Exclusive Interview on COVID-19 with SARS Veteran Dr. Sarah Borwein
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We couldn’t think of a better person than Dr. Sarah Borwein. Originally from Canada, Dr. Borwein has been practicing in Hong Kong for over 15 years, and prior to that successfully ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period. Dr. Borwein is also a mother of three, and has been helping families in situations including epidemics in Asia since 2001.
What would you say are the main differences between COVID-19 and SARS?
COVID-19 and SARS do share some common features: they belong to the same family of viruses, they both seem to have jumped from animals to humans, they both originated in China and both can cause severe pneumonia.
But there are some important differences. SARS was more lethal than COVID-19, but less easily transmitted. It went straight for the lungs, and caused severe pneumonia which became transmissible only when patients were quite severely ill and usually by then in hospital. About 10% died.
COVID-19, on the other hand, is more likely to replicate initially in the upper respiratory tract, with the result that some individuals may shed a lot of virus when they are only mildly symptomatic. It’s not known how many people with COVID-19 develop pneumonia, but of the ones who do, about 20% get severely ill and likely fewer than 2% die. Overall death rates are still not known for sure, but are probably less than 1%.
So COVID-19 is a lot less lethal than SARS, but harder to control because it spreads more easily and by people with milder symptoms. That’s why, despite being considerably less likely to kill you than SARS was, COVID-19 has still in total killed more people in 9 weeks than SARS did in eight months.
Another important difference is that medicine has advanced considerably in the 17 years since SARS. In 2003, it took months to identify the virus and develop a test. For COVID-19 that happened within a couple of weeks.
During SARS, high dose steroid treatment was used extensively in an attempt to dampen down the damaging immune response to the virus. This turned out to cause more harm than good and has been abandoned this time round. Instead, new treatments are proving useful, in particular some HIV drugs that also are active against coronaviruses. Newer antivirals are being trialed and more than 30 candidate vaccines are on the horizon.
All of the vaccine possibilities are pre-clinical though, meaning that even those that are ready to test have to go through a series of trials for safety and efficacy, a process that will take more than a year. And that’s moving at warp speed compared to the usual 5 to 15 year process.
Which lessons can be learnt from SARS to best manage the current outbreak?
The most important thing we learned in SARS was that infectious diseases do not respect borders or government edicts, and cannot be hidden. It requires international cooperation, transparency and sharing of information to control an epidemic. This epidemic will underscore that message, but I wonder if another take away won’t be that the international community has to get in sync in the management of global infectious disease threats. We still like to think of diseases as other countries’ problems right up to the moment when they land on our own doorstep.
We also learned the importance of providing good, balanced, reliable information to the public. In any epidemic, there is the outbreak of disease and then there is the epidemic of panic. And nowadays, there is also what the WHO has termed the Infodemic, the explosion of information about the epidemic. Some of it is good information, but some of it is rumour, myth, speculation and conspiracy theory, and those things feed the anxiety. It can be hard to sort out which information to believe, so it is important to choose trustworthy sources. Panic and misinformation make controlling the outbreak more difficult.
Finally, SARS was the first time we realised that respiratory illness could be spread to healthcare workers. When the SARS epidemic started in 2003, the hospital I worked at had two N95 masks, in case of the occasional case of active tuberculosis. Many people had never even heard of an N95 mask! Now we recognise that healthcare workers, the very people we depend on to help us if we get sick, are at particular risk. Although this risk appears to have been considerably worse for SARS, COVID-19 still poses an elevated risk to our frontline care-givers in hospitals, and special care has to be taken to protect them.
How serious is the situation now in Hong Kong compared to other places, especially in Europe?
As China appears to be bringing its own epidemic under control, cases exported directly from China have ceased. The bigger concern now is international spread.
Hong Kong has seen a steadily increasing number of cases, but no explosive outbreak. While it’s far too early to cry victory, it may be that Hong Kong’s early and proactive response and the mental preparedness of the population have combined in a positive way to help contain the epidemic here. We may also have been a little lucky not to have had an unrecognised super-spreader.
As cases increase in Europe, Iran, South Korea, the US and elsewhere, we must maintain vigilance here. In any case, after the early mild panic settled, Hong Kongers seem to have just dusted off their old SARS habits and gotten on with social distancing, mask-wearing and hand-washing; a bit like riding a long unused bicycle.
Indeed, I am seeing patients who had left Hong Kong earlier in the evolution of this epidemic now returning. They tell me they feel safer here. There is benefit to being in a place that not only has know-how and resolve, but also has been tested before.
A lot is being said and written about masks. How important is it to wear one?
