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SARS report says system failed health workers
CAROLYN ABRAHAM
Globe and Mail Update
The final investigation into the handling of the deadly SARS crisis of 2003 has found that a gutted public health system, command and communication breakdowns and a blind faith in science all failed to protect the people — and most specifically the health care professionals of Ontario.
In a cutting 1,200 page report released Tuesday, Ontario Superior Court Justice Archie Campbell spared no level of authority from criticism.
While the report does not single out any individuals for blame, 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.â€
“The evidence discloses no scapegoats,†Judge Campbell wrote.
“The lack of preparation against infectious disease, the decline of public health, the failure of systems that should protect nurses and paramedics...went on through three successive governments of different political stripes. So too, in a sense, we as citizens failed ourselves because we did not insist that these governments protect us better.â€
The report makes clear that understanding and correcting past mistakes is essential if Ontario is to fare better against the next infectious threat, which many experts predict will be a global influenza pandemic 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, we will pay a terrible price in the next pandemic,†Judge Campbell wrote.
The Ontario government created the SARS Commission under Judge Campbell in June 2003 to investigate the origin, spread and management of the mysterious pneumonia that emerged from the jungles of central China four years ago.
The commission has since filed two reports.
The first in 2004 outlined the deep problems in the public health system and the steps needed to fix it. The second, in 2005, addressed the “glaring deficiencies†in Ontario's emergency response laws.
In this third and final instalment, Judge Campbell focused heavily on improving the safety of front-line workers — “the heroes of SARS†— who continued to show up for shifts while colleagues around them fell ill and they and their families lived in fear of their lives. Two nurses and a doctor were among those who died and health workers made up almost half of all cases.
Yet health workers continued to be at risk, the report found, due to the lack of preparedness and infection control policies that hospitals never adopted and governments failed to enforce. What's more, the report noted that worker-safety measures were prematurely relaxed in the spring of 2003 and health workers wrongly led to believe the disease had been beaten. The wishful optimism resulted in a second wave of SARS out of North York General Hospital that struck 127 people and killed 17 of them.
“The surprise is not that Ontario's response to SARS worked so badly, but that it worked at all,†Judge Campbell said, “given the lack of preparation and systems and infrastructure.â€
Judge Campbell, who is battling cancer and was unavailable for interviews, wrote that progress has been made on a number of fronts to improve Ontario's public health system in the last four years. But, he writes “serious problems persist and much remains to be done.â€
Chief among the report's recommendations is the need for government, hospitals, health officials and health workers to improve infection control measures by adopting “a precautionary principle.â€
The report, for example, describes efforts to contain SARS as hospitals making mistakes “in the fog of war against an invisible enemy.†Initially, no one knew anything about its origins, 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, officials waited for “scientific certainty.â€
“Again and again, health workers in Ontario were told they were safe if they would only do what they were directed to by the hospitals and the government. Again and again, these confident scientific assurances turned out to be tragically wrong.â€
The report notes that “more and more studies have since been published indicating the possibility under certain circumstances of airborne transmission, not just of SARS but of influenza.
“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.â€
The five-chapter report, based on public hearings, government and hospital documents and interviews of more than 600 people, contrasts the devastation SARS wreaked in Ontario with its relatively smooth management in British Columbia thanks to stricter infection control measures and “a far greater commitment to the precautionary principle.â€
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Once again, another piece of evidence suggesting the stupidity of going cheap on public health. In Quebec some 2,000 people have died to C. dificil since 2003, with many of these deaths being quite preventable through simple hospital hygiene. But with no money for people to clean, and nurses too busy to do it, many people lost their lives.
CAROLYN ABRAHAM
Globe and Mail Update
The final investigation into the handling of the deadly SARS crisis of 2003 has found that a gutted public health system, command and communication breakdowns and a blind faith in science all failed to protect the people — and most specifically the health care professionals of Ontario.
In a cutting 1,200 page report released Tuesday, Ontario Superior Court Justice Archie Campbell spared no level of authority from criticism.
While the report does not single out any individuals for blame, 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.â€
“The evidence discloses no scapegoats,†Judge Campbell wrote.
“The lack of preparation against infectious disease, the decline of public health, the failure of systems that should protect nurses and paramedics...went on through three successive governments of different political stripes. So too, in a sense, we as citizens failed ourselves because we did not insist that these governments protect us better.â€
The report makes clear that understanding and correcting past mistakes is essential if Ontario is to fare better against the next infectious threat, which many experts predict will be a global influenza pandemic 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, we will pay a terrible price in the next pandemic,†Judge Campbell wrote.
The Ontario government created the SARS Commission under Judge Campbell in June 2003 to investigate the origin, spread and management of the mysterious pneumonia that emerged from the jungles of central China four years ago.
The commission has since filed two reports.
The first in 2004 outlined the deep problems in the public health system and the steps needed to fix it. The second, in 2005, addressed the “glaring deficiencies†in Ontario's emergency response laws.
In this third and final instalment, Judge Campbell focused heavily on improving the safety of front-line workers — “the heroes of SARS†— who continued to show up for shifts while colleagues around them fell ill and they and their families lived in fear of their lives. Two nurses and a doctor were among those who died and health workers made up almost half of all cases.
Yet health workers continued to be at risk, the report found, due to the lack of preparedness and infection control policies that hospitals never adopted and governments failed to enforce. What's more, the report noted that worker-safety measures were prematurely relaxed in the spring of 2003 and health workers wrongly led to believe the disease had been beaten. The wishful optimism resulted in a second wave of SARS out of North York General Hospital that struck 127 people and killed 17 of them.
“The surprise is not that Ontario's response to SARS worked so badly, but that it worked at all,†Judge Campbell said, “given the lack of preparation and systems and infrastructure.â€
Judge Campbell, who is battling cancer and was unavailable for interviews, wrote that progress has been made on a number of fronts to improve Ontario's public health system in the last four years. But, he writes “serious problems persist and much remains to be done.â€
Chief among the report's recommendations is the need for government, hospitals, health officials and health workers to improve infection control measures by adopting “a precautionary principle.â€
The report, for example, describes efforts to contain SARS as hospitals making mistakes “in the fog of war against an invisible enemy.†Initially, no one knew anything about its origins, 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, officials waited for “scientific certainty.â€
“Again and again, health workers in Ontario were told they were safe if they would only do what they were directed to by the hospitals and the government. Again and again, these confident scientific assurances turned out to be tragically wrong.â€
The report notes that “more and more studies have since been published indicating the possibility under certain circumstances of airborne transmission, not just of SARS but of influenza.
“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.â€
The five-chapter report, based on public hearings, government and hospital documents and interviews of more than 600 people, contrasts the devastation SARS wreaked in Ontario with its relatively smooth management in British Columbia thanks to stricter infection control measures and “a far greater commitment to the precautionary principle.â€
--------------------------------
Once again, another piece of evidence suggesting the stupidity of going cheap on public health. In Quebec some 2,000 people have died to C. dificil since 2003, with many of these deaths being quite preventable through simple hospital hygiene. But with no money for people to clean, and nurses too busy to do it, many people lost their lives.