SARS: The Pandemic that Never Was: Part 2

0:0:02 Narrator: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. This episode is part of a series of special editions of our podcast, focusing on the ongoing Coronavirus pandemic. This week, we're doing something a little different. A group of undergraduate students at the University of Michigan School of Public Health recently created a three-part podcast series looking back at the 2003 SARS epidemic and how it relates to the coronavirus pandemic.

SARS and COVID-19 are both caused by coronaviruses and share a lot of similarities, but they have had very different effects on the world. In this episode, the students dive deeper into the social factors that influence the outcomes of epidemics, including the 2003 SARS epidemic and the COVID-19 pandemic.

0:01:05 Anjali Vaishnav: Welcome or welcome back to SARS: The Pandemic that Never Was. If you haven't had a chance to check out our first episode on the different similarities and differences of SARS and COVID-19, be sure to check out that episode. Our guest, Maddie Malvitz really helped us to understand all the key differences in the different biological components of both diseases, and while I think understanding the biology and pathology of this disease is so crucial to understanding how the SARS outbreak progressed, it's also really important to understand all of the other social factors that really drove disease burden, and so I wanted to bring in another guest, Sophie Blasberg. Hey Sophie.

0:01:40 Sophie Blasberg: Hi Anjali.

0:01:41 Vaishnav: We just wanted to talk a little bit more about some of the different social factors and impacted disease burden and progression during the SARS epidemic and I understand that you have some information about one of those factors.

0:01:52 Blasberg: Yes, I do. I'm here to talk to you about the anti-Asian sentiment that has been going around during both the SARS outbreak and during the current COVID-19 pandemic. So throughout history, disease and discrimination have gone hand-in-hand, and I’ll just enlighted you on a couple of examples. So in medieval Europe, the Jews were blamed for the Black Death, and then in fact, more than 200 Jewish communities were wiped out because they were accused of poisoning wells and for the spread of contagion. And then also in the 1980s, during the aids epidemic, there was a large amount of fear and discrimination of homosexuals, hemophilia and heroine addicts, and the same pattern of disease and discrimination is in the current outbreak.

0:02:43 Vaishnav: Wow. So it's really clear that people discriminate, but not the virus itself. Right, so how do you think that played into the SARS epidemic?

0:02:51 Blasberg: Yeah, so SARS definitely made life way more complicated for a lot of people, just based on their race. Specifically in Canada, and then two studies also have shown that the stigmatization of the Chinese population in Toronto exacerbated an already existing intense racial climate. And then also during my research, I ran into a bunch of first-hand accounts of xenophobia in Toronto. And so many Chinatowns across North America were deserted. And then in Toronto, in fact, there was an informal boycott of the Chinese community, and then this resulted in Chinese-owned businesses in ChinaTown, businesses losing an estimated 40% to 80% of their income.

0:03:42 Vaishnav: That is quite a lot. Wow.

0:03:45 Blasberg: A lot. And it just shows how a virus can impact all aspects of someone's life just based on race. And then also there are reports of empty seats next to people of Asian descent on a subway in Toronto, which it's normally so hard to find a seat there, and then just the shunning of people of Asian descent in general.

0:04:06 Vaishnav: So as you're talking about all these incidents, I can't help but make a connection to what we've been seeing, especially in the last few months in today's pandemic. 

0:04:14 Blasberg: Yeah, so it's almost 20 years later, and we're faced with a horrible history repeating itself around the world. While COVID-19 has been spreading anti-Asian racism has been spreading and physical attacks on people of Asian descent have also been occurring. On May 8th, in fact, the General Secretary of the UN, Antonio Guterres, tweeted “the pandemic continues to unleash a tsunami of heat and xenophobia, scape-goating and scare-mongering” and he also urged government leaders to take action against the hate caused by the virus.So we have people in high places acknowledging that race is a part of this pandemic, which is what we need, you know?

0:05:03 Vaishnav: Definitely, and like it's not even just limited to what we're seeing domestically here in the US, but also globally.

0:05:11 Blasberg: Yeah, so it has been seen across the globe. The Chinese-Canadian community feared a repeat of what happened during the SARS outbreak. And then in January, French-Asians started to use the hashtag #Jenesuispasunvirus, and then in English it means I'm not a virus. And the slogan is still being used today. The first tweet was French-Asian holding up a sign that had the hashtag on it.

0:05:41  Vaishnav: That's really powerful.

0:05:43 Blasberg: And then also the use of anti-Chinese rhetoric has been seen online talking about COVID-19. So just in March alone, there were 10,000 tweets that included the term “kung flu”. And then it's interesting to see how social media has played a role in this pandemic versus its lack of a presence in 2002 during the SARS outbreak. It's also nice to see that Twitter, Instagram and Facebook and Tiktok have taken action to ensure reliable information about COVID on their sites. In late April, the Coalition of Asian-American groups created a reporting center called Stop AAPI to report hate incidents.

