SARS taught us but we’ve more to learn

We’ve made progress since 2003, but not enough, Dr. David M.C. Walker says.

In Ontario, a post-mortem was conducted on SARS shortly after its death. The objective, as it has been for millennia, was to apply the lessons learned from the dead to protect the living. What did we discover and how well did we learn those lessons?

We were reminded that nasty bugs have attacked humans since our very beginnings and would always continue to do so, thus the need to be prepared. We noted that we had sophisticated surveillance for foreign armies, although we had not invested in similar surveillance for pathogens. We were not on the lookout so we did not see SARS coming.

We learned that we did not adequately protect the health-care workers who were disproportionately harmed during SARS. We learned that our hospitals were operating well over their capacity with no ability to meet a surge in demand, and that many people languishing in those hospitals did not need to be there. We noted the challenge of differentiating the roles of politicians and health experts. And, most significantly, we discovered that our public health infrastructure had been significantly degraded and diminished over the previous decades. Our public health laboratory capacity had also become constrained. The very instruments and remedies required to fight SARS were outdated, rusty, inadequate and ill-equipped.

So now that we are in the midst of the predicted pandemic, how are we doing?

In the years following

SARS, much of what we discovered from that post-mortem informed progressive public policy, legislation and change for the better. Public health was reanimated, reconfigured and provided with additional resources. Surveillance mechanisms (local, regional, national and global) were developed and public health agencies were created or enhanced. Careers in public health were made more attractive and rewarding.

The post-mortem reminded us that epidemics and pandemics will always be with us and that we must be prepared for the next one. They come quickly but should not come unexpectedly. On this point, while our response was perhaps slower (unfortunately, initially covert in China) and more graduated than hindsight might judge was wise, we have done far better than with SARS.

In being prepared, however, it seems we have more to learn. We have been severely challenged in protecting our health-care workers with personal protective equipment (PPE). We needed to ensure adequate stockpiles and sources of PPE for our heroes on the front line. We invest heavily in equipping our armed forces, but now first responders, personal support workers, porters, nursing assistants, nurses and doctors are the front line. Rapid efforts to mobilize PPE have been magnificent from all sources of possible supply, but we should have been better prepared.

And were our hospitals ready? Did they have surge capacity? Only recently has a concerted effort been made to “end hallway medicine.” For decades, we have allowed thousands of frail elderly people to languish on stretchers in emergency department corridors and passageways awaiting admission, de-conditioning by the hour, becoming confused and developing all manner of complications. Once admitted, these frail people remain in hospital long after they require acute hospital care, in sunrooms, broom closets and hallways. Solutions have been well-known but very slowly applied. How tragic that it took a virulent pandemic to end this practice, for suddenly we see very few “alternate level of care” patients in hospitals and none in hallways. Let us pledge not to backslide on this, for the sake of our vulnerable.

Lastly, the SARS autopsy revealed the challenges posed to a democratic society by such a health crisis. It revealed the need for politicians to lead us but the requirement for health experts to truth-tell without encumbrance. Performance in this category has varied widely by country but, as time passes, Canada and Ontario will be regarded as having done comparatively very well.

Much fear, sadness, and human and economic loss is being caused by this pandemic, but much good will come from the human ingenuity, creativity and kindness it has evoked. Let us pledge a legacy of learned and relearned lessons and a promise to maintain the critically needed changes we are adopting amid the crisis to care for our society in the future.

David M.C. Walker, MD,

FRCPC, chaired the Expert Panel on SARS and Infectious Disease Control, Ontario, 2003. He is a professor of emergency medicine and policy studies at Queen’s University.