Dodging a Bullet: WHO, SARS, and the Successful Management of Infectious Disease
Identifieur interne : 000054 ( Istex/Corpus ); précédent : 000053; suivant : 000055Dodging a Bullet: WHO, SARS, and the Successful Management of Infectious Disease
Auteurs : Evan S. MichelsonSource :
- Bulletin of Science, Technology & Society [ 0270-4676 ] ; 2005-10.
English descriptors
- Teeft :
- Control measures, Disease cases, Disease control, Disease epidemiology, Economic consequences, Economic costs, Flunet capabilities, Global, Global conference, Global outbreak, Global response, Global spread, Global surveillance, Goarn, Goarn capabilities, Health care workers, Health officials, Health systems, Health threat, Heymann, Hong kong, Hong kong hotel, Hospital workers, Infectious disease, Infectious diseases, Information campaigns, International borders, International community, International level, International travel, Local hospitals, National governments, National level, Next outbreak, Other guests, Outbreak, Policy choices, Policy decisions, Policy response, Policy responses, Poorer countries, Public health officials, Recent sars outbreak, Report disease cases, Respiratory illness, Respiratory syndrome, Response efforts, Response network, Response team, Sars, Sars cases, Sars epidemic, Sars outbreak, Sars preparedness, Significant amount, Singapore, Single hospital, Single magnet hospital, Such problems, Syndrome, Technology society october, Transmission rates, Travel recommendations, Vaccine research, World health organization, World health report.
Abstract
The purpose of this article is to analyze the policy decisions made by the World Health Organization (WHO) in working to fight the spread of the first truly global infectious disease, severe acute respiratory syndrome (SARS), of the 21st century. In particular, the author pays attention to the WHO’s Global Outbreak Alert and Response Network (GOARN) and analyzes how it was employed in coordinating a variety of response efforts around the world. In addition, he identifies and assesses the successes and failures of the GOARN’s policies with regard to the monitoring and containment of the SARS outbreak.
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DOI: 10.1177/0270467605278877
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10.1177/0270467605278877BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / October 2005Michelson / DODGING A BULLET
Dodging a Bullet: WHO, SARS, and the
Successful Management of Infectious Disease
Evan S. Michelson
George Washington University
The purpose of this article is to analyze the policy
decisions made by the World Health Organization
(WHO) in working to fight the spread of the first truly
global infectious disease, severe acute respiratory
syndrome (SARS), of the 21st century. In particular,
the author pays attention to the WHO's Global Out-
break Alert and Response Network (GOARN) and ana-
lyzes how it was employed in coordinating a variety of
response efforts around the world. In addition, he
identifies and assesses the successes and failures of
the GOARN's policies with regard to the monitoring
and containment of the SARS outbreak.
Keywords: World Health Organization; severe acute
respiratory syndrome (SARS); public health
The World Health Organization (WHO),
Globalization, and Infectious Disease
Over recent years, it has become evident that one of
the major drawbacks of increased international travel,
and the rapid speed at which individuals can cross
international borders, with amplified contact between
people from different parts of the world, is that the
threat of certain public health problems, such as the
spread of infectious disease, has taken on new weight
and importance. Whereas the spread of infectious dis-
eases was once checked by the relatively slow move-
ment of foreign-bound vessels and people, there is the
threat that in the contemporary world, deadly infec-
tious diseases can be transported from their place of
origin to the other side of the globe after only a few
hours on an airplane, possibly well before the disease
has even been identified or demonstrated any outward
symptoms. The point is that the growing interdepen-
dence of nations with respect to economics and com-
merce has led to a similar link between nations regard-
ing concern over the global spread of emerging infec-
tious diseases. National governments, along with
organizations working at the international level, are
currently developing policy responses to such diseases
and are attempting to develop a framework within
which they will treat these new threats. In turn, the pur-
pose of this article is to analyze, assess,and address the
policy decisions made by one such entity, the WHO, in
working to fight the spread of the first truly global
infectious disease, severe acute respiratory syndrome
(SARS), of the 21st century.
To start, it is important to note that the WHO's
approach in dealing with the SARS outbreak was to
employ its ability to monitor, survey, and ultimately
contain the global spread of the disease. Though the
worldwide reach of the WHO makes it one of the few
bodies capable of organizing such a broad-scale
response, it becomes evident when studying the SARS
outbreak that individual nations and governments also
played a large role in suppressing SARS transmission.
