Behind the mask
Reporter: Kelly Crowe | Producer: Stephanie Jenzer
CBC News Online | November 19, 2003
For four months, Toronto battled an invisible enemy.
The images were frightening. Hospitals barricaded, health-care workers shrouded, and the sick suffering alone with only a masked face to look at, and a gloved hand to hold.
People fighting back with weapons that were centuries old, and considering measures so extreme they're unheard of in Canadian history.
Here are some stories of SARS told by the people who were on the inside.
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Everybody knows SARS started in China and spread quickly, catching the world by surprise. Few know that some Canadians saw it coming.
Long before Canadians were afraid of the sound of a cough, there were clues.
Back in January, a full two months before SARS invaded Canada, a strange thing was happening in Vancouver's Chinatown.
Surgical masks were disappearing off the shelves.
Canadians had been getting panicky calls from friends and family in mainland China who were in the midst of an epidemic.
"Some of my customers were asking me if I can get the masks for them to send overseas for the family who live there," a Vancouver pharmacist says.
In fact, the epidemic in China was headline news in Toronto's Chinese papers.
Toronto's Sing Tao Daily newspaper asked a prescient question.
What's to stop that epidemic from coming to Canada on a plane?
"It's an infectious disease that's spreading very quickly, so we follow on the lead that it might spread on to the travellers that are going back and forth between China and Toronto, and Canada," says Robert Leung, editor-in-chief of Sing Tao.
When the paper asked Health Canada that question, it was assured the government was monitoring the situation.
The paper reported: "The spokesman for Health Canada said yesterday, they're closely monitoring the spread of pneumonia."
So Sing Tao ran the story. It was early February. The story also read: "But until yesterday, External Affairs and Health Canada had not put up any travel advisory on their websites."
In another month the paper discovered it was right. The epidemic did come to Canada on a plane.
The disease landed at Pearson International Airport, travelling in the lungs of a 78-year-old woman returning from a trip to China. She died at home. But her son soon showed up at a hospital emergency room, also sick. The doctors were stumped.
Nurse Agnes Wong is the one who figured it out. It reminded her of something she'd read in the Chinese paper.
"I read another story about a young family in Hong Kong. They took a trip back to Mainland China and then the father got sick, the daughter got sick and then eventually at the end of the trip two family members died. So that is really sad and very unusual. That stayed with me," Wong says.
She wondered if this Canadian case was the same.
"And then I asked her [the night nurse] to check her travelling history and then when she called me, the night nurse told me that the mother had, in fact, went back to Hong Kong and come back ill. So I told them to notify the physician. It's just somehow I made the connection, maybe it's a nursing instinct. Maybe it's sixth sense."
Health Minister Tony Clement was shocked when he met Agnes Wong and heard the story months later.
"And they said this is the nurse who first figured out that that was a SARS case," he recalls. "'I said, you're kidding.'
"As a person who has this whole bureaucracy of public health officials and all of the medical officers of health, we have 37 medical officers of health in our province, it's a nurse picking up a Chinese language newspaper who adds two and two together and makes four?
"That was a pretty stunning moment. And God bless her. But one of the things I'd like to know, we'd all like to know is, could we have identified this earlier, at an earlier stage, and would that have made a difference?" Clement says.
Everybody knows SARS patients needed to be kept isolated but few know that in the early days there were so many doctors and nurses getting sick Toronto ran out of places to put them.
At Scarborough Grace Hospital, where the virus first hit, the initial days of the battle seemed to be going well. Dr. Sandy Finkelstein thought he had this thing under control. He thought it had only infected one family.
"We thought we were OK. We had dealt with this one family. Everyone was accounted for. And we said, 'You know, it was bad. It could have been worse.' And we had dealt with things reasonably efficiently. And everyone was dealt with. What we didn't know, at the time, was that there were other patients affected through contact in the emergency room," Finkelstein says.
For days, the virus had been silently spreading throughout the hospital.
