Risk Perception and Coping Responses in a SARS Outbreak in Malaysia

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Risk Perception and Coping
Responses in a SARS Outbreak
in Malaysia
Chan Chee Khoon
Aspects of Risk in Public Health
Public health scientists and practitioners are much concerned with
risk analysis and risk communication.Risk analysis and risk estimation are of
course mainstays of the epidemiology profession; together with risk com-
munication, they provide essential elements of health education and health
promotion.
Much of health education and health promotion is furthermore predi-
cated on the assumption of “rational” health behaviour of individuals, an
assumption that has come under increasing scrutiny with the realization
that
“‘fully’ informing individuals about health and health risk does not necessar-
ily lead to a change in health behaviour. The natural reluctance of individuals
to incorporate new health information into their existing cognitive processes
means that new information will be at best only slowly incorporated”
(Whitehead and Russell, 2004).
“there has been a change in the perception of risk by society. We have
moved to a ‘risk perception society’ where what is important is not whether
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352 C. K. Chan
the number or nature of risks have increased [or decreased] in their serious-
ness, but that people believe that this is so and act accordingly... ‘expert’
assessment of the probability of harm appears to have become less important
than the popular perception of risk, with opinion regularly becoming the
basis on which behaviour is based” (McInnes, 2005)
For instance, the cumulative experience from the tobacco control campaign
suggests that risk perception is an altogether more subjective and complicated
matter which may be susceptible to diverse influences and life circumstances
not fully captured by a natural reluctance to assimilate health information.1
This paper explores the theme of risk perception and what influences it
in an emergent infectious outbreak, Severe Acute Respiratory Syndrome
(SARS), which swept through East and Southeast Asia in 2002 and 2003.
In particular, we will explore from the perspectives of diverse actors, their
perception of risk in the unfolding SARS epidemic on the assumption that
their risk perception is expressed in their coping responses, and may be fur-
thermore modulated by the institutional dynamics within groups, agencies
or enterprises.
Risk Analysis and Risk Perception in a SARS Outbreak
Speaking at a public forum in Penang on 17 April 2003, cardiologist
Dr Ong Hean Teik and his Penang Medical Practitioner Society col-
leagues urged the Malaysian public not to over-react2to the Severe Acute
1It is not coincidental that tobacco advertisements, often linked to high-risk recreational activities
such as skydiving, downhill skiing, rock climbing, Formula-1 motor racing, etc evidently seek to modify
risk perception and to reinforce the (subliminal) message: danger is cool, it’s stylish, exciting… the Surgeon-
General says smoking is dangerous for your health… so what? Life’s dangerous… Danger is the Spice of Life…
2Evidently, the hospital industry was not immune to over-reaction either, as when an unnamed
private hospital in Kuala Lumpur imposed a 10-day quarantine without pay on two operating theater
nurses after they flew back from New Zealand in April 2003 with a one-hour transit stop at Singapore’s
Changi airport. Deputy Director-General of Health Dr Ismail Merican deplored such excessive measures,
all the more from healthcare professionals, and further noted that “the main implication (of the quarantine) is
that you will be generating a fear of reporting as healthcare staff may be afraid to report that they have been to affected
countries for fear of a pay cut”(The Star, 18 May 2003). This was a necessary corrective in the wake of an
earlier statement by the Deputy Labor Minister Dr Abdul Latiff Ahmad who had declared that workers
subjected to SARS quarantine should use their annual leave for their period of confinement, and “if the
employees have used up their annual leave, they can still apply for unpaid leave”(The Star, 29 April 2003).