Though I will touch tangentially on such national
responses, it is important to re-emphasize that the
focus of this article is on analyzing the WHO's public
health policies in response to this disease and eventu-
ally to recommend a number of changes and improve-
ments that might help the organization improve its
actions in reply to future global infectious diseases.
To this end, I will begin by briefly discussing the
nature and history of the SARS outbreak, followed by
a description of the WHO's main role in dealing with
this infectious disease. In particular, I will pay most
attention to the WHO's Global Outbreak Alert and
Response Network (GOARN) and analyze how it was
employed in coordinating a variety of response efforts
around the world. Throughout this analysis, I will
identify and assess the successes and failures of the
GOARN's policies with regard to the monitoring and
Bulletin of Science, Technology & Society, Vol. 25, No. 5, October 2005, 379-386
DOI: 10.1177/0270467605278877
Copyright Ó 2005 Sage Publications
containment of the SARS outbreak, policies that
include the creation of a "virtual network" to study the
epidemiology of the disease, the deployment of global
health alerts, and travel recommendations for interna-
tional passengers. Next, by focusing on some of the
shortcomings that were brought to light by the WHO's
and GOARN's response to SARS, I will offer a num-
ber of suggestions that could have improved the
WHO's and GOARN's effectiveness in dealing with
this disease and will help improve their response to
future infectious diseases. Overall, I support the con-
clusion that the WHO's and GOARN's actions with
respect to informing the global public about the poten-
tial severity of SARS succeeded in reducing virus
transmission and in turn cut off the possibility that a
major global health catastrophe would occur. Though
room for improvement still remains, the WHO's and
GOARN's ability to address a novel, complex health
problem by way of gathering, processing, and distrib-
uting information implies that the policies they used to
deal with the SARS outbreak were mostly on target
and succeeded in saving a number of lives around the
world.
SARS and Global Surveillance: The Basics
Though SARS captured the world's attention early
in 2003--and in particular afterthe WHO releasedtwo
global alerts on March 12th and March 15th detailing
what was then known about the disease--the disease
was believed to have originated around the middle of
November 2002 in the Chinese province of
Guangdong. As The World Health Report 2003
(WHO, 2003a) states, "retrospective analysis of
patient records . . . has identified small clusters of
cases, each traced to a different initial case, that
occurred independently in at least seven municipali-
ties" (p. 74). Though there appears to be no direct link
between these initial cases, studies conducted in the
Guangdong region "have detected a virus almost iden-
tical to the SARS coronavirus in domesticated game
animals . . . suggesting that these animals might play a
role in the transmission of the virus to humans" (p. 74).
This initial batch of sporadic cases was amplified
on February 21, 2003, when a doctor who had treated
one of the early SARS patients and subsequently con-
tracted the disease spent a night in a Hong Kong hotel
and in turn transmitted the disease to 16 other guests,
most of whom stayed on the same hotel floor (SARS
Preparedness and Response Team, 2003, slide 3).
Once infected, these individuals carried the virus not
only to local hospitals and treatment centers but across
international borders as well, particularly to Singa-
pore, Toronto, and Hanoi (p. 74). As the disease began
to spread across the world, "SARS first took root in
hospital settings, where staff, unaware that a new dis-
ease has surfaced and fighting to save the lives of
patients, exposed themselves to the infectious agents
without barrier protection" (WHO, 2003b, p. 1). In
addition to severely infecting hospital workers, the
elderly were unduly affected and suffered the most
casualties from the disease, with a case fatality ratio
exceeding 50% (p. 3). By the middle of 2003, nearly
8,500 SARS cases and 1,000 deaths had been identi-
fied in more than 30 countries around the world, pri-
marily in east Asia (mainland China, Hong Kong, Sin-
gapore, Taiwan, and Vietnam) and Canada (WHO,
2003a, p. 75, Figure 5.1).
