The SARS epidemic of 2002-03 provides another glimpse into the significance of emergent infectious disease as an agent of destabilization at both the domestic and international levels. During this outbreak, SARS generated significant levels of fear and psychological trauma in affected populations, impeded international trade and migration flows, and resulted in minor to moderate economic damage to the economies of affected Pacific Rim countries (particularly China and Canada). In this chapter, I argue that while the SARS epidemic may have generated moderate institutional change at the domestic level (particularly in China and Canada), it resulted in only ephemeral change at the level of global governance. In the domain of security, I argue that despite minor demographic effects, the epidemic generated moderate levels of fearinduced economic damage that constituted a direct threat to the material interests of affected states, particularly China, Hong Kong, and Singapore. Moreover, the epidemic possessed the potential to evolve into a global pandemic that might have generated much greater loss of life and economic damage, and thereby constituted a threat to international security.
Despite the fact that the SARS epidemic threatened the prosperity of seriously affected countries, and posed a grave threat to the health of populations in the region, it was successfully contained with relatively little mortality. Specifically, the epidemic resulted in 8,096 cases of infection (morbidity) and 774 deaths (mortality) between November 1, 2002 and August 7, 2003,1 exhibiting a mortality rate of approximately 10.88 percent of those infected. The SARS coronavirus is a novel zoonosis that recently crossed over from its natural animal reservoirs into the human ecology, presumably in late 2002.2 Specifically, the SARS coronavirus resides in bat populations in Southeast Asia,3 which bite and transmit the virus to palm civets (Paguma larvata), whereupon strains that infect civets possess a greater capacity to then infect individual humans and thereafter become endogenized within the human ecology.4
The moderate level of economic damage generated by the epidemic was not so much the result of the (relatively minor) morbidity and mortality that SARS induced, but emanated from the pernicious psychological effects (fear, anxiety, and panic) that the epidemic generated,5 both within infected areas and in uninfected populations. These significant levels of affect resulted in suboptimal economic outcomes for the entire Pacific Rim as tourism ground to halt, international trade flows were slowed, and foreign investors cautiously withdrew capital from the region during the crisis.
Literature on the political dimensions of the epidemic remains exceedingly sparse. The microbiologist Elizabeth Prescott argued that the SARS epidemic illustrates the increasingly acute nature of complex interdependence among countries in the domain of public health, and provides us with lessons that may help countries in their efforts to prevent bioterrorist attacks. She observed that the emergence of the contagion “illuminated significant and vital weaknesses in global and local preparedness for surprise outbreaks.”6 The political scientists Melissa Curley and Nicholas Thomas argued that infectious diseases (the SARS outbreak in particular) represented a significant and growing threat to human security in Southeast Asia. The legal scholar David Fidler has also conceptualized SARS as a threat to the material interests of the state, which aligns with the republican Realist model presented in this work.7 The emergence of the SARS pathogen in China and later in Canada demonstrates that both developing and highly developed countries remain vulnerable to emerging and re-emerging pathogens. Despite the (erroneous) Galenic notion that infectious disease arises solely from and within poor countries, and is only a scourge of the poor, SARS illustrates that disease is not simply a product of the inequitable distribution of wealth. In reality, SARS emerged to take advantage of specific changes in the relationship between its natural reservoirs and the human ecology of Southeast Asia. Its proliferation in Hong Kong, Singapore, and Toronto and illustrates the principal that developed countries are not immune to the deleterious effects of novel epidemic disease agents.
