Severe Acute Respiratory Syndrome (SARS): The International Response

CRS Report for Congress
Severe Acute Respiratory Syndrome ( SARS):
The Intern ational Response
Foreign Affairs Analys t
Foreign Affairs Analys t
Fo reign Affairs, De fense, and Trade Division

Congressional Research Service ˜ The Library of Congress

Severe Acute Respiratory Syndrome (SARS):
The International Response
Severe Acute R espiratory Syndrome (SAR S ), a n ew hi gh l y i n fect i ous di sease,
was first identified b y t he W o rld Health Organiz ati on (W HO) in February 2003.
While the overall number of c o n f i r med cas es is not high by comparison with
st at i s t i cs for ot her i nfect i o u s d i s e a s es, t he di st ance and s peed wi t h whi ch S AR S
spread raised an al arm over t he potential risks to international public health.
Containment appears t o b e working; howe v e r, t here are fears t hat another S ARS
outbreak could t ake p lace during t he re gu lar i nfluenz a season later i n 2003.
The United S tates was instrumental in the global effort to contai n t he spread of
SARS. Affected countries responded i n d i fferent ways . S ingapore and Taiwan acted
quickly and enco u r a g e d international support i n curbing the s pread of the v irus.
China, on the other hand, has been criticized for down-playing t he magnitude of the
problem, p articularly in the early phase of the d isease. This, s ome analysts contend,
ultimately enabled t he virus t o cross borders and i n t he cas e of C anada, hemispheres.
This report t akes a retrospective l o o k a t the global response b y W HO and b y
those countries most affected. It reveals s ome o f t he challenges that may lie ahead
for t he gl obal h ealth community, s uch as global i nterdependence and transparency,
surge capaci t y, m anagem ent o f publ i c fear and i nform at i o n d i s cl osure, coordi nat i o n
of different national responses, and lack of funding. Ex amining t he impacts of S ARS
and l essons learned m ay be useful in the response t o future outbreaks o r i ncidences
of new d iseases. This report will not be updated.

Background ......................................................1
In ternational R esponse ..............................................1
OverviewoftheRoleoftheWorldHealth Organization ...............2
WHO’sGlobalHealthAlertSystems ..............................3
The Global Outbreak Alert a nd Response Network (GOARN) ......3
The Global P ublic Health Intelligence Network (GPHIN) ..........3
TheGlobalThreat ofSARS ......................................3
W HO’s R esponse t o S ARS ......................................4
SARS andInternationalHealthRegulations .........................6
OverviewoftheInternationalHealth Regulations .................6
TheFifty-Sixth WorldHealth Assembly .......................7
Country Responses to SARS .........................................9
Chinaand HongKong ..........................................9
Taiwan .....................................................12
Vietnam ....................................................13
Singapore ...................................................15
Canada .....................................................16
Congressional R esponse ...........................................18
Infectious DiseaseMonitoring ...................................18
CapacityBuilding ............................................18
Im proving U.S. Response C apability ..............................19
FutureChallenges ................................................19
GlobalInterdependenceand Transparency .........................19
DevelopingSurgeCapacity .....................................20
PublicFearandInformationDisclosure ...........................20
National R esponse ............................................20
In adequate Funding ...........................................21

Severe Acute R espiratory Syndrome
(SARS): The International Response
Severe Acute R espiratory Syndrome (SARS), a n ew, h igh l y i n f e ctious viral
diseas e, was first id entified by t he World Health Organization (WHO) in February
2003. It is beli e v e d to have had its begi nnings i n C hina’s Guangdong Province i n
November 2002. A respiratory disease t ha t cau s e s f l u - like s ym ptoms which may
progress to pneumonia, SARS has an average fatality rate o f 15%. Bet ween
November 2002 and J uly 2003, a t otal of 8,437 cases and 813 deaths were reported1
W h i l e t he overall numbers are not high by comparison with other s eri o u s
i n fect i ous di seases, t he speed and d i s t ance w i t h whi ch S AR S s pread rai s ed an al arm
over t he pote n t i a l risks to international public health. C ontainment appears t o b e
working; however, t her e a r e fears t hat another S ARS outbreak might take place
during t he regu lar i nfluenz a season lat e r i n 2003. This report reviews the global
response b y W HO and t hose countries most a ffected. It also ex amines the challenges
that may lie ahead should another outbr eak of SARS (or another unknown i nfectious
di sease) occur. 2
International R esponse
S i nce l at e February, when W HO fi rst i d ent i fi ed t he out break of what l at er
became known as t he S evere Acute R espiratory S yndrome (S ARS ), it has p layed a
key role i n t he gl obal response t o t he disease. SARS i s a s triking ex ample of the
risks t o i nternational public health posed by such infe c t ious diseases. It also
high lights t he need for appropriate mechanisms of containment, parti c u l a r l y as
gl obal t ravel h as become t h e p rimary means o f s preading t he disease around the
Following its i n i tial assessment, WHO m ade contai nment of S ARS its main
goal. “Despite the lack of understanding about the diseas e, its cause, and future

1 For a full discussion of the medical backgr ound to SARS and t he U.S. response s ee CRS
Report RL31937, Severe Acute Respiratory Syndrome (SARS): Public He alth Situation and
2 Other s ources are e xami ning the SARS outbr eak, f or example, J .M. Dr azen, “ SARS —
Looking Back over the First 100 Days ,” The New England Journal of Me d i c i n e , J uly 24,


evolution, the n eed was great to introduce a s eries o f emergency measures to contain
S A R S out breaks i n t he affect ed areas and p revent further i nternational s pread, t hus
reducing opportu n ities for the new disease to establish itself.”3 Although W HO’s
representative i n C hina, Henk Bek e d a m , r e p o rtedly s aid o n J une 5, 2003 that the
out break of S A R S had reached i t s peak w o r l d w i d e, 4 W HO continues t o s tress t he
importance of s ustaining international public h ealth measures against S ARS and
working t owards eliminating i t a s a public health threat. The SARS outbreak may
reveal valuable lessons about the effectiveness o f W HO’s s urveillance and response
systems, and its capacity to respond to similar outbreaks i n t he future. Ex amining t he
evolution of S ARS also demons t r a t e s t h e chains of t ransmission and role of t he
W HO i n responding to unfolding events.
Although W HO led an unprecedented global collaborative effort to contain
S AR S , t he U.S . C ent ers for Di sease C ont rol and P revent i o n (C DC ) al so pl ayed a k ey
role in the global partnership. For more information on t he role of the C DC in
relation t o S ARS, see CRS Report R L31937, SARS: Public Health Situation and U.S.
Over vi ew of the Rol e of t he Wor l d Heal th Or gani z a ti on
The W orld Health Organiz ation (W HO), established i n 1948, is the U.N.
system ’s authority on international public health issues . It assists governmen t s i n
improving national health services and i n establishing worldwide s tandards for foods,
chemicals, and b iologi cal and pharm aceutical products. W HO concentrat e s o n
prevent i v e rat her t han curat i v e p rogram s, including efforts t o eradicate endemic and
other widespread diseases, s tabilize population growth, improve nutrition, sanitation,
and m at ernal and chi l d care. W H O w orks t h rough contracts with other agencies and
pri v at e v o l u n t ary o rgani z at i ons. T he Uni t ed S t at es h as been a m em ber o f W HO
The W HO policy m aking body is the W orld Health Assembly, composed of all
192-member states. It m eets annually in May t o d ecide the overall direction o f t he
Organiz ation and the general program for a s pecific p eriod, and t o adopt the t wo-year
budget. Decisions are m ade b y m ajority vote, ex cept for decisions on the budget that
require a t wo-thirds vote. There i s n o veto p rovision. The Assem b l y e l e c t s t he
Director General as well as t he 32 member states who d esignate persons to serve o n
t h e E x ecut i v e Board. T he Ex ecut i v e Board m eet s t wi ce a year t o revi ew t h e w ork o f
W HO i n m ore d et ai l and prepares i ssues for consi d erat i o n b y t he Assem b l y. T en t o
t w el ve m em b ers o f t he Board are repl aced every year. T he Uni t ed S t at es h as been
a m ember o n t he Ex ecutive Board three out of every four years.