By the time the WHO released two worldwide cau-
tions in the middle of March 2003, it became clear that
SARS posed a potentially dangerous threat for a num-
ber of reasons. First and foremost, there was no vac-
cine and no specific, effective medical treatment avail-
able. In fact, public health officials were not even sure
of the possible vector, agent, or source of the disease,
and therefore, they were ignorant about its potential
for continuous spread. Second, a number of infected
patients and associated health workers had "rapidly
progressed to respiratory failure, requiring intensive
care and causing some deaths in previously healthy
persons" (WHO, 2003b, p. 4). In a talk on the subject
of the SARS outbreak in Singapore, Chorh Chuan Tan
(2003, slide 9) emphasized this point that "atypical
SARS patients"--those that have little or no previous
record of respiratory illness or ill health in general--
can pose the most significant threats to public health
systems, mostly because their symptoms initially go
unnoticed and, therefore, individuals can spread the
disease unknowingly. The idea is that in its onset, the
symptoms for SARS appear quite similar to symptoms
related to the common cold or flu, such as coughing,
sneezing, or a rise in body temperature, and therefore,
these early warning signs are easily ignored as indicat-
ing a more serious disease. In addition, though it began
to become evident that transmission was due to
human-to-human contact during "face to face expo-
sure to respiratory droplets expelled during coughing
or sneezing," it became clear that because that incuba-
tion period for SARS was 7-10 days, the disease could
still be easily transported around the world, again
without the knowledge of the infected individual or
public health officials in a particular nation (WHO,
380 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / October 2005
2003a, p. 74). In fact, by the middle of March 2003,
SARS already appeared to have jumped oceans from
Asia to North America and Europe, and there was little
epidemiological evidence that the disease would die
out naturally or cease to be transmitted.
To its credit, by the year 2000 (if not earlier), the
WHO had begun to foresee a need for an overarching
global mechanism that would help respond to and be
responsible for the capturing, processing, and collat-
ing of information in regard to emerging global infec-
tious diseases, such as SARS. In a paper published in
the Bulletin of the World Health Organization, 2000,
Richard Cash and Vasant Narasimhan (2000) noted
that "it is widely agreed that a global surveillance net-
work system for infectious diseases would help signif-
icantly to control their spread" (p. 1358). In particular,
the authors supported the idea that "global surveil-
lance should be proactive in order to tackle" a number
of problems associated with disease control, including
coordinating of research, reducing the "inaccurate
spread of information," and assisting poorer countries
in bolstering their health systems to better address the
sudden onset of such problems (p. 1364). As noted
earlier, the GOARN was formally established to
address these issues by improving "the delivery of
international assistance in support of local efforts" and
tackling "the broad spectrum of operational issues and
the challenges of a coordinated international outbreak
response" (WHO, n.d., p. 1). In short, the GOARNacts
a supernetwork, or a "network of networks," consist-
ing of science, medical, and public health experts,
national disease control centers, nongovernmental
organizations, WHO regional and country offices,
other international bodies, the media, and popular
electronic discussion sites, all with the aim of search-
ing for reliable disease information and linking actors
with different capabilities and expertise with one
another.
WHO's and GOARN's Policy Response:
Gather, Inform, Contain, and Control
With all of the initial uncertainty surrounding the
SARS outbreak--the lack of scientific information
about possible causes, vaccinations, and immuniza-
tions, the lack of exact data about transmission pat-
terns, and the lack of knowledge about possible future
mutations--the GOARN undertook an important
chain of policy responses: gather quality information,
inform the public at large, and suggest measures that
would contain and control the spread of the disease.
To start, I argue that one of the GOARN's greatest
successes was its ability to assemble a system of dis-
covery to specifically address the SARS outbreak. The
GOARN worked to link together 13 laboratories in 9
countries, along with more than 50 medical clinicians
in 14 countries, to try and identify the causative basis
for the disease, its mode of transmission, and possible
responses (Heymann, 2003, slide 5). This multina-
tional team, which included representatives from the
International Federation of the Red Cross, the U.S.
