CAROLYN ABRAHAM AND LISA PRIEST From Saturday's Globe and Mail Saturday, May. 3, 2003 Just 16 months before SARS hit Toronto, the Ontario government deemed the last of its leading lab scientists redundant and sent them packing as it scoffed at the prospect of any new disease threatening the province. The timing of government layoffs on Oct. 18, 2001, left five top microbiologists in utter disbelief. Walkerton's tainted-water scandal was a fresh memory. Bioterror threats loomed after Sept. 11 and the West Nile virus had made its Ontario debut. But the Ontario government declared at the time that the province no longer needed their scientific expertise, insisting there were no new tests to develop: "Do we want five people sitting around waiting for work to arrive?" said Gordon Haugh, a Health Ministry spokesman. "It would be highly unlikely that we would find a new organism in Ontario." This February, a new organism turned out to be just a plane flight away. The SARS virus made a mockery of government predictions and exposed the weaknesses of a stripped-down public-health system that many had warned was headed for crisis, a Globe and Mail investigation has found. "SARS was an accident waiting to happen ? because of the priorities of the government, the cost-cutting measures, the conditions were great for SARS to take hold," said William Bowie, an infectious disease specialist at the University of British Columbia who answered Toronto's cry for help during the early weeks of the outbreak of severe acute respiratory syndrome. People on the front lines fighting SARS say it is nothing short of a miracle that a "bare-bones" public-health system managed to control the crisis. It was done despite skimpy resources and with the help of a fractured crisis-management crew that relied on favours, volunteers and "begging and borrowing" everything from software to scientists. The outbreak highlighted the dire shortage of health workers to trace those at risk of the disease and glaring shortcomings in the province's laboratory services. It exposed a patchwork communication system that left the containment team no direct means of quickly contacting hospital workers. And with no established, central body of infectious-disease experts in Ontario, officials had to cobble together a last-minute team to track crucial details about the disease, including incubation time and how it was being transmitted. For years, infectious-disease experts have warned that a flu pandemic is looming and that Ontario needed to bolster its support of public health. "It's been very clear to us that we were going to pay for the public-health dismantling that has happened under the provincial and municipal governments," said Allison McGeer, head of infection control at Toronto's Mount Sinai Hospital and one of the key members of the SARS containment team. Ontario's understaffed lab, which sits in Toronto's west end on the ironically named Resources Road, is just one example of the inadequacies. It was once considered a world-class reference laboratory, with dozens of top-notch scientists who watched for coming infections and anticipated new disease threats by designing diagnostic tests to detect them. But by 2003, according to one of those laid off, "there was no one left watching any more." Among those let go in 2001 was microbiologist Ching Lo, who was designing a test for the West Nile and Norwalk viruses, and Martin Preston, who was developing a rapid-detection method for the E-coli bacteria responsible for the Walkerton outbreak. "We're living in the richest province in Canada and we couldn't afford to have a top-notch public-health lab system to support outbreaks," Dr. Preston said. Even before the layoffs, a steady stream of scientists had left the lab, frustrated by cost cuts. None was replaced. Today two microbiologists remain. "I saw the public-health labs and the public-health units being underfunded and under-supported and being dismantled from the inside out. I didn't want to be part of that," said Neal denHollander, who headed the provincial lab's standards and development section until 2001. By the time of the SARS outbreak, lab scientists at the Hospital for Sick Children had decided to band together with colleagues at other hospitals and the provincial lab to do the work that Ontario's public lab used to perform alone. Susan Richardson, head of microbiology at Sick Kids, said her colleague Raymond Tellier decided on his own to develop a diagnostic test for the coronavirus behind SARS. "The ability to respond to this outbreak came from the efforts of individuals," said Dr. Richardson. "[Dr. Tellier] in a hospital lab used his own initiative to work day and night and weekends to develop this test. Efforts such as these, she explained, are "the only reason we have survived this outbreak against all odds." The Sick Kids' work led Dr. Richardson to spearhead the creation of the "Ontario Laboratory Working Group for the Rapid Diagnosis of Emerging Infections." Last month, Ontario pledged $2.5-million for its research on a SARS test. Dr. denHollander, who now heads the regional lab in Toronto that runs tissue-compatibility tests for transplants, applauded the hospital labs. But, he said, "It's filling a void that ought not to exist, that hospitals are doing this speaks largely to the abdication of responsibility here." ** Early in the outbreak, Donald Low, chief microbiologist of Toronto's Mount Sinai Hospital and a key member of the containment team, recognized quickly that officials needed experts who could study the big picture Such a resource was readily available at the B.C. Centre for Disease Control, where microbiologists and disease trackers ? including Ontario's former chief epidemiologist ? work. But Ontario has no such central body, and Dr. Low found himself lobbying James Young, commissioner of public security, to recruit the staff. Dr. Young gave the go-ahead on March 29, as the SARS caseload skyrocketed, and Dr. Low recruited colleagues from Halifax, Ottawa, Kingston and B.C. to form a scientific advisory group, promising to pay their expenses. The willingness of people to volunteer compensated for gaps in the system, said Dr. McGeer; "people like Dick Zoutman, who chaired the SARS scientific advisory committee . . . dropped everything he was doing to help." Some of those who came from other parts of the country were struck by the ramshackle state of the public-health infrastructure in Canada's most populous province. "I saw a lot of people working really, really hard to try and deal with each new onslaught, and at the same time try to create some kind of a co-ordinated management structure that didn't exist," Dr. Bowie said. But infection control was not the only weakness. The ministry seconded University of Toronto epidemiologist Ian Johnson. But Dr. Johnson needed a team to