0:06:30 Vaishnav: That's really cool to see that even though social media has propagated a lot of really horrendous things happening in our country, there are still opportunities to use these platforms for such positive change.

0:06:42 Blasberg: Exactly. And it surprised me that it came in April as the pandemic started in late January. And also the World Health Organization took precautions when naming the virus. So on February 11, when the WHO gave the virus its official name of COVID-19, they chose not to call it SARS COV 2 because using the name of SARS could have unintended consequences, it could create unnecessary fear for some populations, especially in Asia, which was the worst continent affected by SARS, and so they did this to avoid inaccuracy and stigma.

0:07:23 Vaishnav: That's really interesting. I had no idea that intentionality behind that naming.

0:07:28 Blasberg: Right. A name can mean a lot. And so this social injustice has been carried throughout the coronavirus, infections of SARS and COVID. And the large-scale racism is a macro social factor that's related to outcomes of the disease, including more abstract negative effects on mental health in the long-term and in the short-term and an increase in the hostile racial environment that has existed in the current days.

0:07:56 Vaishnav: Definitely. That's a really horrid and unjust social pattern that unfortunately we've had to see the parallel between that first epidemic of SARS and now with COVID-19. But that you so much Sophie for sharing all of that insight and I think it really helps to put all this into perspective and see how much racism has propagated disease burden.

0:08:17 Blasberg: Of course, thank you so much for having me.

0:08:20 Vaishnav: So I wanted to take some time to also discuss another really important driving factor in disease outbreaks, which is communication, how information is presented to community members, how is the disease is talked about, and I wanted to bring in a third guest to help us dive into this a bit more. So hey Stephanie. So I was wondering if you could talk to us a bit more about how communication and media was such an important part of the SARS epidemic.

0:08:47 Stephanie Lai: Yeah, so the Chinese government and media played a large role in driving the SARS burden. In early January, Chinese health personnel in several provinces in Guangdong we're actually aware that there were cases of a mysterious respiratory illness circulating in several cities in Guangdong. The provincial health bureau alerted the ministry of health and a team was sent out to the provinces to investigate the disease.

An investigation report was completed in late January and sent to the Ministry of Health in Beijing with the report marked as top secret, meaning only provincial health officials could open it. However, further government action was actually delayed because of problems within their information flow within the Chinese hierarchy. For three days, there was no authorized provincial health officials available in the document, and after the document was finally read, the provincial bureau distributed a bulletin to hospitals across the province but few health workers were actually alerted of the bulletin because they were already on vacation for the Chinese Lunar New Year. And another issue that this brought up was the Chinese State secrets law which made the handling of public health information classified as a state secret before they were announced by the Ministry of Health.

0:10:22 Vaishnav: So until the Ministry of Health made information about SARS public, any physician or journalists who reported on SARS would be at risk for persecution for revealing these state secrets?

0:10:33 Lai: Yes, actually, one Chinese army doctor named Dr. Jiang who sounded the alarm on the reality of SARS cases in China was actually put under surveillance and hospital officials warned him against speaking to foreign reporters and an army newsletter was actually criticizing him and trying to discredit him.

0:10:50 Vaishnav: Wow. So obviously this must have incited a lot of fear in the public once news of the disease actually got out, I would imagine.

0:10:56 Lai: Yeah, it definitely did. The initial failure to inform the public about SARS actually heightened fears and led to the spread of misinformation. So on February 8th text messages about a deadly flu began circulating in Guangzhou and search words such as bird flu and anthrax began to trend on the internet. Local media did acknowledge the existence of the disease and listed preventative measures, such as vinegar fumes to disinfect the air and panic was spreading and items such as antibiotics, flu medication, even vinegar were sold out.

0:11:29 Vaishnav: Wow. That's very crazy. And I was imagining, did the government have anything to do with the fear and panic that the public was experiencing?

0:11:37 Lai: Obviously the government had a lot to do with it. So they did try to do things to kind of quell that fear that the public was having. So our February 11th Guangdong health officials actually finally broke their silence and they held press conferences about this mysterious respiratory illness and reported that there were over 300 cases in the province. And although they admitted that there were no effective drugs against this disease, they also downplayed the risk of disease and said that it was tentatively contained.

But when some reports came out questioning the government's handling of the outbreak, the propaganda bureau actually halted reporting on the disease and not coincidentally the news blackout continued during the election to the National People's Congress in March. So if China had battled SARS more aggressively in Guangdong in January and early February, the disease might not have spread so quickly and there would not have been as much unpreparedness from the outbreak among healthcare workers, and then also misinformation and fear spreading in the public surrounding the disease.

