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Cost-cutting measures fueled SARS spread

By



 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."