According to the political scientist Yanzhong Huang, the first SARS case “is thought to have occurred in Foshan, a city southwest of Guangzhou in Guangdong province, in mid November 2002.”8 The index case was the physician Liu Jianlun, who inadvertently fomented a global chain of transmission when he traveled to Hong Kong and stayed at the now infamous Metropole Hotel. Liu then infected other travelers who subsequently spread the disease throughout the Pacific Rim countries. On March 12, 2003, the World Health Organization issued a global outbreak alert and initiated international surveillance efforts to track the contagion. By that point the pathogen had spread throughout the countries of the Pacific Rim, with the greatest incidence of cases in China (5,327), followed by Hong Kong (1,755), Taiwan (665), Canada (251), Singapore (238), Vietnam (63), and the United States (33), respectively.9
Effective response to the epidemic was initially compromised by both psychological factors (fear, confusion, and denial) and bureaucratic ineptitude and corruption in China. Political elites in Guangzhou and Beijing conspired in a deliberate attempt to suppress knowledge of the epidemic in both the domestic and international arenas. Health officials in Beijing ordered that reports on the proliferation of the pathogen be classified as “top secret,” such that the disclosure or discussion of the outbreak constituted a direct violation of national secrets.10 The burgeoning epidemic generated profound levels of fear among the general Chinese population and warnings about the virus filtered out to the global community via the Internet. Despite such leaks, Beijing persisted in its attempts to mislead the WHO, as on February 27 the Chinese Ministry of Health declared the epidemic to be officially contained. In fact the disease continued its rapid proliferation throughout the population of Beijing.11 The Chinese façade disintegrated on April 4, when the head of China’s Center for Disease Control publicly apologized to the Chinese people, and to the international community, for failing to inform the public about a highly contagious and often lethal new pathogen.12 The full extent of Beijing’s duplicity became clear on April 9, when Jiang Yanyong, a prominent member of the Communist Party (and a physician), publicly accused the government of covering up the extent of the epidemic in Beijing.13
On April 16 the WHO took the unprecedented step of publicly chastising Beijing for misleading the global community as to the true extent of SARS infection throughout that country.14 Two days later Beijing announced a national “war” on the virus, and ordered all Communist Party officials to reveal the true extent of the epidemic or be held accountable for their deliberate obfuscation. On April 2), the Party leadership demanded the resignation of the Minister of Health, Zhang Wenkang, and the Mayor of Beijing, Meng Xuenong, for their complicity in the conspiracy.15 This move was seen as an attempt to deflect blame from senior party officials for their role in the crisis. On July 5, 2003, the WHO announced that the SARS epidemic had been effectively contained. Despite the fact that the international community successfully contained the spread of the virus in a relatively brief span of time, the medical community insists that it represented a significant global threat. The physician Thomas Tsang commented: “I think there was a possibility of being a global pandemic if the appropriate control measures were not taken.”16
As was argued above, contagion is historically associated with generating profound levels of affect (i.e. fear and anxiety) within affected populations, particularly in the face of a novel pathogen which generates great uncertainty and inhibits effective risk assessment. Uncertainty and fear result in suboptimal decision making which may in turn result in very real damage to a country’s material interests. The SARS epidemic provides a vivid illustration of this dynamic, as the emergence of the novel, virulent, and transmissible SARS coronavirus generated profound levels of anxiety and significant economic damage throughout the countries of the Pacific Rim. This fear was compounded by the fact that public health officials originally suspected that SARS might be a novel and virulent strain of influenza.
As a novel pathogen, SARS presented an enigma to public health personnel who were largely unaware of the symptoms, routes of transmission and effective prevention of transmission during its outbreak. This uncertainty resulted in diagnostic delays, misdiagnosis, and also put health-care workers at considerable risk. Infected health-care providers infected accounted for 21 percent of all cases, ranging from a mere 3 percent of reported probable cases in the United States to 43 percent in Canada. Witnessing that nurses and doctors were unable to protect themselves from the infection, the public developed a highly exaggerated estimate of their personal risk of being infected. Surveys conducted in Hong Kong during the period of contagion indicate that respondents experienced profound levels of negative affect, and psychological stress, as a result of the contagion.17 Echoing the contagionist responses of the past, Beijing’s draconian measures to control the flow of information, and persistent delays in reporting data, only served to magnify the levels of fear and anxiety afflicting the general population. By late April 2003, in a replay of the contagion-induced flights so common in the years of plague and cholera, an estimated million people (about 10 percent of the population) had fled Beijing for other parts of China.18 They would soon find themselves unwelcome even in their hometowns, perceived as vectors of pathogen transmission. In the countryside, worried villagers set up roadblocks to restrict the entry of refugees from Beijing, and a series of riots against rural quarantine centers were also reported in May 2003.19
