SARS: A Warning 207

SARS: A Warning
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Elizabeth M. Prescott

For millennia microbes have quietly afflicted human society in ways that
military strategists could only hope to emulate. Directed devastation
against an enemy occurred even before the causative agent of disease
was known. Attempts to refine and harness this power have resulted in
weapons that hijack nature’s mechanisms for use at man’s discretion.
While human control over the microbial world will always be tenuous,
the proliferation of disease can be controlled. Great strides have been
made towards this end, but the recent emergence of two new infectious
agents should encourage both scientists and international-security
analysts to apply knowledge gained in treating epidemics arising
naturally to intentional biological attacks. It is very likely that infectious
disease will continue to afflict society for the foreseeable future. Thus,
the threat of biological terrorism, as a result of its intimate link with
natural disease, will also be perpetuated. The challenge to the
international community in addressing intentionally inflicted illness, as
well as the naturally occurring kind, is to control and minimise the
devastation of disease, thereby diminishing any reward that could result
from pursuit of an intentional attack and the incentive for staging one.
This means strengthening the domestic and international public health-
care infrastructures that are responsible for identifying and tackling
emerging diseases. If achieved, society will better be able to accept the
risk accompanying disease, regardless of origin, by preparing to counter
it if and when it appears.

Infectious disease
The threat of infectious disease will never be completely eliminated.
Despite early expectations when antibiotics were discovered, few experts
suggest that infectious pathogens are on the decline.1 Many of the
complexities of pathogen containment can be observed in the efforts to
control smallpox. From a scientific perspective, smallpox was an ‘easier’
disease to eradicate than many others that are currently challenging
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Elizabeth M. Prescott is a Research Fellow with IISS-US working on projects involving the
application of the life sciences to security issues. She has worked with the National
Academy of Sciences in the US and holds a D. Phil in Chemical Pathology from Balliol
College, Oxford.
Survival, vol. 45, no. 3, Autumn 2003, pp. 207–226 © The International Institute for Strategic Studies
208 Elizabeth M. Prescott

SARS EPIDEMIC, 2002–July 2003 SWEDEN 3 0

GERMANY 10 0

SWITZERLAND 1 0

CANADA
ANADA UNITED
252 38 KINGDOM 4 0

IRELAND 1 0

FRANCE 7 0
UNITED
STATES
ST TES SPAIN 1 0
73 0
ITALY 5 0

Atlantic
COLOMBIA
OLOMBI
COLOMBIA Ocean
1 0

BRAZIL
Pacific
Ocean 1 0

Number of SARS cases

by country
over 5,000
1,500 –2,000
600 – 700
200 – 300
11 – 100
1– 10

1 number of cases
1 number of deaths
not all cases have
been resolved
 SARS: A Warning 209

IISSmaps
1 0 TOTAL SARS
FINLAND CASES AND DEATHS
ROMANIA 1 0 8,445 812

RUSSIAN
FEDERATION
1 0

MONGOLIA
9 0

CHINA KOREA 3
SOUTH K 0
KUWAIT
5,328 348
1 0

TAIWAN 678 84

INDIA HONG KONG 1,755 298

3 0
VIETNAM 63 5
THAIL
HAILAND
THAILAND
9 2 PHILIPPINES
14 2
MALAYSIA Pacific
Ocean
5 2

INDONESIA
SINGAPORE 206 32 2 0

Indian Ocean

AUSTRALIA
5 0
Initial spread
CHINA
SOU
SOUTH Guangdong
AFRICA Province
HONG KONG
1 1 Hanoi NEW
VIETNAM ZEALAND
ND
Toronto 1 0
CANADA

SINGAPORE
Map compiled using WHO data, correct as of 1 July 2003
210 Elizabeth M. Prescott

public health infrastructures.2 The lack of a non-human reservoir and the

obvious and devastating symptoms observed in an infected individual
allow for easy tracking and surveillance of the disease. In 1978, after an
intense effort, human-to-human transmission, which had propagated
smallpox for centuries, was broken. Yet the global community could not
claim victory over smallpox, as it is impossible to prove that the virus
was not hidden in some unknown freezer waiting to be used as a
weapon. More broadly, new diseases have emerged each year for the last
20 years and the trend is likely to continue if not accelerate. The Institute
of Medicine released a report entitled ‘Microbial Threats to Health:
Emergence, Detection and Response’ in 2003 that
If infectious highlights many of the social and environmental
reasons for this supposition.3 Two oft-cited prime
disease is contributors are globalisation, which propels
microbes over increasingly long distances, and
inevitable, the population increase, which has forced the inhabitation
and development of previously unoccupied
increased risks environments. These new environments may harbour
unknown microbes, confronting the public health
of biological structure with previously unknown threats.
If infectious disease is inevitable, the increased risks
attacks have of biological attacks that have arisen with the greater
saliency of mass-casualty terrorism have made its
made its potential harm all the greater. Thus, containing and
minimising the impact of infection when it does occur
potential harm should be considered a key counter-terrorism goal as
well as an objective of international public health.
all the greater Meeting each goal calls for substantially the same
considerations. The advantages accruing to the
intentional hostile use of biological pathogens are intimately linked to the
difficulties involved in overcoming natural disease. The same
characteristics that make biological pathogens capable of surviving in
hostile environments also make them tricky to contain properly and
permanently. First, biological materials are exceedingly difficult to
quantify.4 The self-replicating nature of DNA makes any attempt to
catalogue or precisely define the number of specific organisms extremely
complex. If no finite number of units can be assigned to a given pathogen,
it is hard to know if a sample has ended up in the wrong hands. Second, a
single microscopic allotment of an agent is hard to detect until allowed to
multiply in favourable conditions. Third, the infrastructure needed to
store and propagate organisms is minimal; for some, a freezer and
homebrew media can be enough. Fourth, the periodic reappearance of
 SARS: A Warning 211

