A stand-in SARS Patient is evacuated from a fire by emergency workers during a disaster training exercise at a designated SARS hospital in Chengdu, Sichuan Province in May 2003. Photo: CFP

Ten years ago, a highly infectious atypical pneumonia swept across China and the world. The disease, Severe Acute Respiratory Syndrome, or SARS, proved to be a turning point for China, as the pandemic exposed flaws in the country's public health emergency response system and the dire need for more information transparency.

Changes have been made as a result of SARS, which infected 5,327 people and killed 349 in China between November 2002 and August 2003. Regulations were passed concerning public health emergencies and information disclosure. There has been progress, especially as authorities are now paying more attention to public health issues, but a lot remains to be done, experts and observers say.

Zeng Guang, chief epidemiologist at the Chinese Center for Disease Control and Prevention, who fought front and center against SARS, said that things started to change in late April 2003 when authorities updated the actual number of cases and took a series of quarantine and prevention measures.

In late 2002, patients in South China's Guangdong Province showed symptoms such as fever, coughing and shortness of breath with some dying. In early 2003, SARS was already spreading from Guangdong to other parts of China. As people continued to travel, the disease went around the world.

A lack of experience in handling such pandemics led to the spread of the disease. Quarantine protocols weren't set. Some SARS patients stayed in hospitals that weren't equipped to treat patients with contagious diseases. Doctors and nurses didn't use proper protection when treating patients and many were infected in turn. One third of the 349 patients who died of SARS were medical workers.

Truth will out

Zeng was sent along with other experts to investigate the cases in Guangdong in February 2003. While visiting local hospitals, he noticed discrepancies between the number of cases and the numbers that were reported back to higher authorities, as many hospitals were afraid to report the real facts.

A similar fudging of the truth also happened in Beijing, where real numbers weren't available or made public.

SARS provided some valuable lessons in disease control, said Zeng. At the beginning of the outbreak, disease control wasn't a priority, and people were most concerned with treatment and rooting out the cause of the disease. After epidemiologists and disease control experts were consulted, patients were transferred to specialized wards or hospitals, and some hospitals, like the Peking University People's Hospital in Beijing, were quarantined to prevent further infection.

Different departments and medical systems also lacked communication and collaboration mechanisms. The military hospitals in Beijing for instance were not under the jurisdiction of the municipal government, but a lot of SARS patients in Beijing initially visited such hospitals for treatment. A lack of collaboration made it difficult for authorities to grasp the full picture of the disease.

In late April 2003, a joint command center was set up to direct disease control. A mechanism has also been established to ensure the collaboration of health, education, transportation and civil affairs departments.

In May 2003, the government passed a regulation on public health emergency responses. It set up a monitoring and report system for possible contagious disease outbreaks, unknown widespread diseases or major food poisoning cases. Emergency response offices were soon set up at local governments and health administrations.

"The most important improvement after SARS was increased awareness at every level of government and among the public," said Tong Zhaohui, a respiratory doctor at Chaoyang Hospital who worked on SARS cases for days on end during the outbreak.

After SARS, the country also increased investment in building public health systems and medical workers were trained for such emergency responses.

The emergency response system has been put to the test repeatedly over the past decade, particularly during the influenza A H1N1 in 2009 and bird flu pandemic.

Almost immediately after the world's first A H1N1 case was diagnosed in Mexico on April 25, 2009, China announced information about the new strain of flu virus and issued regular updates on cases in China. Strict quarantine measures were taken at boarder inspection sites. The first vaccine for A H1N1 was even produced in China. By December that year, A H1N1 had still affected over 115,800 people and killed 560 in China.

But there are also doubts as to whether the authorities overestimated the impact and seriousness of A H1N1, leading to a waste of money and resources, said Zhou Zijun, a professor from the School of Public Health at Peking University.

Tong agrees that there was some overreaction, as the influenza strain was neither as contagious as SARS nor as deadly as bird flu.

