On November 16, 2002, physicians at the First People’s Hospital, in the Shunde district of Foshan City, in the southern province of Guandong, China, reported an unusual case of severe pneumonia. A few days previously, a local farmer had been admitted the hospital complaining of a high fever and a dry cough, and had died soon after. Though no one knew it at the time, this was the first reported case of the first major new disease of the 21st century: SARS.
A month later, the second case was reported about 200 km away, in the city of Heyuan, also in Guandong, and in the following three months, more than 300 cases were reported across the province, many of them lethal. Amazingly, long before the outbreak had spread even this far – and months before it became an issue of worldwide public concern – an organization on the other side of the planet was already sensing the danger. Canada’s Global Public Health Intelligence Network, or GPHIN, had been set up just a few years before the outbreak as an electronic global health observatory, monitoring the Internet and other global electronic media for signs of potential disease outbreaks or other health crises around the planet. Twenty-four hours a day, seven days a week, GPHIN’s software scans tens of thousands of digital sources in eight languages for the first hints of trouble.
On the 27th of November – just 11 days after the first reported case – GPHIN picked up reports of a “flu outbreak” in China and sent them on to an equally remarkable organization called GOARN, the Global Outbreak and Alert Response Network. GOARN is a global network of more than 120 public health surveillance and response organizations operated by the World Health Organization. Each year, it identifies and coordinates responses to more than 50 public health outbreaks around the world – but SARS was the first new outbreak GOARN had to contend with which started spreading rapidly and internationally. In many ways, SARS shared features of both the pathogen that killed Jamaica’s urchins, and the contagion of uncertainty that spread through the financial network: it was fast, lethal, easily transmissible and on the move.
During the global SARS containment effort, GOARN proved invaluable, linking together some of the world’s best virologists, epidemiologists and other public health experts in a worldwide collaborative network that shared what was being learned about what caused SARS, how it was transmitted, and where it was likely to go next, all in real-time. This in turn enabled the World Health Organization to offer specific, up-to-date, scientifically informed guidance to governments and to the public directly about how to best prevent the spread of the illness as it was unfolding.
Nowhere were these communications better implemented than in Singapore. SARS had arrived there in February 2003, carried by a 26-year-old woman returning from a vacation with several friends in Hong Kong. There, she had a chance encounter in the elevator of the Metropole Hotel with an infected physician, a respitory specialist from southern China who was there to attend a wedding. The doctor (who became too sick to attend) acted as a ‘super spreader’, passing the illness not only on to her, but also to seven other international guests who were staying on the same floor of the hotel – perhaps by something as innocuous as leaving trace amounts of the virus on an elevator button. It was a crucial, silent and disastrous moment in spread of the disease, as two of these fellow hotel guests later carried the virus back to their home countries of Vietnam and Canada, initiating its spread there, while the young woman, unwittingly, brought it back to Singapore.
Between arriving back home and being admitted to the hospital on March 1st, 2003, the young woman infected at least 20 others over a period of several days. Then, once in the hospital, she infected one of her doctors, nine nurses, and nine of the approximately 30 family members and friends who visited her – all before her SARS was diagnosed. The disease subsequently spread to four other healthcare institutions and a vegetable wholesale center. Starting with this first case, during the period between March and May 2003, 238 probable SARS cases and 33 deaths were reported across Singapore. As the virus spread, so did public panic.
Singapore’s response to the emerging threat was an all-out, national effort, intended to be as comprehensive and as swift as the disease itself. Once it was clear that the infection was capable of spreading rapidly in hospitals, a single medical facility, Tan Tock Seng Hospital, was designated as an isolation hospital for SARS patients. All departing and arriving passengers at Singapore’s airports and seaports were given temperature checks to detect possible cases. Taxi and bus drivers were similarly checked, and public transport operators displayed stickers to indicate that the drivers had been checked and were not infected. All schools in the country were closed for ten days. Home quarantine was established for more than 6000 people known to have come into close contact with a SARS infected person; quarantined citizens had webcams set up in their homes and were called randomly during the day to ensure their compliance with the measure. The employment law was amended to ensure that quarantined citizens were compensated, alleviating economic pressures on those forced to stay at home; when a new case was discovered, a team of 100 trained “tracers” tracked down every person that the infected person might have come in contact with, from family members and neighbors to business colleagues and even local vendors on their commute to work, and placed in quarantine as well.
