Fear and Stigmatization: Undiagnosed Side Effects of SARS

During my senior year of my undergraduate experience, I participated in two senior capstone courses for both of my majors. My Chinese Language and Culture capstone looked at the Chinese internet as a method to achieve individual empowerment through family reunification [Read here]. My International Studies capstone course was on pandemics and taught by a professor who had previously held positions at the World Bank, WHO, and USAID among other international offices before her teaching career. For my final paper in this class, I focused on the social aspects of the 2003 SARS pandemic – particularly fear, stigmatization, and discrimination. Currently in the midst of the COVID-19 pandemic, I looked back at this paper with intrigue but also sadness at all of the similarities and lessons not learned.

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Introduction:   

A cough, a sneeze, a slight fever – these are mundane symptoms that irritate almost everyone at some point during the year due to a mild cold or seasonal allergies. If more serious concerns arise, most people then turn to the internet or to their doctors to glean possible answers. Now imagine that no information is available online or anywhere else. Only rumors or unknown truths by a government that is widely distrusted are accessible. This was the frustrating situation many Chinese citizens experienced during the SARS epidemic in 2003. In November of 2002, this new disease spontaneously came out of Guandong province, yet it took China nearly four months to report the incident to the World Health Organization (WHO). The lack of information available paired with the wild assumptions made by individuals and groups incited fear and panic in many.  From China’s mishandling of information related to SARS, the larger global response to the situation, as well as individual discrimination against those directly and indirectly affected by SARS, this paper shows how fear impacted the 2003 SARS epidemic, leading to unnecessary escalation and preventing positive communication that is essential to resolving global issues today.

            This paper is broken into four sections, first providing a brief background on SARS and the role of fear and discrimination. It will start with the national perspective, including the China’s attempt to cover-up the virus and the criticisms in the global media that followed.  Looking at fear on an individual level, this paper will then address the issue of discrimination and the challenges for those most personally affected by the disease, their acquaintances, and ethnic Chinese abroad. This paper will conclude by discussing some of the subsequent national and international lessons from the SARS pandemic and the encouragement of increased tolerance for all peoples involved in pandemic crises.  

Background

            The first outbreak of the severe acute respiratory syndrome (SARS) was recorded in Guandong Province, China in November 2002, and quickly became an epidemic, infecting over 8,000 people and killing 774.[1] SARS is a viral respiratory illness that causes typical flu-like symptoms, including a high fever, headache, discomfort, and body aches for about five to seven days.[2] The disease is spread through close contact, respiratory droplets produced from sneezing or coughing, and coming in direct contact with an object contaminated by respiratory droplets.[3] The possibility of airborne transmission of SARS escalated fear about this epidemic.[4]

            Heightened by air travel in today’s globalized world, SARS spread to over thirty countries in just a matter of weeks.[5]  Jeffrey Drazen, the editor-in-chief of The New England Journal of Medicine, wrote about the World Health Organization (WHO) sponsored conference after the SARS outbreak, in which he says,“The SARS virus shows that when confronted by a common enemy, we can forget our differences and work together fruitfully. This was the most important lesson from the conference and from SARS.”[6] While this type of peaceful organization is the goal in global crises, much of the literature shows that Drazen’s idealized statement was not actually realized. The world blamed China on a national level for being irresponsible in their response and panicked people around the globe blamed ethnic Chinese individuals whether or not they had any likely exposure to the disease.

            The WHO accused the Chinese government of underreporting instances of SARS, and other critics condemned China for prioritizing their social stability and national image over public health.[7] The government’s attempt to suppress information is visible in the existing literature. The vast majority of the information available from peer reviewed sources regarding Chinese nationals and the epidemic came from Taiwan, Hong Kong, and even Japan on the status of Chinese international students. Very little originated from within Mainland China, and no internet search garnered any 2003 reports from the China Central Television’s (CCTV) English pages on SARS.  This speaks to the power of the strict government censorship and controlled news media. In the case of SARS, secrecy fanned the flame for the epidemic.

             During the SARS outbreak, some became fearful or suspicious of all people who looked Asian, regardless of their ethnicity or exposure to SARS.[8] Many individuals recall being discriminated against and being barred entrance to hotels, stores, and other public buildings because they were Chinese and may carry the virus.[9] Most of the research directly related to fear and stigmatization were on psychological effects and the psychosocial consequences, but this paper attempts to fill in a gap in the existing literature by analyzing the role of global media in exacerbating the discrimination of Chinese people and in some cases ethnic Asians as a whole.