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SARS and Risk in Malaysia 353
Respiratory Syndrome (SARS) epidemic, stressing the low case fatality ratio
which at the time was crudely estimated at 4 to 5% of clinically diagnosed
SARS cases (The Star, 19 April 2003).
Shortly after, Roy Anderson and his colleagues at Imperial College
(London), at the Chinese University of Hong Kong and the University of
Hong Kong re-calculated the numbers based on 1,425 cases in Hong Kong
(∼one-quarter of the cumulative total of cases worldwide at the time). They
estimated a case fatality ratio of 13.2% (6.8%, non-parametric estimate) for
cases below 60 years of age, and 43.3% (55%, non-parametric estimate) for
those aged 60 and above (Donnelly et al., 2003).
In the 1918–1919 flu pandemic which killed 30–40 million people world-
wide (Johnson and Mueller, 2002), case fatality ratios were not reliably
known, but have been variously cited at ∼1% in the US,3between 1 and 2%
in Switzerland,4and the global average did not exceed 5%. This was in the
chaotic aftermath of the horrific bloodletting between the world’s imperial
powers (Kolata, 1999).
A case fatality ratio5for SARS ranging from 7 to 55% among different age
groups, in the more affluent regions of Southeast Asia and mainland China,
Hong Kong, Taiwan, and suburban Toronto, in less tumultuous times, is
not much cause for comfort.
Thankfully, SARS in the event was less contagious (or produced fewer
symptomatic cases) when compared with flu epidemics. By the end of June
2003, the chains of transmission had been broken in the SARS-affected
countries, and the much-feared scenario of uncontrolled community spread
to the peri-urban and rural hinterlands (areas with weaker institutional
capacity) fortunately did not materialise.
Remarkably, this rapid control was achieved in the absence of
reliable diagnostics, vaccines, or efficacious therapies, notwithstanding the
3Interview with CJ Peters: SARS — The New Viral Threat (WebMD, 7 April 2003)
http://my.webmd.com/content/article/63/71969.htm (accessed on 1 May 2003)
4Calculated from data reported in Ammon. 2002.
5The case fatality ratio, for a number of reasons, is an unstable parameter when an epidemic is rapidly
evolving. It is of course an artifact of case definition criteria, at the time (early May 2003), WHO’s criteria
for suspected and probable SARS cases which would very likely change when more reliable laboratory
tests for SARS infection became available. When used in combination with revised clinical criteria, the
designated suspected and probable SARS cases may well be re-assigned to different categories, and case
fatality ratios would be correspondingly revised in line with the new defining criteria.

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354 C. K. Chan
unprecedented research collaboration (World Health Organization, 2003)
which led to the rapid isolation and identification of the microbial agent
involved, SARS coronavirus (Peiris et al. 2003), and the sequencing of its
genome (Ruan et al., 2003).6
WHO gave much credit to institutional responses such as isolation, con-
tact tracing, ring fencing, and quarantines (i.e. centuries-old techniques) for
rapidly bringing the pandemic under control.7
Less mentioned were the individual coping responses and risk avoidance
behaviours (reduced travel to SARS-affected areas, avoidance of restau-
rants and crowded locations, delays or cancellations of elective medical and
surgical procedures, outpatients diverting to non-hospital primary care set-
tings) and the possible contributions of seasonality effects or cross-reacting
immunity from related endemic micro-organisms (Ng et al., 2003). Most
importantly, the economic and financial stakes involved ensured that SARS
would not be a “neglected disease”.
SARS and “Collateral Damage”
Among clinicians and pathologists, there is some convergence towards
the view that the lung pathology seen in SARS patients (diffuse alveolar
damage) may in part be due to immune overreaction (cytokine dysregulation and
hyperinduction of inflammatory response) provoked by the SARS coronavirus
(Ksiazek et al., 2003; Wenzel and Edmond, 2003; Oba, 2003).
By analogy, some have lamented loudly about a societal or indi-
vidual “overreaction” in the risk avoidance responses to the outbreak,
with the resultant “collateral damage” on East Asian national economies
disproportionate to the seriousness or severity of the epidemic of
2002–2003.
In Singapore for instance, 206 probable cases of SARS were diagnosed
between March 2003 and June 2003, of whom 32 died. Malaysia, which
6These early exchanges however very soon gave way to a mutual wariness at the point when intel-
lectual property claims were filed for the pathogen’s sequences and other patentable findings with
commercial potential. (see: Gold. 2003; Lancet editorial, 25 September 2004).
7Gro Harlem Brundtland, Director-General, World Health Organisation “… SARS can be contained
despite the absence of robust diagnostic tests, a vaccine, or any specific treatment. When awareness, commitment,
and determination are high, even such traditional control tools as isolation, contact tracing, and quarantine can be
sufficiently powerful to break the chain of transmission …” (WHO website, accessed on 5 July 2003).

