Some people say Canada should have been better prepared for SARS. So what really happened? The worst appears to be over. Toronto seems slowly to be coming out from under the shadow of SARS as the crisis abates, and now the soul searching begins. In hospitals and clinics, some health-care professionals say the system simply wasn't prepared to deal with an outbreak of this scope. Opportunities to contain the virus early on were missed with disastrous results. They say SARS exposed the flaws in emergency response measures at the federal, provincial, and municipal levels.

Dr. Rex Verschuren can barely keep up. The patients just keep on pouring in to the Lapsley Family Doctors Clinic in Scarborough, as many as 200 a day.

It's busy enough with all four doctors here, but these days Dr. Verschuren is all alone. The other three doctors are sick with SARS. Two of them are fighting for their lives, one in his mid 50s, the other in his early 30s.

"They're young and healthy otherwise, and they should pull through, but, as I say, there's five patients in critical condition still, and two of them are my colleagues," Verschuren says.

March 31 was the day their nightmare started. At the time, they knew very little about SARS, even though it had been taking hold in Toronto-area hospitals for at least 18 days.

"It's scary and you do what you need to protect, and we rely on Health Canada to give us information like this so that we can protect ourselves. But in this case, it was one of those things that got through. The information wasn't there. And we weren't able to protect ourselves," Verschuren says.

So when an infected patient and several members of his family came to the clinic, the doctors didn't realize what they were dealing with. There were already two or three weeks during which time Toronto public health or the Ontario Medical Association or Ontario Health or Health Canada could have contacted family doctors and given some advice.

"No one did at that time, but again, because they were probably already very busy with the high-risk situation in the hospital. But I don't think they had the staff," he says.

The infected patient who had visited that family clinic eventually died of SARS in a nearby hospital. Only then did the clinic doctors know they had a problem. They didn't hear it from public health. They figured it out for themselves, and the doctors put themselves into quarantine.

"As soon as we found out that the patient had died, before public health had told us to shut down, and one of the doctors started to feel like he had a cold, we shut the clinic down, and we called in public health to quarantine or get everybody in," Verschuren says.

Clinic doctor scrounges for masks

For some reason, Dr. Verschuren was spared, and now, with his quarantine up, he's back at work trying to run the clinic alone. He's even had to scrounge for masks. He called Toronto public health and asked for masks.

"They didn't have any at the time to give out. I said, 'What are we supposed to do?' They said, 'There's nothing you can do.' In the meantime, we had drug companies, we had well-wishers, we had patients, we had other doctors offering us masks for protection when they heard of our plight. So the community came right away. One could argue that Health Canada was doing something and we just were too busy to notice, but I would have liked to have had more notice and had more support right away."

Who was supposed to tell the family doctors what to do? Was it the head of the provincial operation centre, Dr. James Young, Ontario's Commissioner of Public Safety? Or was it Dr. Colin D'Cunha, Ontario's chief medical officer of health?

An official with Toronto public health says doctors were calling and asking for help, but everyone was waiting for the provincial operations centre to draft province-wide protocols.

Gene Long from Toronto public health says a specific advisory for family doctors was finally faxed and e-mailed on April 2, using the Ontario Medical Association's mailing list. Dr. Verschuren says he didn't get anything from the OMA until his practice was closed and he was in quarantine.

"The OMA started sending us bulletins on how to deal with SARS, what to deal with it, how to screen patients. This is after we were sick," he says.

An ambulance worker without protection becomes seriously ill

On March 16, the second week of the SARS outbreak, ambulance workers were given a memo advising them to wear masks and gloves. Greg Bruce didn't have time to read the whole thing. He had to go pick up a patient.

"You don't think much about it," Bruce says. "But once I got in the door and spoke to the patient's wife, it was apparent that this man was a SARS patient to me, even with the limited knowledge that we had at that point about SARS because he had an exposure while at a previous trip to the hospital. So we took him to the hospital, and two days later I developed fever, body aches, stuff like that, and right away I said this isn't good. Right away I knew I was infected."

That patient was Joseph Pollock, infected in hospital, sent home, only to return to hospital to die of SARS. His wife, Rose, was also infected and also died in the outbreak.

No one ever called Greg Bruce to tell him he'd been exposed to SARS. He connected the dots and figured it out for himself. He couldn't convince the emergency room doctors at Scarborough Grace Hospital; even though he'd told them he'd been exposed to SARS, he was sent away twice back into the community, back home to his family. On the third try, too sick to walk, with an abnormal chest x-ray, he was finally admitted. For a while, he thought he might die.

"When you're sitting in an ICU, sucking for your breath and there's respiratory therapists trying to pump you full of medicine, all of a sudden at 37 years old, death becomes a real possibility in your life. Not many people face that at that stage of life," Bruce says.

Even though he couldn't convince the emergency room, he knew he had SARS from the beginning. At home for six days with a raging fever, he isolated himself, keeping his family and the rest of the community safe.

For health officials, it was good luck, luck they were blessed with several more times. Toronto's medical health officer revealed there were other cases of patients who had symptoms who had been exposed who were sent back out in the community.

Throughout the outbreak, the health officials kept their regular date with the media. At least four officials were at the table representing at least four separate jurisdictions.