Singapore’s all-out response to contain the disease drew widespread praise from institutions from the World Health Organization to the World Bank, but international press coverage also suggested that the country’s success was due, at least in part, to its government’s ability to clamp down repressively on its citizens. Time Magazine’s reporting was characteristic, noting that Singapore “ruthlessly nipped its SARS problem in the bud with draconian quarantine measures.”
Yet the truth, according to according to Dr. Peter Sandman and Dr. Jody Lanard, crisis communications experts who closely followed Singapore’s response, was just the opposite. Singapore’s successful response to SARS rested not on repression, but on its near pitch-perfect use of public communications throughout the unfolding emergency.
In a crisis, the first challenge is to establish trust, and that means not sugar-coating the truth. “The most important risk communication recommendation during an evolving crisis is to avoid over-reassurance – in fact, to err on the alarming side rather than risk falling into over-reassurance,” writes Lanard. “This may well raise public anxiety in the short term, but it reassures the public in the long term that leaders are going to be honest with them. Paradoxically, over-reassuring statements tend to generate distrust – especially when the statements turn out wrong.”
As SARS panic spread across the country, Singapore’s prime minister at the time, Goh Chok Tong, said publicly that SARS could possibly become the worst crisis Singapore had faced since independence. When asked by a journalist if he was being alarmist, Goh responded: “Well, I think I’m being realistic because we do not quite know how this will develop. This is a global problem and we are at the early stage of the disease. If it becomes a pandemic, then that’s going to be a big problem for us … At the moment, I’d rather be proactive and be a little overreacting so that we get people who are to quarantine themselves to stay at home. The whole idea is to prevent the spread of the infection.”
According to Lanard, “Prime Minister Goh was illustrating an important outbreak communication principle, which is well-supported by the social science literature: Don’t aim for zero fear.” In a public health crisis, some fear is appropriate. And as long as it’s appropriately controlled, it helps. After the epidemic subsided, data suggests that Singaporean citizens who were more anxious took more recommended SARS precautions than those who were less so.
The Singaporean government also told its citizens what to expect – that this was an unprecedented situation, and that things would not return to normal for quite some time. This, according to Lanard, allowed people to emotionally rehearse for a wide variety of possibilities and get used to what might happen.
Just as importantly, when difficult choices confronted the government, Goh and his cabinet held public meetings to involve the public in key decisions. Lanard points to one example involving the most difficult part of the response: the quarantine. “People got angry about quarantine violators, particularly a man who went to a local bar waving his quarantine order in the air, and bragging that he was supposed to be at home. The Prime Minister and other officials held public meetings where they posed the dilemma of posting the names of those under quarantine order, rather than keep them confidential on medical grounds. After much discussion, they would ask for a show of hands, pro and con regarding revealing the names. The newspaper ran opinion polls on the issue. The public usually stated that they wanted other people’s names published – but not their own, if they were quarantined! Ultimately, the names were not posted. And all during this period, volunteers were taking food to the quarantined families, providing them with cell phones – and making sure they were home.”
Such responses demonstrated the government’s respect for the public’s feelings, and made them stakeholders in critical choices, building deep trust between citizens and the public health authorities. Post-outbreak surveys suggested that Singaporeans’ belief that they could communicate openly with their government was one of the most important contributing factors in their compliance with SARS precautions.
Consider how very differently a crisis like the global financial meltdown of 2008 might have turned out if financial ‘listening posts’, like GPHIN, had been established to scan constantly for the earliest signs of potential imbalance; and if they were jointed to a coordinated network of globally empowered regulators, like GOARN, which could suggest and coordinate appropriate interventions. Political leaders, empowered with much better data about what was happening, would have at least the opportunity – if not necessarily the skill or motivation – to communicate with the efficacy of Singapore’s leaders, and to bolster the resource which was the crisis’ first casualty: trust.