SARS - The view from the community

D Owens 歐德維
Deputy Editor, The Hong Kong Practitioner

Since writing the last editorial, information relating to this new disease continues to be accumulated at an extraordinary rate. At the time of writing SARS has infected 0.02% of our population over a period of time representing 21 cycles of infectivity using an average incubation period of 4 days. This represents a spread of 8.4 to 42 cycles using a range of incubation of 2-10 days. The majority of cases can be traced to a known SARS contact and less than 3% of quarantined household contacts of known SARS cases develop the disease. Data accumulated from the epidemic suggests that SARS is an illness with low infectivity in the incubation and very low infectivity in transient social contact. It appears to be a disease which is highly infectious in close proximity to an ill patient. Although the data has yet to be formally analysed and published, it is reasonable to think that viral load will be a significant factor in the epidemic spread and possibly in the severity of the disease.

SARS is an infectious disease. Like all infectious diseases it is the nature of the evolution of the epidemic that is of most importance to the population. In population terms the percentage mortality of this disease is significantly less important than the percentage of the population that will suffer from the illness. This is a simple but very important point. Hospitals and hospital based medical specialties contribute significantly to the health of individual patients but very little to the health of populations. The major factors driving population health occur at a macro level and include socioeconomic, educational and environmental factors in addition to the obvious lifestyle choices such as smoking, exercise and diet.

As Family Practitioners we must recognise the importance of a broad population perspective. We pride ourselves on a holistic view of health. Physical, psychological and social factors influence all of our interactions. In this context, 99.98% of our population have not suffered from the physical manifestations of this disease but the vast majority have suffered psychologically and socially. It is conceivable that the mortality in Hong Kong from the economic, social and psychological fallout will ultimately be greater than from the disease itself.

In Hong Kong as in other countries the media have focused almost exclusively on the disease with very little understanding of the process of the epidemic. In general the level of news reporting in Hong Kong has been very poor. Doctors have been quoted on a variety of issues. The mortality, the mutagenicity of the virus, airborne or droplet spread, the teratogenicity of ribavirin, the benefit of masks. Some of this opinion has been poorly informed, emotional and speculative. One of the important lessons to learn from this episode is the danger of extrapolating data from very small numbers of ill patients in hospital to the wider community. This was a mistake which was made in the early days of the AIDS epidemic and it is a mistake that has been repeated with SARS. Prominent hospital specialists have been describing the SARS virus as highly infectious several weeks after epidemiological evidence demonstrated that it quite clearly was not, except in close proximity to the most ill patients from whom the specialists get their experience.

The prominence given both in the media and within the profession to the opinions of hospital specialists is in part a result of a medical structure in which the political power base rests almost exclusively with hospital specialists. SARS is an infectious disease. It is a Corona virus epidemic. As Family Practitioners we may not be expected to be up to date with the intensive care management of Adult Respiratory Distress Syndrome but we would certainly be expected to understand the evolution of a Corona virus epidemic. This new virus appears to produce severe and presumably immunologically mediated complications in a significant number of patients. The management of these complications and the battle against the disease is taking place in hospital. The battle against the epidemic is taking place in the community. Ultimately it is the blunt instruments of education, case identification and quarantine that will control the SARS epidemic and not the number of ventilators or intensive care beds.

This is the dilemma of new diseases. The tendency is to look for expert opinion. The disease experts tend to be found in the universities and hospitals. The health experts, in general can best be found in the community. Family Practitioners and public health doctors are trained to look beyond the organism and the organ towards the health of groups and populations. The vast majority of interventions in any health care system take place at a community level. Our expertise is, or should be in education and the provision of information. Ultimately it is these relatively simple interventions which will do the most to control epidemic spread and reduce the population mortality due to infectious disease.

This is one of the clearest messages from the early days of the SARS epidemic. Hong Kong has an excellent hospital based medical system. It also has an excellent public health system. These systems are fragmented and communicate poorly. In most countries with a mature medical structure the majority of doctors would practice within the community. Family Doctors act as a central exchange connecting the organism specialists at one end of our professional spectrum with the population specialists at the other end. Whether or not they are formally trained in the specialty of Family Medicine community doctors would normally represent a strong group with significant medico-political influence and power. This is lacking in Hong Kong. There is a tendency to defer to hospital specialists even in a situation in which our expertise as specialists in Family Medicine is clearly greater.

In the coming months there will be significant debate about our handling of the SARS epidemic. The nature of the economic fallout will ensure that time and money will be available to improve systems. It is important that we as Family Practitioners are not excluded and it is essential that we are forceful in establishing a role in this process. The long term health of the population of Hong Kong will ultimately be determined by factors outside of medicine and predominantly by socioeconomics. The factors within the control of medicine will predominantly be low cost and low tech. Education, the provision of information, assistance with behavioural modification and the provision of preventative medicine will be significantly more important than transplants and ventilators. Hong Kong has excellent hospital specialist and public health systems. What is really needed for the continued health of the population of Hong Kong is a strong, well trained and powerful primary health care system. This is a challenge which will require strong leadership.

This editorial is dedicated to the expertise and bravery of the front line medical and nursing staff involved in the treatment of SARS patients. It represents a view from the perspective of a community doctor. It is not intended in any way as a criticism of hospital doctors. I have worked in hospital medicine on the other side of the fence. These personal opinions are in part a reflection of my previous experience of TB and AIDS.

Editor's Note :

Dr Owens has been producing an update on SARS for the college website. It is available on http://www.hkcfp.org.hk/