SARS war: combating the disease
Authors: Lisa Saiman
Journal: Journal of Clinical Investigation (2003)

Leung Ping Chung and Ooi Eng Eong have presented a heartfelt account of their battles with severe acute respiratory syndrome (SARS) during the initial appearance of this new pathogen in their countries in early 2003. Leung works at the Prince of Wales Hospital in Hong Kong and Ooi at the Environmental Health Institute in Singapore. Both cared for patients with SARS and contributed to the public health efforts to combat and control this global epidemic.

Leung and Ooi briefly trace the course of the epidemic in the first chapter. Unfortunately, due to changes in the clinical case definition, delays in confirmatory laboratory testing, and delays in reporting, the numbers cited are now outdated. However, the importance of demanding complete transparency by governments in order to avoid the further spread of SARS is justifiably highlighted in several places. This reviewer would have welcomed Leung and Ooi’s insights regarding the cast of government officials who denied or validated the epidemic’s importance and who hindered or assisted in its control.

The descriptions of the mass quarantines and the use of legislative means to enforce quarantines are of great interest, particularly to a Western reader. For instance, when over 200 cases of SARS were discovered in an apartment complex in Hong Kong, the building was cordoned off and police officers wearing protective masks, gloves, and gowns set up barricades to prevent anyone from entering or leaving the building. Leung and Ooi include a personal vignette of the difficulties in obtaining groceries for residents caught unprepared by the mandated quarantine. In Singapore, the Infectious Diseases Act, which mandated quarantine of all persons who had contact with SARS patients, was invoked. Hefty fines were levied for those persons who did not comply with the quarantine. The fear and paranoia of the general population are detailed as are the frenzied demands for masks and, in efforts to strengthen the immune system, vitamins and Chinese medicinal herbs.

The relative contributions of such drastic means in curtailing the outbreak remain unknown, and these measures are not recommended by the World Health Organization (WHO). The recommendations and contributions of the WHO are outlined, albeit briefly, as is the dramatic success of the unprecedented coordinated international diagnostic and control efforts. Unfortunately, these efforts are described only through April 3, 2003, leaving the reader with an incomplete story. The WHO didn’t declare that the epidemic was over (for the 2002–2003 season at least) until July 2003.

The abundant photographs are vivid portrayals of the impact of SARS on the countries in Asia that were most affected. Signs proclaiming school closings, pictures of airplane crews and passengers on buses wearing masks to protect themselves, and numerous photographs of cleaning staff — all wearing masks and gloves — disinfecting elevators, public buildings, and train stations are shown.

Perhaps due to the speed with which this book was written and published, there are several redundancies and numerous inaccuracies and unproven conclusions. For example, Leung and Ooi state that the case fatality rate is 4%, but in fact the rate is more than double that at 10.9%. They also imply that convalescent serum from recovering patients might be a useful therapy. There are no published reports of the efficacy of this treatment, which was used only by Leung and Ooi and not by others who treated patients with SARS. To date, there are no specific therapeutic interventions for SARS; supportive care is the standard.

The intended audience for this book is unclear. The book is too technical for a lay person, yet there are numerous recommendations for personal hygiene and general health in addition to recipes for traditional Chinese remedies. The redundancies, as well as changes in tone and reading level, are distracting.

Despite the book’s flaws, physicians, epidemiologists, and historians alike will find aspects of SARS war: combating the disease of interest. Readers should not expect totally objective science, but a tangled description of what occurred during a very complex and difficult situation for all; there were no precedents to rely on. As Leung and Ooi state, “Overreacting became a public health policy guideline in efforts to identify, contain, and control the epidemic.” While this book suffers from a lack of skilled editing and peer review, it honestly captures what it was like “on the ground” in Singapore and Hong Kong during the darkest days of the SARS outbreak. While other, more comprehensive books on SARS will no doubt be published in the future, this book presents a stirring chronicle.