn]

CRS-15

Singapore

Some civil libertarians criticized the Government of Singapore in its response

to the SARS virus as being too harsh. However, the World Health Organization

commended Singapore on its response to the virus. Dr. David Heymann, Executive

Director of communicable disease programs at the WHO described Singapore’s

actions as “exemplary”, and stated that “Singapore has been one of the most

successful countries in its response to SARS.”76 The World Health Organization

removed Singapore from the list of areas with local SARS transmission on May 30,

2003.77

Singapore’s actions against SARS were viewed as swift and widespread. For

example, the Ministry of Education required all schools to provide students with a

personal thermometer, and to teach them to check their own temperatures daily. All

students taking the national language exams in June 2003, underwent temperature

checks before entering testing sites. The Ministry also required the Institutes of

Higher Learning to segment their large campuses into smaller sections to reduce

movement across the campus and to facilitate contact tracing. Singapore required all

students and households to have thermometers by June 2003. Other steps taken to

prevent the spread of SARS included: directing all SARS cases to one hospital,

installing video cameras in the homes of all quarantined individuals, electronically

tagging violators of quarantine orders, using body thermal scanners at airports,

enforcing mandatory temperature checks for all individuals departing Singapore and

those arriving from SARS affected areas, requiring all food handlers to take their

temperatures twice a day, and applying mandatory temperature checks for entry to

many public events. On March 24, 2003, the Singapore Ministry of Health invoked

the Infectious Disease Act to isolate those infected with SARS, and prevent the

further spread of the virus. The act was amended on May 23, 2003, by requiring all

those who broke the home quarantine to be tagged, arrested, detained, and/or fined.

The first offense is punishable by up to $10,000 or 6 months imprisonment and

repeat offenders can be fined up to $20,000 or 12 months.78

WHO, “Update 53 - Situation in Singapore and Hong Kong, interpretation of areas with

recent local transmission.” May 12, 2003. [http://www.who.int]

WHO, “Update 70 - Singapore removed from list of areas with local SARS transmission.”

May 30, 2003. [http://www.who.int]

Singapore Ministry of Information ,”Ministerial Statement in Parliament, SARS - A

National Response.” April 24, 2003. [http://app.sprinter.gov.sg/data/pr/2003042408.htm];

Ramesh, S, “Singapore toughens Infectious Disease Act to deal with SARS outbreak.” April

25, 2003. Channel News Asia. [http://www.channelnewsasia.com]; Government of

S i n g a p o r e , “ H o m e Q u a r a n t i n e In f o r m a t i o n . ”

May 27, 2003.

[http://www.sars.gov.sg/family.html]; and Singapore Ministry of Education, “Arrangements

for the 2003 GCE ‘O’ & ‘A’ Level Mother Tongue Language Mid-Year Examinations.”

May 27, 2003. Government of Singapore. [www.sars.gov.sg]

CRS-16

The Government of Singapore also unveiled a $230 million SARS relief

package on April 17, 2003. Key elements include:

a Home Quarantine Allowance Scheme, which pays an allowance

to the self-employed and to small business owners who have

employees affected by home quarantine orders;79

! property tax rebates for commercial properties and tourist hotels;

! 50% reduction in foreign worker levy for unskilled workers

employed by tourist hotels;

! a Bridging Loan Program, which offers working capital loans to

tourism-related small- and medium-sized enterprises;

! a Skills Redevelopment Program and SARS Relief Tourism

Training Assistance Program, which offers funds to employers who

send their employees to certified training courses in the tourism

sector;

! diesel and road tax rebates for taxis, and operator licence fee

waivers;

! rebates on aircraft landing fees and rental spaces at airports;

! 50% reduction in port dues for cruise ships; and

! dollar-for-dollar matching of funds for the Courage Fund, a tripartite

fund established to help the victims of SARS and affected health

care workers. The fund received nearly $10 million in just 7 weeks.80

Singapore was removed from the list of areas with recent local transmission on

May 31, 2003. To date, 206 people have contracted SARS in Singapore, and 32 have

died of the virus. The last probable case was reported on May 18, 2003.

