(Un)Civil Societies Report: May 19, 2003

19 May 2003, Volume 4, Number 12

IN FOCUS

SARS SPREADS FROM SOCIETY'S WEAKNESSES... Since its discovery in the Chinese province of Guangdong in February 2003 severe acute respiratory syndrome (SARS), as of 17 May had infected a known 7,661 persons of whom 623 have died worldwide, mainly in China (525; 243 in Hong Kong), Taiwan (35), Singapore (28), Vietnam (5), and Canada (23), according to the World Health Organization (WHO). In Eastern Europe, one suspected case has been reported by WHO in Bulgaria and one other in Romania as well as one in Poland. In Russia, where there have been several dozen cases feared, so far only one case in Blagoveshchensk is suspected strongly of being SARS. Nevertheless, given the region's history of suppression of press freedom and government information, its long border with China, and deteriorating health services in the last decade, there are fears that the disease could spread quickly (see "Russia: Does the Poor Health Infrastructure Leave It Vulnerable to SARS?" rferl.org, 7 May 2003).

As a WHO official explained, "Where there is no information flow, SARS can easily take hold, and then it is very difficult to contain," IRIN, the United Nations news agency, reported on 8 May. Meanwhile, heavily centralized and even repressive systems in the types of societies that repress the free media, such as in Vietnam and Singapore, have, in fact, contributed to stopping the disease. The chief merits of two types of society -- the security needed for stability in a closed society versus the flexibility needed for innovation in an open society -- will continue to be debated, as they have for decades. Yet, now these discussions seem almost beside the point in the face of new challenges like SARS. Paradoxically, both centralized and strong protective measures and even the temporary emergency suspension of human rights have been required as well as transparency and individual initiative to eradicate the disease.

Like Chornobyl's radiation and AIDS before it, SARS has attacked societies at their weakest points. The secrecy spawned in Soviet police states that continues in government practices -- perceived as their weaknesses -- involves suppressing crucial health information if it appears to denigrate the state's abilities to protect public health. The instinct is to close ranks and protect the system's incompetent officials regardless of the damaging effect. Media reporting is controlled, people are unable to make decisions for themselves to avoid risks, initiative is punished rather than rewarded and, without feedback, the centralized system breaks down from the strain of coping. Yet those very same features of state security and secrecy in controlled, closed, or semiclosed societies that cause disease to spread are often the means used to stop the spread of disease and are often effective -- so effective that open societies reach for them, too, in a crisis.

On the one hand, China's heritage of the communist-style closed society and its takeover of Hong Kong and nonrecognition of Taiwan were factors obstructing the containment of the virus, wrote Ellen Bork in "The New York Sun" on 10 April. Four months went by before China began to admit SARS was a problem. Later, Bork notes that the Beijing-appointed chief executive, C.H. Tung, "behaved like a cheerleader for Hong Kong, downplaying fears, praising the efforts of local scientists rather than alerting the public to the problem or demanding cooperation from his comrades on the mainland." Two weeks went by before schools were closed or quarantines imposed in Hong Kong when the disease was discovered to be spreading, while the secretary for health was blaming WHO for "sowing discord." Even today, China continues to remain defensive. "You can see how much trouble the Hong Kong government created for itself after it made everything public.... They didn't have the ability to control and handle the disease, so what good was it to make everything public?" Bork quoted the deputy governor of Guandong as saying recently. She cites another Chinese official involved with negotiating China's accession to the World Trade Organization, who criticized Hong Kong press coverage. The politics of nonrecognition of Taiwan have also hindered the crusade against the disease. Denied entry into WHO because it is not recognized by mainland China, Taiwan submitted its information about SARS directly to WHO unsolicited, although it was supposed to go via Beijing as a "province."

Yet, on the other hand, the positive features of open societies with their bustling market economies and the free flow of people, goods, and services also make them extremely prone to new epidemics, and the high cost and inequity of health-care delivery means that an adequate response is not ensured. SARS is the disease of the globalization era, where a person can hop on a plane, be in another country across the world within hours, and then fly again and take a disease to yet another country. That reality means that not only China's suppression of information can be cited as a factor in the spread of SARS or that, unfortunately, Western democracies can feel their systems are superior in coping with the threat. Freedom of movement is also a threat -- and stopping it has had economic as well as human-rights implications. Canadian officials were angered when WHO issued an advisory against travel to Canada in April, due to cases spreading out of control from a hospital -- angered not only because of decision making removed from their national sovereignty, but because of the implications for freedom of movement and business. (The warning was lifted on 29 April and subsequently it was declared that no new cases had appeared on 14 May). Some critics believed WHO's decision to urge travelers to avoid Canada was political, guided by a desire to balance the heavy criticism to which China and other developing countries were subjected to for mishandling the containment of the disease. Like the geographically-neutral term "SARS" itself, it appeared as if WHO was trying to be as critical of the "global North" as it was of the "global South" -- to enable WHO to make the argument to affronted Chinese officials that China was not being unfairly singled out.

