The SARS commission chaired by Ontario Justice Archie Campbell was appointed by the province in 2003 to examine how its health system handled the crisis, which killed 44 people in the Toronto area and struck down more than 330 others with serious lung disease.

In his third and final report, released on Jan. 9, Campbell said the outbreaks were likely not preventable, but more could have been done to protect the safety of health-care workers. Campbell based his findings in the 1,204-page report, called Spring of Fear, on public hearings, government and hospital documents and confidential interviews with more than 600 people connected to the SARS outbreaks.

"If the commission has one single take-home message, it is the precautionary principle that safety comes first, that reasonable efforts to reduce risk need not await scientific proof. Ontario needs to enshrine this principle and to enforce it throughout our entire health system," the report concluded.

"When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today … Until this precautionary principle is fully recognized, mandated and enforced in Ontario hospitals, workers will continue to be at risk."

The lesson of SARS is that governments and health-care systems need to be ready for the unforeseen, according to the report.

Campbell found no scapegoats, but rather a system failure, including poor preparation for dealing with infectious disease, a decline of public health, and a failure to protect nurses and paramedics because of a lack of resources under provincial governments of all political stripes. He also said that citizens of Ontario failed themselves by not insisting that governments provide better protection.

"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 should never have happened. Underlying all their work was the magnificent response of the public at large: patient, co-operative, supportive."

Systemic problems ran "like steel threads through all of SARS," the report said, through all hospitals and government agencies in the province. The problems identified in the report include:

• Poor internal and external communications.
• Problems with preparation and planning for an outbreak of a virulent disease.
• Accountability issues: who is in charge and who does what.
• Problems with worker and patient safety.
• Infection control, surveillance and lack of independent safety inspections.
• Resource problems including people, money, laboratories and infrastructure.
• A lack of the application of the precautionary principle that action to reduce risk should not wait for scientific certainty.

Two nurses and a doctor died from SARS, and 72 per cent of those infected in Ontario contracted the virus in a health-care setting, the report said. It called hospitals dangerous workplaces, like mines and factories, that lack the basic safety culture and systems that are expected and accepted in other workplaces and in British Columbia's hospitals.

The workplace regulator moved more quickly in B.C. than in Ontario to inspect hospitals during the outbreak, to ensure workers were protected as required by law. British Columbia was spared the devastation that Ontario experienced, in part because B.C. showed a greater commitment to applying the precautionary principle, Campbell concluded.

Hospitals in Ontario also failed to apply the precautionary principle in using N95 respirators to protect nurses, the report said. "It is no wonder that health workers became alarmed when they saw their colleagues sicken and die. It is no wonder that they became angry when they saw such incidents recur again and again with no apparent improvement in their safety."

Campbell's first interim report, in April 2004, addressed problems of public health infrastructure in Ontario and recommended changes to improve safety. The second interim report, in April 2005, addressed deficiencies in the province's health protection and emergency response laws and suggested how to correct them.

Since then, the Ontario government has taken steps to improve protection from infectious diseases, such as improving hospital practices, disease surveillance and provincial public health and emergency legislation.

In response to the final report, Ontario Labour Minister Steve Peters said his ministry won't be shut out in a future health care crisis. Occupational health and safety committees in hospitals and other health-care facilities now bring nurses and managers together to recommend safety improvements. The pandemic advisory working groups also include labour representatives.

Health-care workers will also be trained on the use of N95 respirators, and more will be available in hospitals as Campbell recommended, Peters said.

Campbell's report suggests five of the commission's 25 recommendations over the last two years have been accepted, such as compensating people who are quarantined for lost wages.

The Testimony

The SARS commission held public hearings in Toronto in late 2003 as part of its inquiry into the outbreak in Ontario.

The following are highlights from that testimony. Full transcripts are online at the commission's website.

From September 29, 2003

The first day of testimony was marked by calls for the Ontario government to develop a plan for infectious disease control. The Ontario College of Family Physicians and Family Physicians Toronto called for a "general" to run future crises, saying there were too many lieutenants, and not one central commander.

Barb Wahl

"Ontario is now no more prepared for the outbreak of an infectious disease like SARS than it was last March or June. In fact, in some ways, we are worse off. We're still not clear on what protocols need to be followed to prevent the spread of SARS and to protect front-line nurses when they care for infected patients. Tensions remain between those who know we must proactively advocate for safety and those who are content to sit back and react once illness reappears. Being proactive is crucial. A reactive approach costs lives."
- Barb Wahl, president of the Ontario Nurses' Association.

"Clearly we have become complacent. As we prepare for SARS III or whatever new and potentially devastating disease is around the corner, there's a feeling that nothing has changed. While a fair amount of work is being undertaken including preparation of new community guidelines behind the scenes, family doctors have been left to feel that there is no comprehensive plan for the next time; a plan that will allow us to be proactive and reactive. If we continue to be complacent and we wait until a crisis is upon us, it will be too late. The time for action is now."
- Dr. Yoel Abells, chair of Family Physicians Toronto.

"We were frustrated by our limited involvement in the decision-making processes at an operational level during the SARS outbreak. We recommend that in future any policy framework developed should involve those individuals or stakeholder groups with specific expertise in developing practical and workable policies and guidelines in their affected areas from the beginning of the process."
- Dr. Larry Erlick, president of the Ontario Medical Association, arguing that doctors needed more interaction and influence with decision makers.

September 30, 2003

"Many of the lessons learned from SARS are being implemented right now and we are better prepared to deal with SARS if it should happen again; better positioned to handle new infections or new permutations of existing diseases. We have already made significant changes based on the knowledge gained from SARS."
- Hugh MacLeod, assistant deputy minister, acute services division, Ontario Ministry of Health and Long-term Care.

"My concerns are, fundamentally, that we failed to take the measure of SARS. We failed to understand what it was about and we did that because we didn't put sufficient emphasis on data collection, data analysis and learning about the infection. Second of all, I'm concerned that we spent a lot of time on unnecessary, unhelpful and harmful intervention."
- Dr. Richard Schabas, chief of staff at York Central Hospital, formerly the chief medical officer of health for Ontario.

"It's a crisis, and in a crisis it's disordered. The idea of an emergency, in fact, is to return order to a situation that is not orderly. Crises are not happy times for people who like order in their lives."
- Dr. James Young, commissioner of public safety for Ontario.

October 1, 2003

"We were dealing with a disease that had no test, no diagnostic criteria for diagnosis, no idea of the clinic course and, at least at the outset, no treatment. The treatment that we had initially was found to be ineffective. No knowledge of disease transmission and no idea of the duration and infectivity. Pretty hard to develop any kind of coherent plan if we have that type of information."
- Dr. Brian Schwartz, of the Ontario SARS Scientific Advisory Committee.

"I assisted with the intubation of a patient with SARS and assisted with an intubation of another patient suspected to have SARS. It took phone calls to occupational health, infection control, our director, and human resources, and many more days of waiting before they would change their minds, recognize the reality of the situation and allow us to order the good masks."
- Keith Olimb, president of the College of Respiratory Therapists of Ontario.

November 17, 2003

"Why were health-care workers put at risk when we had information, we had processes in place indicating adequate protection needed to be taken and yet that information wasn't given to the nurses and other allied health professionals?"
- Barb Wahl, president of the ONA.