Infectious Disease in Asia: Policy Implications for Canada

INFECTIOUS DISEASE IN ASIA: POLICY IMPLICATIONS FOR CANADA

Sonny Shiu-Hing Lo Department of Political Science University of Waterloo [email protected]

Executive Summary

1. With the onset of globalization, infectious diseases have become lethal to the health of the world’s population. Canada must enhance its government capacity at both federal and provincial levels so as to cope with the ramifications of infectious diseases, particularly bird flu.

2. Three indicators are critical to the enhancement of the government’s capacity in response to infectious disease: (1) preparedness, (2) openness and (3) responsiveness. During the outbreak of Severe Acute Respiratory Syndrome (SARS), governments in both Asia and Canada were severely under-prepared. During the bird flu and SARS outbreaks, Asian regimes illustrated varying degrees of preparedness, openness and responsiveness.

In the SARS and bird flu crises, the government’s capacity for infectious disease control was the strongest in Singapore, followed in descending order by Hong Kong, South Korea, Vietnam, China and Taiwan.

3. The implications of the Asian experience for Canada involve the need to emphasize the importance of inter-departmental coordination, the decisiveness of governments at the federal/provincial/territorial levels, the enactment of nationwide emergency regulations, the supremacy of national security over democratic rights, and the alleviation of manpower shortages at hospitals when managing infectious disease outbreaks.

4. This paper proposes a 20-point action plan for the Canadian government at federal/provincial/territorial levels so that the overall governmental capacity in coping with any flu pandemic would be substantially enhanced. The plan emphasizes cohesion in various aspects: the role of companies; the government’s communication with poultry workers; the management of pets; the handling of illegal immigrants; the management of overseas Canadians returning to Canada; schools’ preparation; the regulation of the sale of anti-flu drugs; border security; improved hospital management; modifications in quarantine measures; the importance of education campaigns; the need for more antivirals and vaccines; the renovation of hospital ventilation systems; the strategies of municipal governments; airport emergency measures; the full utilization of Canada’s vast geographical space; the private- public partnership; the conduct of simulation exercises among all levels of governments; the launching of nationwide publicity; and the call for Canadian officials overseas to monitor the development of any global health crisis.

1. Introduction: The Global Reach of Infectious Disease

Public health crises have been numerous in Asia Pacific: the bird flu in Hong Kong in late 1997; the dengue fever in Macao in 2000; the Severe Acute Respiratory Syndrome (SARS) in Mainland China, Hong Kong and the Republic of China (ROC) on Taiwan in the early half of 2003; the bird flu in China in 2004 and intermittently in 2005 and 2006; the emergence of bird flu in Indonesia and Thailand in 2005 and 2006; the sudden occurrence of fish infected with a cancer-causing chemical called malachite green in China, Hong Kong and Taiwan in 2005; and the eruption of H5N1 in South Korea in November 2006. In early 2007, bird flu erupted in Japan, Thailand and Indonesia.1 All these health crises in Asia stemmed from infectious diseases, the most important of which are bird flu and SARS.

Since the outbreak of the bird flu in Hong Kong in December 1997, infectious disease has become a human and national security threat to Asia Pacific.2 In Asian cities where the population density is high, such as Hong Kong and Macao, the emergence of any flu pandemic would endanger the lives of all citizens. In geographically spacious countries, notably the People’s Republic of China (PRC) and Indonesia, any looming flu pandemic would be socially destabilizing and politically delegitimizing. The Spanish flu that broke out in 1918 resulted in civil disorder and riots in American cities.3

Infectious disease is defined here as viruses that can be transmitted either from animals to human beings or from humans to humans. Its examples include HIV/AIDS, venereal diseases, bird flu, West Nile virus and SARS. Although HIV/AIDS have been persisting in Asia since its emergence, the pace in which victims are infected is much slower than bird flu and SARS. However, in terms of human fatality, HIV/AIDS have caused far more deaths than bird flu and SARS in Asia.4 Furthermore, HIV/AIDS have not yet generated abrupt consequences such as the urgent need to test the body temperatures of air passengers at airports, like the SARS crisis in Hong Kong and Singapore, and the tremendous economic losses incurred to the aviation industry. For these reasons it will not be examined here.

In the era of globalization, bird flu and SARS can expand far more swiftly than HIV/AIDS due to the nature of transmittal, furthermore if they can be transmitted from animals to human beings and then from humans to humans. Extensive air travel now available around the world means that any contagious disease in Asia has the potential for immediate economic, social and political repercussions in other parts of the world.5 Due to Canada’s proximity to Asia and their

1 “Japan confirms deadly bird flu outbreak,” Associated Press, February 3, 2007; “Bird flu strikes again in Thailand,” Scientific American, February 2, 2007; and “UN bird flu chief warns world to expect spike in bird flu outbreak,” Associated Press, February 4, 2007. 2 The flu pandemic is viewed as inevitable in the entire world. See Michael T. Osterbolm, “Preparing for the Next Pandemic,” Foreign Affairs, July/August 2005, pp. 24-37. 3 Laurie Garrett, “The Next Pandemic?,” Foreign Affairs, July/August 2005, pp. 3-23. 4 In 2006, an estimated 8.6 million people in Asia were living with HIV, including 960,000 people who became newly infected in 2005. About 630,000 Asians died from AIDS-related illness in 2006. See “Asia: 2006 AIDS Epidemic Update,” http://www.who.int/hiv/mediacentre/05-Asia_2006_EpiUpdate_eng.pdf, access date: November 28, 2006. 5 After the outbreak of SARS in Hong Kong, half a million protestors took to the streets on July 1, 2003 to demonstrate against the Tung Chee Hwa government’s mishandling of SARS and other policies, such as civil service reform and educational changes. The Hong Kong case fully demonstrated the delegitimizing impact of

frequent interactions, any flu pandemic in Asia will have immediate consequences on parts of the Canadian economy. In retrospect, the SARS outbreak in Greater China severely affected Toronto, although Vancouver was relatively free from the crisis.

In the wake of SARS, bird flu has become the foremost danger confronting Asia and the world. As the World Health Organization (WHO) warns, “Of the 15 avian influenza virus subtypes, H5N1 is of particular concern for several reasons. H5N1 mutates rapidly and has a documented propensity to acquire genes from viruses infecting other animal species ....[T]his virus have a high pathogenicity and can cause severe disease in humans.”6 The migratory routes of birds from Siberia cover Asia and Europe. In early February 2007, the H5N1 virus killed 2,500 turkeys in a British poultry farm.7 If the H5N1-infected birds increasingly pose a human security threat to many nation-states and cities, the continuous surveillance of their migratory patterns by satellites is critical to the well-being of all peoples in the world. The new director- general of the World Health Organization, Margaret Chan, stressed the need to set up a global surveillance system monitoring health crises during her campaign for the election of director- general in early November 2006.8 As the H5N1 virus requires the possibility of airborne transmission in order to spread—and that is readily available, the disease is much more easily communicable than HIV/AIDS.9 If so, the sharing of health intelligence data amongst the member states of WHO will be indispensable for the battle against the flu pandemic.

According to the Canadian Influenza Pandemic Plan, any outbreak of the Influenza A epidemic will have an immediate impact on Canada’s society and economy. An estimated 4.5 to 10.6 million Canadians would become clinically ill and fail to retain their working capability.10 An estimated 2.1 and 5 million people would require outpatient care; between 34,000 and 138,000 people would require hospitalization; and between 11,000 and 58,000 people would die in Canada during the influenza pandemic. The economic impact would be between $10 and $24 billions.

