The Phantom Menace: Lessons Learnt From The SARS Outbreak In Singapore

Like many of my fellow colleagues, I never imagined that I would ever witness an epidemic of such proportions in my lifetime. Sure, we’ve all read about The Black Death, the Spanish / Asian / swine / avian flus, which claimed tens of millions of lives over the past century or so, but no disease in recent years has hit this close to home, or caused as much morbidity and mortality locally in such a short period, as the Severe Acute Respiratory Syndrome ( SARS ).

The months of March and April 2003 will be etched in our minds forever, but let’s not forget some important learning points we can garner from this historic event.


Lesson 1: Microbes shall inherit the earth

The first lesson I learnt from this is how helpless and fragile humans really are. Despite unbelievable medical advances in the past few decades, despite the development of new and powerful antibiotics, despite improvements in living conditions and lifespans, we are still defenceless against something so small it can only be seen under an electron microscope.

The culprit, a new breed of coronavirus, is capable of striking anyone, from young children to the elderly, but also displays a disturbing ability to kill strong healthy adults. No effective treatment is available at the moment, and the anti-viral agent Ribavirin shows inconclusive results and is associated with a whole slew of potential complications, while possible serums and vaccines are still undergoing clinical trials.

It is a humbling fact. We may be at the top of the food chain, but in truth, we all live by the micro-organisms’ rules.


Lesson 2: The world is one giant microbiological melting pot

Overcrowding, poor sanitation, malnutrition, war – those were the original catalysts for some of the worst global pandemics. But urbanization has brought its own dangers, as deforestation and expansion of living communities disrupt the natural order of the ecosystem and expose our virginal immune systems to a multitude of new pathogens. HIV and the Ebola virus are postulated to have jumped species in this manner, while the coronavirus, like its porcine and avian counterparts, probably skipped over to humans through the process of domestication and farming.

Now, in the 21st century, air travel can work for and against us – providing invaluable assistance in the transport of medical supplies and expertise to affected areas, but also helping to spread diseases across entire continents. A relaxing vacation can turn into a nightmare, as evidenced by 2 of Singapore’s index cases, who contracted SARS during a holiday in Hong Kong, where they stayed at the now infamous Metropole Hotel, and caught the illness from another hotel guest -- a Chinese doctor who earlier treated a SARS patient in his country.

Conditions are unlikely to change. If anything, they will only continue to progress in the same direction. And considering how microbes possess a built-in mechanism of constant mutation, we could say that the world is their stage, and we humans, mere players.


Lesson 3: Rising to the occasion

This crisis tested the characters of all Singaporeans, but none were as scrutinized as those on the frontlines of the battle – ie. the healthcare workers – and I am extremely proud to say that our medical community is one fearless bunch. Over at the CDC and Tan Tock Seng Hospital (TTSH), which to this day continue to receive any new suspect SARS cases, doctors and nurses work tirelessly, with some even volunteering to cover SARS wards and intensive care units.

The large surge in patient numbers resulted in manpower shortage, and medical officers in particular, were shunted from other departments to help care for SARS patients. Predictably, a few blanched at the idea and even refused to accept their new duties. However, most soldiered on, overcoming their anxiety and fulfilling their Hippocratic oaths.

In all other government hospitals, special fever wards were set up, and small teams of doctors and nurses assigned to man them. Although I passed when I was approached ( in deference to my worried parents ), I know of many who agreed without any hesitation whatsoever. A number of them are married with children, and admitted that their greatest fears were either infecting their families, or dying from SARS themselves. But in the end, their sense of duty to their patients and the medical profession emerged the victor.

It has been a great inspiration to the rest of us, and these heroes and heroines also showed the world what our healthcare workers are made of. We salute you all!


Lesson 4: The dark side of human nature

It is said that crazy times can drive people to do crazy things, and this was illustrated perfectly by some of the jaw-dropping antics of certain Singaporeans in desperate need of psychotherapy.

My favourite is the middle-aged man who repeatedly flouted home quarantine orders, then went out to a Queen Street eatery one night, and blatantly bragged about his law-breaking behaviour.

Another man, who recently returned from China with a fever, gave new meaning to the term “in denial”, by escaping from TTSH’s A&E department after being forcibly sent there straight from the airport. He was later put on home quarantine and cleared of SARS, but his lack of social responsibility was frightening, and may have resulted in disaster if he had contracted the disease.

And let’s not forget how healthcare workers, especially nurses, were ostracized by unenlightened members of the public. Bus-drivers refused to stop for them, passengers avoided them, beauty parlours wouldn’t give them appointments, and landlords threatened to evict them. Doctors didn’t suffer such degradation, probably because we don’t wear uniforms. But I found myself withholding information about my job, and fretted about possible repercussions when using my credit card, which bears the Singapore Medical Association’s logo. Luckily, the few times my profession was discovered, I was treated with respect, and even thanked by a few appreciative people. And due credit should be given to the many organizations and individuals who made the effort to pay tributes and donate generously to the Courage Fund.


