Released by : Herman B. "Dutch" Leonard
Date : August 2003

When SARS first appeared, it had all the hallmarks of a true crisis: urgency, apparent potential to create widespread and substantial (and perhaps even catastrophic) damage, and significant novelty. The novelty - the fact that there were no obvious analogous experiences that could provide reliable guidance about how best to respond - is a defining element of a true crisis. Situations of high urgency that are not novel - a modest earthquake, for example, in an area long known to be susceptible to such events - should not create a crisis, because public officials and the larger public should be prepared with plans, trained and practiced response teams that are adequately resourced, and a command and communications structure that should permit effective response to the situation. Thus, a reasonably predictable situation should produce only a routine emergency - not a crisis.

By this definition, the outbreak of SARS not too long ago was clearly a true crisis.  It was of unknown origin, unusually deadly, clearly contagious and in some limited settings apparently highly contagious, spread by one or several vectors that were difficult to identify or understand, unresponsive to commonly effective treatments, and possibly even exacerbated by some normally useful treatments.  Public health officials found themselves dealing with a deadly, expensive adversary with poorly understood characteristics.  They felt - and mostly were - far behind the "power curve" in their attempts to control and suppress the epidemic.

How effective they were - whether they could have been expected (collectively, or in specific locations where SARS appeared at different times) to have performed better, or, by contrast, whether in the circumstances of a novel outbreak they performed about as well as could reasonably have been expected - has been and will (quite properly) continue to be the subject of editorials, evaluations, and public debate.  This is an engaging debate, with arguments on both sides, and it can and probably will consume a great deal of time and attention.

But it is not the most relevant debate or discussion we should be having about SARS today.

The crucial question for today is how we should be organising and preparing public organisations (like public health departments and public hospitals), private organisations (like private hospitals and physician organisations), and the public at large for a possible reappearance of SARS.  A central responsibility - one public officials and relevant private organisations need to be facing now - is to insure that, if SARS does reappear (in some reasonably predictable form), it does not again become a crisis.  This time, if it reappears in anything like its prior form, it would be an unconscionable failure of our powers of anticipation if we were to allow it to be a surprise for a second time.

There are several forms in which SARS could reappear that are reasonably predictable based on its behavior over the last eight months - a period during which it emerged, spread dramatically but only in a few concentrated locations, and then apparently "went to ground."

Many well-known viruses have exhibited this pattern, and our experience with them gives us at least some basis for assessing the range of possible future appearances of SARS.  We can distinguish four importantly different possibilities, each of which calls for different elements of an overall prudent response:

Case I:  First, SARS could simply disappear.  If it resulted, as some experts now believe, from human contamination from improper food-related handling of an animal host of the virus, and food-preparers are made aware of this risk and take appropriate precautions against it, SARS could be isolated in its animal reservoir and not re-emerge into the human population.  This is, obviously, a widely shared hope - but hope is an emotion, not a policy.  We can hope that this scenario has high probability, and we can hope that it comes true, but it is not safe to rest policy on this assumption by itself.

Response if Case I occurs:  If our hopes are realised, we will not have to deal with a recurrence of SARS.  We should remain ready, with a well-developed reporting and response system, in case it does recur - but if it does not, we will not need to expend resources beyond those necessary to support reporting, reasonable planning, and appropriate readiness for action.

Case II:  Second, SARS could disappear for an indefinite period and then reappear episodically in a form similar to its recent appearance.  SARS is apparently harbored in an animal reservoir, and some other virulent viral diseases that are thought to emerge from an animal host (most notably Ebola) follow this pattern.

Response if Case II occurs: If we find ourselves in Case II, with episodic recurrences of SARS outbreaks, we will find the prudent investments in reporting, planning, and readiness made in response to the possibility of Case I both wise and useful.  In addition, Case II will require the expenditure of operational funds, to provide an appropriate response in the case of each outbreak.  Thus, the possibility of Case II calls for the same reporting, planning, and readiness funds as Case I, and also for maintaining availability of resources to pay for an operational response in the case where it is needed.  Prudence would also suggest investments in medical research on SARS, with the hope of finding better and more cost-effective methods of containment and of treatment.

Case III:  Third, SARS could emerge in essentially the same form as it took before, and thereafter exhibit a reasonably consistent annual cycle.  Several other viral respiratory diseases - most notably influenza and the common cold (to which the virus that causes SARS appears to be related) - exhibit this pattern.  Characteristics of the relationship between the virus and seasonally-varying patterns of human interaction often generate systematic seasonal patterns in disease appearance and progression, so this is not an unreasonable possibility - though it is also by no means a sure bet.

Response if Case III occurs:  Like Case II, Case III calls for investments in reporting, planning, and readiness and for available operational funding - but now all of these resources would have to be arranged on an expected annual basis. 

Case IV:  Finally, SARS could reappear in some completely unpredicted and unpredictable form.  There is enough that is different about this virus and its initial emergence that it could follow a path we have not previously experienced.

Response to Case IV if it occurs: If we find ourselves in Case IV, the reappearance of SARS would again present significant novelty, and we would have to face it, as before, with ingenuity and improvisation.  There is no good way to prepare for the additional features that this kind of event presents - except to maintain high-performance public organisations and infrastructure, and to practice improvisational responses.

Given the uncertainty about which of these four cases will occur, and the differing implications of each for what preparations and actions we should undertake, what can we do now to prepare for this range of possibilities?  First, we need to recognise that since we have so little experience and data about SARS, we should not be confident that we know how, when, or where it might reappear, and we need to be reasonably prepared for the whole range of possible outcomes.

