SARS: aftermath of an outbreak
Authors: Paul Caulford
Journal: The Lancet (2003)

Paul Caulford is the chief of Family Medicine and Community Services at Scarborough Hospital and assistant professor in the Department of Family and Community Medicine, University of Toronto. He can be contacted at Suite 207, 3030 Lawrence Avenue East, Scarborough M1P2T7, Ontario, Canada Until severe acute respiratory syndrome (SARS) struck, we were a typical community-based hospital providing the best possible health care to the people of Toronto, Canada. We delivered babies, did surgery, looked after sick children. None of us could have envisioned the devastation that was to follow the arrival of our SARS index case, nor the chain of infectious-disease events that this newly emerged coronavirus was to trigger. We were plunged into a medical nightmare. I had never expected to see so many of my colleagues fall so seriously ill as a result of doing their job; nearly 6 months later, many are too ill, weak, and traumatised to return to work. They remain fatigued, short of breath, and some are still attached to respirators. Some have permanent lung scarring and ongoing respiratory complications. Others have died. The recent funeral of a second health-care worker to die from SARS was reminiscent of a public memorial service for a police officer or firefighter—professionals usually associated with the ultimate sacrifice incurred in the line of duty. It underscored the "new normal" SARS has created. A few months ago, Toronto was the last place I expected to see the beginning of a new, potentially worldwide plague. Until now, plagues were something from our past, from a time before antibiotics and vaccines. SARS quickly whipped our normal routines and patterns of health-care delivery into a frenzy. It caught us off guard, unsuspecting, unprepared. We scrambled desperately to contain its spread, to match it move for move. In the beginning we were overwhelmed by the numbers falling ill, by the severity of their clinical presentation, and we were disadvantaged by our lack of firm information about the virus. Workers who staffed our emergency rooms and intensive-care units fell suddenly ill, they needed care, and were no longer able to give it. If SARS returns—and I believe it will—we must become accustomed to seeing our colleagues in hospital, on respirators, alongside their patients. Within days of the first signs of the disease in March, 2003, (SARS 1), I was confronted with scenes in my hospital resembling those from the film Outbreak. Hospitals began sealing entrances and controlling access. Patients were not allowed visitors; along with quarantined staff who chose not to return home, they were trapped inside. Command centres were quickly established in affected hospitals. Half jokingly, we referred to them as our bunkers. Now, on reflection, I know we were in a war-like situation. Decisions were made more quickly. New loops of decisionmaking were necessary and quickly established. Our governments, in cooperation with nurses' and doctors' organisations, established a Provincial Operations Centre, from which all directives were given. Infectious-disease experts were seconded from other parts of the country and from the USA. As it turned out, we would need all the help we could get. Despite all our efforts, many hospitals became infected at alarming rates, making non-SARS care too risky. Elective surgery, including that for newly diagnosed cancers, was postponed as operating rooms and outpatient clinics shut down across the city. It would be months before they reopened, and some still have not. Elderly non-SARS patients who simply happened to be in hospital at the time of the outbreak became trapped for weeks after their recovery, as transfers between hospitals and nursing homes were halted. SARS created a staffing nightmare for hospitals in a health system that was already reeling from staff shortages—the result of years of underfunding in our health sector. As medical and nursing staff fell ill with SARS, vital patient care services collapsed. A hospital cannot run safely without its intensive-care unit! It wasn't long before our emergency department, the busiest in the city, was forced to close down, placing a terrible strain on other facilities and our community. We were devastated. We already had major difficulties in providing timely care, and now SARS had dealt a crippling blow to health resources. Then, just when we thought SARS was beaten, we were jolted again by SARS 2. The virus behaved unusually. The index case arrived in our emergency room with symptoms mimicking those of any typical case of community-acquired pneumonia. Early patterns of transmission had suggested vectors other than droplets, and these seemed to now be at work. Yet unlike influenza, for example, SARS didn't do well out in the community, preferring instead to spread and victimise those in close contact with it. In some families the infection rate approached 100% of household members. Health-care workers in close contact began falling ill at alarming rates. Intubation and other close facial contact, such as that during administration of nasal oxygen were soon recognised as high risk procedures. Forgetting to wash your hands frequently would prove a deadly sin. On the front lines we suspected the virus possessed an impressive array of infectious mechanisms. Were some patients "super shedders"? Why were children not getting SARS? We openly speculated that, like other viruses, there might be asymptomatic, subclinical, or at least mild cases going undiagnosed. If the virus behaved unusually, so did we. A new caring and concern for each other emerged in the face of this common threat. Perhaps it was always there but had been suffocated by medical politics and the brinkmanship inherent in fragile medical egos. Within 48 h, our community hospital had set up a fully operational SARS assessment clinic. Staff helped each other tie on their infection control gowns. We reminded each other of infection control procedures, such as when we had forgotten to double glove, or put on our face shields. We told each other not to cut corners, that our hands were dirty and not to touch our faces. Our infectious-disease specialists volunteered their time to teach us. Gone were medical politics. Present was the cooperation and the willingness by so many to take on superhuman workloads, voluntarily and without hesitation. Cleaning staff volunteered to work in the SARS units. If there is anything I will miss about SARS, it is this—the purposefulness of the work, the fellowship in care and the imperturbability of my colleagues. If any harboured fears for their personal safety, none was apparent. SARS had pleasantly reminded me that people behave at their best when things around them are at their very worst. What will the world community learn from this initial round of SARS? Will it be seen as the revealing gift it was? I fear not! From where, and how did this potential plague emerge? SARS must change us, the way we treat our planet, and how we deliver health care, forever. Will we be ready when it returns? SARS brought one of the finest publicly-funded health systems in the world to its knees in a matter of weeks. It has unnerved me to contemplate what the disease might do to a community without our resources and technologies. Without substantive changes to the way we manage the delivery of health care, both locally and on a worldwide scale, we risk the otherwise preventable annihilation of millions of people, either by this virus, or the next. Every hospital, every emergency room, every nursing home in every community in the world should be ready for SARS, putting in place a precise plan of response that can be activated the very moment there is a suspected case. But before that, and for that to happen, every nation's government should sit down and join forces in a partnership of world health.