3 W HO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons
for t he Immediate Future. WHO: Geneva , M ay 20, 2003.
4 United Nations Foundation, “SARS: WHO Declares Outbreak ‘Over its Peak.’” J une 5,

2003. [ UNWire/20030605/34097_story.asp]

WHO’s Global Health Al ert Systems
The Global O utbreak Al ert a nd Response Netw ork (G O ARN). In
April 2000, W HO formally established the Global Outbreak Alert and Respo n s e
Network (GOARN) which b rought together 112 institutions and n etworks o f p eople
and t echnical resource s t o r e s pond to dis ease outbreaks o f i nternational concern.
T h i s gl obal h ealth security network p rovides not only an operational framewor k ,
drawing on dat a, ex pertise, an d skill, but al so aims to standardize t he international
response. 5 It relies o n its partners and agreed st andards o f p ractice i n responding to
potential t hreats, which m ay include e m e r gi n g diseases and t he intentional u se of
biological agents. In four years, between J anuary 1998 and M arch 2002, GOARN6
ex amined 538 such cases in 132 countries.
The Global P ublic Health Intelligence Netw ork (GPHIN). WHO also
relies on the Global Public Health Intelligence Network (GPHIN), which is a
cust om i z ed search engi ne t h at t racks Int ernet com m uni cat i ons. T hi s s ys t em p roved
t o be very useful i n pi cki n g u p t el ecom m uni cat ed al ert s i n C h i n a. The s ys t em i s al s o
useful to WHO i n clarifying or refuting i nformat i on that may creat e disruption or
panic. Other t ools i nclude geogra p h i c a l mapping technology and an event
management and t racking s ys tem t hat provides an overview o f operations.
The Gl obal Thr eat of SARS
It was cl ear t h at S A R S present ed a seri ous gl obal t hreat . Lack o f i n form at i o n
about the cause and evolution o f t he new d isease m ade its potential impact unknown.
W HO concluded t hat t h e v i rus comes fro m a strain likely t o i nclude frequent
mutations and links to animal s pecie s , w i t h implications for t he likelihood of
establishing endemicity an d underlining t he importance o f finding the m eans t o
cont rol o r cont ai n i t . S everal fact ors w ere d eem ed cri t i cal i n t h i s anal ys i s :
! The s ym ptoms are non-specific and common;
! The s ym ptoms can be se v e re and s ome p atients require intensive
care for respi rat ory fai l u re;
! The d i s ease s preads easi l y from one l o cat i o n t o anot her v i a ai r t ravel
as demonstrat ed in transmission patterns from t he initial outbreak in
Asia to other regions, s uch as North America and Europe;
! There i s n o v acci ne or t reat m ent yet avai l abl e and di agnost i cs t est s
are of limited use. A number of antiviral s are not effective;
! The caus a t i v e agent is not well understood, so the potential for
continued s pread remains;
! C ert ai n cases m ay cont ri but e t o t he rapid s pread of infection;
! Hospital s taff, who are a v i t a l l i n k t o t he control o f i nfection, are
disproportionately affected as are o ther close contacts of the patients;

5 For more i nforma tion on t he Global Out break Alert a nd Response Net w o r k, s ee:
[ h t t p : / / www.who.i nt / c sr / out br eaknet wor k] .
6 W HO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons
for t he Immediate Future. WHO: Geneva , M ay 20, 2003, p. 4.

! The d i s ease requi res i nt ensi ve t reatment in isolation and is a burden
on health care systems.7
By com p ari s on t o S A R S , ex cept i n t he case o f H IV / A ID S , ot her n ew di seases
t h at have em erged i n t he l ast few d ecades have not present ed t he sam e com b i n at i o n
of factors t hat pose s uch a heavy global risk t o i nternational h ealth. S ome o f t hese
diseases have not sustained s trong human-t o-human transmission, others have relied
on food or a vect or (such as m osquitos) for t ransmission, and s till others have had an
identifiable, often contai nable, geographic l ocation.
WHO’ s Response t o S ARS
Once the s everity of the d isease was recogn iz ed, i n February and March 2003,
WH O t ook aggressive action. Ex amining t he factors outlined above and t he
chronology o f events unfolding in China, Hong Kong, Vietnam, and Tor o nto, it
identified i nternational t ravel as a primary means of s preading t h e v i ru s . It al so
concluded at t he time that some people might be highly infectious , o r “ s u p er
s p r e a d ers”. Identifyi ng these i ndividuals could be critical to the control of t he
di sease. 8 On March 15, 2003, W HO i ssued emer gency t ravel recommendations as
a global alert and response t o i nternational t ravelers, h ealth care p rofessionals, and
border authorities. Later i n M arch it recommended s creening passengers at airports
coming from areas with recent l ocal transmission and gave advice to airlines on
appropriate procedures if a case was suspect ed duri n g fl i ght . In A pri l and M ay, o n
several o ccasi ons, t he W H O i ssued i t s m o st st ri ngent travel advisories recommendi ng
the postponement of all but essential t ravel t o areas considered high risk for S ARS,. 9
W H O a l s o quickly moved t o s et up systems for — and increase awaren e s s o f
the need for — immediat e i solation and quarantine of t hose with or suspect ed of
having SARS. In addition, it began t he detailed work of contact traci ng to find the
source of the s pread. T hese procedures al ong with simple diagnostics and screening
all contributed to the ongoi ng containment effort.
The response t o S ARS p laced heavy d emands on W HO and its GOARN
partners. T i m e was v ery m uch o f t he essence. W HO pulled t ogether a
comprehensive n etwork, i ncluding m obilizing a response on t he ground, providing
resources and s upplies, monitoring and repo r t i ng, and es tablishing scientific and
m edi cal col l aborat i on. The W HO i ssued t ravel p r o c e d ures t o prevent and m anage
probable cases of SARS. 10 It es tablished a collaborative m ulti-center res earch project

7 T he eight bullet points are drawn from a discussion in Severe Acute Respiratory Syndrome
(SARS): Status of the Outbreak and Lessons for t he Immediate Future. W HO: Ge ne va , M a y


8 T B and Outbreaks Weekly, “Severe Acute Respiratory Syndrome; WHO points at ‘ super
spreaders’ as ke y t o s topping SARS,” April 29, 2003.
9 W HO, Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons
for t he Immediate Future. Geneva : W HO, May 20, 2003, p. 6.
10 For mor e det ai l , see [ www.who.i nt / c sr / s ar s/ t r avel ] .

on SARS and brought together clinicians for S ARS diagnosis and t reatment.11 It a l s o
developed guidelines, recommendations, and descriptions concerning case
defi ni t i ons, cas e m anagem ent , l aborat ori e s, biosafety, blood safety, epidemiology,
mass gatherings , and goods and animals from S ARS-affected areas.12
An ur ge n t plan for t he operational response t o S ARS was developed and
i m p l e m e n t e d . T h i s i n c l u d e d p roviding ex pertise and supplie s i n S A R S - a f f e c t e d a r e a s
and hospitals, and “in t he air” t h r o u g h t echnology t o b ring the b est minds to the
collaboration required. This plan resulted i n:
! A global alert
! Rapid case i dentification
! Global reporting s ys tem and verification
! Regu lar updates and advice
! In ternational field support and logi stics coordination
! Epidemiologi cal and clinical networking
! Laboratory n etwork 13
Through t his n etwork, and daily conference calls, epidemiologi sts were able t o
discuss cases, refine t heir definitions, examine chain s o f t ransmission, track progress,
and i ncrease t heir understanding of what wo rked best where. Similarly, individuals
working i n t he clinical network were able t o s hare ex periences with different forms
of t r eatment, ex amine t he possible reasons for t he range o f i ndividual responses to
t h e d i s ease, and d evel op gu i d el i n es for i nfe ct i o n cont rol . The n et work of t h e
laborat ories enabled many scientists to work together to come up with the
identification of t he SARS virus.
S c i e ntists have much to learn about SARS, i ncluding understanding t h e
evolution o f t he disease, design ing ear ly d e t ection, prevention and treatment
strategi es , and es tablishing effective s urveillance s ys tems. Until then, contai nment
m ay rem ai n t he m o st effect i v e cont rol t ool. If S ARS b ecomes endemic, t he W HO
may find t he application o f m odels of response for other i nfectious diseases, s uch as
malaria, meningitis and yellow fever useful in combating t he diseas e and developing
t h erapi es and vacci nes.14
WHO h as is s u ed an appeal for funding to support its surveillance and
monitoring activities i n Asia. It hopes t o help t hose h ar d e s t hit by t he disease
economically, to continue with their efforts to control SARS, and ultimately to