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SARS and Risk in Malaysia 355
recorded five probable cases and two deaths from SARS, nonetheless
suffered comparable economic losses largely visited on the travel and
tourism, entertainment and hospitality, as well as the health services
industries. Two months into the epidemic, average hotel occupancy
rates in Singapore had fallen to 20–30% (vs. 75% for February 2003, 74%
for the whole of 2002); by late April 2003, tourist arrivals were down by
67%, and retail sales down by 10–50% (Lim et al., 2003), with many small
traders folding. Singapore’s projected GDP was forecasted to shrink at least
1% ($875 million) as a direct consequence of the SARS epidemic. Aside
from tourism-related services (hotel, restaurant, retail, airlines, cruise, travel
agencies, and taxi services) which together account for 5% of Singapore’s
GDP (2002), the health services industry also experienced markedly reduced
hospital admissions from its local and regional clienteles.
In Malaysia, where tourism accounts for 7% of GDP and ranks second
after manufactured exports for foreign exchange earnings, revenue losses
were projected to approach $1 billion. By the end of April 2003, airlines
were reporting 50–60% cancellations of bookings (Malaysian Airlines alone
reportedly suffered a revenue loss of RM131 million ($34.5 million) due
to the cancellation of over 700 flights to SARS-affected destinations). As a
result, air-travel arrivals fell by more than 40%, and hotel occupancy rates
dropped to 30–35% (Ariff, 2003). As was the case in Singapore, patient
admissions into Malaysian hospitals also fell markedly. The Association of
Private Hospitals of Malaysia (APHM) surveyed its 48 member hospitals
in May 2003. Of the 37 hospitals that responded, 42% reported a drop of
5–10% for inpatient numbers month-on-month (comparing April 2003 with
May 2003); 31% reported a decline of 15–20%; 22% reported a decline
of 30%, and 2.5% reported a decline of more than 40%. Overall, patient
admissions for the respondent hospitals (all with 50 beds or more) fell by
5–40% in May 2003 (Bakar, 2003; Business Times, 2003).
Faced with this novel disquieting outbreak, there were loud laments
that the economic fallout was disproportionate to the seriousness or
severity of the epidemic. This “collateral damage” inflicted on national
economies overshadowed the direct human cost (lives lost, temporary or
long-lasting infirmity, family and personal tragedies), when furthermore
contrasted against the persistent, devastating, but all too often invisible
plagues in the poorer countries of the South: HIV/AIDS, tuberculosis,

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malaria, water-borne diseases, hunger and malnutrition, which collectively
(and often acting in concert) cause more than 12 million avoidable deaths
annually.
Clearly, risk perception has consequences for the risk avoidance and coping
responses of individuals and communities, quite apart from the institutional
responses of state agencies in the form of isolation, contact tracing, ring fenc-
ing and quarantines, and various surveillance and epidemic control measures
imposed on members of society. A more nuanced management of emergent
infectious outbreaks therefore has to be sensitive not only to the characteris-
tics of the emergent pathogens (lethality and other nonfatal sequelae; modes
of transmission and sequestrability of the outbreak) and the social ecology of
its emergence and spread, but also has to take into account the differentiated
risk perception, risk avoidance, and the coping behaviours of diverse at-risk
parties. These include the general public, travellers and intending travellers
(including migrants), family members and close contacts of patients and
other at-risk individuals, healthcare institutions and enterprises, healthcare
staff (including diagnostic, research and other support staff), other govern-
mental agencies, travel and hospitality industries and their staff, politicians,
local (national) as well as the international disease control agencies.
In the rest of this paper, we will explore from the perspectives of diverse
actors the theme of risk perception and what influences it, using an integrative
framework which draws upon the social, biological and ecological dimen-
sions and their interactions.
The social ecology of SARS in Malaysia and Singapore
The social ecology of SARS in Malaysia includes the politically influential
tourism sector and its ancillary industries, with foreign exchange earnings
second only to manufacturing exports, and accounting for 7% of GDP in
recent years.
With the notable presence of corporations such as the Malaysian Air-
lines System (MAS), Faber Group Bhd, Pernas International Holdings Bhd,
World Resorts Bhd, YTL Corp Bhd, Landmarks Bhd, and Sunway City
Bhd in this services sector, it was unlikely that SARS would be a “neglected
disease”. The Malaysian Institute of Economic Research (MIER) had fur-
thermore projected that the GDP growth for 2003 could fall from 5.7%