disease undermines efforts to control proliferation. Many organisms that

engender great fear are well ensconced in natural reservoirs. Plague,
tularaemia, and anthrax are all endemic to the United States as well as
many other countries where they may be easier to access during a natural
outbreak. Even if all samples from offensive bio-weapons programmes
around the world were contained, there would be no insurmountable
barriers to prevent an interested party from taking an agent from an area
where it is part of the ecosystem. Finally, the natural morbidity of
pathogens is more than sufficient to create significant devastation without
extensive technical manipulation.

Nature’s attacks
Modern medicine has proven quite capable of developing interventions for
diagnosed diseases over time. But it is less adept at identifying and
accessing known remedies quickly, especially in an extreme health
emergency. The recent natural outbreaks of Severe Acute Respiratory
Syndrome (SARS) and monkeypox have illuminated significant and vital
weaknesses in global and local preparedness for surprise outbreaks. Lessons
learned from these epidemics should help address limitations and minimise
vulnerabilities in the public health defences, facilitating a more robust
preparation for the deliberate introduction of a pathogen as a weapon.
In late November 2002, the first cases of an atypical pneumonia began
to appear in southern China.5 The disease, which was later dubbed
Severe Acute Respiratory Syndrome, resulted in an aggressive form of
upper respiratory distress with no effective treatment, no vaccine and a
fatality rate of about 15%.6 The epidemic grew, and its spread was
exacerbated by weaknesses in the political and public health
infrastructure. China, treating the epidemic as a state secret, prohibited
disclosure to public health authorities and the citizens whom the disease
could potentially infect. Denial of the growing epidemic barred the use of
well-established methods of disease prevention that later proved to be
the most effective line of defence against the disease.
On 11 February 2003 the World Health Organization (WHO) was
alerted to an outbreak of atypical pneumonia in Guangdong province,
China, which was reported to have infected 305 persons and caused five
deaths. A medical doctor, unknowingly infected, travelled to Hong Kong
on 21 February and stayed a single night on the ninth floor of a hotel.
During this brief stay he infected at least 12 other people. Subsequently,
these individuals travelled and seeded outbreaks in Vietnam, Singapore
and Toronto, where infected health care workers spread the disease
further. This rather simple sequence of events is credited with the global
spread of the disease. By 15 March, the WHO had received reports of
212 Elizabeth M. Prescott

more than 150 cases, primarily concentrated in hospitals in Hong Kong,

Hanoi and Singapore. It was not until 2 April, when the WHO was granted
permission to visit Guangdong province, that it was confirmed that the
earlier reported atypical pneumonia was symptomatically consistent with
the case definition of SARS, which was appearing in hospitals around the
world. Shortly thereafter, the disease spread via international travellers to
20 countries around the world, resulting in 3,000 cases and more than 100
deaths. The accumulation of cases along international air travel routes was
identified and the WHO issued emergency travel recommendations aimed
at curbing the spread of the disease.
Once a new disease was recognised, the international scientific and public
health communities responded. The causative agent was conclusively
identified and found to be related to the common cold, a coronavirus, on 17
April. By 23 April, however, the number of cases exceeded 4,000 and soared
to 5,000 by 28 April. The rate of new case detection accelerated to about 200
a day for the first few weeks in May. The number of known cases
worldwide passed 6,000 on 2 May and 7,000 on 8 May, at which point SARS
was being reported in 30 countries. The global outbreak then began to
subside, with the 8,000 case mark not reached until 22 May. By late June, the
daily increment in cases had dwindled to a handful. By July 2003, all
countries in which SARS had materialised were removed from the WHO
travel advisory. However, the death toll had exceeded 800 people globally.
There is little doubt that the reduction in the number of cases of SARS
was the direct result of aggressive and appropriate intervention on the
part of governments and health care providers. After linking the spread
to high-density travel zones and with mounting cases in several hospitals,
the WHO issued a global alert about severe atypical pneumonia on 12
March. Raising the awareness of the public and health care providers to
the threat enabled almost all countries with imported cases to prevent
further transmission and keep the number of additional cases low
through quick and determined efforts to track and isolate individuals.
These measures included persistent temperature-taking and removing
exposed or symptomatic persons from airlines at transfer points. Prompt
detection, immediate isolation, infection control and contact tracing were
critical in curbing the spread of the disease.7 What is less clear is what
role, if any, the progression of seasons may have played in dampening
the epidemic.8 It is known that the SARS virus is less stable at higher
temperatures, which suggests that the onset of spring may have helped
prevent person-to-person transmission. This leaves open the question of
whether the virus will return in the future.
In the current era of extensive transnational trading and mass
international travel, SARS may be the ‘first severe and readily
 SARS: A Warning 213

