- The Washington Times - Sunday, May 25, 2003

Special correspondent John Zaracostas interviewed Dr. Balaji Sadasivan, Singapore’s minister of state for health, for The Washington Times last week at the annual World Health Assembly meeting in Geneva. Dr. Balaji, 48, is a U.S. trained neurosurgeon and president of the Asian-Australasian Society of Neurological Surgeons.

Question: Singapore has a sophisticated economy, and you have been confronted with a major challenge — the new SARS virus. Your city-state has been applauded internationally for its rapid reaction and attempts to stem the spread of the disease. Can you discuss what the lessons are for other governments?

Answer: Well, when we had the outbreak, we did not know what we were dealing with in the early days of the infection. But we were lucky. We had good conditions on the ground. They defined the disease for us, and we developed a strategy on how to deal with it with the help of the World health Organization. We implemented the measures, and essentially the outbreak is under control.

The last person [in Singapore] who fell ill with the SARS infection was on 23 April, and he was isolated on 27 April. We thought we would be off the WHO list on 18th May, but on 11th May we isolated a suspected SARS case, and on 18th May his test came back and we changed his status to a probable SARS.

The person is a foreign resident in Singapore but travels extensively in the region. We have traced all his movements at Singapore; he has no connection with any of the other SARS patients. Because he was isolated early, no other patient has been infected by him. And this is the only case we found this month, May.

We’re still trying to see if it’s a new index case, rather then a case [from] the previous outbreak in April.

Q: But on your policy responses — in a nutshell, what were the three or four things that you did to contain it?

A: I think we gave the resources to the clinicians, and they isolated the SARS patients, and their contacts and the infection came under control.

More important than that was the fear associated with SARS, and we learned [that] public communication is very important. So we shared everything that we knew and everything that we did not know about the outbreak with the public, and then with the help of the public, brought the outbreak under control.

Q: So morale is key here?

A: Morale is key, information is key. When you start you don’t know much. If you tell the public what you know, what little you know, then they’re with you.

If you don’t tell them everything that you know, and you keep information from them, then they allow their imagination to get the better of them, and then fear gets magnified many times more.

Q: You’re also very vigorously pursuing research into the virus, and you have a vibrant biotech industry in Singapore. Is this likely to jump-start more research in these fields?

A: I think our research institutes did very well. The Genomic Institute of Singapore was one of the institutes that decoded the genome that came up with a PCR test diagnostic kit set that we used for the last three, four weeks. [PCR kits allow rapid detection of the distinctive genetic information of a virus using “primers.”]

It was very, very effective, because it allowed us to make definitive diagnosis of SARS. We are sending those kits to China for use and control of the SARS problem. Now, if the SARS problem is resolved there may be no commercial value from the kits. But I think that is not the important factor. The important thing is that when we needed to know about the virus, they achieved what they were set up to do.

Q: On the question of cost — you’re a highly developed economy what would be the average cost of treating a SARS patient in an emergency situation with ventilators, and the special equipment? What is the public cost?

A: In terms of cost, we made a SARS treatment C-class treatment. [This usually means individuals] need to pay about 5 percent of the cost. That’s really a very small amount, and one of the reasons for making them C-class is so poor people can afford it. For those who are very poor and cannot afford to pay, we have a fund that will pay for it.

Foreigners are also charged the same C-class rate, and if they cannot afford to pay, the Tourist Promotion Board has agreed to foot the bill. So essentially, paying the SARS health care bill for the public was not an issue for the Singaporean authorities.

But in terms of the larger cost, of course, it cost our economy $1 [billion] to 2 billion.

Q: This doesn’t specify the average cost of treating a SARS patient. Would it be in the tens of thousands of dollars?

A: I think if you took the total cost, yes, on average. [But this does not take into account] all the protective gear [and] the reorganization of the health care system. I think it may have cost our health system a million dollars or more [for each] of 200 cases.

Q: There have been attempts by WHO to put forward a rapid-alert system not only for viral outbreaks, but influenzas or even a bioterror attack, God forbid. This is the first time we have seen the system really tested to the limits. Is it delivering well and coordinating well, or does it need more funding?

A: I think the early-warning-system coordination worked well — at least for us.

You talk about this as being a viral outbreak. Now, what about other infections? See, when a group of people start falling sick, you don’t know it’s a virus.

So when WHO alerted us, they just told of an illness in which people are falling sick with atypical pneumonia. The cause at the time could have been bacterial, could be some other organism, or even a virus. So it’s only about one month after the outbreak we knew for certain it was a coronavirus

So, I think the early-warning system of the WHO did fantastic.

When the cases fell ill in Hanoi, within days of them falling ill Hanoi notified the WHO. They told the whole world. We had our surveillance system of infectious disease. It matched. We took the precautions. A week later the WHO had its global alert.

One thing that helped us greatly in managing the outbreak was that WHO came up very early with criteria to define the illness. Since we don’t know what was the cause.

They didn’t have a confirmed SARS, or a definite SARS diagnosis. They used a “suspect” and a “probable.” They drew criteria for that, so we could all talk the same language across the world, and that helped us greatly in the management of SARS.

Q: Looking ahead, the WHO’s [SARS coordinator], Dr. David Heymann, and others have said SARS signifies the globalization of disease, and that now you need to have a global approach. Someone’s virus is everyone’s problem?

A: I agree with them. One hotel led to an outbreak in several countries — Hanoi, Toronto, Hong Kong, and Singapore. And because WHO pooled the information and advised what to do, I think we’re all showing results.

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