WHO Expert Consultation on Outbreak Communications

21 Sep 2004

By Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and Health

Venue: Traders Hotel

Speech by Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and for Health, at the WHO Expert Consultation on Outbreak Communications, 21 September 2004, 8.30 am, at Traders Hotel

Distinguished guests

Ladies and gentlemen

Let me first extend a warm welcome to all of you, and especially to our visitors, some of whom are visiting Singapore for the first time and have travelled a long way. I do hope that despite your busy meeting schedule, you will find some time to savour the sights and sounds of our island nation.

I am delighted to have the opportunity today to address you on this very important subject of outbreak communications. Last year the outbreak of severe acute respiratory syndrome or SARS taught all of us the importance of communications in managing a disease outbreak.

SARS in Singapore

SARS hit Singapore even before it had a name. In early March, our doctors diagnosed three women who after returning from Hong Kong developed atypical pneumonia. A week later, health care workers started falling ill. By the third week, we had designated our second biggest hospital as the SARS hospital and closed our schools. We had also decided, based on our scientific analysis of the clinical and epidemiological data from our patients, that the outbreak would be fought with the thermometer and the use of quarantine. People were afraid. Communication was essential in explaining the outbreak, rallying Singaporeans to support the measures taken and getting them to change their individual habits to support our national effort to control the outbreak.

SARS - a Global Disease

SARS was also a global disease. It is the first pandemic of the 21st century. It started in the Chinese province of Guangdong in November 2002. Historically, the spread of contagious diseases followed the routes of commerce along land and sea routes. In the 21st Century, air travel has made all countries of the world close neighbours and disease outbreaks can now leap over oceans along air-routes. SARS spread from China via Hong Kong to much of this region primarily through air travel and leapt across the Pacific Ocean to Toronto, again, through air travel. SARS infected more than 8,400 people worldwide, of which 20 per cent were healthcare workers, and left in its wake, many deaths and untold human suffering.

WHO Communications during SARS

During the SARS outbreak, communication was important between the national health agencies and WHO. The most dramatic example, early in the SARS outbreak, was the case of the Singapore doctor who was returning from New York via Frankfurt on an SIA flight. He had treated the first SARS patient in Singapore and then travelled to New York to attend an infectious disease conference. He was medically cleared in New York to fly back to Singapore. Because we were concerned about the outbreak in our hospital and worried that the infection may spread internationally, we contacted WHO and Germany. At Frankfurt, the flight was stopped and the passengers were quarantined. This case showed the world, dramatically, how rapidly the disease could move around the world via air travel. WHO travel advisories had a great impact on world travel in two ways. It allowed normal travel to continue in areas where there was no risk. It reduced travel significantly in areas where there was risk. Without the advisories, all travel may have been affected. By segmenting risks during the outbreak and communicating this risk to travellers and businesses, travellers and businesses could develop rational strategies to cope with the outbreak.

About a year has passed since the global SARS outbreak. The emotions and hype associated with the outbreak have settled. It is timely to look at the SARS outbreak in an objective manner and see what lessons it can teach us on communications during outbreaks. I am very happy therefore that Singapore has the privilege to support and to host this first of its kind WHO Consultation on Outbreak Communications. Your deliberations over the next few days will help to forge consensus on outbreak communications principles, strategies and tools, and generate a document and other materials that could serve as a basis for teaching workshops and guidance on best practices.

SARS Communications Strategy in Singapore

When the SARS outbreak occurred, none of us in Singapore had any experience in outbreak communications. Some of the elderly doctors recollected their schooldays just after World War Two, when schools were closed because of a polio outbreak. So as the outbreak progressed, we evolved our communication strategies based on first principles. There are three aspects of our communications strategy in Singapore that I would like to comment on. They are the tools, the communicators, and the content.

The Tools

Let me start first with the tools:

We used every communications tool available to us to explain the outbreak and rally the people. The most memorable to me was the almost daily evening media conference that the Ministry held to update the media. The conference had no time limit and we answered every question the media asked. If we did not have the answer to a question, we told the media we would try and provide the answer at the next conference. TV, radio and print journalists converted the information from the media conference and the press release into news items that the public could comprehend. We owe a great deal to our journalists and media people. They reflected the fear and worry that was in the community. Their questions were the questions Singaporeans wanted to ask. By answering their questions, we were made accountable to the public on an almost daily basis. This enhanced the trust and confidence that the public had in my Ministry's measures to control the outbreak.

There were also countless dialogue sessions to explain the outbreak to various groups including foreign missions, banks, businesses, industry, associations and community groups. TV and radio carried SARS education items, talk shows and SARS news. We even had a dedicated SARS TV channel. Newspapers and posters carried the same news in different creative ways like the use of cartoons. SARS Web sites and the internet were also mobilised to communicate with the public.