            The issue of discrimination needs to be treated as a serious aspect of the epidemic, and it is necessary to address it in order to improve public health. According to Dr. Margaret Chan, Hong Kong’s director of health, discrimination could discourage SARS patients from seeking attention in time.[10]  In addition to being a preventative health measure, working to eradicate the discrimination that comes along with the disease is a human response to better the conditions of those who are already suffering. It is clear that secrecy, shame, and stigma all led to discrimination in the 2003 SARS epidemic. While China certainly could have responded faster, the blame must not be on solely one country or group of people. This epidemic proved that the world still has a long way to go in extending tolerance on both international and individual levels.

National Criticism and Response

            On April 18, 2003, CNN published a report that accused Beijing authorities of having gone to “staggering lengths” to hide SARS patients from visiting WHO inspectors.[11] Infected patients were allegedly driven around in ambulances during the visit, and at another military hospital SARS patients were moved to a hotel. These more elaborate attempts to cover cases were just one facet of the problem regarding China’s response to SARS. An overwhelming issue was simply underreporting to the WHO and other national structures. Internal Ministry of Health reports put the confirmed number of SARS cases in Beijing at between 200 and 300, yet the Ministry of Health had only publicly admitted to 37 cases in the first few months.[12] Citizens within China remained ignorant of the severity of the situation because CCTV, the national news network, did not list the number of cases.[13]

            These actions were driven by a fear of negative economic ramifications through decreased travel to regions in China and a plunge in trade of Chinese goods. Despite efforts to prevent economic consequences, China’s worries became a reality once information about SARS was released, causing one of the worst economic crises in Southeast Asia. The economies of Hong Kong, Singapore and Taiwan were hardest hit, but it had negative effects for Malaysia, Thailand, and China, as well.[14] People cautiously avoided stores and restaurants in areas where SARS had been reported. China was put on travel advisory lists by many countries, forcing travelers to cancel or postpone their trips, which severely impacted the service industries.[15]  As far as London and Paris, the effects from SARS were felt in the luxury product lines. Business travelers feared SARS as well, so companies reduced involvement in international work. Thus sales in tourist attractions, airport shops, and hotels fell. Travel to the Asian region dropped significantly, causing a 20% decrease in hotel occupancy in Singapore and a 40% drop is Cathay Pacific flights.[16] The Singaporean government issued at $130 million aid package to the tourist industry after a 61% decrease in tourism and 50% decrease in retail sales.[17] 

            The global economic impact SARS created show the influence of globalization today as well as the interplay of different fields. Former president Hu Jintao stated that SARS not only affected people’s health and safety, but it also affected national development and reform projects.[18]  While medical health professionals quickly tried to find medical explanations for SARS, economists faced other questions in predicting how long the disease itself but also fears about the disease would last. China realized that encouraging friendly and open relations with neighboring countries was paramount in minimizing damages from the SARS epidemic.  China could not do this without ensuring their neighboring countries that another SARS-like incident would not happen again, forcing the country to commit to a new level of openness about health information. The economic future of China relies heavily on foreign investment and trade among Asian countries, both of which are in jeopardy if the China is seen as a health threat and the government is seen as irresponsible.[19] “SARS has been our country’s 9/11,” said Xu Zhiyuan, a columnist for the Economic Observer. “It has forced us to pay attention to the real meaning of globalization.”[20]

            While many countries in the Southeast and East Asian region were affected by SARS through both economic recession and medical of the disease, Japan had only two instances of SARS in their country. As the Head of State, protecting the Japanese people from contracting the illness was the greatest objective which led Junichirō Koizumi to adopt new SARS prevention policies in May of 2003. Japan’s position was one of prevention. These new policies asked for people in Beijing to leave the area and urged Japanese students in China to return to Japan. For those who had traveled recently to China and come back, the policies asked them to self quarantine for a period of time.[21] This new policy also gave the government the power to forcibly hospitalize probable patients if needed.[22] Prioritizing people over business, Japan also asked the workers for Japanese cooperations in China to come back to Japan, knowing this could cause economic setbacks for Japan.[23]

