What communication lessons can practitioners learn from the Singapore SARS crisis?

A crisis of epidemic proportions: What communication lessons can practitioners learn from the Singapore SARS crisis?

Chong, Mark

SARS and its dramatic socio-economic consequences seem to be a classic case of the social amplification of risk – a framework which explains why strong public concern and drastic socioeconomic impacts may accompany risk events with seemingly minor physical consequences (n1). While SARS can pose significant risks to individual health, its social and psychological impacts are disproportionate to the relatively low global mortality rates associated with the disease. Indeed, social institutions such as the media may amplify perceived risk to the extent that perceptions of risk occur before, or even in the absence of, any actually occurring accidents or hazards (n2). Individual or collective behavioral responses to the perceived risk may result in serious economic or social repercussions such as declines in residential property values, social and community conflict, distrust of risk management institutions, and the development of stigma (n3).

SARS first surfaced in Singapore in early March 2003 when three women who had just returned from Hong Kong were diagnosed with the disease. Thereafter, healthcare workers started getting ill, and the infection spread to other hospitals and a wholesale vegetable market. The crisis severely affected the economy and disrupted everyday life – malls, restaurants, hotels and other tourism-related businesses were severely hit and people minimized social contact. Moreover, healthcare workers were stigmatized and shunned by members of the public. By the time SARS was contained in mid-2003, there had been 33 deaths and 328 infections in Singapore.

Nonetheless, the way in which Singapore managed the SARS crisis received glowing praise from international health experts and agencies. A spokesman from the US Center for Disease Control and Prevention said: “I can’t think of anything that Singapore could have done better. Based on the knowledge they had at any given time, they made the right set of decisions… Singapore keeps pushing the envelope.” (n4). Dr. Peter Sandman, a risk communication specialist in New Jersey, U.S. also praised Singapore’s risk management: “For managing urgent health problems, you can’t beat a country like Singapore that knows it can’t hide the problem but genuinely can respond as strenuously as needed….Singapore’s open and responsive risk communication is impressive” (n5).

This study focuses on the risk communication strategies of Singapore’s health spokespersons – particularly those at the Tan Tock Seng Hospital (thereafter referred to as “TTSH”) and the Ministry of Health – in Singapore during the 2003 SARS crisis. Singapore’s experience is worth studying as TTSH won the International Public Relations Society’s Gold Award in 2004 for its SAR communication efforts. In addition, its communication efforts generated a groundswell of public support, generated US$16 million in public donations for SARS victims through the setting up of the Courage Fund, and attracted an unprecedented number of nursing staff in 2004(n6). The focus on health spokespersons such as physicians is appropriate – they often take on the role of media spokesperson in an epidemic, as the high level of social trust in them makes them the primary source of health information in bio-defense efforts (n7). Furthermore, since they engage in external communication to promote public awareness, surveillance, mobilization and response with regard to biological threats (n8), physicians play potentially important risk amplification and attenuation roles. Indeed, what physicians say to the news media may have a direct impact on how the public makes health-related decisions such as appropriate responses to health crises (n9).

Issues of social trust are important components of the social amplification of risk. For example, distrust “acts to heighten risk perceptions, to intensify public reactions to risk signals, to contribute to the perceived unacceptability of risk, and to stimulate political activism to reduce risk” (n10). Trust is especially important in risk situations such as health epidemics because these situations tend to be highly emotive: “When people can not understand they have to believe. And whether they believe or not is a matter of trust” (n11). Indeed, the social assimilation of science and scientific information has become for the most part taken for granted that it is for all intents and purposes an exercise of trust (n12).