Centers for Disease Control, and the Pacific Public
Health Surveillance Network, participated in daily
phone calls, established secure Web sites to share
information internally, and worked with national gov-
ernments--and in particular the Chinese govern-
ment--to amass a significant amount of disease and
epidemiological information. In addition, the
GOARN responded to the needs of local public health
officials by sponsoring a number of "on the ground"
field teams, consisting of nearly 150 personnel, in
China (mainland, Hong Kong, and Taiwan), Singa-
pore, Vietnam, and the Philippines. These teams were
not only able to help local health authorities find meth-
ods to control disease spread, improve communica-
tion, and handle logistics, but they were also able to
assist researchers around the world by providing them
with biological samplesand raw data from a number of
locations (SARS Preparedness and Response Team,
2003, slide 11). Moreover, the GOARN had the fore-
thought to send nearly 50 individuals to other unin-
fected countries in the region, including Malaysia,
Laos, and Cambodia, with the hope of gathering infor-
mation from these "border zones" about disease trans-
mission that in turn could help inform the public health
response of those nations that were actually dealing
with the disease (slide 12). Finally, the GOARN estab-
lished a senior management group, consisting of high-
level country, regional, and international public health
officials, able to interact with one another via tele-
phone conferences to discuss worldwide response
options and to discuss the global alerts and travel
recommendations that were ultimately released
throughout the middle of March 2003.
Still, the GOARN realized early in the process that
it needed assistance from additional sources if it was to
accurately and comprehensively gather enough infor-
mation to quickly stop the spread of the disease. For
instance, the GOARN also chose to enlist the help of
the Global Public Health Intelligence Network
(GPHIN), a "worldwide web-crawling computer
application" that "systematically searches for
Michelson / DODGING A BULLET 381
keywords in seven languages to identify reports of
what could be disease outbreaks" (WHO, 2003a, p.
76). By enlisting the GPHIN as a tool in the search for
possible information about the growing epidemic, the
GOARN undertook a sensible policy position: that it
would be open to input from any and all viable
sources. Along the lines of encouraging the sharing of
information about the disease, the GOARN partnered
with WHO's Influenza Laboratory Network (FluNet)
with the hope that by forming such an alliance with a
vaccine research and development group, the GOARN
would be able to better systematically piece together
information that could possibly lead to an effective
vaccine. Though I will discuss some of the shortcom-
ings of these partnerships later on, the point here is that
in working to gather as much data as possible, the
GOARN's approach ensured that the widest net would
be cast and that possible epidemiological leads would
not get lost.
Second, the WHO, and the GOARN in particular,
followed through with its policy of providing open
channels of communication and an unhindered flow of
information by ensuring that the world at large was
made aware of the dangers of the SARS outbreak as
quickly as possible. In particular, the WHO took the
unprecedented step of issuing not one but two global
alerts detailing the nature of the disease, its mode of
transmission, and suggestions for halting its spread.
On March 12, the WHO, acting on the information
gathered by the GOARN and its partners, reported
publicly on the recent spike of respiratory illness in
hospital workers in Hanoi and Hong Kong, and on
March 15, it stated that this "worldwide health threat"
was being spread, in particular, by air travel. In short,
the WHO agreed that the best policy option they could
adopt in order to stop the spread of SARS around the
world was impressing upon governments and individ-
uals alike that air passengers, hospital workers, and the
elderly should be identified as possible "spreaders" of
the disease and that any suspected or identified cases
should quickly be sealed off, quarantined, or isolated.
Moreover, in addition to its global alerts and travel
advisories, the WHO sponsored a number of press
releases,press conferences, and interviews, along with
maintaining a continually up-to-date Web site, all in
the spirit of guaranteeing that the presence of a signifi-
cant amount of information would encourage the pub-
lic to be vigilant and work together toward stopping
the spread of this deadly disease (Rodier, 2003, slide
11).
Admittedly, the WHO's policy choices were lim-
ited. To start, the lack of any SARS vaccination or
immunization precluded a reliance on preventive med-
ical interventions. Nevertheless, even without such
drugs or medication, "a climate of increased aware-
ness" helped ensure the new cases were quickly identi-
fied and in turn spurred those who demonstrated
symptoms to seek medical attention (WHO, 2003a, p.
79). For example, "many hospital staff cited the WHO
advisory . . . as one reason why cases were quickly
detected and isolated" and that "in areas experiencing
imported cases," these alerts "prevented any further
transmission or kept the number of locally transmitted
cases very low." (p. 79; WHO, 2003b, p. 6). Similarly,
the success of the WHO's universal and targeted infor-
mation campaigns also shows up with respect to inter-
national air passengers. Despite the fact that SARS
cases were exported to a total of 32 countries, only one
major outbreak occurred after the March 15 travel
advisory (Heymann, 2003, slide 26). Again, the notion
here is that due to the WHO's forceful public warn-
ings, individuals experiencing SARS-like symptoms
appear to have avoided international travel and in turn
reduced the risk that the disease would be spread to
additional countries.
