It's a Small World after All:
Ethics and the Response to SARS
By Jeffrey Kahn
University of Minnesota

As I sit writing this, I have a scratchy throat, watery eyes, a faint headache and the beginnings of congestion in my head-maybe even a slight fever. Oh, and I've been on an airplane more than a few times over the past month. So my first worry isn't that I've got a classic spring cold, but that I have something far more sinister.

The outbreak of SARS, the viral respiratory ailment, is having wide-ranging impacts on public health, public confidence, and the world economy. Responses to infectious disease outbreaks are a test of the public health infrastructure not only in individual countries and localities, but also in terms of the international sharing of information and linked responses. In that sense, SARS is the first test for the post-9/11 world, and drives home the point that public health in the twenty-first century is a truly global issue requiring global responses in a world made increasingly smaller by easy and efficient travel. As I write, the World Health Organization (WHO) updates almost daily its recommendations against "nonessential" travel to infected areas.

How best to attack an illness like SARS? Identification and isolation of cases of infectious disease are the longstanding tools of public health, but they are notoriously difficult to implement effectively and raise obvious ethical concerns around coercive isolation and even quarantine. The fact that President Bush used his executive authority to add SARS to the list of illnesses for which the state can impose mandatory quarantine is evidence of the raw exercise of state power that quarantine represents.

An illness that spreads through the air is a public health nightmare, but controlling one whose symptoms parallel the common cold means that isolation outside of hospital settings is practically impossible. Efforts in cities like Toronto make the point. After the infection was apparently passed among the largely Filipino members of a church, authorities recommended that those with any SARS symptom stay home, and that those in worship settings change their practices—including restrictions on close contact like hugging, handshaking, and drinking from common cups. This isn't isolation or quarantine, but it affects religious freedom. And as the outbreak continues to be perceived as affecting the Asian community, stigma follows close behind, with Chinatowns and other centers of Asian population turning into veritable ghost towns.

The most effective tool in fighting SARS has been and will continue to be international cooperation and accurate and wide sharing of information with both the public and public health professionals. In this spirit, WHO is coordinating a virtual global virology laboratory with daily conference calls to share information, each starting with greetings of "good morning, good day, good evening"—evidence of their truly global nature.

The opposite example is the Chinese government, which has been criticized for grossly underreporting cases. As the New York Times editorialized (17 April 2003), "Information is a necessary disinfectant. It cannot be put to use in societies where everything is perfect by decree." China seems to have acceded to pressure and is beginning to report more accurately the scope of SARS across the country. Since SARS is in some respects a dry run for the world's response to a terrorist attack using smallpox or other infectious agent, the stakes are even higher for the coordination of the public health response.

But even with coordinated responses, questions remain. Can the outbreak be controlled and effectively eradicated, or will it cycle across the world seasonally like the flu? Will it remain a bigger problem in some parts of the world than others or become a true pandemic? Whatever the answers to these questions, public health and its policies, with all their ethical implications, will play a key role in an increasingly smaller world, in which failure will come at the price not only of health, but of public confidence and trust.

This essay appears in the May-June 2003 issue of the Hastings Center Report.