While trust functions to reduce the complexity people face in society – and it does so by relieving them from the effort of making complex judgments by allowing them to select experts and information sources based on trust (n13) – it is extremely fragile. While it takes a long time to build trust, trust can be undermined or destroyed immediately by a single error or accident. Once trust is lost, “it may take a long time to rebuild it to its former state. In some instances, lost trust may never be regained” (n14). Moreover, trust has an asymmetrical quality – one requires a relatively large number of confirmatory experiences to build trust and a disproportionately small number of instances to undermine it (n15). To complicate risk management and communication, distrust is self-reinforcing and self-perpetuating: On the one hand, it inhibits the interpersonal interaction and communication that is so crucial in overcoming distrust. On the other, distrust distorts our perception of events and reinforces our existing beliefs (n16).

A recent review of the literature (n17) shows that trust consists of two dimensions: a general trust dimension – which is concerned with trust-relevant aspects such as competence, care, fairness, and openness – and a skepticism dimension. Both dimensions are expressed in a series of statements, several of which are incorporated into the research instrument for this study (see Appendix 1). In addition, studies have shown that public participation is related to the perceived trustworthiness of the organizations responsible for making risk decisions (n18). Thus, risk communication based on policy and management decisions that are the outcome of a participatory process enjoys greater public support (n19). As broad stakeholder participation becomes increasingly critical to effective risk management and assessment, risk communication needs to be framed around the nurturing of trust through participation (n20). Seen this way, public participation in risk management is akin to the model of two-way symmetrical public relations (n21) which has been enshrined as one of the general principles in the framework of excellent public relations, as it involves “bargaining, negotiating, and strategies of conflict resolution to bring about symbiotic changes in the ideas, attitudes, and behaviors of both the organization and its publics” (n22). Hence, “public participation” may be added as another trust-relevant dimension.

My paper attempts to answer two research questions:

1. What trust-building (i.e. risk attenuation) strategies did the health officials use during the SARS epidemic?

2. What can public relations practitioners learn from them?

The answers to these questions may offer valuable lessons for public relations practitioners who are confronted with crises of epidemic proportions, such as the dreaded bird flu pandemic.


To evaluate the crisis communication strategies used by the health officials in Singapore, I conducted a quantitative content analysis of their statements to the Straits Times from March 1, March 2003 (when SARS first surfaced in Singapore) to 31 May, 2003 (when Singapore was declared to be SARS-free by the World Health Organization). The Straits Times was selected as it is the newspaper “of record” in Singapore. The search was conducted using the Lexis-Nexis database, with the word “SARS” in the headline (or lead paragraph) and the phrase “Tan Tock Seng” in the full text of the article. The decision to use “Tan Tock Seng” as a keyword was based on the Singapore government’s designation of TTSH as the “SARS hospital” in the country. The search returned a total of 222 relevant articles. Commentary pieces and articles appearing in the “sports” and “science & technology” sections of the newspaper were not included in the analysis. The articles were subsequently coded by two coders who had received training on how to use the coding instrument.

I developed a coding instrument (see Appendix 1) based on a general trust dimension and the dimension of skepticism. Verbatim and paraphrased statements made by TTSH physicians, TTSH non-physician staff, and spokespersons from the Ministry of Health were the unit of analysis. Each statement was identified and coded for the presence of the following trust-relevant aspects: (T) competence, (2) care, (3) fairness, (4) openness, (5) participation, and (6) skepticism. Each of these aspects was operationalized and expressed as two representative statements (see Appendix 1). The first five aspects are trust building or risk attenuating, while the last aspect (i.e. skepticism) is trust eroding or risk amplifying.

Intercoder reliability was calculated using Scott’s pi as it accounts for chance agreement, is appropriate for two coders and nominal variables, and because it is a highly conservative index (n23). To assess reliability, two of the authors double-coded a randomly selected sample of 40 articles that are a subset of the full sample. Coding was performed independently and without any consultation or guidance. The coders obtained a Scott’s pi of 0.91.