The profound levels of epidemic-induced fear resulted in substantial negative economic impacts on affected countries, although such impacts were brief. The transmissibility of the pathogen, and the perceived risk of exposure through social interaction, induced significant behavioral change in affected populations. Consonant with the historical experience of influenza, social distancing techniques were utilized and people were cajoled into avoiding mass gatherings in public places. Moreover, the fear of contagion and the implementation of anti-epidemic measures also discouraged travel and interrupted transport services, inducing substantial declines in consumer demand, particularly in the service sector. Such adverse demand-induced shocks affected two industries in particular: retail sales and tourism. By mid April 2003, retail sales in Hong Kong had declined by 50 percent relative to mid-March indicators. Additionally, tourism arrivals from mainland China had declined by 75-80 percent, and the entertainment and restaurant industries had recorded an 80 percent decline in business. In general, the economic shock was far greater for those economies with a prominent service sector and which possessed a larger share of impacted industries (i.e., retail sale and tourism) within that sector. This may explain why Hong Kong, with its losses accounting for 2.9 percent of GDP, suffered the worst. In early April 2003, Stephan Roach, an economist with the firm Morgan Stanley, estimated the global economic cost of SARS at circa US$30 billion.20 The Far Eastern Economic Review later estimated initial SARS-related damage to regional GDP growth at US$10.6-15 billion. If SARS had continued to spread, quarantines could have affected manufacturing, which accounts for approximately 30 percent of Asia’s GDP (minus Japan), by closing factories and slowing trade. If the costs of premature deaths of income-earners, lost workdays of sick employees, and health care were factored into the equation, the eventual bill for the region could total almost $50 billion.21
China sustained significant losses in its service sector, which makes up 33.7 percent of the country’s GDP. SARS caused a decline in sectoral productivity of 6.8 percent during the second quarter. According to a government economist, the loss borne by the sector was 23.5 billion yuan, including 20 billion in tourism and 3.5 billion in retail sales. Based on the economic indicators of China’s economy affected by SARS, the Asian Development Bank put the GDP losses in China at US$6.1 billion, or 0.5 percent of total GDP. If calculated by total final expenditure, the total loss is 17.9 billion, or 1.3 percent of China’s GDP.
Aside from SARS-induced disruptions in the tourism and retail sectors, the fear-induced hoarding of essential goods and currency threatened fiscal liquidity. Moreover, calls by other countries for the quarantine of Chinese goods threatened China’s export-driven manufacturing sector. If SARS had persisted and resulted in the disruption the production and supply chains, the increased risk profile associated with doing business in China would have led to a reduction in foreign investment and exports, damaging China’s manufacturing sector. The end result would be a decline in the economic growth rate, on which the regime’s legitimacy hinges.
The SARS epidemic generated moderate damage to the Canadian economy, but this damage was brief. At the sectoral level, the SARS epidemic had a pronounced negative effect on the Canadian economy in the second and third quarters of 2003. Industries that bore the brunt of the contagion included tourism and hospitality, and the film industry. Toronto’s billion-dollar-a-year film, television, and commercial business was badly damaged by the epidemic of 2003, as foreign production houses withdrew their operations from the city. According to Joe Halstead, then Toronto’s commissioner of economic development, the SARS epidemic resulted in a decline of production, resulting in a loss of $163 million (roughly 18 percent) for the film sector in 2003. Commercial production in the city exhibited a similar decline of $32.8 million in 2003 (roughly 20 percent).22 These statistics were compiled from permit applications that production houses must file with the City of Toronto. Tourism in Ontario also took a significant hit as a result of the epidemic, with Toronto witnessing an estimated a decline of 18 percent during 2003, largely as a function of the epidemic and its aftereffects.23 According to Jeff Dover of KPMG, the SARS epidemic resulted in the loss of approximately C$993 million in the Tourism sector of the Canadian economy during the second and third quarters of 2003.24
On the macro level, SARS seems to have been largely responsible for a pronounced economic downturn in the Province of Ontario, where it resulted in two consecutive quarters of economic decline in 2003. Ontario Finance Minister Gregory Sorbara noted that the widespread decline was “an economic downturn that was driven by SARS.”25 According to Finance Ministry estimates, Ontario’s real GDP fell by 0.7 percent in the second quarter of 2003, and by a further 2.5 percent in the third quarter. The economy rebounded in the fourth quarter, when growth reportedly increased by 4.5 percent.26 The Minister of Health for Ontario during the epidemic, Tony Clement, revealed that SARS had cost the province’s health-care system $945 million as of June 27, 2003. Cost increases were associated with extra staffing needs, special supplies required to protect health-care workers, and expenditures to build specialized SARS isolation and treatment facilities.27 The best estimate is that the contagion cost Ontario at least C$1.5 billion in 2003.
Global SARS-induced economic damage in 2003 amounted to US$4050 billion. This seems relatively minute compared to the multi-trilliondollar global economy; however, the damage becomes more apparent when it is stated in terms of a loss to the annual GDP of a given country. The economists Lee and McKibben analyzed the effects of the epidemic, and their most conservative models estimated that SARS generated a 2.6 percent decline in GDP for Hong Kong, and a 1.1 percent decline for mainland China, during 2003.28 The Asian Development Bank estimated that SARS induced a 1.1 percent decline in GDP per annum for Singapore as well in the most conservative scenario.29 Those figures represent a significant drag on economic productivity per annum for those affected countries, and therefore we may conclude that SARS constituted a substantive threat to the material interests of those countries.