            With tensions already high due to economic worries, the international media did not help the situation. Many headlines incited fear, insinuating that SARS could have a similar effect to that of the extremely deadly 1918 flu epidemic or the world HIV crisis and using the buzzwords “deadly SARS virus,” or “the killer SARS virus.”[24] In reality, the morbidity rate of SARS was reasonably low around 12%, but panic spread faster than the disease itself in many parts of the world, resulting in many countries’ extraordinary measures to prepare for a SARS outbreak.[25]  While wearing face masks in many parts of East Asia is common practice for a variety of reasons, including illness or pollution, the media saturated with images of Asians wearing masks combined with health authorities’ warning of airborne transmission was another channel that allowed the two thoughts to become interlinked and increased discrimination against Asian populations specifically.[26]

            China also faced strong political criticism in the media, which inflamed the already negative sentiment toward the country during this time. Many online newspapers discuss the WHO’s increasing anger towards China’s attempt to cover up the epidemic.[27] Writers in the New York Times called the SARS epidemic “a national train wreck.” Other titles, such as the Guardian’s, Sars Virus “Came from Outer Space,” were not particularly pointed politically, yet did contribute to the alienness of this new disease and the fear associated with the unknown.[28]  In Washington D.C., Jeffrey Bader, the vice president of an international consulting firm stated that “China ha[d] a credibility gap that need[ed] a quick mend.”[29]  In line with Bader’s views, many news articles used the phrases, “uncovering more lies” or “exposing the Chinese government’s lies,” which showed countries’ opposition to China’s handing of SARS as well as exacerbating readers’ tendency of mistrust in the Chinese government.

            The outbreak of SARS in China clearly shows the strength of the strict government censorship, but also the limitations in withholding such vital information. Erik Eckholm of the New York Times argued that “not only is SARS a serious threat to lives, but the epidemic has also exposed with embarrassing clarity — to the Chinese people and to the world — the costs of China’s tight political control over information and bureaucracy.”[31]  Once China realized the country was under harsh criticism from around the world for the mishandling of SARS, China became transparent.[32] This is exemplified by former President Hu Jintao’s demand on April 17th, 2003, for authorities in China provide full support for SARS research and cooperate with international agencies, including the World Health Organization. Moreover, Madame Wu Yi, the Vice Premier and Minister of Health admitted China’s failure at the 56th Annual World Health Assembly when she said in her address, “There were defects in our control and no uninterrupted flow of information. All that plus inefficiency of some localities and departments has made our work of SARS control somewhat passive for a period of time.”[33] Human rights activist Wei Jingsheng noted that the SARS epidemic created this unusual moment of openness in which China’s leadership had to reveal not only to the World Health Organization, but also to the Chinese people, that they had erred.[34]

            The political condemnation China received prompted the government to act quickly once all the information came to light in the public. In early April of 2003, some 120 officials were fired for dereliction of duty on the fight against SARS, including China’s Minister of Health at the time, Beijing’s mayor, and several Communist Party leaders at various levels.[35]  China allowed WHO doctors to complete a week long investigation in Guandong province, where SARS originated. The SARS outbreak in China exposed shortcomings in the country’s public health infrastructure, including the lack of state funding, surveillance systems, and significant shortages in facilities and medical staff who were ready for an epidemic.[36] China’s entire public health system was in a state of transition as institutions changed from fully subsidized state-run programs to partially state-run ones.[37] In hopes of remedying their reputation and controlling the disease, China set up the National SARS Control Headquarters, as well as local governments’ SARS control steering panels. The Central Government sent inspection teams to 31 provinces, municipalities and autonomous regions on China’s mainland to supervise and guide local SARS control work at close quarters. Additionally, an open and transparent SARS cases report and information release system was put in place to keep the WHO and the general public updated on the status of the epidemic. Madam Wu also listed “stringent quarantine and precautions” and the use of isolation and observation for all SARS patients, suspected patients, and those having had close contact with SARS patients with  treatment wherever detected.[38]  Perhaps most needed, China promised significant efforts to publicize information on SARS control and prevention and to enhance public awareness and ability of self-protection.[39]

