Forgotten lessons of 2003
Ontario failed to heed warnings to prepare for future health disasters
From inadequate data systems to insufficient surge capacity, here are the warnings Ontario failed to heed from SARS,
year ago, on a winter evening in Toronto, a man was admitted to hospital complaining of fever and a dry cough after returning from a trip to Wuhan, China.
Since Canada’s first COVID-19 case on Jan. 25, 2020, more than 18,000 Canadians have died, including over 5,600 in Ontario. The virus has entered every corner of life — ravaging seniors’ facilities, shuttering schools and most businesses, damaging entire sectors of the economy, leaving thousands with lasting health issues, exposing deep-rooted systemic inequality and causing unimaginable loss.
Could it have been prevented? More than 17 years ago in the winter of 2003, a Toronto woman visited her family doctor complaining of fever and dry cough after returning from a trip to Hong Kong. She did not have COVID-19 — she had Severe Acute Respiratory Syndrome (SARS), an infectious respiratory disease that shares almost 80 per cent of COVID-19’s genes.
The SARS pandemic, infecting more than 8,000 people globally and 400 in Canada, nearly all in Ontario, was less widespread than COVID-19, but it caught the province off guard and laid bare a health system grossly unprepared to deal with an infectious disease.
The systemic failures caused preventable suffering and loss, including 44 deaths in Canada, all in Toronto, and were balanced only by the courage of health-care workers who stepped up at great personal risk.
In the years following SARS, several and provincial and national reports took stock of Ontario’s failings and suggested a path forward.
A landmark report on the epidemic by the late Ontario Superior Court Justice Archie Campbell, released in January 2007 and accepted by the province, remarked that “SARS showed that Ontario’s public health system is broken and needs to be fixed,” warning that the province was vulnerable to future disasters.
When COVID-19 first hit, many were hopeful that Ontario’s experience during SARS would inform a more competent pandemic response. One year since Canada’s first COVID-19 case, it’s clear many of the same issues still plague us. The Star spoke to infectious disease and public health experts — some whom were involved in reports on SARS — about the lessons Ontario didn’t learn from SARS and where to go from here.
Inadequate data and information systems
Part of the reason SARS got so bad is because Ontario failed to quickly identify and communicate new cases of the virus. Justice Campbell’s report found this failure contributed to the outbreaks in hospitals and enabled SARS to re-emerge after it was thought to have been contained. SARS primarily affected health workers, patients and visitors in several GTA hospitals, forcing temporary closures at hard-hit Scarborough Grace and York Central during the first wave, and at North York General during the second wave in May 2003.
Nearly two decades later, experts say we still lack the data systems needed to manage a global pandemic — especially one much larger in scope than SARS.
In April, Ontario failed to identify new cases and outbreaks and get the information out in a timely manner. As COVID-19 ravaged the long-termcare system, the Star found official sources were vastly underreporting the number of deaths and failing to disclose where they were occurring.
Testing and contact tracing lagged. Between March and August, the Ontario auditor general noted it took on average 5.75 days to test specimens and start case management in Toronto — ample time for the virus to spread.
Dr. David Naylor, who chaired the National Advisory Committee on SARS and Public Health in 2003, said civilians have had to step in to fill some of the gaps — like Dr. Jennifer Kwan, who posts daily updates on key COVID-19 metrics to her Twitter account.
While these people deserve praise, he said, “there’s something wrong with a situation where we have to rely on this kind of, if you will, bootlegging operations to get data assembled and analyzed.”
After months of calls to track COVID-19’s disproportionate impact on racialized communities, Ontario began mandating race-based data in July, “a bright spot” in the data story, Naylor said. Before this pandemic there was a “wilful blindness” to race-based disparities in public health.
“Now we see, thanks to COVID that there are serious fault lines … and there seems to be more openness to collecting and using those data.”
Amid high rates of community transmission, Ontario’s inability to explain where new infections are coming from makes it difficult for the public to grasp policy choices, said Ashleigh Tuite, an epidemiologist at the University of Toronto.
“There’s been a desire from the public to understand why we’re saying what we’re saying. Why are we saying that restaurants and bars aren’t safe? Or why are we saying that schools are or are not safe? That sort of data isn’t being released and it’s not always collected in a systemic way.”
Dr. David Mowat, a former Ontario medical officer of health in the 1990s, says weak data systems that were not sufficiently upgraded post-SARS have hindered Ontario’s response.
Poor communications and lack of an independent public health voice
At nearly every point during SARS, poor communication exacerbated the virus’s spread. When Canada’s first SARS patient was hospitalized in Toronto in February 2003, Ontario health officials had not been alerted that a new deadly disease had been spreading through China for months. When SARS resurfaced that May, journalists had to pry news of an emerging outbreak at North York General Hospital out of health officials during question period at a press conference.
Dr. Colin D’Cunha, Ontario’s chief medical officer of health during SARS, was criticized for being too close to government and failing to lead effectively. The Campbell report found “the crisis was, to a large extent, managed around” D’Cunha, and that there was a “perception among many who worked in the crisis that politics were at work in some of the public health decisions.”
After the SARS experience, the Liberal government under Premier Dalton McGuinty made changes to the legislation to “… clarify that the CMOH is a central authority during times of potential health emergencies, free to act on his/her own initiative based on assessed risk.”
