SARS outbreak exposes public health decay in Toronto

Politicians and public health officials in Toronto and across Canada—from the city’s mayor to the federal health minister—have denounced the World Health Organization (WHO) for advising against travel to the city because of SARS (Severe Acute Respiratory Syndrome). Words such as “disbelief,” “dismay,” “overreaction,” “gross misrepresentation” and “irresponsible” have been hurled against the UN’s health monitoring agency.

Unfortunately, the outraged chorus typifies the official response to the SARS outbreak. From the day the first Toronto SARS case was identified, belatedly, on March 13, the authorities have been more preoccupied with covering up the underlying crisis in the city’s public hospitals and stemming the impact on tourism, retail and other vulnerable businesses than with ensuring public safety.

Their efforts to allay public fears and prevent economic fallout have oscillated between draconian and punitive measures—including emergency hospital shutdowns and individual quarantine court orders—and pleas for people to remain calm and keep on living, and, most importantly, spending, as normal. As a result, not just SARS victims but other seriously ill patients have suffered, sometimes catastrophically.

An examination of the SARS statistics and the timeline of its international spread confirms that the WHO had good reason on April 23 to add Toronto, together with Beijing and the Chinese province of Shanxi, to its list of no-go areas for visitors, joining Hong Kong and the Chinese province of Guangdong.

The WHO said the decision to advise postponing all but essential travel to Toronto was based on three factors: the magnitude of the city’s outbreak, the fact that it had spread from hospital workers into the community, and the fact that people traveling from Toronto had exported the disease to other countries.

Of the 4,288 probable cases reported by WHO on April 23, 140 were in Canada (nearly all in Toronto), making it fourth on the casualty list, after China (2,305 cases), Hong Kong (1,458) and Singapore (189). Canada’s 13 deaths (the toll has since risen to 16) also placed it fourth after China (106), Hong Kong (105) and Singapore (17). Canada had the highest rate of fatalities among those afflicted by the disease.

Last week, Toronto and Ontario health officials admitted that the infection may have escaped into the wider community, beyond the original cases that could be traced directly to two major Toronto hospitals—Scarborough Grace and York Central. Those exposed to confirmed SARS patients included 500 members of a religious group, residents of a 247-unit condominium complex, a number of train commuters and funeral attendees.

Dr. David Heymann, the WHO’s director of communicable diseases, pointed to the case of a person infected with SARS who left Toronto and sparked a cluster of five cases in another country. He would not name that country, but it is believed to be the Philippines, where a Toronto nursing assistant died of SARS. Other transmissions “seeded” from Toronto have been reported in the United States and Australia.

One reason for this international transmission is that Health Canada, the relevant federal authority, rejected an earlier WHO advisory, issued on March 27, that all passengers departing from Toronto’s Pearson airport be individually screened by medical personnel for SARS.

Apart from the WHO, 28 countries have advised their residents not to travel to Toronto. In the US, the Centers for Disease Control and Prevention issued a separate April 21 alert, advising visitors to Toronto to take basic precautions, including frequent hand-washing and avoiding health care facilities caring for SARS patients.

The WHO issued its latest travel advice “in order to protect public health and reduce opportunities for further international spread,” noting that SARS had already spread along international air routes to 25 countries on five continents. WHO officials fear that SARS, with a 6 percent mortality rate—higher than influenza, which kills 250,000 people globally—could become a permanent human contagion. They said the SARS virus was still mutating and could become more deadly.

Dr. Max Hardiman, who heads WHO’s international health regulation branch, defended the travel alert, explaining that SARS was a new disease whose method of transmission was not completely known, with no vaccine, no effective treatment and no proven way to avoid infection, except by avoiding contact with affected areas.

This elementary application of the customary “precautionary principle” of public health provoked outrage in the Canadian political and public health establishment. “I am just shaking my head here in disbelief,” Dr. Colin D’Cunha, Ontario’s commissioner of public health, told a news conference.

A damning timeline

While the Canadian media has lauded the response of health officials to the SARS outbreak as “exemplary,” the record shows otherwise. Health workers and doctors have made Herculean efforts to protect and care for those exposed to the disease, often at the cost of contracting SARS themselves. But the city’s chronically under-funded and understaffed public health system has performed disastrously.

Unlike China and Hong Kong, where the disease spread through residential and casual contact, in Toronto the hospital system has become the vehicle of transmission.

The WHO issued its first SARS health alert on February 11. This was distributed to Toronto health authorities more than two weeks before the city’s first SARS fatality, Kwan Sui-Chu, having recently returned from Hong Kong, went to her doctor with the known symptoms of fever, coughing and muscle tenderness on February 28. Her doctor, apparently not notified of the SARS alert, sent her home with an antibiotic prescription, the norm in Canada.

Kwan Sui-Chu died on March 5, but a coroner listed her cause of death as “heart attack.” On March 7, her son, Tse Chi Kwai, suffering the same symptoms, attended Scarborough Grace hospital, only to be left on an emergency room gurney for 12 hours, exposed to hundreds of people. No connection was drawn to SARS until Tse died on March 13.

