Public health lesson of SARS: First step in treating is reporting

A sound public health system is dependent on the vigilance of individual physicians.

Editorial. May 19, 2003.

Information is tightly controlled in China. So it is unlikely that world health officials will ever know the full story of exactly how severe acute respiratory syndrome spiraled into a public health crisis in that country before spreading to other parts of the region and then across the globe.

It is clear that Chinese government officials used incredibly poor judgment in deciding not to report the new infectious disease to world health officials until after the World Health Organization had begun to hear rumors that it had taken hold in the country.

The adverse attention and economic repercussions that the Chinese presumably wanted to avoid are now visited manyfold upon their nation.

China reportedly has a reporting system for infectious diseases, but observers don't hold out great hope for its effectiveness. For instance, it is generally accepted that the number of AIDS cases in China is grossly underreported. In any event, it is uncertain what alarm individual physicians could have sounded in such a closed and government-controlled society.

There is little doubt that had the first cases of SARS been detected in this country, United States public health officials would have been quick to alert the world health community. But the depth of that information, and how quickly it could be reported, would have depended heavily here on the good judgment and efforts of individual physicians.

The SARS outbreak, much like anthrax before it, underscores the importance of the individual physician in discovering and containing illness and disease outbreaks in this country.

Every physician is a link in the infectious disease reporting system. And just as each link is necessary to complete a chain, every physician who comes into contact with an epidemic in its early stages is integral to its timely treatment and containment.

Yet it is a commonly held belief that many physicians here are reluctant participants and do not always report.

According to an article we published last year, (AMNews, April 22/29, 2002), U.S. public health officials believe that only 50% of reportable diseases are actually reported. The reasons for not reporting are myriad: Physicians can't keep track of the long list of reportable diseases, the reporting systems are awkward, doctors don't know if the reports they submit are received and acted upon.

The reporting system is not flawless, but its faults are not reason enough to ignore the obligation to report. Since physicians are now on the lookout for SARS, it -- or anything resembling it -- is unlikely to go unreported.

But had the disease unexpectedly turned up (or more unlikely, had its genesis here) it is not a given that it would have been quickly discovered.

It presents in its initial stages much like the common flu and appeared on the scene in late winter. It is not inconceivable that many physicians would have decided they need not bother to report a suspicious flu-like illness so near the end of the season.

The consequence of such a decision: a missing link that would likely have made the job of identifying and containing SARS more difficult for public health officials.

Medicine and public health in the United States, and throughout the world, benefit enormously from our open society.

Contributing to the knowledge and awareness that are its strengths is essential.

China's experience is at the very least a reminder of the importance of reporting in matters of public health. And the consequences of silence.

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Copyright 2003 American Medical Association. All rights reserved.