collect and analyze the data from the dozen Ontario public-health units reporting SARS cases. So out went another call for volunteers, bringing in workers from as far away as Winnipeg. "We needed a centralized agency within the province to handle this sort of thing. We needed somebody in charge who had the authority to make decisions and the resources to do what had to be done to carry them out," Dr. Low said. "Instead we were borrowing and begging to carry out a proper investigation." Dr. Johnson, a mild-mannered scientist given to backpacks and corduroys, began work on April 1, building a computerized database with software Health Canada had passed on. "The main challenge for me was that each of the health units already had their systems in place for three weeks, and they were going flat out," Dr. Johnson explained. He had to create a standard SARS case report form and a system for each public-health unit to call the ministry daily with information on each new patient. Without this collated data, Dr. Low explained, all that existed were fragments of information that did not allow recognition of trends. It was Dr. Johnson and his epidemiological team that gathered enought patient data to be sure the maximum incubation period for SARS was 10 days. "The average was four to five days," said Dr. Johnson. "But knowing the maximum period was important for planning quarantine times." It turned out to be a major stroke of luck for the containment team. Even before Dr. Johnson arrived, health officials had recommended 10-day quarantine periods. This, said Dr. Bowie, was based on the Hong Kong experience and "a whole lot of finger-crossing." Dr. Bowie was dismayed to learn when he got to Toronto that an epidemiology team was not in place. "In a more desirable world, that would have already existed," Dr. Bowie said. "But they had to start from scratch." He was not entirely surprised. For years, he has attended planning meetings for the predicted flu pandemic with colleagues from other provinces, and marvelled at Ontario's shortcomings. "Ontario does not seem able to pull together an integrated effort, either for pandemic planning or to deal with bioterrorism," he said. "It's gotten progressively worse. Advice has been ignored for a long time." At the local level, Sheila Basrur's health unit was forced to pull staff away from investigations of syphillis cases and an outbreak of tuberculosis in Toronto's hostels to work on SARS. "We would try to beg, borrow or steal staff from other health units who could voluntarily come to Toronto and help out for a week or two and then go back to their home base," Dr. Basrur said. Twenty people were borrowed from other health units in the province, 62 were reassigned from other investigations, accounting for a total of 305 people in Toronto charged, among other things, with tracing the movements of thousands of people. "It's like ripping the bandage off of one wound to stop the bleeding of another one," Dr. Basrur said. ** The lack of a central communication system haunted health officials on the front line. For years, Dr. McGeer, Dr. Low and their colleagues had lobbied for an electronic, province-wide database that would allow doctors to connect patient information with lab results or any epidemiological data. "You have an electronic file and you might have a hand-written result, and so someone can access that file, but not know about the note, and so there is no connection made," Dr. Low said. During the SARS outbreak, the rapid flow of information about suspect cases relied on telephone calls, faxes, and e-mails, all flooding in from hospitals and clinics to the public-health units. Dr. Johnson has been compiling this data into a central data base, but only provincial ministry officials have access, he explained. In fact, in the seventh week of the outbreak, the province has still not decided whether it will allow health officials in Toronto and York to have access to the system that their information helped create. Dr. Johnson said the issue is whether York officials should be allowed access to Toronto data, and vice versa ? even though they routinely exchange such information by phone. "You are trying to balance privacy issues with the speed of trying to respond to an outbreak," Dr. Johnson said. Monika Naus, once Ontario's chief epidemiologist, and now the associate director of epidemiology services at the B.C. Centers for Disease Control, an arms-length provincial agency, said she too realized the need for a centralized system when she left Ontario in 2001. "B.C. has much less stringent data-sharing information," she said. Meanwhile, communication lines between the containment team and the hospital staff also proved less than efficient. Dr. Bowie noted that the scientific advisory body would draft policies for infection-control measures and pass them on to the executive SARS committee, which included Dr. Young and Ontario commissioner of public health, Colin D'Cunha. "We never really knew if the directives were passed on, or if they weren't," Dr. Bowie said. Sometimes, the scientists would discover that the directives sent did not resemble those they had drafted. The inefficient communications left some doctors wondering what they might have been able to prevent if they had known crucial details about how people were contracting SARS. Dr. McGeer, for example, noted that early in the outbreak at Scarborough Grace Hospital, there had been infections associated with intubating a patient. "Maybe if we had that data," she said, "we might have seen more clearly the risk involved in certain procedures and prevent what happened at Sunnybrook [where several health workers contracted SARs after a four-hour long effort to intubate a patient]." ** The Ontario government has pledged a full postmortem on the handling of the SARS outbreak. Dr. Bowie said this week from B.C. that he hopes to be included. "SARS is a tragedy," he said. "But it would be a much worse tragedy for Canadians not to learn from the lessons we can take from this." Ontario Health Minister Tony Clement, widely lauded for his leadership role in the outbreak, now appears to be fully supportive of boosting public health. And Health Ministry spokesman John Letherby noted that Ontario has increased its spending on public-health labs to $62.6-million in 2002-2003 from $41.7-million the year before. That includes wages, cost of equipment, supplies and other items for Ontario's 37 public-health units, but not overall budgets, he said. Yet, in the middle of a provincial emergency ? declared for the first time in history for reasons of public health ? Dr. Basrur wonders why this week's Throne Speech did not mention public health. "I challenge you to find any mention of public health in there," she said. ". . . We're in the middle of a wake-up call and people are still sleeping."