0:12:41 Vaishnav: So as I was talking to Sophie earlier, I was noticing so many connections of anti-Asian discrimination during the SARS period to today's COVID-19 pandemic. And unfortunately, as you've been talking about all this information about the media and misinformation, there's been so many connections that I've been drawing to things that we've experienced today about how COVID-19’s communication has been spread. I was wondering if you could maybe speak more to that connection about media and government during this era of COVID-19.

0:13:14 Lai: Yeah, for sure, Anjali. There's actually been a lot of parallels between SARS and COVID in terms of media coverage in China. So China has been severely censoring the circulation of information about COVID-19. They have been removing local news reports and scrubbing social media platforms such as Weibo clean. So Weibo is essentially the Chinese version of Facebook, so to some users who are using WeChat, a messaging app to work, friends and family about the virus also had their accounts suspended because they were said to have spread sensitive information or legal content. In fact, one doctor named Dr.Le who quietly sounded the alarm on the virus enterprise and WeChat messaging with other doctors was called in for questioning and forced to recant his previous statements. And when the world began covering the Guangdong quarantine after the city was locked down, the Chinese government dispatched over 300 reporters from state media agencies to counteract critical coverage of their handling of the virus and then control the narrative as well.

COVID-19 has also had its fair share of controversial media coverage and misinformation circulation in the United States and many other countries as well. The surge of numerous rumors, hoaxes, and misinformation regarding the etiology, outcomes, preventative measures, and cure for COVID-19 has masked healthy behaviors and promoted erroneous policies increased the spread and poor health outcomes of COVID-19. Some of the most outrageous alternative remedies that have been said to prevent or treat COVID-19 include herbal therapies, teas, essential oils, (____) and even colloidal silver. And rhetoric from some politicians have also created the narrative that the pandemic isn't as dire as it seems, and that public health guidelines should not be taken seriously, which has led to the preventable deaths of thousands of people, because they would rather believe and put their trust in politicians that don't believe in the science rather than public health and infectious disease experts

0:15:16 Vaishnav: Alright, well, thank you so much, Stephanie. And unfortunate that they're so body parallels that we keep drawing between the determinant of communication and the media between SARS and COVID-19, but I think a very crucial piece of information to really understand the totality of this epidemic. And while these two social determinants that we've discussed today, obviously play an important role in determining the spread of the outbreak, I don't think that we can ignore how healthcare systems were then able to manage or not manage the spread of SARS. And so finally, I'm joined today here with my guest, Catherine Marudo who has some more insight into how healthcare workers and health systems were impacted by SARS. Hey Catherine are you there?

0:15:57 Catherine Marudo: Yeah, I'm here Anjali. Thanks for having me.

0:16:00 Vaishnav: Of course. I was wondering if you'd be able to speak more to how SARS affected frontline workers back in 2003.

0:16:08 Marudo: Yeah, so in the United States we were very fortunate. It is estimated that there were only roughly 33 cases of SARS in the US, and these Americans may have traveled to countries where SARS was spreading, but fortunately, SARS do not have a significant transmission penetration in the States. However, not all countries were as fortunate as we were, and other countries hit hard were Canada, Singapore, and Vietnam. And for these countries, the SARS epidemic was really a wake up call. For many of these countries, their health systems pandemic planning was in their infancy stages, like Maddie had mentioned in the first episode, and the 2003 outbreak really exposed the tremendous risks that their healthcare workers and first-line responders faced during the emergency response.

0:16:55 Vaishnav: I like that you called it a wake-up call, and I was wondering where you think that call is heard the most, and are there any examples that maybe come to mind?

0:17:03 Marudo: Yeah, really one of the first examples that come to mind is Taiwan. In Taiwan, though less than 10% of their nurses left are considered to leave their jobs, they still faced a significant increase in workload, stress, damage to social relationships due to their infection risk, and they also had a really negative perceived personal fatality risks from SARS and these are really important predictors for these healthcare worker retention in Taiwan hospitals.

0:17:34 Vaishnav: Got it. And as distinct as this example is, I can't help but think that there are probably many global themes, if we wanna call them, in the deficiencies of healthcare systems across the world.

0:17:45 Marudo: Yeah, you're exactly right on point with that Anjali. Globally, the SARS epidemic exposed severe deficiencies in our global modern health care systems capacity to respond to these novel pathogens. Back in 2003, the exact nature and the impact of this virus was relatively unknown, and really having only sparse knowledge on the novel virus and lacking any form of effective interventions, public health officials like those in Ontario, Canada really only had enforcement control measures like quarantine mandates to implement, and a lot of individuals didn’t see this as anything that resembled what we now defined as evidence-based frameworks. And this brought up a lot of tensions and push backs from its citizens, and this really gave a rise to tension between security, public health credibility and the enactment of public health actions or programs, and I don't think that these tensions have disappeared since 2003. We see this now, even in the States, with push-backs against public health interventions like social distancing, mask wearing and stay-at-home orders.