The final successful aspect of the WHO's and
GOARN's policy response to the SARS outbreak was
to suggest certain containment and control measures,
in addition to a reduction in air travel, that would help
stop the spread of the disease. For example, the WHO
made certain that strict infection control measures
were implemented: infected individuals were quaran-
tined; possible transmission points, such as hospital
air ducts, were sealed off; and cases were monitored
and followed-up for 10 days after the patient's recov-
ery (Rodier, 2003, slide 13). Second, rigorous body
temperature surveillance was undertaken for all hospi-
tal staff and patients who could possibly have been
exposed to the disease. In short, these preventative
actions succeeded in breaking the chain of transmis-
sion and worked to control and contain any new infec-
tions. In regard to international air passengers, individ-
uals leaving an infected area were subject to
screenings at the airport, thereby taking care that the
disease could not be transported to another country. In
fact, this form of passenger screening at the airport led
to the identification of two disease cases in Hong
Kong, and the infected individuals were subsequently
hospitalized to prevent any further spread (WHO,
2003a, p. 79). By suggesting such actions, the WHO
382 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / October 2005
was able to provide national public health systems
with tangible, concrete measures that would help stop
the SARS outbreak quickly and avoid any further
outbreaks in the future.
Suggested Changes: WHO, GOARN,
and the Next Worldwide Health Threat
Though I have argued, up to this point, in favor of
the WHO's decision to openly discuss the nature of the
SARS epidemic, to gather and analyze data by way of
GOARN, to provide the public with timely informa-
tion, and to suggest possible public health contain-
ment and control measures, I still hold that there are a
number of steps that WHO--and in turn GOARN--
could take to improve their response to the next global
health threat. The difficulty, however, of developing
suggestions based on the lessons learned from the
SARS outbreak is that the next outbreak could possi-
bly be characterized quite differently and therefore
would require the adoption of a new set of tools in
order to address the associated problems. Although
this is a possibility, I argue that the recommendations
and improvements I discuss and analyze below will, it
is hoped, still be useful in dealing with a variety of dif-
ferent diseases and that they are significant enough to
warrant close attention from public health officials.
First, countries must be encouraged to report dis-
ease cases in an accurate and timely manner so that
SARS-like epidemics can be better prevented in the
future. If the Chinese government had reported its
knowledge of the disease to the international commu-
nity when it was first identified in November 2002, the
SARS outbreak might have been slowed, altered, or
avoided altogether. As of now, unfortunately, govern-
ments may choose to conceal information for fear of
"social and economic consequences," including "loss
of credibility in the eyes of the international commu-
nity, escalating negative economic impact, [and] dam-
age to the health and economies of neighboring coun-
tries." (WHO, 2003a, p. 78). Similarly, the drop off of
air travel in all areas of the Far East during and imme-
diately after the SARS epidemic might make govern-
ments even more cautious of reporting disease cases,
especially if their countries would be stigmatized and
if they do not want to admit publicly that their health
systems are not robust enough to address and deal with
such a monumental task. Instead of facing such nega-
tive externalities, governments might restrict the flow
of information with the hope that a single disease case
might either die out or only have to be controlled
locally.
I contend, however, that these negative social and
economic factors should be used as motivating tools to
encourage governments to report cases. In addition,
the international community, including the World
Bank and United Nations, should pledge that "resusci-
tation" funds will be made available to those countries
that experience outbreaks but actively take steps to
report information. The point here is that governments
must be made aware that there are high social and eco-
nomic costs for not reporting such epidemiological
information. For instance, the East Asia Development
Bank has estimated that the SARS outbreak might
have ended up costing Hong Kong nearly 4% of its
GDP, Taiwan 1.9%, and Singapore 2.3% (Heymann,
2003, slide 22). Some estimates put the total actual
costs of the disease outbreak for East and Southeast
Asia at nearly US$30 billion, and in the wake of such
disinformation, the level of public panic and govern-
ment blame has been quite intense (WHO, 2003b, p.
2). If such disease outbreaks are allowed to go uncon-
trolled and unreported in the future, governments
might have even more serious problems to deal with,
including restricting access to public spaces, the clos-
ing of schools and hospitals, and diverting resources to
maintaining large quarantine zones. Governments
must realize that these economic indicators and social
drawbacks could have been, and will be, drastically
reduced if the diseases in question are dealt with more
effectively and more openly earlier on.