The mask issue has created a lot of confusion. Masks are not all that effective at preventing transmission of viral infections, particularly when worn by healthy people. They are by no means the most important measure you can take to protect your health. In fact, if you wear a mask incorrectly, touch or adjust it frequently, re-use it, or fail to wash your hands before putting it on and after taking it off, you may actually increase your risk.
That said, masks are not entirely useless and do have a place.
Who should wear a mask:
– People who are sick, to prevent them spreading their viral droplets when they cough or sneeze
– People caring for sick people at close quarters
– In a health-care setting
– People whose occupation requires them to have close contact with clients
– When you can’t avoid crowds
As it has become socially unacceptable in Hong Kong to NOT wear a mask, there may be situations in which you might choose to wear a mask simply to make other people feel comfortable. But in general, healthy people do not need to wear masks, except when they need to be in crowded places, or with possibly sick people.
Which precautions are the most critical to stay safe?
Other more important measures for protecting yourself are hand washing, avoiding crowds, and keeping at least 3-feet away from people with fever or cough. Hand-washing is the most important. Alcohol-based hand sanitiser is an acceptable alternative, except when your hands are visibly soiled.
It’s becoming apparent that COVID-19 is a clustering disease. It spreads, for example, within households, at meetings and conferences, on cruise ships, at large food-sharing events, in old age homes, and at religious gatherings. While it’s not entirely clear what the mechanism of transmission is in these settings, it underlines the importance of social distancing measures.
Get enough sleep, eat well, and get some exercise. In other words, look after your general health.
Do not travel, go to work or socialise when you are feeling unwell yourself. It won’t be appreciated!
And if you haven’t already done so, get a flu shot. It won’t protect you against COVID-19, but it will prevent Influenza, which is a nasty illness in its own right, and can land you in hospital or quarantine, and overburden the system at a time when the resources are needed elsewhere.
How does the climate influence the virus? We read that with warmer weather the virus may go away but there are cases in countries like Singapore.
We really don’t know the answer to this question. It is true that some viruses that are spread by respiratory droplets, as COVID-19 is believed to, spread more easily when the air is cold and dry. In warm, humid conditions, they fall to the ground more easily and that makes transmission harder.
But there is still a lot we don’t know about exactly how COVID-19 is spread and the effects climate may have on it. We don’t know if this coronavirus will behave like other ones. It’s a new virus, after all. And in any case, even when summer arrives in the northern hemisphere, it will be winter in the southern hemisphere. It would be nice COVID-19 disappeared when the weather gets warmer, but it would be foolish to count on it.
Should any international travel be postponed for now, especially if we head towards a pandemic?
Travel does spread the disease around the world, so delaying non-essential international travel is increasingly being suggested as part of trying to slow Coronavirus down. The Hong Kong Department of Health has now made this recommendation officially.
A major issue is that as travel restrictions mount, and countries escalate their response to Coronavirus, there is a growing risk of being asked to self-isolate or even quarantined either while away or after return. Even though transmission on airplanes has not been reported, you might still get quarantined if you are unlucky enough to be seated within a few rows of a case that gets confirmed after your arrival.
Cruise ships definitely seem to be high risk at the moment, and best avoided.
It’s important to note that some countries that report few or no cases have limited testing ability, meaning that it is hard to know what is actually going on. Poorer countries in Asia, Africa and elsewhere may have significant outbreaks that have not yet been detected.
What are the questions that you hear the most from your patients?
The most common questions are “how serious do you think this is?” and “should I be worried?”
The answer is that from an individual point of view, worry is neither necessary nor helpful. The disease seems to be generally mild for most people, certainly much less serious than SARS was. Early indications are that the illness is likely to be no worse than a flu-like illness for the majority of healthy, younger people. The elderly, and those with other medical problems, especially diabetes or heart disease, are thought to be at higher risk of becoming seriously ill. It’s for those people that controlling this epidemic is vitally important.
From a public health point of view, however, this is an urgent situation. A highly transmissible disease, even with low fatality rates, can cause huge disruption and can actually end up killing more people than a less contagious disease with higher case fatality rates. That’s why so much effort is being made to stop or at least curb it. It’s imperative that we slow the spread and reduce the numbers so that hospitals and healthcare systems can cope.
Which psychological impacts do you see so far on the community in Hong Kong?
The mental health effects of this outbreak are the most serious impact of this outbreak so far. The school closures, the cancellation of many events, the working from home, the isolation and the uncertainty about how and when this will end are creating an atmosphere of fear and sadness that is taking a toll on many people. Especially coming on the heels of the months of protests we had beforehand.
