Table 2.1: Framework for Public Health Policy ManagementWhat makes it complicated is the litany of factors including the paucity of information, delineation of information (useful versus irrelevant, “noisy” and poor quality data), time sensitivity and the unpredictability of public response to the policy.
There are no right or wrong policies, just good or bad ones.
Defining the PolicyThe intention of any policy must be explicit. It helps both the decision maker and the affected persons, and aligns the definition, facilitating its planning and implementation.
For the SARS contingency, there were a multitude of public health and public-related policies; and they were all linked. In line with the national control measures of containment within the hospitals and borders, contact tracing and public education, the SAF and the Ministry of Defence also had its host of policies:
SARS preventive measures within the units.
Overseas training and other official duties to SARS-affected countries.
Management of new enlistees and NSmen on in-camp training.
Infection control measures at the medical centres.
Response and contact tracing response during a SARS-related incident.
Alteration of social norms.
PlanningA number of considerations contribute towards the development of a policy. While a policy promulgated on-the-fly need not necessarily be ineffective, it would be fallacious to skim the surface without examining the associated ramifications. And any oversight may prove to be extremely unforgiving.
Evidence-based ApproachBasically, evidence-based approach is predicated on logic and common sense. However in an outbreak situation, this approach may prove to be a double-edged sword. On the one hand, it inhibits irrational decisions. On the other, there is insufficient information about the “enemy”. Little was known about the causative SARS virus and its transmissibility at the beginning. Whatever the evidence showed, it was always prudent to demonstrate caution until more was known. More often than not, there was a tendency for the evidence to change. The SARS virus was thought initially to be a paramyxovirus, then meta-pneumovirus and finally verified as a coronavirus. And because the various postulated species were distinct from one another with varying modes of transmission and survivability in the environment, the public health policies for each would have been different.
Planning Norms and AssumptionsThe lack of evidence does not preclude the use of planning norms and assumptions. These pieces of information need not be based on a “best-guesstimate”. Rather it can be inferred from analysis of the epidemic curve and the pattern of transmission. Early in the outbreak, the WHO provided important data that were used as planning norms:
- Incubation period of up to 10 days.
- Mode of transmission was by direct and close contact only. There was no air-borne spread.
- Period of infectiousness only occurred when the patient was having fever or respiratory symptoms (Symptomatic).
- Fever was the first and most consistent symptom in all cases.
- Case definition of probable and suspect cases.
Such norms proved useful in the implementation of temperature screening policies as a means of entry into the workplace/school; quarantine policies (using 10 days as a threshold, for example, someone who had returned from a SARS-affected country was not likely to have any risk if he had been asymptomatic for more than 10 days) and clinical management policies (triaging of febrile patients at the medical centres and decision-trees for referral to a designated SARS hospital).
What would also have helped tremendously was the availability of a highly sensitive and specific diagnostic test such that we could predict or even diagnose which suspect case would become a probable case. Unfortunately this took time to develop. Even though preliminary antibody and genetic test kits were developed within a phenomenally short two months, it was still not fast enough for the patients and the public.
Resource AvailabilityResources imply human expertise, personal protective equipment and surveillance systems. Obviously prior preparedness will obviate concerns, but it will not be absolute. Anything short of complete and sustainable supplies would lead to decisions that need to weigh the issue of availability with probability of failure in control measures. There is thus also a need to optimise and prioritise resources from various sources.
Take the issue of N95 healthcare grade respirators: these could not be issued to every healthcare worker. Instead those who directly handled patients or were involved in the screening process were given the equipment first. Similarly, while it would have been more ideal to do contact tracing for all probable and suspect cases, limited resources dictated that it should be done first for probable cases, and only when suspect cases turned probable. This was the initial instance in both Singapore and Taiwan , where pragmatism over-ruled idealism. All decisions thus required a certain degree of risk stratification and corresponding prioritised management.
Time SensitivityThe mounting of an outbreak response incorporates a function of time. Responsiveness is paramount, and control measures need to be instituted early to prevent attrition. The damage related to uncontrolled transmission can be devastating and the efficacy of control measures diminishes as the number of affected cases increases.1 During the SARS outbreak, dynamism and change were consistently present. As more was known about the disease, policies needed to be continually adjusted.