This paper aims at analyzing the governmental capacity of Asian states in tackling the flu crisis, drawing their lessons from Canada, and providing concrete suggestions on how the federal, provincial and municipal governments of Canada, together with the private sector, can consolidate their capacity in anticipation of any flu pandemic. The central thesis of this paper is that Canada has much to learn from the bitter lessons of SARS and the ways in which some Asian cities like Singapore and Hong Kong dealt with the outbreak. A democratic country does not necessarily mean that its federal and provincial governments must have the capacity to control the flu pandemic effectively. Arguably, governmental decisiveness during any flu pandemic would be far more important than the protection of civil liberties. Provincial differences in Canada have already revealed the different emphases on how provincial

SARS. For a description of the Hong Kong response to SARS, see Elspeth Thomson and Yow Cheun Hoe, “The Hong Kong SAR Government, Civil Society and SARS,” in John Wong and Zheng Yongnian, eds., The SARS Epidemic: Challenges to China’s Crisis Management (Singapore: World Scientific, 2004), pp. 199-220. 6 “Avian Influenza: fact sheet,” January 15, 2004 in http://www.who.int/csr/don/2004_01_15/en/, access date: June 29, 2006. 7 “Lethal strain of bird flu virus confirmed in British turkey farm,” Associated Press, February 3, 2007. 8 Sing Tao Daily, November 7, 2006, p. A1. 9 “No end see to bird flu challenge,” Toronto Star, March 7, 2006, p. A11. 10 Canadian Influenza Pandemic Plan, available in www.phac aspc.gc.ca/cpip pc/pi/so2 e.m/, access date: November 10, 2006.

3 governments perceive the flu pandemic. Yet, if the Canadian governments at the federal, provincial and municipal levels, together with the private sector are able to implement an

action plan, which will be examined at the end of this paper, Canada’s capacity of managing any flu pandemic will be hopefully and substantially enhanced.

2. Government Capacity in Response to Infectious Disease in Asia

Governmental capacity refers here to the ability of governments to take emergency measures in response to the outbreak of any infectious disease. It is the most important challenge in globalization where human and national security are at stake because of the speed with which infectious diseases can be transmitted to a large segment of the local population.

Three indicators are critical to the process of enhancing governmental capacity in response to infectious disease: (1) preparedness, (2) openness and (3) responsiveness. In the case of SARS, governments in Asia and Canada were totally unprepared.11 However, Table 1 shows that the case fatality ratio in Canada was 17 percent, a number lesser than that of Hong Kong where SARS left an indelible imprint and a painful memory. Other Asian states witnessing a relatively high ratio of case fatality included Singapore, Thailand, Taiwan, Malaysia, the Philippines and Vietnam. China had the largest number of people infected with SARS. Although their case fatality ratio was claimed to be seven percent, 349 people died of the mysterious disease.

Arguably, Canada’s performance during the SARS outbreak might not be an accurate indicator of how it would react to another new epidemic. SARS did not appear to be a pandemic that necessitated any tougher or more draconian measures from the Canadian government at the time of the outbreak. This argument was flawed. The SARS crisis was unprecedented and even microbiologists could not quickly predict whether it would be temporary or not. Judging from the fatality ratio in Canada, Ottawa and its provincial governments clearly underestimated the speed with which SARS could affect the Canadian population. The National Advisory Committee on SARS published an insightful report that recommended a better mechanism for the federal, provincial and territorial governments to strengthen disease surveillance programs. It also recommended a harmonization of public health legislation at the three levels of government.12 The report concludes: “The challenge now is to ensure not only that we are better prepared for the next epidemic, but that public health in Canada is broadly reviewed so as to protect and promote the health of all our present and future citizens.”13 In sum, Canadians must humbly learn from any inadequacies in Canada’s crisis management of SARS, which could perhaps be a prelude to another new epidemic in the future.

11 On Asia’s vulnerability during the SARS outbreak, see Mely Caballero-Anthony, “SARS in Asia: Crisis, Vulnerabilities and Regional Responses,” Asian Survey, vol. 45, no. 3(May/June 2005), pp. 475-495. 12 Learning from SARS: Renewal of Public Health in Canada: A report of the National Advisory Committee on SARS and Public Health, October 2003 (Public Health Agency of Canada), in http://www.phac- aspc.gc.ca/publicat/sars-sras/naylor/exec_e.htm/#publicOrg, access date: February 1 2007. 13 Ibid.

Table 1: SARS and the Impact on Various Countries and Places, November 1, 2002 to July 31, 2003

Cumulative number

of cases Date Case Date onset Number onset fatality first Areas Female Male Total of last ratio probable deaths probable (%) case case

Australia 4 2 6 0 0 26/2/2003 1/4/2003

Canada 151 100 251 43 17 23/2/2003 12/6/2003

China 2674 2607 5327 349 7 16/11/2002 3/6/2003

Hong Kong 977 778 1755 299 17 15/2/2003 31/5/2003

Macao 0 1 1 0 0 5/5/2003 5/5/2003

Taiwan 218 128 346 37 11 25/2/2003 15/6/2003

France 1 6 7 1 14 21/3/2003 3/5/2003

Germany 4 5 9 0 0 9/3/2003 6/5/2003

India 0 3 3 0 0 25/4/2003 6/5/2003

Indonesia 0 2 2 0 0 6/4/2003 17/4/2003

Italy 1 3 4 0 0 12/3/2003 20/4/2003

Kuwait 1 0 1 0 0 9/4/2003 9/4/2003

Malaysia 1 4 5 2 40 14/3/2003 22/4/2003

Mongolia 8 1 9 0 0 31/3/2003 6/5/2003

New Zealand 1 0 1 0 0 20/4/2003 20/4/2003

Philippines 8 6 14 2 14 25/2/2003 5/5/2003

Republic of 0 1 1 0 0 27/2/2003 27/2/2003 Ireland

5 Republic of 0 3 3 0 0 25/4/2003 10/5/2003 Korea

Romania 0 1 1 0 0 19/3/2003 19/3/2003

Russian 0 1 1 0 0 5/5/2003 5/5/2003 Federation

Singapore 161 77 238 33 14 25/2/2003 5/5/2003

South 0 1 1 1 100 3/4/2003 3/4/2003 Africa

Spain 0 1 1 0 0 26/3/2003 26/3/2003

Sweden 3 2 5 0 0 28/3/2003 23/4/2003

Switzerland 0 1 1 0 0 9/3/2003 9/3/2003

Thailand 5 4 9 2 22 11/3/2003 27/5/2003

United 2 2 4 0 0 1/3/2003 1/4/2003 Kingdom United 13 14 27 0 0 24/2/2003 13/7/2003 States

Vietnam 39 24 63 5 8 23/2/2003 14/4/2003 Source: Modified table from http://www.who.int/csr/sars/country/table2004_04_21/en/index.html

