TCS Daily

Disease Without Borders

By David Gratzer - January 1, 2005 12:00 AM

Editor's note: The following remarks were delivered at the Risk: Regulation and Reality Conference by Dr. David Gratzer, a physician and a Senior Fellow at the Manhattan Institute. The conference was co-hosted by Tech Central Station and was held on October 7, 2004 in Toronto, ON.

James Glassman: Please come in. We are ready to start. I'm going to introduce our next speaker and I apologize for mispronouncing his last name. Everyone in Canada knows Dr. David Gratzer. You may have heard about, certainly you've heard about him, you've read about him, and you may even have been treated by him. He's the author of Code Blue, Reviving Canada's Healthcare System, which was awarded the Donner Prize for the best Canadian public policy book in 2000. He is also the editor of Better Medicine, Reforming Canadian Healthcare, and a Senior Fellow at the Manhattan Institutes Center for Medical Progress. He's often quoted on health matters both in Canada and the United States and he's a popular speaker. In 2002 he was one of 30 people profiled in a McLain's Magazine cover story on the leaders of tomorrow, featuring young Canadians who are already changing the world. So let's welcome Dr. David Gratzer, as he speaks on the issue of disease without borders. [Applause]

Dr. David Gratzer: Well, let me begin by thanking you for that very kind introduction. As I was listening to these Teddy Roosevelt-like achievements described one after another, I was reminded of a comment a former girlfriend made of me: on paper you seem like such an interesting person. [Laughter]

Ours is a world filled with information. We live in the age of 24-hour news cable. We live in an age of the Internet. We live in an age of the Drudge Report. The smallest of events are recorded and noted around the world. Let me just give you one quick example. The President of the United States, early in his first term, eats a pretzel, chokes on it, and CNN provides live updates. The flipside of the coin is, when so much is recorded, when there is so many "crises," it is easy to forget events that have occurred just a short time ago. It's easier, still, to forget the lessons that they might teach us.

I was reminded this the other day because I was invited to do grand rounds at a community hospital in the Toronto area. This was back in May. They had asked me to speak on late-onset schizophrenia. I walked through the Emergency Room, on the way to the auditorium, and thought it was such a nice ER. The staff seemed so friendly - I thought what a pleasant campus. It had slipped my mind that just 12 months before I gave that presentation, Scarborough Grace was the site of first SARS outbreak in North America. Indeed, twelve months before, chaos reigned: the entire hospital was closed; its staff, quarantined.

Not that long ago, SARS was a very real problem for us Torontonians, for those in Asia, indeed for the entire world. Obviously the crisis has passed. But there are important observations to make and lessons to learn. Let me begin with a few disclosures. I have an undergraduate degree in microbiology, but I'm not a virologist. I'm a physician, but I'm not a public health doctor. I have an interest in statistics, but I'm certainly no actuarial. It's my intention today to provide you with a few casual observations I've made about SARS and perhaps to think about what the larger implications are of this virus and how we dealt with it.

Observation one: this wasn't the big one.

Like the plot of a bad movie where a series of small inconsequential events occur in the distant land and end up plaguing the west, the SARS outbreak that began in Guangdong, China, eventually burned here in Toronto. We shouldn't be totally Toronto centric. In all, 34 countries had "likely" or "probable" cases of SARS, ranging from Northern Europe all the way to Southern Africa.

As you'll recall, there were many gloom and doom predictions. "Epidemic" and "uncontrolled situation" were words used to describe Toronto's plight by some in the American media. There were fantastic predictions as well. A public health expert went on Nightline predicting 60,000 deaths in North America alone. Canadians, incidentally, weren't completely immune to the excitement, either. I remember reading a Canadian columnist who suggested that SARS might be our Hiroshima.

But, at the end of the day, there was no North American plague. It didn't wreck havoc on our large cities. In fact, the death toll here in Toronto wasn't particularly high. Only 44 people, in the end, succumbed to the mystery virus. Now, look, 44 people is 44 too many, but we must keep perspective. In all but a few cases the patients actually suffered from comorbidity, that is to say that they had major illness before they contracted SARS. It was a vulnerable population, as they say. Some of the victims -- and I've just picked a couple -- included a 78 year old man who had kidney failure, and a 99 year old gentleman ill with cancer. 44 needs to be in further perspective: that is how many people succumbed to the illness in three months. Over that period, roughly 150 people died from influenza, over 3,000 people died in Ontario alone from tobacco-related illnesses. 44 is 44 too many, but it wasn't an epidemic.

