SARS and ASEAN: Some facts - Some perspective

April 27, 2003

Last week, health ministers from East Asia and South East Asia met to agree strategies to combat SARS. Next week ASEAN leaders meet for further chinwags in Bangkok, comfortably ensconsed in the top-class Mandarin Oriental, Shangri-La and Sheraton Orchid Hotels in the business traveler dormitory square kilometer. The agenda next week is to formulate ASEAN strategies to combat SARS. Decisions made there will have key implications for economic health, business strategy, and indeed the way business is done in Asia and ASEAN generally.

Most publicised anticipated decision now is the institution of mandatory health checks for all travelers crossing borders in South East Asia, no matter the SARS-status of the departing country.

Now while all measures to prevent the spread of this economically debilitating virus must be welcome, it is a simple solution developed as an easy option likely to receive consensus among a group of nations socialised to go easy with each other, keep negotiations and information exclusively among a privileged few, and generally keep their nose out of each other's business.

For the first formal multi-lateral decision to focus on border and airport health checks smacks of self-interest, defensiveness, and ignores the facts presented below that suggest inter-country transmission is one of the least of their SARS-related problems if they are indeed to formulate truly regional strategies.

Last week the Thailand infection count jumped from 7 to 8. The case was a returning national from the UK, where she had met with Chinese associates in a meeting. No way that outgoing border checks in South East Asia would have prevented that.

Let's look at a few facts.

SARS has so far killed 300 and infected 5,000 worldwide, the great majority being in China (including Hong Kong). Infections in China (again including Hong Kong SAR) account for over 80% of all cases worldwide, and confirmed cases are still rising fast. Hong Kong today announced another 12 deaths, equalling a previous daily "record". Thankfully daily new cases in Hong Kong may just be on the verge of reducing.

Infections in other Asian countries including Australia account for a further 15% with Singapore accounting for almost 2/3 of these. That leaves 5% of infections spread through the Western world, with Canada and Toronto in particular accounting for the majority of these.

While originating from China, and perhaps exacerbated by lack of transparency in reporting and reluctance to admit a problem for fear of causing panic among the general populace and maybe even repercussions on international trade and FDI, SARS is not soley an Asian problem. It is at once most devastating for China and Hong Kong which accounts for 80% of infections with no evidence of a levelling off, and Singapore which accounts for 3%. But in terms of infection rates per population, other Asian countries like Australia, Malaysia, Thailand, the Philippines and even Vietnam (one of the first countries affected through transmission from China and where new cases have dropped off to such an extent that the WHO may be considering dropping them from the list of SARS-affected countries) have similar or less rates than Western countries.

Even in China, infections are increasingly localised; in Hong Kong particularly in one apartment block, increasingly now in Beijing, and among health care workers. In Canada, the outbreak is relatively isolated to Toronto. In Singapore, various targeted locations such as hospitals and food markets have been identified. There seem to be well defined risk factors associated with certain locations which one "super-spreader" has visited, suggesting that remedial measures could be far better targeted than simple border screenings and scattergun approaches.

There is strong evidence from a downward trend in reports of new cases over the past few days, that the SARS threat may be reducing, especially in countries other than China and Hong Kong. And it may also be reducing in Hong Kong with the welcome reduction of new cases in Hong Kong announced today.

The following graph provides data on the number of confirmed cases for countries with more than 3 confirmed infections as of 24th April based in part from the daily World Health Organization (WHO) SARS reports. It also provides data on incidence - the proportion of cases of the total population (total population estimates sourced from the latest World Fact Book figures).

These proportions will of course change in future due to varying reporting issues (such as is the case of China and perhaps some other Asian nations), epidemeological curves, and whether transmission is increasing or decreasing in each centre.

Your correspondent is no epidemiologist, but to me the graph is informative for several reasons.

In terms of incidence, apart from Hong Kong and Singapore, Asian countries have similar or even lower rates compared to Western countries. Note that China's incidence is very low, but this may be due to under or delayed reporting, as well as the vast geography and widely distributed population where medical services are not as available and reporting almost non-existant in rural and far flung provinces. The incidence in Beijing alone and Shanzi province alone is quite high.