transmissible new disease to strike a globalised society’.9 As such it could

serve as a watershed: the moment the world was forced to acknowledge
the internationally interdependent character of global public health.
Accordingly, developed countries must accept that they are only as
secure as the world’s weakest public health system and for as long as it
takes a passenger to travel from that location.
A less severe outbreak of disease subsequent to the SARS crisis drove
home the point. On 15 May a child with unusual raised white lesions on
her hand was presented to a primary care physician in the US state of
Wisconsin.10 As the primary lesion originated at the site of an animal bite,
the doctor suspected that an ill pet may have been involved. The animal
died and was sent for testing to determine the cause. The child was
subsequently hospitalised and shortly thereafter the parents began to
show similar symptoms. On 30 May a biopsy of a lesion on the mother’s
hand showed an unidentified virus morphologically consistent with a
poxvirus.11 It was not until more conclusive tests demonstrated that the
virus was of the orthopox family, directly related to
smallpox, that the results were communicated to the Developed
state health officials, who subsequently notified the US
Centers for Disease Control and Prevention (CDC).12 countries must
On 7 June, after identifying the virus as monkeypox,
the less virulent cousin of smallpox, the CDC made the accept that
final diagnosis – some 19 days after the initial
presentation to the physician. The virus has they are only
demonstrated a fatality rate of 1% to 30% in outbreaks
in Africa.13 This first appearance of the virus in the as secure as
Western Hemisphere is thought to have originated
from a pet prairie dog that is presumed to have been the world’s
infected by a Gambian rat shipped from a region in
Africa where monkeypox is considered endemic. The weakest public
precise origin of the outbreak was resolved with a
laboratory test confirming imported rodents to be health system
carriers of the monkeypox virus in early July. As a
precaution, the CDC issued guidance that the smallpox vaccine should be
offered to health-care professionals and those who had been directly
exposed to an infected animal.14 As of 1 July 2003 there were 81 suspect or
probable human cases of monkeypox in six states in the US, though no
reported fatalities.

Lessons for countering bio-terrorism

Both the SARS and monkeypox epidemics were the result of natural
processes within the microbial world. But many parallels could be drawn
214 Elizabeth M. Prescott

to what would likely occur in the event of the intentional use of an

infectious pathogen. First, the disease outbreaks were not announced
and appeared in otherwise healthy populations. The anthrax attacks in
Washington DC in 2001 were accompanied by letters that raised
suspicion that they were intentional. Future attacks are unlikely to be so
well signposted. Second, the diseases had spread, undetected, for some
time before they were identified and treated. Minimising the lag time
between identification of the index case (or cases) and the measures
taken to control an epidemic is crucial to limiting the spread of disease.
Prophylactic measures against infection have obvious benefits; every
person who is protected from infection requires one less treatment to be
performed. Third, the diseases caused great confusion and raised many
questions about how best to proceed with a pathogen of unknown
origin. With emerging diseases, current scientific knowledge and practice
will almost inevitably be insufficient to allow effective action timely
enough to preclude the spread of infection. It is critical that the best
information available from all sources be compiled rapidly in order to fill
the epistemological void as much as possible. This requires coordination
of communication across all branches of public health, veterinary
medicine and environmental science. Finally, the SARS and monkeypox
cases demonstrate that quick and appropriate public health intervention
proved to be the best short-term solution available to limit and
eventually control the spread of disease from an unknown source.
Yet modern science does not have the capacity to predict all possible
new diseases or protect against the entire spectrum of scenarios that
nature or malicious individuals can devise.15 Therefore, emerging
infections, or a biological attack with an unknown infectious agent,
require a more holistic approach to illness than disease-specific treatment
or vaccine stockpiles. The development of broad spectrum antibiotics and
antivirals should be strongly encouraged so that a repertoire of versatile
solutions may be utilised by communities confronted with a problem that
will only be fully understood in retrospect. Additionally, creating
capacity to develop and use diagnostics in non-standard conditions will
be critical to being able to respond in a timely manner to novel
circumstances. Further, the existence of ‘surge capacity’ must be ensured
so that when a disease is identified there is scope to accommodate the
short-term increase in patient load.16
Overall, the system needs to be better able to adapt to the
unpredictable in a very short timeframe. Achieving this type of dynamism
will be a challenge to governments and organisations that often function
on the basis of current appropriations practices and longer-term planning.
The CDC is customarily allocated funds for specific projects or treatment
 SARS: A Warning 215