The Ministry of Health and TTSH officials used all five trust-building (risk attenuation) strategies during the SARS crisis. Nonetheless, the dominant trust-relevant aspect emphasized in the statements made to the Straits Times was “openness” (41.3%). This was followed by “participation” (19.3%), “competence” (17.94%), “care” (15.72%), “fairness” (13.5%), and “skepticism” (10.8%) (see Table 1). The emphasis on openness is especially salient in light of the fiasco unfolding in China, where health authorities were involved in covering up the seriousness of the SARS epidemic and stonewalled the World Health Organization’s investigative efforts. The scandal rocked international confidence in the Chinese government’s communication and management of the crisis. Unlike their China counterparts, the Singapore health officials and TTSH staff appreciated from day one the importance of open communication to effective prevention, preparation for, and response to health threats – it is the key social process that facilitates information sharing among policy makers, health care providers, and public members who need to coordinate efforts during a crisis (n24).

The strong call for public participation was a little more unexpected, given that Singapore has not traditionally had a political system that values dialogue with the public. However, the novelty and mysteriousness of the disease – there was still much that the health professionals and authorities didn’t know about the disease and the progression of the outbreak – made it all the more critical for the Ministry of Health and TTSH to acknowledge that they had little control over the external situation and to engage citizens as “sentries” in a system of surveillance. Furthermore, this partnership with members of the public was essential in creating the relations “needed to damp the social amplification of minor risks – as well as to generate concern where it is warranted” (n25). Indeed, TTSH had made creating public ownership of the battle against SARS a top priority (n26). Said risk communication specialist Peter Sandman:

“In spectacular risk-communication fashion, Singapore has ‘shared control’ with its public. The most dramatic example of this was the joint Health and Education ministries’ decision on March 25 to close nearly all the schools – not on medical grounds, they said, but because ‘principals and general practitioners have reported that parents continue to be concerned about the risk to their children in schools’. In one sentence, Minister Teo Chee Hean assured four groups of stakeholders that they were being heard and taken seriously: principals, general practitioners, parents – and the general public. The ministers can’t do everything the public wants – but the public knows its wishes will be considered.” (n27)

Participation is especially important in health and bio-defense efforts, as it is critical for health officials, health care workers and the public to gather and share relevant information to detect any infection threats, to understand the nature of such threats, to identify the extent of infection, and to inform the development of strategies that effectively respond to and minimize harm from such hazards (n28, n29).

Interestingly, Ministry of Health officials – not TTSH physicians and staff – played the dominant role in communicating to the public about SARS-related risks. Indeed, all five types of trust-building (risk attenuating) statements were made predominantly by the Ministry of Health (MOH):

This could perhaps be explained by the national implications of the SARS crisis, the Ministry’s role as custodian of the nation’s health, and TTSH’s position as the “SARS” government (versus private) hospital. Moreover, the Singapore government had put in place stringent procedures for the approval and dissemination of messages (e.g. press releases) to the public. Thus, data from the hospitals had to be verified daily by the Epidemiology & Disease Control Division at the Ministry of Health and then by the Director of Medical Services, and the Minister for Health presided at every press conference (n30). This practice of “speaking with one voice” and using a credible source to communicate messages can calm public fears and prevent panic (n31) AS rumors run rampant in a health crisis, it is all the more critical to have command and control over the flow of information so as to stem misconceptions and curtail speculation.

Nonetheless, such a single-minded, unified communication response would have been difficult in a press environment different from Singapore’s. Singapore has a system of press management that combines “watertight legal controls with a compelling political ideology that encourages not just obedience, but also active support” (n32, 65). Moreover, the government has always insisted that only it can be in charge of the national agenda. The Singapore press – interestingly – does not view itself as the “fourth estate” but as a “pro Singapore” social institution (n33).

Skepticism about the management of the SARS crisis was expressed nine times by various citizens. Of these skeptical comments, none were made by spokespersons from TTSH or the Ministry of Health. Nonetheless, five were made by citizens of some influence: 1) The news editor of the Straits Times (twice); 2) A local communications professor who criticized the government for taking initial rumors about SARS too lightly; 3) The husband of a deceased patient who criticized the hospital’s incapability; and (4) The head of a counseling center who said the government’s stringent measures lacked the “human touch.” Nonetheless, “skepticism” accounted for only 3.53% of the total number of trust-relevant statements made to the Straits Times – probably not significant enough to dampen the overall trust-enhancing (i.e. risk attenuating) thrust of the risk communication.