Even then, hospitals did not screen health workers or close family members of SARS suspects, permitting the disease to spread more widely, infecting York Central hospital and exposing some 500 members of a Catholic church group on March 28.

By that stage, after years of federal and provincial spending cuts, hospital closures and job destruction throughout the public health system, hospital and emergency services were so over-stretched that health workers who were exposed to infection were obliged to remain on the job. Some returned to work wearing surgical masks and gloves. (This week, health officials announced that these measures were inadequate for protection against SARS.)

Having allowed hundreds of people to become infected, health officials claimed they could prevent any general spread into the community by taking a series of drastic actions. Compulsory 10-day quarantine orders were issued against suspected victims, isolating them from their families and forbidding them from going to work.

For three weeks, all but the most critical life-saving surgery was halted across Ontario, resulting in the death of at least one patient and threatening the lives of thousands of others. Surgery waiting lists, already unacceptably long, grew dramatically.

For example, the backlog at the University Health Network (which includes Toronto General, Toronto Western and Princess Margaret Hospital) before the SARS outbreak meant cancer patients queued 62 days on average for surgery. If SARS continued, network president Tom Closson said, the wait could extend to 100 days, four times what it should be. Other “non-emergency” patients, needing hernia or gall bladder surgery, would have to wait even longer.

Visits to hospital patients were banned for most relatives. All Ontario residents who felt flu-like symptoms were urged not to seek medical attention, but to voluntarily quarantine themselves, regardless of the economic and social costs involved. For the entire Greater Toronto region, home to nearly 5 million people, just two SARS clinics were established, where patients with SARS symptoms have waited outside, in cold weather, up to three hours to be examined.

The emergency could worsen. Late last week, Sunnybrook Hospital, one of Toronto’s two major regional trauma centers, closed its critical care, cardiovascular intensive care and SARS units after four key operating room staff members were hospitalized with SARS symptoms. Another eight acute care workers were placed under quarantine. Patients who visited the units recently were instructed to isolate themselves at home. Sunnybrook has treated half of Ontario’s SARS cases, while also managing much of Toronto’s surgical and urgent care needs since mid-March.

Underlying these disasters is a deeper crisis. Since 1995, the federal Liberal government and the Ontario Tory government have been jointly responsible for wholesale public hospital closures, reductions in bed numbers and job cuts. Chronic shortages of nurses, doctors and other health workers have resulted.

Before the 2000 federal election and again earlier this year, federal and provincial leaders made grandiose claims of agreeing to undertake major new spending on health care—seeking to head off intense public dissatisfaction with deteriorating services. But in real terms, federal public health expenditure remains below what was spent in 1994, and Ontario has been in the forefront of privatizing and contracting out health services.

Workers’ hardship dismissed

SARS has had a serious financial impact on working people, especially in low-paid jobs. In addition to the estimated 10,000 people under quarantine, thousands more have been laid off or placed on reduced hours in the retail, hotel, restaurant, hospitality and tourism industries. With hotels operating at 50 percent capacity or worse, Hotel and Restaurant Employees International Union Local 75 President Paul Clifford described the impact as more severe than the crisis that followed September 11, 2001.

Only those workers under quarantine may qualify for a federal government waiver on the waiting period for unemployment insurance. If their applications are accepted, they can draw benefits—worth less than 60 percent of their wage—for up to 15 weeks. The hotel union has demanded the waiver’s extension to laid-off workers, plus compensation for the many employees who normally receive no benefits because they work only on a part-time or temporary basis.

Despite his government’s role in compounding the disaster, Ontario Premier Ernie Eves contemptuously dismissed calls for compensation for SARS shut-ins, even to help pay for groceries, medications and other extraordinary expenses. He declared it would cost “tens of billions of dollars” to set up a compensation scheme. Prime Minister Jean Chrétien, for his part, has made federal assistance contingent on the province first providing aid.

Federal Heritage Minister Sheila Copps, a candidate to replace Chrétien as Liberal Party leader, was quickly shot down when she said Ottawa would pay 90 percent of the cost of fighting SARS, calling the outbreak an “epidemic” and a “national emergency.” Health Minister Anne McLellan branded her statement “the height of irresponsibility,” claiming that Toronto remained utterly safe.

While impervious to the needs of ordinary people, government and business leaders met yesterday with the aim of developing a “revival strategy” for the corporate sector. Speaking after the meeting, Ontario cabinet ministers and business leaders offered little by way of a specific plan, stressing instead the need to “get the message out” that the city and the province are safe. Enterprise Minister Jim Flaherty said: “You can assume there will be a major marketing initiative.”

His remarks unwittingly summed up the overall official reaction. The SARS outbreak has laid bare the immense costs to health and social well-being resulting from the systematic running down of the public health system. It has highlighted the vulnerability of major cities, such as Toronto, Beijing and Hong Kong, to new, possibly drug-resistant, virus strains. But the primary concern in Canada’s ruling circles is to come up with a marketing campaign that will protect business profits.