While Chinese officials worried publicly about damage to their image and the erosion of their authority due to spreading panic, Canadian leaders were concerned about public health as much as the impact on tourism. Officials swiftly moved to devise methods to isolate the infection and take the proper precautions yet not wholly suppress freedom. Thus, even during the travel advisory, Canadian officials did not cancel major-league baseball games and even made discount tickets available to encourage people to come. The players of U.S.-based teams, the Kansas City Royals and the Texas Rangers, came to Toronto to be hosted by the Toronto Blue Jays, but avoided city excursions or touching fans, and used their own pens when autographing.

Thus, it would seem that freedom of information coupled with a willingness to find flexible solutions to the civil rights and economic implications of health-mandated suppression means the societies based on respect of individual rights would triumph in the battle against this disease. And yet another feature of the developed West rooted in the priority of the individual -- elaborate safeguards on the privacy of individual information, particularly health information -- was also cited by doctors as an impediment to the combat of SARS. Indeed, the strengths and weaknesses of universal health care funded by the state, as in Canada, versus the patchwork of private and public insurance plans and the presence of large numbers of poor uninsured persons in the United States, are also crucial factors in the handling of the disease.

In the U.S., the Health Insurance Portability and Accountability Act of 1996, which went into effect in April 2001 with a period of two years for compliance, unfortunately coincided with the onset of SARS in the U.S. The law was originally designed to address a common problem of the nonuniversal system, whereby workers changing jobs lose their health insurance. The law was also fashioned to prevent an invasion of privacy in order to deny insurance or employment, especially as more and more information is placed on institutional computer hard drives and begins to migrate from internal networks to the Internet. "The New York Sun" cited a New York City hospital official on 25 April who said a doctor who had referred a patient to the emergency room was later refused information due to the new regulations. "If that had been SARS, it could have impeded proper medical treatment," he was quoted as saying, particularly because there was still confusion about how the new rules should be applied. While protecting an individual's private information, the legislation is supposed to recognize "the legitimate need for public health authorities and others responsible for ensuring the public's health and safety to have access" to the information. Paradoxically, then, fearing state fines or patients' lawsuits, American doctors might tend to hide rather than disseminate information -- and for different motivations than their counterparts in China. Just as with the problem of travel bans, the solution appears to lie in juggling the balance between transparency for the sake of the common good versus misuse of private information to deny health care or employment.

...IS HALTED BY ITS STRENGTHS... A SARS scare at New York's JFK Airport last week illustrated the kind of increased vigilance and readiness needed to quickly isolate suspected victims of SARS, "The New York Times" reported on 7 May. A sick traveler from Pakistan turned to a medical van for help upon arrival, and the van driver immediately donned a mask and gloves and drove him to an isolated ward. Doctors withheld his name and some of his history to protect his privacy, but reporters were instantly following the case. The patient agreed to stay in the hospital overnight at the request of health officials so he was not held against his will, said "The New York Times," but there has been one case of this type already since the epidemic spread. The U.S. has 66 suspected cases; the JFK case turned out not to be one of them.

Nearly two dozen U.S. states recently revised public health laws to allow quick quarantine and isolation action in an emergency, "The New York Times" reported on 18 May. While doctors continue to have concern about capacity to receive many victims at once, and to then keep them in isolated rooms due to the great cost, preparations are steadily under way.

The implications are troublesome for the reform-minded in China and elsewhere in Southeast Asia. While their weaknesses in secrecy and cover-ups have been exposed by SARS, it is also the strengths of the Communist societies -- the ability to rapidly centralize government responses and command public compliance -- that have been cited in stopping the disease. The U.S. and other countries affected by the disease have also been compelled to implement stringent policies such as stopping persons entering the country who appeared to have SARS symptoms and forcibly detaining them to be quarantined. Communist countries that could go farther did -- in Vietnam, a key factor in curbing the disease was that all the medical personnel surrounding the first known case were kept in their hospital and not allowed to go home, as they did in other countries. North Americans as well as Vietnamese are contemplating special border machines that can tell the body temperatures of incoming passengers at airports. In China, officials announced that a new interpretation of existing law will even involve punishment of those responsible for spreading or hindering the prevention of the disease through imprisonment or even execution, the official government news agency Xinhua, as well as Western news agencies, reported last week.

