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Coping with SARS

May 8, 2003 at 12:00 AM EST
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RAY SUAREZ: To discuss the questions posed by the SARS virus are: Marilyn Chase, a health reporter for the Wall Street Journal and the author of The Barbary Plague: The Black Death in Victorian San Francisco; Dr. Jeffrey Koplan, the former director of the Center for Disease Control and a vice president at Emory University; and Dr. Howard Markel, the director of the Center for the History of Medicine at the University of Michigan. He’s the author of the upcoming book, When Germs Travel.

Dr. Markel, give us an overview, if you will, of the different kinds of responses to the outbreak of SARS, the different kinds of countries and different kinds of societies had, and did it lead to different outcomes?

DR. HOWARD MARKEL: Well, in some ways, if you were designing a course called Epidemics 101, you’d find a lot more similarities of how this epidemic mirrors other epidemics in the past.

The sudden rise of a disease from nowhere, its easy transmission, one nation that obscured its details, global travel — as long as people have been traveling, so too have germs, scapegoating — as you just heard about Berkeley, the University of California, intense media coverage, calls for quarantine and so on.

Most disturbing are the disproportionate levels of panic that are attributed to SARS or the sudden epidemic compared to the scourges that kill us every day. But there are, of course, differences between different countries — different countries like China, where it’s not a very transparent society, it’s a rather oppressive regime — were more likely to obscure cases back in November and December, which would have allowed us to get a better handle on that disease.

In Vietnam, for example, they very rapidly ordered a quarantine and they seemed to have contained it. Even in Canada, where there were quarantines a week or so ago, it was more of a voluntary effort. In fact, they were just saying on your report that they’re asking people to stay at home if they are sick.

So you can never separate in an epidemic how it unfolds in each national context or each culture.

RAY SUAREZ: Dr. Koplan, as Dr. Markel mentioned, this disease arrived in many places by plane.

Did it sort of leapfrog ahead of a world where there are national health systems and city boards of health and county boards of health?

DR. JEFFREY KOPLAN: Well, again, it’s nothing new of travel of epidemics or infectious diseases by various means of travel.

Quarantine began in Venice when ships came with infected passengers and they were kept out of the city for 40 days of quarantine. So that’s not really new.

I think the threat, though, as you describe it, is going from countries with relatively strong public health infrastructures to places that have much less in the way of both health care and public health where diseases can spread more quickly, outbreaks can be unrecognized, and they can pose problems both to themselves and their neighbors, and their neighbors are every other country in the world.

RAY SUAREZ: Marilyn Chase, though there have been no deaths in the United States, this is not territory that is completely unknown to American history, is it?

MARILYN CHASE: Not at all. In fact, 100 years ago in San Francisco, there was the first epidemic of the 20th century, which met with very similar range of human responses.

RAY SUAREZ: How so? Tell us a little bit more about the Barbary Plague.

MARILYN CHASE: Well, in 1900, a coal-fired steamship, called the Australia, made its way into the port of San Francisco carrying in its hold some passengers, some mail and some infected stowaways, which were rats. And the rats crept into Chinatown where they began spreading the disease through flea bites to the citizens of Chinatown. What resulted there, similar with what we originally saw in southern China, was a cover-up by politicians who wanted to save face, who wanted to preserve trade and tourism. And the results, predictably, were a deeper epidemic.

RAY SUAREZ: And, also, at least at the beginning, a racialized face to a disease?

MARILYN CHASE: Absolutely. In that day, the media were not above blaming Asian people for fostering the disease, although they were its victims. In addition, the police of San Francisco enacted a racially focused quarantine around Chinatown, and the arbitrary display of police powers prompted predictable protests and lawsuits, even riots.

RAY SUAREZ: Dr. Markel, talk a little bit more about that tug-of-war between… that you heard about the resistance there in San Francisco to police presence to try to restrict people’s movements.

It may be in their own good as it’s explained to them, but it’s not something that people are often happy with.

DR. HOWARD MARKEL: Well, you know, you really hit it right on the head. There’s always a tug-of-war in public health between the needs of the many and the needs of the few: The civil liberties of those who are ill or suspected of being ill and those who are charged with protecting the public health of a community. In fact, that’s the oldest law in public health.

And it’s a very difficult tightrope to walk. And certainly San Francisco in 1900 was not the first and sadly not the last where a certain group was scapegoated.

It’s a very unsavory combination when you have a contagious, frightening disease that’s easily spread and a so-called socially undesirable group. For example, in 1892 there was a worldwide cholera pandemic, and that was blamed largely on Russian Jewish immigrants coming into New York City that year.

And President Benjamin Harrison ordered a 20-day quarantine law for all Russian Jews, but not other immigrants coming on the same ship. We can find other examples certainly before and certainly since. HIV/AIDS comes to mind where gay men and intravenous drug users in the early ’80s were scapegoated as the cause or source of that epidemic.

And I do worry about Chinese in particular and Asians in general being scapegoated for the SARS epidemic that we’re experiencing being right now.