Even those inside the operation centre say they were never sure who was in charge, a sign of the jurisdictional maze that has been plaguing Canadian public health for years, a problem well known to infectious disease experts like Dr. William Bowie at the University of British Columbia.

"I think there were a lot of people on the frontline putting in huge… putting in very long days, in some cases putting their lives at risk, who were very busy trying to put out fires without the degree of coordination one might have liked to have seen initially," Bowie says.

Dr. Bowie says most people in the public health-care community knew Ontario had particular problems.

"Ontario has largely decimated its frontline public health folk. And infection control, which is the key line within the hospital setting, has also been certainly compromised largely I think in both cases because of cutbacks and efforts to save money," Bowie says.

Vancouver health official takes swift action at the airport

On March 27, at the Vancouver airport, in the midst of the SARS outbreak, Dr. John Blatherwick, the medical officer of health, gets a call warning a flight is on its way in from Japan carrying passengers who had just come from China and were possibly sick with SARS.

"So I phone the quarantine officers at the airport. I found out they weren't screening Japan Airlines flights. There were only two of them, and they were being rather overworked," Blatherwick says.

So Dr. Blatherwick rounded up his own people, doctors and nurses, sent them for a quick training session, and got them security clearance so they could start meeting the flights.

The last-minute moves indicated again that Canada wasn't ready for SARS. But why not?

There have been wakeup calls before. In February 2001, there was an Ebola scare in Canada. International headlines warned that woman in Canada may have Ebola. It was a false alarm. At the time, it was also described as a wakeup call.

"Some of us feel passionately that we should have had more (safeguards) in place, but again, we failed to convince the decision-makers that that's one of the important priorities," Bowie says.

In September 2001, anthrax starts killing people in the United States. White powder begins showing up all over North America. It was another wakeup call, this time to bioterrorism. Health officials realized it would show up first at the hospital as a mysterious illness and they should be ready.

Ottawa announced there would be a national bioterrorism committee. A full year later, it still hadn't met, an admission made at the time by the chairman, infectious disease expert Dr. Donald Low.

"In fact, the committee's meeting for the first time. We're getting together in December. Committee members have been frustrated," Low says.

Even before all of that, there was a national report, the first of its kind, criticizing the state of Canada's public health. It identified a series of weaknesses, but it was never officially released.

"I would say that when somebody delivers you a report entitled public health capacity in Canada and it's never heard from again… it's questionable whether it was handled very well," says Dr. John Frank of the Canadian Institutes of Health.

Even if that report didn't sound the alarm, there were other official warnings. The auditor general in 1999 warned Parliament there were serious problems in public health. The experts say spending cutbacks have created some of the problems, but what about simpler gaps, like infection control practices in hospitals?

A recent Canadian study showed that more than half of hospital workers don't even routinely wash their hands.

"What we know is that you need to have a national system. It's the same point I made before. If there's no national system that ensures standards across all hospitals for infection control and that monitors them with consistent measures to see how they're doing, we really can't leave this to local governments and to provinces and territories, many of which are too small to really have the right kind of resources to do the job," Frank says.

On Monday, April 28, the SARS outbreak in Toronto appeared to be over. The two men who shared the responsibility were clearly relieved and impatient with the critics.

"It's very easy with a retroscope to look back and to make great diagnoses and do things, but I think, you know, (When) I think of people on the frontline, seeing a whole lot of things, but never having seen a SARS case, I think we need to look and learn. But it isn't easy being out there on the frontlines and trying to make the differential diagnosis," says Dr. James Young, Ontario's Commissioner of Public Safety.

As Dr. Young has said, we can all try to be Monday morning quarterbacks.

"You know, you should consider this to have been a very difficult outbreak to control, and I think we can give a lot of credit to the authorities, which was a mixture of folks, local, provincial, and federal, who got on the scene and have, as far as we can tell by the curve of new cases against time, it looks like they've got it under control in Toronto and in Vancouver. But to think that we should sit on our laurels now and not build a stronger and better national capacity in public health, that would be foolish. This is an opportunity to ask ourselves, do we have a modern public health system? Do we have the elements that every modern nation state looks for to have an effective public health response?" Young says.

The outbreak isn't over at the Lapsley Family Clinic. Dr. Rex Verschuren is still missing the three other doctors, and he's only seeing the most urgent patients.

"We still are left out by ourselves and totally exposed. Unfortunately, because there still hasn't been (any) more directives. We don't really know what we're doing. We're still staying gowned and gloved," he says.

He's also worried about his two colleagues who are still critically ill, wondering if their infections could have been prevented.

"I think in retrospect, yes, there was time. There was time to warn people or at least let them know that this was coming. And there was probably time to have a process set up for this. Maybe we should have had emergency sets at every doctor's office, hospital, every clinic that are not to be opened unless a bulletin is given that something is coming. It's easy to say in retrospect, but at the time, I really don't know how they handled it. It's perceived as not being handled very well by the medical community."

For now, he's staying gloved and gowned. Everyone coming in the door is being carefully watched, and he's trying to keep the clinic running, hoping his colleagues make it through this SARS battle in case they have to fight another one.