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Reflections 10 Years After SARS

For the last edition of the OHPE in 2013 we asked public health professionals and all of our readers to provide their brief insights regarding how the SARS outbreak in Canada in 2003 changed public health.

Contents

I Reflections from the Public Health Agency of Canada
Submitted by David Butler-Jones, Chief Public Health Officer

II How SARS changed public health
Submitted by Public Health Ontario

III Association of Public Health Epidemiologists in Ontario (APHEO)
Submitted by Cameron McDermaid

IV Ontario Public Health Association
Submitted by Sue Makin

V Personal reflections from a public health nurse
Submitted by Carol Popovic

VI SARS and the Schooling of Public Health
Submitted by Frank Welsh

I Reflections from the Public Health Agency of Canada
Submitted by David Butler-Jones, Chief Public Health Officer

Time has passed so quickly, it is worth reflecting how different the situation of Public Health would be without SARS. It was tragic for those affected and so many responded courageously. At the same time it pointed out many of the deficiencies and gaps in the system and challenged the economy and public trust in our health and political institutions.

For the Agency (and I know for others as well) every event prompts reviews and application of the lessons learned. The silver lining is that as a result, there were also structural and capacity changes as well as political engagement such that Canada was able to respond to the 2009 pandemic as good as or better than any other jurisdiction, stopping the pandemic before Christmas.

The pandemic of 2009 hit North America first and hardest. The difference between 2009 and 1918 is that the world and our capacities have changed. We and the Americans have strains from 2009 that kill ferrets (the best animal model of human disease) faster and nastier than the 1918 virus we have.

For the first time in history we were able to dramatically alter the course and impact of a pandemic. Without the experience of SARs and efforts since in Canada and elsewhere we would have had a very different experience of H1 2009. Additionally this has assisted Public Health in its work in other areas such as chronic disease prevention, health promotion, social determinants,  one health and others. Not only in enhanced focus and capacity, and while there are still many challenges, one example of fundamental change is as follows:

When the Agency first started in 2004 public health issues of any kind were rarely on Ministers’ and Deputys’ agendas.
Now they are a significant part of all Deputy Minister and Minster federal/provincial/territorial  meetings.

Making it practical so that the theory is applied and we can demonstrate the results and tell the story is essential.  Finally to hear, at the UN special meeting on Chronic Disease in New York and the WHO Social Determinants meeting in Rio in 2011, Ministers, Presidents and Prime Ministers using the language of Public Health and speaking to public health approaches suggests to me a fundamental generational change. In spite of current budget pressures and the gap between where we are and need to be, it bodes well for the future.

II How SARS changed public health
Submitted by Public Health Ontario

The lessons Ontario learned from SARS resulted in Operation Health Protection, the establishment of Public Health Ontario (http://www.publichealthontario.ca/en/Pages/default.aspx) and many other enhancements that shape today’s public health system and health care practices.

Ontario’s public health system has significantly improved infection prevention and control practices, surveillance and epidemiology, integrated data and information systems, communications and coordination, and emergency preparedness.  Technology advances have resulted in more effective monitoring, case tracking and information flows. And international, national and provincial regulatory systems support more integrated and transparent reporting and collaboration.

In the current MERS-CoV and H7N9 outbreaks, information such as case definitions and counts, laboratory testing protocols and synthetic genetic coding, and clinical guidelines for assessment and treatment have been developed and shared much more quickly globally, while guidance has been provided faster to local health system partners.

The public health sector has made great gains in improving the flow of communications and relaying information and instruction in real time to those who need it. However, much remains to be done, particularly given the evolution of media and communications.  

 While public health must continue to rely on traditional media as a primary means of information dissemination, new communications channels such as social media provide additional opportunities to convey information more quickly and clearly, and to interact directly with their audiences. Knowledge organizations can establish trust and credibility by being available, transparent, and open to communicating ideas and science directly through such means.

Public health practitioners will need to develop methods and approaches to working with new media channels to provide evidence and information, monitor and respond quickly to misinformation, and engage in dialogue. By doing so, public health will continue to be a trusted voice and source of information.

III Association of Public Health Epidemiologists in Ontario (APHEO)
Submitted by Cameron McDermaid

This year has been an interesting year for the Association of Public Health Epidemiologists in Ontario (APHEO).  We’ve continued to see strong engagement from the public health epidemiology community.  With a core of representation from municipal public health units and diverse representation from a number of other public health related interests, APHEO is a strong community of practice for public health epidemiology in Ontario.

This community of practice and the communication it supports is important because of the changing landscape of public health practice in Ontario.  The last ten years has seen a substantial amount of change.  Following the Ontario experience with SARS in 2003, the recommendations of the Campbell Commission acted as an impetus for change in terms of jurisdiction and responsibility.  As an example, Public Health Ontario has matured into an organization that provides transparent and coherent scientific support for public health practice both at the provincial and municipal level.