Canada

When SARS first emerged in the country some criticized Canadian officials for

waiting too long to quarantine 500 members of a prayer group widely believed to

have been the source of the virus in Canada.81 WHO officials also complained that

the Canadian government had been slow to relay current information. Relations

between the U.N. agency and Canadian authorities were strained when the WHO

decided to place a SARS travel advisory on Toronto. Canada appealed to the WHO

to remove the travel advisory, because officials claimed they could trace all

occurrences of the virus.82 On May 14, 2003, two days after the 24th SARS victim

died, the WHO removed the travel advisory, citing 20 days had passed without new

Singapore Ministry of Information ,”Ministerial Statement in Parliament, SARS - A

National Response.” April 24, 2003. [http://app.sprinter.gov.sg/data/pr/2003042408.htm]

Ministry of Manpower, “Joint Media Release from the Ministry of Finance and Ministry

of Trade & Industry: Government Unveils $230 million SARS Relief Package.” April 24,

2003. [http://www.mom.gov.sg]

Krauss, Clifford, “Disease Has Canada Doubting Its Leaders,” New York Times, April 19,

2003.

Brown, DeNeen L., “Virus Worry Fades in Toronto, but Concerns Lingers.” April 24,

2003. The Washington Post. [http://www.washingtonpost.com]

CRS-17

cases. However, on May 23, 2003 Toronto health officials reported that four new

suspected SARS cases were under close surveillance.83 On May 26, 2003, the WHO

placed Toronto back on its list of countries with recent local transmission, but it did

not place a travel advisory on the city.

Following criticism of bureaucratic delay, Canadian officials took a number of

steps to contain the virus, including inviting the U.S. Centers for Disease Control

(CDC) to monitor its hospitals, closing a number of hospitals and clinics, and

quarantining those individuals suspected to have SARS. Canada also undertook a

number of initiatives to aid businesses and individuals adversely affected by SARS.

On April 30, 2003, the Government of Canada passed the SARS Assistance and

Recovery Strategy Act, which protects the jobs of people affected by SARS, and

enables employees to take unpaid leave of absence for SARS-related reasons. It also

included $1.7 million in new funding to help scientists develop a new test and

possible vaccine for SARS. All tourist facilities in Toronto were also exempt from

retail tax from May 1, 2003 to September 30, 2003, under the act.84

Another government initiative implemented to assist Canadians affected by

SARS is the SARS Grant Initiative. Eligible full-time and part-time health care

workers affected by SARS can receive $400 per week and $200 per week,

respectively. This initiative complements adjustments made to the Employment

Insurance (EI) Act, which allows up to 15 weeks of special benefits when an eligible

claimant is unable to work because of illness, injury or quarantine. The Government

of Canada has adjusted the EI program so that those who become ill due to SARS are

not immediately required to provide a medical certificate, and no longer have to wait

two weeks to receive benefits.85 Other SARS-related actions include:

committing $10 million toward a marketing campaign;

arranging special payment schedules or temporary deferral of

mortgage payment for those who find it difficult to pay mortgages

due to SARS;

! extending tax due dates, establishing flexible payment schedules and

waiving tax penalties or interest for those affected by SARS; and

! offering a four-month postponement of capital payments without

penalty and small capital loans to small businesses affected by

SARS.86

The Straits Times, “Officials fear four in Toronto hospital may have SARS.” May 23,

2003. [http://straitstimes.com]

Premier Erne Eves Media Office, “Premier Ernie Eves’ SARS strategy bill passes on first

day of legislature.” May 13, 2003, Canada NewsWire.

[http://www.newswire.ca/releases/April2003/30/c6392.html] and Brown, DeNeen L.,

“Canada Seeks Help From CDC in Fighting Virus.” April 23, 2003. The Washington Post.