of particular diseases. In recent budgets (including fiscal-year 2002 actual,

FY2003 presidential and FY2004 estimated), the spend for both
‘epidemiological services and response’ and ‘infectious disease control’
have decreased despite the increasing burden on these services.17 When a
pathogen (like SARS or monkeypox) emerges, the CDC must reallocate
money from planned improvements or responses to other previously
known diseases (like West Nile virus) to surveillance and detection.
Recent budgets have allotted increased money to allow the CDC to focus
on bio-terrorism, but these funds are often linked to certain projects that
may not allow the flexibility needed to adequately assess the real
weaknesses in the public health system.18 In short, budgeting in advance
for unpredictable expenditures is not something that putative
appropriations procedures do well. A politically acceptable mechanism
needs to be devised for allocating public health funds that does not
necessitate intentionally overestimating what is required for a known
disease under the expectation that there will be other more pressing but
as yet unknown problems to absorb the overflow. Federal budget
authorities, then, need to standardise authorisations for unanticipated
infectious disease outbreaks from whatever source. The costs of the SARS
and monkeypox mobilisations could serve as guidelines.
In the counter-terrorism arena, the ideal consequence of improved
public-health response to the outbreak of infectious disease is of course,
deterrence. If the overall impact of infectious diseases were minimised by
a strong public health system capable of early detection and control of
outbreaks, the potential ‘rewards’ from bio-terrorism would be smaller
and the incentives for terrorists to use biological agents as weapons
consequently diminished. There are several important caveats to this line
of reasoning. First, terrorism need not inflict high human mortality rates
to accomplish its aim.19 The anthrax-laden letters in Washington DC
resulted in few fatalities but significant disruption. There was a
significant social burden that resulted from the public health precautions
that were necessary to stem the morbidity of such an event. Thus, it may
be that the heavy public health measures required to minimise
transmission of disease would merely transform biological weapons of
‘mass destruction’ into weapons of ‘mass disruption’.
If the public does not believe that an attack can be limited in scope by
strong surveillance and response, it is unlikely that a terrorist will be
dissuaded either. Nevertheless, depending on the relative degrees of
increased disruption and greater public confidence that reforms might
involve, this is still likely to constitute a net gain. Certainly the strength
of any early detection and response system would have to be
demonstrated before it could serve as a deterrent to a potential terrorist.
216 Elizabeth M. Prescott

Deterrence would pivot on reinforcing the public’s perception of the

strength and credibility of the public health system. To achieve this, an
epidemic or attack may have to be quickly neutralised to verify to a
potential perpetrator that the costs of achieving his aim have increased. In
particular, public health professionals need to show that they are
responsive to the scientific and wider public concerns about an attack or
emerging epidemic. In the anthrax attacks in Washington DC in 2001,
there were perceived differences in how exposed groups were treated.
Staff on Capital Hill received prophylactic antibiotics, while individuals
exposed at postal facilities were told that there was no reason for such
action. At the time the decision was made on the best available scientific
information. As with many aspects of emerging disease, however, the
science was incomplete. Still, similar examples have been taken on board
by public health professionals to determine how best to convey
information and empower the public to take useful action in an
environment with incomplete information. In recent years, the CDC has
scaled up its communications with the media recognising the importance
of timely and honest relay of information to the public.20

Current challenges to improving international response

To accomplish the goal of a reliable and expedient response to an
emerging disease or biological attack, the domestic and international
public health infrastructure needs to be improved in two key areas:
sensitivity and connectivity.21 Sensitivity, in this context, means the
capability to identify quickly and accurately an illness that is out of the
ordinary. This capability turns on ordinary clinicians’ alertness to
unexpected illnesses. Simply put, they need to recognise when something
presented to them is suspicious enough to warrant further investigation.
For instance, plague, which still occurs in rural areas of the US, may not
be easily identifiable to an urban doctor where its appearance should
raise the most suspicion. Quickly identifying the unusual is a key to
picking up epidemics in the early stages.
Additionally, procedures for reporting suspicious cases to public health
authorities need to be streamlined. At present, they are cumbersome for
clinicians, resulting in contact being made only when a disease is
confirmed rather then while it is being considered. In the monkeypox
example, a primary care physician admitted to suspecting smallpox early
on; however, the CDC was not notified until the virus had been further
characterised.22 This delayed the possibility of prophylactic use of the
smallpox vaccine until well into the incubation period. At the same time,
it is possible for a public health system to be overly sensitive. Every case
of childhood chicken pox should not prompt an alert of suspected bio-
 SARS: A Warning 217

terrorism. However, when a virus is in a rarely seen family, like the pox
viruses (despite its common name ‘chicken pox’ is not a pox virus), health
care professionals should be able to report that finding to the appropriate
public health officials quickly, and without exceptional effort.
Connectivity with respect to public health infrastructure resides in a
robust, international communications capacity among clinicians, public
health entities and relevant international bodies. Currently, social and
financial pressures discourage passing on vital health information until
suspected disease is closer to confirmation. As a result, early warnings
are not given and thus critical preventative action is not taken in a
timeframe that could potentially reduce the burden of disease. Open and
timely dialogue between public health communities is essential. The SARS
virus, emerging in a country that felt it was capable of controlling the
epidemic domestically, proved especially unresponsive to the Chinese
government’s measures for reasons that are not entirely understood.
Alerting the WHO enabled China to receive much needed support
domestically and awareness globally, allowing for an appropriate
response to the microbial threat. This highlights some of the incentives
for countries to release information to the public and world health
authorities.
At the same time, it is necessary to understand and devise ways of
mitigating the attendant economic and political costs to individual
countries or regions so that the burden may be shared among those
benefiting from the action. The inability of China to control the
dissemination of public health information suggests that freedoms may be
evolving there with the help of modern technologies and media.
Although the move toward a more open standard of disclosure will be
welcomed by many, it could perversely discourage future international
collaboration by other regimes that impose tight political control over
information. Further, the billions of dollars in lost revenue, trade and
direct investment are likely to make China an unpleasant example of the
cost of being open to international scrutiny.23 Yet the stigma of a poor
public-health response that will attach to the Asian economy in the near
term could well outweigh any inhibition among illiberal governments to
improve their practices. The international repercussions of perceived
laxity in reporting the disease on the part of the Chinese government
resulted in the resignation of key officials. Further, it has been suggested
that the events that unfolded around the SARS epidemic may force the
Chinese government to rethink the ‘theoretical framework for
government’ that is currently in place.24
The response of officials in Vietnam, a country that was hit with a
severe outbreak of SARS, could ameliorate negative perceptions by
218 Elizabeth M. Prescott