Other changes include the Ontario Public Health Standards that replaced the Mandatory Health Programs and Services Guidelines in 2009 and established the minimum requirements for fundamental public health programs and services in Ontario. The guidelines are now accompanied by a new performance management accountability agreement system that evaluates successful delivery of public health programs and services.

This landscape will continue to evolve. The need for a high level of public health practice expertise and support, transparency and optimal communication in multi-jurisdictional events such as SARS, commitment to performance excellence, the evolution of new data sources, and the development of fledgling public health priorities such as built environment will add complexity but also an unprecedented richness to public health practice. APHEO and its members look forward to these challenges and working with our colleagues to address them and improve the health of the population in Ontario.

IV Ontario Public Health Association
Submitted by Sue Makin

On behalf of the Ontario Public Health Association, I would like to extend greetings to PHO and thank you for being such an engaged and contributing partner with OPHA as we work together to advance public health in Ontario.  And, there has never been a greater need or more opportunities to do so since SARS.

No doubt, SARS had tragic consequences for individuals, families, communities and health professionals alike.  But, the experience was a call to action for the public health sector, internationally, nationally, provincially and at the local level.  Emergency planning became much more than a hypothetical exercise. As a result, we were far more prepared when H1N1 come along. And, how we manage communicable diseases was certainly advanced.

But, the impact extended far beyond emergency planning and communicable disease control.  The limitations of the public health sector became glaringly clear. Organizations, including OPHA and constituent societies immediately began advocating for an investment in public health that would both expand it and build on our existing capacity. That investment has come in a variety of forms over the past ten years. The funding formula for local health agencies changed and Public Health Ontario was established to support evidence-based practice and knowledge exchange.

Still, there is much to do to continue the advancement of the public health sector and OPHA, in partnership with the constituent societies will continue to play a role in doing so. Through knowledge exchange activities like our forums and webinars, through support to new professionals, through the development of a leadership centre, and through ongoing advocacy on a broad range of public health issues, we will strive to continue to advance the capacity of Ontario’s public health sector.

V Personal reflections from a public health nurse
Submitted by Carol Popovic

My memories are on a personal level. My mother was ill and I had to take her to an ER in a small community but I also had my small children with me. The staff were anxious about the children being present and the risk of SARS. I tried to balance being with my mother and the concerns of staff.  I missed being present when the physician assessed my mother and could not advocate on her behalf.  She was sent home on an antibiotic prescription and died the next day with a massive coronary. I always felt SARS had a role in that premature discharge and the fact that I was not there to advocate adequately on my mother's behalf!

VI SARS and the Schooling of Public Health
Submitted by Frank Welsh

The story of SARS is one with which most are familiar, but with any story that becomes interwoven with our past, it’s crucial that we do not forget its lessons. Only two years after the September 11 terrorist attacks in the United States, when the world was distracted by war and the ever-present vigilance against another attack, the SARS virus showed up quietly in the Guangdong province of China then quickly moved to Kowloon, an urban area in Hong Kong. The virus then made a great leap, across an ocean and most of a continent to Scarborough, Ontario where it became entrenched in the hospital setting and eventually brought Canada’s largest city to its knees. When all was said and done, about 8,500 persons worldwide were likely infected resulting in over 900 deaths. Canada was the non-Asian country hardest hit with 438 likely SARS cases resulting in 44 deaths. The toll was highest among health care workers with more than 100 becoming ill leading to three deaths.

Along the way, the SARS outbreak taught us lessons in migration health, epidemiology, infection control and public health emergency response. It showed the effect that even small outbreaks can have on people – the impact of fear – and the need for strong leadership and effective risk communication. The local economy was temporarily, but significantly derailed – thank you to the Rolling Stones for bringing life back to Toronto!

The question though, is have we learned our lessons? Since 2003, the Public Health Agency of Canada has been established, and our understanding of the roles and responsibilities of the various levels of government during emergencies has improved. We have had the opportunity to respond to the H1N1 pandemic and several large-scale foodborne disease outbreaks, as well as myriad smaller issues. In each case, there have been improvements in how we react, new lessons to learn and a better understanding of how to recover. As such, the SARS outbreak was the first catalyst for us to develop an understanding of the complex and evolving world of infectious disease outbreak management in the 21st century. For example, social media was practically non-existent during the SARS outbreak and yet played a significant role in our response to H1N1.

Our ability to respond to a future SARS-like outbreak has improved, but our capacity to do so without stripping resources (human and financial) from other core public health functions remains a serious question. We must remain vigilant in our surveillance and training, and be prepared to respond as we never know from which quarter the next challenge will emerge.