Individual Discrimination

            For those whose lives were personally affected because of the disease and stigma surrounding it, these efforts did not come soon enough. In some cases, however, the government’s disease control tactics may have caused even greater fear. A widely used tactic in China, advocated by Madame Wu, was quarantining infected patients. In the late spring of 2003, there were some 16,000 quarantined individuals in Beijing alone.[40] A Center for Disease Control (CDC) publication by Bobbie Person et. al argues that exclusionary practices, including quarantine and isolation, can lead to the further discrimination and stigmatization of specific populations.[41]  In the case of SARS, some have argued that quarantine was at best ineffective and at worse “unnecessarily harmful.”[42] This is due to both quarantine violations and the psychological stress associated with the practice. Simply being placed under quarantine can lead to stigmatization and loss of medical confidentiality, since the reason is typically known to others.[43]

            In a 2004 study, symptoms of post-traumatic stress disorder and depression were displayed by one third of those quarantined.[44] These results were comparable to a study conducted in Taiwan showed that some 45% of the SARS patients exhibited psychiatric problems even after discharge.[45] This is no surprise as many continued to face discrimination on both personal and professional levels. More than 16% of respondents in one study showed a tendency of avoiding former SARS patients.[46] The avoidance of recovered SARS patients was confirmed in a survey conducted in Hong Kong, which revealed that near 20% of the population believed that SARS could be transmitted through minor interactions with people who had been recovered for 18 months.[47] This included avoiding shaking hands, dining, using the elevator, and even having contact with the children of recovered SARS patients.

            These misconceptions on the health status of recovered SARS patients and continued ability to transmit the disease undoubtedly affected their social lives and psychological wellbeing. Recovered patients were confronted with more challenges in the professional arena, as many of them found themselves out of work and hard pressed to find a new job. The Hong Kong survey further discovered that 35% of respondents indicated having experienced job-related discriminatory practices in regards to recovered SARS patients.[48]  This included people’s beliefs that former SARS patients should not serve in the food service industry, as school teachers, or as medical personnel.  Perhaps even more astonishing, 72.7% believed that recovered SARS patients would have longterm negative health consequences due to SARS and that they would be unable to perform well at demanding jobs.[49]

            Another response method that was widely used during the SARS epidemic was the formation of networks of community members by the Communist Party who monitored the activities of fellow citizens with the specific purpose of hunting down possible SARS cases, apartment by apartment.[51] This significantly increased the emotional toll on infected people and those associated with SARS victims, as it made it very obvious which buildings had infected individuals.[52]  A huge aspect of the problem is the stigma associated with people who have had SARS or any contact with it. Recovered patients, doctors, nurses, and even the neighbors of SARS patients, have been shamed and shunned by friends, coworkers, and their own families.[53]

            A clear case of this was at the Amoy Gardens apartment complex in Hong Kong, where over half of the population mistakenly believed SARS was a fatal diagnosis.[54] The Amoy Gardens consists of 19 buildings and 17,000 residents.[55]  In a survey conducted of these residents, 88.1% that SARS deeply affected their daily lives, particularly in their social relationships, work, and family life.[56] Victoria Ng, a resident there, recalls her experience of discrimination after only one person in her building became infected with SARS, and that individual was quickly moved out. Despite this, her eight brothers and mother refused to see her for two months, and her friends wouldn’t go out with her. Furthermore, her boss required her to wear two layers of facial masks at work, which distanced her from her coworkers and made her physically identifiable as a medical threat.[57] Her story was congruent with many of the residents of Amoy Gardens who faced SARS-related stigmatization, most commonly taking the forms of being shunned, insulted, marginalized, and the rejection of work, interpersonal relationships, services and schooling.[58]  These are the types of complaints of out outrageous discrimination against people with any connection to SARS that flooded the Hong Kong Equal Opportunities Commission during the time.[59]               

            Ethnic Chinese people abroad also faced stigmatization. The association of SARS with Chinese or Asian people as a group led to a surge in discrimination as people were shunned on subways, children in schools were singled out, and outright hate messages were sent to Chinese organizations.[60] Many experienced SARS-related fear, worry, or a sense of helplessness about the epidemic.[61] A survey conducted in Japan found that nearly 60% of Chinese students studying abroad at Kyoto University felt that their college lives were impacted by SARS. The importance of taming sensationalized news that spread fear-instigating rumors can be seen in some of the personal experiences of these Chinese international students. One student remarked, “I felt depressed because Chinese people were blamed for their unhygienic habits or eating wild animals which were said to have resulted in the SARS spreading.”[62]  Another reflected on his feelings during the epidemic by saying, “I felt much discriminated when I was barred from staying in a hotel in Tokyo just because I am a Chinese and might carry SARS virus.”[63] Many remembered being prohibited from entering stores, movie theaters, restaurants, and other businesses which singled Chinese and Taiwanese for the prevention of SARS.[64] The students felt that not only was their government was being condemned, but that they too were criticized.