"It wasn't until I had the second or third ICU staff member come up to me and say: 'Sandy, I have a fever.' And that's how most people presented with SARS. They'd all present with cough or illness. They'd come to me and say: 'I have a fever.' I'd quickly cover my mouth and grab a mask, if I'm not wearing one, and I put one on them."
Soon there were so many people sick they'd run out of places to put them. Then someone remembered West Park, the old TB hospital on the other side of the city.
Long ago abandoned, the rooms were completely empty. Somehow, in what they would later call a miracle, the ward was up and running by nightfall.
Dr. Donald Low became the doctor in charge.
"They came by taxi, they drove themselves there. They came by ambulance. I mean, in the middle of the night, the elevator would open up and here were two patients bringing themselves to hospital," Low recalls.
"Everybody was sort of flying by the seat of their pants and, you know, trying to use proper precautions, not really knowing what proper precautions were going to be. It was such a bizarre time."
All the patients at West Park were doctors and nurses. They were cared for by their colleagues who didn't know at the time they were taking their lives in their hands. One of the nurses working beside Low later died of SARS. She infected her husband, who also died.
"Her only real concern was, would she take this home to her family." Low says. "And when she did, then the husband became infected and he died of it. They both went into hospital the same day and [were] quite ill and quite acutely ill. She volunteered and said, you know, nobody was assigned to that ward. The people that worked there did it because they volunteered to do it, and they worked hard. It was really hard work because everybody was being treated with all this cocktail of antibiotics that we had concocted. So everybody was getting IVs and getting medications all night. So every four or five, six hours, they had to go in and hand out the drugs. So there was a lot of interaction."
Everybody knows that front line workers were in danger of being infected. But few know that the virus almost sent the highest levels of the Ontario government into quarantine.
In those early weeks the virus had the city to itself. Uncontained, it was free to spread through hospitals, between friends and family and by the third week it had slipped inside the very heart of the provincial command centre.
It happened when one of the scientists on the front lines went into the war room to brief officials.
Dr. Allison McGeer didn't know it at the time but she had been infected with SARS.
"Allison phones in and said she's not coming in." Dr. Low recalls. "This was Sunday. She's not feeling well. I said OK.
"And then Monday�. I talked to Allison again and now she had a fever and I said you've got to come down to the hospital, we have to asses you. And well, she had SARS. And so then we realized, my god, we've been exposed to her."
"There's an element of, you know, this is spilt milk, right?" McGeer says. "There's nothing you can do about it and I suppose the good thing was that there were so many things to do at the time that there was an element of, you know, once bad things have happened, well, simply, you've got to take a deep breath and focus on the million other things that had to be done."
Among those things that had to be done was to figure out if she'd infected anyone else. It turned out the exposure went all the way to the top of the provincial government.
It was the Blue Jays' season opener. The health minister, Tony Clement, was in the crowd. The premier, Ernie Eves, was there, too. They were sitting in different sections.
"I didn't watch too much of the game, as it turned out, because I was getting calls constantly," Clement says. "I had visited the provincial operations centre a couple of times that week already and the premier had paid a visit, as well. I got a call from [Ontario's chief medical officer of health] Dr. [Colin] D'Cuhna indicating that one of the people who had been there over the weekend had come down with SARS."
"Then I had to figure out how exactly to tell the premier that he might have been exposed to SARS. So I contacted one of his aides who was at the game. The premier was in another area of the SkyDome and I was just a little bit further down. And I indicated to her that there might be an issue.
"A couple of things [were] running through my mind. I don't want the provincial operations centre to be non-existent. That would not be a good thing for Ontario and I didn't want the premier infected with SARS. I didn't see any up-side to that. I had many strange nights with this, with this virus, and that was one of the strangest.
"At the ball game. Yeah. I don't even know what the score was. I have no idea who won.
Everybody knows Toronto got help from scientists across Canada. But few know that once they were here, they threatened to quit in frustration.
