Early in 2003, SARS (severe acute respiratory syndrome) was in newspaper headlines across the world. There was fear and panic among the public at large and, arguably for the first time, modern healthcare systems were confronted with a public health scare of unprecedented proportions. After first emerging in Asia in February 2003, and then spreading globally, SARS affected over 8000 people world-wide; of which over 800 died. SARS proved to be a serious viral respiratory disease caused by a coronavirus, more specifically the SARS-associated coronavirus (SARS-CoV). The fear generated by SARS was greater even than the HIV/AIDS epidemic because of the swiftness of the outbreak, leading to sudden mortality in a short space of time in a relatively high number of cases. Nobody was immune to acquiring SARS and it was this fact that created both individual and international panic, further exacerbated because the exact causative agents of the disease were initially unknown.

As an epidemiologist, my early interest was in tracking the disease. However, I have also become concerned with highlighting the effect of SARS on healthcare systems in general and on health human resources in particular. Now that the initial panic and fear is behind us, it is worth reflecting on what was learned from the SARS outbreak and, here, on how it impacted on nurses and the nursing profession. The anxiety caused by the crisis, and the indefinite aetiology of the disease, had serious implications for individual nurses as well as the nursing profession at large.

By the nature of their profession, nurses risk exposure to infection on a daily basis. Nurses were among the front-line workers in the battle to contain SARS. Infection control measures are routine in all healthcare settings but, even with the rapidly introduced extra precautions, nurses and other healthcare workers were not protected from contracting SARS because of the highly infective characteristics of this particular contagion. Fear and apprehension among healthcare workers inevitably rose after the death of Dr Carlo Urbani, an expert on communicable diseases and the World Health Organization (WHO) officer who identified the invasion of SARS into Vietnam. Overall, healthcare workers represented a significant proportion of reported SARS cases, with 18% in China, 22% in Hong Kong and 25% in Canada. More than half of the SARS cases first identified in Hanoi (China) were healthcare workers. Indeed, the index case for the spread of SARS in Hong Kong was a doctor.

For some healthcare workers, dedicated commitment to their profession was outweighed by an overwhelming fear of contracting SARS or transferring the disease to their family members. Some of the nurses caring for SARS patients resigned, as did other workers (including laboratory technicians, radiographers, and hospital support staff). This simply intensified the existing shortage of staff, not just in nursing but in most of the health professions and, as we all know, a workforce shortage is being experienced virtually world-wide. Thus the workload of the remaining staff was further intensified on top of the extra work created by SARS procedures and protocols in any confirmed or suspected case of SARS. With these added pressures and working in an atmosphere of fear, SARS inevitably had a considerable effect on the psychological status of healthcare professionals. Some workers chose to quarantine themselves in their hospital or reduce contact with their family and community to minimize the risk of disease transfer. Economically too, SARS had an impact on healthcare workers who resigned or stayed off work, and on healthcare systems as a result of the extra costs of managing the outbreak.

So, the SARS outbreak presented serious challenges to the modern world, not only within healthcare systems but also, in numerous ways, it impacted on governments and on individuals. At the governmental level, SARS highlighted the lack of adequate emergency response systems, the insufficient numbers of nurses, and the increasing pressures on healthcare professionals. At the individual level, the SARS outbreak challenged the commitment of many healthcare workers to their profession. Among the many questions we should now be asking is whether nurses have the right to refuse to undertake certain duties and responsibilities when their own lives are at risk. Florence Nightingale stated: ‘If we are permitted to finish the work…given to us to do, it matters little how much we suffer in doing it. In fact, the suffering is part of the work…’ (Montgomery Dossey 1999). However, in a very different era, the advent of SARS raises some challenging questions. For example, what is the responsibility of governments and organizations to protect nurses and provide a safe environment? What is the impact of workforce shortage and casualization of the workforce on the ability of healthcare systems to cope with any situation of emergency and added pressure?

Different countries have responded differently to these issues. In Canada, for example, the government has introduced some changes to employment insurance and sickness benefits, and has formulated special job protection rules for workers affected by SARS. In Hong Kong, the labour department urged employers to deal flexibly with affected workers and compensation payments were made to quarantined, absent, or suspended workers (and likewise in Singapore). In Taiwan, however, health officials gave notice that workers refusing any job assigned to them might be fired. Recognizing the need to motivate and retain health personnel, some health authorities have acted positively: for example, in Singapore ‘Courage Fund’ was set up to encourage and acknowledge health workers for their efforts.

Four months after its emergence, SARS was successfully brought under control across the world. However, the fear of its re-emergence still exists, a fear that was brought to the fore again in August 2003 when an isolated case of SARS was diagnosed in Singapore. It is right that we remain apprehensive and vigilant because the epidemiology and ecology of the disease are still not fully understood. SARS aside, there are likely to be other new and deadly contagions to deal with in the future. In this regard, nurses need to lobby governments for long-term policy structures and strategies to increase the pool of nurses and strengthen healthcare systems and, in particular, to ensure that they have the capability and capacity to respond properly to any future public health emergencies of this kind. The SARS outbreak demonstrated the indispensable role that nurses play in dealing with a real threat to the public health. It is clear that in order to maintain a sustainable health system, advanced human resources planning is absolutely crucial. At the individual level, there are also fundamental questions that every nurse must now consider with regard to his/her commitment to a profession that, even in this modern age, is not without personal risk.


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  2. Reference
  • Montgomery Dossey B. (1999) Florence Nightingale Mystic, Visionary, Healer. Springhouse Corporation, USA.