The Asian experience revealed variations in the openness of different nation-states and cities under the onslaught of infectious diseases. In late 1997, when the bird flu composed of H5N1 virus loomed in Hong Kong, there were speculations that it might originate from South China.14 In the beginning, the HKSAR government was tight-lipped on the origin of the bird flu for fear of antagonizing Beijing. Encountering the mysterious death of a few citizens, a cross-departmental coordination committee headed by the former Secretary for Administration, Anson Chan, made a bold decision to implement the policy of slaughtering 1.2 million chickens and birds to prevent the spread of the virus. As well, the Hong Kong government extracted samples of chickens imported from China to see whether they were infected with H5N1—a move that abandoned its politically “correct” stance. Hong Kong’s relative openness in dealing with the bird flu was mainly attributable to its vibrant mass media and the dense population. In densely populated cities like Hong Kong and Singapore, their governments cannot afford the luxury of being slow to react to infectious disease. Singapore responded to SARS quickly and effectively, forcing the suspected SARS carriers and patients into compulsory confinement where surveillance cameras were put in place.15

14 The speculations that bird flu originated from the PRC could be seen in some Hong Kong Chinese newspapers, notably Oriental Daily and Apple Daily. 15 People exposed to SARS were required to stay home, watched by a camera and sometimes tagged with an electronic wrist band. They could be imprisoned if they went out. See “Singapore’s SARS measures welcome,” New York Times, April 22, 2003. The Singapore police not only had temperature test twice daily but also set up a temporary lock-up centre at the old Jurong Police Station to deal with suspected SARS carriers. “Police take precautionary measures against SARS,” Strait Times, April 39, 2003. Also see “SARS: How Singapore

The relative openness of the Hong Kong and Singapore governments in tackling SARS was a far cry from the PRC. At the early phase of the outbreak of the mysterious virus, the central government in Beijing encountered a cover-up problem of local governments in Guangdong province. In April 2003, when President Hu Jintao dismissed the Health Minister and the Beijing mayor for mishandling SARS, the central government began to mobilize the localities and mass media to address the SARS crisis.16 Due to the need to protect its image as a regional and global power, the PRC leadership sensed the urgency of containing the infectious disease.17 Any failure to do so would undermine the PRC’s global image as a responsible international actor controlling the transnational outreach of infectious disease.

The belated openness in China’s tackling of SARS was partly attributable to the pressure from the WHO whose representatives in Beijing pushed Beijing to be more transparent on the occurrence of SARS cases. Still, when WHO delegates were sent to inspect Beijing’s 301 Military Hospital, the Hong Kong media revealed that SARS patients had already been transferred to other places outside the purview of WHO investigators. Issuing travel advisories that recommended persons who visited Hong Kong and the PRC to consider postponing their trips from April to May 2003, the WHO action was mild and diplomatic.

China’s slow openness toward SARS was comparable to other Asian states affected by bird flu. In February 2004, Indonesia admitted the outbreak of bird flu dating back to August 2003.18 It was alleged that the Thai authorities covered up the outbreak of bird flu for the sake of protecting its exports of poultry.19 While Singapore responded to SARS decisively, the reactions of China to SARS and that of Indonesia and Thailand to bird flu showed that Asian regimes differed in their infectious disease control. Mainly due to the congested nature of city- states, governmental capacity in Singapore and Hong Kong was forced by the circumstances to be strong. In geographically spacious states, like China and Indonesia, the problem of localism represents a fundamental obstacle to the combat against infectious disease. Matrix 1 below shows that the larger the size of a country, the more relaxed it would become in dealing with public health crises. Endowed with a large physical space, PRC leaders at the central and local levels were originally relaxed toward the outbreak of SARS until it affected other parts of the world and generated an international concern. Moreover, the more open the regime toward infectious disease control, the more effective it would be in tackling the crisis. Although

outmanaged the others,” Asia Times, April 9, 2003. Unlike Hong Kong where schools were closed after much governmental hesitation, the Singaporean government made a decisive move to close nearly all schools on March 25 mainly due to the concern of parents. 16 See Ernest Zhang and Kenneth Fleming, “Examination of Characteristics of New Media Under Censorship: A Content Analysis of Selected Chinese Newspapers’ SARS Coverage,” Asian Journal of Communication, vol. 15, no. 3 (November 2005), pp. 319-339. 17 For the political implications of the SARS crisis for China, see Tony Saich, “Is SARS China’s Chernobyl or Much Ado About Nothing,” in Arthur Kleinman and James L. Watson, eds., SARS in China: Prelude to Pandemic? (Stanford: Stanford University Press, 2006), pp. 71-104. 18 Jo Revill, Everything You Need to Know About Bird Flu & What You Can Do To Prepare For It (London: Rodale, 2005), p. 183. 19 “Thai curry favor with poultry industry,” in http://birdflubook.com/a.php?id=79, access date: November 28, 2006.

7 Singapore is viewed by some scholars as having an authoritarian polity, it displayed a relatively high degree of openness in controlling SARS.20 Similarly, Hong Kong’s media

scrutiny of the administration and the governmental transparency in reporting the development of SARS illustrated its openness. However, given the lack of decisiveness and poor coordination on the part of the Hong Kong leadership during SARS outbreak, its effectiveness in infectious disease control was arguably weaker than Singapore (see Matrix 2). Regime openness in tackling health crises and the size of a state or a city directly determine the effectiveness of infectious disease control. Moreover, leadership decisiveness and departmental coordination are critical to the responsiveness of a regime to the outbreak of infectious diseases. Overall, the effectiveness in disease control is shaped by variables such as the physical size of a state or city, regime transparency in tackling health crises, and regime responsiveness which embraces leadership decisiveness and departmental coordination.

20 For the view that Singapore is an authoritarian polity, see Garry Rodan, “Embracing electronic media but suppressing civil society: authoritarian consolidation in Singapore,” Pacific Review, vol. 18, no. 3 (September 2005), pp. 393-415. For the view that Singapore is a democratic polity, see Thomas Bellows, “Economic Challenges and Political Innovation: The Case of Singapore,” Asian Affairs (New York), vol. 32, no. 4 (Winter 2006), pp. 231-255.

Matrix 1: Infectious Disease Control, Regime Openness and Size

Regime openness in disease control

Size of a Low Degree High Degree state or city

Small Moderate degree of High degree of effectiveness effectiveness in disease control in infectious disease control (Singapore) Low Degree of effectiveness Moderate degree of (People’s Republic of China) effectiveness

Large

Matrix 2: Infectious Disease Response, Leadership Decisiveness and Departmental Coordination

Leadership decisiveness in disease control

Departmental Low Degree High Degree Coordination

Weak Low degree of responsiveness Moderate degree of to disease outbreak responsiveness to disease (Hong Kong) outbreak

Moderate Degree of High degree of responsiveness responsiveness to disease to disease outbreak outbreak (Singapore)

Strong

Responsiveness is an indispensable indicator of governmental capacity. It involves whether political leaders are decisive in taking action to cope with infectious disease; whether departmental agencies can communicate and coordinate with each other without squabbling; whether surveillance and quarantine measures are taken sufficiently; whether public and private sectors can cooperate with each other and mobilize citizens against communicable disease; whether citizens are resilient in resisting the blitz; whether international collaboration can be forged; and whether the epidemiological diagnosis of the virus is swift and whether vaccines are utilized fairly and effectively. In brief, responsiveness embraces political

leadership, inter-departmental communication and coordination, surveillance and quarantine measures, public-private partnerships, public resilience, international cooperation, and epidemiological dimensions.