11 For more i nforma tion a bout the W HO collabor ative network, see [http://www.w h o .int/
12 Links t o i nforma tion under t hese headings can be found at
[ ht t p: / / www.who.i nt / c sr / s ar s/ gui del i nes] .
13 W HO, “The Operational Response,” April 16, 2003.
14 W HO, “Severe Acute Respiratory Syndrome (SARS): Status of the Outbreak and Lessons
for t he Immediate Future,” Geneva , Switzerland, May 20, 2003, p. 7.

eliminat e t he diseas e as a gl obal t hreat . 15 The W HO has an annual budget of nearly
$850 million. It relies h eavily on its 192 member states for resources and t eams o f
ex pert s. 16
SARS and I nter nati onal Heal th Regul ati ons
The outbreak of SARS has raised m any public health questions, i ncluding the
appl i cat i o n o f i nt ernat i onal l aw. A ccordi n g t o D avi d P . Fi dl er, P rofessor o f Law at
Indiana S chool of Law i n Bloomingt on, the l egal implications affect three m ain areas
— International H ealth Regulations (IHR); public health meas ures and civil and
political rights; and principles of state responsibility in responding to SARS. 17 This
sect i o n wi l l focus o n t he IHR b ecause of i t s rel evance t o W HO.
Overvi e w o f the I nternational Health Regulations. In 1951, under
Article 21 of the W HO constitution, member st ates adopted the International S anitary
Regu lations, which in 1969 became known as t he In ternational Health Regu lations
(IHR). Amendments were made in 1973 and 1981. The m ain purpose was to control
the s pread of diseases with minimum impact on world t raffic t hrough t he
devel o p m ent of a gl obal s urveillance s ys tem, the use of procedures at ports and
ai rports, and the creation of diseas e- specific p rovisions. S ome argue that the
regu lations have not been effective i n ensuring protection against diseas es in a world
of i n creasi n g t rade and t ravel . Ex pert s m ai nt ai n t hat a key reason for i neffect i v eness
lies i n t he limited number of diseases to w h i c h t h e IHR applies. Originally, t he
regu lation covered s ix diseases — s mallpox , relapsing fever, typhus, cholera, plague,
and yel l o w fever. 18 Today t he IHR applies only t o t he last three d iseases. S mallpox
is considered to have been eradicated some years ago . R elapsing fever and typhus had
been so successfully controlled t hat t hey were n o l onger consi d ered a publ i c heal t h
t h reat . T he IHR d o not appl y t o m ore recent i nfect i ous di seases such as HIV/ AIDS
and S ARS. Member states were therefore under n o obligation t o report t he outbreak
of a n ew i n fect i ous di sease nor were t h ey requi red t o rest ri ct t rade or t ravel even i f
i t woul d b enefi t cont ai nm ent .19
In the 1990s, t he WHO i nitiated a revi sion of the IHR to address t he limited
scope of t h e d i s eases covered, i n crease i t s relevance t o t he kinds of infectious disease

15 The Australian, “WHO Seeks $306m for SARS Fight,” May 23, 2003.
16 Washington Post , “SARS Sh o w s W HO Di sease Hunters’ Skills, and Li mits,” May 31,

2003. [http:// www.washingt]

17 T he American Society of International Law, SARS and International Law, April 2003, see
[ h t t p : / / www.a s i l .or g/ i n s i gh t s ] .
18 WHO, “Int er nat i onal Heal t h Regu l a t i ons.” [ www.who.i nt / c sr / i h r / e n . ] ; T he Amer i can
Society of International Law, SARS and International Law, April 2003.
19 T he American Society of International Law, SARS a nd International Law, April 2003,
s e e [ ht t p : / / www.a s i l .or g/ i n s i gh t s ] .

threats m ost p revalent or likely t oday, and t o m anage t he ret u rn of ol d d i s eases. T hese
revisions are s cheduled to be finaliz ed in 2005.20
In 2001, the W orld Health Assembly adopted a resolution concerning member
response t o i nternational public health em ergencies and gl obal h ealth security with
reference t o epidemics. In 2002, another resolution m ade t he response m ore s pecific,
and i ncl uded h eal t h ri sks rel at ed not onl y t o n at ural occurrence, but t o acci dent al or
del i b erat e u se of bi ol ogi cal and chem i cal agent s .21
The S ARS outbreak added m omentum t o d iscussions about revising the IHL
that were already well under way. As recently as J anuary 2003, t h e 192 member
states had b een discussing the d etails of th e n e w f r a m e work, with a resolution for
completing t he revi s e d r e g u l ations. Although t he IHR were recogn iz ed as being
outdated, the case o f S ARS h ighlighted the p roblem s o f t r a n s parency — China
denied the p roblem ex isted for months, a nd the i nformation p rovided from Toronto
was criticized by some as inco mplete and not timely enough.
The Fifty-S ixth World Health Assembly. Fi dl er argu es t h at “t he S A R S
epidemic may encourage W HO member stat es to accept a more robust i nternational
legal framework for global i nfectious diseas e control t han has ex isted historically.”22
At the Fifty-Six th W orld Health Assembly in May 2003, the m ember s tates adopted
two resolutions relevant to the S ARS outbreak, one specifically on SARS, t he other23
on the revision of IHL. The S ARS resolution focuses on eleven recommendations
to WHO m em ber states i n addressing the S ARS outbreak; i t also requests t he W HO
Di rect or General t o t ake s peci fi c act i ons. None of the s e a re new obligations or
bi ndi ng on m em b er st at es as earl i er p ress reports might have suggested. R ather, they
build on the role o f t he W HO and high light the n eed for i nformation s haring and
international cooperation i n com bating an outbreak such as SARS. 24

20 WHO Executive Boa r d , R e v i sion of the I nternational Health Regulations, EB111.R13,
A genda It em 5.12, 111th Session, J a nuary 24, 2003. Report by t he Secretar i a t , W H O
Executive Board,”Revision of the I nternati onal Health Regulations,” EB111/4, Provisionalth
Agenda item 5.12, 111 Session, December 15, 2002.
21 W HO, Revision Process of t he Interna tional Health Regulations (I HR).
[ h t t p : / / www.who. i n t / c s r / i h r / r e vi s i o n / e n / ] . P r e vi o u s r e s o l u t i ons i n cl ude: W HA48.13 on new,
emergi ng, and re-emerging i nfectious diseases, WHA54.14 on gl obal h e a lth security,
epidemic alert a nd response,EB111.R13 on r e vision of IHR, and EB111.R6 o n t he
prevention a nd control of i nfluenza pandemi cs and annual epidemi cs. See Fifty-Sixth World
Health Assembly, Geneva, 19-28 May 2003, A56/48 - Revision of t he International Health
22 T he American Society of International Law, SARS and International Law, April 2003.
23 World Health Assembly, Severe Acute Respiratory Syndrome (SARS), W HA56.29, May

28, 2003; and World H ealth Assembly, Revision of the I nterna tional Health Regulations ,

WHA56-28, May 28, 2003. For a discussion of thes e r esolutions in international l aw, s ee
T he American Society of International Law, Developments Involving SARS, I nternational
Law, and Infectious Di sease Control at t he Fifty-S ixth Meeting of t he World Health
Assembly, J une 2003. See [ http://www.].
24 T he American Society of International Law, Developments Involving SARS, I nternational