For more than a year now there have been no cases of SARS reported outside of China. Now, look, one should be a little bit careful about predicting viral spread. It's a little calling an election before the ballots are counted. There are wild cards. We really don't know what is going on in China. Like the testimony of a perjurer insisting that he's now telling the truth, Chinese numbers are always suspect. It's also possible the virus could mutate or that there is some sort of an animal reservoir for the virus. But, for now, it seems safe to assume that as quickly as SARS appeared and wrecked damage, it has now disappeared.

The second observation: SARS was an awesomely humbling experience.

Ours is also an age of incredible medical science. We live in the era of MRIs, laparoscopic surgeries, second generation antipsychotics. Of course it wasn't always like this. Doctors like to emphasize the long tradition of medicine. When you graduate from medical school, you take the hypocritical oath, dating back some two millennia. But, of course, what we really understand to be medicine is a thoroughly modern creation, maybe 60 years old or even younger. Just a short time ago, many would succumb to what are now treatable illnesses. Some examples: Winston Churchill's father, demented in his late 30s from neurosyphilis; Calvin Coolidge, President of the United States, stood by idly and pathetically as his son died of a simple infection on his foot (his son was 16); FDR, the great American President, died of a stroke secondary to high blood pressure. Illnesses that have plagued society like influenza, like diphtheria, like pneumonia, have become more and more scarce. Some statistics: at the turn of the 20th century, 50 percent of all deaths were attributable to just three infectious diseases. Today, they've been marginalized as killers, accounting for under 5 percent of all deaths in North America.

And yet when the topic of SARS comes up, what strikes us is how impotent we ultimately were. Despite our ability to map genomes, we don't have a confirmatory test yet for the disease. We didn't have a vaccine during the outbreak, probably we won't have a vaccine for years to come. Nothing has proven successful in treating this illness. Our best anti-virals and steroids don't touch it. How do we contain SARS? We are left with the bluntest of instruments for containment. Isolation and quarantine.

In some ways, Toronto's experience with SARS was a case of déjà vu. Isolation and quarantine were the weapons used in the last major struggle in an outbreak in North America, that is, smallpox in 1885, in Montreal, then Canada's largest city. If you have a chance, take a look at Michael Bliss' book on this topic, appropriately titled, Plague. It began with a train conductor, by year's end, 6,000 people had died in a city of 100,000.

Needless to say, isolation and quarantine are imprecise. They make for a strategy of catch-up, like trying to catch a serial killer by only going to past crime sites. The success of these measures requires two conditions, strong public support and limited movement. As Professor Bliss notes, the former didn't materialize for months in 1885 with deadly effect; it takes, after all, only a handful of people to break a quarantine for containment to be lost. The second condition is increasingly unrealistic since the day Charles Lindberg's Spirit of St. Louis touched down in Paris. Intercontinental travel has made incredible distances a matter of hours to traverse, not days or even weeks. If people can travel the world with ease, alas, so can viruses.

Consider using only isolation and quarantine it took Toronto more than three months to contain an outbreak caused by just one person with the illness, an effort that included the quarantining of more than 10,000 people, the closure of two public hospitals and the semi-closure of a dozen more. The economic fallout for Canada approached a full percentage off the GDP for the quarter.

Now here's a scary question to ponder: What would have happened if the strain were more virulent?

Observation three: there were important lessons to learn.

This wasn't the big one, but we can still learn from it. If you live in Canada -- and I apologize for the Canadian centric aspect of my speech -- public officials and columnists have lined up behind two ideas. First, we've got to boost funding for public health. And, second, the federal government has to take a greater role in public health. I disagree with both ideas. The SARS outbreak does indeed show the importance of disease control, but boosting all public health funding based on the handling of SARS would be akin to dramatically increasing police funding because a detective solved a crime. Yes, in an age of SARS and West Nile Virus, disease control is essential. Unfortunately, too much of Toronto's public health efforts -- and the initiatives of like organizations across this country -- focuses on second hand smoke, pesticide use, and a gamut of social engineering projects, including a ban on spanking. If anything, the recent episode suggests that public health needs to be better organized, not better funded. As for a greater rule for Ottawa, the recent performance of Health Canada suggests a department rife with incompetence and indecision. Ottawa needs to be held accountable, not put in charge.

