The final investigation into the handling of the deadly SARS crisis has found that a gutted public-health system, command and communication breakdowns and a blind faith in science all failed to protect the people -- but most specifically-- the health-care workers of Ontario in 2003.
In a cutting 1,200-page report released yesterday by the SARS Commission, Ontario Superior Court Justice Archie Campbell concludes that while some improvements have been made to Ontario's public-health system, four years later "serious problems persist and much remains to be done."
In fact, the report includes a three-page chart that suggests only five of the 25 emergency recommendations the independent commission has made over the last two years have been "accepted."
These involve measures to compensate people under quarantine for lost wages, and clarify official lines of communication.
Judge Campbell, battling cancer and unavailable for interviews, warns that correcting past mistakes is essential if Ontario is to fare better against the next infectious threat, which many experts predict will be an influenza outbreak that could fell tens of thousands and prove far trickier than SARS to contain. "If we do not learn from SARS and we do not make the government fix the problems that remain," he writes, "we will pay a terrible price in the next pandemic."
The report singles out no individual for blame, but it concludes that system-wide failures contributed to the outbreak of severe acute respiratory syndrome, which in five months killed 44 people, sickened 375, quarantined thousands and brought the province's health system "to its knees."
"The surprise is not that Ontario's response to SARS worked so badly, but that it worked at all," the report notes, "given the lack of preparation and systems and infrastructure."
The Ontario government created the SARS Commission under Judge Campbell in June, 2003, to investigate the origin, spread and response to the mysterious pneumonia that emerged from China four years ago.
The commission has since filed two reports. In this third and final instalment, Judge Campbell focuses on improving worker safety. "The heroes of SARS" continued to show up for shifts while colleagues fell ill and they and their families feared for their lives.
Two nurses and a doctor died and health workers made up almost half of the cases.
Yet health workers continued to be at risk, the report finds, due to the lack of preparedness and infection-control policies that hospitals never adopted and governments failed to enforce. What's more, the report notes that worker-safety measures were prematurely relaxed in the spring of 2003 and health workers were mistakenly led to believe the disease was gone. The optimism contributed to a second wave of SARS out of North York General Hospital that struck 127 people and killed 17 of them.
Unions representing front-line workers lauded the report for recognizing hospitals to be as dangerous as "mines and factories" and for urging that health workers be given a stronger voice in the system.
Linda Haslam-Stroud, president of the Ontario Nurses Association, a 52,000-member union, said in a statement that during SARS, Ontario "did not have an adequate supply of protective equipment, and employers did not provide appropriate training for equipment that did exist.
"This sort of situation cannot be allowed to happen again. The government now has clear recommendations on what needs to be done to prevent another similar situation."
Chief among those recommendations is a call to improve infection control by making sure "a precautionary principle" is the reigning culture in hospitals and the public-health system.
Initially, no one knew anything about the origins of SARS, how the virus could be transmitted, the course of the disease or its death rate. But instead of working from the worst-case scenario that SARS might be spread through airborne transmission and scaling back containment measures as more was learned, the report found that officials waited for "scientific certainty."
"Scientific knowledge changes constantly. Yesterday's scientific dogma is today's discarded fables. When it comes to worker safety in hospitals, we should be driven . . . by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty."
But Donald Low, chief microbiologist at Toronto's Mount Sinai Hospital and one of the key public-health experts managing the SARS outbreak, predicted that living by the "precautionary principle" could pose big challenges for any hospital in practice.
"If you had a cluster of patients on a ward with pneumonia, and you wonder if this could be transmitted in the ward, do you close it? Do you get everyone in full gear and go into full negative air pressure?" Dr. Low asked.
The report, based on public hearings, government and hospital documents and interviews of more than 600 people, makes a raft of new recommendations to improve worker safety and the tragic situations families can face in a lethal outbreak. Among them:
Develop and rehearse emergency plans to close hospitals and find a way of immediately notifying staff, both on and off duty, of any potential risks.
Design a system to track and trace patients and visitors to a hospital at a given time.
Ensure the Ministry of Labour prepares and oversees initiatives involving protective gear for workers during a health crisis