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SARS and Risk in Malaysia 357
to 3.7% (Ariff, 2003) (subsequently revised upwards to 4.3% in July 2003),
which helps explain the strenuous efforts by the authorities to keep Malaysia
off the WHO list of SARS-affected countries where local transmission had
been detected.
Throughout the outbreak, the local travel and hospitality industry desper-
ately urged its nervous patrons not to “over-react” to the SARS epidemic.
They may have been right about overly active survival instincts, but one
would be reasonably wary about them as impartial arbiters of “appropri-
ate” risk perception in the local context. The same individuals (and their
political representatives) however urged caution upon those who contem-
plated travel outside the country to SARS-affected destinations such as
China, Hong Kong, Taiwan, Singapore, and Toronto (Malaysiakini.com,
17 March 2003).
Tourism can evidently be a risk deflator under certain circumstances. In
a letter to editors of the Malaysian newspapers dated 28 March 2003, Aseh
Che Mat, Secretary General of the Home Ministry (which decides on the
annually renewable publishing permits of Malaysian newspapers) made clear
the government’s preferences in information management:
as you already know, SARS cases have received wide coverage in
mainstream newspapers of different languages, including specific
cases of deaths… The government is concerned that such com-
prehensive and widely-publicised reports will lead to undesirable
implications, including striking fear among the people and jeopar-
dising tourist arrival… Therefore, the ministry seeks the coopera-
tion of editors to adjust the reports on the SARS, by not focusing
on death cases [as this] could adversely affect the confidence of the
public and tourists... (Malaysiakini.com, 1 April 2003)
whilst in Penang (an important regional tourist destination), State Executive
Councilor for Culture, Arts & Tourism Kee Phaik Cheen similarly urged
that the media should not highlight SARS stories as this would keep
tourists away (New Straits Times, 23 March 2003).
Ms Kee had furthermore invested much effort in promoting Penang as a
regional center for medical tourism, and she would have been keenly aware

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that this service sub-sector was doubly vulnerable to emergent outbreaks
such as SARS, where nosocomial transmissions are implicated.8
Meanwhile, her federal counterpart Abdul Kadir Sheikh Fadzir, Minister
of Culture, Arts & Tourism declared at a meeting on 23 May 2003 of Asean
national tourism organisations:
Asean countries need to find a meaningful way to cooperate. We
should remove travel restrictions and cut red tape. Our tourism
industry is being held ransom by these events. Hence we need
to simplify existing travel procedures. We should consider travel
within Asean as part of domestic travel … (Malaysiakini.com, 23
May 2003)
In contrast, Singapore’s approach to epidemic management was evidently
based on the following premises:
•credibility as one of those intangibles which have enormous economic
value (and costs, when it is undermined)
•bite the bullet, absorb the short-term costs
•be highly transparent, in order to curb uncontrolled, damaging rumours
•use organised, timely deployment of institutional resources
•enact tough measures infringing on individual liberties for the “greater
good” (and lest we succumb to temptations to invoke “Asian values”, let
8Singapore, which probably had the most detailed records of the unfolding outbreak among the
SARS-affected countries, reported that as of April 30, 2003, 76% of the island state’s probable SARS
cases had acquired their infections in a healthcare setting, in particular in the public hospitals which
took on much of the burden of handling the SARS epidemic; the remaining SARS cases either had
household, multiple, or unknown exposures (Morbidity and Mortality Weekly Report, 9 March 2003).
Likewise, in Malaysia, among the eighteen designated hospitals with special isolation wards for SARS
patients, not a single private hospital was to be found. Indeed, when two foreigners insisted on being
admitted into a private hospital for SARS observation, the Association of Private Hospitals of Malaysia
(APHM) responded by persuading the Health Ministry to invoke emergency quarantine powers “if a
patient refused to be admitted into a public hospital…. the district health officer concerned can issue a quarantine order
making it compulsory for a patient to be admitted into a dedicated [i.e. government] hospital…The [private] hospital
had to admit them [at the time] because there were no guidelines outlining what private hospitals could do if they had
to handle such a case. Now they know what to do,” according to APHM president Dr Ridzwan Bakar (The
Star, 7 April 2003). Weighing on their minds, evidently, beyond the expense of maintaining a SARS
isolation ward, was the further worry that a hospital’s fee-paying clientele would avoid a “SARS-tainted”
hospital. One wonders how the private hospitals would cope if the hospital sector in Malaysia were ever
to be completely privatised.

