Toronto pandemics past: SARS shocks Ontario’s health care system

On March 12, 2003, the World Health Organization issued a Global Alert announcing outbreaks of atypical pneumonia in Hong Kong and Hanoi.

Toronto Public Health and Dr. Allison McGeer at Mount Sinai Hospital were able to identify the mystery illness as Severe Acute Respiratory Syndrome – SARS. But its cause and spread, the length of its incubation period and how it should be treated were unknown. 

With little science to guide them, Toronto’s Medical Officer of Health Sheela Basrur and her staff began to track cases. More than 200 Toronto Public Health staff worked from 8 am to 11 pm on the SARS Hotline. They would respond to more than 300,000 calls during the outbreak.

Toronto Public Health’s Reportable Disease Information System was so primitive it had to be abandoned.

The five-year plan that had been developed in 2000 to upgrade the system had become a victim of the Harris government’s “Common Sense Revolution.”

The tracking of cases was done on paper with colour-coded post-it notes. Toronto was using 19th-century tools to fight a 21st-century disease.

Controlling the epidemic in Toronto was hampered by confusing communications. That resulted in mixed messaging for the public and for hospital staff. In fact, it would lead to an avoidable second wave.

There was also fear of attaching a racial or social stigma to SARS. The fear hindered contact tracing. That diffidence did not prevent boycotting of Chinese restaurants or shunning of health workers and their children.

The Toronto Sun reported that newsrooms were being inundated with callers from Western Canada. They made threats, warning Ontario residents to stay away from their provinces.

SARS hit public and professional confidence in Canada’s health system hard. Despite the tremendous hard work and bravery of health care workers, there was shock, humiliation, recrimination, complaints of incompetence and betrayal.

Provincial emergency declared too late

On March 23, Scarborough Grace closed its emergency and intensive care units. The hospital also halted new admissions and transfers and closed its outpatient clinics. Anyone who had entered the hospital after March 16 was quarantined at home for 10 days. Personal protection equipment (PPE) was required for staff; SARS patients were placed in negative pressure rooms.

On March 26, the Ontario government declared a provincial emergency. All hospitals in the GTA and Simcoe County activated Code Orange. Surgeries were cancelled, visitors, including families of dying patients, were banned, suspected SARS patients were placed in isolation.

There were suggestions that Code Orange was overkill. A proposal to dedicate one hospital for the treatment of all SARS patients and allow others to function as usual was rejected. SARS patients were scattered through 20 hospitals in the GTA, causing the inevitable spread of infection.

By April 6, 84 probable and suspected cases and seven deaths could be traced to Sui-chu Kwan. And her contact in an elevator on the ninth floor of the Metropole Hotel in Kowloon in late February. Standing beside her was a doctor from Guangdong. He was coughing vigorously, with atypical pneumonia that had been raging in China since November. Kwan would die shortly after her return to Toronto. Her 44-year-old son, Chi Kwai Tse, reported to Scarborough Grace Hospital shortly after. He was placed in an open observation ward with two other patients. The two patients he’d shared the observation ward with – and the wife of one of them – would die soon after him.

Fuelling public anxiety

Quarantine of people who had been exposed to SARS involved solation at home of up to 100 contacts. That was about 8 times the rate adopted in China and 25 times the rate in the United States. Despite compliance being only about 57 per cent, a total of more than 23,000 people or around 7,000 at any one time were quarantined.

Dr. Richard Schabas, Chief of Staff at York Central Hospital and who would go on to become Ontario’s chief medical officer of health, found that to be “inefficient and ineffective” – not to mention, “fuelling public anxiety.”

By April 12, the SARS coronavirus was genetically sequenced at the Michael Smith Genomic Sciences Centre in Vancouver. But there was no diagnostic test for it.

When the World Health Organization imposed a travel advisory on Toronto two weeks later, Mayor Mel Lastman was furious.

“Where did the WHO come from? Who did they see? Who did they talk to? Did they go to our hospitals, did they go to our clinics, did they go anywhere?”

The advisory was lifted after a visit to WHO headquarters by provincial Health Minister Tony Clement, Ontario Chief Medical Officer of Health Colin D’Cunha and Barbara Yaffe, Toronto’s Director of Communicable Disease Control. The outbreak appeared to be declining but it was not. The second wave of SARS was about to erupt.

Code Orange precautions come and go

Ontario Health and Health Canada published newspaper ads on May 1 proclaiming that “Canada Has Turned the Corner on SARS.”

The WHO removed Toronto from its list of areas with recent transmission. And Code Orange precautions were discontinued. Hospital staff were no longer required to wear PPE routinely or maintain social distance from their colleagues. The tally of casualties in Toronto at this stage was 140 probable, 178 suspect infections and 24 deaths.

Then five patients at St. John’s Rehab Hospital fell ill with what was later identified as SARS. Two of them had been in the orthopedic ward of North York General where eight cases of what was thought to have been post-operative pneumonia turned out to be SARS.

Anyone who had visited St John’s or North York General during that month was ordered into quarantine. North York General also stopped all new admissions. And SARS was found in patients who had been transferred from St. John’s to Toronto General, Scarborough General and Baycrest Centre for Geriatric Care.

All hospitals in the GTA resumed infection control procedures. The WHO returned Toronto to its list of areas with local transmission but did not renew its travel advisory. When the second phase ended, 118 cases including 17 deaths were connected to North York General Hospital.

Lost faith in the health care system

In his provincial SARS Commission report, Justice Archie Campbell noted that

“The second outbreak had a terrible impact on the morale of health workers. Many lost faith in the system and the ability of their employers to protect them. It was not only the public who had been led to believe that SARS was gone. Nurses and health workers were told that SARS was contained and that there were no new cases. SARS was over. Nurses at North York General, concerned about outbreaks of staff illness and clusters of SARS-like illness were told by the hospital “not SARS” when it turned out that these cases were in fact SARS.”