Still, muddled communications and unclear separation between public health and government have become a frequent criticism of Ontario’s COVID-19 response, with many accusing Dr. David Williams of failing to stand up to Premier Doug Ford and implement effective health policy.
According to Dr. Zain Chagla, infectious disease specialist for St. Joseph’s Healthcare in Hamilton, trouble can arise when politicians are the ones delivering the public health messaging, such as with Ford’s frequent press briefings.
“It really does skew the messaging and it really starts drawing partisan lines across public health measures,” he said, which hurts public trust, and as a result, compliance. He said health officials in Ontario have often failed to articulate the science and how it informs policy.
Throughout the pandemic, public health measures have been criticized for being vague and misleading, including the current stay-at-home orders that permit Ontarians to gather in groups of five while demanding people stay home unless absolutely essential — with no definition of what essential entails.
Insufficient surge capacity
“SARS taught us that we must be ready for the unseen. That is the most important lesson of SARS,” wrote Campbell in his report’s prologue.
“… However, there is no longer any excuse for governments and hospitals to be caught offguard and no longer any excuse for health workers not to have available the maximum level of protection through appropriate equipment and training.”
Surge capacity refers to a system’s ability stretch beyond its limit in times of emergency — in the context of a pandemic, to accommodate a heightened demand for things like medical supplies and hospital beds.
In 2007, on a recommendation from Campbell’s SARS Commission, Ontario said it would buy 55 million N95 masks to protect health workers the next time a respiratory virus hit. But over the years, the masks expired, and the province didn’t replace them.
Then came COVID-19, and the province was left scrambling once again.
“There was no question that we had problems with stockpiles and really didn’t have the appropriate manufacturing capacity or stockpiles to respond rapidly and effectively to this pandemic,” Naylor said.
Since Canada wasn’t making N95s, it had to rely on manufacturers in China and the U.S. In August, the Ontario and federal governments announced a deal to begin making N95s at a plant in Brockville.
Chagla said the N95 shortage made the government hesitant to mandate public masking — they didn’t want civilians taking masks from vulnerable health workers.
Ontario has also struggled to keep up with the need for hospital beds in COVID’s second wave, with the province recently announcing funding for a new facility in Vaughan to deal with COVID overflow.
A nurse in Scarborough described scenes of dying patients arriving at the emergency room with nowhere to put them. Toronto hospitals have been forced to send patients as far as Kingston for care.
Ontario has fewer hospital beds per capita than any other province and there’s little “wiggle room” for emergencies, says Tuite.
Failure to prevent institutional outbreaks and protect health workers
SARS is remembered as the virus that ravaged hospitals. COVID-19 will be remembered as the virus that ravaged Ontario’s long-term-care system, where 3,298 residents had died from the virus as of Friday.
Seventy-two per cent of SARS cases were contracted in health-care settings, and 45 per cent were health-care workers. Doctors, nurses, paramedics, medical technicians, cleaners became infected, many unknowingly passing the virus to their families. Two nurses and one doctor died.
One of the main reasons health workers were so vulnerable during SARS is because Ontario failed to apply the precautionary principle — the practice of taking precautions to reduce risk in absence of full information — particularly in protecting against airborne transmission.
The precautionary principle was a “key lesson” from SARS that Ontario failed to heed, says Mario Possamai, who advised Campbell on the SARS Commission. In his October 2020 report “A Time of Fear,” he details how Canada’s failure to employ the precautionary principle endangered health workers, who made up nearly 20 per cent of Canada’s cases in late July — twice the global average.
Back when little was known about COVID-19, Possamai says we should have been protecting against airborne transmission by mandating health workers wear N95s and ramping up air purification and ventilation systems in facilities like hospitals, schools and long-termcare homes.
“They’ve been given surgical masks, and surgical masks are not sufficient for an airborne disease,” he said. “They should have been wearing N95s right from the word go.”
There is now a widespread consensus that COVID-19 can be transmitted through the air.
For Chagla, the issue isn’t that we aren’t taking precautions — it’s that we still don’t know which precautions to take since the evidence hasn’t been generated.
“I think the failure is the fact that we are 10 months into this, and we’re still talking about the precautionary principle as it compares to SARS when there’s been thousands of times more cases of COVID-19 in every health-care system as compared to SARS, which affected a small region of the Greater Toronto Area.”
After SARS, Naylor said, we should have taken stock of different institutions and their vulnerabilities when it comes to infectious disease. “There’s a terrible, tragic lesson to be learned here about who is vulnerable when a respiratory virus grips through a population and how we have to be much better prepared to deal with it.”
Seventeen years is a long time in public health. The death and suffering of SARS reinvigorated interest and investment in the public health system — but over time, memories faded, budgets were cut, and lessons went unlearned. The failure to learn from old mistakes is not a new condition.
“David Naylor clearly identified this issue in his report,” Mowat said. “The history of public health in Canada is that there’s an outbreak, and then there’s a response, and there’s further investment as a result of that outbreak, and then it fades away, and then there’s another outbreak.”
“He said — his exact words — ‘this cycle must stop.’ ”
This could be the most important lesson we take from COVID-19.