Besides the usual calls, though, for more money and bureaucracy, there are important lessons. Consider that in three months, we struggled to contain an outbreak caused by just one index case. What's important to realize then is the best way of containing a virus is to keep it in its country of origin.

China's month long cover up was unconscionable and dangerous. SARS cases were reported eventually in 34 countries. But here's the irony: Chinese authorities knew well in advance of the SARS outbreak, as early as November 2003. If they had acted immediately, SARS may never have left the remote villages of Guangdong. So, why didn't Chinese officials act? Though Chinese authorities were notified of an unusual and dangerous outbreak of virus, they opted not to pursue matters for fear that it would dampen year-end political celebrations, a stupid and near-sighted decision.

Our safety, a half planet away, is determined by bureaucratic decisions in countries like China. Presently, international infectious disease is pinged on self-disclosure by individual nations, effectively a giant honor system. If there's an outbreak of bird flu in Denmark, for example, we rely on Danish officials to notify everyone and then we'll all take appropriate steps. Well, we've seen the honor of Chinese officials and we need a more robust system. Do we expect any better from government bureaucrats in, say, Syria or Zimbabwe should the next issue arise? When it comes to stupid and near-sighted decisions on infectious disease, our lives are literally on the line.

Now, how could we rethink international agreements? Harvard Professor Jerome Groopman wrote in The Wall Street Journal that we need an international health concordant for the containment of infectious disease, much in the way we have treaties to prevent the proliferation of biological and chemical weapons. Perhaps it's an idea worth pursuing. But regardless of whether or not we can fashion a new treaty, we must recognize that the security of the west depends on proper containment of infectious diseases. Maybe the United Nations can fashion a new treaty, maybe not.

The United States and other western countries like Canada have taken a hard line on governments that support terror. Western governments have used sanctions, diplomatic isolation and even regime change to tame them. Why should bio-terror, caused by negligence, be any different?

Now, we offer a carrot for good behavior. If any country suffers an outbreak, it can notify the World Health Organization and be rewarded with careful attention from the brightest minds in science, medicine, and pubic health. Any rational country would jump at that opportunity. But, autocratic nations aren't always rational. Thus, there needs to be a stick for countries that conceal outbreaks. From this point forward, we should treat such nations as international pariahs. The United States, Canada, and like-minded nations should form a coalition of the healthy to prepare for disease proliferation with physical isolation and economic muscle. In a day and an age when even the most backward and authoritarian countries seek trade, this threat would be taken seriously.

But even this might not be enough. SARS shows us that we must take steps to stop potential epidemics from entering North America in the first place. It sounds simple enough, of course, but for weeks literally nothing was done to stop SARS. Travelers entering Singapore in April,2003, were greeted by thermal scanners, teams of nurses, and the possibility of a 10-day quarantine. No wonder: 99 percent of SARS cases the first presentation included a fever. Yet passengers arriving in North America had limited screening. This is unacceptable. SARS burned in Toronto's hospitals for weeks before a single thermometer came out in China's airports. Why should North America be dependent upon other countries for her public health? The free flow of passengers is crucial to world commerce, obviously. But when uncontained outbreaks occur in another part of the world, homeland security includes homeland screening. In retrospect, officials of the CDC and Health Canada were slow to act.

What would I suggest we do in the next outbreak? Airport screening. Clearly, this would be expensive and time consuming. But looking at the deep problems faced by Singapore, Hong Kong, Taiwan, and Canada -- all countries infected by travelers -- it is a small price to pay.

