Experiences SARS in China:
Public Health Ethics Issues
Public Health Ethics Issues
Jesse Huang,MB,MHPE,MPH,MBA
Assistant President/Dean for Continuing Education
Professor of Epidemiology
Chinese Academy of Medical Sciences
Academy of Medical Sciences
Peking Union Medical College
[e-mail]
I will present
will present
a description of 2003/2004 SARS chronology
in China and
Chi
my observations on Public Health Ethics
Issues during the SARS events with some
reflections
fl
A description of
o 2003/2004 SARS
SARS
chronology in China
chronology in China
2003 Chronology
2002
11/16: 1st case of AP of unknown
etiology Fushan China
etiology, Fushan, China
12/17- 22: 2 AP pt. transferred to
Guangzhou from Heyuang. 7 HCWs:
infected. Information: blocked
2003 Chronology
2003
1/2: Population panic in Heyuang city.
People rushed to buy herbal medicine,
Heyuang reported 1st Cases
1/3: Heyuang Newspaper: Local CDC
article:There is no epidemic in Heyuang.
cough, fever and other symptoms are
caused by cold whether
Perhaps this is the first article on SARS in
Chinas media.
2003 Ch
2003 Chronology
2003
1/14: Provincial CDC was informed an
Provincial CDC was informed an
AP outbreak in Zhongshan. Several pts
quickly progressed to respiratory failure
quickly progressed to respiratory failure
and die. Outbreak also among HCWs.
The early February, epidemic reached
peak in Guangzhou.
2003 Ch
2003 Chronology
2003
2/8: Cellular phone short text message
Cellular phone short text message
circulated 40 m times X 3 days, Rumors:
fetal flu BT etc Epidemic news occurred
fetal flu, BT, etc. Epidemic news occurred
in Hong Kongs media
2/11: News Conference: 305 cases, 5
News Conference: 305 cases
deaths since 11/16, 2002. The epidemic is
under control
under control
2003 Ch
2003 Chronology
2003
2/11 and 2/14: PROMED issued the global
warnings
2/18: Xinhua New Agency reported that
Chinese CDC has discovered the cause of
the disease: chlamydia
Guangdong disagreed: the cause is the
virus
2003 Ch
2003 Chronology
2003
2/21: A Dr. arrived HK, stayed in
Metropol, room 911, passed the virus to 7
persons and consequently spread the
virus around the world
2/26: a Metropol guest carried the virus to
Vietnam, infected 20 persons, including
Dr. Urbani,
died of the disease in
Thailand on 3/29
2003 Ch
2003 Chronology
2003
3/1: Beijing had 1st SARS case from
Shanxi, (infected in Guangzhou). SARS
spread in the capital. The information
was blocked again
3/12: WHO issues a global SARS alert
2003 Ch
2003 Chronology
2003
3/26, GD released Feb. number: cases
increased from 305 to 792, the death toll
increased from 5 to 31
people begin to suspect the previous
claim that the epidemic is under control
2003 Ch
2003 Chronology
2003
4/3, Health Minister announced that the
SARS spreading is under control. Beijing
had 12 cases and 3 deaths
A retired military doctor, a PUMC alumni,
revealed the truth that Beijings epidemic
is not under control
2003 Ch
2003 Chronology
2003
4/20: 2 top gov officials were removed from
their post.
4/25: Vice-Premier Wu Yi: Heath Minister
Measures were taken to contain SARS
spreading
5/23: WHO took GD and HK from its travel
warning list.
6/24: WHO took Beijing from its travel warning
list.
From 2003 Chronology
Were Chinas public
Chi
health systems working?
health systems working?
2003 Chronology suggests
China did not have prepared public health systems
The central command system: not working
Information systems: not functioning
Rapid diagnosis capacity: lacking
Field epidemiologists: not prepared
Pharmaceutical stockpile: not enough
Hospitals and HCWs: not prepared
Risk communication skills: poor
There are several public health ethics issues
AS Mirror
AS A Mirror
SARS returns to test
returns to test
China again in 2004
China again in 2004
2004
2004
Guangdong: 1/5-31
4 sporadic community-aquired cases
Quick response, complete control
cases were likely to be caused by Civet cat.
Beijing/Anhui: 4/22-5/7
9 cases, 2 clear transmission chains
Quick response, complete control
Lab contamination is the source of outbreak
contamination is the source of outbreak
Guangdong, 1/5-31
Acknowledgement to Dr. Luo Huiming of GD CDC for using the following 5 slides
Beijing: 2004/4/22-5/7
2004/4/22
Be prepared,
Keep
distance
distance
from AP
Sources: Beijing CDC
2004 Ch
2004 Chronology (Beijing)
(B
4/21, 5:00 PM: a suspected SARS
case report received
Isolation,
Quarantine
and
field
investigation began 40 minutes later
4/21 night, SARS lab network began
to operate
2004 Ch
2004 Chronology (Beijing)
(B
4/22 evening, lab confirmed
diagnosis
4/22, 7:00PM, MOH released epidemic
7:00PM MOH released epidemic
info to public
4/22
4/22-23, three potential epidemic
sites were closed
2004 Chronology (Beijing)
2004 Chronology (Beijing)
4/22, Ditan hospital: ready to take
SARS
SARS pt.
