SARS: The Trinidad Perspective

After passively viewing SARS from the sidelines in Trinidad then setting foot on the battlefield in Canada, one learns quickly to appreciate the devastating reality of this disease and its awesome potential as nature’s own weapon of mass destruction. There is nothing like a wickedly contagious viral disease to lead one on to reconciling with the fragility of one’s own mortality.

After a steady diet of seemingly unlimited news reports on the subject, I am getting more worried with each passing day, about the snail’s pace of our nation’s preparation and the efficacy of our surveillance measures. I personally cannot be sure our authorities are up to the task. Judging by the serious deficiencies that are already showing up in the system in the recent examples of lack of preparedness, one has to conclude that those in charge do not yet have a full grasp as to the awesome potency of this disease and the incredibly complex measures and impeccable thoroughness that are required to forestall the encroachment of this disease.

One would think that the fact that SARS, being the great equaliser that it is — being equally lethal to politicians and to bureaucrats as to common folks — would have been more than sufficient motivation to get the show on the road by now. If it is that we are cowardly resigned to the inevitability of an epidemic in our own backyard, then we are doing the right thing. We better remember though, to hasten to spend lots of quality time with our loved ones and friends because at least one out of six of us will not survive the first rounds and likely many more in the succeeding cycles as the virus continues to mutate.

The reality is that even with the concerted mobilisation of the abundant resources and expertise in Toronto and the laudable resolve, discipline and selflessness of their medical personnel, the battle against this horrific disease has not been easy. Admittedly, this arduous exercise could have been made easier were it not for seemingly innocent mistakes, mainly centering around the initial indecisiveness in undertaking prompt quarantine and containment measures. Additionally, most underestimated the ferocity of this rogue strain of the common coronavirus and its unrelenting and unforgiving attitude. Judging by our slow progress to date in this country, it seems we are destined to repeat those very same fatal mistakes.

With the fatality rate estimated at around six percent of those infected, it is not difficult to extrapolate the effects of an unchecked epidemic in this country. A theoretical possibility of over 70,000 fatalities is indeed a frightening number. But this is not all! It may be much worse! Factor in the general low standard of our health care, the demonstrably low morale level of our health care personnel and the relatively limited medical facilities and equipment available to us as compared with that in Canada, Singapore, Taiwan and Hong Kong, the final fatality rate could well be beyond our imagination. In addition, SARS is particularly devastating to those with lower levels of immunity such as our AIDS patients and our malnourished. Additionally, latest estimates from some sources are suggesting that the effective rate may well be as much as 15 percent fatalities across the board and around 25 percent among those over 60 years of age.

For those who find it difficult to grasp the concept of mass fatalities, they need only consider the 1918 to 1919 Spanish flu pandemic which accounted for more than 20 million deaths worldwide even at a fatality rate of only three percent. However influenza is a lot more contagious than SARS. It was noted that if the SARS virus has the same transmission rate, there would be tens of millions of cases today in China instead of the approximately 4,000 reported. So you see, God may also be Chinese! It is inexcusable that given the advantage of time and being fully aware of the potency of this disease we are far from being battle-ready. After all this time, it seems we have not yet gotten past the most basic of the essentials, the simple and generally ubiquitous face mask. Although the issue of the proper face mask surfaced at least a month ago, we are still learning up to a few days ago that the three wards designated as the nation’s main treatment centres still did not have the required N95 masks which are readily obtainable at most corner drug stores in North America. This is at a time when hospitals in Toronto have already advanced on to eye goggles, face shields and now special infection-limiting ‘spacesuits’. With the Hong Kong experience where 25 percent of the people infected were front-line medical personnel, no one must fault ill-equipped nurses and doctors if they refuse to turn up for work in these wards.

In pragmatic terms only, it is fortunate for us and other less developed countries that SARS took hold in Canada if only for the happy outcome that an inordinate amount of resources and expertise were promptly and properly allocated. The vast experience gained from the earlier anthrax episodes in North America also proved very useful. Within weeks the genetic make up of the identified virus had been mapped, containment procedures including those for protection wear have rapidly evolved to reduce drastically infections to medical personnel and an unprecedented cooperative effort has been launched by scientists and governmental authorities to fast track the development of a vaccine which they hope to have available within months rather than years. Already China has developed a new test which detect SARS within one hour and which they claim to be an “absolute certain indicator.”

This massive mobilisation clearly underlines the fact that developed countries do have the resources and expertise to bring rapid control to contagious diseases but would only do so if it affects them directly. The neglect in rendering timely assistance to Africa to check AIDS and West Nile at the early stages when it would have made a difference is now made even more glaring. We in Trinidad and Tobago must actively avail ourselves of these advantages, drawing on the work already done and the experience garnered. There is neither time nor need for us to re-invent the wheel here!