While the epidemic inflicted significant short-term economic damage to Pacific Rim economies, it also has important implications for intra-state governance. The SARS epidemic revealed significant problems in governance within those sovereign states most affected by the epidemic (Canada and China). The effects of the contagion on governance in Canada, and the dubious responses of the government at both the provincial and the federal level deserve serious investigation. Canada provides a very good example that even a wealthy advanced democracy can experience profound problems in the domain of public health governance. Indeed, SARS revealed the limitations of Ontario’s public health-care infrastructure, dramatically eroded by the cuts initiated by the administration of Premier Mike Harris throughout the 1990s, and prompted the federal and provincial governments to review the country’s public health policy and infrastructure. The effects of the contagion on governance in Canada, and the questionable responses of the government at both the provincial and federal levels, therefore deserve serious investigation. Specifically, the epidemic revealed that Canada’s public health infrastructure was fragile—particularly in the province of Ontario, which saw the most significant outbreak of SARS outside of China. Gambling that budget cuts in public health controls wouldn’t matter, in 2001 the of Harris administration laid off five scientists charged with regional disease surveillance.
Ontario experienced significant problems in infection control, ranging from the questionable leadership of Colin D’Cunha, to problems in staffing hospitals, to the persistent violation of quarantine and subsequent spread of infection. The infection of Walkerton’s water supply with E. coli went unheeded. The Canadian case also illustrates chronic problems in communication between the provincial government in Toronto and the federal government in Ottawa, exacerbated by the perennial conflict over which tier of governance should preside over matters of public health. At present such duties are relegated to the provinces, as is the matter of funding which is supplemented through transfer payments from Ottawa. Partisan differences may have also led the Liberal administration of Prime Minister Jean Chrétien to be less than cooperative with the Conservative administration of Ontario. The Chrétien administration also demonstrated a significant failure of leadership during the crisis. The federal Minister of Health, Ann McClelland, often proved less than cooperative in her dealings with the province and with the World Health Organization. Moreover, Chrétien displayed an appalling lack of leadership when he refused to interrupt his vacation abroad to return to Ottawa and deal with the rapidly expanding epidemic in the Toronto metropolitan area. As a result of these glaring deficiencies in the Canadian response to SARS, several Commissions of Inquiry were commissioned to determine precisely how the system failed, and to develop recommendations for improving the response capacity of Canadian public health delivery.30
Prescott chides Canadian officials for their myopic response to the emergence of contagion in Toronto: “. . . Canadian officials appeared to be more concerned with the short-term impact of a (WHO) 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.”31
Ultimately, the Canadian response to the exogenous shock of the SARS epidemic provides some evidence to confirm the punctuated-equilibrium model. Specifically, in 2004, the Canadian federal government created a new cabinet-level Public Health Agency, led by a Chief Public Health Officer who (despite a certain degree of autonomy) reports to the Minister of Health. A central mission of this nascent agency is to facilitate cooperation between the federal and provincial governments in the domain of public health emergencies. This clearly demonstrates the increasing salience of public health issues in the mind of Canadian political elites. One thing is clear: the SARS debacle has resulted in the elevation of public health to the level of “high politics” in Ottawa. This is evident in the Canadian National Advisory Committee on SARS and Public Health’s reference to Benjamin Disraeli’s argument that “public health was the foundation for the happiness of the people and the power of the country” and “the care of the public health is the first duty of the statesman.”32 The question is: Can the scientific community sustain the momentum generated by the SARS epidemic to maintain investment in Canadian public health infrastructure, or will political elites revert to the typical human pattern of forgetting about the threat of contagion until the next pathogen arrives?
