Commission of Inquiry into SARS Issues Final Report

By Elizabeth J. McIntyre

Justice Campbell’s Commission of Inquiry into SARS issued its final report January 9, 2007. It is an eloquent, comprehensive, insightful report outlining the failures during the SARS outbreak in Ontario in the spring of 2003 and prescribing corrective measures, which must be taken to prevent a similar crisis from recurring in the future (such as an influenza pandemic). He concludes that the internal government missteps and health care sector leader ignorance about occupational health and safety led to disaster. Justice Campbell praised the health care workers who held the Ontario health care system together amidst blunders all around them.

In the report, Justice Campbell compares the success of Ontario and British Columbia in responding to SARS. The report reveals that while B.C. had an index SARS patient admitted to Vancouver General:

“...there was no further spread. A combination of a robust worker safety and infection control culture at Vancouver General, with better systemic preparedness, ensured that B.C. was spared the devastation that befell Ontario.”

In contrast, Ontario officials exhibited an ignorance of occupational health and safety law and principles.

Justice Campbell emphasizes there is no time for, or value in, finger-pointing. He concludes that the SARS crisis was the product of deep-rooted systemic problems, and individuals heroically worked tirelessly did the best they could within a profoundly dysfunctional system. For instance, in the raging N95 respirator controversy, he cautioned:

“It would be too easy to personalize this debate and point out that some of those who most vociferously opposed the N95 and fit testing, and who were most disdainful of nurses and independent safety experts who prefer precaution, were the very people on whose watch nurses became sick despite the assurances that they were safe.”

He further found that:

“Hospitals did their best within the limits of their lack of preparation, their generally inadequate infection control systems, and their inadequate worker safety systems. Inevitably they made mistakes in the fog of war against an invisible army.”

Infection Control/Occupational Health and Safety Disconnect

Justice Campbell was very alert to the problems arising from the disconnect between the infection control and the occupational health and safety communities in Ontario. He wrote:

“There were during SARS two solitudes: infection control and worker safety.”

His report prescribes an end to these solitudes and the need of both communities to be mutually respectful of each others’ knowledge and expertise to combine their efforts and collaborate to make the system ready for the unseen.

“Although no one did foresee and perhaps no one could foresee the unique convergence of factors that made SARS a perfect storm, we know now that new microbial threats like SARS have happened and can happen again. However, there is no longer any excuse for governments and hospitals to be caught off guard and no longer any excuse for health workers not to have available the maximum level of protection through appropriate equipment and training.”

Justice Campbell also found that the discord was not confined to the relationship between the infection control and occupational health and safety communities - it also plagued inter-ministerial and intergovernmental relationships.

The Precautionary Principle

Justice Campbell outlines the compelling evidence that led him clearly and unequivocally to advocate the adoption of the precautionary principle “throughout Ontario’s health, public health and worker safety systems ...”. This single most important recommendation in his report, if implemented, would have widespread implications for worker health and safety. He was emphatic in his call for this change.

“Some of the same Ontario hospital leaders who argued against the N95 respirator required to protect nurses and who actually denied there was a safety law that required the N95 to be fit tested still insist that science, as it evolves from day to day, comes before safety. 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.”

“What we do need is a common-sense approach to worker safety in hospitals coupled with a measure of scientific humility in light of the terrible and sometimes fatal failures in scientific advice and hospital safety systems during the SARS outbreak ... It is better to be safe than sorry.”

Justice Campbell found the evidence demonstrates that B.C. followed the precautionary principle and “... stopped SARS in its tracks.”

Hospitals are Dangerous Workplaces but Don’t Apply Occupational Health and Safety

Justice Campbell’s comprehensive investigation found that:

“Hospitals are dangerous workplaces, like mines and factories, yet they lack the basic health and safety culture and workplace safety systems that have become expected and accepted for many years in Ontario mines and factories and in British Columbia’s hospitals.”

The Commission also found “seven systemic problems that run like steel threads through all of SARS, through every hospital and government agency”, and specifically:

• communication
• preparation planning
• accountability: who’s in charge, who does what
• worker safety
• systems: infection control, surveillance, independent safety inspections
• resources: people, systems, money, laboratories, infrastructure
• precautionary principle: action to reduce risk should not await scientific certainty”

The report makes extensive recommendations about legislation, policies and procedures to finally establish and solidify a health and safety culture in Ontario’s health care sector.