The IHL Resolution t akes an important political step in em phasizing the need
for m ember s tates t o cooperate with other s tates and the W HO in m o n i toring and
responding to infectio u s d i s e ases. Although t he SARS outbreak high lighted the
st rong need for revi s i o n o f t he IH L, t h en W H O D i rect or General G ro Harl em
Brundtland al so pointed out the d ifficult balance t o b e s truck i n revising t he
regulations, s uch as s tate obligations to report sensitive health information, protection
of human righ t s and civil liberties i n light of an international health threat , and the
impact on immigration policies and deci sions. 25 The IHL Resolution does not gi ve
WHO a s i gnificant i ncreas e i n authority in terms o f i ntervention during a potential
public health threat , nor does i t give W HO the power to reprimand a s tate that does
not comply.26 However, the IHL Resolution l ays t he political groundwork for states
to respond appropria t e l y, m uch o f t he encouragement t o comply will likely come
from i nt ernat i onal p ressure as t h e S AR S case d em onst rat ed. 27
The IHL resolution was adopted as an interim m easure until the IHL revisions
are finaliz ed in 2005. The W HO opted for t his t wo-step p rocess rather t han i nsisting
that members immediat el y approve the i ncorporation of t he resolution i nto t he IHL. 28
Some ex perts s uggest that this resolution will encourage W HO collaboration within
countries and also p rovide momentum for implementation o f t he measures outlined
in the resolution.29 The U.S. d elegation i nitially as ked for a postponement of action
on the proposed resolution, hopi ng to include it in a broader discussion, but later
conceded when it did not enlist m ember s upport. 30 Others suggested that this was a
“negotiating t actic” used t o avoid t oo early a commitment by the United S tates.31

24 (...continued)
Law, and Infectious Di sease Control at t he Fifty-Sixth Meeting of t he World Health
Assembly, J une 2003. See [ http://www.].
25 Washington Fax, Brundtland Urges Health Security Measures for WHO Member States,
26 T he American Society of International Law, Developments Involving SARS, I nternational
Law, a nd I nfectious Di sease Control at t he Fifty-Sixth Meeting of t he World Health
Assembly, J une 2003. See [ http://www.].
27 Washington Post , “ W H O G e t s Wider Power t o Fight Gl obal Health T hreats,” M ay 28,

2003. [http:// www.washingt]

28 Washington Post , “WHO Gets W i d e r P o we r t o Fight Gl obal Health T hreats,” May 28,

2003. [http:// www.washingt]

29 ProM ed,”Comme nt on WHA Resolution,” May 28, 2003.
30 Washington Post , “WHO Gets Wider P o we r t o Fight Gl obal Health T hreats,” May 28,

2003. [http:// www.washingt]

31 U nited Nations Foundation, “WHO: Members V ote t o Give Age ncy New Powers in
Outbreaks, More”UN W ire, May 28, 2003. See
[ UNW ire/20030528/33949_story.asp]

Country Responses to SARS
The S ARS v irus rapidly s p r ead t o 30 countries, ultimately infecting 8,43732
people, of whom 8 1 3 died. Each country handled the v irus differently. S ome
countries, like Vietnam, immediately called for international s upport. O t h e r s , like
China, initially downplayed the s everity of the v irus within their borders. Although
the United S tates reported 75 S ARS cas es i t had no S ARS-related deat hs.33
Countries experiencing five or more SARS deaths are discussed in this section.
Other countries that reported S ARS d eaths include: France (1), M alaysia (2),
Philippines (2), S outh Africa (1), and Thailand (2).
Chi na a nd Hong Kong
Reports of S ARS outbreak coverups surfaced in mainland China i n April 2003.
Many bl am ed C h i n a for t h e gl oba l S A R S c r i si s, whi ch s eem s t o h ave s t art ed i n
southern China. Cr itics argued that had China been forthright in proclaiming the
ex tent of the S ARS p roblem, t he disease would not have spread throughout the
country, and eventually to other countries.34
In response t o i nternational criticism about its complacency and cover-up i n
preventing t he spread of the v irus, t he Chinese government took a number o f s teps
to demonstrate t ransparency and vigilance i n combating t he spread of SARS. The
Mayor of Beijing and the M inister of Health were fired. 35 Chinese authorities also
quarantined those with symptoms of t h e d i s ease and t hose with whom they had
contact, o ften thousands at a time. 36 Entire apartment buildings , m arkets, hospitals,
universiti es , a n d s chools were s hut down. All s chools i n Beijing were closed for
nearly three m onths.37 Chines e authorities banned all tourist visits from t he central
part of the country and Tibet. 38 China also closed s ome border crossings, including

32 W HO, Cumulative Number of Reported Probable Cases of SARS. J uly 10, 2003.
[ h t t p : / / www.who.i nt / c sr / s ar s/ count r y/ 2003_07_11/ en/ ]
33 For more i nforma tion on how the United States c ombated t he spread of SARS see CRS
Report RL31937, Severe Acute Respiratory Syndrome (SARS): Public He alth Situation and
34 Pomfret, J ohn, “Beij i ng T old Doctors t o H i d e SARS V ictims.” April 20, 2003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
35 Pomfret, J ohn, “ T housands Flee Beij ing, Fearing SARS.” April 24, 2003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
36 Eckholm, Erik, “ 4,000 Quarantined in Beij ing a s Suspected SARS Cases Climb.” April

25, 2003. The New Y ork Ti mes. []

37 The New Y ork Ti mes , “ As SARS Eases, Beij ing Classes Resume. ” M a y 1 9 , 2003.
38 Maynard, Michelin e , “ Passport, Mask, Thermometer.” May 11, 2003.

some between China and Mongolia and pos tponed reopening the Khunjirap crossing
between China and Pakistan. 39
C h i n ese o ffi ci al s enact ed new l a w s t o fi ght S A R S . O ne of C h i n a’s m ost
controversial l aws, calls for t he imprisonment o r ex ecution o f anyone found
intentionally spreading t he virus. The first person facing punishment under t his l aw
is Dr. Li S ong. Authorities charge Dr. Li with vandalism and violating an i nfectious
di sease l aw. 40 Hospital o fficials argue that he left a hospital knowing h e h ad SARS,
and ultimately spread the virus to his family and m ore t han 100 others in the s mall
town of Li nhe. Dr. Li ’s mother, father and w i f e have died of SARS, while Dr. Li
remains i n j ail. 41
Other l aws s ought to halt the s pread of the virus through fines . Authorities i n
the s outhern town of Guangz hou began fining i ndividuals who s pit i n public 50 yu an
(about $6 US), a fine t hat m any will find difficult to pay.42 In Shangh ai, t hose found
spitting, as well as throwing away cigarette stubs or fruit peels i n public areas, and
dum pi ng garbage and sewage i n t h e wrong pl aces are s ubj ect t o a fi n e o f 200 yu an
(about $24 US), compared to 50 yu an prior t o t he SARS outbreak. 43
China’s m oves t o address t he spread of SARS have a l s o i n c l uded financial
assistance. The Chinese Ministry of Finance allocated a total of 440 million yuan
(about $53 million) to reinforce t h e fight against SARS.44 Provincial and local
governm ent s al s o o ffered assi st ance t o t hose affect ed by S AR S . Assi st ance i n cl uded
the distribution of t em porary s ubsidies, disinfect ants, protective s urgi cal masks and
soap. One Beijing district, the Dongcheng District, rep o r t ed t hat i t deci ded t o
provide 420 thousand yuan (about $51 thousand) to its low i n c o m e residents, and
Chaoyang District allocated 350 thousan d yuan (about $42 thousand) towards t he
purchase o f p reventive aids.45 Meanwhile officials i n Hong Kong announced a $1.5
billion aid package, which i n c l u d e d wai ving water and sewage charges for the

39 China Internet Information Center, “China T emporarily Cl oses Some Border Ports.” M ay

12, 2003. [http:// www.china.or]

40 Kahn, J oseph, “Man’s Virus Infects T own, Killing His Family.” May 15, 2003. The New
York Times. []
41 Supporters of Dr. Li point o u t a n u mb e r of i nconsistencies i n t he charge s. Although
Chinese officials claim Dr. Li s pread the virus throughout Linhe when he walked out of Ba
Meng Hospital on April 8, 2003, SARS wa s not placed on the mandatory quarantine list
until April 14, six days l ater. Furthermore, members of Dr. Li’s f amily contend t hat he did
not know that he was i nfected with SARS, a nd he only l eft t he hospital after complaining
of poor treatment. Dr. Li also reportedly wal ked out of the f acility to care f or his parents
who suddenly became ill. T he Li f amily are currently searching f or a l awyer.
42 BBC News, “ Spitting ban to combat SARS.” May 14, 2003. []
43 People’s Daily, “SARS Epidemic Increases Pers o n a l Hygi ene Awareness.” April 28,

