New maps: Experts warned about pandemics for years
Why we didn’t listen, and why we didn’t learn from SARS
Happy Thursday everyone,
In 2009, I was managing a cardiac hospital in England during the swine flu pandemic. It overloaded our ICU, and for a period of time, we were triaging urgent heart surgery cases daily. It was scary, and I remember thinking: “what would we do if this was much worse?”
Compared to COVID-19, Swine Flu was minor – just a terrible flu season.
Experts have been warning us about pandemics for years. Today, we’ll explore a critical question: why didn’t we listen to them? I hope you enjoy.
-Kapil
In 2003, a novel coronavirus struck the world. It was called SARS. It shut down infected cities for weeks. Poor protocols in hospitals led to chains of infections and unnecessary deaths. The long-term economic effects devastated some industries for years.
Luckily, SARS didn’t spread aggressively. The outbreak could be controlled, and SARS only ended up affecting a handful of cities – most notably in China, Hong Kong, Taiwan, Canada and Singapore.
After the outbreak was over, investigations were commissioned. How was it that the responses to this novel virus were so uncoordinated? What could we do to make sure this never happened again? The brightest minds in our public health world were called to service. Recommendations were issued.
Maps were built. Maps to help make sure this didn’t happen again.
But here the story takes a turn.
In countries like Taiwan, those maps were followed well.
In Canada, we took a meandering path.
Almost 20 years later, a second novel coronavirus has swept the world. It could have been called “SARS 2”, but instead was called COVID-19.
In Taiwan and other Asian countries affected by SARS in 2003, a well-oiled pandemic response sprang into action. The country instituted escalating emergency measures – even before a single case made it into their borders. Despite being so close to mainland China, Taiwan – with a population of 24m – has only recorded 440 cases. Here’s a remarkable first-person account of Taiwan’s response.
In Canada, that didn’t happen. Despite our first-hand experience with SARS, our response looked like every other country: wait until cases start to appear and then react. Today, we have 63-thousand cases.
Thank goodness we reacted well. Thank goodness for the tireless efforts of our public health leaders and front line health care workers. Toronto easily could have looked like New York if we didn’t.
But reacting well is wrong standard. How is it that we didn’t learn enough from our first-hand experience with SARS – and act proactively?
How is it that we discarded the well-built map public health experts created for us in 2003?
How is it that we’ve been ignoring expert advice about pandemics for years? Even Bill Gates has a TED Talk on the subject from 2015.
And, how is it that we learned so little from all the other almost-pandemics from 2003 to 2020: Swine Flu, MERS, Ebola, Zika?
Talk to any public health expert, and they’ll tell you: the prospect of a pandemic has always been present. One year before COVID-19, Dr. Anthony Faucci (the head of the US National Institute of Allergy and Infectious Diseases) was asked what keeps him up at night. He replied: “the thing I’m most concerned about… is the emergence of a new virus that the body doesn’t have any background experience with, that is very transmissible… and has a high degree of morbidity and mortality”
Why didn’t we listen to these experts, even when they are some of the most senior public servants in our countries?
Before we can answer this question, it’s important that we delve into the map these experts built in 2003 in response to SARS. Because it leads to an inescapable thought – that just like Taiwan, we didn’t need to have more than a few hundred COVID-19 cases in Canada.
SARS infected 330 people in Ontario and killed 44. Because of how the disease spread, outbreaks were largely confined to hospitals – with 100 health care workers infected, and 3 dying.
There wasn’t just one expert report in the aftermath of SARS – there were many. In particular, a 1,200 page report by the Ontario SARS Commission, an independent commission chaired by a judge from Ontario’s Superior Court (the Campbell report); an expert panel struck by the Government of Ontario (the Walker report); and a National Advisory Committee struck by the Federal Government (the Naylor report).
Reading through these reports is sobering. There are dozens, and dozens of recommendations.
Many were implemented, like the creation of the Public Health Agency of Canada – a national body to coordinate public health. Our provinces now have pandemic plans. And hospitals implemented a sea-change in infection-control measures. Our public health system is in a much better place than it was during SARS.
Yet, many lessons from 2003 remain unlearned and haunt us 20 years later.