0:18:50 Vaishnav: So would you say that you feel like history might be repeating itself today as we continue to see these overwhelmed Medical Systems and this push back and tension not only in the US, but globally as well?

0:19:03 Marudo: Yeah, unfortunately, I think that is the case, and I think that comes with novel viruses like we saw in SARS in 2003, and also COVID-19 now. The science is always changing and convincing the public that we're following the science may be a difficulty that both government officials back then in 2003 had and even now we're facing currently.

0:19:26 Vaishnav: So you talked about how healthcare worker retention was impacted during the SARS epidemic. Is there anything like that where we're seeing happen today? Another example of history possibly repeating itself.

0:19:38 Marudo: So similar to nurse retention, low nurse retention during the SARS epidemic, a study in Korea found that nurses during this COVID-19 pandemic found that working with COVID-19 patients caused their health care systems to have low job retention. Another study and the Philippines also found that an increase in the level of fear regarding COVID-19 was associated with decreased job satisfaction and increased job turnover for these nurses and really really what I take from these historical and contemporary findings is that they highlight a continued need for modern health care systems to really support the physical and mental well-being of its front line workers as really they're the foundation and they're critical to pandemic preparedness and response for many countries.

0:20:17 Vaishnav: Definitely. And despite pandemic preparedness, if it was greater, if it was less or something that I would assume stays constant is some type of dispropriate budden on the disease, whether it’s SARS, whether it's COVID-19. Are there any notable populations that were possibly hit very hard by both Coronavirus outbreaks?

0:20:47 Marudo: Yeah, I think this is a great and important question, and unfortunately for both the SARS epidemic and the COVID-19 epidemic, we really see a more significant proportion of disease burden falling on the poor and disadvantaged. For both SARS and COVID-19 overcrowding, poor housing conditions, lack of access to clean water, underlying health conditions and low socio-economic statuses really increases one's risk of disease unfortunately. Yeah, and furthermore, even in our own Michigan community we’re seeing this in Detroit. Black individuals and African-Americans in Wayne County were disproportionately and continue to be disproportionately affected by COVID-19 in many ways. Whether it be in infection rates, access to testing and care, access to clean running water, poor housing conditions, you name it.

0:21:44 Vaishnav: So it seems like all of these different factors continue to perpetuate through our communities and then lead to poor health outcomes, which exacerbate these poor living conditions, access to healthcare, access to running water, so it's almost cyclic.

0:21:56 Marudo: Yeah, definitely. And even in diseases outside of SARS and COVID-19, we see it in others, so it's definitely unfortunate. And with the new vaccine coming out, I think it'll be really interesting and important to see how equity will be prioritized in ensuring that these disadvantaged populations get access to affordable and timely COVID-19 vaccinations given their disproportionate disease burden.

0:21:23 Vaishnav: Definitely and I suppose only time will tell how that plays out. But let's hope that this isn't an instance where history repeats itself. Well, thank you so much, Catherine and to all of our other guests that joined us in today's episode. It's clear that from both SARS and COVID-19, we see a really great lesson in public health for centuries of pandemics to come. Pandemics disproportionately affect poor and disadvantaged and addressing all of these different social determinants of health that we discussed today and even more, is so imperative for countries to reduce health inequities, especially in developing countries that have these weaker healthcare systems, and I think key to this is definitely leveraging public health, building public health infrastructure in response capacity and countries, and taking advantage of the fact that we are aware of what these social determinants are that are impacting disease burden, like effective communication, increasing medical literacy, promoting prevention measures, you name it, there are so many different ways that we can help to build up the infrastructure that is going to prepare us for these different outbreaks that unfortunately, inevitably we will see in our future. And so I hope that you all join us back for our final episode where we'll be talking more about what this pandemic and what the SARS epidemic has really allowed us to learn and possibly what our future will look like as a consequence.

0:23:49 Narrator: Be sure to listen next time for Part Three of this three-part series produced by students at the University of Michigan School of Public Health.

This has been a special edition of Population Healthy, a podcast from the University of Michigan School of Public Health. During the ongoing coronavirus pandemic, we’ll work to bring you analysis from our community of experts to help you understand what this public health crisis means for you. To stay up-to-date in between special edition episodes, be sure to check out our website publichealth.umich.edu, subscribe to our Population Healthy newsletter at publichealth.umich.edu/news/newsletter and follow us on Twitter, Instagram, and Facebook @umichsph.