Designated hospitals
Kimma Chang suggests: "Rather than having every hospital become a 'SARS hotbed,' why not follow the example of Singapore? There they require that people with fevers call a special hotline, after which patients are picked up by ambulance according to a computer generated priority system and taken to a specially designated hospital. Then they undergo meticulous screening and diagnosis at the designated hospital to determine whether they are in fact SARS cases, whether they need to be kept for observation, or whether they need to be treated in a negative-pressure isolation room."
Chang notes that Singapore's designated SARS hospital has separate floors for preliminary diagnosis, suspected cases, probable cases, and serious cases, and is provided with the best possible equipment for quarantine and treatment. On the one hand this minimizes the risk of the disease spreading more widely, and on the other patients know that they will be able to rest easy and get the best possible care there, and don't have to, as they do now in Taiwan, get moved around from place to place.
Of course, it is asking a lot of any hospital to be a designated SARS hospital, and it is a rather terrifying prospect for the staff there. For this reason all hospitals should contribute to the staffing of the special facility in rotation-time spent caring for patients, a 'vacation' in quarantine, and then a return to their original hospitals. Staff must also be provided with the best possible protective gear and financial bonuses, so that the sense of anxiety felt by caregivers can be reduced to a minimum.
Identifying and isolating cases is only the first step, however. The second step is isolating all those with whom they have come in contact.
Stay put!
Theoretically, except for a small number of "superinfective" individuals, in general SARS is not that infectious. "Only about 4% of people living with SARS victims actually get SARS themselves," says Chen Chien-jen, a member of the Academia Sinica, who took over the job of minister of health only in mid-May, right in the heat of the crisis.
But this does not change the fact that those who have been in contact with a SARS victim are the highest risk group, and should be quarantined, and this policy must be rigorously executed without exception. Success in this endeavor depends to a large extent on the public-mindedness of citizens and their willingness to obey the law.
Before the disease began to spread widely, many citizens did not take the home quarantine rules seriously. Fortunately, as waves of new infections have struck, people now increasingly accept the logic of the policy of "isolating oneself to protect others." When the Huachang housing complex was sealed, there was little protest or complaint, despite fears that quarantined individuals might lose their jobs or that their children would fall behind in school. Beginning on May 20, a "telecom monitoring system" was launched for the 12,000 category A people (i.e. persons who had been in direct contact with a known SARS case) to prevent them from "sneaking around" and posing a risk to society.
Regrettably, even as the country was getting tough on domestic quarantine, in mid-May a doctor from Mackay Memorial Hospital caused an international incident when he showed SARS symptoms while in Japan. Assuming that he only had the flu, he took some cold medicine and finished his travel itinerary, only later discovering that one of the patients he treated in hospital later died as a probable SARS victim. Japan was furious and Taiwan had to issue a formal apology.
While the furor caused by this particular incident has cooled, it highlights the need to raise awareness and civic-mindedness among medical professionals and citizens as a whole, and raises issues of balancing individual rights against public safety.
Not a very catchy field of study
Stepping back for a moment from the immediate struggle at hand, objectively speaking what advantages and disadvantages does Taiwan have in coping with a situation like the present one compared with those countries which are now fighting the same epidemic?
"Our weaknesses are in fact a product of our original strengths," says Twu Shiing-Jer, minister of the ROC Department of Health. Over the past half century, Taiwan has successfully eradicated various communicable diseases like smallpox, cholera, malaria, and polio, and its accomplishments in the field of public health are widely recognized.
But the downside of having conquered these illnesses is that the number of patients is constantly falling, so most young doctors prefer to specialize in growth fields like illnesses of advanced industrial societies or problems of the elderly. Virology, bacteriology, and epidemiology are considered "sunset subjects." The result is that there has been no one to take the baton from the previous generation, and gatherings of specialists in these fields can be mistaken for meetings of a senior citizens group.
Moreover, various specialized medical centers that formerly carried the ball for epidemic illnesses-such as the hospitals dedicated to tuberculosis, leprosy, and even sexually transmitted diseases-have been compelled by market forces to close or restructure. Though the general hospitals that have replaced them have state-of-the-art facilities, they do not have an adequate number of negative pressure isolation rooms with independent climate control. And while several teaching hospitals have invested heavily in electron microscopes for studying viruses, these have not been used or maintained in so long that they have become useless.
With little experience dealing with epidemics, today's officials, hospitals, and citizens have let their guard down. During the enterovirus epidemic in 1998, there was a major controversy because the government delayed notification of the threat. While this is not the case with the SARS epidemic-there are press conferences almost every day at every level of government from the premier down to local government officials, as well as at all major hospitals, so that there is considerable information available-SARS has still had an impact of unprecedented scope, with related issues that include the quarantine of over 10,000 people, sealing of hospitals and neighborhoods, closing of schools, creation of dedicated facilities, proper use and distribution of masks and protective clothing, and economic aid to affected industries. One official admits, "We are all improvising as we go," hoping to find the best approaches through trial and error.