2003. []

44 People’s Daily, “ China Allocates US $6.25 ml n on Anti-SARS Measures.” May 23, 2003.
45 People’s Daily, “ Beij ing M oves to Aid Economically disadvantage d r esidents in SARS
fight.” April 24, 2003. []

general public for u p t o four months, i ncreas ing i ncome t ax rebates, waiving license
fees for h eavily affected ind u stries, guaranteeing $450 million i n l oans to affected
busi n esses, i n creasi n g m edi cal research spendi ng, and reduci n g com m erci al rent s for
stores at public housing s ites and other government controlled p rope r t i e s . 46 The
Chinese Government also reserved $128 million f o r a Hong Kong marketing
cam pai gn now t h at t h e ci t y has b een rem oved from t he W H O l i s t o f i nfect ed areas. 47
According t o t he Chinese Government, t he international community donated about
$76.6 million t o aid its fight against SARS.48
On June 10, the WHO sent a high-level team, i ncluding Dr. David Heym ann,
Ex ecutive Direct o r fo r C ommunicable Diseases at WHO, to China t o assess the
current situation and plan a s trategy for the future. T h e y proposed steps for
ex am i n i n g and d et ect i n g cases, d efi n i n g p rocedures for cont act t raci ng, and
responding to local transmissions. W HO was p articularly concerned about the
capaci t y of t h e C hi nese rural h eal t h syst em s t o d eal wi t h em ergi ng i n fect i ous
di s e a s es, from effective m onitoring an d reporting t o adequate hospital care. 49
However, it found t h at surveillance systems in two key rural provinces were
effect i v e. 50 China has al so surprised m any with the s peed with which i t brought its
outbreak under control. Some studies suggest that the m ortality rate may h ave b een
lower,andthecureratehigher,thaninot h e r parts o f t he world. Differences in
inc u b a t i o n p e riod and groups at high est risk m ay provide clues for figh ting t he
di sease. Accordi n g t o Dr . Heym ann, “Long-term containment d epends on finding
answers t o a long list of s ci entific questi ons. C hina has m uch t o o ffer t he rest of the
On J une 24, 2003, W HO removed its rec o m m e n d ation t hat p eople s hould
postpone all but essential t ravel t o Beijing, China. Beijing was the l ast area i n t he
world t o h ave t he travel warning lifted. Beijing, with a cumulative t otal of 2,521
probable cases and 191 deaths, h as had t he largest outbreak of SARS anywhere in the
world, followed b y Hong Kong with 1,755 cases and 2 9 6 deaths, and Guangdong
Province with 1,511 cases and 5 7 d eaths. 52

46 Bradsher, K eith, “ Epidemic Spurs Plan t o Revive Hong K ong.” April 24, 2003. The New
York Times. []
47 Bradsher, K eith, “ Relieve d Hong K ong Starts to Shed Masks.” M ay 25, 2003. The New
York Times. []
48 People’s Daily, “FM Spokeswoman Briefs on Assistance to Ch i n a f o r SARS Battle.”
May 9, 2003. []
49 WHO, “Update 77 — W HO Officials t o V isit China,” J une 10, 2003.
50 WHO, “Update 59 - Report on Guangxi (China ) visit, situation i n T aiwan, risk of SARS
t r ansmi ssi on dur i ng a i r t r avel .” May 19, 2003. [ ht t pwww.who.i nt / c sr / s ar s]
51 WHO, “Update 77 — W HO Officials t o V isit China,” J une 10, 2003.
52 WHO, “Update 87 - World Health Or ganization changes last remaining t ravel
recomme ndation — f or Beij ing, China.” J une 24, 2003. []

The doub ling o f S ARS d eaths 53 i n Tai w an prom pt ed W H O t o s end a t eam t o
i nvest i gat e t he i s l and’s S AR S s i t u at i on. The s harp i n crease i n n ew cases and d eat hs
surprised s ome as Taiwan i nitially appeared successful in curtailing m ortality,
avoiding international community transmission, as well as maintaining a relativel y
low number of new cas es compared to mainland China. The government of Taiwan
took early steps t o avoid a massive SARS outbreak, i ncluding imposing m andatory
10-day quarantines on all v isitors arri ving from C hina, Hong Ko n g , S ingapore o r
Toronto; cancelling m ore t han 100 commercial flights; cancelling h igh s chool ex ams
scheduled for t he e n d o f M ay; and monitoring the t emperature of visitors to many
public buildings and hotel s.54
In May 2003, the P resident of Taiwan, who has b een vocal in his d esire t o gain
Taiwanese observer s tatus t o t he W HO55, stated t hat Tai wanese hospit a l o fficials
from Taipei M unicipal Hop i n g Hospital m ay have tried t o cover up a SARS
outbreak. 56 In response, Taiwanese authorities f ired the s uperintendent of the
hospital and relocated all 200 patients and 900 employees from Hoping Hospital t o
a designated S ARS facility while the hospital was being disinfect ed.57 Shortly after,
the Tai pei C ity Government fined t he H o p i ng Hospital 1.1 million Tai wan dollars
($31,682 US) and four other hospitals 1.5 million Taiwan dollars ($43,202 US) each
for d elaying reporting S ARS cases to hea lth authorities, and revoked t he licence of
t h e form er J en C h i Hospi t al s u p e r i nt endent , Li ao C heng-hsi ung, accusi ng hi m o f
covering up a S ARS outbreak while serving. 58 The Tai wan M inister of Health, Dr.
Twu S hiing-jer, voluntarily resign ed on May 16, 2003, taking full responsibility for
t h e S AR S s pread. 59 Two d ays l ater, m ore t han 140 medic a l employees across t he
island report e d l y r es igned t o avoid dealing with SARS patients.60 The m edi cal
workers charged that the government had f ai l ed t o p rovi de suffi ci en t p r o t ect i v e
gear. 61

53 WHO r eported 10 SARS deaths in T a iwan on May 6, 2003, and 24 SARS deaths on May


54 Luh, Shu Shin a nd J ohn Pomfret, “T aiwan Bidding to J oin WHO.” M ay 10, 2003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
55 T a iwan is not a W HO me mber, t hus it sought China’s c onsent before s ending a t eam.
56 Luh , S hu Shin a nd J ohn Pomfret, “T aiwanese President Sugge sts Hospital Covered Up
Disease.” M ay 13, 2003. The Washington Post . [ ht t p : / / www.washi n gt onpost . com]
57 Ib i d .
58 Channel News Asia, “T aiwan officials confident of bringing SARS under c ontrol despite

55 new cases Friday.” May 23, 2003. [h ttp://]

59 McNeil J r ., Donald G., “Taiwan Health Minister Quits Over Hi s Handling of SARS.”
May 16, 2003. The New Y ork Ti mes . []
60 Culpan, T im, “ T a iwan P o s t s D a i l y Record for SARS Cases.” May 21, 2003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
61 Connolly, Ceci and T im C u l p an, “ U.S. Doctor with SARS Symptoms to Return
Home .” May 23, 2003. The Washington Post . [ ht t p : / / www.washi n gt onpost . com]