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SARS and Risk in Malaysia 359
us note the following distinctly communitarian sentiments expressed by
a prominent occidental):
today we emphasize individual rights over community needs more
than we did 50 to 75 years ago. Restraining the rights and free-
doms of individuals is a far greater sin than allowing the infec-
tion of others. The restraints placed on Typhoid Mary might not
be acceptable today, when some would prefer to give her unlim-
ited rein to infect others, with litigation their only recourse. In
the triumph of individual rights, the public health perspective
has had an uphill struggle in recent pandemics … We typically
[reconsider control measures] only after an outbreak. Perhaps
we should have further debate on the social context for con-
straints and persuasion to contain the spread of infectious agents
(Lederberg, 1997).
The Singapore government, well known for its unflinching pragmatism
in matters of individual (human) rights, let alone “animal rights”, was res-
olutely readying itself with simulation exercises in anticipation of avian flu
outbreaks:
Singapore will gas and burn thousands of healthy chickens next
week as part of a simulated bird flu outbreak exercise, a senior offi-
cial said yesterday. There is no bird flu in Singapore but the city-
state is desperate to avoid a local outbreak of the illness, which has
prompted the slaughter of tens of millions of chickens across Asia
and killed 19 humans. Health officials will cull the 5,000 chickens
at an isolated poultry farm Wednesday by gassing and then incin-
erating them, said Dr Ngiam Tong Tau, Chief Executive Officer
of the Agri-Food and Veterinary Authority. Police officers will be
stationed around the farm to prevent unauthorised entry and civil
defence officials will decontaminate personnel before they leave,
Ngiam said. Doctors will also be on hand to screen workers and
simulate dispensing anti-viral drugs, he added. Singapore’s Deputy

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360 C. K. Chan
Prime Minister Lee Hsien Loong has said the government would
rather “overreact rather than under-react” to the bird flu threat.
The city-state can ill-afford a repeat of last year’s ordeal with the
Severe Acute Respiratory Syndrome (SARS), which killed 33 peo-
ple here and did massive damage to the nation’s economy (The Star,
13 February 2004).
Ten days earlier, Mr Lee’s Thai counterpart, Prime Minister Thaksin
Shinawatra had publicly “lambasted WHO for suggesting the flu [virus]
could mutate and spread to pigs and then even more easily to humans.
Ethically speaking, researchers should only discuss low possibilities of such
cross-strain spreads in labs, not in public,” Thaksin told reporters (The Star,
3 February 2004) (see also footnote9).
Singapore, unlike Thailand, is not a leading exporter of chicken and
poultry products to the world market. Nonetheless, the Singapore govern-
ment has no lesser stakes invested in the travel and tourism sector (most
prominently, the national air carrier Singapore Airlines), while Temasek, the
government’s investment and asset holding company, accounted for 21%
of the market capitalisation of the Singapore stock exchange at that time
(Financial Times, 14 February 2004).10
What might explain these contrasting approaches? The answer proba-
bly lies somewhere between “Singapore exceptionalism” and the “relative
autonomy of the technocratic state”.
At the WHO Global Conference on SARS (2003) in Kuala Lumpur,
Dick Thompson, WHO’s risk communication officer re-iterated the
wisdom distilled from the management of epidemic outbreaks past and
present:
People are at their best when collectively facing a difficult situation
straight-on. Things get much more unstable when people begin
9In the aftermath of the Indian Ocean tsunami of 26 December 2004 which claimed more than
5200 lives (and another 4500 missing) in Thailand, it emerged that the possibility of a tidal wave hitting
Thailand’s most popular tourist beaches was downplayed out of concern for the country’s burgeoning
tourist industry (Bangkok Post, 7 January 2005).
10The Malaysian government’s investment and asset holding company Khazanah has similarly large
stakes (34% of market capitalisation) in the Kuala Lumpur stock exchange. (Special Report: Reshaping
Khazanah, www.theedgedaily.com, 18 May 2004).