The importance of preparedness. A clear observation in 2003 was that we had failed to adequately resource public health departments in our country - “Public health and emergency infrastructure were in a sorry state of decay, starved for resources.” And as a result, we didn’t have the necessary systems to “prevent SARS or to stop it in its tracks.”
We did make many investments in response to SARS. Entirely new agencies were created. But did we resource them effectively? Ontario’s most recent budget proposed cutting $200M from public health units by 2022. And, three years ago, our province allowed 80% of our $45-million emergency stockpile – which included 55-million N95 respirator masks – to expire because of budget cuts.
Declaring victory too early. A 6-week long provincial emergency was lifted in mid-May 2003 and safety precautions relaxed. One week later, a second outbreak occurred infecting 118 people and killing 17. That second outbreak – entirely preventable – was responsible for nearly 40% of SARS deaths.
Today, some provinces have already begun opening their economies. But new cases of COVID-19 haven’t shown signs of decelerating enough yet. It seems we’ve forgotten the painful lesson of declaring victory too early.
The precautionary principle. In 2003, there was a debate whether N95 respirators were necessary in hospitals. They were, but due to the newness of the disease, the science wasn’t clear. This lack of protection led to health care workers being unnecessarily infected. The Ontario SARS Commission wrote:
“Perhaps the most important lesson of SARS is the importance of the precautionary principle… we cannot wait for scientific certainty before we take reasonable steps to reduce risk”
Over the first two months of COVID-19, a debate raged over whether people should wear masks in public. It seems that we forgot about the precautionary principle. The science has now caught up, but how many infections could have been prevented?
But there’s an even larger question. Had we really based our response around the precautionary principle, wouldn’t we have also closed our airports and borders sooner – just like Taiwan?
Protecting essential workers. The Ontario SARS Commission noted significant deficits in how hospitals protected their workers – specifically in compliance with Ontario’s workplace safety laws. The commission concluded that the Ministry of Labour should ensure worker safety during emergencies.
Workplace safety is a major concern during COVID-19, with outbreaks at employers like meatpacking plants. Are workplace safety standards being effectively followed? Many workers are voicing big concerns – but the Ministry of Labour doesn’t appear to be asserting itself.
SARS was a tragedy. From it, experts built a map to make sure this never happened again.
But it seems that we didn’t reach for that map much over the last two decades.
Instead, the map we’ve been using to guide our collective journey didn’t incorporate those experts and their expertise.
And it’s not just in pandemic preparation. Take any major topic, from transit, to urban planning, from hospital capacity to climate change. There are incredible expert reports sitting on shelves, gathering dust.
How did we lose our way?
This is a story about all of us and the maps we’ve been using to navigate the last decade. Maps which lave led us to this very moment – a great series of expert reports on how to be ready for a pandemic, sitting on a shelf, half-implemented, while a real pandemic sweeps the country and grinds our economy to a halt.
A different set of decisions from 2003 to 2020 could have produced an entirely different result when the pandemic struck. We had all the knowledge at our fingertips to react like Taiwan did and limit our COVID-19 cases to just a few hundred, instead of over sixty-thousand.
Can we point to a bureaucrat or politician to blame? If only it were that easy. Our incredibly skilled bureaucrats work within the constraints of what’s politically feasible. They take their direction from politicians, who take their direction from voters. Meaning, the signals that drive our public health system come from all of us.
And over the last decade, the signals we’ve been sending are remarkably consistent: we have other, more pressing issues on our mind.
Prior to COVID-19, when was the last time you thought of SARS?
It’s a tough pill to swallow. Unlike so many developed countries, Canada went through a coronavirus outbreak 17 years ago – and from that experience had all the maps we needed to avoid most of COVID-19.
And most of us never realized how unprepared we were.
It’s not like anyone presented us with one map that said ‘learn everything we can from this disaster so it never happens again’, and one map that said ‘learn some things but not all’, and we chose the latter.
Instead, we became distracted by other issues in our lives. Our memory of 2003 faded. And we forgot that dozens and dozens of experts had carefully poured their intellect, passion, and energy into safeguarding us all.
I hope that we can build a better map to navigate a post COVID-world.
Many expert panels will be struck in Canada alone. They will be staffed by dozens of experts. Many recommendations will be issued. A map will be built.
All we have to do is choose to follow it – and stay the course.