As I mentioned earlier, it is hoped that international
actors could be convinced to reward such good con-
duct with aid and assistance and in turn create incen-
tives for national governments to support open report-
ing of disease epidemiology from the local to the
national level and from the national level to the inter-
national level. Therefore, I suggest that in order for
nations to possess the capability to gather such neces-
sary information, the international community must
help in providing additional resources that can be
devoted to collecting data, managing inputs, and coor-
dinating responses. Along these lines, one tangible
option that should be explored is to expand FluNet
capabilities in East and Southeast Asia. Countries
such as China, Singapore, Indonesia, and Thailand
only have one FluNet laboratory, a strikingly small set
of resources when compared with national network
capabilities in such places as Australia, Russia, Can-
ada, and the United States. Unfortunately, it is evident
that in the case of SARS, the disease hit hardest in
Michelson / DODGING A BULLET 383
areas where FluNet capabilities were weakest, and
there is the strong possibility that future such out-
breaks could follow a similar pattern (Heymann, 2003,
slide 4). It is hoped that if the international community
is devoted to building increased health capacities in
East and Southeast Asia, this mismatch between pub-
lic health capabilities, on one hand, and disease bur-
den, on the other hand, will be reduced.
Similarly, in conjunction with the idea that the
nations of East and Southeast Asia must develop better
health research competencies, GOARN must work to
systematically include more institutions and experts
from these regions in its own network. Although a list
of GOARN partners includes a number of organiza-
tions from outside East and Southeast Asia, there are
only a few from within these regions and none directly
representing China, Taiwan, Hong Kong, or Singapore
(Rodier, 2003, slides 9, 10). The problem is that SARS
and other diseases can tend to develop in locales where
FluNet and GOARN capabilities are scarce or nonex-
istent. Therefore, any subsequent monitoring and sur-
veillance attempts are hampered by a lack of capital,
manpower, and overall competency. If the WHO could
strengthen FluNet and GOARN capabilities in these
areas, then perhaps governments would be even more
inclined to report disease cases, because they would
actually possess increased means to deal with them.
The idea here is that because networks are only as
strong as their weakest link, the WHO must reinforce
FluNet's and GOARN's abilities in the vicinities of the
world where they are most in need.
Third, countries should be encouraged to develop a
plan of action that would be implemented in case of a
widespread disease outbreak. In particular, public
health officials need to focus on how local hospitals,
clinics, and care centers should be mobilized to treat
and deal with patients. As the WHO's SARS Prepared-
ness and Response Team (2003) mentioned in a pre-
sentation to the WHO Global Conference on SARS,
"many countries did not have adequate surveillance
mechanisms in place," and therefore, "there was a lack
of ability to analyze data for evidence based decision
making at national and sub-national levels" (slides 23,
24). To demonstrate the importance of such planning,
consider the situation, mentioned earlier, that occurred
on February 21, 2003: An individual infected with the
SARS virus entered a Hong Kong hotel and transmit-
ted the disease to other guests. Once some of these
guests became ill enough to seek care in a hospital,
they were admitted to eight different hospitals around
the city, thereby transmitting the disease to over 150
additional patients (Heymann, 2003, slide 12). The
suggestion here is that if the WHO could have helped
designate one hospital early on as a "SARS equipped"
hospital, then perhaps such high transmission rates
would have been avoided.
I argue that the WHO should encourage the stream-
lining of hospital admissions and the funneling of
patients with similar symptoms to a single magnet
hospital for a number of reasons. First, it would make
vaccine research and disease epidemiology easier to
accomplish, because such practices would pool a
larger number of cases together. Second, this sugges-
tion makes sense economically because it would only
require public health officials to fund, upkeep, and
maintain a single hospital to the high standards needed
to stop the transmission of such respiratory diseases.
Third, such a setup would allow that the most qualified
staff could be dispatched and distributed to this single
hospital, thereby ensuring that the greatest numbers of
patients would receive the highest level of care.