Schabas was more succinct: “SARS 1 was not avoidable. We were struck by lightning. Everything after that was.”

Nelia Laroza, a 51-year-old nurse at North York General became the first Canadian health care worker to die from SARS on June 29. Premier Ernie Eves and Health Minister Clement attended her funeral at St. Michael’s Cathedral with hundreds of her friends and colleagues.

A second nurse, Tecla Lin died of SARS on July 19. Family physician Nestor Santiago Yange died August 13. They were Toronto’s last SARS casualties.

About 40 per cent of SARS infections were of health care workers; the majority of them women.

As well as the stress of treating a new and potentially fatal illness, there was stress on their families. Health care workers wore masks at home, ate alone, slept in basements and lived in dread of passing SARS onto their partners or children who were afraid that they might die.

One nurse reflected in Campbell’s report. “I said to my husband, I’m going to go, but I am so afraid, and we both had tears in our eyes because I thought I was the next one to get it. I haven’t got SARS but I thought I was going to be the next one, because all our nurses were falling down. But I was one of the ones that could go in. I think it’s your duty to go in as a nurse, to go to the last, to the very end.”

Another said: “I have never faced anything so frightening. Looking back, I think at the time because we were tired and we were working, because it was so surreal you didn’t have the opportunity to absorb it. That’s when the nightmares came. The going in circles, the questioning, did we do it right, could we have done it better?”

Worldwide the final tally was 8,098 probable cases of SARS, including 774 deaths. Some 26 countries would be effected. In Canada, there were 438 cases, 224 of them and all 44 deaths in Toronto.

SARS post-mortem

Why was Ontario so unprepared for SARS?

Justice Archie Campbell summed up the situation in the SARS Commission report:

“Our public health and emergency infrastructures were in a sorry state of decay, starved for resources by governments of all three political parties. The health system’s capacity to protect its workers was in a state of neglect: what little existed was badly malnourished. There was no system in place to prevent SARS or to stop it in its tracks. The only thing that saved us from a worse disaster was the courage and sacrifice and personal initiative of those who stepped up – the nurses, the doctors, the paramedics and all the others – sometimes at great personal risk, to get us through a crisis that never should have happened.”

University of Waterloo historian Heather MacDougal says that Toronto’s confrontation with SARS in 2003 might have been more successful if lessons had been learned from a much more deadly pandemic of 85 years earlier.

In Toronto’s Health Department in Action: Influenza in 1918 and SARS in 2003 she writes that “Lack of cooperation by provincial and federal authorities added further difficulties to the challenge of organizing contact tracing, quarantine, and isolation for suspected and probable cases and providing information and reassurance to the multi-ethnic population.”

In 1919, while the city was busy cutting its health budget, Charles Hastings concluded from his battle with influenza that “We require the centralization of authority. Whether that be a public health service, a local government board, a department of health, a ministry of health or a secretary of health, it matters little, but all authority should be centralized under one department, if we are going to have efficient results.”

Hastings’ wish was granted, laying the foundations of the system that Basrur had to work with during SARS in 2003, the system that is being tested again in the year of COVID-19.

Life after SARS

SARS was estimated to have cost Toronto businesses $1 billion. Worst hit were the tourism, entertainment and hospitality industries. Hotel room occupancy and tourist revenues slumped. Some 12,100 hotel staff lost their jobs, others were asked to take pay cuts or leave without pay.

Even as the second wave of SARS was rolling through North York General, council voted to allot $2 million of the $25 million committed by the three levels of government to assist Toronto’s economic recovery to “Toronto You Belong Here” campaign.

The idea was to encourage people who lived within a two-hour drive of the city to double or triple attendance at such events as the Caribbean Festival, the Molson Indy and the Royal Winter Fair. The campaign was backed by a promotional video to promote Mayor Lastman’s insistence that Torontonians are the warmest, most welcoming people on Earth.”

The Toronto03 Alliance (T03) chaired by David Pecaut,was set up to revitalize tourism in the GTA after SARS. Its focus was on the U.S. border states. Funding from the federal government was $10 million, from the private sector $1.2 million.

T03 supported Molson Canadian Rocks for Toronto, “SARSStock”, at Downsview Park with The Rolling Stones, Rush, The Guess Who, AC/DC, Justin Timberlake and many more. Some 150,00 tickets were sold – a single-day record for Ticketmaster. Some 450,000 to 500,000 are estimated to have attended, proof of life, in a crowd unafraid of SARS.

T03 also conceived “Kids Summer Road Trip,” family-oriented events and attractions in and around Toronto through August and September.

Also on offer, “It’s Time for a Little Toronto,” a theatre, dinner and Blue Jays package for $85. For $169, there was a stay in a hotel, dinner in a top restaurant and a tour of the city and harbour, Toronto Zoo, the ROM and the AGO.

The memory of “It’s Time for a Little Toronto” remains in “Winterlicious” and “Summerlicious.” The events are praised as “a great example of how a city picked itself up after a solid blow” by the World Bank

The success of T03 inspired Luminato, the spring festival of the arts Pecaut and Tony Gagliano devised in late 2004 that launched in 2007. The square named after Pecaut after he died of cancer in December 2009 has been the launch pad of Luminato ever since.

Luminato’s 2020 program promised to be “about light and shedding the light on the city of Toronto.”

It had to be cancelled in this year of COVID-19, along with every other event that normally draws a crowd.

Seventeen years after SARS the city has established the Toronto Office of Recovery and Rebuild to plan for a COVID-19 recovery. This time the mountain that faced Toronto after SARS will be much higher. And, this time, Toronto will have company. That mountain will have to be climbed by practically every city on the planet.


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