We see a range of reactions, all the way from “the sky is falling” to “this is a huge over-reaction”. But actually, I’ve been impressed at how many people seem to take a calm and sensible approach.
For more information about children and COVID-19, check our Exclusive Interview with Pediatrician.
The outbreak brought anxiety to many parents. As a mother yourself, what tips can you share to help parents cope with work, home schooling, and pandemic fear?
During SARS, there was no such thing as Google Classroom or Zoom. Online learning was limited to sending assignments back and forth by email. In some ways, I think that was less stressful than trying to have a full online classroom, especially as many kids are now on different time zones. On the other hand, it does help to try to maintain normal routines insofar as possible.
Children’s reactions will be influenced by your reaction, so model a calm, common-sense approach. Reassure them that they are safe and, in an age-appropriate way, answer their questions. Find ways for them to socialise and exercise, and do the same for yourself!
I think it’s also important to let go of guilt and anxiety about your children’s schooling. For those in important exam years, this is a difficult situation, but for others it isn’t the end of the world if they don’t have a perfect school year. What we learned in SARS is that everyone is in the same boat, and things smoothed themselves out in the end. It’s also quite normal and OK if you don’t enjoy home-schooling your children. Some people do like the process, but it surely isn’t for everyone. If you find it very stressful, then find ways to outsource or share the burden. It doesn’t make you a bad parent.
What does help is to try to find some silver linings. Writing down funny or strange things that happen can help to create positive memories around this intense experience. They will become part of the tapestry of the story of their childhood.
Remember that as far as we know so far, this virus does not cause severe disease in children, even if they do get it. The same was true of SARS.
Some good resources:
– Calming kids’ fears about Coronavirus: https://go.brainpop.com/coronavirus
– Supporting children through the healthcare crisis: https://drive.google.com/file/d/1hIcpNBehI2olRFs0UUkYQ76IyctCyIKT/view?usp=drivesdk
– Optimising Distance Learning: https://www.cdt.com.hk/optimising-distance-learning/
How optimistic are you on this outbreak’s future path and the ability of healthcare systems to contain it?
To a large extent, we are trying to predict the unknowable. This is a new virus with many uncertainties around it. It is possible that it will disappear like SARS did or dissipate when the seasons change. But it would be very foolish to count on that.
I am less optimistic than I was that this disease can be contained, i.e. stopped. But I am optimistic that mitigation measures can and will be effective in limiting its impact.
The danger with this disease is not to the individual; we’ve already determined that the risk for most people is low. The risk is of having too many serious and critical cases for our healthcare systems to cope with. Through social distancing and vigorous public health measures, we can slow transmission and reduce the incidence of disease so that we can cope with the numbers. The goal is to do this long enough to hone effective treatments and develop and deploy a vaccine.
During the Spanish Flu pandemic of 1918-1919, the places that fared the best were the ones that took the disease seriously from the start, isolated sick people early, instituted comprehensive social distancing measures and continued public health measures until the epidemic was unquestionably under control. St Louis, which did this, had half the death rate of Philadelphia, which did not. In a series of natural experiments in which different places did these things to various degrees, the effectiveness of simple public health measures was proven over and over again.
Here in Hong Kong, we are fortunate to have one of the best public health systems in the world, strong epidemic planning and deep experience. Hong Kong took early and vigorous action and has a population that is disciplined in mitigation measures. Several authorities have singled out Hong Kong and Singapore as examples of places where COVID-19 has been well managed to date, stating that we provide hope and many lessons to other countries. We must not relax at this point; however. It’s important that we continue our stringent public health measures and cooperate with social distancing until the epidemic is truly over globally.
Any final advice to best manage this difficult period?
This is a bit like anticipating a hurricane. On a pandemic scale, COVID-19 has the potential to be a Category 5 storm. But just as hurricanes often weaken as they approach shore, pandemics are also not fixed in their severity. In fact, with epidemics, our own actions can reduce the impact of the disease. Ironically, as the virus goes global, local actions become more important. By slowing down the spread of disease, we can lessen its effects and reduce the severity. We hope that the storm will lose strength or dissipate, but we must plan as if it won’t.
In any case, the storm WILL pass and the great majority of the population will survive it unscathed. No one enjoys battening down the hatches, but that is what we have to do.
In the meantime, keep calm, wash your hands and try to keep it all in perspective.
Dr. Sarah Borwein is a Canadian trained General Practitioner who co-founded the Central Health Group and has been practicing family medicine in Hong Kong for over 15 years. Dr. Borwein successfully ran the Infection Control program for the only expatriate hospital in Beijing during the SARS period, and was also the lead communicator for the international community in Beijing at the time.
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