Finally, by creating a single magnet hospital to handle
emerging infectious diseases and, in particular, emerg-
ing infectious respiratory diseases in a given city or
country, the WHO would help quench the spread of the
disease as quickly as possible and therefore help guar-
antee that the disease will become less likely to spread
internationally. It is hoped that by creating such a mag-
net facility, East and Southeast Asian public health
officials will be able to more effectively handle the
surge of patients that occurs during an outbreak and
become more prepared to cope with infectious dis-
eases in general.
Finally, I contend that one of the key changes that
must take place before the WHO, and the world in gen-
eral, is forced to confront another emerging infectious
disease outbreak is that necessary information must
become even more targeted and focused on high-risk
individuals so that these groups can become increas-
ingly aware of how to identify signs of infection and
what to do in case such a situation arises. In particular,
because health care workers are at a high risk for con-
tracting such diseases--and because in the recent
SARS outbreak, transmission among health care
workers occurred more often and earlier on as com-
pared with the population in general--they must
receive training that helps them recognize symptoms
and be encouraged to report unusual cases to the
proper authorities. As Aileen Plant (2003, slide 11)
noted in a presentation to the WHO Global Confer-
ence on SARS, the early reporting of infection by sick
health care workers not only improves their chances of
384 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / October 2005
getting any potential treatment, but it can also act as a
significant indicator of the health status of the rest of
the population. The idea here is that health care work-
ers can serve as a first line of defense--as a starting
point--against infectious disease by working to cut
off transmission, always practicing medicine in a
hygienic manner and being continually aware of their
patients' symptoms.
Similarly, as I mentioned earlier, because more than
50% of the fatalities due to SARS occurred in individ-
uals aged 65 years or older, the elderly population
must be informed of their increased risk for experienc-
ing the most severe brunt of the disease (Heymann,
2003, slide 24). Perhaps part of the WHO's assistance
package for a country's accurate and timely reporting
of infectious disease information could be devoted to
funding public information campaigns that focus on
the elderly, and in particular on the elderly that live in
communal settings such as retirement homes. This
funding scheme would help remove some of the bur-
den of financing such costly measures from the coun-
tries themselves. Similarly, a nation should do all it can
to reduce transmission among elderly individuals,
because such a reduction in transmission rates would
not only save the lives of a number of people, but it
would also lower the costs associated with staffing and
supplying the magnet hospital discussed above.
Although the goal throughout this recommendation
section has been to develop a coherent set of options
that the WHO, the GOARN, and individual countries
could have implemented that would have helped
reduce the social and economic costs of the recent
SARS outbreak, the hope is that such changes might
come about in the near future so that the next epidemic
can be identified sooner, stopped earlier, and treated
faster.
Conclusion: Policy Success
and Preparing for the Future
While analyzing and discussing the policy choices
the WHO advanced in addressing the recent SARS
outbreak, one of the issues that has become clear is that
for better or worse, this organization had few options
or paths to follow. The novelty of the disease, coupled
with its ease of transmission and high cross-border
mobility, necessitated a rapid learning process that
involved networks and institutions working around the
world, and around the clock, to come up with accurate
epidemiological results, suggestions for public health
interventions, and perhaps a possible vaccine or
immunization. Because of these particular traits, the
WHO realized that the entire globe was truly at risk;
SARS could have been transmitted to many more
countries and affected many more people than it actu-
ally did. Without a doubt, it is important to re-empha-
size the notion that such a successful result was not
preordained or guaranteed. As the WHO's SARS Pre-
paredness and Response Team (2003) claims, a "high
level of leaders and commitment was crucial in imple-
menting strong and effective public health interven-
tions" (slide 21). The idea supported throughout this
article is that in addition to such strong leadership and
commitment, part of the reason why such a cata-
strophic outbreak did not occur is that the policies the
WHO did have the ability to choose--open communi-
cation of data, public reporting of information, and
suggestions to restrict air travel and nonnecessary
hospital admissions--went a long way in successfully
mitigating the effects of this disease.
Nevertheless, even when acknowledging such suc-
cess, a number of important and prescient lessons
emerged. For one, "the SARS experience has demon-
strated the need to stimulate very rapid, high-level
research to generate the scientific basis for recom-
mending sound control interventions" (WHO, 2003b,
p. 7). In other words, the gathering, compiling, and
coordinating of information needs to be viewed as a
public health intervention in and of itself, especially in
the context of an emerging infectious disease. For this
reason, organizations must make it explicit that their
policies include such qualities as frankness, open dia-
logue, and information sharing. As The World Health
Report 2003 states, the containment of SARS should
also be viewed as further "proof of the effectiveness of
GOARN in detecting and responding to emerging
infections" and that communication with at-risk
groups about epidemiological data and disease pat-
terns will play a central role in regard to how success-
ful scientific research can be conducted and managed
in the future (WHO, 2003a, p. 81).