Vietnam martialled an impressive response precisely because of its rigid centralized control, "The New York Times" reported on 8 May. The developed Western countries in Europe and North America may have the health infrastructure, the free media, and the flexibility to respond even to diseases that spread because of its openness, but the traditional communist societies in Southeast Asia have used their centralized control to the good to stop the disease in ways the West finds unacceptable.

It is precisely the society like Russia's that is caught between rigidity and reform that is likely to be the most vulnerable, especially given a heavy influx of Chinese economic migrants working as traders in the Far East. Even before SARS became known, the Russian government had expressed concern about Chinese guest workers and immigrants and a new law on foreigners was expected to be used to curb their numbers. As with other punitive efforts in a Russia caught midway in reform, it was likely to engender more corruption and noncompliance than not.

By taking the punitive approach, and either barring entry completely or rounding up migrants or immigrants already in place, Russian authorities run the risk of making possible victims of SARS even less likely to turn to the public health system for help when they are sick, and thereby spreading the disease. Still, no one could argue that monitoring migrants and closing borders with China was the right thing to do to reduce the chance that the disease would get a foothold in Russia. Deputy Health Minister and head of the State Health Inspectorate Gennadii Onishchenko announced restrictions on Chinese citizens entering the Russian Far East and Siberia, "Izvestiya" reported on 6 May. Shortly before Onishchenko announced the restrictions, Russian border guards temporarily stopped allowing Chinese citizens to enter Russia through the Amur River port of Blagoveshchensk, the newspaper reported.

Regional authorities have begun taking their own preventative measures: Khabarovskii Krai's governor has ordered the internal affairs directorate to stop approving invitations to citizens of countries with SARS cases and tourism agencies have been banned from sending children's groups to Southeast Asian countries. Surface-transport links and postal service with Taiwan, Hong Kong, and the rest of China was also implemented, RIA-Novosti reported (see "RFE/RL Newsline," 12 May 2003). Passenger and cargo traffic from China to Amur Oblast and its capital, Blagoveshchensk, has been completely halted. The costs of the cancelled tours and stalled business has taken a tremendous toll; an Aeroflot official said about $1 million a week is being lost (see "RFE/RL Newsline," 12 May 2003)

Weeks ago, Russia specialists analyzing the issue of SARS on "Johnson's List," a popular Internet discussion group, predicted that SARS could become a serious problem in Eurasia not only due to the long border with China but the tendency toward secrecy and bureaucracy and the poor health-care system. One U.S. health consultant argued that Russian ministries seemed to be aware of the dangers and seemed prepared to cope with them centrally and locally; other readers thought the capacity was not there. To date, the issue of secrecy in Russia is not as acute as in China. With the appearance of one case, "the bureaucratic machine began to pick up speed," polit.ru reported on 14 May -- in part because the Russian media -- freer than China's -- continues to cover the story criticically and ask hard questions. Officials issued orders to disinfect public transportation, conduct daily medical checks of children, and institute quarantine facilities at airports and railroads, RIA-Novosti reported. "Just in case, the bureaucrats decided to begin the disinfection with themselves; the hallways at the city government offices will be disinfected," said polit.ru -- and with that tongue-in-cheek comment comes evidence that bureaucratic evasiveness will be harder to get away with in Russia than in China.

SARS has compelled a need not only for governments to cleanse themselves but to be open about how the struggle is going in protecting the population and to move quickly, trusting experts and efficiently trading information locally and internationally. For this reason, Central Asian countries may face difficulties in stopping the disease due to obstruction of information and initiative as well as poverty. In Kyrgyzstan, the health minister appealed to the government to close the borders, akipress.org reported on 8 May (see "RFE/RL Newsline," 12 May 2003), but the process has not been instant. Although Chinese sources have said that a Kyrgyz citizen was treated for SARS, the Kyrgyz Health Ministry insists it knows nothing. Meanwhile, Kazakhstan, which shares the longest border with China, has virtually closed its border, IRIN reported on 8 May, with only Kazakhs entering who are being evacuated home from China. Some isolation hospitals are being prepared in Almaty. So far, WHO has not reported any cases in Central Asia.

