Yesterday Canada's Campbell commission released its report on the 2003 SARS outbreak in Toronto. SARS is most infectious in the latter part of its disease course, so it isn't surprising that 45% of the victims were health care workers. Two nurses and a doctor died. SARS was a deadly occupational disease.
In the 1200 plus page report, Judge Campbell and his colleagues place the blame on a broken health care system but find no individuals at fault. The Toronto Globe and Mail is disappointed. My initial reaction was irritation they saw a need for scapegoats, but as I read the column by Murray Campbell (presumably no relation to the commission Chair), I saw his point. But first the nub of the Campbell Report:
"The lack of preparation against infectious disease, the decline of public health, the failure of systems that should protect nurses and paramedics and others from infection at work - all these declines and failures went on through three successive governments of different political stripes," the report concludes.Judge Campbell found that the only thing that saved Ontario from a worse disaster was the courage and sacrifice of health care workers - nurses, doctors and paramedics - who worked long hours at great personal risk.
[snip]
"The surprise is not that Ontario's response to SARS worked so badly but that it worked at all, given the lack of preparation and systems and infrastructure," he writes. "SARS was stopped by the front-line workers and the scientists and the specialists who stepped up and who were not afraid to take the strong measures that worked in the end." (Globe and Mail)
The Campbell Report identified specific system failures, failures that look eerily familiar to those observing today's pandemic flu preparedness:
- 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.
- Most importantly, a lack of the application of the precautionary principle that action to reduce risk should not wait for scientific certainty. (CBC News)
But as Globe and Mail columnist Campbell observes, systems don't fail by themselves. They fail because they are badly designed, improperly operated or allowed to decay and fall into disrepair. Workers die because worker safety has a low priority. These are all consequences of the actions of individual people.
Columnist Campbell is not so reticent about criticizing Judge Campbell:
Instead of finding "scapegoats" and holding them accountable, Judge Campbell reflects the blame back on the millions of people who use the health system and didn't complain loudly enough to politicians about how lousy things had become.
"We all failed ourselves and we should all be ashamed because we did not insist that these governments protect us better," the report says.
It is a little too neat. We are not experts on infection control. We know little about system analysis or preparations for a pandemic. It's likely even that the politicians who rotated through the Health Minister's seat at the cabinet table were woefully ignorant. But there were people who did know -- or ought to have known -- all the stuff about infection control, communications systems and workers' rights. They failed us. But we will never know who they are.
The US didn't have a SARS outbreak. But if you substitute SARS for pandemic influenza and roll the clock back to 2003 we could be Canada. We can truthfully say there are people who know -- or ought to know -- all the stuff about infection control, communications systems and workers' rights. They are failing us.
Not all. But too many.
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We were lucky. A good chunk of the SARS debacle was also due to the poor infection control practiced at most western hospitals. I'm willing to bet that in the pre-antibiotic era they were much more careful about infection control, since that was all they had to combat the spread of bugs. The hospitals that I've looked at are laughable in terms of what is practised.
The contrast between the outbreaks in Toronto and Vancouver tell the story. Vancouver's outbreak was tiny and well-controlled because British Columbia had maintained a well-supported Centre for Disease Control, whereas Ontario had eliminated most of their public health infrastructure to cut costs.
The public can't be expected to know how important this infrastructure is. The responsibility falls on public health administrators and the government.
There needs to be one more item added to the list of the specific system failures. That is, Denial.
Denial of the very existence of a danger, due not always to a lack of scientific certainty, but in fact more frequently, due to the political and commercial pressures on the powers-that-be, to declare the country free of any such danger.
Here is an example of an interesting news item today:
Reh Atemalem Susanti, writing for "TEMPO Interactive" in Jakarta, quotes Aburizal Bakrie, the Coordinating Minister for The People's Welfare in Indonesia, as saying that "currently 16 out of 30 areas in Indonesia are already claimed to be free of bird flu."
"The remaining 14 areas are not yet free from bird flu, including Jakarta," he conceded, during the "Year 2006 Evaluation and the People's Welfare Coordination Policy Plan 2007? press conference at his office, today (10/1).
Ya right.
Indonesia is a country with vast forests and mountainous regions that are almost impenetrable.
For a Government official to declare such regions free of anything, let alone of the H5N1 virus, which is able to hide out in wild mammals as well as in birds, is a bit much, even for a politician.
Had Vietnam not been declared to be "free of Bird Flu" ?
As was of course China, which was also free of Bird Flu.
Until that is, more human cases of the virus were fond over there.
In his defence, the Coordinating Minister for The People's Welfare, described the difficulties involved in the battle against the Bird Flu virus.
"Bird flu", he said, "was very difficult to handle because the virus carriers are animals that are mobile."
JM
Whatever happened to SARS, by the way.
The fact that it nearly went pandemic,and the outbreaks were stopped, doesn't mean the virus has vanished off the face of the earth, does it?
It seems as if the general public looks at the SARS outbreak as if it were a minor war...some uppity country that tried to take over, was squashed in its tracks and obliterated, never to rise up again.
But although they stopped it (finally) in Canada, so that it couldn't spread throughout NA and to the rest of the world, what about the virus at its origins in China? Still there, somewhere, right? Lurking about. Or did it mutate itself out of being a human pathogen? Isn't that pretty much the only way we ever truly get rid of these deadly viruses...if they themselves self destruct?
MiH: One of the big mysteries. Perhaps it went back to its wild reservoir and contact with that reservoir has stopped (e.g., palm civet or something else). A lot of us think it will come back at some point. It is not very contagious, at least compared to flu, so that's a plus. And maybe it has changed its transmissibility. When you find out what happened, tell the rest of us.
It goes beyond lack of public expertise, callous politicians, and perfidious judges. At every public forum on health issues, when citizens are allowed to attend, they line up to declare their approval of public care, more please, we'll even pay taxes. However, the corporate media, columnist Campbell's employer among them, publish as if they were facts a steady stream of negative opinions from lobbyists, false think-tanks, and political fixers.
A Scenario: Your patient is having a pneumonia. His/her spouse works as an airplane steward flying between the European airports. The patient's spouse had a "common cold" last week. How would you proceed in diagnosing?
Lina: you follow the protocol for ILI. Look at sputum, check for cough, GI problems, temp, CBC, chest X-ray, pulse-ox, etc., start antibiotics, ask questions about where the patient has been and family. It's not rocket science; more like a process of elimination.
Thank you. Could you (or someone) please give a link to the ILI protocol?
Or is it alike the protocol for community acquired pneumonia?
So always start antibiotics, but there's still always a delay in diagnosing the viral pneumonia? Only after if the antibiotic doesn't seem to give a response? How long should wait for response (how many different antibiotics) before giving antiviral?
The culture always takes time to give any answer.
Sorry if stupid questions...
Anyone? :)
This Nova scotia document defines "ILI" as Influenza-Like Illness".
It recommends several times following the "ILI protocol". When I encountered a statement, "(the development of a. protocol is recommended as a provincial coordination. activity)", I stopped searching.
http://www.nsaho.ns.ca/uploadedFiles/PandemicplanningSept2006.pdf
In the light of the SARS episode and recent report, it is scary that such a protocol has yet to be developed. OTOH somebody is willing to say so, in (semi)public.
"(the development of a. protocol is recommended as a provincial coordination. activity)"
huh! Well, how would you people advise me about the above case? Antibiotics started. When to start antivirals? After the swab culture reply has come it's already too late to start i.e. Tamiflu, isn't it?
I find this quite interesting to see that no one can answer. After all, the Tamiflu should be started quite early.