For bars which are so short that actual figures cannot be deduced from the graph, Vietnam has 63 confirmed cases, accounting for (roughly) 0.8 infections per Million of population, Malaysia has 5 cases at 0.2, Australia 4 cases at 0.2, the Philippines 4 cases at 0.1 and Thailand 7 cases at 0.1. In comparison, Canada has 198 cases at 4.7, and the US has 41 cases at 0.2.

Other reasons for Asian countries having sometimes higher incidences include physical proximity to China as the source of the epidemic, and the high levels of inter-regional air-travel.

Most densely populated urban centres (such as Hong Kong and Singapore) have by far the greatest proportion of the population infected, suggesting that the virus is highly correlated with very high population densities. Recent SARS alerts from the WHO suggests that SARS is not as highly contagious through informal contacts as previously suspected, but is spread mainly though close personal contact as may be the case with health workers and immediate family.

As always, with a new disease of which little is known, conservative preventive measures are sensible. Beijing's moves today to ban all public gatherings or meetings of over 50 people, as well as to isolate infected hospitals less recently, are justifiable while SARS infection rates grow at alarming rates.

Admonishments to the populace to practice good hygiene is also sensible, as all affected countries are doing. Surprisingly however, one of the most hygienic, or some would stay sterile countries in the world - Singapore - also displays very high infection rates, though the rate of increase may be showing signs of slowing down. One cause that has not been discussed of yet but is worthy of follow-up is eating culture. 85% of Singaporeans are ethnic Chinese, and many eat the same traditional way as Chinese world-wide - by sharing a communal plate of rice or noodles by probing the same with their chopsticks. I remember when first arriving in Singapore a couple of decades back I was dismayed at the practice and carefully watched the plate for parts that were not touched by other's chopsticks. I justified it as a symbol of mutual trust, but now I'm not quite sure!

Next, let is remember that SARS with 300 deaths and 5,000 infections does not even come close to the threat to the world as a whole that Malaria, TB, or HIV AIDS does. These diseases mainly affect developing and poorer countries. According to a WHO report these diseases cause 5 Million deaths and 300 Million illnesses every year. In the ten minutes you take to read this article, 20 African children will die of Malaria (PDF). SARS so far seems not to respect boundaries of class or wealth. SARS strikes at the already developed economic pillars of tourism and direct investment in the case of more developed countries such as China, Singapore, Thailand, Malaysia and Taiwan. To the rich man SARS is a disaster, to the poor man it's insignificant.

While Thailand's infections rose to 8 and deaths to 2 over 6 weeks, over 500 Thais were killed in road accidents over the 8 days of the annual Songkran Thai New Year holidays earlier this month alone. That's many more than all SARS deaths worldwide over 5 months.

So lets look at the facts, and put SARS in perspective. Singapore, China, Canada, Taiwan, the UK, US and Vietnam have experienced local transmission. That leaves Malaysia, Thailand, Indonesia, Cambodia, Laos, Myanmar, Brunei and the Philippines - in short the majority of ASEAN - who still perceive the SARs threat as "foreign". That may well change.

Transmission across borders is primarily a national issue, not a regional issue. Border health checks, especially outgoing, are sensible for visitors from Singapore, China and Hong Kong, but wont do anything for the tourism industry or for business which keeps the economic clock ticking. No businessman is going to want to waste hours or days as they are shuffled off to hospital or quarantine for an innocent fever or sniffle. No tourist who has saved up for 12 months for a 2 week holiday in Thailand will risk spending that time in quarantine for similar.

Far more sensible is to consider ways to discourage close personal contact, and increase hygienic practices. Targeting travelers is only a very small part of the solution. Increasing border and airport checks are an easy solution but a poor one and less effective than other solutions that will require greater openness and transparency amongst delegates at the ASEAN SARS Summit in Bangkok on Tuesday. Singapore - perhaps one of the most transparent administrations in the world - deserves a very strong voice. We can only hope that bi-lateralism and genuine co-operation prevails to a far greater extent to combat AIDS than it did to combat the Asian financial crisis or assist in the East Timor issue in recent past.

We expect far more creative and painful solutions than more thermometers in departure lounges.

Chao Phraya River Rat in Strategy and Business Management on April 27, 2003 06:13 PM

Sponsor APMF Member

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