Sars and poverty – the missing argument

Robert Walgate
1 May 2003

The western media complain that the outbreak of Sars, the new pneumonia from China, is overplayed because of its few cases and deaths. As of 29 April there were 5462 cases and 353 deaths, according to the World Health Organisation (WHO) statistics. (For most recent information see here). But the real reason for WHO’s original Global Alert on the outbreak on 12 March remains almost unreported.

The great remaining concern is not for the jet set and countries with adequate health systems, but for what would happen if the virus gets loose in the poorest developing countries.

A Vietnamese success story

When WHO put out the first alert “we were extremely worried”, said Julie Hall of WHO’s Global Alert and Response Network. “That was why we put out the alert”, she told me. “People say, so few people have died, why worry? But that completely underplays its potential. Its potential – as we saw in Vietnam – is that when it gets into a hospital, within a week half of the health staff are sick. It can decimate health care systems in no time at all.” In a poor country that can be devastating, and its health system could soon be overwhelmed.

Klaus Stöhr, a WHO virologist and its chief scientist on Sars, said on Tuesday 29 April in a teleconference from Geneva that while laboratories and companies are seeking vaccines and treatments “we do believe that it will be much less costly, it will mean much less death and disease for the next five, ten, hundred years, if we are capable of dealing with this disease now.” This is our one-off chance to get rid of this disease, he said. “We don’t need another pathogen floating around. We have enough to do with TB, Aids, malaria, other upper respiratory tract infections, diarrhoea, and so on.”

Vietnam, where WHO scientist Carlo Urbani first warned the world of the disease and later died of it, has since managed to get a grip on its outbreak, with a total of just sixty-three cases and five deaths, but it may not be typical among developing countries.

In Vietnam the government quickly agreed to hosting an international expert task force – unlike China, which delayed such an invitation disastrously – and, with support at the highest political level, enabled excellent collaboration between the government, the task force and WHO.

“So we were able very quickly to put in the measures needed to contain the outbreak,” said Pascale Brudon, one of the experts involved, in a call from Hanoi. “First, we put in complete and aggressive control measures in the two Hanoi hospitals affected – in one where health workers and patients had been initially infected, and in another that the government had identified as an isolation hospital for additional patients. And second, the government established a very active case detection system, not only in Hanoi but also in the countryside. The measures were “extremely appropriate” the expert said. “We can see the results today with the outbreak contained.”

Aileen Plant, WHO representative in Hanoi, said controlling Sars is mainly about identifying cases early, working out what their contacts have been, and following up the contacts to ensure that if they develop the disease in their turn, they do not infect any other people. “It’s all about good surveillance and a plan of action for when a case does occur,” said Plant from Hanoi. “The government gave us very high-level support, we had access to the Minister of Health and key bureaucrats through the whole outbreak, with public acknowledgement and early coverage in the Vietnamese press.” Moreover this response took place in the face of health staff getting the disease and some of them dying, but the health system kept fighting, Plant said.

According to Pascale Brudon, “the response was mainly due to the ongoing extremely good relationship between WHO and the government, and the fact that Carlo Urbani himself was highly appreciated in the Ministry of Health. So when we discussed with the government they quickly understood this could be potentially very negative for Vietnam.”

A spreading concern

But Plant said Vietnam was unusual among developing countries in being able and willing to muster such a response. “I think we have to say it’s special to a large extent because we have seen such excellent cooperation – and in other countries it will vary enormously how much this happens.”

Next door in China, authorities were extremely reluctant first to admit the existence of the disease, and then to allow in international experts to review the situation, with the result that China alone now has more cases than the rest of the world put together, with 3469 cases and 159 deaths announced by 30 April. In Beijing alone, nine hospitals now deal exclusively with Sars patients. Just outside Beijing, a 1000-bed complex has been built to accommodate incoming patients, and health authorities say that the Sars outbreak could overwhelm the city’s already crowded hospitals.

Moreover the disease is moving into western China, rural areas where less than one in five people can afford to go to a doctor and the health system is crumbling. The quoted mortality from Sars – now said to be 6% – is for countries and situations where all critically ill patients can get intensive care and oxygen. Some experts believe it will be much higher – 10-20% in areas poorly served in that respect.

I talked to a Nepali doctor – whose country borders western China through Tibet – and she expressed enormous concern that the disease would reach her rural people, where “it’s rugged and mountainous, there’s no good road access and you have to get there by plane.” There are still people coming in from Tibet, she said, and families have many cross-border connections.

And south of Tibet lies India, with nearly as big a population as China (around one billion), and a creaking partly privatised health system. So far India has only announced one case. But supposing cases begin to cross borders carried by ordinary, poor folk rather than travelling by jet? Then there is Africa, where the interaction of Sars with Aids – no doubt a deadly cocktail – has yet to be tested. WHO is desperate to clamp down on Sars before it reaches there. That is the tragic scenario that we are trying to stamp out, and why “only” 353 deaths matter so much.

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