            In North America, Asian American communities were also adversely affected. Aided by shocking headlines and images of Chinese people wearing face masks in the media, some became fearful of all Asian appearing people, regardless of nationality or legitimate risk of carrying SARS.[65] New York’s Chinatown was hit particularly hard with discrimination. A Vietnamese owner of a Chinatown restaurant was sent details of his own death through phone calls, online postings, and the local newsprint.[66] In a misguided attempt at an April fool’s joke, someone posted a warning of infected employees at a restaurant in Boston’s Chinatown, which fueled rumors and exaggerated stories.[67] These situations were unfortunately quite common. When racism did not take the form of outright aggression, subtle microagressions like only wearing masks around Asian Americans occurred. Additionally, studies show that during the epidemic, 14% of Americans reported avoiding Asian businesses and restaurants.[68]  Chinatowns became associated with the disease and contagion, and business and tourism to those areas decreased dramatically.

            Why were so many people worldwide wearing masks, pushing elevator buttons with tissues, avoiding shaking hands, and inciting discriminatory language on ethnic Chinese people? Experts suggest that people are biologically programmed to fear anything unknown and threatening, and much about SARS remained unknown to people around the globe at the time.[69] David Ropeik, director of risk communication at the Harvard Center for Risk Analysis and author of Risk! A Practical Guide for Deciding What’s Really Safe and What’s Really Dangerous in the World Around You, points to stereotyping as a specific method that offers people a way to define a threat and avoid it. He says, “If there’s a them that we can identify as a source of the risk, real or not, it is a form of taking control of our safety to act against them.”[70] Self protection is a large motivation of people for utilizing stereotypes and condemning seeminlgy high-risk population groups, like the Chinese in the case of SARS.[71]

            In an interview with USA Today, Dick Thompson of the World Health Organization stated in late spring of 2003 that most places with significant outbreaks were under control and that wearing a mask wasn’t going to have much of an effect, even in crowded tier one cities like Beijing. Moreover, he made clear that SARS was a significant public health risk, but not a risk to any particular individual.[72] The amount of misinformation and ignorance during the SARS epidemic incited fear, which provoked the discrimination of infected individuals as well as ethnic Chinese people across the globe. It is for these reasons that taking a proactive role in informing the public about pandemics is such an important prevention tool, so that marginalized communities don’t have to suffer more than they already do. Miscommunications and inconsistent health policies have been noted as factors which amplified the stigmatization of people in Hong Kong and worldwide.[73]

Discussion

             Though China was heavily criticized for their initially lackadaisical reaction to SARS, their strident efforts during the epidemic must be recognized. Vice minister Wu Yi’s statement of her goal to build a comprehensive system for sudden-breaking health crises in China is significant because this was the first time a Chinese leader publicly addressed the lack of an emergency response system.[74] Moreover this is momentous because of China’s cultural tradition of not wanting to “lose face.” Madame Wu more officially conceded the country’s mismanagement of SARS in her 56th World Health Assembly address. Wu’s address also hints at China’s long history of isolationism when she said, “Globalization has increasingly turned the homeland of mankind into a global village. No country can hope to live a life of leisure and comfort behind the closed doors.”[75]  China’s distrust of foreign technologies and foreign governments due to colonization in the 20th century undoubtedly played a role in China’s initial attempt to contain and suppress information.[76]  Thus, another huge step forward for China was letting WHO doctors in the country to conduct tests and advise public health workers. China’s experience with international communication during SARS has set a new precedent in the country for the importance of health information sharing.  