Human Resources Development Canada, “Severe Acute Respiratory Syndrome News

Release.” March 28, 2003. Human Resources Development Canada.

[http://www.hrdc-drhc.gc.ca/common/news/insur/030328.shtml]

Government of Canada, “Government of Canada Action to Contain the Effects of Severe

Acute Respiratory Syndrome (SARS).” May 2, 2003. Prime Minister of Canada website.

[http://www.pm.gc.ca/]

CRS-18

In June 2003, health workers concerned about their safety, including hundreds

of nurses, demonstrated in Canada to demand danger pay, protective suits, and a

public investigation into the cause of the SARS resurgence. Some nurses claimed

that hospital officials were slow to respond to their warnings that patients in other

wards showed SARS-like symptoms. Still, some family practitioners expressed

concern that health officials failed to notify them when the virus first resurfaced. As

a result, some family practitioners fell ill with the virus.87 When the virus resurfaced

thirteen people died of SARS and thousands were quarantined.88

Toronto was removed from the list of areas with recent local transmission on

July 2, 2003. The last probable case was reported on June 12, 2003. To date, 250

people have contracted the virus and 38 have died of SARS.

Congressional Response

Infectious Disease Monitoring

The rapid spread of the SARS virus underscored the importance of establishing

a database system that would allow rapid and accurate information sharing on

emergent infectious diseases. The Senate FY2004 Labor, Health and Human

Services (HHS) and Education appropriations bill provides over $370 billion for

infectious disease control at CDC, including $25 million for SARS research,

prevention and control. It also includes $50 million to develop a Global Disease

Detection System at the CDC that would enable the United States to effectively

respond to a global infectious disease threat. The Senate bill also increases NIH

funding for emerging infectious disease from nearly $600 million in FY2003 to $1.7

billion.

Capacity Building

Congress has also recognized the need to strengthen state and local capacity to

respond to a bioterrorist attack or infectious disease outbreak. The Senate bill

proposes that CDC funds for that purpose be maintained at FY2003 levels, $940

million. Part of strengthening state and local capacity includes the support of the

Health Alert Network (HAN). Prior to HAN, one-half of local public health

departments did not have e-mail. The HAN system has been used to share

information about SARS. Forty million U.S. dollars have been reserved for this

purpose in the Senate version of the FY2004 Labor, HHS, and Education

appropriations bill.

June 12, 2003.

June 2, 2003.

The Washington Post, “SARS Takes Toll on Nurses.”

[http://www.washingtonpost.com]

WHO, “Cumulative # of Reported Probable Cases of SARS.”

[http://www.who.int]

CRS-19

Improving U.S. Response Capability

The rapid spread of the SARS virus has demonstrated the need to quickly and

effectively respond to an intentional or natural infectious disease outbreak. Congress

appropriated $77.5 million to the CDC Epidemic Services and Response program in

FY2003. The Senate version of the FY2004 Labor, HHS and Education

appropriations bill increases funding for those efforts to $127.5 million in FY2004.

The CDC Epidemic and Response program provides resources and scientific

expertise for operating and evaluating surveillance systems; develops and refines

research methods and strategies for public health practitioners; and trains public

health professionals who respond to public health emergencies and outbreaks. The

Senate version also directs over $578 million to the Health Resources and Services

Administration (HRSA) to combat bioterrorism.89

Future Challenges

The SARS outbreak has provided lessons that may have future application. The

WHO/CDC intervention greatly increased the effectiveness of the global response.

A number of factors influenced the outcome, such as the system of global alerts and

awareness, and access to immediate, high-level research and scientific collaboration.