The SARS epidemic exposed significant shortcomings in China’s governance structure. Initially, the government chose not to publicize the outbreak for fear that this would have a negative effect on economic development. The suppression of information persisted even after the epidemic spread to Beijing, in part because the party did not want the contagion to disrupt its National People’s Congress meeting, a showcase for the Communist Party’s highly controlled and carefully staged version of participatory democracy. By April of 2003, it was evident that SARS had captured the attention of the central leadership. However, the formulation of policy to check SARS was impeded by lower-level government officials who manipulated and distorted the flow of information to the higher echelons. Despite the fact that the Ministry of Health was cognizant of a deadly new pneumonia in Guangdong on January 20, 2003; the Chinese Center for Disease Control and Prevention (CDC) did nothing to check the spread of the contagion until April 3. The Chinese government thus waited more than three months before taking decisive action in late April of 2003. Echoing the Canadian case, rivalries existed between various health bureaucracies, territorial governments, and between military and civilian and institutions. Paradoxically, the SARS crisis also granted an opportunity for the Chinese government to address internal governance problems. As Hirschman suggests, politicians have strong incentives to exploit crisis and danger and emphasize the risks of inaction in order to mobilize opinion and arouse action.33 The political scientist Yanzhong Huang has argued that the legitimacy of the current regime in China is largely performance-based, rooted in delivering economic growth.34 The possibility of an economic recession caused by SARS, therefore, posed a direct threat to the regime’s material interests, and to perceptions of its legitimacy. In the words of Premier Wen Jiaobao, “the health and security of the people, overall state of reform, development, and stability, and China’s national interest and international image now are at stake.”
The perceived crisis impelled the central leadership to mobilize the state’s capacity for containment of the contagion. On April 17, China’s leaders convened an urgent meeting to initiate a national campaign to check the spread of the epidemic. This dramatic change in the trajectory of national policy was synchronous with a relaxation of media control as the government publicized the number of SARS cases in each province, with daily updates. Three days later, the Health Minister (Zhang Wenkang) and Beijing’s mayor (Meng Xuenong) were ousted for their egregious mismanagement of the crisis. The crisis also precipitated government efforts to increase bureaucratic control and designate greater financial resources for an anti-SARS campaign. On April 23, a task force known as the SARS Control and Prevention Headquarters of the State Council was established to coordinate national efforts to combat the disease, with Vice-Premier Wu Yi appointed as commander-in-chief of the task force. The same day, a national fund of 2 billion yuan (US$242 million) was created for SARS prevention and control. As part of a national campaign to mobilize the apparatus of governance, the State Council sent out inspection teams to 26 provinces to examine government records for unreported cases and to fire officials for lax prevention efforts. According to the official media, by May 8 China had dismissed or penalized more than 120 officials for their ineffective response to the SARS epidemic. These actions energized local government officials, who then abandoned their initial hesitation and jumped onto the anti-SARS bandwagon. In retrospect, the SARS crisis challenged the traditional concept of governance in China and helped to significantly elevate the status of public health on the government’s agenda. The government has now realized that economic development does not trickle down, and that public health should be treated as an independent criterion of good governance. Premier Wen Jiabao said that “one important inspirational lesson” the new Chinese leadership learned from the SARS crisis was that any “imbalance between economic development and social development” was “bound to stumble and fall.” Huang argues that the government since then has earmarked billions of dollars for the public health sector. More attention has also been paid to the basic needs of the disadvantaged portion of the population, including farmers and workers. The epidemic also created incentives for Chinese leaders to adopt a new, more proactive attitude toward HIV/AIDS. Since then, discourse and action surrounding HIV/AIDS have changed dramatically, with senior leaders facing the epidemic with a greater sense of responsibility.
Partially because of the profound economic impact of SARS, partially because of the fear it had created among their citizens, heads of state, diplomats and politicians became involved early and visibly, fully participating in outbreak control through frequent press briefings, declarations, and provision of political and economic support to the global containment effort.
—David Heynmann, in Fidler 2004, p. xiv
As the SARS epidemic intensified, the ten member states of ASEAN (the Association of Southeast Asian Nations) grew increasingly aware of the threat the contagion posed to their people and their economies. Anxiety in this region actually was intensified by earlier shocks to governance in the region, such as the Asian economic crisis of 1997-98, as well as the regional environmental “haze” issue that resulted from ubiquitous fires throughout the region during the same time period. Indeed, fear arose in Singapore that SARS could provoke its worst economic crisis since the country had gained independence.35 While such concerns over economic loss were shared by leaders in this region, the rapidly spreading epidemic also generated a strong sense of the urgency of regional cooperation. On April 26, the Health Ministers of the ASEAN countries and those of China, Japan, and South Korea met in Kuala Lumpur to voice their willingness to cooperate. On April 29, leaders from the ASEAN countries attended the emergency summit in Bangkok.36 The Bangkok summit was initiated by Prime Minister Goh Chok Tong of Singapore, who was also instrumental in setting the agenda. ASEAN thus became the ideal platform for discussing this issue. Initiated by Goh, the communiqué issued by Bangkok summit articulated a “collective responsibility to implement stringent measures to control and contain the spread of SARS and the importance of transparency in implementing these measures.”37 ASEAN members agreed that all countries in the region would immediately commence mandatory screening for SARS at their borders. The declaration issued by member states agreed on various measures to stop SARS transmission, including sharing information on the movement of people by building a SARS containment information network, coordinating prevention measures by standardizing health screening for all travelers (i.e., common protocols for air, land, and sea travel), adopting an “isolate and contain” approach (rather than a blank ban on travel), and establishing an ad hoc ministerial-level joint task force to follow-up, decide and monitor the implementation of the decisions made at this meeting and the “ASEAN + 3”38 health ministers’ special meeting on SARS.