serving as an example of what can be accomplished with immediate and

high-level political commitment when faced with a public health crisis.25
Experts credit the Vietnamese government’s willingness to close their
northern border and commit $2.6 million dollars to ensure that a second
wave of disease did not enter the country.26 Additionally, the French-run
private hospital that was the site of the first case, was immediately
isolated. This move probably stemmed the spread of infection. More
broadly, the Vietnamese government focused on curbing disease rather
then protecting the economy. In contrast, Canadian officials appeared to
be more concerned with the short-term impact of a travel advisory on
tourism, retail and other industries, even though the epidemic appeared
to have spread through the community and to other countries partially
because the Canadian health authorities had ignored a WHO advisory
that all departing passengers from Toronto be screened by medical
personnel.27 Vietnam’s example indicates that an open political
commitment to curbing disease may be as critical to the public confidence
required to control an epidemic as any medical treatment or vaccine.28
The fact that the Vietnamese government is relatively illiberal might also
make its example more saleable to authoritarian regimes otherwise less
inclined towards global cooperation.
Finally, the systematic refinement of the role of government services
and personnel from outside the ordinary circle of emergency public-
health functions could significantly improve response capabilities.
Ultimately, the public health system was able to curb the transmission
and the morbidity of the SARS and monkeypox epidemics with
techniques that have long been practiced. These include prompt detection
of cases, immediate isolation, strict infection control and vigorous
tracing.29 Indeed, the overall response frequently crossed the line
between public health and hard security. Schools, hospitals and borders
were closed. Tools designed for tracking criminals were implemented to
identify and trace those who may have been exposed to the pathogen.
The military, in some cases, was called in to assist in identifying
individuals and enforcing quarantine orders. Prompted by the recent
crises, governments should study the ways in which peripheral services
were employed, determine how to optimise their participation in future
crises and institutionalise prescribed practices.

Weaving a tighter global net

In the intensified security environment of the post-11 September world,
much attention has been placed on preparing for what was previously
thought to be unimaginable. Threats of impending biological terrorism
have resulted in plans to develop and procure vaccines that it is hoped will
 SARS: A Warning 219

provide an invaluable tool in the fight against an emerging infection of

natural or artificial source.30 Stockpiles of these medications are being
stored to guard against potential attack. The US Strategic National
Stockpile, overseen by the Department of Homeland Security, is designed
‘to ensure the availability and rapid deployment of life-saving
pharmaceuticals, antidotes, other medical supplies, and equipment
necessary to counter the effects of nerve agents, biological pathogens, and
chemical agents’ and was allocated $300m in the president’s FY2003
budget. Comparable amounts were estimated for FY2004.31 In addition,
several governments are accumulating enough smallpox vaccine to
immunise populations in the event of an attack with the
US acquiring at least 289 million doses by the end of A global
2002.32 Vaccines for anthrax, plague, tularaemia, Q fever
and other pathogens that could be used in bio-weapons ‘system’ of
are in various stages of development. 33 However,
focusing only on remedial and preventive tools at the surveillance
expense of mechanisms to facilitate their most efficient
distribution will leave countries acutely susceptible to does not imply
attack. Only by developing the capacity to connect the
appropriate medications and vaccines in time and place a single type of
with disease outbreaks will there be definitive
movement toward a true ‘bioshield’.34 To enable all the infrastructure
parts to work together, the capacity of global health
surveillance needs to be improved with a concerted embracing the
effort directed towards detecting emerging disease
both domestically and internationally in the most entire world
efficient way possible. A real-time epidemiological
system designed to identify changes in the background health of a
population would enable governments to capitalise on the current body of
epidemiological knowledge of infectious diseases management.
A global ‘system’ of surveillance, however, does not imply a single type
of infrastructure embracing the entire world. Any such expectation would
be politically unrealistic. Each region or country will need to design a
system that best suits the legal, economic, social and cultural nuances of its
situation. The various players – governments, private industry, public
entities and legal establishments – will then need to communicate and
cooperate to meet the common aim of increased disease detection and
response. Improved global surveillance and inter-governmental
coordination will likely be aided by technological advances and by
multilateral bodies that help increase the number and refine the training of
medical and public health professionals as well as cultivate an environment
where communities can communicate multilaterally, and both formally and
220 Elizabeth M. Prescott