WHO offici al s believe that lapses in infection control, particularly in em ergency
rooms, may h ave b een one of the reasons for t he rapid i ncrease i n cases.62 Reports
seem to support t he assertion t hat Taiwanese health offici a l s m a y not have taken
enough m easures to limit the s pread of the v irus both within and among the hospitals.
The Dean of H o p i n g Municipal Hospital’s R adiology Department reported t hat,
“Everything wen t wrong. T h e re is no proper quarantine facility.” It was reported
that hospital s taff did not separate SARS patients from non-SARS patients, and did
not ask p atients about their m edical history. Concern about Taiwan’s ability to
contain t he virus was heightened wh en CDC o fficials announced on May 23, 2003
that an A m erican doctor s ent with the W HO/CDC t eam to investigat e Tai wan’s
recent upsurge i n S A R S cases was s uspect ed t o have bec o m e i n f e c t ed wi t h S A R S
and was returned to t h e U . S . t o undergo t reatment. 63 CDC o fficials added t hat
Hoping Hospit al made the critical mistake of sending SARS patients t o o ther
hospitals for t reatment, unwittingl y s preading t he diseas e.64
In addition t o its collaborative efforts with CDC and WHO, Taiwan bolstered
its quarantine efforts, strengthened its contact traci ng capabilities, and improved its
infection control p ractices. T he Govern ment of Taiwan also released a $1.44 billion
U.S. ai d package, which s ought to assist ailing businesses and families of S ARS
victims, establish S ARS prevention m echanisms, and creat e effective S ARS contact
t raci ng m echani s m s . 65 Tai w an was rem oved from t he W H O l i s t o f areas wi t h recent
local transmission on J u ly 5, 2003. It s l ast p robable case was reported o n J une 19,

2003. To date, 671 people h ave contracted the v irus, o f whom 84 have died.

Vietnam, the poorest o f t he SARS-affect ed countries, was the first country to
contain t he SARS virus. The W HO removed Vietnam from i t s l i s t o f a ffected
countries less than five weeks aft er it recorded its first S ARS d eath. 66 Vi et nam w as
hailed as a success s tory largely b ecause of its rapid response t o t he health crisis, and
its cooperation w i t h WHO and CDC o ffici als who offered critical technical
assi st ance.67 According t o t he W HO, Vietna m w a s fortunate to have had only one
carri er, who spent l ess t h a n t hree days am ong t h e general publ i c pri o r t o
hospitalization. This limited t he number of contact s t hat t he man m ade.

62 WHO, “Update 59 - Report on Guangxi (China ) visit, situation i n T aiwan, risk of SARS
transmission during air travel .” May 19, 2003. []
63 Altman, Lawrence and Donald G. McNeil, “U.S. Doctor with Symptoms to Fly Home f rom
Taiwan.” May 23, 2003. The Washington Post . [ ht t p : / / www.washi n gt onpost . com]
64 Chung, Lawrence, “Complacency and infighting l ed to worsening outbreak.” May 23,

2003. T he Straits T i mes website. [ http://www.]

65 Channel News Asia, “T aiwa n’s parliame nt approves special budget of US $1.44 billion
to combat SARS.” May 23, 2003. [http://www.cha]
66 Naka shima, Ellen, “V ietnam T ook Lead in Containing SARS.” M a y 5 , 2 003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
67 WHO, “Update 39 - Optimism i n V iet Nam, caution urged when using diagnostic tests.”
April 25, 2003. [http://www.w]

S o me observers praised t he success o f t he country with less resources than its
SARS-affected neighbors t o ra p i d ly cont ain t he virus. One Vietnamese h ealth
official ex plained t hat Vietnam’s response contrasted with China’s i nitial response
in that Viet nam did not seek to downplay the potential impact of the diseas e and it
welcomed international assistance. Fr ance q u i ckly announced that it would o ffer
m o r e than $100,000 to help sterilize Hanoi French Hospital, where t he first S A R S
case w as det ect ed. 68 The W HO and C DC donated m asks, gowns and o ther
equipment; J apan contributed two ventilators and other medical s u pplies; Doct ors
W ithout Bo rders s ent a medical team; and Vi etnamese medical workers were t rained
in infection control t echniques.69 V i e t namese doctors also voluntarily quarantined
them selves in Bach Mai hospital, the designated S ARS hospital, to avoid spreading
the virus to thei r families and the general community.
The gove r n ment of Vietnam o rdered the establishment o f p rovincial and
municipal s teering committees responsible for closing down any entity and i solating
any i ndividual who contracted SARS or was suspect ed to be infect ed with the virus.70
It al so t rai ned m edi cal workers, cust om s o ffi cers, ai rl i n e s t aff and t hose worki ng i n
the t ourism s ectors.71 The Finance Ministry spent about $2 million o n m edical
equipment and activities rel at ed to SARS prevention72 and t argeted a little more than
$1 million for Viet nam’s b o r d er provinces tasked with preventing S ARS from
leaving or entering Vietnam .73 The Government of Vietnam recently announced that
it intended t o s pend an additional $3.3 million t o prevent SARS from r et u r n i n g.74
J ohnny Chen, b elieved t o h ave carried SARS to Vietnam from C hina, d ied o f S ARS
o n M a r c h 13, 2003. A little more than a m onth l ater on April 28, 2003, t h e W H O
announced that Vietnam was the first country to have contained t he deadly virus. A
total o f 6 3 p eople contracted SARS in Vietnam, 5 o f whom died. 75

68 Asi a Ti mes , “ V i etnam s h ows how to beat SARS.” April 30, 2003.
[ h t t p : / / www.a t i me s .c om]
69 Naka shima, Ellen, “V ietnam T ook Lead in Cont a i n i n g S ARS.” May 5, 2003. The
Washington Post . [ ht t p : / / www.washi n gt onpost . com]
70 Ministry of Foreign Affairs, “Further precautions taken t o ward off SARS.” March 31,

2003. [http://]

71 Ministry of Foreign Affairs, “Deputy Prime Minister asks all provi nces to establish SARS
control committees.” April 16, 2003. [http://www.]
72 Ministry of Foreign Affairs, “30 billion V ND for SARS prevention work.” April 8, 2003.
[ h t t p : / / f a]
73 Ministry of Foreign Affairs, “Further precautions taken t o ward off SARS.” March 31,

2003. [http://]

74 Ministry of Foreign Aff a i r s , “Ni nety returnees from Beij i ng to leave i solated centre.”
May 12, 2003. [http://]

Some civil libertarians criticized the Government of Singapore i n its response
to the S ARS virus as being t oo harsh. However, the W orld Health Organization
commended S ingapore o n its response t o t he virus. Dr. David Heym ann, Ex ecutive
Di rect or of com m uni cabl e di sease p rogram s at t he W HO d escri b ed S i ngapore’s
act i ons as “ex em pl ary”, and st at e d t h a t “ S ingapore h as been one of the m ost
successful countries in its r e s p o nse to SARS.”76 The W orld Health Organization
removed S ingapore from t he list of areas with local SARS transmission on May 30,


S i ngapore’s act i ons agai nst S AR S w ere v i ewed as s wi ft and w i d espread. For
ex ample, the M i n i s t ry o f Education requi red all schools t o provide students with a
personal t herm om et er, and t o t each t h em t o check t h ei r o wn t em p erat ures dai l y. A l l
students t aking t he nationa l l angu age ex ams in J une 2003, underwent t emperature
checks before entering t es ting s ites. The M inistry also required t he Institutes of
High er Learning t o s e gm e n t t heir large cam puses into smaller s ections to reduce
movement across t he cam pus and t o facilitate contact traci ng. S ingapore required all
students and households to have thermometers by J une 2003. Other s teps taken t o
prev e n t t he spread of SARS included: di recting all SARS cases to one hospital,
installing video cam eras in the homes of al l quarantined individuals, elect ronically
taggi ng violators o f quarantine o rders, using body ther m al s canners at airports,
enforci n g m andat o ry t em p erat ure checks f or all i ndividuals departing S ingapore and
t hose arri vi ng from S A R S a ffect ed areas, r equiring all food handlers t o t ake t heir
temperat ures twice a day, and applyi ng mandatory temperature checks for e n t r y t o
many public events. On M arch 24, 2003, the S ingapore M inistry o f Health invoked
the Infectious Disease Act to isol a t e t hose i nfected with SARS, and prevent t he
further s pread of the v irus. T he act was amended o n M ay 23, 2003, by requiring all
those who broke the home quarantine t o b e t a gged, arrested, d etained, and/or fined.
The first offense is puni s h able by up to $10,000 or 6 m onths impri sonment and
repeat offenders can be fined u p t o $20,000 or 12 months. 78