Coordinated efforts through the WHO/CDC, national governments, and the public

health professionals also led to positive results, as in the case of Vietnam. Dr. Julie

Gerberding, Director of the Centers for Disease Control and Prevention, had high

praise for WHO’s leadership during the crisis and emphasized communication and

transparency as key to responding to international health crises. Areas in which

improvements have been called for in the global response to infectious disease threats

include:

Global Interdependence and Transparency

Lack of transparency in promptly reporting and monitoring SARS outbreaks

directly contributed to the spread of the disease worldwide and had wide-ranging

impacts beyond the obvious health factors. The case of SARS demonstrated that

state responsibility within a globalized world does not end at its borders and that

future containment relies on openness and cooperation in the interests of all

populations.

For more information on Congressional efforts to combat SARS, see CRS Report

RL31937, Severe Acute Respiratory Syndrome (SARS): Public Health Situation and U.S.

Response.

CRS-20

Developing Surge Capacity

The ability of public health systems and the availability of resources to deal with

a threat like SARS were clearly inadequate. Addressing the need and ability to

mobilize additional resources, both within the country itself, and through the WHO

network during an emergency, would improve the response to similar challenges in

the future. Some have expressed concern about the impact SARS could have had if

the outbreak had reached developing countries with minimal health care

infrastructures, particularly those already weakened by HIV/AIDS. Others have

argued that SARS has underscored the importance of boosting aid efforts that offer

structural support, such as aiding in the training of health care professionals, donating

medical supplies and equipment, upgrading health technologies, and ensuring

universal inoculation against resurgent diseases such as tuberculosis.

Public Fear and Information Disclosure

The WHO had to strike a balance. On the one hand it was pressed to give

information, and use aggressive tactics of containment. On the other hand, the

information about SARS may have contributed to public panic and anxiety,

discrimination in some cases, and other impacts, such as economic losses. Some

argue that the WHO did not take into account the impact of its decision-making

concerning travel advisories and global alert warnings and that the SARS risk

sometimes did not demonstrate the need for such a response.90 Some governments

in the future may be hesitant rapidly and openly to share outbreak information,

because they may want to avoid potential negative economic impacts, such as job

losses, hotel closures and flight cancellations as occurred at the height of the SARS

crisis. For example, 60,000 restaurant and hotel workers in Hong Kong lost their jobs

or were placed on unpaid leave during the SARS outbreak.91 In Singapore, year-byyear comparisons showed that tourist arrivals fell 15% in March 2003 and 67% in

April 2003, and hotels reported occupancy rates of only 10 to 30%, compared to

usual occupancy rates of 70% or more during the first quarter of the year. 92

National Response

The weakness of national surveillance systems and health networks within any

one country can dramatically affect the area and rate at which a disease spreads. If

the SARS virus had spread more rapidly and extensively throughout the affected

countries and for a sustained period, it could have had a significant impact on the

health care systems, and other systems. Those in need of health care, such as those

with cancer, requiring surgery, or those requiring immediate medical attention may

not have been able to receive care. In order to contain the SARS virus, hospital

wards and, at times, entire hospitals were shut down for weeks at a time to

Far Eastern Economic Review, “SARS: A WHO-Induced Panic?” May 22, 2003.

MSNBC, “Record SARS

[http://www.msnbc.com]

deaths

Hong

Kong.”

April

15,

2003.

Channel News Asia, “National Wages Council (NWC) wage guidelines for July 2003 to

June 2004.” May 27, 2003. [http://www.channelnewsasia.com]

CRS-21

decontaminate them. Significant resources were used to quarantine SARS-infected

individuals, schools were closed, and other private facilities were adversely impacted.

Such problems caused by SARS illustrate the need to develop effective national

response systems.

Inadequate Funding

WHO officials and others have argued that there is a need for increased funding

for laboratories and epidemiological research in the fight to contain diseases like

SARS. Improvements to the existing surveillance network and national capacity to

address emergency health issues are also badly needed. For example, GOARN

reportedly needs $200 million to reinforce its network.93

Associated Press,”New WHO Chief Plans More Action on SARS,” May 21, 2003.

EveryCRSReport.com

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