LESSONS LEARNED FROM SARS

Excerpts from the SARS Commission Executive Summary: Volume One ♦ Spring of Fear

Precautionary Principle

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.[1]

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.

A precautionary approach also was in use at Vancouver General Hospital when it received B.C.’s first SARS case on March 7, 2003, the same day Ontario’s index case presented at Scarborough Grace Hospital. When dealing with an undiagnosed respiratory illness, health workers at Vancouver General automatically go to the highest level of precautions, and then scale down as the situation is clarified. While the circumstances at Vancouver General and the Grace were different, it is not surprising that SARS was so effectively contained at an institution so steeped in the precautionary principle.

In Ontario there was a systemic failure to recognize the precautionary principle in health worker safety, and in the identification and diagnosis of a respiratory illness that mimicked the symptoms of other, better-known diseases. Amid this systemic absence of the precautionary principle, it is not surprising that in Ontario, unlike in Vancouver, SARS caused such devastation, infecting 375 people, including 169 health workers, and killing 44, including two nurses and a physician.

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.

Listening to Unions

Just as hospitals should listen more carefully to the concerns of nurses and other front-line health workers, the Ministry of Health would be well advised to listen more carefully to the reasonable concerns of health worker unions which have enormous front-line experience in the actual problems of worker safety on the ground. Their expertise is reflected in the thoughtful and detailed presentations by unions that represent Ontario’s health workers, and in particular the joint work of the Ontario Nurses’ Association and the Ontario Public Service Employees Union. The problems of worker safety have been explicitly recognized by Minister of Health George Smitherman speaking to an audience of nurses in May 2005:

One of the things I was struck by … [was] the number of nurses that work in environments, hospital environments perhaps more particularly, that actually are unsafe … We have a lot of work to do on that.

It is important for Ministry officials to take this ministerial direction seriously. It is important for Ministry officials to avoid any impression that the Ministry has adopted an adversarial or dismissive attitude towards those who voice the legitimate concerns of those at risk on the front lines.[2]

Worker Safety Laws and Regulations

The evidence reveals widespread, persistent and ingrained failures by the health system to understand and comply with Ontario’s safety laws including the Occupational Health and Safety Act and related regulations. Ontario’s worker safety laws are based on the Internal Responsibility System[3].  SARS revealed an important structural problem when implementing the Internal Responsibility System in the health care sector: the fact that physicians often make worker safety decisions even though they may not be hospital employees.

The Commission therefore recommends:

• Worker safety in hospitals and other health care institutions requires reasonable legislative measures to include all physicians within the worker safety regime without interfering with the essential independence of physicians and without making them hospital employees. Such legislative measures may need to include not only the Occupational Health and Safety Act but also those statutes that govern the administration of health care institutions and the medical profession. It would be presumptuous for the Commission to recommend a prescriptive solution at this time. That task will require a good measure of consultation and a thorough analysis of the complex professional and statutory framework within which doctors work in health care institutions. The Commission recommends the amendment of worker safety, health care, and professional legislation to ensure that physicians who affect health worker safety are not excluded from the legislative regime that protects health workers. Because the prescriptive solution will require consultation and analysis and time and patience, it is essential to start now.

• That the Ministry of Labour conduct a meaningful review of the Occupational Health and Safety Act and related regulations in consultation with workplace parties and worker safety experts to examine how the Internal Responsibility System can better be implemented in the unique conditions of the health care system.

• That the Ministry of Labour and the Ministry of Health work together to harmonize requirements addressing health and safety in legislation and/or regulations administered by both ministries, which may overlap or conflict.

• That the Ministry of Labour and the Ministry of Health work together to review possible statutory or regulatory amendments to enhance the process for reporting, tracking and sharing of information, and removal of any barriers to information sharing related to outbreaks of infectious disease.

Joint Health and Safety Committees

The evidence reveals that Joint Health and Safety Committees, a fundamental component of Ontario’s worker safety regime, were often sidelined during SARS.

The Commission therefore recommends:

• That in any future infectious disease outbreak, the emergency response ensure the involvement of Joint Health and Safety Committees in a manner consistent with their statutory role in keeping workplaces safe.

• That worker safety programs at health care institutions include training for senior management on their roles and responsibilities with regard to Joint Health and Safety Committees.

• That management and worker representatives on Joint Health and Safety Committees be provided with appropriate training and sufficient time from their other duties to fulfill their JHSC obligations in a meaningful way, especially during public health crises.