China and representatives from Hong Kong were invited to attend a follow-up summit later the same day. During that special meeting, however, ASEAN diplomats were very careful not to directly criticize Beijing’s mishandling of the epidemic, but rather to solicit China’s cooperation in dealing with a highly sensitive issue. The idea was for ASEAN leaders to agree on a set of resolutions and measures for China to sign on to. Aware that the image of the China and the reputation of its new leadership were at stake, Wen was cooperative during the Bangkok conference. He pleaded for understanding from other ASEAN leaders. “In the face of the outbreak of this sudden epidemic,” he said, “we lack experience with its prevention and control. The crisis-management mechanism and the work of certain localities and departments are not quite adequate.”39 This was an astonishing admission of culpability from a regime that is loath to admit responsibility for any mistake or wrongdoing. In an ASEAN-China joint statement, China agreed to “associate itself with the measures proposed by the ASEAN declaration.” This endorsement by Beijing was indeed remarkable, given that a total embracement of the measures decided by the ASEAN leaders would be perceived in China as an act of submission.40
A central problem to pathogen surveillance and containment throughout the region was the dearth of public health infrastructure among many of the poorer countries, an issue of state capacity. To strengthen regional capacity, Beijing provided $1.2 million, subsequently emulated by Thailand and Cambodia.41 While it was a positive gesture, such meager amounts did not truly generate any significantly increased levels of regional public health infrastructural capacity. Despite the rhetoric of cooperation, containment remained the responsibility of its sovereign member states to implement those principles and to engage in suppression of the contagion.
The political analyst Eric Cheow argues that the fact that the SARS virus developed and emerged in Guangdong province suggests that poverty and low state capacity are the principal variables governing the emergence of infectious disease. “As East Asians develop a sense of community,” Cheow writes, “they must look urgently into developing the poorer regions so they will not remain poor, underdeveloped and, thus a hotbed of chronic diseases, which may have been eradicated in the richer and more developed countries.”42 Such assumptions betray a certain degree of ignorance regarding the ecological mechanics of microbial emergence and evolution. As was noted above, selective evolutionary pressures will force microbes to adapt to (and colonize) ecological niches in countries of both high and low state capacity.43 Ergo, the assumption that the most virulent and transmissible of new pathogens necessarily emanate from the least developed countries (and regions within those countries) is empirically specious.44
Moreover, the success of various countries in controlling the epidemic demonstrates that a prosperous country that exhibited significant levels of endogenous capacity (such as Canada) had a much more difficult time in containing the infection than did countries of lower capacity, particularly Vietnam. The most recent epidemiological evidence suggests that SARS appears to thrive under conditions that promote nosocomial transmission.45 Therefore, the sealed, air-conditioned hospitals of developed societies appeared to facilitate SARS transmission. Conversely, Vietnamese hospitals are often open-aired, diminishing the probability of nosocomial transmission. In other words, the SARS coronavirus appears to be more transmissible in the sealed hospital and urban environments of countries with technologically sophisticated health infrastructures. SARS, then, would seem to pose a greater threat to countries of higher capacity, and thus the effects of pathogens on a given society are dependent to some degree on the human ecology of the society involved. This suggests that, in the face of a nosocomial pathogen such as SARS, social ingenuity may offset any lack of technical ingenuity and infrastructure.