Lesson 5: The death toll

Like any other outbreak, SARS claimed its fair share of human lives all over the world. However, Singaporeans bore witness to tragedies which, though small in number, proved a heavy burden to bear.

One index case, a woman in her 20s, lost both her parents and her church pastor to the disease, while she survived. Many others cross-infected their loved ones, and some were unable to be at their relatives’ bedsides when they passed on, due to strict isolation guidelines.

But from the medical community’s perspective, the loss of 2 of our fine, young doctors caused the most anguish, as evidenced by the eulogies in this month’s SMA News, and the many outpourings of grief from those who knew them both. They were bright yet humble, with happy families and so many things to look forward to, but their lives came to untimely ends, cut short by an undiscriminating and unforgiving disease.


Lesson 6: The media

Regular readers of my blog are well-acquainted with my complaints regarding the local press’ handling of an already sensitive situation. A short recap would include the unnecessary revelation of the “super-infector’s” name ( not to mention the indelicate label itself ), some puzzling columns that served to glorify reporters rather than the medical workers, plus a rather mean description of an inquiry involving a local infectious diseases specialist who boarded a flight from New York despite being unwell and having been in contact with a SARS patient prior to falling sick.

Subsequently, they came to their senses, and started doing some good features on staff working at TTSH. They’ve also kept the entire nation well-updated with all the facts and figures, and helped in the process of contact tracing by highlighting new hotspots ( e.g. the Pasir Panjang wholesale market ).

Sure, there were a few hiccups in the beginning, but I hope the local media will learn from their mistakes, and avoid making them again in the future.


Lesson 7:The authorities

The government pulled out all the stops, which accounts for its effectiveness in curbing the spread of SARS in the community. From shutting down schools and enforcing home quarantines, to mass transfer of affected wards and disallowing visitors to hospitals, our ministers took their tasks very seriously, and the results have been no less than astonishing, considering the fact that 5 million people currently populate this tiny little island.

Protective gear was also generously provided, and I never had any trouble getting N95 masks, gloves or space suits whenever their use was required. Contrast this with countries like China, where doctors were denied even simple surgical masks, and you’ll be glad you live in Singapore.


Lesson 8: Keeping the faith

This is a small bit about my Christian beliefs, so if you’re squeamish, you can skip this part.

Some of you may remember that I was only recently baptized, after 15 long years of contemplation and indecision. But contrary to many non-believers’ opinions, being Christian doesn’t guarantee a cushy life, and yes, sometimes even the most mature Christian questions his faith in the face of immeasurable tragedy.

Ponder this: The 2 doctors who perished from SARS were both devout Christians, and so were their loved ones. One of these doctors was engaged to be married in September, yet his fiancée remains steadfast, and even says, “I do not question why God took you away.”

Many of you may find it difficult to comprehend, but having previously been tested myself, as well as having a close friend who also grappled with his faith after his father’s death earlier this year, I recommend Philip Yancey’s excellent book, titled “Where Is God When It Hurts?” to anyone who yearns for answers to these important questions. Any comments are most welcome.


Lesson 9: Band of brothers ( and sisters )

If anything, this epidemic has only made our nation stronger. Besides equipping us with the skills and knowledge to face further similar situations, a few of our ministers ( who are doctors themselves ) took the extra step of donning masks and visiting affected hospitals to assess the situation in person. The public, hopefully, now realizes the vital role it has to play in the prevention of further outbreaks, and will continue to comply with implemented guidelines, and show some social responsibility should the need arise.


Lesson 10: A close shave – changes in the way we practise medicine

As an emergency medicine trainee, I recall my first posting in the ER in 2001, where I saw hundreds of patients with a wide variety of complaints, including fever and respiratory symptoms. At the time, in the pre-SARS era, we attended to all these people without any form of protection. And when intubating during resuscitations, we wore surgical masks ( with or without shields) most of the time.

In February this year, during a call covering the MICU, I took care of a 21-year-old female with fulminant pneumonia. She was critically ill upon admission, requiring mechanical ventilation, and had just returned from a mission trip to Indonesia. She collapsed later that night, and when I ran into her room to resuscitate her, I did not wear a mask. Neither did a few of the other nurses who assisted me.

You can thus understand why these events came to mind when SARS reared its ugly head in Singapore. In hindsight, I shudder to think what would’ve happened if that 21-year-old girl had been the index case. ( She turned out to have community-acquired bacterial pneumonia, albeit in its most severe form. )

So although we haven’t had any new infections for almost 2 weeks now, there will be a major change in medical practices, both here and globally. There is just no way of telling if and when the next wave will hit. We just have to be prepared at all costs.


What’s next?

Your guess is as good as mine! But I will tell you this: SARS is not the last epidemic we will ever see, and it definitely won’t be the last of the new pathogens to hit the unsuspecting human race. When and where the next outbreak will originate remains the $64,000 question, but as Pete Davies said so ominously in his article, “The Cycle of Death”, “Once again, we (will) find ourselves at the mercy of nature.”