As they prepare risk and crisis communication strategies in anticipation of the bird flu pandemic, public relations and corporate communication practitioners around the world can learn a few things from Singapore’s experience:

1. Openly sharing knowledge – even admitting ignorance – of health-critical information and creating opportunities for public feedback is of paramount importance in a situation of uncertainty and information scarcity, which will almost certainly be the case in a bird flu pandemic. Doing this effectively will require full support from the organization’s top management, who must believe (or be persuaded to believe) that being transparent about what one knows or doesn’t know and making citizens stakeholders in the communication process can help attenuate risk perception.

2. Nonetheless, openness and public participation need to be complemented by consistent and timely messages of competence, care, and fairness. Without expressions and evidence of competence, even organizations that practice open communication and support public participation may appear paralyzed and unsure of how to deal with the crisis at hand, thus eroding public confidence in their ability to solve the problem. And, if an organization has a track record of, or reputation for competence, it can draw on the reserve of trust and goodwill that has been developed by earlier efforts. Without expressions of care and fairness, the public may perceive that organizations do not have their best interests at heart – a perception that could undermine the public’s willingness to cooperate with the authorities and thus encourage a dangerous “all for himself” attitude that could jeopardize public safety and risk management efforts.

3. Leverage the credibility of health authorities (e.g. Ministry of Health) in communicating about crises – especially in places where there is high social trust in the competence and integrity of the government and public officers.

4. Internal communication is also critical to establishing and maintaining trust. The role of internal communication is especially important in health epidemics, as medical and nursing staff working in healthcare institutions are vulnerable to falling ill and succumbing to the very infectious diseases that they monitor, prevent and cure. Indeed, during the SARS crisis in Singapore, a lack of understanding of the disease and its transmission led to intense fear and irrational behavior towards healthcare workers. If TTSH and the Ministry of Health had not taken strong internal communication measures to strengthen the morale and esprit de corps of these workers, there is no telling what the Singapore SARS story might have been.


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(n2) Ibid, 1.

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(n15) Ibid, 12.

(n16) Ibid, 12.

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(n18) National Research Council. (1996). Understanding risk: Informing decisions in a democratic society. Washington, D.C.: National Academy Press.

(n19) Arvai, J.L. (2003). Using risk communication to disclose the outcome of a participatory decision-making process: Effects on the perceived acceptability of risk-policy decisions. Risk Analysis, 23 (2), 281-289.

(n20) Ibid, 9.

(n21) Grunig, J.E., & Hunt, T. (1984). Managing public relations. New York: Holt, Rinehart and Winston.

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(n26) Ibid 6.

(n27) Ibid, 5.

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(n31) Benjamin, G.C. (2002). Managing terror: Public health officials learn lessons from bioterrorism attacks. Physician Executive, 28 (2), 80-83.

(n32) George, C. (2000). Singapore: The air-conditioned nation. Essays on the politics of comfort and control 1999-2000. Singapore: Landmark Books.

(n33) Latif, A. (1998). The press in Asia: Taking a stand. In Asad Latif (Eds.), Press freedom and professional standards in Asia. Singapore: Asian Media Information and Communication Center.

Dr. Mark Chong

Mark Chong is Practice Assistant Professor of Corporate Communication at the Lee Kong Chian School of Business at Singapore Management University (SMU). His research, which focuses on corporate, marketing, and risk communication, has been published in both academic and trade journals.

Before joining academia, Dr. Chong worked for more than nine years as a corporate and marketing communication professional in the Asia-Pacific. He has held various positions in multinational corporations and agencies, including Hewlett-Packard and The Hoffman Agency.

Dr. Chong graduated with a Ph.D. from Cornell University. He also has a Master of Science degree from Cornell and a Bachelor of Arts degree from the University of Calgary.

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