The Communicators

Next, I would like to comment on the communicators - that is the people involved in communications - Everyone who was in a position to communicate was involved. Ours was national effort to bring the outbreak under control; Our Prime Minister led the way. Through his open letter, his press conference to launch the SARS combat team and the televised dialogue session, Singaporeans were rallied. The parliamentary debate to pass legislation to help control SARS was telecast live and MPs through the parliamentary debate expressed the emotion of the people and their determination to overcome SARS. Ministers, community leaders and grass-root leaders helped bring the SARS control message to every Singaporean.

The Content - Scientific Accuracy and Honesty

Finally I want to comment on the content of our communications. As this relates to a disease outbreak, my ministry, the Ministry of Health was responsible for much of raw information on which communications was based. At our Ministry, the first principle we followed was to take as scientific an approach as possible. Early in the outbreak, our doctors told us that there was no evidence that children were at risk, so when we closed schools, we were careful to point out that the closure was due to the anxiety of parents and not because of any medical evidence that we had. Again, when there were suggestions from individuals that my Ministry should recommend the wearing of masks as a public health measure, we did not do so because there was no scientific evidence to support such a recommendation.

Our public health measures were again based on scientific data derived from the first 20 cases. The analysis suggested that the best way to bring the outbreak under control was through temperature monitoring and using quarantine measures. Our public health measures during the outbreak were essentially a progressive refinement of temperature taking and quarantine. Later in the outbreak, when the data showed that 85% of those who caught the infection did so in the hospital setting, we concentrated on the application of these measures in the hospital setting. The advantage of taking a scientific approach is that it can be explained to people easily and the measures taken can be defended in a logical manner.

Initial Foreign Media Response

In the early days of the outbreak, the issue was given a political dimension by some of the Western media. A newspaper in LA called Singapore "authoritarian", and CNN asked me in an interview how Singaporeans were responding to the infringement of their human rights. Responding to a critical media report that appeared in the Toronto Star on 25 April 2003, comparing our so called harsh measures adopted by Singapore to those in Toronto, our then Senior Minister Mr Lee Kuan Yew remarked: "Let's produce results. Then the PR will look after itself". This, we took close to heart. Above all we had to be honest to our own people and our responsibility for the protection of public health overrode all other considerations.

Transparency

A second important principle we followed was to be as transparent as possible. This meant that all our clinical data was shared with WHO and other health agencies. Every afternoon, all the data and information on developments over the last 24 hours would be collated at my Ministry at a conference chaired by the Director of Medical Services. The conference was attended by observers from WHO. So WHO had the same raw information from the epidemiologist and clinicians as my Ministry. While we prepared our report for the day and made our decisions on what new measures to implement, they prepared their own reports which they sent to their headquarters. This transparency helped everyone. It gave WHO confidence in the quality of the information they received. It gave us, my Ministry and Singaporeans, the confidence that if we did anything that did not make medical sense, the international medical community would point this out to us.

Honesty, accuracy and transparency must be the bedrock of any communications strategy and our SARS experience has re-enforced our belief in this.

WHO and SARS Communication

SARS also highlighted the critical role of WHO in forging a global response and in communicating this response. As a result of SARS, WHO's authority and leadership has come to be widely acknowledged by all. The global alert issued by WHO in March 2003, the first time in its history, gave every country in the world time to prepare for this potential epidemic. It alerted us to a crisis that was already brewing. WHO's definitions for "suspect" and "probable" SARS allowed doctors in all countries to communicate in the same scientific language and compare their experience. The travel advisories allowed risk to be communicated in a logical manner and helped businesses and travellers cope with the epidemic. WHO's communications had a major impact in the way SARS was controlled. It is timely therefore for WHO to organise this consultation to discuss outbreak communications.

Positive Developments from SARS

There have been positive developments as a result of the SARS outbreak. The world is more sensitive to the dangers of pandemics. The international approach to the Avian Flu outbreak which has affected, North America, Europe and Asia has been more organised and systematic. There is concern that the Avian Flu virus may mutate into a highly contagious form and trigger the next human flu pandemic. We are fortunate that WHO has taken a pro-active approach in monitoring this disease.

REDI Centre

In Singapore, a tangible outcome of the crisis was the setting up of REDI (Regional Emerging Disease Intervention) Centre here at Biopolis, which was officially opened in late May. I do hope some of you will have the occasion to pay a visit to the REDI Centre. The REDI Centre will promote regional cooperation, manpower and infrastructure capacity building and cutting edge research in the area of infectious diseases. REDI Centre is a joint effort between Singapore agencies and US agencies like the US Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH) and the US Dept of Health and Human Services (HHS). Through the REDI Centre, we can work with WHO to contribute to regional and global efforts to better prepare ourselves to handle and minimise the impact of emerging diseases like SARS and the Avian Flu.

Concluding Remarks

Friends, the challenge before us is to learn from our past experience. We must work together to harness the positive forces of globalisation to minimise the impact of future outbreaks. The first WHO Expert Outbreak Consultation meeting in Singapore is an excellent step in this direction. I wish you all a fruitful meeting and an enjoyable stay in Singapore.

Thank you.