Political leadership was found wanting in the initial phase of the bird flu in Hong Kong in December and early January 1997. As more people succumbed to the deadly virus, Chan’s intergovernmental coordination committee had no choice but to make the timely decision to slaughter all the chickens—a turning point in the evolution of political leadership. Nevertheless, it took the HKSAR government eight years from the outbreak of bird flu to decide that all the chickens and ducks would have to be slaughtered in a centralized house in 2009. By contrast, since 1993 all poultries have been required to be processed at a slaughtering plant under the management of an Agri-Food and Veterinary Authority in Singapore.21 The different approaches adopted by Hong Kong and Singapore fully revealed the former leadership indecisiveness and the latter political will.

Communication and coordination proved to be the disturbing dimensions of disease control in Hong Kong, Taiwan and Mainland China. At the inception of the bird flu, the former chief of the Department of Health (now director-general of the WHO), Margaret Chan, asserted that she ate chickens every day—a remark that provoked severe criticisms later as more people infected with the disease passed away.22 The initial communication between the HKSAR government and the public with regard to SARS was plagued by an official refusal to admit the severity of the problem. The former Secretary for Health Yeoh Eng-kiong maintained that the mysterious virus did not spread to the community, but the deadly disease penetrated the society rapidly and soon the critical situation discredited him. Although the HKSAR government later improved its daily communications with the public by reporting the number of citizens infected with SARS, the entire crisis demonstrated communication and coordination problems between the Hospital Authority (HA) and the public, and between the HA and private hospitals. The privately-owned Baptist Hospital failed to report the conditions of suspected SARS patients to the HA and the government. Moreover, Margaret Chan reportedly had reservations on whether the suspected SARS-infected residents in the Amoy Garden should be segregated and quarantined.23 When the index patient carrying the SARS virus from China stayed in Ward 8A of the Prince of Wales Hospital, there were opinion differences between the hospital authorities from the Chinese University of Hong Kong and government officials. The former hoped to shut down the hospital, but the latter refused to do so. During the SARS crisis, the communication between PRC health authorities and their Hong Kong counterparts was by no means institutionalized. Since mid-2003, China and Hong Kong have improved their cross- border communication by reaching an agreement on information sharing, informing the other side of any health crisis, conducting collaborative research on infectious disease. The Macao government has also been incorporated into the regional communicative network, facilitating health information exchange.

21 Legislative Council of the Hong Kong Special Administrative Region: Role of the Panel on Food Safety and Environmental Hygiene, Report of the duty visit to study the operation of poultry slaughtering in Singapore on 25, 26 and 28 July 2006 and Kuala Lumpur on 29 July 2006, LC paper no. CB(2)3134/05-06, p. 3. 22 Chan graduate from the University of Western Ontario for her doctorate. See Sing Tao Daily, November 9, 2006, p. A1. For her controversial remarks during the bird flu crisis in 1997, see World Journal, November 10, 2006, p. A21. 23 Ming Pao, November 9, 2006, p. A 15.

With regard to surveillance and quarantine measures, the HKSAR government during the SARS outbreak decided to install infra-red temperature testing equipments at the airport and ports so as to identify potential SARS-carriers. The equipment served as a useful tool by which immigration and health officials were able to track down SARS-infected victims. Singapore’s surveillance was the most impressive one in Asia, mobilizing nurses and doctors dressed in fully protective gowns and masks to treat SARS patients, who might have to use cordless phones and video-conferencing to communicate with their close relatives.24

Public-private partnership could be seen in Hong Kong’s tackling of SARS when groups were mobilized by the government and civic associations to resist the mysterious disease. The local mass media contributed tremendously to the processes of scrutinizing governmental management of SARS, exposing the problem of inadequate facilities, and criticizing reckless remarks made by government officials and HA leaders. In contrast, China’s mass media were relatively weak, failing to reveal the spread of the disease until the central government gave the green light for them to launch an anti-SARS campaign. Public resilience was prominent in both Hong Kong and China where numerous health care workers tragically succumbed to the disease. Despite the rising number of death tolls in both places, health workers displayed their professionalism and loyalty by resisting to the end.

Taiwan unveiled a certain degree of the demoralization of health care workers. A few of them were so frightened of the disease that they escaped from their hospital by jumping out of its windows. Hospital chiefs were squabbling over the SARS solutions--a phenomenon complicated by the politicized nature of hospital administrators supportive of political parties from different ideological persuasions. Exacerbating the weak Taiwan capability was its inability to partake in the WHO formally as a member. An argument can me made to sympathize with Taiwan’s limited governmental capacity in coping with SARS because it lacked experience, unlike the HKSAR which had endured the assault from bird flu. In May 2006, Taiwan’s tenth attempt at entering the WHO as an observer failed. The Taiwan government complained that it was due to the PRC’s opposition.25 In June 2006 the WHO website listed Taiwan as one of the areas apart from the PRC which were infected with bird flu. Taiwan Foreign Ministry protested because the information provided on the WTO website was misleading and hurt the island republic’s image in tourism, international trade and human security.26 Although the American government and the Canadian House of Commons support Taiwan’s participation in the WHO as an observer, the PRC insists that Taiwan is part of China and therefore the island is “ineligible” for becoming a member or an observer of the WHO.27 Although the new WHO director-general Margaret Chan vowed to assist Taiwan in its

24 “Little fuss as no-visitor rule kicks in,” Strait Times, April 30, 2003. 25 Sing Tao Daily, May 24, 2006, p. B15. An Austrian journalist association complained that Taiwan journalists were barred from covering the WHO meeting because the WHO said that Taiwan was not a member of the United Nations. 26 Ming Pao, March 11, 2006, p. A11. 27 In May 2005, the Conservative Party initiated a bill that supported Taiwan’s participation in the WHO and it was approved by the Foreign Affairs Committee under the House of Commons. See World Journal, May 20, 2006, p. A7. 151 members of the lower and upper houses in Canada signed a joint letter appealing to the WHO to accept Taiwan as an observer because the outbreak of any flu pandemic would severely affect t Taiwan, which has about 150,000 citizens visiting Canada every year. For the American support of Taiwan, see Ming Pao, May 20, 2006, p. A25.

participation in WHO technical activities,28 it remains to be seen how Taiwan can be effectively incorporated into the WHO umbrella of combating infectious disease.

Internationally, Hong Kong and China cooperated with the WHO during the SARS crisis. The outbreak of bird flu in China in 2005 and 2006 raised the question of sharing samples with the WHO on the virus testing. The WHO representatives in China once complained that Beijing was reluctant to provide samples for further experiments. On the other hand, the new WHO director-general Margaret Chan vows to maintain her impartial position toward the PRC, which had lobbied many countries in the world to vote for her. Indeed, with the election of Canada- trained Chan as the WHO head, it is encountering the challenge to engage China and to bring it into the orbit of better cooperation.29

In the SARS and bird flu crises, governmental capacity in infectious disease control was the strongest in Singapore, followed consecutively by Hong Kong, South Korea, Vietnam, China and Taiwan. In November 2006, South Korea took an immediate action to slaughter 125,000 chickens, and 236,000 poultry including pigs, dogs and cats during the outbreak of H5N1.30 Vietnam was viewed as a successful example of containing its spread in 2003. Yet, its success could not be exaggerated. Due to their smaller number of SARS cases, Hanoi was able to contain the virus by adopting a tightly monitoring system. It remains to be seen whether Vietnam can contain the spread of bird flu. In fact, the smuggled chickens from China to Vietnam carry the danger of transmitting H5N1 across the border.31 With an increase in human traffic and trade flows across the Sino-Vietnamese border, infectious disease may be able to penetrate Vietnam rapidly but invisibly.