In all cases, reasonable prudence would call for building an effective and comprehensive reporting system so that authorities like local and national public health officials, and the World Health Organisation are able to recognise the reappearance as quickly as possible and respond to it on a timely basis.  If a future outbreak is similar to the first outbreak, experience in different locations during that outbreak suggests that time is of the essence in containing the outbreak within as small a geographic area and part of the population as possible.

Additionally, all cases would call for planning and readiness spending, and for preparations for bearing operational costs and fielding operational resources in the event of an outbreak.

The possibility of Case III implies the necessity of preparing resources for operational deployment, particularly in areas (like South Asia) where the earlier outbreaks took place.  Reasonable prudence would suggest that these areas face a higher probability of a recurrence, and therefore that they should have identified resources that could be deployed in the event of an outbreak to identify people who might have been exposed, to treat those who may have fallen ill, to protect health caregivers and others involved in treatment and support of SARS patients, and possibly to quarantine or otherwise isolate people who have been exposed in cases where it appears that such actions are necessary.  All of these resource uses were needed in some locations during the first outbreak; the use of each is thus reasonably foreseeable in the event of a recurrence that is similar to the original outbreak.  No jurisdiction in which a SARS recurrence is a material possibility should be found to be without plans and identified resources in the event of a renewed outbreak.  To be caught in such a position would be a failure to have exercised reasonable anticipation and prudence in the face of a clear and material possible danger.  There is no dishonor in being surprised once by SARS; there is no way to avoid being surprised by something that is truly novel.  But being surprised twice by the same thing would be an inexcusable failure to learn once fair warning has been provided by the first SARS outbreak.

If Case IV occurs, the wide range of possible occurrences that might then result makes the specifics of what we would be preparing for too uncertain to make it cost-effective to build specific additional capacity, but it would be wise to have contingency plans for what to do in case surge capacity is needed.  For example, identifying possible sites that could be used for quarantine, identifying sources for supplies that may be needed, and generally thinking through alternative approaches that might be taken in different circumstances that might emerge may substantially increase the rate at which an effective response can be mobilised, and may help to avoid costly mistakes. 

In addition, if SARS does recur, the actions of the public will be crucial to the success of efforts to contain and respond to the outbreak.  Public cooperation with reporting, travel restrictions, and possibly with more significant interventions (like quarantine) will be essential determinants of the success at efforts to contain and suppress a renewed outbreak.  Thus, preparing the public for the possibility of a renewed outbreak and for its role in the event of future outbreaks is an essential component of any effective overall public strategy for addressing SARS.

Which cases should we be preparing for?  Case I is, of course, our fondest hope - but it is only that.  We cannot assume that the disappearance of SARS is permanent.  Thus, we have at least to prepare for Case II (episodic recurrence).  We would have to consider ourselves lucky if SARS does not reappear at least episodically, so we clearly need to be prepared if it does.  Do we need to prepare for Case III (an annual recurrence)?  Fortunately, we don't need to.  We have no strong reason to believe that SARS will follow this pattern.  And even if it does, if we are prepared for an episodic recurrence, then we are ready for the first annual recurrence (if that is what is going to occur).  So we can prepare for episodic recurrence, and if that does not begin to show an annual cycle we can continue in the same vein; if SARS does appear next year and disappear again later, then we will have a reasonable presumption that it has an annual cycle, and we can prepare accordingly.

But what about Case IV (a reappearance of SARS in a novel form)?  We always need to be prepared for the appearance of unexpected, potentially deadly diseases (or other threats, for that matter).  The fact that SARS has appeared once makes it, perhaps, a little more likely that a variant of it will reappear in some novel form.  But there are many other possible diseases (and other threats) that might emerge, and we cannot try to guess what their specific forms will be.  Instead, we need to be generically ready to respond to evolving threats.  How do we do this?  Much of the first line of response will be provided by the public sector - and therefore we need to maintain strong public sector administrative, planning, and response capacities, together with robust systems for being able to raise resources when necessary.

In summary, given the range of possibilities we face regarding future SARS outbreaks, prudence would counsel:

(1)      development of a comprehensive reporting mechanism to provide early detection and early notification to public health and other relevant officials should there be a renewed outbreak of SARS;  

(2)      reasonable efforts at planning and maintaining readiness to deal with the possibility of a renewed outbreak;

(3)      identification of operational resources that would be required in the event of an outbreak;

(4)      development and maintenance of a general public capacity to respond to novel dangers - for example, by improving coordination among different agencies of the government, practicing the ability of different response organisations to work together and to improvise in unusual circumstances; and

(5)      aggressive efforts to inform the public about (a) the possibility of future SARS outbreaks, and (b) what may be required from the public and from individual members of the public in the event of future outbreaks.

The overwhelming implication of our existing knowledge of SARS is that if it recurs and we are not ready, we have failed in the most elementary of public duties - the duty to anticipate and prepare for reasonably likely hazards to the public health and well-being.  Such a failure will turn what should be a routine challenge - since we have learned a great deal in the last 10 months about how to address a SARS outbreak - into a true crisis.  But this would then be a crisis of our own making.

 Herman B "Dutch" Leonard is a Professor of Public Management with the John F. Kennedy School of Government at Harvard University and a Visiting Professor with the Harvard Business School at Harvard University.

 Prof Leonard is scheduled to visit Malaysia in September 2003. He will address a full-day seminar on `Leadership in Crisis Situations' in Kuala Lumpur on the 25 September 2003. For information or to register for this event, please contact MIM at 03 2165 4611, visit www.mim.edu or email enquiries@mim.edu< /a>.