In the future, screening ought to be done the moment the WHO warns of an emerging epidemic. Future outbreaks may warrant even stronger measures. Today's screening is typically done at our airports. In the future, the disease screening should be done at their airports. If there is an outbreak in China, then the CDC, working in partnership with Health Canada, ought to certify airports for proper exit screening. No plane that takes off from a non-certified airport would be allowed to have landing rights on this continent. Of course, in an age of jet travel, a businessman could arrive today from Helsinki, having attended a conference in Hong Kong the night before, after a meeting in Hanoi two days previously. But just as airlines are now required to report a travelers' manifest (a list of their passengers and recent travels to assist with anti-terrorism), when an outbreak occurs, airlines ought to provide such a list to assist with infectious disease containment.

I have outlined strong measures. Today, for the most part, we've forgotten about SARS. That is a grievous misjudgment. North America has porous borders and assumes confined plagues. That assumption fell apart last spring as quickly as SARS spread. This flu-like virus killed only 44 people in Toronto, but it was a warning. September 11th shows us the consequences of unheeded warnings. Thank you. [Applause]

James Glassman: Thank you, David. You are interesting not just on paper, but in real life. So, actually, I have a quick question and then we'll hear from the floor. Do you think SARS has a chance to come back, and, if not, what would be the big one? What are your candidates?

Dr. David Gratzer: These things are so difficult to judge. As you know, there are many people in the mutual fund industry, who, for a little bit of money, will tell you what the next hot stock is, and, for the most part, those predictions don't come true. I think, likewise, the world of public health is filled with people with an opinion and predictions. Is SARS going to come back? Look, there were predictions it would come back last winter. It didn't. There are predictions it'll come back this winter. We don't really know. The way viruses often work, particularly very contagious viruses, is that they have an animal reservoir. The flu has an animal reservoir in pigs, giving them an opportunity to mutate and change, which is why even though all of us have good immune systems we could still get a flu this winter. Is there an animal reservoir for SARS? No one knows.

But, the point is: SARS may or may not come back, but the lessons of SARS remain. Statistically speaking, mankind periodically gets hit with some type of an outbreak, whether it's the plague, or the 1918 influenza (which killed more people than the First World War).

So, is SARS the big one, and we just got lucky the first time around? Difficult to tell; we'll see if it mutates. But, eventually, there will be a big one. And then the question is, how do you deal with it? Given the damage wrought on Toronto and the astonishing collateral damage, I think the question is not to ask is SARS the big one, but, what to do when we do get the big one, whether or not it's SARS.

James Glassman: Questions, please. Actually, let's do the business with the microphone because it's just easier to hear. And, actually, other people with questions can just line up behind him.

Male Audience Member: David, do you think that while SARS caught on here in Canada as a problem, but not in states, I'm just wondering, can you give any thought to the role of our public healthcare system in Canada and what role it might have played in let's say making the problem worse than better?

Dr. David Gratzer: Well, look, it's easy to be critical of our public healthcare system, I think undoubtedly crowded emergency rooms, like at Scarborough Grace, probably weren't particularly helpful in terms of disease containment. That said, the overall lesson of SARS is that a lack of preparation can be devastating. I think that speaks less to our healthcare system than our public health officials. Certainly the reports that have come out of Toronto suggest that many of these public health officials and microbiologists were more interested in fighting over the data and who gets to publish the data than they were about figuring out what to do about SARS. In the end, only 44 people died. We got lucky. It doesn't matter whether you've got a public healthcare system like Canada's, you've got a mixed system like Hong Kong's, or you've got a private system like in the United States, you've got to figure out how you're going to contain the virus. Obviously our healthcare system has a lot of problems, but I think in this particularly instance we are all equally vulnerable.

James Glassman: Other questions? By the way, there is no anecdote to SARS, is that correct?

Dr. David Gratzer: No.

James Glassman: And you don't expect there will be, being a virus as it is.

Dr. David Gratzer: In an age of the Internet, people can communicate so quickly and easily. Lots of private and public laboratories are working on these things. Some may have even mapped the genome at this point. But then the question is, how do you treat? And in terms of viruses, we're still quite limited in our antivirals. The case studies suggest that wherever we use antivirals and steroids, people are no better off than controls -- which is to say that with all of our medical technology, with all of our advances, with all of the money in pharmaceutical industry, bed rest is as good as our fanciest drugs.



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