China’s response to SARS was divided into two phases, including the earlier stage in which a sluggish response was compounded by localism, and the later stage where leadership from the top was intertwined with a full-scale mobilization of the public to combat SARS. Although Taiwan is politically democratic, its capacity in disease control turned out to be weak in the SARS crisis. On average, a nurse in Taiwan has to take care of 20 to 30 patients and there is a total shortage of 20,000 nurses.32 The relatively underdeveloped health care system and the lack of effective monitoring system in cooperation with China, Hong Kong and Macao rendered Taiwan an isolated island republic under the threat of any flu pandemic.

Macao remains untested in its governmental capacity to tackle SARS. Surprisingly but fortunately, it did not have a single case of SARS in 2003. However, dengue fever occasionally broke out. The Macao government contained dengue fever quickly, thanks to its mobilization of neighborhood associations that successfully acted as not only an effective intermediary between the government and citizens but also a mobilizing vehicle against mosquitoes. Whenever cases of bird flu broke out in China, the Macao government dispatches officials to visit the mainland and look into the situation.33

28 “Chan praises healthy cooperation,” China Daily, November 28, 2006. 29 Chan is also a Canadian and she held a doctorate in medicine from the University of Western Ontario. 30 “South Korea to kill cats, dogs over flu fears,” Malaysia Star, November 27, 2006. However, some critics said that the South Korean reaction appeared to be over-sensitive. 31 30 smuggled chickens from China to Vietnam were found to have H5 virus. Ming Pao, April 7, 2006, p. A11. 32 United Daily Evening News (Taiwan), March 30, 2006, cited in Today Daily News, March 31, 2006, p. B10. 33 When bird flu broke out in Guangdong in March 2006, Macao officials went to Zhongshan and Zhuhai to inspect the situation. TVB News, March 7, 2006.

3. Implications for Canada: Difficult Choices Ahead

The varying degrees of preparedness, openness and responsiveness of Asian governments in their handling of infectious disease have implications for Canada. The Canadian preparedness in anticipation of an influenza epidemic remains insufficient. A gap exists between the health elites who appear to be more prepared and the masses who are relatively unprepared. An indispensable ingredient of preparedness is crisis consciousness. Surprisingly, after the SARS crisis, a majority of Canadians have appeared to treat the flu pandemic as a non-issue at least in the short run. None of the candidates who participated in Ontario’s municipal and mayoral elections in November 2006 raised the issue of how should the province tackle any outbreak of the influenza pandemic. The question of the flu pandemic was virtually absent in public debates and candidates’ platforms.

However the Canadian Influenza Pandemic Plan does illustrate the high degree of governmental preparedness at the federal level. Yet, the plan merely encourages provincial and local governments to educate the citizens on the flu crisis. The word “encourages” is used in the plan, showing that the federal government decentralizes the responsibility for education and publicity to the provincial and local governments. Except for the occasional television and newspaper advertisements on flu shots and West Nile Virus, the publicity of the influenza pandemic has remained very weak. Perhaps the provincial and municipal governments have to avoid creating any unnecessary public panic. Still, more publicity on the flu pandemic would heighten crisis consciousness of most Canadians. Apart from the ongoing stress on the need to frequently wash their hands against any flu virus, a deeper understanding of how the public will be mobilized to tackle any arrival of the flu epidemic is imperative.

The updated Canadian Pandemic Influenza Plan for the Health Sector has put forward detailed recommendations to strengthen preparedness, including surveillance, vaccines, antivirals, health service emergency planning, public health measures, and communications.34 Although the updated plan mentioned that a Health Emergency Communications Network had been created to improve federal/provincial/territorial interactions in response to the SARS, and that a communications subcommittee was formed, it remains unclear how these bodies coordinate with each other. From a critical perspective, additional layers of bureaucracy appear to be seen as an effective remedy; nonetheless, the actual operations of these committees will have to be reviewed and tested in simulation exercises. Otherwise, bureaucratization in the form of setting up new agencies would arguably not guarantee a significant improvement in intergovernmental communications and overall governmental preparedness for another new epidemic. The example of Hong Kong’s chaotic hospital response to SARS proved that inter- departmental coordination was critical to an effective response. The Canadian influenza plans are undoubtedly detailed, but arguably they have neglected the technicalities of how various departments would coordinate among themselves. Coordination can be improved only through simulation exercises and real challenges.

The updated Canadian Pandemic Influenza Plan for the Health Sector delineates a National Emergency Response System that involves the interactions between the Prime Minister and

34 See The Canadian Pandemic Influenza Plan for the Health Sector (2006), in http://www.phac-aspc.gc.ca/cpio- pclcpi/so3_e.html#261i, access date: February 1, 2007.

provincial premiers, between the cabinet committee for security, public health and emergencies and provincial minister, and between deputy ministers at the federal level and their counterparts at the provincial level.35 However, the vertical chain of command remains long and complicated. The bureaucratization approach adopted by the updated plan raises two serious questions: whether the line of accountability will be clear to all actors and whether it will generate a very cumbersome process unintentionally detrimental to a swift response to crises. Critically speaking, it is doubtful whether the updated plan can significantly ameliorate Canada’s preparedness and response to any new epidemic.

Furthermore, while the Canadian society is far more open or transparent than many Asian states, the local mass media generally lack an intense interest in probing the influenza pandemic. Perhaps the mass media at the national, provincial and local levels have been preoccupied with other salient issues, such as federal-level politics, Canadian military’s involvement in Afghanistan, Quebec’s status, transport, crime, education, environment and tax. The irony is that while Canada is endowed with a highly sophisticated mass media, they have not yet developed an inquisitive mind in investigating the multiplicity of issues surrounding any imminent flu pandemic, especially public preparedness and governmental responsiveness.

If crisis consciousness and preparedness are seemingly weak in Canada, responsiveness becomes the most critical variable shaping the Canadian governmental capacity in controlling any flu pandemic. The Asian response has an important bearing on the Canadian context.

Singapore’s swift response to enforce strict quarantine of SARS suspects and segregate them in safe houses deserves the Canadian attention. Critics question whether the Singapore model jeopardized the individual rights of SARS-infected victims. Arguably, centralization and perhaps authoritarianism are necessary in any swift governmental response to infectious disease. Tight surveillance of the SARS victims, who were put in solitary confinement, constituted an effective deterrent to infectious disease. Unlike Hong Kong where individual rights were emphasized in a way that could endanger public safety during the SARS outbreak, the Singapore government was ironically and fortunately free from the political burden of protecting individual rights in the fight against SARS. Unlike Hong Kong where the business sector was concerned about the impact of border control on the economy, the Singaporean business did not really constrain the governmental handling of the SARS crisis. The Singaporean experience pointed to the tremendous state power and unified societal forces that could be galvanized to prevent the spread of SARS. In a small city like Singapore, administrative centralization and political authoritarianism are the virtues for the prevention of the population from being wiped out during the outbreak of a rapidly transmitted infectious disease. Authoritarianism is usually denounced by liberal academics as undesirable in the process of Western-style democratization, and as such has been swept under the carpet as the most effective resistance against the encroachment of any flu pandemic.