Because as stated earlier, such openness was not
only valuable but necessary, SARS emerged as a
global disease. In short, it became evident that "the
responsibility for containing the emergence of [such a]
new infectious disease showing international spread
lies on all countries" (WHO, 2003b, p. 8). Of course,
more robust, well-established health systems, such as
those present in the United States or Canada, are sig-
nificantly more capable of dealing with such out-
breaks and have the financial and human resources
available to devote to such problems. Unfortunately,
Michelson / DODGING A BULLET 385
one of the more striking and glaring lessons demon-
strated in the SARS outbreak was that "poorer coun-
tries are [more] vulnerable . . . and [can] experience
harsher economic consequences when outbreaks are
reported" (Cash & Narasimhan, 2000, p. 1365). The
hope is that before the next outbreak occurs, the WHO
will be able to work with and educate the international
community, including national leaders, public health
workers, and at-risk populations, about how to prepare
and prevent further losses and reduce any residual neg-
ative effects from an as-yet-unknown infectious dis-
ease. In the end, that is what the SARS outbreak dem-
onstrated: that additional preparation for dealing with
emerging global infectious diseases is the key to pro-
tecting the world from another outbreak.
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Evan S. Michelson currently works as a research associate
in the Project on Emerging Nanotechnologies at the Fore-
sight and Governance Project of the Woodrow Wilson Inter-
national Center for Scholars. He has a master of arts in in-
ternational science and technology policy from The Elliott
School of International Affairs at the George Washington
University, a master of arts in philosophical foundations of
physics from Columbia University, and a bachelor of arts in
philosophy of science from Brown University. He recently
conducted science policy research at the Korea Science and
Engineering Foundation as part of the National Science
Foundation's East Asia and Pacific Summer Institute
program.
386 BULLETIN OF SCIENCE, TECHNOLOGY & SOCIETY / October 2005
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Retrieved April 1, 2004, from <uri xlink:type="simple">http://www.who.int/csr/outbreaknetwork/guidingprinciples/en/print.html</uri></citation></ref></ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Dodging a Bullet: WHO, SARS, and the Successful Management of Infectious Disease</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Dodging a Bullet: WHO, SARS, and the Successful Management of Infectious Disease</title></titleInfo><name type="personal"><namePart type="given">Evan S.</namePart><namePart type="family">Michelson</namePart><affiliation>George Washington University</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2005-10</dateIssued><copyrightDate encoding="w3cdtf">2005</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">The purpose of this article is to analyze the policy decisions made by the World Health Organization (WHO) in working to fight the spread of the first truly global infectious disease, severe acute respiratory syndrome (SARS), of the 21st century. In particular, the author pays attention to the WHO’s Global Outbreak Alert and Response Network (GOARN) and analyzes how it was employed in coordinating a variety of response efforts around the world. In addition, he identifies and assesses the successes and failures of the GOARN’s policies with regard to the monitoring and containment of the SARS outbreak.</abstract><subject><genre>keywords</genre><topic>World Health Organization</topic><topic>severe acute respiratory syndrome (SARS)</topic><topic>public health</topic></subject><relatedItem type="host"><titleInfo><title>Bulletin of Science, Technology & Society</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">0270-4676</identifier><identifier type="eISSN">1552-4183</identifier><identifier type="PublisherID">BST</identifier><identifier type="PublisherID-hwp">spbst</identifier><part><date>2005</date><detail type="volume"><caption>vol.</caption><number>25</number></detail><detail type="issue"><caption>no.</caption><number>5</number></detail><extent unit="pages"><start>379</start><end>386</end></extent></part></relatedItem><identifier type="istex">58E331AFEC38591A0D92B072A7D9FD49E33906A9</identifier><identifier type="ark">ark:/67375/M70-DLRRG7K2-9</identifier><identifier type="DOI">10.1177/0270467605278877</identifier><identifier type="ArticleID">10.1177_0270467605278877</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/ark:/67375/M70-DLRRG7K2-9/record.json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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