informally. Currently, the technological issues are being addressed by

agencies such as the US Department of Defense, the WHO and US
National Institutes of Health (NIH), all of which are looking for ways to
track and gather information on public health that can
The amount be used to detect aberrations in global health.35 These
technological advances should be augmented by
spent on improvements in the global public health workforce.
Additional and appropriately trained medical and
public health public health professionals, equipped to deal with the
appearance of unknown pathogens, will be crucial.
surveillance in These professionals must be encouraged to establish
working relationships between domestic agencies and
the US is the across international boundaries in order to facilitate the
rapid communication and responses that would be
total amount necessary in a time of crisis.
Further, informal lines of communication between
spent per professionals and the public need to be fostered. The
role of the media and personal communication in the
person on all SARS epidemic demonstrates the importance that
these mechanisms can have in disease identification
health care in and control. Early ‘rumours’ and text messages
bouncing among millions of Chinese cell phones were
some African the first signs that a ‘fatal flu’ was taking grip in
Guangdong province.36 In fact, about 40% of disease
countries outbreaks later identified by the WHO are first
recognised through a system designed to scour the
Internet for hints and rumours of emerging diseases.37 This allows early
identification or refutation of any mounting suggestions of illness while
also providing a non-formal channel of notification. The media, with its
global pervasiveness, will remain a useful tool for bringing together
global stakeholders and play a crucial role in public health preparedness.
But there is a balance between transparency and security that must be
struck in order to reassure the public that they are safe against bio-
terrorist attack while ensuring that terrorists are not apprised of
exploitable weaknesses in the public health infrastructure.
Additionally, tailoring methods of disease control to specific
countries, regions and cultures needs to be explored. The amount spent
on public health surveillance in the US (about $2 per person per year) is
the total amount spent per person on all health care in some African
countries, yet it is in these countries where infectious diseases are most
likely to first appear. Increasing the global capacity to detect disease in
real time will hinge on the ability of developed countries to assist
 SARS: A Warning 221

developing countries with creating infrastructure, educating local public

health professionals and implementing appropriate technology to enable
identification and control of infectious disease. While a daunting task,
especially combined with the many other health challenges in developing
countries, it should be possible to improve dramatically the standard of
epidemiological surveillance around the world by emphasising the reality
that pathogens of the developing world are becoming indistinguishable
from those of the developed world, and that cooperative efforts will
therefore benefit all participants.
There are salutary signs that this message is filtering to the top. The
infectious disease community is keenly aware of the intimate link
between disease surveillance and global security. In the US, a significant
amount of the money dedicated toward bio-terrorism preparedness has
ended up under the control of National Institutes for Allergy and
Infectious Disease (NIAID), which is part of the NIH. The FY2003
presidential budget allocates $5.9bn for defence against biological
terrorism, with $1.75bn going to NIAID to focus on basic and applied
research.38 NIAID has gone to great lengths to stress the
interconnectedness of infectious disease and bio-security, recognising the
need to strengthen the capacity of the US public health system to identify
and respond to infectious disease outbreaks, whether intentional or
natural.39 The relationship is becoming more apparent within the policy
and security communities as well. After the SARS outbreak, identical bills
were introduced to the US Senate and US House Committees on Foreign
Relations focusing on the need to train individuals around the world in
order to create more local capacity to deal with emerging disease.40
Additionally, the SARS epidemic was prominent in discussions at the
WHO’s 56th World Health Assembly (WHA) where the International
Health Regulations that constitute the legal framework for global
surveillance and reporting of infectious disease are currently undergoing
substantial revision.41 The regulations to date have required the reporting
of only three diseases – yellow fever, cholera and plague. Further, a
resolution was passed at the WHA granting the WHO the authority to
verify disease outbreaks though official and unofficial channels allowing
for ‘on the spot’ investigations to determine the severity of outbreaks.42
This is a major step towards enabling rapid reaction to disease outbreaks
as well as addressing emerging infections on an international and inter-
governmental level.43

SARS: a wake-up call

Much as a vaccine is designed to prime the immune system against a
future microbial threat, natural disease outbreaks should raise awareness
222 Elizabeth M. Prescott

of the need for enhanced and more comprehensive global public health
surveillance. SARS, having piggybacked its way around the world under
a veil of secrecy and fear, demonstrates that a country’s health and
economy are only as robust as the weakest global link. This has forced a
much-needed reconsideration of the implications of global health on local
security. Meanwhile, the appearance of monkeypox – previously confined
to the jungles of Africa – in the heartland of America has provided a
timely test of how a ‘developed’ public health system would cope with an
unannounced threat.
Clearly it is impossible to eliminate completely the risk of biological
agents ending up in the hands of those who desire to use them for malign
purposes; society must learn to understand and live with the risks. The
focus must turn to minimising the impact of all pathogens regardless of
source by strengthening the global capacity to deal with disease. A
comprehensive plan of global health surveillance is needed, through
which infectious disease can be detected and responded to in an
expedient and efficient manner, so that society will be able to decrease
the burden of natural illness while simultaneously preparing for a
possible crippling biological attack. Increasing the sensitivity of a health
care system is a crucial step in the early detection, diagnosis and
treatment of disease of both natural and intentional origins. In addition,
a strong public health system should simultaneously diminish the
incentive for the use of biological weapons by undermining the degree to
which these agents can disrupt and devastate society. The emergence of
SARS should be viewed as very realistic dry runs for the unfortunate day
when an outbreak may be of more sinister origin and could potentially
have an unpredictably devastating impact.