Shared fate across the strait?
Since there is currently no medication to treat SARS, the only effective strategy is to keep people away from affected areas, to isolate infected persons, and to not give the virus any chance to find new hosts so that it dies out naturally. But given the state of the epidemic in mainland China, this could be a problem.
Lee Ching-yun, a professor emeritus at National Taiwan University medical school, who is known as "the father of epidemiology in Taiwan," says with a sigh that Taiwan has really been too intimate with the mainland. Even in mid-May, there were many travelers back and forth. In fact, as of May 20, more than 25,000 Taiwanese had returned to Taiwan from seriously affected areas like Hong Kong and Guangdong; fortunately, there have been no reports of any infections as a result.
Indeed, the epidemic seems to be nearing its end on the mainland. Meanwhile, the number of cases in Taiwan continues to climb. Is there no end in sight?
"There's no need to be pessimistic," says Chen Hour-young, a researcher at Taiwan's Center for Disease Control, which is in charge of monitoring the virus. No matter how much a coronavirus mutates, it is still just a type of cold, and as everyone knows, the number of cold sufferers drops dramatically as soon as summer arrives. So we can likewise expect the SARS virus to chill out.
You've had it... maybe
Chen Hour-young says that the three main indicators for whether an epidemic will spread are weather, antibodies, and pathogens.
The SARS virus' level of activity and lifespan both markedly decline at temperatures over 35 degrees Celsius or humidity over 60%. This is especially the case in well-ventilated spaces, where the virus will die in less than half an hour under these conditions.
Antibodies are another reliable indicator of an epidemic. SARS may be frightful, but the fact is that some people are unaffected by a virus no matter how ferocious it may be, and will not become seriously ill.
Look for example at the enterovirus-71 epidemic in 1998. Because this type of virus had not existed in Taiwan for a long time, most children lacked natural antibodies, and the epidemic left 78 children dead and more than 400 others impaired for life. But three years later, a survey by the Center for Disease Control showed that 68% of 15-year-olds had antibodies to enterovirus-71, indicating that many people had caught the virus but never even realized it.
With such precedents, will SARS turn out the same way? Former CDC director Chen Tzay-jinn points out that while at present the death rate from SARS is about 10-20%, this could be a serious overestimate. Because there is as yet no comprehensive system for testing for antibodies, the national infection rate-the number that experts are most interested in-remains a mystery. "Since we don't really know how many people have been infected nationwide, how can we calculate the rate of fatalities?"
Chen says that in Guangdong, where strict quarantine measures have not been taken and public health resources are inadequate, the epidemic has apparently begun to naturally slow down on its own. Does this mean that most people have been mildly infected and their bodies have produced antibodies, so that the virus cannot find any "fresh" victims without natural defenses, and therefore is retiring from the field?
All-out prevention, normal life
As for tracking pathogens, often they can be traced through so-called "intermediate hosts." For dengue fever, for example, every summer the health authorities conduct a search for areas with high numbers of the kinds of mosquitoes that carry that illness as a clue to which areas are most at risk.
Unfortunately, with SARS being passed directly from one person to another, a lack of intermediate hosts means a lack of indicators for monitoring, warning, and quarantine. At present it is widely believed in the medical community that after this first appearance by SARS, in which it has taken 600 lives worldwide, it could very well become a localized illness that periodically resurfaces in mini-epidemics. If this is the case, then Taiwan, which is a high-risk area, urgently needs to construct an effective system for monitoring and studying epidemic illnesses, so that when the next one hits we will be ready.
With great uncertainty still surrounding the epidemic, should Taipei be "sealed up" and everyone put under quarantine? Should Taipei really shut down all businesses, schools, and public venues and halt all commercial activities to create a "vacuum" for ten days in order to bring the virus down? Faced with conflicting demands and advice, former CDC director Chen Tzay-jinn borrows the advice of Singapore senior statesman Lee Kuan-yew: "Full-scale prevention, normal life." He hopes that citizens will remain calm and not act irrationally.
While disease is indeed frightening, if the critical factors can be identified and the policies based on this identification rigorously implemented, then the harm caused by SARS will be kept to a minimum. Let us hope that when the tide of SARS recedes, the Taiwan society that surfaces will be a more coherent, more tolerant, and more mature one.
@List.jpg?w=522&h=410&mode=crop&format=webp&quality=80)
