Lessons not learned from the SARS inquiry: The Precautionary Principle be expressly adopted as a guiding principle
A question of hindsight: Why did officials wait so long?
Many may not know that following the deadly SARS outbreak in Canada in the early 2000’s, an inquiry was held to determine what went wrong ( and quite a bit did ), how to fix it, and to learn from those mistakes in order to ” give a legacy of betterment to those who died, those who fell ill, those who suffered so much and those who fought it with such courage.” 13 essential questions were asked. http://www.archives.gov.on.ca/en/e_records/sars/report/v1-pdf/Vol1Chp2.pdf While the report focused primarily on events in Ontario, the lessons learned were critical for the reform, preparation and decision making of all officials across Canada.
Because of past and ongoing concerns and criticisms voiced by ER docs, nurses, infectious disease specialists, journalists and people like myself, I wanted to go back and see exactly what happened and what was learned during SARS, to see if the recommendations and learned experiences have been applied by government officials, both elected and appointed. In the middle of a global pandemic, it makes for both compelling reading, and it provides a critical lens with which to view the current timeline of decisions made in handling Covid-19…and there is much to be critical about.
One of the best and ongoing timelines of the unfolding crisis management at the federal level has been given in this piece in the Edmonton Journal. https://edmontonjournal.com/news/national/the-road-to-canadas-covid-19-outbreak-timeline-of-federal-government-failure-at-border-to-slow-the-virus/
This timeline is a stunning read, made even more so because of how provincial counterparts parroted the federal messaging, telling citizens the risk to Canadians/ British Columbians etc, was low… until very quickly they all had to do an about face. (I posted a very small timeline of key moments here in BC, in this post https://lailayuile.com/2020/03/17/covid-19dont-let-hindsight-be-the-most-astute-advisor-measures-we-need-to-keep-our-communities-safe-and-operational/)
Risk Management 101: The Precautionary Principle
Why the Precautionary Principle has been ignored repeatedly by officials who hesitated to close borders, hesitated to order the public to stay home, hesitate still in closing down work camps and constructions sites, is surely going to be a matter considered by another inquiry down the road.
From page 3 of the Executive Summary of the Sars Commission report:
In The Commission of Inquiry on the Blood System in Canada, Mr. Justice Krever said:
‘Where there is reasonable evidence of an impending threat to public
health, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat.’
The importance of the precautionary principle that reasonable efforts to reduce risk
need not await scientific proof was demonstrated over and over during SARS. The
need to apply it better is noted throughout this report.
One example was the debate during SARS over whether SARS was transmitted by
large droplets or through airborne particles. The point is not who was right and who
was wrong in this debate. 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.
We should be driven by the precautionary principle that reasonable steps to reduce
risk should not await scientific certainty.”
Despite being in a state of emergency in BC, and requests for citizens to stay home and limit excursions from our homes, we have heard repeated assertions and mention of the economy as a reason why places where people work and live in close quarters have not been shut down.
From Page 4 of the same summary:
“The Commission therefore recommends:
• That the precautionary principle, which states that action to reduce
risk need not await scientific certainty, be expressly adopted as a guiding principle throughout Ontario’s health, public health and worker
safety systems by way of policy statement, by explicit reference in all
relevant operational standards and directions, and by way of inclusion,
through preamble, statement of principle, or otherwise, in the
Occupational Health and Safety Act, the Health Protection and Promotion
Act, and all relevant health statutes and regulations.
• That in any future infectious disease crisis, the precautionary principle
guide the development, implementation and monitoring of procedures, guidelines, processes and systems for the early detection and
treatment of possible cases.
• That in any future infectious disease crisis, the precautionary principle
guide the development, implementation and monitoring of worker
safety procedures, guidelines, processes and systems.”
If these recommendations should be applied to health care and disease control within health systems, is it not prudent to assume they be applied to actions taken in all venues where disease transmission may occur rapidly?
How is it that the risk is great enough to consider releasing some non violent offenders from prison early, yet men who live, eat and work in close quarters in work camps, are not in the same category of risk?
Where isn’t the precautionary principle applied there? A serious question for the powers that be, particularly since we are now all defined as essential and non essential workers, to try and keep everyone who isn’t essential at home to break the chains of transmission.
There are photos circulating online of workers being taken to and from the Kinder Morgan work camp in buses. There are photos of men all working shoulder to shoulder on construction sites in downtown Vancouver. We know men were in isolation with flu like symptoms at the site C work camp. Mayor Lori Ackerman declared a local state of emergency over the concerns of what might happen, and was quickly reined in when Farnsworth then declared a provincial state of emergency which nullified her actions. The site C camp remains open as do others, yet one builder said the guidelines were too little, too late and shut down his sites, urging others to do the same. https://www.nanaimobulletin.com/news/construction-company-shuts-down-all-job-sites-says-new-b-c-guidelines-are-too-little-too-late/
How much did we actually learn from the SARS Commission?
Which brings me to a key recommendation from the SARS Commission:
“1. Medical Independence and Leadership
Public confidence requires that the fight against infectious disease be driven by
medical expertise, free from bureaucratic or political pressure. The Commission, in its
first interim report, recommended more independence for the Chief Medical Officer
of Health. The government has made significant progress in that direction, by
amending the Health Protection and Promotion Act to give the Chief Medical Officer
of Health a greater measure of independence.”