Before the emergence of SARS, international health regimes (as governed by the International Health Regulations) were badly dated, for two reasons. First, since their inception in 1951, the IHR had not been revised adequately in the face of other emerging novel pathogens. The member states of the WHO had last formally revised the IHR in 1969. Yet since 1970 humanity has witnessed the emergence of more than 30 previously unknown pathogens, and none of those were covered by the IHR in 2003, when they only required member states to report the incidence of smallpox, cholera, plague, and yellow fever. Further, under the provisions of the IHR the reporting of pathogen-induced morbidity and mortality remained the exclusive domain of sovereign member states. Countries have long sought to suppress the flow of information regarding endogenous epidemics, because the emergence of contagion typically generates significant negative effects on the economy and society of infected polities.46 Thus, states have had significant material incentives to refrain from issuing timely and accurate reports on domestic epidemics to the global community. Beijing’s early attempts to suppress the flow of information to the WHO and the insistence by Canadian officials that the WHO’s travel advisories were erroneous both reflect this historical pattern of tension between sovereign member states and the WHO.
Nonetheless, some positive changes have taken place in the international health governance regime since the 1970s as a result of technological advances, the rise of new and reemerging infectious diseases, and the increasing involvement of non-state actors in addressing global microbial threats.
The WHO was instrumental in building the Global Outbreak Alert and Response Network, which was effectively mobilized to deal with the SARS contagion. Developed in 1997 and formalized in 2000, the GOARN is a network of approximately 120 partner networks engaged in pathogen detection, surveillance, and response. “During the response to SARS,” the physician David Heynmann observed, “GOARN electronically linked some of the world’s best laboratory scientists, clinicians, and epidemiologists in virtual networks that rapidly created and disseminated knowledge about the causative agent, mode of transmission, and other epidemiological features of SARS.”47
During the World Health Assembly meetings of May 2003, member states of the World Health Organization stipulated that the organization should redouble its efforts to garner and analyze data from non-state actors. Specifically, the WHA requested that the Director-General of the WHO “take into account reports from sources other than official notification.”48 The new ability of non-state actors to communicate data directly to the WHO would seem to have broken the sovereign state’s historical monopoly regarding the reporting of public health information, but this is only possible in those societies with sufficient telecommunications infrastructure.
In 1995, the WHO sought to revise the IHR so that the WHO could be allowed to use information from non-governmental organizations for epidemiological surveillance of infectious disease outbreaks.49 Revisions to the IRH were finally completed in 2005, and member states must now immediately report the following pathogens to WHO: SARS coronavirus, novel strains of human influenza, smallpox, and polio. Adopted by the World Health Assembly in May 2005, the revised regime entered into force globally on June 15, 2007. The new regulations clarify the WHO’s authority to recommend strategies of containment to member states, including various restrictions (such as quarantine) at ports, airports, and terrestrial borders and on means of international transportation.50 This successful revision of the IHR, directly induced by the SARS scare, put an end to a decade of dithering by member states. Thus, SARS changed the calculus of the material interests of member states to reflect the threat that disease posed to their material interests, resulting in rapid innovation and change of the existing regime.
However, Fidler’s arguments that we are now witness to a transformative or “post-Westphalian order that effectively limits the sovereign state’s ability to compromise processes of global health governance under the auspices of international organizations (e.g., the WHO) are rather overstated. While the SARS epidemic appeared to have increased the power and authority of the WHO, the shift in power from sovereign states to the international organization was largely ephemeral. The sovereign state remains very capable of obfuscation through the nonreporting of disease data, and through other means of thwarting international efforts to address the spread of contagion. One need only look at the history of obfuscation and denial by political leaders in subSaharan Africa (Thabo Mbeki of South Africa and Robert Mugabe of Zimbabwe in particular) in the context of the HIV/AIDS pandemic to observe such obstruction.51
The SARS epidemic exhibited emergent properties in that it featured a novel zoonotic pathogen (the SARS coronavirus) that jumped across animal reservoirs into the densely packed populations of southern China, whereupon it became endogenized in the human ecology of the region. It was then distributed via air travel throughout Southeast Asia, and from there to Canada. Finally, it appears that SARS was transmitted in nosocomial fashion, such that it thrived in the highly contained buildings of the developed world. Again, the epidemic that emerged was unanticipated and substantially greater than what would have been predicted by its constituent parts. Thus, globalization aided and abetted the emergence of the SARS epidemic. The psychological impacts of the contagion (fear, anxiety, stress) were greatly augmented by the actions of the global media, and by advances in telecommunications technology (such as the Internet and cell phones ). However, on a positive note, such technological advances were also responsible for circumventing the suppression of data from China, thereby alerting the world to the mounting crisis.
Ultimately, it was not the global sharing of norms that led to the containment of SARS; rather, it was the sovereign state’s concern for its material (primarily economic) interests that impelled states to take action to control SARS. In this case republican Realist theory provides a theoretical framework that explains the behavior of countries, particularly the desire to obscure the extent of the problem to the global community, and to initially resist the recommendations of international institutions (i.e. the WHO), even though such resistance may prove counterproductive and irrational over the longer term. Furthermore, the SARS epidemic reinforces the functional efficacy of the contagionist model and the postulates of the Florentine school, as pathogen containment was instituted by sovereign states through mechanisms of quarantine.
