At the height of the SARS crisis that hit East Asia in 2003, the Health Minister of Vietnam, Madame Tran Thi Trung Chien, told me, “Mr Indu, we can catch crabs only during low tide.” Vietnam being largely a coastal country, she had very cogently contextualised Churchill’s famous quote, “Never let a good crisis go to waste.”
I used to head health sector operations at the Asian Development Bank at that time and was involved in planning and supervising the implementation of its response to the SARS crisis. Considered a major public health crisis at the time, it pales in comparison to the current Covid-19 crisis in terms of both spread and impact. SARS infected only slightly over 8,000 people in 29 countries, with 774 deaths. Nonetheless, it shook the people and governments in East Asia out of their slumber and many of them indeed did not let this crisis go to waste.
Lessons learnt from the SARS epidemic have helped shaped East Asian countries’ response to the Covid-19 outbreak. Vietnam stands out among them — out of 288 cases between January 23 and May 8, only 47 are active, and none have died.
What SARS taught
Lifestyles perceptibly changed in many East Asian countries after SARS. In places like China, Hong Kong, Taiwan, Japan and Korea, the use of face coverings in public places became the norm. The practice was continued even after the outbreak was over. People with coughs and colds attend office with face coverings. New norms developed for touching of surfaces in public places. In East Asia, most people now press elevator buttons with a finger knuckle, avoiding direct contact with their fingertips. People are also more careful and use more hygienic sense in using public restrooms. Frequent handwashing is a norm.
SARS also prompted some introspection about working and travel arrangements. Faced with temporary travel restrictions during the epidemic, the Asian Development Bank experimented with undertaking loan negotiations through videoconferencing. This turned out to be as efficient as face-to-face meetings and has now become the norm. A realisation set in that much of business travel could be severally rationalised.
But more than any of these outcomes, by far the biggest impact of the crisis was that governments realised the importance of investing in health. Before SARS, governments were generally not keen to borrow from development banks for the health sector and preferred bilateral grant resources instead. They would prioritise hard infrastructure projects for loan resources. As they would often rely on a false dichotomy — hard money for hard sectors and soft money for soft sectors. After the crisis, this mindset changed. Many countries realised that they were spending too little on the health sector and that the relatively small grant funding from bilateral donors would not suffice.
China recognised the weakness of its health system and adopted a two-pronged approach of strengthening its government health facilities and expanding health coverage through social health insurance, much like Ayushman Bharat. Government health expenditure tripled in a few years’ time and almost entire population received health assurance. Other countries, even smaller countries like Laos and Cambodia, also invested heavily in their public health systems, improved their surveillance and reporting capacities, and significantly increased their health sector budgets. A healthy demand for large loan projects in the health sector ensued. For example, Vietnam borrowed heavily to establish a strong and interlinked laboratory system covering the entire country.
SARS, and subsequently H1N1, also prompted East Asian countries to deepen their regional cooperation on pandemic preparedness and response. Coordinated by the Association of South-East Asian Nations and other international development agencies, systems and agreements were put in place to identify emerging health emergencies and share information.
SARS also provided a major push to the World Health Organization’s effort to revise the International Health Regulations (IHR) to make them more effective. The revisions allowed WHO to seek information from member states and mandated sharing of any epidemic information with neighbours. Starting in 2003, the revised IHR were approved by all member states within 18 months in May 2005 — a speed akin to that of light in the glacial world of international agencies where negotiations on only one phrase can take years.
These reforms have definitely helped East Asian countries in effectively dealing with the Covid-19 pandemic. These countries, despite being closely connected with China through trade, tourism, culture and the diaspora and having ageing populations, have seen a relatively modest impact of the pandemic. While further research will tell us more, anecdotal evidence suggests that the widespread hygienic and face-covering practices and strong public health systems have helped in this process. Many of these practices and systems developed as a response to SARS, H1N1 and MERS.
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A crisis to learn from
Lives, social practices, working arrangements and the health sector will surely irreversibly change with the Covid-19 crisis in our country as well. Let us wait and watch the shape and extent of these changes. The extent to which handwashing and other hygienic and physical distancing practices become part of our lifestyles; our work arrangements change, with greater reliance on technology-enabled conferencing and supervision and reduced travel; access to healthcare increase through enhanced use of telemedicine; our disease reporting and surveillance systems become stronger; and expenditure on health becomes comparable to our peer nations, is yet to be seen.
I firmly believe that India too will not let this crisis go to waste.
Indu Bhushan is Chief Executive Officer, Ayushman Bharat-PM-JAY