            When Madame Wu assumed the role of Minister of Health in the midst of the SARS epidemic, all eyes were watching to see how she would handle this situation. She replaced Zhang Wenkang after he was fired for his role in covering up the crisis. Wu took a firm stance on SARS and used innovative methods in her leadership. Wu believed in the need for state controlled media to minimize the number of rumors about the disease. She also sought out the voices of the people and made visits to even rural areas of Chinese so that she could see the gaps in health infrastructure around the country. Wu advocated strong efforts to control the movement of students and migrant workers in order to reduce the spread of the disease.[77] She also wanted to ensure adequate medical supplies for SARS patients and cracked down on those selling counterfeit medication. Wu’s response to the pandemic was one of swift development and cooperation with international bodies, which earned her the title of “Goddess of Transparency” by Time Magazine, a spot on the Forbes Most Powerful Women of 2004 list, and the nickname the “iron lady” within the country.[78] Despite these accolades, Wu humbly stated in 2007 her desire for no one to remember her. 

            As one of the boldest actors in the SARS epidemic, her name will most definitely be remembered. Before SARS, China did not have an emergency response plan, a threat-level standard for sudden-breaking public health incidents, a system of responsibilities or a chain of command in the event of a public health crisis. Additionally, there were no specific guidelines on how information should be dispersed, how to handle the news media, coordinate government offices,  mobilize society or control measures that should be taken in the midst of a public health crisis.[79] As Hu Yonghua, a professor in the school of Public Health at Peking University, reflects on the anniversary of SARS, he says, “SARS was a disaster, but it was also an opportunity – an opportunity of development in public health in China.”  Much progress has been made in public health infrastructure since the SARS epidemic. China has sought to address their health system deficiencies through an 11.7 billion yuan capacity building project on both national and provincial levels.[80] China built physical infrastructure with pressure isolation wards as well as equipped may cities with these new pressure isolation ambulances, but according to many public health experts, the most important upgrade was the creation of new information and reporting systems. The State Council established the SARS Prevention Command Center, and the Ministry of Health created the public health monitoring and warning system as well as an epidemic network reporting system.[81]  Additional progress was seen during the creation of the “Ordinance on Response to Sudden-breaking Public Health Incidents” and the Health Emergency Response Office.

            The SARS epidemic influenced not only China’s government and health system, but policy on a worldwide scale, again showing how SARS revealed the impact of globalization on disease and vise versa. In response to the SARS outbreak, WHO was given greater capacity to initiate and respond to such epidemics when delegates unanimously adopted a new resolution, which allowed WHO to act on information from sources other than government notifications and to conduct on-the-spot investigations.[82]  These efforts were put in place to ensure that control measures within an affected country were sufficient to contain the disease and protect against its international spread. Additionally, the International Health Regulations of 2005 is considered a public health landmark for WHO. This new legal framework established requires states to notify WHO of events that “may constitute a public health emergency of international concern” as well as highlights the need to establish effective communication networks both between countries and with the WHO.[83] More specifically related to the SARS epidemic, the new framework lists SARS as one of the four disease that require immediate, mandatory notification and assessment.[84]

            While the aforementioned efforts all indicate significant progress in public health, along with these broader policy changes, much work needs to be done to mitigate discrimination and fear towards infected individuals.[85]  Not only is this an issue of dignity for those affected, stigmatization is a public health concern that is critical in controlling transmission. The fear of being socially marginalized or stigmatized may make people less willing to seek timely medical care when early clinical symptoms arise.[86] Furthermore, Studies have shown that during disease outbreaks, the general public requires immediate information and certain groups of the population that may be more susceptible to stigmatization need special attention from public health professionals.[87] According to an article published by USA Today, unnecessary anxiety can produce health effects that are unrelated to SARS that suppress the immune system, increasing one’s vulnerability to heart disease and even cancer.[88]

            There was almost no information about the health status of recovered patients, making it easy for the fear and discrimination of SARS patients to continue even after recovery.  Most people’s social avoidance of former SARS victims was considered a self-protection maneuver. Public health initiatives can address people’s fears about an epidemic through increased health literacy and access to information, which can help find cases earlier and play an integral role in reducing stigma and fear of an disease.[89] Educating the public in order to deconstruct misconceptions on the disease has been particularly effective in mitigating the fear and discrimination with HIV/AIDS.[90] Joseph Lao et. al suggest that SARS patients were seen more as victims, whereas AIDS patients were seen as personally responsible for their illness. They indicate that for this reason, it would be easier to detract stigmatization from SARS with the proper dispersal of information.[91]  The government, media, and researchers all have a responsibility to work closely together to alleviate fear for the sake of individuals and for the health of the country.

