Credibility of Evidence Informing Response Pathways
Evidence is deemed credible if it is scientifically rigorous, and the legitimacy and authority of its producer. The credibility of the evidence used to guide some of the response decisions to SARS was questionable. Specific examples include the use of quarantine (Holm 2009; Jacobs 2007; Tracy et al. 2009) and travel advisories (Paquin 2007) both locally and globally.
The use of quarantine as a control measure, although considered to be highly effective, is controversial. A telephone-based survey in the Greater Toronto Area aiming to ascertain public perceptions of the use of quarantine found that while quarantine was perceived to be a necessary and effective strategy, its ethical implementation should involve the collaboration of policy-makers, public health organizations, and the general population, and should be closely regulated to ensure appropriate use and protection of individual rights (Tracy et al. 2009). Despite these recommendations, Toronto quarantined significantly more people during the SARS outbreak compared to the other affected cities, including Hong Kong and Shanghai (Jacobs 2007). Given the reported psychological distress reported by those quarantined, Toronto might have considered other strategies, such as the use of face masks to better “distribute the burden of containment measures” (Jacob, 2007, p. 532). Critics note that the extensive quarantining in Toronto lacked proper policies and procedures to guide its implementation (Jacobs 2007). Others highlight a lack of public record detailing any consultation between public health officials and the Ontario Human Rights Commission (Jacobs 2007). There was little public scrutiny, which was suggested to be the result of effective conditioning of the public consciousness to believe that quarantining recommendations would be made fairly and legitimately by senior public health officials (Jacobs 2007). Ultimately, it was not quarantining that was problematic, but the lack of apparent or sufficient evidence to guide its implementation.
Beyond extensive quarantining, The World Health Organization issued travel-advisories as an additional control measure to contain further national and international spread of SARS from Toronto (Paquin 2007). This travel-advisory cost Toronto $1.1 billion and restricted the international right for freedom of movement (Paquin 2007). Paquin (2009) criticizes these travel-advisories for various reasons. For example, the advisories were not made by the WHO in consultation with Toronto authorities and led to an uneven global distribution of the burden of SARS (Paquin 2007). Furthermore, the travel advisories were based on old data resulting from delayed communication between the federal government of Canada and the WHO, as information had to first travel from municipal to provincial to federal health authorities (Paquin 2007). Once again, the evidence used to inform the response was outdated and therefore considered unjustified. As such, there were problems with both the lack of quality evidence and the travel advisory as a response.
Quarantining and travel advisories reflect the profound ethical and political implications inherent in responding to infectious disease outbreaks. The evidence on the efficacy of the two primary responses—quarantining and travel advisories—was inadequate to justify the extent of their implementation.