The Singapore model is not applicable to Canada. The argument that authoritarianism is necessary for the combat against infectious disease is surely unacceptable to most Canadians who champion individual liberties. If a flu pandemic takes place in Canada, it is very doubtful whether the public will reach a consensus on any swift action by the Canadian government to contain it. Any strict quarantine measure through the forced segregation of patients would be

35 Ibid., Annex L.

easily seen as a violation of individual rights. Trade unions that have been traditionally powerful in Canada would likely object to measures that would quarantine their members. It remains doubtful whether unions composed of nurses and doctors would be supportive of the Canadian government’s emergency measures during the flu predicament. Business groups in Canada would likely argue against closing the border temporarily with Asia, not to mention closing the border with the United States, because they perceive border security measures as detrimental to trade and commerce. Similar to Hong Kong where the pro-capitalist and pro- business government hesitated to impose border control prior to the apex of SARS because of its fear of any adverse impact on the economy, Canada’s capitalist state would most likely encounter very difficult choices in the event of a flu pandemic.

At the beginning of a flu pandemic, the Canadian government would surely be anxious about the negative economic impact of tight border control. Provincially and locally, there would most probably be a fragmentation of elite opinions, including both politicians and business people, on the scope of border control measures, thus complicating the federal government’s decisions. Yet, the experience of Hong Kong and Singapore in the SARS crisis demonstrated that at a critical juncture, their governments had to impose border control measures, enforce strict quarantine, and forbid the arrival of air flights from infected areas. These measures would be very difficult to be implemented in Canada if the vociferous trade unions, influential business chambers, and opposition politicians were squabbling with the governments at the federal and provincial levels.

At a particular juncture where infectious disease entails human-to-human transmissions, the Canadian government would have to evoke emergency regulations, which will be applied to federal, provincial and municipal levels, so that decisive actions would be legalized to stem the inflow and outflow of the flu pandemic.36 Ideally, the House of Commons would pass a motion in support of the government’s decision to declare a national emergency. Internal national security would be of paramount importance to Canada regardless of how the critics would react to decisive measures. The greatest potential danger to Canada during the outbreak of the flu pandemic would predictably be the precedence of democratic rights over national security. At a critical juncture, all Canadians including opposition parties, business groups and trade unions will have to be united in supporting whatever measures adopted by the federal/provincial/territorial governments to combat the onslaught of a flu pandemic.

It is tempting to argue that any democratic regime has to strike a balance between democratic rights and national security in the event of the flu pandemic. As with the combat against terrorism, Western states have been under severe criticisms for trampling individual rights for the sake of protecting themselves against “terrorist” attacks. Any flu pandemic will be tantamount to biological terrorism. In response, decisiveness and authoritarianism would be the sine qua non for the containment of deadly infectious disease.

If the community activists call for a lottery system to decide who would receive vaccines instead of following a pre-determined priority list of citizens, the Canadian government’s

36The updated Canadian Pandemic Influenza Plan for the Health Sector pinpoints that the “federal/provincial/territorial legislative frameworks for health emergencies have not been analyzed for comparability and interoperability.” See http://www.phac-aspc.gc.ca/cpip-pclcpi/so3_e.html#261i, access date: February 1, 2007.

capacity would be severely curtailed. Any lottery system adopted to allocate vaccines would generate governmental clumsiness. Fairness has to be observed in the governmental treatment of citizens receiving vaccines, for citizens at the lower end of the priority list would be treated later. Groups and individuals will be allowed to voice their views freely, but such views should not usurp the authoritative power of the government to allocate resources in time of the flu crisis. Governmental capacity, which also embraces the ability to distribute resources and mobilize manpower relatively free from societal lobbying, will have to be maintained in Canada during any flu pandemic. Canadians will have to appreciate that any flu pandemic will be comparable to another world war instead of being a larger SARS-type outbreak.

As with the Asian cases, Canada’s governmental capacity in disease control will be shaped by political leadership. Hong Kong’s response to the SARS crisis unveiled serious problems in departmental coordination, especially communications between the Department of Health and the Hospital Authority.37 When the Prince of Wales Hospital’s authorities intended to close the entire emergency ward so as to prevent any members of the community from being infected, the Health Department held a different view. The case of Hong Kong demonstrated that a fragmented health system without sufficient communication and decisive political leadership could have catastrophic consequences.

The implications for Canada are obvious. Health Canada would have to communicate with all hospitals intensively and accurately. Provincial health authorities must frequently coordinate with the federal counterparts, whereas municipal health officials would need to report accurately on the health circumstances and statistics to municipal governments. Given the three level structure of government in Canada, coordination and communication will surely become serious undertakings. Plans are already in place to cope with any flu pandemic, but simulation exercises will have to be conducted to test the communication finesse between federal and provincial health authorities, and between municipal and provincial health officials.

Timing is a baffling problem calling for political leadership. When the HKSAR government under C. H. Tung toyed with the idea of installing temperature-testing and infra-red equipments at various border checkpoints, the sophisticated detectors could not arrive at Hong Kong immediately as it took at least a week to buy, prepare, test and install them. Critics said that the HKSAR government should have decided the use of such detectors much earlier. Before the HKSAR government decided to implement temperature tests on all primary and secondary school students, it had hesitated until parents complained vociferously about the safety of their children.38 The timing of all decisions relating to infectious disease will be a huge challenge to Canada’s federal, provincial and municipal governments.

As with Taiwan, Canada’s health care system is in lack of doctors and nurses. The manpower shortage in Canada has to be addressed urgently. In the event of the flu pandemic, a gradual attrition of hospital staff would be inevitable. Some of them would succumb to the virulent infectious disease, as with the SARS outbreak in Toronto. To replenish the loss of staff,

37 A useful review of how the Hong Kong government coped with the SARS crisis can be found in Christine Loh and Civic Exchange, eds., At the Epicentre: Hong Kong and the SARS Outbreak (Hong Kong: Hong Kong University Press, 2004), pp. 117-138. 38 The author wrote a commentary in Ming Pao advocating that the HKSAR government should close the schools and I received a phone call from a parent saying that my demand echoed the views of many worrying parents.

Canada would have to mobilize reserved hospital workers, including medical students and all immigrants with health care background.

What Canada can learn from Hong Kong is that the Canadian health system can be consolidated by privatizing health care delivery so that the federal and provincial government would have more resources deployed to health,39 increasing the pay of its hospital staff, enhancing the manpower immediately through the drastic change in job matching of landed immigrants, and improving the coordination between all the hospitals and the municipal/provincial governments.

4. A 20-point Action Plan for Canada

An unknown variable affecting Canada and the world will be the length of any flu pandemic. While the length of the pandemic is perhaps uncontrollable, the private and public sectors can take preventive measures to tackle the flu pandemic.

First, all Canadian companies will have to test their emergency plans. The Canadian Manufacturers and Exporters have assisted various corporations to formulate emergency plans in response to any flu pandemic. It formulates an impressive 20-point checklist for all enterprises, including the identification of a manger responsible for the flu pandemic plan, the pandemic’s financial impact, the need to build confidence among employees, the preparation for a 35 to 50 percent absenteeism during the two week peak period, and the appeal to all companies to test and share their plans with the government.40 Yet, the proportion of companies sharing their flu pandemic plans with the local governments is unknown. In time of a sudden flu crisis, the impact on Canadian companies would perhaps be much larger if there were no simulation exercise with regard to the flu pandemic plan prepared by various companies.