RAY SUAREZ: Dr. Koplan, in addition to being a physician, you’re an administrator at a large university with a large international presence. What kind of discussions have you had at Emory about how to handle the influx of international students?

DR. JEFFREY KOPLAN: We’re going to handle them by welcoming them no matter what country they come from. We have students coming in next week from other parts of the world, including some in which there’s transmission of SARS. We believe there’s a rational public health approach to take in this. It’s very similar to what’s been going on at airports and at customs stations already — which is if, one, the rational issue is if you’re sick, don’t travel, don’t go to work, as was expressed earlier, as well.

And our view is that we’re accepting students based on their intelligence, their performance and their responsibility, and that will come into play in their ability to identify themselves as ill or not ill, and they’ll behave responsibly. We’re here to help them if they should come here and get sick. We’ve got facilities and people prepared to help them, should that happen.

But let’s keep in mind that in many of these places — China has a population of over a billion people and does have several thousand that are ill and does have ongoing transmission, and it is a problem — but I still think the appropriate public health response and certainly that of our academic community at Emory is to treat it in a rational, non-fear based and non-xenophobic manner.

RAY SUAREZ: Marilyn Chase, for their part, what are administrators at Berkeley saying about why they’ve chosen the path that they have?

MARILYN CHASE: Well, the administrators of U.C. Berkeley have said that they were expecting in under three weeks an influx of approximately 500 students from SARS-affected countries.

The university said it was not prepared to monitor these students, to isolate these students and to care for these students should they become ill, in addition to their obligation to protect the thousands of other regular Berkeley students. So they have chosen to tell these students that they should not come to summer school.

There’s been some dismay, obviously, by some members of the Asian community as well as some top-level state public health officials who are a bit dismayed and a bit concerned obviously about the potential for this to snowball. But U.C. has said it’s working with CDC to set up proper procedures and facilities, and that it will be ready to receive all students for the fall term. So we’ll have to stay tuned.

RAY SUAREZ: Well, right now there isn’t a diagnostic screen, is there, a blood test or some way that you can prove you don’t have SARS or aren’t incubating it?

MARILYN CHASE: That’s correct. CDC is working day and night to perfect diagnostic tests that would include antibody tests as well as gene-based tests called PCR. But these tests have to be calibrated and checked against a broad cross- section of blood samples from a number of SARS patients to make sure that they’re checking for the right biological targets and so that the tests perform optimally in the field. And this hasn’t been perfected yet as a result of which the tests haven’t been deployed widely.

RAY SUAREZ: Dr. Markel, if we look out from today, 7,000 infected, just over 500 dead, and look at the ways that some of these societies where SARS has taken root are coping, is the story from now on about how they respond really one of duration, that the pressure will be eased by a quicker response to this?

I mean, in one Chinese province they’re suggesting that people no longer shake hands but bow. In another province, hotels are posting signs that say that they don’t allow anybody from Beijing to stay at the hotel in order to reassure their guests. Is really a quick resolution or at least a shorter one what takes the pressure off finally?

DR. HOWARD MARKEL: Well, I think that’s classic epidemic behavior, too, that panic rises with the number of cases that rise.

Let me put it to you this way: Corona viruses, which is the cause of the SARS epidemic tend to like cold weather and most likely will go dormant — the term burn itself out is not as accurate but won’t be as widespread as the summer months continue, although most experts predict that it will probably return next winter.

But if we were to have this conversation eight or 12 or 14 weeks from now, if I called you and I said, “I’d like to go on the show and talk about SARS,” you’re likely to say, SARS? That happened already; that was several weeks ago.

And it’s not just the media. It’s normal human behavior. The hue and cry of an epidemic, the panic “we’ve got to do something” the calls for action, are greatest as those spectacular cases are on the rise. What’s truly problematic is once that goes down, so too does our interest in all the infectious diseases that kill us on a daily basis.

RAY SUAREZ: Well, let me go quickly at that point to Dr. Koplan then, because if what Dr. Markel says is true, how should public health professionals be laying the groundwork for this dormancy period for public attention to go down and be prepared for perhaps a springing up again of this virus when the weather starts to get cold again?

DR. JEFFREY KOPLAN: Well, if I could preach Dr. Markel’s point, it’s not just public health officials. Public health officials have been trying to prepare for this for decades with grossly inadequate support, funding and resources. And I think the point Dr. Markel was making is we get worked up and concerned about this in the face of an acute threat, and then as that threat diminishes, so does our level of support and interest and we move on to something else.

It would behoove us to take this threat very seriously. And even if it does wane over the summer months it is a warning and we better listen to it, because if it’s either going to be this corona virus or the flu pandemic or something else, that argues for us to strengthen our public health system, and that strengthening means more epidemiologists in county health departments, in state health departments, better lab facilities, better communications. And we’ve underinvested in it, and we need to get on the stick and do it and do it soon.

RAY SUAREZ: Dr. Koplan, guests, thank you all.