The SARS war room was at the top of a government building. It was designed for more traditional emergencies like fires and floods. But this was a health crisis. They didn't' need firefighters. They needed scientists. So Dr. Low started calling his friends.
"So I started phoning and said will you come to Toronto. I had my secretary come in and she phoned people all day Saturday and anybody who returned the call got asked to come," Low says.
High in a tree in the B.C. wilderness Dr. Bill Bowie was cutting branches when his pager went off.
"By the time it got to me it was basically, 'Help! Can you come to Toronto as soon as possible,'" Bowie says.
He was on a plane in five hours. What he found in Toronto shocked him.
"There was an awful lot of scrambling with folks trying to make decisions when they didn't have from my perspective the background or understanding of what the problem entailed," Bowie says.
It wasn't clear who was in charge.
There was Dr. Colin D'Cunha, Ontario's chief medical officer of health. He had the authority over hospitals and health units.
There was Dr. James Young, Ontario's commissioner of public safety.
There was Health Minister Tony Clement. He says the premier personally asked him to take control. So, in the end, they were all in charge.
"So, basically, we created a new structure which meant that Dr. Young and Dr. D'Cunha and I were joined at the hip for four months," Clement says. "There were certain things delegated to them, there were certain things that I took charge of and was responsible for and, basically, we tried to act as one mind throughout all of this."
It was an awkward command structure that caused confusion and delay and baffled almost everyone.
"I felt that we needed somebody, a single person in charge, so that they could be given authority, they could be given the responsibility and the resources to co-ordinate this," Low says. "We really needed a SARS czar, somebody to oversee this whole thing. I think it would have been the right thing to do."
On the front lines, Toronto public health officials were coping with a 21st-century disease using a tool from the last century paper. The thousands of cases had overwhelmed their old computer system. Dr. Sheela Basrur is Toronto's medical officer of health.
"It's like designing the bucket when you're fighting the fire," Basrur says.
"We had flip charts and colour-coded post-its as one of the key ways in which we shared information and passed it on between shifts.
"As issues would be dealt with they 'd be literally struck off the list with a big magic marker... As someone's status changed, the pink note would go from one flip chart to another.
"[It was] absolutely manual, highly visual, expeditious, but not efficient, if you know what I mean, when it comes to such things as reporting to the ministry or to the media what was our total number of cases, how many were in hospital, how many were in ICU, how many were on ventilators. At one point, it was practically a matter of counting stick men every single time they called us up to ask for more recent numbers, and that's no way to run a public health unit," she says.
It was no way to keep track of an outbreak, either. With paper statistics piling up all over the area the scientists couldn't get an accurate big picture view of the outbreak. That made it hard to give critical advice to front-line workers.
"We were making decisions and recommendations in the dark trying to do the best we could with what folks could supply, knowing that the people in the front lines trying to supply this information were absolutely overwhelmed trying to deal with minute-to-minute disasters," Dr. Bowie says.
Ontario realized it needed a better system, so more experts were called in to design one in the middle of the outbreak. They set up at Dr. D'Cunha's office at the opposite end of the city. Dr.Young and the scientists were still downtown. Soon the two groups were fighting over the information.
There was an accusation that Young's people were hoarding data.
"I think there were discussions about how fast the flow went," Young says. "I've heard that comment. I think it wasn't getting to them as fast or as easily as they wanted it to get to.
"I held a meeting and I suggested that we look at where the data was flowing, and emphasized the need for the data to get to the scientific committee."
The scientists needed that information to answer key questions: how fast was SARS spreading, how long was it incubating, and was the quarantine working? It was also taking too long to get their advice out to the front lines. They were so frustrated, they threatened to quit.
"There was a delay between the writing of the documents and getting the documents out to the hospitals that needed them because they were crying for this information," Low says. "They sometimes would get delayed and they would get changed and tweaked and all, and the science committee at one time had said, 'look, you either get this out or we're quitting,' and they got it out."
The whole experience was so discouraging Bill Bowie gave up and went home.