Conclusion:

            The 2003 SARS epidemic clearly shows how globalized our world has become. Not only did the disease spread across country borders, fear and discrimination associated with SARS also travelled rapidly. From the initial hiding of SARS to the harsh media criticism to the individual discrimination people encountered, fear was at the fore of it all. While both China and the world at large have learned a lot in the years since SARS in regards to access to health information, timely communication, and openness with the global community, a lesson that seems to remain untouched over and over again is that of tolerance. The media and individuals were quick to blame China, which most definitely faltered at the beginning of the epidemic, but made strident efforts to remediate the situation, which must be recognized. China’s longstanding position as an isolationist country makes their willingness to comply with WHO an even more important indicator of progress.

            On an individual level, SARS was devastating for those who lost jobs, experienced deteriorated mental health, and were isolated from friends, family, and other connections due to the disease. Research shows that the impact of this type of epidemic on individuals and communities can be even worse if the public response is not organized and the facts are not understood.[92] SARS showed the importance of disseminating information promptly but also the need for a nuanced, well-thought out approach. Public health must consider the needs to protect the whole population while also preventing fear and and further stigmatization of the most vulnerable groups.  In the Canadian Family Physician, Renata Leong MD wrote, “With fear as its accom­plice, [SARS] has threatened much more than our physical well-being. It has attacked basic notions of a civilized society, including respect for human dignity and public good.”[93] This sentiment needs to be read again and again and absorbed profoundly. In truth, it is not just up to China, overseeing international bodies, and foreign governments to glean important lessons from this epidemic. Individuals, as citizens of affected countries, non-affected countries, and of the globe at large, play perhaps one of the most important roles in making sure the fear and panic of SARS is not replicated in the future. 

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Pappas, G., I. J. Kiriaze, P. Giannakis, and M. E. Falagas. “Psychosocial consequences of infectious diseases.” Clinical Microbiology and Infection 15, no. 8 (2009): 743-747.

Person B., Sy F., Holton K., Govert B., Liang A., and National Center for Inectious Diseases/SARS Community Outreach Team. 2004. “Fear and Stigma: The Epidemic Within the SARS Outbreak.” Emerging Infectious Diseases 10 (2): 358-63.

Qingguo*, Jia. “Disrespect and distrust: The external origins of contemporary Chinese nationalism.” Journal of Contemporary China 14, no. 42 (2005): 11-21.

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Wynia, Matthew K. “Ethics and public health emergencies: restrictions on liberty.” The    American Journal of Bioethics 7, no. 2 (2007): 1-5.

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[3]          “SARS Basics Fact Sheet.”

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[8]          Person B., “Fear and Stigma,” 359.  

[9]            Zheng, G., M. Jimba, and Susumu Wakai. “Exploratory study on psychosocial impact of the severe acute respiratory syndrome (SARS) outbreak on Chinese students living in Japan.” Asia-Pacific Journal of Public Health 17, no. 2 (2005): 126.

[10]         Bradsher, Keith. 2003. “Now, the SARS Emotional Toll.(Foreign Desk)(study Finds Large Number of Recovered SARS Patients Have Psychiatric Problems Afterward, and Find Themselves Stigmatized by Employers and Others).” The New York Times, A16.

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[28]        Meikle, James. “Sars Virus ‘came from Outer Space'” The Guardian. May 23, 2003. Accessed May 04, 2016. http://www.theguardian.com/society/2003/may/23/sars.publichealth.

[29]        Garrett, Laurie. “SARS Forces Change in China.”

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[78]        “Wu Yi, Always Remembered by Chinese People.” All China Women’s Federation. March 3, 2008. Accessed May 04, 2016. http://www.womenofchina.cn/womenofchina/html1/people/officials/9/1801-1.htm.

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[85] Person B., “Fear and Stigma,” 361.   

[86] Person B., “Fear and Stigma,” 361

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[92] Zheng, G., “(SARS) outbreak on Chinese students living in Japan.” 133.

[93]         Leong, Renata. “LETTERS – SARS Wars: Family Physicians Undeployed Soldiers.” 2003. Canadian Family Physician 49: 962 

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