Second, governmental communication with poultry workers and chicken farmers will have to be enhanced. They have already been alerted to the likelihood of the outbreak of bird flu. The Chicken Farmers of Ontario vowed to try its best to prevent the spread of any bird flu from the farms to the community. During any flu pandemic, how to separate the poultries produced locally in Canada from those imported from Canada would be critical. If the local farms were safeguarded against the flu crisis, the extent to which they continue to provide regular food supply would need constant assessment, necessitating a partnership between agricultural and health officials on the one hand and farmers on the other.

39 The debate in Canada over whether some medical services should be privatized is highly ideological. Pro- welfare supporters argue that private hospitals and clinics should not supersede the role of government in providing health care. However, they totally overlook the fact that many other places, like Hong Kong, have a well-run system of mixed private and public hospitals, which if implemented can perhaps alleviate the financial burden of the federal and provincial governments in health-care delivery. This does not mean that the Hong Kong system of health care delivery is desirable, for its public health hospitals have been plagued by huge financial deficits and maladministration. The point is that the Hong Kong model of mixed private and public hospitals would perhaps be borrowed to deal with the Canadian health system so that the latter would hopefully deploy more financial resources to tackle other issues, such as the preparation of a flu pandemic. 40 “Pandemic Preparedness: 20-point checklist for small business,” in http://www.cme- mec.ca/pdf/Pandemic_CMESME_list.pdf, access date: December 1, 2006.

Third, in the event of the flu pandemic, it will be unclear how pets would be managed at the provincial and territorial levels. Ideally, pets would have to be segregated so as to prevent human beings from being infected more easily. Yet, such segregation would arouse the opposition of pet lovers and owners. A moderate solution is to encourage all pet owners to have their pets undergo voluntary quarantine and medical check-ups. During the peak of the flu pandemic, tougher measures segregating pets from human beings would perhaps have to be considered. Any emergency regulation enacted by the federal government to deal with the flu pandemic would have to incorporate the question of how pets would be dealt with so that provincial and territorial governments would be legally empowered.

Fourth, given the fact that 200,000 illegal immigrants are staying in Canada, their fate and possible access to health care would become critical issues in the event of the flu pandemic. They are afraid of visiting the doctors for fear of having their identity discovered and then being deported.41 Yet, urgent medical health care would have to be provided to the underground population, who would be required to register themselves with the authorities, with the implication that there would be a partial amnesty. If not, illegal immigrants without access to health care services would become an extremely vulnerable segment of the society. The federal government must deliberate with the provincial governments on the future of illegal immigrants, whose susceptibility to the flu outbreak would directly or indirectly shape the extent of death toll in Canada.

Fifth, during the high tide of the flu pandemic, Canadian citizens who are residing in overseas countries and who return to Canada would perhaps have to be segregated into camps remote from the urban communities. The idea is not to discriminate against them, but to provide safeguards against the likelihood of any returnees who may be infected with the flu virus. Indeed, the question of evacuating Canadian citizens from places where the flu pandemic erupts would be a tricky one. Hong Kong would surely become a place necessitating emergency planning due to the 250,000 Canadian citizens residing there. The 1.2 million Canadians residing and working in the United States would also call for special policy considerations in the event of any global flu pandemic. If evacuation were implemented, the spread of the virus would be practically facilitated. If evacuation were discouraged, then returned Canadians would have to encounter the prospects of being quarantined at a relatively remote place for a certain period of time. Even though the SARS outbreak in Toronto showed that 13,000 Torontonians who traveled to infected areas voluntarily quarantined themselves for days to prevent others from possibly being infected,42 this self-initiative would have very limited impact in the event of the flu pandemic. The police efforts at tracking down the whereabouts of Canadians, who returned to Canada from SARS-affected places, would become insufficient during the flu pandemic unless all returnees would be temporarily quarantined in safe houses.

Sixth, at the apex of the flu pandemic, schools would have to be closed in Canada at all levels, thus disrupting the studies of hundreds of thousands of children. Kindergarten, elementary schools, high schools and universities would have to terminate their classes, affecting teaching and research in an unimaginable scale. Each school is required to test their emergency plan at least once from now onwards. Emails and Internet classes would have to be implemented

41 “Illegals afraid to see a doctor,” Toronto Star, May 23, 2006, p. A4. 42 Sing Tao Daily, April 19, 2006, p. A12.

provided that all schools are required to formulate their emergency plans. Otherwise, a lack of preparedness would generate massive panic and frustrations at the grassroots level.

Seventh, the health authorities would have to regulate the illegal sale of anti-flu drugs and vaccines through illicit channels and the Internet. During the flu pandemic, criminal elements would perhaps take advantage of the public health crisis to sell substandard vaccines and drugs through various channels, including the Internet. Similarly, whether Tamiflu would trigger criminal syndicates to produce fake anti-virals remains unknown.43

Eighth, at the apex of the flu crisis, the border with Asia, Africa, Europe, America and other parts of the world would have to be temporarily closed so that the virus would be disallowed to transmit to human beings further. Yet, this measure would have calamitous consequences on the domestic economy and aviation industry. Air transport that is so crucial in globalization would have to be temporarily terminated, but critics have already questioned the effectiveness of air travel ban.44

Ninth, the already strained hospital manpower would mean that health workers would be under stressful work conditions, but the government would have to garner their unreserved support. Complaints about any public maladministration of hospitals would perhaps erupt, ranging from inadequate masks to the lack of strict quarantine measures on the flu-infected patients. Effective hospital management would constitute the determining factor shaping Canada’s resistance against the flu epidemic.

Tenth, quarantine measures would have to be modified and adapted to the circumstances. The Singaporean model of using cell phones and video-conferencing for communications between patients and their loves one would have to be considered in the Canadian context. Family members of the flu patients must be persuaded to understand the complexities of the infectious disease. Without a widespread public education, a sudden flu pandemic would likely split the society of Canada. Some observers have rightly noted that the Canadian government would have to launch a more assertive publicity campaign so that more members of the public would comprehend the origins, complexities and consequences of any flu pandemic.45

Eleventh, a large-scale educative campaign should be launched to increase the crisis consciousness of all Canadians toward any flu pandemic. In the event of the flu crisis, the multicultural pockets in Vancouver and Toronto would become inactive, forcing citizens to stay at home and suffer from the psychological impact of reported deaths every day and night. In the worst case scenario, members of some ethnic groups would run the risk of being stereotyped as “undesirable” virus carriers due to the origin of the flu pandemic in their “home

43 In 2006, fake anti-flu vaccines were found in China and Hong Kong. It is noteworthy that Tamiflu was reported to have neurological disorder among a few cases. 44 Some people have already questioned whether air travel ban would effectively curb the flu pandemic. They argue that such a measure would only delay the spread of the flu virus and that it would not be sustainable in the long run. 45 Harris Ali of York University has accurately observed that compared to the publicity campaigns in Hong Kong and Singapore, Canada lags behind in terms of appealing to citizens to frequently wash their hands, to avoid contacts with birds, and to shun the practice of feeding birds. See Ming Pao, April 19, 2006, p. A4.

countries,” even though they have long treated Canada as their permanent homes.46 To put it bluntly, racial discrimination would unfortunately re-emerge in the event of a large-scale flu pandemic, unless the Canadian government at all levels is able to launch an extensive education campaign to inculcate the knowledge of the flu pandemic into the minds of all citizens, ethnic misunderstandings would become a potential time-bomb undermining Canada’s social harmony. In the event that most members of the public remain complacent, their relative lack of preparedness will mean that social mobilization against the spread of the flu pandemic will be difficult and time-consuming. Educating the public extensively about a flu pandemic will not necessarily create panic. Instead, it aims at paving the way for societal unity and social mobilization during a flu pandemic.