The matter of early detection and isolation has to be the obvious key for us to stave off what can surely become a national disaster, unprecedented in our history. We simply need to set out our very best efforts at our ports of entry for surveillance, interception and interdiction. A reasonable investment now at these strategic front lines will clearly bring the best results. When one considers that Hong Kong, Singapore, Taiwan and Japan have each lost over TT$6 billion within the last few months, one has to be convinced that time is money, and in this case money we do not have. One individual, a 78-year-old woman was the original source of Toronto’s problems setting off the chain reaction which saw 20 deaths, 138 people infected and over 10,000 quarantined and a direct cost to government of about TT$120 million per day. In Singapore a 26-year-old airline attendant brought home the problem after shopping in Hong Kong and changed that nation forever. Indeed, in the wink of an eye this can also happen to us.

In Singapore incoming travellers are made to march single-file past teams of nurses who are specifically trained to question passengers and to detect even minor clues of symptoms. This has to be more effective than asking passengers to voluntarily fill out a questionnaire as we do here and which is also being done in some other countries. That is precisely the kind of perfunctory measures that serve no practical purpose but only to allow the bureaucrats to appear to be doing something and meeting the criteria of those who do not know any better. Any Trini will tell you that most of us cannot be counted to be compliant, not even to stay orderly in line to purchase Panorama tickets. We must also learn from the Singaporeans of their experience with their state-of-the-art infrared temperature scanners which detect elevated facial temperatures of incoming travellers. Their isolation and containment procedures ensure, among other things, that those placed under quarantine in their own homes are carefully monitored to ensure they do not stray and those that do, risk severe penalties even conviction with a trial. Though one wonders about the viability of adopting such tough measures here given our carefree attitudes and abhorrence for structure and rules, one has to appreciate nonetheless that a tough businesslike approach has to be implemented. Tough times call for tough measures.

Merely throwing scads of money at a programme of this nature will never do it. Winning this battle literally requires every single person along the entire chain of command and at the front lines to be people of impeccable character, who are deeply committed, competent, caring, knowledgeable and thorough. One slip-up along the line could release our own ‘typhoid Mary’ into the population and then we are on our way down the chute. Indeed, we must recruit the best of the best. Our ‘dat good so’ attitude will not cut it here. In our society too many of us place our priority on fame, position and wealth at all costs and damn be to accountability and standards; worse yet, those in authority allow this simply because they themselves are of the same ilk. Accountability is what governance and management is all about; sadly it has been a rare commodity among most of our public officials and has percolated down to the man in the street.

The Prime Minister must accept the fact that in reality he is the commander-in-chief of this war with the ultimate responsibility to serve and protect the people. In fulfilling that responsibility, he is expected to ensure that he selects the right people and to provide the necessary resources. Most important of all, he needs to be ever mindful that he bears the responsibility for the outcome of the actions of those he appoints. Should there be any breach in the defences, particularly leading to fatalities, he has to expect that he would be held directly accountable by the people. The SARS problem is much too important a matter, being literally one of life and death, that politicians must not be allowed to conveniently shift blame to their subordinates and to bureaucrats. The country must put in place without delay, a strong dedicated disease control organisation with capability similar to the Centre of Disease Control in the US drawing on the latest technology and containment procedures worldwide. With some luck, SARS may not arrive this year but most experts agree that SARS cannot be put back into the bottle and would rear its ugly head on a cyclical basis. In these unusual times of AIDS, SARS, West Nile and Ebola a strong disease control organisation has to be a necessity and not an option.

Also, the Prime Minister should promptly seek to appoint a management team of proven movers and shakers, preferably retired businessmen and professionals, to work in conjunction with the relevant health and immigration authorities to plan, initiate and implement measures and procedures. We have seen all too often that even with the best of intentions and the best laid plans, many major projects have fizzled along the way for lack of proper management skills and proven business experience to ensure follow through. A disciplined businesslike approach will prove to be far more effective than ‘gallerying’ and ‘ole talk’. Equally important, would be to assemble a small team of field auditors who would be charged with continuously monitoring and testing the system for breaches and reporting directly to the Prime Minister, continually apprising him of the status of the programme. Patronage, party partisanship and ego must be put aside at least for now; constitutional reform too. We as a people also have to grow-up and understand the reality we are to face in these increasingly trying times. Useless hindsight of the ‘woulda’, ‘coulda’ and ‘shoulda’ variety, would effectively mean that we have failed to act when we had the chance. We need to be more responsible for our fate as now more than ever, the action or inaction of one person could affect all. Indeed, we are now truly our brother’s keeper!

In time when SARS, West Nile, Ebola and God knows what other new contagious diseases, take hold in various parts of the world, those countries which have shown their foresight and tenacity in keeping these diseases at bay would be viewed with much envy and respect by their less fortunate counterparts. Good stewardship here will inevitably bring credibility for both the countries and their leaders and economic prosperity has to follow. The choice is so reminiscent of the old TV commercial showing a scruffy auto mechanic holding up an oil filter and admonishing ‘pay me now or pay me later’. Do we do what we are supposed to do now, or we do nothing and pay the ultimate price later? Mr Prime Minister, the decision is clear!