76 WHO, “Update 53 - Situation i n Singapore and Hong K ong, i nterpretation of areas with
recent l ocal transmission.” Ma y 12, 2003. [http://]
77 WHO, “Update 70 - Singa pore r emoved from lis t of a reas with local SARS transmission.”
May 30, 2003. []
78 Singapore M inistry of Information ,”Mi n i s t e r i al Statement i n Parliament, SARS - A
Na tional Response.” April 24, 2003. [http://app.s] ;
Rame sh, S, “ Singapore t oughens Infectious Di sease Act to deal with SARS outbreak.” April
25, 2003. Channel News Asi a . [http://] ; Government of
Singapore, “Home Quarantine Inf orma tion.” May 27, 2003.
[ h t t p : / / www.s a r s .gov.s g/ f a mi l y . h t ml ] ; a n d S i n ga p o r e M i n i s t r y o f E d u c a t i o n , “ A r r a nge me n t s
for t h e 2 003 GCE ‘ O’ & ‘ A’ Leve l M other T ongue Language Mid-Year Examinations.”
May 27, 2003. Gove r n me nt of Si ngapor e. [ www.sar s]

The Government of S i n gap o re also unveiled a $230 million S ARS relief
package o n April 17, 2003. Key elements i nclude:
! a Home Quarantine All owance Scheme, which pays an allowance
to the s el f-employed a n d t o smal l busines s owners who have
employees affected by home quarantine o rders; 79
! property t ax rebates for commercial p roperties and tourist hotels;
! 50% reduction i n forei gn worker levy fo r u n s killed workers
employed by tourist hotels;
! a Bridging Loan P rogram, which offers working c a p ital l oans to
tourism-related s mall- and m edium-sized enterprises ;
! a S kills Redevelopment P rogram and S ARS R elief Tou ri s m
Training Assistance Program, which o ffers funds to employers who
send thei r employees to certified t raining co u rses i n t he tourism
! di esel and road t ax rebat es for t ax i s, and operat o r l i cence fee
! rebat es o n ai rcraft l andi ng fees and rent al s paces at ai rport s ;
! 50% reduction i n port dues for cruise ships; and
! dollar-for-dollar m atching o f funds for t he Courage Fund, a t ripartite
fund established t o hel p t he victims of SARS and affect ed health
care workers. The fund received n early $10 million i n j ust 7 weeks.80
S i ngapore was rem oved from t he l i s t o f areas wi t h recent l ocal t ransm i ssi on on
May 31, 2003. To date, 206 people h ave contracted SARS in Singapore, and 3 2 h ave
died of the v irus. The last probable case was reported o n M ay 18, 2003.
When SARS first emerged in the country so me criticized Canadian officials for
waiting t oo long to quarant i n e 5 0 0 members of a prayer group widely believed t o
have been the s ource of the v irus in Canada. 81 W HO o fficials also complained t hat
the C anadian government had b een slow to relay current informat i o n . R e l ations
between the U.N. agency and Canadian authorities were s trai ned when t h e W HO
decided t o p lace a S ARS t ravel advisory on Toronto. Canada appealed to the W HO
t o r e m o ve t h e t ravel advi sory, b ecause offi ci al s cl ai m ed t hey coul d t race al l
occurrences of the v irus. 82 On May 14, 2003, two d ays after the 2 4 th SARS v i ct im
died, t he WHO removed t he travel advisory, citing 2 0 d ays h ad passed without new

79 Si ngapore Ministry of Infor ma t i o n ,”Ministerial St atement i n Parliament, SARS - A
National Response.” April 24, 2003. []
80 Ministry of Manpower, “J oint M edia Release from t he Ministry of Finance and Ministry
of T r ade & Industry: Government Unveils $230 million SARS Relief Package.” April 24,

2003. [http:// m. go v. sg]

81 Krauss, Clifford, “Di sease Has Canada Doubting Its Leaders,” Ne w Y or k T i me s , April 19,


82 Brown, DeNeen L., “ V i rus W orry Fades i n T oronto, but Concerns Linger s .” April 24,

2003. The Washington Post . [ ht t p : / / www.washi n gt onpost . com]

cases. Howev e r , o n M ay 23, 2003 Toronto h ealth officials reported t hat four new
suspected SARS cases were under close surveillance. 83 On May 26, 2003, the W HO
placed Toronto b ack on its list o f countries w ith recent l ocal transmission, but it did
not place a t ravel advisory on the city.
Following criticism of bureaucratic delay, Canadian offici al s t ook a number of
steps t o contai n t he virus, in cl u d i n g inviting t he U.S. Centers for Disease C ontrol
(CDC) t o m onitor its hospitals, closin g a number of hospitals and clinics, and
quarantining t hose i ndividuals suspected to h a ve SARS. C anada also undertook a
number of i nitiatives to ai d businesses and individuals adversel y affect ed by SARS.
On April 30, 2003, the Government of Canada passed t he SARS Assistance and
R ecovery S t rategy Ac t , which p rotect s t he jobs of people affected by SARS, and
enables employees to take unpaid leave o f absence for S ARS-related reasons. It also
included $1 . 7 million i n new funding to help scientists develop a new t est and
possible v accine for S ARS. All t ourist facilities i n Toronto were also ex empt from
retail tax from M ay 1, 2003 to September 30, 2003, under t he act.84
Another government initiative implemented to assist Canadians affect ed by
SARS is the S ARS G ran t Initiative. Eligible full-time and part-time health care
workers affected by S ARS can receive $400 per week and $200 pe r w e e k ,
respectivel y. This initiative complem en ts adjustments m ade t o t he Employment
In surance (EI) A ct , w hi ch al l o ws up t o 15 weeks o f s peci al benefi t s when an el i gi b l e
claimant is unable t o work b ecause of illness, injury or quarantine. The Government
of Canada has adjusted t he EI program so t hat t hose who become ill due to SARS are
not immediat el y required t o provide a m edical certificat e, and no l onger have to wait
t w o w eeks t o recei ve benefi t s . 85 Other S ARS-related actions include:
! committing $10 million t oward a marketing cam paign;
! arrangi n g s peci al paym ent s chedul es or t em p o r a r y d eferral o f
mortgage paym ent for thos e who find it difficult to pay m ortgages
! ex tending tax due dates, establishi ng flex ibl e paym ent s chedul es and
waiving t ax penalties or i nteres t for those affect ed by SARS; and
! offering a four-m o n t h postponement of capital p ayments without
penalty and s mall capital l oans to smal l businesses affect ed by

83 The Straits Ti mes, “Officials f ear four in T oronto hospital may have SARS.” May 23,

2003. []

84 Premier Erne Eves Media Office, “Premi er Ernie Eves’ SARS strategy bill passes on f irst
day of l egislature.” May 13, 2003, Canada NewsWire.
[ il2003/30/c6392.html ] a nd Brown, DeNeen L.,
“Canada Seeks Help From CDC in Fighting V irus.” April 23, 2003. The Washington Post .
85 Huma n Resources De ve lopment Canada, “Severe Acute Respirat o r y Syndrome News
Release.” March 28, 2003. Huma n Resources Deve lopment Canada.
[http://www.hrdc-drhc.gc .ca/ common/news/insur/030328.shtml ]
86 Gove rnme nt of Canada, “ Gove rnme nt of Cana da Action t o Contain t he Effects of Severe
Acute Respiratory Syndrome ( SARS).” M ay 2, 2003. Prime M inister of Canada website.