"I didn't leave happy," Bowie says. "If I had felt that I or we were contributing to our potential I would have been quite happy to stay there for months."
Everybody knows SARS closed hospitals, but few know that officials considered closing the entire city because they believed thousands of people could die.
As the politician presiding over the SARS crisis Tony Clement would think about little else for months, worrying he was seeing the world's next pandemic breaking out on his watch.
The SARS stress still shows on Clement. He's thinner than he was back in March. He calls it the SARS diet. He lost 30 pounds.
"The worst-case scenario they presented to me was of a worldwide pandemic, which based on the mortality rate at the time we thought [was] 10 per cent it turned out to be 15 per cent based on that mortality rate, you're looking at a million Ontarians who could perish, as a result of this disease. That was our worst case scenario."
With that on his mind Clement was considering measures that were unprecedented in Canadian history.
Already hospitals were shut down. Surgery was halted.
Behind closed doors, the health minister was talking about cancelling ball games, closing movie theatres, shutting down the airport and cutting off the city.
"I asked them to draw up some scenarios that would mean quarantining the whole city, that's correct," Clement says.
"This was obviously a very stressful time for everyone, not least for our health-care workers. But at the time you're thinking, this is a terrible, horrible situation that could be made worse if we make the wrong decisions, if we take it lightly, if we somehow put on our rose-coloured glasses and wish it were away.
"I was emphatic, as were others to be fair, that we have to plan for the worst. Give me the worst-case scenarios. If it means a cordon sanitaire around Toronto, give me how that works."
Added to that, Clement had to convince the Catholic Church to change its most sacred rites over the Easter weekend.
"This is serious stuff. I phoned Cardinal Abrosius. I said, 'Sir, I hope you don't mind but the Catholic rite is going to change a little bit over the Easter weekend. You know, you can't share the cup and all of the things that we're used to seeing.' So he was very good about it as were most Christian religions over the Easter holiday. And we got through it but that was the highest period of tension."
Everybody knows about the public battles waged against SARS.
But few know about the private struggles, when the fight became personal.
For Dr. Sheela Basrur it was in May. Toronto's senior health official had told a weary city that SARS was beaten.
Exhausted, she left for Jamaica. A week later, barely back on a plane headed for home, Basrur was forced to confront her worst fear.
"The door on the plane shut. They handed out the newspapers. The newspaper that I held and the paper next to me both had headlines that said 'SARS returns.' The bottom fell out of the pit of my stomach because I realized that somehow or other we had made a mistake. We had called it over when it clearly wasn't over and I had no idea how it could have happened. And no way to find out what had gone wrong until we got home," Basrur says.
For Dr. Don Low, "personal" meant putting his own health on the line day after day for months.
He was one of the first doctors in the world to see SARS patients face to face. He sat on their beds, toured infected hospital wards. Low still shudders when he thinks about how close he came to becoming sick himself.
"I don't know how I got by without getting this thing," he says.
I mean, I was in rooms with people coughing. I walked out with the same mask I do, hung it up and I wore it next time; I mean all the things you're not supposed to do. I did that time and time again. I just don't understand how I got away with it."
Dr. Allison McGeer was the only person on the command team who did get SARS. She was forced to face her own mortality. It's a fight that's still personal. McGeer says she's suffering post-traumatic stress.
"I think probably others around me are suffering more than I am," she says, "I continue to do SARS things because I know that they have to be done. But you listen to the shake in my voice now. I'm too much time on SARS and it's hard to focus on things. I 'm not concentrating the way I usually do. I'm not functioning at a level that I normally function at. You know all of us ought to be off doing other things for a period of time but there's still a lot of stuff that needs to be done to make sure that we're not going to be there again."
The ghost of SARS still lingers in the hospital corridors, in nurses who are still too weak to go back to work, who now hesitate to attend to patients with fever. Almost 400 people were dangerously sick and 44 people died, leaving those families to forever bear the cruellest scars.
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