Twelfth, to prevent any flu pandemic from causing havoc on the Canadian society, the Canadian government has to rigorously enhance the reserves of anti-flu vaccines, which have already been increased from 16,000,000 shots to 50,000,000 shots.47 The stockpiles of anti-flu vaccines will have to be consolidated if Canada has to construct an effective shield against the encroachment of the flu pandemic.

Thirteenth, in light of the fact that many hospitals in China had their windows open so as to ensure better air circulation during the SARS crisis, the Canadian government will have to ensure that the ventilation system of public hospitals, government buildings and other public places at all levels will have to be frequently inspected and cleaned. Due to the weather conditions in Canada, many hospital and buildings have their windows tightly closed, a practice that would perhaps exacerbate the transmission of infectious disease. The outbreak of Legionnaire disease in the Seven Oakes Homes Hospital in Toronto in 2005 was a cause for alarm, for it revealed the problematic ventilation system of at least some Canadian hospitals.

Fourteenth, municipal governments need to adopt a two-pronged strategy to educate the public on the flu pandemic and to improve their capacity. It is reported that Toronto would not have the ability to cope with a large-scale flu pandemic; that 2.6 million citizens would be unable to receive timely vaccinations, and that Ontario as a whole would have 35 percent of the population infected with the flu virus.48 Top leaders of all municipalities should be required, not just urged, to conduct exercises to enhance their flu management capacity. An auspicious sign is that many municipal regions, such as the Peel region and the York Region in Toronto, formulated emergency plans to cope with infectious disease such as the flu pandemic and the West Nile virus.49 Nevertheless, simulation exercises will have to be implemented to improve municipal preparedness.

Fifteenth, since Canada is endowed with its vast physical land space, it has tremendous potential to develop make-shift hospitals, quarantined camps, and special funeral services to tackle the flu pandemic. The specific sites of public cemeteries to bury the victims of the flu

46 Some members of the Chinese community felt that during the SARS outbreak, the Canadian Chinese in Toronto were unfairly labeled by other Canadians as potentially virus carriers. 47 Ming Pao, May 14, 2006, p. A8. 48 Today Daily News, April 16, 2006, p. A4. 49 Ming Pao, April 15, 2006, p. A2 and Sing Tao Daily, May 29, 2006, p. A8. Some other municipalities have their websites on the flu pandemic. Waterloo, for example, has its own website updated from time to time. It was estimated that in the worst case scenario, 127,000 people in the Waterloo region would need outpatient care. Up to 2,400 would have to be hospitalized and 700 would die. See The Record, April 28, 2006, p. B2.

pandemic have to be identified by all municipal governments. Corpse management will require more technical details to be hammered out between the funeral service specialists and health officials concerned. The physical vastness of Canada will have to be utilized to the fullest extent to cope with any flu pandemic.

Sixteenth, Canada’s airports must consider emergency measures, such as the installation of infra-red temperature testing detectors and detailed recording of passengers’ personal data, including their addresses and final destinations in Canada. While it would be costly for all airports to install the equipments, the airports in all Canadian cities, especially Vancouver, Toronto, Ottawa and Montreal, will need them. All airports with international flights and connections to other Canadian cities would have to need tighter measures against the flu pandemic.

Seventeenth, public-private partnership in the form of requiring all private organizations to test their emergency plans will be necessary. Conducting simulation exercises on their emergency plans for several hours will by no means bring about economic costs to private organizations, but they will equip more Canadians with the basic skills necessary to ward off any national health crisis.

Eighteenth, simulation exercises will have to be conducted between the federal government and provincial governments, between each provincial government and its municipalities, and between each municipal administration and local communities. A careful reading of all the websites of Canada’s provincial governments shows that some provinces give scant attention when publishing their emergency flu pandemic plan. While the websites of the Ontario and British Columbia governments publish their emergency plans in detail, some provinces do not have sophisticated emergency plans on their websites, notably Prince Edward Island, Newfoundland and Labrador, and Nunavut.50 Nova Scotia provides scant information, rather than a plan, on its website. All the provincial plans touch upon coordination and communication, but surprisingly only Quebec provides the most comprehensive and elaborated structure on the specific agencies responsible for coordination and communication. Not all provinces have shown a consensus on the definitions of coordination and communication, with some stressing the inter-provincial dimension while others showing a more balanced view on internal departmental cooperation and federal-provincial partnerships. Perhaps due to its experience with SARS, the Ontario plan mentions the need for media conference, video- conference and teleconferencing interactions with public health officials. The discrepancies in provincial plans demonstrate their varying cultures and attitudes in response to the danger of any flu pandemic.

Nineteenth, Canadians in general are complacent and relatively relaxed about the likelihood of any flu pandemic; nonetheless, this attitude has to change at least slightly. More publicity will have to be launched nationwide to educate the public on the flu pandemic and to increase their awareness on how to tackle an abrupt crisis. While multiculturalism is usually hailed as the strength in Canada’s political system and social mosaic, the diversified cultural groups existing and proliferating in Canada need to be cognizant of how they should act collectively in the event of a bio-terrorist war. Otherwise the eruption of the flu pandemic would plunge the Canadian society and polity into turbulence.

50 For details, see www.influenza.gc.ca/index_e.html#6, access date: June 27, 2006.

Twentieth, officials of the Canadian federal government will have to heighten their sensitivities toward any possible flu crisis. Canada would have to prepare an emergency plan to discuss with the United States on the conditions under which border control would have to be implemented during the high tide of any flu pandemic.51 Moreover, Canada’s official representatives in Asia have to enhance their information-gathering activities with regard to the development of infectious disease. Equipped with updated information provided by the Canadian consular and embassy officials stationed in Asia, Ottawa will have an accurate picture of the ongoing development of bird flu in Asia Pacific.

Conclusion

Canada has much to learn from the bitter lessons of SARS and the ways in which some Asian cities like Singapore and Hong Kong dealt with SARS. A democratic country does not necessarily mean that its federal and provincial governments have the capacity to control the flu pandemic effectively. Arguably, governmental decisiveness during any flu pandemic will be far more important than the protection of civil liberties. The coordination among government departments at all levels will be a critical variable shaping the responsiveness of the Canadian government to any flu pandemic. Emergency regulations would have to be enacted by the House of Commons so that Canadians will remain united across all the provinces and territories to fight against the offensive from any flu pandemic. Provincial differences in Canada have already revealed the different emphases on how provincial governments perceive the flu pandemic. Yet, if the Canadian governments at the federal, provincial and municipal levels, together with the private sector, implement the 20-point action plan as proposed in this paper, Canada’s governmental capacity of managing any flu pandemic will be hopefully and substantially enhanced. Canadians should no longer be complacent. Although detailed plans have already been published to tackle any forthcoming flu pandemic, the questions of governmental coordination, public education, crisis consciousness, and social mobilization will become critical to the public health and national security of all Canadians.

51 The United States is deeply concerned about the development of bird flu in Asia, conducting a close surveillance of the routes of migratory birds, banning the import of chicken meat from China in May 2006 when the PRC had cases of bird flu, and stockpiling Tamiflu in preparation for the flu pandemic. See Ming Pao, March 2, 2006, p. A11 and May 4, 2006, p. A10. Also see World Journal, April 14, 2006, p. A2.