Acknowledgements
Research conducted by Genevieve
Lester and other IISS-US staff
contributed significantly to the
preparation of this article.
Notes
1
R. Stein, ‘Infections Now More
Widespread: Animals Passing them to
Humans’, Washington Post, 15 June
2003, p. A01.
2
‘Smallpox Surveillance – Worldwide’,
Centers for Disease Control and
Prevention, Morbidity and Mortality
Weekly Report (henceforth CDC
MMWR Weekly), 24 October 1997,
46(42) 990–994. Information on the
efforts to eliminate smallpox can be
found in J.B. Tucker, Scourge: the Once
and Future Threat of Smallpox (New
York: Atlantic Monthly Press, 2001).
3
Institute of Medicine, Microbial Threats
to Heath: Emergence, Detection and
Response. (Washington DC: The
National Academies Press, 2003)
4
J.B. Tucker, talk at the US Institute for
Peace entitled ‘Biosecurity: Assessing
Strategies to Prevent the Misuse of
Dangerous Pathogens’, 18 June 2003.
5
For a detailed description of the
unfolding outbreak, see the WHO
document ‘Severe acute respiratory
syndrome (SARS): Status of the
outbreak and lessons for the
immediate future’, 20 May 2003,
http://www.who.int/csr/media/
sars_wha.pdf.
6
Data is from WHO ‘Update 83 – One
hundred days into the outbreak’, 18
June 2003. http://www.who.int/csr/
don/2003_06_18/en/. For reference,
the death rate for influenza is about
2–3% (CDC), plague 11% (WHO) and
smallpox about 30% (WHO).
7
‘Severe Acute Respiratory Syndrome
(SARS): Status of the Outbreak and
Lessons for the Immediate Future’,
WHO, 2003.
SARS: A Warning 223
8
R. Nowak and D. Mackenzie, ‘Too
Soon to Celebrate’, New Scientist, 5
July 2003, pp. 10–11.
9
Ibid.
10
K. Reed, J. Melski, E. Stratman. ‘Index
Case and Family Infection of Monkey
Pox from Prairie Dogs Diagnosed in
Marshfield, WI (Clinical Photos)’,
May–June 2003.
11
MMWP Weekly, 13 June 2003, 52(53);
537–540, http://www.cdc.gov/
mmwr/preview/mmwrhtml/
mm5223a1.htm
12
R. Weiss, ‘Monkeypox Cases Increase
to 37 in Midwest; State, Federal
Response to Outbreak Debated by
Health Officials’, Washington Post, 10
June 2003, p. A02; S. Mitchell,
‘Monkeypox shows Gap in Bioterror
Readiness’, United Press International,
12 June 2003.
13
Y.J.F. Hutin et al. ‘Outbreak of Human
Monkeypox, Democratic Republic of
Congo, 1996-1997’, Emerging Infectious
Disease, vol. 7, no. 3, May–June 2001,
pp. 434–438.
14
CDC, ‘Updated Interim CDC
Guidance for Use of Smallpox
Vaccine, Cidofovir, and Vaccinia
Immune Globulin (VIG) for
Prevention and Treatment in the
Setting of an Outbreak of Monkeypox
Infections’, 25 June 2003, http://
www.cdc.gov/ncidod/monkeypox/
treatmentguidelines.htm
15
M.J. Powers and J. Ban, ‘Bioterrorism
Threat and Preparedness’, The Bridge,
National Academy of Engineering,
spring 2002.
16
WHO document, ‘Sever acute
respiratory syndrome (SARS): Status
of the outbreak and lessons for the
immediate future’.
17
Epidemiological Services and
Response which allow the continued
preparation and response to ‘both
acute (disease outbreaks) and chronic
threats to the nation’s health’ received
$76.158 million in the FY ’04 estimate,
224 Elizabeth M. Prescott
down $1.975 million from the FY’03
President’s Budget of $78.113 million.
Infectious Disease Control, which
focuses on improving the ‘nation’s
ability to target, control and prevent
outbreak of infectious disease both in
the US and abroad’ went down from
$334.733 million in FY’03 President’s
Budget to $331.640 million in the
FY’04 estimate, a loss of $3.093
million. http://www.cdc.gov/fmo/
CDCATSDRBudgetRequestFactSheet.pdf,
http://www.cdc.gov/fmo/
FundingbyBudgetActivityTable.pdf
18
Of the amounts $1.5bn allocated for
terrorism in FY2003, $100m is to
purchase additional smallpox vaccine,
$300m for the Strategic National
Stockpile and $20m for necessary
security upgrades at CDC facilities.
Some $16m will go to upgrade
internal preparedness and response
capacity and to better plan for
potential biological, chemical, disease
and radiological threats, and $945m to
help upgrade state and local agencies
preparedness and response capacity.
19
M. J. Powers, ‘Deterring Terrorism
with CBRN Weapons: Developing a
Conceptual Framework’, Occasional
Paper #2, Chemical and Biological
Arms Control Institute, Washington
DC, February 2001.
20
Speech by Julie Gerberding, Director
of the Centers for Disease Control
and Prevention at the American
Society for Microbiology General
Meeting in Washington DC May 2003.
21
The terminology is from works by C.
F. Chyba: ‘Biological Terrorism and
Public Health’, Survival, vol. 43, no.1,
Spring 2001, pp. 93–106; ‘Toward
biological security’, Foreign Affairs,
May/June 2002, pp. 122–136;
‘Biological Security after September
11th’, Stanford Journal of International
Relations, Fall–Winter 2002, vol. 3, no.
2, pp. 12–15, http://
www.stanford.edu/group/sjir/
22
Mitchell, ‘Monkeypox Shows Gap in
Bioterror Readiness’.
23
J. Pomfret, Disease Expert Praises
Chinese Response’, Washington Post,
12 June 2003.
24
E. Eckholm, ‘Spread of SARS Acts as a
Rude Awakening for China’, New
York Times, 12 May 2003. Once the
Chinese went public on the issue, the
government response was in stark
contrast to what might have
happened just a few years ago. The
experience shows how much China
has changed, while also showing how
much further they need to go in
openness in government and
communicating with the public.
25
‘Sever Acute Respiratory Syndrome
(SARS): Status of the Outbreak and
Lessons for the Immediate Future’,
WHO, 2003.
26
‘How Vietnam Beat the Bug’, CNN, 28
April 2003 http://www.cnn.com/
2003/WORLD/asiapcf/east/04/28/
sars.vietnam/index.html
27
‘Toronto Mayor Rails Against WHO
Warning’, CBC News, 24 April 2003;
‘SARS Experts Say WHO Advisory an
“Overreaction”’, CBC News, 24 April
2003.
28
See Marilyn Chase, Barbary Plague: the
Black Death in Victorian San Francisco
(New York: Random House, 2003).
29
Chase, Barbary Plague.
30
Information on President George W.
Bush’s plans to protect against
chemical and biological weapons can
be found in ‘Fact Sheet: Bush Plans
Protections Against Chemical,
Biological Weapons’ at http://
usinfo.state.gov/topical/pol/arms/
03020333.htm
31
More information on the NPS can be
found at http://www.bt.cdc.gov/
stockpile/
32
‘Canada to stockpile smallpox
vaccine’, CBC News, 4 February 2003;
‘UK Stockpiles Smallpox Vaccine’,
BBC, 12 April 2002; US data from
 SARS: A Warning 225