In J une 2003, health workers concerned about their s afety, including hundreds
of nurses, demonstrated in Canada to demand danger pay, protective s uits, and a
public investigation i nto t he cause of the S ARS resurgence . Some nurses claimed
that hospital o fficials were s low t o respond to their warnings t h a t p a t i e nts i n o ther
wards s howed SARS-like s ym ptoms. Still, some family practition ers ex pressed
concern t hat h eal t h offi ci al s fai l ed t o not i fy t hem w hen t he vi rus fi rst resurfaced. A s
a res ult, some family practitioners fell ill with the virus. 87 W h en t h e v i rus resurfaced
thirteen people d ied o f S ARS and thousands were quarantined. 88
Toront o was rem o v e d from t he l i s t o f areas wi t h recent l ocal t ransm i ssi on on
J u ly 2, 2003. T h e l ast p robable case was reported o n J une 12, 2003. To date, 250
peopl e h ave cont ract ed t h e v i rus and 3 8 h ave d i ed o f S AR S .
Congressional R esponse
Infectious Di sease M onitoring
The rapid spread of the S ARS v irus unders cored t he importance o f establishing
a d at abase s ys t em t hat woul d al l o w rapi d and accurat e i n form a t i o n s h a ri ng on
emerge nt infectious diseases. The Senate FY2004 Labor, Health and Human
Services (HHS ) and Education appropriations bill provides over $370 billion for
infectious diseas e control at C DC, i ncluding $25 million for SARS resear ch,
prevention and control. It al s o incl udes $50 million t o devel op a Global Diseas e
Detection S ys tem at t he CDC t hat would enable t he United S tat e s t o effectivel y
respond to a global i nfectious disease t hreat. The Senate bill also increases NIH
funding for emerging i nfectious disease from n early $600 million i n FY2003 to $1.7
Capacity Building
C ongress has al s o recogn i z ed t h e n eed t o st rengt h en st at e and l o cal capaci t y t o
respond to a b ioterrorist attack or infectious disease outbreak. The Sen a te bill
proposes that CDC funds for t hat purpose b e m aintained at FY2003 lev e l s , $940
million. Part of strengthening s tate and l o cal cap acity includes t he support of t he
Health Alert Network (HAN). P rior to HAN, one-half o f l o c a l p u b lic health
departments d id not have e-m ai l . The HAN syst em has b een used t o share
information about SARS. Forty million U.S. dollars have been r e s e r v ed for t his
pu r p o s e i n t he Senate version o f t he FY2004 Labor, HHS, and Education
appropriations bill.

87 The Washington Post , “ SARS T a ke s T o l l o n Nurses.” J une 12, 2003.
[ h t t p : / / www.washi n gt onpost . com]
88 WHO, “Cumulative # o f R e p o r t e d Probable Cases of SARS.” J une 2, 2003.
[ h t t p : / / www.who.i nt ]

Improving U.S. Response Capability
The rapi d spread of t h e S AR S v i rus has d em onst rat ed t h e n eed t o qui ckl y and
effectively respond to an intentional o r n at ural infectious disease outbreak. C ongress
appropriated $77.5 million t o t he CDC Epidemic Services and R esponse p rogram in
FY2003. The S enate v ersion of the FY2004 Labor, H H S a n d Education
appropriations bill increases funding for t hose efforts t o $127.5 million i n FY2004.
The C DC Epidemic and R esponse p rogram provides r e s ources and s cientific
ex p e rt i s e for operating and eval uating s urveillance s ys tems; devel ops and refines
res ear ch methods and s trategies 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 t o t he Health Resources and S ervices
Administration (HRSA) t o combat bioterrorism.89
Future C hallenges
The S ARS outbreak has p rovided l essons that may h ave future application. The
W HO/CDC i ntervention greatly increased the effectiveness o f t he gl obal response.
A number o f factors i nfluenced the outcome, s uch as t he system of gl obal alerts and
awareness, and access t o immediate, high -lev el research and s cientific collaboration.
Coordin a t e d efforts t hrough t he W HO/CDC, national governments, and t he public
health professionals al so led t o positive res ults, as i n t he cas e of Vietnam . Dr. J ulie
G e r b e rding, Director of the C enters for Disease C ontrol and Prevention, had h igh
praise for W HO’s l eadership during t he crisis and emphasiz ed communication and
transparen c y a s k ey t o responding to intern ational h ealth crises. Areas in which
improvements h ave b een called for in the gl obal response t o i nfectious disease t hreats
Gl obal I nter dependence a nd Tr anspar ency
Lack of transparency in promptly report i ng and m onitoring SARS outbreaks
directly contributed to the s pread of the d isease worldwide and h ad wide - r a nging
i m p a c t s b e yond the obvious health factors. The case o f S ARS d emonstrated that
state responsibility w i t h i n a globalized world does not end at its borders and t hat
future containment relies o n openness and cooperation i n t he i n t e r ests o f all

89 For more i nforma tion on Congressional e fforts t o c ombat S A R S , see CRS Report
RL31937, Severe Acute Respiratory Syndrome (SARS): Public He alth Si t u ation and U.S.

Devel opi ng Sur ge Capaci ty
The ability of public health systems and the availability of resources to deal with
a t hreat like S ARS were clearly inadequate. Addressi n g the need and ability to
mobilize additional resources, both within the country itself, and t hrough t he WHO
network during an emergency, would imp rove the response t o s imilar challenges in
the future. Some have ex pressed concer n about the impact SARS could h ave h ad if
the outbre a k h a d reached developing countries with minimal h ealth care
i n frast ruct ures, p art i cul arl y t hose al ready weakened by HIV/ AIDS . Ot h ers h ave
argu ed that SARS has underscored t he importance o f boosting aid efforts t hat o ffer
structural support, such as aiding in the t ra ining o f h ealth care p rofessionals, donating
medical supplies and equipment, upgradi ng health technologies, and ens u ring
universal inoculation against resurgent d i s eases such as t ubercul osi s .
Publ i c Fear and I nfor mati on Di scl osur e
The W HO had t o s trike a b al an ce. On the o n e hand it was p ressed t o give
information, and use aggressive tactics of contai nment. On the other h and, the
information about SARS may h ave contributed to pub l i c p a n i c and anx i ety,
di scrimination i n som e cases, and ot her impacts, such as ec onomic losses. Some
argu e t hat t he W HO d id not take into account the impact of i t s d ecision-making
concerni ng t ravel advi sori es and gl obal alert warnings and t hat t he S AR S risk
sometimes d id not demonstrate t he need for s uch a response. 90 Some governments
in the future m ay be hesitant rapidly and openly t o s hare ou t b r e a k information,
because they may want t o avoid potential n egative economic impacts, such as job
losses, hotel closures and flight cancellations as occurred at t he height of the S ARS
crisis. For ex ample, 60,000 restaurant and hotel workers i n Hong Kong lost their j obs91
or were placed on unpaid leave during t he S ARS outbreak. In Singapore, year-by-
year comparisons showed that tourist arriv a l s f e ll 15% in March 2003 and 67% in
April 2003, and hotels reported o ccupancy rates of only 1 0 t o 3 0%, compared t o
usual o ccupancy rates of 70% or more during t he first quarter of the year. 92
Nati onal Response
The weakness of national s urveillance s ys tems and health networks within any
one country can dramatically affect the are a and rate at which a disease s preads. If
the S AR S v i r u s had s pread more rapidly and ex tensively t hroughout the affected
countrie s and for a s ustained period, it c ould h ave h ad a s ignificant impact on the
heal t h care s ys t em s , and ot her s ys t em s . T hose i n n eed of heal t h care, such as t hose
with cancer, requiring surgery, or those requiring immediat e m edical attention m ay
not have been abl e t o recei ve care. In order t o cont ai n t he S AR S vi rus, hospi t a l
wards and, at times, entire hospital s w ere shut down for weeks at a time to

90 Far Eastern Economic Review, “ SARS: A WHO-Induced Panic?” May 22, 2003.
91 MSNBC, “Record SARS deaths in Hong K ong.” April 15, 2003.
[ h t t p : / / nbc .c om]
92 Channel News Asia, “National Wages Council (NWC) wage guidelines for J uly 2003 to
J une 2004.” May 27, 2003. [http://www.]

decont am i n at e t hem . S i gn i fi cant resources were used t o quarant i n e S AR S -i n fect ed
individuals, s chools were closed, and o ther private facilities were adversely impacted.
Such problem s caused by S ARS illustrate the need to develop effective national
response s ys tems.
I nadequate Fundi ng
W HO o fficials and others have argu ed that there i s a need for i ncreased funding
for l aborat ori es and epi d e m i o l o gi cal research i n t h e fi ght t o cont ai n d i s eases l i k e
SARS. Improvements t o t he ex isting s urveillance net work and national capacity to
address emergency health issues are also b adly needed. For ex ample, GOARN
reportedly n eeds $200 million t o reinforce its network. 93

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