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An implicit tension exists between the priorities of public health and those of clinical medicine. While medicine deals primarily with individuals who are ill, and seeks to cure or ameliorate their condition, public health deals primarily with communities and populations, and prevention of illness is our major priority. In a sense, SARS, severe acute respiratory syndrome, encapsulates a not unrelated set of issues relating to priorities and values for individuals and the community.
Why is SARS a serious concern? Any infectious disease that spreads by the respiratory route on aerosol droplets has to be taken seriously, because one individual can infect many others. The major risk factor for acquiring the infection is breathing. In the absence of an effective drug or vaccine, we know that some infectious diseases similarly transmitted by the respiratory route have wreaked havoc: 20-40 million deaths from the influenza pandemic of 1918, the decimation of the population of Hawaii by the first introduction of measles and the lingering epidemic of tuberculosis that afflicts 8 million people annually now. Even with good vaccines, 36,000 people died in the U.S. last year from influenza, and even with good drugs for tuberculosis, over 2 million people died worldwide. The good news about SARS is that it is not the most rapidly spreading respiratory infection known, generally requiring close contact--—the worrisome aspect is that is among the deadliest.
With more people dying from motor vehicle accidents and gun injuries than SARS, are we overreacting? I would note that deaths from auto accidents and gun injuries are not increasing exponentially; SARS, as it first evolved, was. The highest priority in any epidemic is to stop transmission to healthy people. In the absence of a specific diagnostic test, vaccine or drug, standard public health precautions are the only tool available—establishing a broad case definition so as not to miss cases, putting in strict protections in hospitals to protect first line medical staff and patients, isolating people suspected of having SARS so that transmission of infection is limited, and quarantining people who have been in contact with known cases who may develop the disease and honest and timely reporting. The key is to take action at the earliest possible stage, before the numbers get high. Vietnam did that, and the World Health Organization (WHO) has just lifted its travel alert; China did not, and there are thousands of probable cases and so many suspected cases that the medical capabilities are now under severe strain.
In a public health sense, a university is an epidemic waiting to happen. Harvard has a responsibility for the lives of its 18,000 students who live and work in close quarters, and a need to exercise prudence even when the information available is less than ideal. When it became clear that SARS was spreading from China to Hong Kong, Vietnam and Toronto, the administration issued a travel advisory urging faculty and students not to travel to those countries in which transmission of SARS was continuing. Within a few days of that alert, several of us were besieged by journalists from Toronto upset that their city had been cited by Harvard before the Centers for Disease Control (CDC) issued a travel alert. Later that afternoon, Toronto discovered 29 new cases and 500 people exposed, and later that week the tone of questions from the press changed to whether Harvard knew something that their health authorities did not. It is in the nature of epidemics to be unpredictable.
In a more profound sense, the University is a community. The decision to restrict travel and ask members who did return from a country in which SARS was being transmitted and exported to notify their Deans or the University Health Service, and possibly not return for 10 days, was inevitably made under the uncertainty of how the epidemic will evolve. The intent from a public health standpoint was both to protect individuals and prevent their exposure to unnecessary risk, and to protect our entire community. It was recognized that the policy may cause serious academic and professional problems for a portion of our community, but it was clearly intended to prevent more dire consequences to the larger community. In my own experience, my entire college was quarantined for several months as a result of a polio outbreak. The policies of CDC and WHO and the University are under constant review. It was predictable that Toronto, like Vietnam, would soon be able to show that they have stopped SARS transmission within and beyond their borders for 20 days; that is unlikely to be the case soon in China. In my view, the value question raised by SARS is whether individuals within this University will be willing to forgo individual needs to be respectful of the life and lives of the university community.
Barry R. Bloom is a professor of immunology and infectious diseases and Dean of the Harvard School of Public Health.
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