http://www.hhs.gov/news/press/ csr/ihr/en/. Information on the 56th

2002pres/20020329.html World Health Assembly held on 28
Information on the US efforts to May 2003 in Geneva can be found at
supply smallpox vaccine can be found http://www.who.int/mediacentre/
at http://www.smallpox.gov/ notes/2003/npwha3/en/
33 42
P.K. Russell, ‘Vaccines in Civilian The resolution (WHA56.28) can be
Defense Against Bioterrorism’, found at World Health Assembly IHR
Emerging Infectious Disease, vol. 5, no. Revisions http://www.who.int/gb/
4, July –Aug 1999, pp. 531-533. EB_WHA/PDF/WHA56/ea56r28.pdf
34 43
The term ‘BioShield’ generally refers ‘Key Steps forward on International
to a programme put forward by Health Rules To Support Rapid
President George W. Bush in his 2003 Response to Public Health Threats’,
State of the Union address. WHO, 2003, http://www.who.int/
35
Institute of Medicine, Microbial Threats mediacentre/releases/2003/prwha7/
to Heath: Emergence, Detection and en/
Response. (Washington DC: The
National Academies Press, 2003)
36
A. Zeitlin, ‘SARS and the Chinese
Media: A Brief Opening’, China Brief,
vol. 3, issue 13, 1 July 2003, published
by The Jamestown Foundation.
37
‘Severe Acute Respiratory Syndrome
(SARS): Status of the Outbreak and
Lessons for the Immediate Future’,
WHO, 2003.
38
More information on President Bush’s
FY2003 distributions for homeland
security expenditures is available at
http://www.whitehouse.gov/
homeland/
homeland_security_book.html. For
information on NIAID’s portion, see
http://www.niaid.nih.gov/
biodefense/about/default.htm
39
Statement By Anthony S. Fauci,
NIAID Director, ‘NIAID’s Role In
Biodefense’, at http://
www.niaid.nih.gov/biodefense/
about/directors_statement.htm
40
S.871 Global Pathogen Surveillance
Act of 2003, introduced into the US
Senate, 10 April 2003; H.R.2329 Global
Pathogen Surveillance Act of 2003,
introduced into the US House of
Representatives, 4 June 2003.
41
More information on the
International Health Regulations
adopted by WHO Member states can
be found at http://www.who.int/
226 Elizabeth M. Prescott