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SARS and Risk in Malaysia 361
to feel ‘handled,’ misled, not levelled with. That’s when they are
likeliest to panic or go into denial, likeliest to ignore instructions
or develop paranoid hypotheses. Make it clear what you know and
what you don’t know.
The Singapore government has repeatedly and publicly proclaimed the
crucial importance (and competitive advantage) of credibility in governance
and in public management, all the more emphatically as it fights to retain its
carefully nurtured pre-eminence as a regional financial and business centre.
This evidently extends to disease control and epidemic management, some
aspects of which have been described as draconian and convenient for rein-
forcing social and political control in an already authoritarian polity (chapters
by Liu, and Ong, Yeoh and Teo in this volume).
In any case, the Singapore government’s blend of transparency and
considered coercive measures seems to have found favour not just within
international disease control agencies such as the WHO, but has also won
acceptance among many of its own citizens and residents. This came across in
the preliminary findings of Stella Quah (National University of Singapore’s
Department of Sociology) and her research collaborators at the University
of Hong Kong, reported thus in the Economic and Political Weekly11:
in spite of many similarities between the two cities, the citizens
[of Hong Kong and Singapore] expressed quite different views…in
their acceptance of measures undertaken by their respective govern-
ments to deal with SARS. Initial findings showed that, intriguingly,
there is a discrepancy between the perception of the risk of catch-
ing SARS and the acceptance of the quarantine measures. Hong
Kong residents appeared to perceive a greater risk of getting SARS;
yet they were more against measures such as the quarantine than
their Singaporean counterparts. Of the Singaporeans surveyed, 91%
accepted being put under quarantine even in the event they had no
contact with any SARS patients, compared to 72% of the Hong
Kong group. (Xiang & Wong, 2003).
11The Hong Kong group of course may have been quite astute in recognizing that the higher preva-
lence of SARS in Hong Kong at that time put the uninfected quarantinees there at greater risk of
nosocomial transmissions as well as residential infectious risk (such as at Amoy Gardens where there was
evidence of environmental, aerosal spread).

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Normalising Death and Disease
Amartya Sen once observed that if poverty itself were contagious, it
would speedily dispel the nonchalance and indifference of the privileged and
sequestered. He was speaking of poverty, but his dismay is equally pertinent
to our troubling capacity for selective anaesthesia, for “normalising” human
health disasters, especially when they occur among marginalised communi-
ties with limited “voice”. Most glaringly, there were the 3.1 million AIDS
deaths in 2004 (2.3 million of them in Sub-Saharan Africa — Aids Epidemic
Update, December 2004), more than one million malaria deaths annually in
poorer countries, and similarly high fatalities from tuberculosis, waterborne
diseases (most importantly, diarrhoea), malnutrition, and other preventable
diseases of poverty often acting in concert.
By contrast, the continent-wide uproar in Europe over “mad cow disease”
(bovine spongiform encephalopathy, BSE) and its putative human version,
variant Creutzfeld-Jacob disease (vCJD), which has recorded less than 200
deaths in the 15 years since the disease was first recognized in the late 1980s,
seems grossly out of proportion.
SARS, by these yardsticks, would similarly not count as a major direct
threat to global public health, notwithstanding the immense economic losses
inflicted on East and SE Asian economies. Yet, precisely because of this latter
consideration, SARS assuredly would not be a “neglected disease”.12
Six weeks after issuing a global alert on SARS, the World Health Organ-
isation announced that:
the Severe Acute Respiratory Syndrome (SARS) outbreak is begin-
ning to come under control. Its medical officer for global alert and
response Dr Mark Salter said that although the outbreak was not
12Neglected diseases, as highlighted by Médecins Sans Frontières ( MSF): of the 1,393 new drugs approved
between 1975 and 1999, only 16 (or just over 1%) were specifically developed for tropical diseases (such
as malaria, sleeping sickness, Chagas’ disease, kala azar) and tuberculosis, diseases that account for 11.4%
of the global disease burden. For 13 out of those 16 drugs, two were modifications of existing medicines,
two were produced for the US military, and five came from veterinary research. Only 4 were developed
by commercial pharmaceutical companies specifically for tropical diseases in humans. These tropical
diseases mainly affect poorer communities in countries of the South, which do not constitute a valuable
enough market to stimulate adequate R&D by the multinational pharmaceutical companies. (Trouiller
et al., 2002; Cohen, 2002; Kremer & Glannerster, 2001).