When I hear appointed health officials talk about keeping the economy going, mentioning the economy repeatedly, I’m not hearing a doctors concern, I’m hearing a politicians. It doesn’t matter if its a provincial official or a federal one, the economy is a politicians concern and that concern should not drive public health policy or decisions in a time of crisis, where it has been shown time and time again that early and aggressive intervention and restrictions work. We are not under draconian restrictions. We need essential services only during this time.
Should we be worried about the economy? Of course. But breaking chains of transmissions takes precedent above all. Or it should. Jacinda Arden had it right and continues to have strong support for her early and strong actions. Justin Trudeau might want to spend some of his alone time to take notes. https://www.straitstimes.com/asia/australianz/new-zealand-pm-ardern-declares-national-emergency-as-country-reports-47-new
This is where I veer off into another issue: differing and contradicting experiences and opinions between medical professionals. Having read the full SARS Commission reports, I understand better perhaps, her rationale of testing on health care professionals and care homes and contacts.
As detailed in the SARS reports, their concerns were often ignored and negated during the SARS outbreaks and many became ill because proper precautions were not taken early on in the outbreak with regards to PPE, )personal protection equipment).
Instead of assuming the worst and taking the biggest protections early on, nurses and doctors only increased the protections as the risks became better known and bigger. This resulted in transmissions that should have been avoidable. This is directly mentioned within the report, as was the recommendation to require whistleblower protection for health professionals who come forward and speak out. But Covid 19 isn’t SARS, and the infectious viral shedding periods are reportedly different.
Different professional opinions: Don’t kill the messenger and listen to the front lines.
In my last post, I brought the message from Dr. David Forrest, a calm but powerful message of caution and warning to practice physical distancing and self isolation and why. Many said he was over dramatic.
Last weekend Royal Columbian ER doctor Sean Wormsbecker posted a video to youtube, sharing his concerns that he was not allowed to test people who were sent home to self isolate. He said the province was lowballing numbers of postives by not testing people with symptoms who are in self isolation, and expressed concerns those people didnt take it seriously.
Dr. Bonnie Henry disagreed publicly yesterday in her daily update, saying she and her colleagues on the front lines were talking to people who self isolated. And maybe the people she has spoken to are, but many people are not being followed up on who have symptoms at home.
I don’t doubt that Dr. Henry is correct in her opinion. But I also don’t doubt that an ER doctor on the very front lines is correct in his either. Both have very different perspectives and experiences inherent to their positions right now. And its not hard to find news reports of doctors being threatened or fired in other jurisdictions for speaking out. It is prudent to point out that whistleblower protection was also a key recommendation in the SARS report to ensure those who speak up do not suffer employment loss or reprisals.
We are in a period right now with Covid-19 research, in which many different studies are already out and will continue to come out. It’s very common for different doctors and scientists to hold different views even in the face of scientific evidence. An example of this is the appearance by Dr. Patrician Daly on CBC yesterday, which is causing a lot of concern online today, because of what she said in a segment with respect to self isolation of foreign travellers, and with respect to transmission of the virus.
You can listen at this link, select the March 30th segment, and fast forward to the 54 minute mark: https://www.cbc.ca/listen/live-radio/1-4-bc-today
In her response to the senior calling in to report a couple who refused to self quarantine after travelling, in a building of seniors, she says:
- that returned travellers in mandatory quarantine are allowed to go out to do their essential services ( whats the point of quarantine if they go out into public ?)
- travellers that are supposed to be in self isolation with no symptoms pose no risk to others
- repeats that if they have no symptoms they pose no risk
- Vancouver coastal health is not going out to enforce orders and relying on good will, or following up on federal quarantine orders.
- repeats again that people who have no symptoms pose no risk to the caller
Then we get to another caller Randall at the 1:01 mark, who also asks about asymptomatic people spreading virus. She says:
- We do not believe people who are asymptomatic spread the virus before they have symptoms or if they have no symptoms, again, there is no evidence asymptomatic people spread the virus.
This is showing to be inaccurate and gives mixed messaging to public who had many questions below a facebo
The CDC in the US is now saying the opposite, and in fact stating asymptomatic people are spreading it. That up to 25% may be capable of doing so.
And again, If we learned anything from the SARS Commisions, it is that the precautionary principle dictates we do not wait for science to prove it, we must treat everyone as though they may have it, except those in our family bubbles who have not been out or about. This is a key guiding principle that must be followed in health and in dealing with the economic consequences of this pandemic.
Dr. Patricia Daly creates confusion when she says not to be concerned. This is why we wash our hands, it’s not just symptomatic people who can spray droplets. An asymptomatic person with virus can sneeze too, or touch their mouth or nose and then transfer that onto a doorknob. Seriously.
I’ve gone on too long, but this is important. This needs to be said. We are not seeing spikes yet but we are not through the next incubation period yet. We already know its spreading through our communities by community transmission now. We see the idiots having parties and gathering to pass a joint around between friends. And the order that gatherings of 50 people or less is ok, is still causing confusion. The messages must be simple numbered orders front page of every paper.
It’s incredibly important to stay home and stay safe. More than ever, anything that’s not essential shouldn’t be happening. In the end, it will be better to have looked like we went too far, rather than not far enough.Especially if it saves one of your friends or family.
Until next post, here is the link to the full SARS reports. A compelling read right now.