The outbreak of SARS is a good example of an “exogenous shock,” emanating as it did from reservoirs in the natural world. It has undermined the Galenic mythology (still prevalent) that infectious disease is primarily a concern solely for the developing countries, with their limited levels of endogenous state capacity. Conversely, the SARS epidemic illustrates a central axiom of microbiology: that microbes will continue to evolve to colonize all available ecological niches, notwithstanding the wealth of a given society.52 Therefore, as a result of the SARS contagion, developed countries realized that they too were vulnerable to the proliferation of debilitating and lethal pathogens.
One would logically expect that epistemic communities played a central role in proactively generating effective international regimes to deal with pathogens such as SARS, in that microbiologists effectively communicated their concerns to decision makers who then modified existing political regimes to deal with forthcoming epidemics. Unfortunately, such a proactive model is not borne out by the evidence, as the provisions of the IHR were not sufficiently revised to deal with emerging pathogens before the epidemic. At the domestic level, the influence of epistemic communities was similarly limited: in both the Chinese and Canadian examples, calls by scientists for greater investment in public health infrastructure were consistently ignored by political elites. Indeed, it is evident that domestic partisan politics resulted in significant erosion of Ontario’s public health infrastructure, human capital, and funding base before the arrival of the SARS contagion.53 Thus, domestic politics trumps the influence of epistemic communities in preparation for disease threats, perception of threat, and the efficacy of response to threat. In sum, given the limited influence of the public health community, countries typically exhibit reactive and not proactive stances regarding the surveillance and the control of infectious diseases.
By inflicting significant socio-economic costs on affected states, the SARS epidemic exposed the vulnerability of existing governance structures, reshaped the beliefs, norms, motivations, and preferences of individuals who weathered the crisis, and ultimately led to macro-level changes in domestic political governance, while enhancing the dynamics of regional health cooperation among the Pacific Rim countries. However, SARSinduced effects on the international system, and the relations of power between sovereign states and international organizations, were largely ephemeral. In this domain, the greatest effect of SARS was that it functioned as a catalyst to accelerate revision of the International Health Regulations and to get the list of reportable diseases updated.
SARS posed a significant material threat to the prosperity, effective governance, and security of affected states (China, Hong Kong, Canada, and Singapore in particular). Furthermore, SARS generated significant changes in public health governance within such affected states (particularly in Canada and China), leading to the formation of new institutions.
Conversely, and contrary to Fidler’s assertions, the epidemic does not seem to have generated significantly increased compliance of sovereign states with international health regimes. Nor has the World Health Organization used the expanded powers it manifested during the SARS crisis, though arguably it could employ such strategies again to contain the burgeoning HIV/AIDS pandemic.
Why was the response to SARS so different from the relatively apathetic international reaction to HIV/AIDS, malaria, and tuberculosis? The SARS epidemic exhibited several factors that led to the temporary empowerment of the WHO: the emergence of a novel virus, coupled with seemingly high levels of virulence and transmissibility, generating high levels of uncertainty and fear. Further, the SARS epidemic was an exogenous shock that affected the material interests of global political and economic elites, and it presented an immediate socioeconomic crisis for decision makers to address at the national, regional, and international levels.
The case of SARS also illustrates the paradoxical role of modern technology in the face of novel outbreaks of contagion. Specifically, technology exhibited positive effects in the containment of SARS: cell phones and text messaging were used to transmit warnings from within China, facilitated the networked response of the WHO through the GOARN, and assisted in the accurate diagnosis of the pathogen. However, the rapid spread of the virus was accomplished through jet airplane technologies, nosocomial transmission was facilitated by modern hospital environments, and the global media played a significant role in generating anxiety and fear throughout the world.
Today, efforts to provide public goods such as improved global pathogen-surveillance systems and pathogen-containment regimes are the product of two central factors, namely fear and the attendant threat to the material interests of sovereign states (and global elites) generated by contagion. A significant amount of leadership to provide such public goods in the domain of public health has in fact been provided by hegemonic pressure from the United States, with the assistance of many other developed countries (and non-governmental organizations), in order to shore up surveillance and containment capacity within developing countries. This issue of regional and national capacity will continue to affect the dynamics of global health governance.54