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SARS and Risk in Malaysia 363
over, the disease had reached the “normalization” phase... Since
the WHO had issued recommendations on effective control mea-
sures, the disease had been successfully controlled in several places...
In Western Europe, individual imported SARS cases have been
immediately isolated and the disease has been stopped there and
then... it was only in countries which had suffered from infec-
tions before the disease was identified that SARS was still spreading
(The Star, 26 April 2003).
Many infectious outbreaks become less virulent as the epidemic ages,
as host and pathogen co-evolve, as human coping behaviours impinge on
the pathogen’s mechanics of transmission, and possibly on the genetics of
its virulence. Less frequently, they may transiently become more virulent
(Ewald, 1994).
Virulence aside, it would be sad if life-threatening infections became less
fearsome the more its spread was confined to marginalised communities,
where cases may emerge, transmit disease, and die (or recover) without
attracting much attention, where there was limited institutional capacity to
carry out the field epidemiology, meticulous contact tracing, ring-fencing
and quarantines which can be the mainstays against an out-of-control
community spread.
In this connection, the British Broadcasting Corporation (BBC) noted
that with privatisation and the collapse of the pioneering primary healthcare
system in China,
millions of Chinese [have] lost access to free medical care because of
[the] country’s economic reforms... most people must [now] pay
in cash when they see a doctor...As 90% of patients suffering from
the atypical form of pneumonia [SARS] recover relatively quickly,
thousands of people [may be] attempting to heal themselves, or
letting chronic [or acute] disease go untreated [while] authorities
[remain] unaware of the spread of disease...It is a cheap solution for
patients unable to foot the cost of medical treatment. But it means
that authorities cannot [identify and] quarantine SARS carriers, and
thus control the disease (Williams, 15 April 2003).

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By late June 2003, the chains of transmission had been broken in most of
the SARS-affected countries and the much-feared scenario of uncontrolled
community spread into the peri-urban and rural hinterlands (areas with
weaker institutional capacity) fortunately did not materialise in countries
like China.
SARS was evidently not as contagious as earlier feared, and the lower pop-
ulation density in rural China and lesser possibilities for nosocomial spread
may have further combined with ad hoc community initiatives, drawing
upon the institutional memories of China’s barefoot doctor system to suc-
cessfully deal with the limited leakage (or backflow?) from affected urban
metropolises (rough and ready at times including arbitrary blockades and
vigilante style sequestrations).
Concluding Remarks: Emerging Diseases,
Emerging Markets
In the event of its re-emergence, effective and cheap solutions, how-
ever, may not be on the horizon given the unseemly rush to patent the
SARS coronavirus genomic sequences by Canadian, US, Hong Kong,
Singaporean, Chinese, and other institutions wary about each other’s inten-
tions and seemingly unable to resist the potential profits from diagnostic
tests, vaccines, and medical treatments (Gold, 2003).
Further progress in SARS research may now have to contend with the
secrecy dictated by commercial imperatives (Matthijis, 2004), in contrast
to the early co-operative efforts and exchanges between otherwise highly
competitive laboratories which identified the etiological agent in record
time, and led to its sequencing within three weeks (Peiris et al., 2003; Ruan
et al., 2003).
Dr Julie Gerberding, Director of the US Centers for Disease Control and
Prevention (CDC) characterised it as “defensive patenting” on the part of
the National Institutes of Health, to keep the prerogatives within the public
sector domain (Nature, 2003).
Those who are mindful of the Bayh–Dole Act (1980) and the Stevenson–
Wydler Act (1980) in the US and how they paved the way for publicly
funded scientist-entrepreneurs to launch the biotechnology revolution, may