ExecutionAn excellent policy without the expected level of execution will not achieve the desired outcome. For example, to issue a policy on HQO to all contacts of SARS patients would only be effective if all these contacts could be traced and accessed. In Taiwan, there were a number of contacts that could not be traced and hence community transmission could not be excluded.
TransparencyOne important lesson gleaned from the SARS contingency was the need to maintain transparency. Singapore and Toronto had demonstrated transparency in their numbers, control measures and deficiencies. Transparency can work if one is highly supportive and committed towards containment and eradication of the disease. Bertha Henson of The Straits Times opined that concealing numbers behind a façade of ineffective control measures proved to be detrimental for both China and Taiwan.2 The literal “explosion” of new SARS cases when exposed by independent audits or the media merely aggravated anger and frustration of the people. The SAF had also taken steps to ensure that proper measures taken were pub licised; these included the screening of recruits before their entry into Basic Military Training Centre, temperature screening and answering any public queries both verbally and in writing.3
Information Management and Public EducationPublic measures at any level require the right delivery and understanding of their intention. Confusion and perception of inadequate policies or worse, having an inappropriate policy will only fuel the fear of the affected persons. The Taiwan authorities were deemed as “draconian” in some of their measures such as the sudden cordoning and closure of Taipei Ho Ping Municipal Hospital following a cluster of SARS cases.4 There were also anecdotes of taxi drivers who refused to pick up TTSH healthcare workers because the hospital was the designated SARS hospital in Singapore.5
Similarly, any measures taken within the workplace has to be conveyed thoroughly to minimise any potential speculation. The use of various media is also necessary in undertaking such an endeavour. The internet has proved to be a marvellous medium for inter-connectivity between public health professionals and scientists; policy makers and their people.6
Singapore created the SARS television channel in addition to daily press releases, health messages over the radio and through posters. Even the Prime Minister issued an open letter to Singaporeans to explain the policies on SARS management.7 Within the SAF, cascade briefings were conducted and information was readily accessible to every serviceman.
Multi-agency ApproachSARS was not merely a battle for the healthcare personnel. The widespread spillover effects also impacted upon businesses (the tourism industry was one of the hardest hit), schools (there was a period when all schools up to tertiary institutions were closed to allay parental concerns), immigration (when other countries suggested that Singapore could have exported the cases to them rather than treating them locally; and also contact tracing of illegal foreign workers), and transport (when there were instances of taxi-drivers bringing suspect SARS cases to hospitals and the death of a taxi-driver who was later diagnosed to have carried the SARS virus).8 All governmental and non-governmental agencies have their role to play, and it is essential to have a common game-plan which clearly delineates the responsibilities and role of the various players to ensure consistency in delivery of policies and optimisation of resources.
“Hard” and “Soft” ApproachesDo we impose a hard-line approach towards the delivery of policies at the risk of invoking public furore? Singapore initially issued warnings to those who flouted their HQOs. On the other hand, China threatened offenders with life imprisonment and capital punishment.9 Sometimes we cannot afford the softer approach of influencing behavioural change because we do not have the luxury of time. The issues of personal freedom and confidentiality may sometimes have to be sacrificed for the good of the general public. When the contacts could not be traced in Taiwan , their names were made public in a bid to trace them.
Command EmphasisThe commanders and the leaders must take the lead in the implementation, compliance and enforcement of public health measures. A lenient and complacent approach in a particular area increases the risk of a breakthrough spread. When a cluster of febrile cases occurred in the Institute of Mental Health, the Singapore Minister in charge of the SARS Committee admitted it was a tactical error as the hospital was not expected to succumb to SARS (it was later found to be an influenza outbreak and not SARS; still it proved to be a valuable lesson).
EvaluationThe dynamic environment of SARS management required constant feedback and evaluation of its policies. Information and knowledge constantly changed and the stakes were high. There were a number of performance indicators used. Most important were the incidence of probable and suspect SARS cases, persons admitted for observation and those on home quarantine. These were outcome measures for the various implemented policies. A decreasing trend would strongly suggest the response was on the right track.