The central government had allocated about 5 billion yuan ($801 million) in preventing and treating A H1N1 as well as issuing surplus vaccines for the disease that are now piling up.

"It shows that our judgment about an epidemic, about its potential influence, is problematic: we underestimated SARS and went overboard with A H1N1," said Professor Zhou.

Caution prevails

Zeng, however, believe when there are people's lives at stake, there's nothing wrong with taking extra caution. He said that all in all, China did a good job handling A H1N1.

Besides the lack of experience and an emergency response system at the time of the SARS outbreak, a major reason that the disease took such a big toll on people's lives was the official coverup.

In March 2003, Tong, the respiratory physician, was asked to consult on SARS patients in Beijing along with other doctors. There were dozens, if not hundreds of cases, at the time in Beijing. But the public knew very little of what was really going on.

"I knew that things like this couldn't be kept a secret forever; the truth would come out eventually," said Tong.

There were already rumors around the country about the disease and some people were stocking up on masks, vinegar and cough medicines. But accurate, authoritative information was scarce.

The authorities didn't address the issue until early April, when Zhang Wenkang, health minister at the time, downplayed the situation at a press conference and said there were over 1,000 cases in China and only 13 cases in Beijing. He reassured the public that the disease was under control.

The officials didn't face the truth until Jiang Yanyong, a retired doctor from the PLA General Hospital (also known as 301 Hospital) in Beijing, blew the whistle and told Time magazine that there were many more cases than officials had disclosed. On April 20, health officials updated the number of cases in Beijing to 339 and over 1,800 in the country.

It was an attempt to maintain stability and harmony prior to the annual legislative meetings, analysts later sought to explain the coverups.

The days around these legislative meetings are when the public should fully express their opinions and concerns, but instead the people and media are hushed up, said Yu Guoming, a professor of journalism and communications at Renmin University of China.

Coverups are not uncommon when authorities handle crises such as coal mine accidents, natural disasters or environmental catastrophes. This represented the old way of thinking and governing that price stability and control are above everything else, said Yu, who leads the Public Opinion Institute.

According to a survey the institute carried out immediately after SARS, the public rated the government's performance at 46 out of 100 before officials told the truth.

Credibility crunch

The government's credibility took a major blow. Zhang and the former mayor of Beijing Meng Xuelong were later sacked. The government issued a regulation on information disclosure and instructions on risk communications. In 2006, the Ministry of Health issued a notice requiring health departments at different levels to give regular updates on contagious diseases and emergencies.

Chen Tiansi, a reporter at China National Radio, said she was impressed by how the authorities responded and disclosed information during the A H1N1 outbreak in 2009.

Chen, who covered health issues between 2008 and 2010, said there were daily news conferences and the health authorities kept in close contact with the media. Information about latest cases and disease prevention was immediately available while the spokespersons and experts fielded questions directly.

"I think the authorities responded very rapidly and were open and transparent during the A H1N1 outbreak," said Chen.

"The government established some principles and mechanisms, which is good, but in practice, things haven't changed completely," Yu noted.

In some cases, information disclosure remains slow and coverups still happen, such as during coal mine accidents. In April 2011, truck drivers dumped toxic waste that contained chromium close to a river in Qujing, Yunnan Province. The local government covered it up for months, by which time the chromium had contaminated the drinking water supply.

However, since SARS, public health experts like Zeng are able to weigh in more on policymaking. While acknowledging the improvements, Zeng said that there are still many challenges ahead. "Our administrators and policymakers still need to raise awareness about public health issues, and our people need to be better educated," he said.

There have been many public health issues over the past decade, including food safety, poisonous pill capsules, and disease prevention after major natural disasters such as earthquakes.

"On the one hand, we are able to respond to these incidents better than before, but how to prevent such things from happening is a much bigger issue concerning our system, our honesty, and our mode of development," said Zeng.

But like many other experts, Zeng is confident that if a crisis like SARS were to come again, the country would be much better prepared.