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SARS and Risk in Malaysia 365
be wary of this as a leaky safeguard with predictable consequences for global
healthcare equity, in a market-driven setting (Keusch and Nugent, 2001).
Patents on life forms are anathema to some including myself, but if we
have to live with patents in biotechnology, it might be better if patentable
findings from publicly funded research, conducted in an international col-
laborative effort and which are of global public health importance, should be
vested in an international agency such as the World Health Organisation.13
In conclusion, we have thus argued that the perception of risk associated
with the SARS infectious outbreak was disproportionate to the (direct)
threat it posed to global population health. This inflated perception of
risk, driven more by economic rather than epidemiological considerations,
ensured that SARS would not be a “neglected” disease. Indeed, SARS was
an attractive candidate for patentable research aimed at diagnostic tests, vac-
cines and therapies, precisely because of the perceived market potential for
these commodities. As such, it underscores the irrationality and inequity
13On 3 September 1999, US activists Ralph Nader, James Love, and Robert Weissman wrote to
Harold Varmus, Director of the US National Institutes of Health “to ask that you enter into an agreement
with the World Health Organization (WHO), giving the WHO the right to use health care patents
that the US government has rights to under 35 USC Sec 202 (c)(4) of the Bayh-Dole Act or under
37 CFR 404.7, for government-owned inventions. Under the regulations concerning government-
owned inventions, the US government has an “irrevocable, royalty-free right of the Government of the United
States to practice and have practiced the invention on behalf of the United States and on behalf of any foreign
government or international organization pursuant to any existing or future treaty or agreement with the United
States. 37CFR404.7(a)(2)(i)”. With respect to government’s rights in inventions funded by the US
government through grants and contracts to Universities and small businesses under the Bayh-Dole
Act, the US government has worldwide rights to practice or have practiced inventions on its behalf
(37CFR401.14), and it may require that foreign governments or international organizations have the
right to use inventions, under 37CFR401.5(d). As you must know, the US government has rights
to a large portfolio of health care inventions that were invented with public funds. These include
inventions in many HIV/AIDS drugs, such as government-owned inventions on ddI, ddC and FddA,
and university and contractor inventions such as d4T, 3TC and Ritonavir, as well as drugs to treat
malaria and many other illnesses. The private pharmaceutical companies that have obtained exclusive
rights to market these products charge prices that are excessive, and too expensive for many patients,
including persons in the United States and Europe. Most seriously, the hardships are particularly difficult
in developing countries, where countries do not have high enough national incomes to pay for expensive
medicine”. Dr Varmus, in his reply dated October 19, 1999, stated that “Congress enacted the Bayh-
Dole Act and the Stevenson-Wydler Technology Innovation Act (with later amendments, including
the Federal Technology Transfer Act of 1986) to encourage the transfer of basic research findings to
the marketplace. The primary purpose of these laws is economic development: specifically, to provide
appropriate and necessary incentives [through exclusive licenses] to the private sector to invest in federally
funded discoveries and to enhance US global competitiveness”. A subsequent request dated 28 March
2001 and addressed to US Secretary of Health and Human Services Tommy Thompson was similarly
denied.

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366 C. K. Chan
which often arises from market-driven priorities in biomedical research and
product development. Furthermore, this episode also hints at the promise
and possibilities from a needs-driven scientific endeavour, utilising the coor-
dinated talents and resources available worldwide, in contrast to the pitiful
constraints of demand-driven commodified knowledge.
Acknowledgements
Helpful suggestions and references from TG Yap, HL Chee, KL Phua,
J Cardosa and MP Pollack are gratefully acknowledged, but opinions
expressed in this article do not necessarily reflect their views. The author
was also supported by a Nippon Foundation API senior fellowship (2004–
2005) for his research on health systems in transition, and health and social
policies in East and SE Asia.
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