4/23, Central command system
began to work
4/24, 747 closed contacts were
747 closed contacts were
quarantined and completed 80%
close contacts investigation
close contacts investigation
2004 Chronology (Beijing)
2004 Chronology (Beijing)
5/10, Quarantine of 719 close contacts
Quarantine
719 close contacts
ended
5/23, all quarantine ended, no more new
case.
7/1: released investigation results to public:
Cause outbreak: of lab contamination, CDC
director resigned.
I will present
will present
a description of 2003/2004 SARS chronology
in China and
Chi
my observations on Public Health Ethics
Issues during the SARS events with some
reflections
fl
Comparison of 2003 and 2004 SARS in China
Comparison of 2003 and 2004 SARS in China
Public health system
2003 SARS
2004 SARS
Central command system
Not working
Working
Information systems
Not functioning
Functioning
Rapid diagnosis capacity
Lacking
Working/improving
Field epidemiologists
Field epidemiologists
Not prepared
prepared
Well prepared
prepared
Pharmaceutical stockpile
Not prepared
Prepared
Hospitals and HCWs
and HCWs
Not prepared
prepared
Prepared to treat
to treat
Not prepared to
alert and report
Risk communication skills
Poor
Good
Public health ethics
hardly considered
Partially addressed
My Observations/Reflections
Trust and Transparency
Experts scientific integrity and
social responsibility
social responsibility
Atypical pneumonia
Medication and vaccine
Massive Civets Cat culling
Patients privacy protection
MDs obligation of reporting ID
Trust and Transparency (1)
The need for transparency stems in
part from the governments ethical
thi
imperative to treat citizens with
respect
Openness and accountability are
important to public health governance
Transparency provides a feedback
mechanism
Trust and Transparency (2)
Public health officials have the
health officials have the
responsibility to involve the public in the
process of formulating public health
process of formulating public health
policies as well as to explain and justify
any infringement on general moral
any infringement on general moral
considerations.
Trust and Transparency (3)
Public health officials should honestly
health officials should honestly
disclose relevant information to the public.
Accordingly, citizens should have the right
citizens should have the right
to request and receive information.
Citizens input should be solicited.
Trust and Transparency (4)
Chinas SARS experience tell us that
controlling costs due to panic and
disruption were magnified by an initial
lack of public information, contributing to
a large over-estimation by individuals of
th
the perceived probabilities of infection and
death.
Trust and Transparency (5)
A key policy question for government is
how to win the trust and confidence of the
th
th
population, minimize panic and disruption
and mobilize the public as a partner in
th
combating SARS
Trust and Transparency (6)
Lets review Chinas experience:
During the early stage of SARS outbreak,
information was blocked
Local CDC article did not tell truth
120 m short text message circulated in 3
short text message circulated in
days
Trust and Transparency (7)
Lead to public panic/societal crisis
Guangdong and central Health Minister
both did not tell truth
Gov lost public trust, very difficult to
mobilize public to participate in situation
mobilize public to participate in situation
lost control
Trust and Transparency (8)
Lessen learned :Transparency is essential to
create and maintain public trust and
accountability
Action 1: SARS information transparency
after removal of two official on April 20,2003
Quickly stabilized society, rumor
disappeared
disappeared
Trust and Transparency (9)
Gov. regains the trust eventually
Public participated in control activities by
social distancing, personal hygiene, etc.
SARS outbreak controlled
Action 2:Timely disclose accurate outbreak
information become a permanent part of
<<the Infectious disease control and
prevention law>>
Issues re: scientific integrity and
social responsibility
Atypical pneumonia
Medication and vaccine
Massive Civets Cat culling
Pt. privacy protection
MDs obligation to report ID
Atypical pneumonia
Originally call Unknown pneumonia
Then, for stability reason, rename: Atypical
for stability reason rename: Atypical
pneumonia
WHO: SARS
SARS
Still call AP, do we respect scientific
integrity?
Medication and vaccine
All of the following claims and actions were without any
scientific evidence, misleading the public, raise the
issue of scientist integrity and social responsibility
again
Medication and vaccine were over-emphasized
TCM herbal, Immuglobin, antiviral
medication
A professor claim to produce SARS
professor claim to produce SARS
vaccine in one month
have quick(2 hours) SRAS diagnosis
kit
kits
Patients privacy protection
During SARS crisis, the first case
name was published on media,
bli
reported
reported in public meeting
Even in the international
conference, pt. names were fully
reported
reported
MDs obligation to report ID
Active participation of MDs is essential
to
to an effective response to outbreak
MDs have unique skills/positions to
identif and
identify and report first case of ID
Early detection is critical in the ID
prevention and control
It is MDs roles and obligations to eraly
detect and report ID
2004 SARS experience
Case
Onset
date
Suspect
Time interval
SARS
SARS date
Song X
Li X
Yang XX
3/25
4/5
4/17
4/20
4/22
4/22
27 days
days
12 days
6 days
Reflection
SARS crisis has taught us a lot
Public health ethics is new in China
We are still learning
We will be better
will be better
THANKS
THANKS
Q&A