...AS NEW APPROACHES TO CONQUER DISEASE MUST BE SOUGHT. Some Western commentators have cited the SARS crisis as an example of modern exigencies that will compel closed societies to open. Yet, Jasper Becker, a journalist writing for "The New Republic" from Beijing, says hopes for an increased liberalization and transparency in China, for example, due to the sobering realities of SARS, are misplaced. China appears to be returning to 1950s military-like campaigns to ensure conformity in professional health organizations and propagandistic celebration of its scientific prowess despite the lapses that led to the spread of SARS. Neighborhood committee leaders with red handkerchiefs tied around their arms are patrolling and reporting on fellow citizens, and police are checking cars to see if anyone is suffering from SARS symptoms. Doctors are discouraged from talking to foreigners outside of party-controlled lines. Although the mayor of Beijing and the health minister were fired for covering up SARS, causing some expectation of increased accountability, control over media and health professionals has been stepped up. Just as some economic liberalization in recent years has been accompanied by political crackdowns in China, SARS is unlikely to force major reform, says Becker.

Taken by themselves, neither the factors of press freedom and public accountability of Western and transitional democracies versus the willingness of traditionally more closed societies to use high degrees of centralization and force to control disease will determine the outcome in conquering disease. Siddhartha Mukherjee, another writer for "The New Republic" who is a clinical fellow at Harvard Medical School, has called for both increased international centralization and coordination of integrated surveillance systems coupled with national initiative and transparency in dealing with international organizations, following the proposal of medical writer Laurie Garrett, author of "The Coming Plague." Garrett has noted that looking for the old, known diseases like polio is not enough, and even the willingness of national health systems to gather and report data publicly is not enough. New systems must be devised to track unknown diseases and coordinate the analysis internationally. That means not just collating reports of diagnoses of old diseases, but getting health professionals to feed information about just the symptoms themselves, so that analysts can begin to see clusters, and also to report warning signs like increased patient visits to health facilities. Such a system would have to be run by an agency like WHO, and both bureaucratic inertia within such bodies, as well as resistance by its individual country members resentful of outside intrusion, will stymie an effective centralized struggle against new diseases. Still, Mukherjee says, "had an animated, pervasive syndromic-monitoring unit been on the lookout, it might have registered unusual death notices in Guangdong or even picked up rumors from hospitals in Beijing."

While it seems as if reporting every sneeze or increase in doctor visits could flood the system with meaningless data and could be technically impossible for lesser-developed countries, with such a system of "overreporting" of symptoms versus diagnoses, the pattern of SARS would have clearly emerged. What costs and difficulties could be involved to establish such a worldwide system? International protection systems for the environment or human rights or culture have proved to be riddled with politics and obstruction of all kinds, yet health is so basic to human life, reason some experts, and can cause such disastrous effects to economies, that there may be more motivation to cooperate in an international surveillance system, even requiring the deployment of monitors locally -- who of course will be under party control in a country like China.

The hope is also that doctors' own professionalism and their hunches will serve the system and keep it from being cluttered with extraneous data. The first doctor to die in Hong Kong, a lung specialist, suffering himself from vague fever and chills in February, told his colleagues to don masks and gloves while examining him and thus saved their lives.

Vietnam's success in curbing the disease combined the old techniques of centralization with the new techniques of transparent cooperation with outsiders -- WHO -- and more openness with information. A WHO official was quoted by "The New York Times" on 8 May as saying, "It was the speed, the leadership, the transparency, the flexibility, the intensity with which they [health officials] educated people [about] what to do" -- suggesting that not only lumbering communist-era bureaucratic instincts were at work.

Ultimately, combating the "globalization" diseases like SARS will require methods characteristic of both open and closed societies usually not found in one amalgam and which seem contradictory on their own. Democracies are faced with troublesome restrictions of human rights like freedom of movement and privacy in the name of public health and nondemocracies are faced with the inevitable need for freedom of information and accountability. All societies are faced with the high cost of providing health care for everyone. Regrettably, like all overwhelming threats, the disease is likely to cause countries to reach for past solutions that proved workable while harsh rather than to create something new and flexible for the future -- and yet flexibility will be rewarded with the halt of the disease at not too high a cost.

Aileen Plant, who led the fight against SARS in Vietnam for the WHO, summed up the issue of how to deal with treacherous new diseases: "This was real, old-fashioned infectious disease containment," "The New York Times" quoted her as saying on 7 May. "It all comes back to the same thing, which is stopping infected people from infecting other people." Whether by force or by freedom, those hoping to stop the disease must yield to its imperatives.