Abstract
Freedom of movement is undoubtedly a fundamental international right. However, circumstances may arise where that right must be curtailed. Was the 2003 SARS outbreak in Toronto one such circumstance? Guénaël R.M. Rodier thinks WHO’s decision to impose a SARS-related travel advisory was justifiable, even reasonable, though it caused a loss of over $1.1 billion in the Greater Toronto Area. That travel to an infected area was the most common epidemiological link with SARS infections supports Rodier’s position. However, as suggested in the Naylor report, issuing a travel advisory does not keep infected individuals from leaving Toronto and such individuals account for 5 of 6 cases where SARS was spread from Canada. That alone would discount Rodier’s argument and the WHO decision on purely logistical grounds. But there is an ethical question as well. Was the travel advisory implemented fairly? This question is best judged using Nancy E. Kass’s framework for public health. From that framework, two points are placed in immediate relief.
First, the Toronto authorities were not given an opportunity to state their case to WHO before the travel advisory was implemented. Second, the framework requires that burdens be distributed fairly and the travel advisory did not do that, or even attempt to do so.
MeSH terms: Bioethics, public policy, severe acute respiratory syndrome–virus, World Health Organization, social protection, environment and public health, disease outbreaks
Résumé
Le droit de circuler librement est sans aucun doute un droit international fondamental. Certaines situations peuvent toutefois nécessiter la suspension de ce droit. Était-ce le cas lors de la crise du SRAS à Toronto en 2003? Selon Guénaël R.M. Rodier, la décision de l’OMS de publier un avertissement aux voyageurs était valable, et même raisonnable, bien qu’elle ait causé des pertes de plus d’1,1 milliard de dollars dans la Région du Grand Toronto. Le fait que les déplacements vers les zones infectées aient été le lien épidémiologique le plus commun entre les personnes infectées par le SRAS vient corroborer cette position. Cependant, comme l’indique le Rapport Naylor, la publication d’un avertissement aux voyageurs n’a pas empêché des sujets infectés de quitter Toronto; or, ces sujets ont représenté cinq cas sur six dans la propagation du SRAS en provenance du Canada. D’un simple point de vue logistique, cet argument mine la thèse de Rodier et met en doute le bien-fondé de la décision de l’OMS. Mais il faut aussi tenir compte de l’aspect moral. L’avertissement aux voyageurs a-t-il été mis en oeuvre équitablement? Le meilleur moyen d’envisager cette question est d’utiliser le cadre pour la santé publique de Nancy E. Kass. Deux points ressortent immédiatement de ce cadre.
Premièrement, on n’a pas laissé aux autorités torontoises la possibilité de plaider leur cause auprès de l’OMS avant la publication de l’avertissement aux voyageurs. Et deuxièmement, le cadre précise que le fardeau des conséquences doit être distribué équitablement. Or on ne l’a pas fait, ni même tenté de le faire, pour cet avertissement.
References
- 1.Mazzuli T, Lain K, Butany J. Severe acute respiratory syndrome: Overview with an emphasis on the Toronto experience. Arch Pathol Laboratory Med 2004;128:1346. [DOI] [PubMed]
- 2.Gostin LO, Bayer R, Fairchild AL. Ethical and legal challenges posed by severe acute respiratory syndrome: Implication for the control of severe infectious disease threats. JAMA. 2003;290(24):3229. doi: 10.1001/jama.290.24.3229. [DOI] [PubMed] [Google Scholar]
- 3.Naylor CD. Canadian National Advisory Committee on SARS and Public Health, Learning from SARS: Renewal of Public Health in Canada: A Report of the National Advisory Committee on SARS and Public Health. Ottawa, ON: Health Canada; 2003. [Google Scholar]
- 4.Singer PA, Benatar SR, Bernstein M, Daar AS, Dickens BM, MacRae SK, et al. Ethics and SARS: Lessons from Toronto. BMJ. 2003;327:1342–44. doi: 10.1136/bmj.327.7427.1342. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Farquharson C, Baguley K. Responding to the severe acute respiratory syndrome (SARS) outbreak: Lessons learned in a Toronto emergency department. J Emerg Nurs. 2003;3:222–23. doi: 10.1067/men.2003.109. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Svoboda T, Henry B, Shulman L, Kennedy E, Rea E, Ng W, et al. N Engl J Med. 2004. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. [DOI] [PubMed] [Google Scholar]
- 7.Rodier GRM. Why was Toronto included in the World Health Organization’s SARS-related travel advisory. CMAJ. 2003;168(11):1434. [PMC free article] [PubMed] [Google Scholar]
- 8.Schrag SJ, Brooks JT, Van Beneden C, Parashar UD, Griffin PM, Anderson LJ, et al. SARS surveillance during emergency public health response, United States, March-July 2003. Emerg Infect Dis. 2004;10(2):185. doi: 10.3201/eid1002.030752. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Naylor CD. Canadian National Advisory Committee on SARS and Public Health. Learning from SARS: Renewal of Public Health in Canada: A Report of the National Advisory Committee on SARS and Public Health. Ottawa: Health Canada; 2003. [Google Scholar]
- 10.Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776. doi: 10.2105/AJPH.91.11.1776. [DOI] [PMC free article] [PubMed] [Google Scholar]