Well Braced for the SARS Struggle

BOSTON — In 1918, the federal government issued a report on what would become, to that point, the most virulent epidemic in human history -- a report that today seems rather mild and misinformed. “The disease now occurring in this country and called ‘Spanish Influenza’ resembles a very contagious kind of ‘cold’ accompanied by fever, pains in the head, eyes, ears, back or other parts of the body, and a feeling of severe sickness.” Such understatement was inevitable; rapid diagnosis and real-time communications were unheard of. Not until 1933 did scientists even identify the flu virus.

Compare that to the Centers for Disease Control and Prevention’s muscular and nimble response to severe acute respiratory syndrome. With breathtaking speed, the CDC has delivered essential information and advice to the public, the media, medical professionals and airline employees. That’s in part because when SARS first appeared on the scene, scientists had long been preparing for another flu pandemic. And although SARS is not influenza, the lessons that public health has learned in the last century -- and especially in the last few anxiety-racked years -- show how far we’ve come in upgrading our defenses.

The emergence of SARS is indeed eerily reminiscent of the 1918 flu. To appreciate how, let’s briefly scroll back to the end of World War I. Generals were launching their final battlefield offensives. Chemical and biological weapons were ready for deployment. And out of Asia swept a lethal new respiratory infection, soon to become a globe-girdling epidemic.

We have been riveted recently by suspected terrorist caches of ricin and botulinum toxin, by the possibility of secret smallpox and anthrax stocks and by the prospect of Iraq’s using blister and nerve agents on our forces. During the Great War, Central Powers spies infected Russian horses and mules on the eastern front with glanders, which in turn infected soldiers. Both sides dispersed mustard gas, chlorine gas and other deadly vapors. Indeed, it was the depravity of World War I that led to the 1925 Geneva Protocol, the treaty that the Bush administration says it is defending in Iraq.

Like SARS, which unbeknown to the West first struck China’s Guangdong province in November, the 1918 flu pandemic smoldered unseen in Asia before catching fire around the world. That September, a U.S. surgeon general’s report alluded to the disease’s origins in “the Orient.” With its dense concentration of people, livestock and domestic and migratory fowl, southern China is a perfect breeding ground for recombinant influenza strains. As early as 1917, some historians say, the infection appeared in French army camps, jumping later that year to German recruits. How had the new flu originally spread from China to Europe? Perhaps with Chinese immigrant workers.

Back then, movement of troops on ocean liners fueled the virus’ transcontinental blitz. By the end, between 20 million and 40 million people died (although some estimates run to 100 million). The new strain of a seemingly familiar disease killed at least twice as many people as those who perished from battle wounds over the war’s four horrific years, and it took most of its victims in just four months.

Today, it’s high-speed airline travel -- capitalism, not combat -- that has broadcast SARS worldwide within four months. So far, SARS does not spread as easily as the 1918 flu -- a lucky break, since its mortality rate is higher. But the current epidemic underscores the fact that, war or no war, microbial evolution rambles on undeterred. And evolution is gaining a human assist. As we’ve seen with international epidemics of food-borne salmonella, the global spread of drug-resistant staph and strep, mosquito-ferried diseases such as West Nile virus and most grievously with AIDS, viruses and bacteria need no visas to cross national borders.

Which brings us back to public health, our only bulwark against such threats. Unlike the 1999 West Nile virus debut or the 2001 anthrax attacks, SARS has not caught the CDC off-guard. On March 14, the agency activated its Emergency Operations Center, which has since been operating around the clock. As with SARS and West Nile -- both naturally occurring events -- should anthrax or smallpox or any other intentionally sown epidemic arrive, the EOC will immediately plunge into action. With its central command station, secure communications with intelligence, emergency response and health officials, and high-tech geographic information system for disease mapping, it will redefine our battle strategies against disease.

In the last year, not only the CDC but state and local health departments have learned that it takes realistic drills to expose the gaps in our public health defenses. But communication is hard to practice. How the federal government would handle communications during a public health disaster has been a particular concern.

To its credit, the CDC has conveyed a message that is both honest and reassuring. Last fall, I asked CDC Director Julie Gerberding how she would quell public panic if bioterrorists should strike the United States. She said she would emulate then-New York City Mayor Rudolph W. Giuliani’s openness after 9/11. “He read the news, he told the truth, he said what he knew when he knew it, and he told people what he didn’t know and what they were doing about it.” SARS isn’t bioterrorism, except in the sense that all infection is -- but the effects are the same. And as SARS charts a frightening course, Gerberding and other CDC officials have lived up to their promise.

The 1918 flu struck during what we now consider to be the golden age of public health. Just a couple of decades earlier, the germ theory of disease had been articulated, leading to dramatic improvements in sanitation, food inspection, rodent control and other measures.

We may be on the verge of a second golden age, but only if public health -- more crucial than ever but still chronically underfunded -- gets the dollars and respect it’s due. In 2003, we no longer believe any war will end all wars. We also know that new infectious diseases will always be with us. SARS is the merely the latest development in an endless cycle of emergence, one that can be countered only with eternal vigilance.