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The other war

BMJ 2003; 326 doi: (Published 26 April 2003) Cite this as: BMJ 2003;326:937
  1. Richard Kirk, senior consultant in paediatric cardiology (kirkcr{at}
  1. The Children's Medical Institute, National University Hospital, Singapore

    We live in extraordinary times. I work in Singapore, which is one of the countries that has so far been hardest hit by severe acute respiratory syndrome (SARS). Only six weeks ago I was worrying about flight schedules for conferences, planning our family vacation in China, and looking forward to our Easter visitors—now such activities seem trivial and our visitors, rightly, have stayed away.

    What has been the impact on our daily lives? In short SARS has affected every aspect—work, home, and social. At the hospital all entrances except the main one are sealed off and the admittance procedure is comparable to that of a high security prison. Visitors are only allowed through once they have made their purpose clear and their identity details, and contact, travel, and health information have been recorded. Their temperatures are taken and they are issued with masks. Corridors and outpatient areas usually bustling with patients, visitors, and staff are eerily empty. Entry to any patient area is through a triage desk manned by staff wearing masks, gowns, and gloves. Routine hospital appointments have effectively ceased as patients shun going to hospital, preferring to email or phone for advice—we are becoming armchair physicians. Paranoia even extends to the university library, where I was handed a book by a librarian wearing surgical gloves.

    For staff work only begins after our temperatures are confirmed as normal. We change into theatre blues and put on masks. For all patient contact we rigorously wash hands and don hats, gowns, and gloves. Any patient with a temperature is presumed to have SARS (however unlikely this is) unless proven otherwise. Of course, patients with diseases other than SARS are still treated and need to have their management explained—but how to counsel effectively through a mask to masked people? I never appreciated how much one conveys by facial expression. Most administrative meetings are cancelled and those that go ahead are preceded by repeat temperature taking.

    We stopped carefree embraces and kisses in our family for 10 days

    With the possibility of whole hospital services grinding to a halt if key staff are either sick or quarantined our clinical service has been split into two—half of the staff work at home for two weeks while the remainder undertake the clinical work; then the two groups rotate. The rationale is that if one team is infected or requires to be quarantined the other can maintain the clinical service.

    Schools have been closed to reduce the risk of infection and to allay parental fears. After contact with a staff member who developed SARS, we stopped carefree embraces and kisses in our family for 10 days and my wife was requested to stay away from work. Some of our non-hospital friends prefer contact by telephone rather than face to face and have cancelled our evenings out together.

    It is difficult to keep SARS in perspective—particularly as the UK news and websites have concentrated on the Iraqi war, with little coverage of SARS. Our family and friends in England believe that we are over-reacting—perhaps we are. However, when I wonder if it is a figment of the Asian imagination, I visit the World Health Organization website and see its concerns and advice on travel restrictions to areas affected by SARS, the first such restrictions for 10 years. I see too that it is not exclusively an Asian problem; Canada is equally affected and more countries report suspected cases by the day. I wonder too if all the measures are appropriate (note the term “appropriate”—evidence based medicine seems so inadequate with such a new disease). Perhaps not, but when you are in the front line with a potentially lethal illness, a desperately worried population, and the need to maintain healthcare services, who would argue for continuing life as normal until we acquire the evidence?

    So I am filled with a mixture of emotions. Sadness that our hospitals have become a place to be feared. Concern that I may unwittingly harm the health of my family and my friends through my profession. Pride that despite the well founded fear of this disease (one colleague is in intensive care and another has died—not to mention many others throughout the region) my colleagues and I are all doing our best to care for our patients, while protecting ourselves in order to break the vicious cycle of transmission. Guilt that I am away from the hospital for two weeks while my colleagues remain in the front line. Respect for those who have fought previous “wars”—the plague and leprosy to name but two, with far fewer resources. Thankfulness that mankind has the intelligence, means, and for once international cooperation to work together for the common good and to have identified the virus in such a short time. Hope that this scourge will be rapidly conquered and some normality will return to the professional and private lives of not only myself, my family, and my immediate colleagues, but also of the many others fighting this disease across the world.

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