In 2003, the severe acute respiratory syndrome-related coronavirus came to Canada. SARS caused a major crisis, mainly in Toronto and its suburbs, for the health-care system and public-health officials. Hundreds fell ill, and 44 died, before the epidemic was brought under control. Now that cases of a novel coronavirus have been confirmed in Toronto and Vancouver, officials have begun referring to “the lessons of 2003” and how they have prepared us for this challenge. What are those lessons? In a new series, TVO.org interviews three people who were involved in dealing with the SARS crisis to ask them what insights they’d offer their counterparts today. Today, I talk to Bonnie Henry, currently serving on the front lines of the coronavirus outbreak as British Columbia’s health officer. In 2003, she served as an associate medical officer of health in Toronto.
Matt Gurney: Right up until the day of SARS, the morning of, how would you have described your job?
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Bonnie Henry: [laughs] I’m still trying to explain to my mother what I actually do! I’d been with Toronto Public Health since just before 9/11 — I joined just the week before the attacks. And that had changed us. Not just the 9/11 attacks, but also the anthrax attacks that followed. The world had changed, and we were preparing for the worst. The office had already changed a lot by 2003. At the time, I was responsible mostly for communicable diseases and vaccine programs for one quarter of Toronto. I also had oversight and provided medical support for a number of the sexual-health clinics Toronto ran. Some days, I worked in the clinics themselves, but we also had broader public-health responsibilities. We had a whole gamut of responsibilities. So many crazy things that would come up. Our job was to make the population healthy, keep them healthy, and protect them from infectious diseases and environmental hazards.
Gurney: What about the day SARS came to Toronto?
Henry: I remember it. It’s seared into my memory. I had been working a lot on tuberculosis. The United States had changed their policy toward Tibetan refugees. Some had come to Canada, and one was infected with TB and had stayed in public shelters in Toronto. I spent the morning on TB. The Rotary Club in Kingston had invited me to talk to them about polio eradication that evening. I had done some work with the WHO and UNICEF the year before on polio in Pakistan and Afghanistan. I was riding a train back from Kingston. I got a call on my phone, and a colleague told me there were two strange cases in Toronto. One was suspected measles, which we worry about a lot. It can spread rapidly if there are low immunization rates and be very harmful, especially to young children. The other was a suspected TB case at a hospital in Scarborough. “How about you take the TB,” he said, “and I’ll take the measles.” And I said, “Sure, okay, sounds good. I’ll do the TB.”
Gurney: You probably thought then that you’d had gotten the less-interesting case.
Henry: Yes, exactly. So I got back to Toronto and spoke to the physician at the hospital. Long story short, it was the first case in our health-care system. He was a man in his late 30s; he was from Hong Kong but had no travel history there in six years. His mom and dad had gone back to Hong Kong to visit another son who’d stayed there. The mom was in her late 70s. She had travelled to Hong Kong and had flown home and become sick. Part of her travel package was two nights at the Metropole Hotel.
Gurney: I know that name from the reading I’ve been doing about SARS.
Henry: Yes. A physician from Guangdong who had come to Hong Kong for a wedding was also on the ninth floor. They spent two nights there and flew back home to Toronto. She’d gone to a family doctor and then another doctor, both in the community, and been diagnosed — quite rightly — with a virus. She was told to rest, drink lots of fluids. She had underlying illnesses, and she died at home. Her son, the man in the hospital with what we thought was TB, had found her in the morning and called 911. The dispatcher told him and his brother, who also lived in the home, to begin CPR.
Gurney: Oh, boy. So they were as close to her as could be.
Henry: Yes. Exactly. She did die. And the coroner attended, as always in the case of an unexpected death. The family was told a heart attack, complicated by the virus. But the son got it from her.
Gurney: It’s tragic, but, so far, there’s nothing here that would have worried anyone. Old ladies die in their beds.
Henry: They do. That’s exactly it. But the son was different. This was a young, previously healthy man with no travel history, suddenly getting a severe pneumonia. He spent a number of hours in the emergency department. He was given nebulized therapy. With retrospect, that is one of the things that began to spread the disease within the emergency department. We learned a key lesson from that — we are much more attuned to how respiratory illnesses can spread. So I was at the hospital, investigating it, trying to figure out what was going on.
We realized it was being transmitted. Patients and health-care workers were incubating this disease and transmitting it to others. So, essentially, I closed the hospital. I ordered no more admissions, and we moved everyone home we could and put them in isolation. Every patient had to be one-to-a-room, and every health-care provider had to wear gloves, masks, and gowns. At first, when I said we needed masks, gowns, and gloves for any contact with any patient, there was disbelief. We had not paid attention to infection prevention and control. Wearing gloves was not the norm. Masks were not the norm, even around patients who were coughing. We’ve learned that. Hand-washing is constantly reinforced. Gloves are normal. Masks are normal. We protect our mucous membranes from exposure. But, every time there’s a crisis, we’re reminded again that it’s human nature to slip, to be complacent.
Gurney: It’s human nature, absolutely.
Henry: It is. It is. And we learned that. A focus on infection prevention and control is essential. That was a big lesson for us. Not just in parts of hospitals, but everywhere. When I’m in a long-term-care home, I’m looking around, making sure we’re protecting those people. And we learned the importance of keeping health-care workers immunized. We didn’t collect information. That’s always been a challenge. We’re not there yet, but we’re doing better.
Gurney: Let’s just step back in the timeline a bit — we’ve moved a bit into the immediate part of the crisis. Let’s go back to that train ride from Kingston. You get this call about a possible TB case. Did you know already about what was happening in China? Were you aware? Information had begun to trickle out, but was there anything that made you sit up and think, wow, we’d better pay attention to overseas?
Henry: Yes and no. A big part of public health is monitoring what’s happening around the world. I was aware that, in November and December, there had been an outbreak of unusual pneumonia in China. China had acknowledged this. They said, yep, there was an outbreak — 300 cases and 13 dead, but it’s solved now! They blamed an unusual bacteria. And we said, huh, okay. And then it was radio silence from China. There were rumours in Chinese media, but this was before social media. So there wasn’t the instant evidence like this time. But the Chinese government was very actively telling us, nope, nothing going on here, look away, look away. That’s completely different this time. China has been forthcoming. Believe me, my heart has been in my throat since this started. All my SARS post-traumatic stress has come out.
Gurney: A whole city feels the same way, I think. People are on edge. I see more masks in Toronto every day.
Henry: I just worried that China was downplaying things again. But social media is so active now. There are 1.4 billion people in China who won’t let these things go unheard. China’s been very forthcoming. They’re making every effort they can. We’re holding our breath, but this is what we learned. Communication is key. All tragedy is a failure of communication. But to answer your question, when did we first know? I met with the infection-control experts at the hospital to try to figure out what was going on. We heard the story that our patient’s mom had died at home and had recently travelled to Hong Kong. And one of the nurses there said, hey, isn’t there something going on in Hong Kong? Slowly, the pieces came together. I also had a long conversation with the daughter of the mom, our patient’s sister. The patient — the son, the brother — he became very sick very quickly, and he died. Our job — my job, Toronto Public Health’s job — was finding out who he’d been in contact with since he’d shown symptoms. His family — his brother, his wife, his young son, his sister — had all had extensive contact with the mom and dad and the patient. And some of them were getting sick.
Gurney: You mentioned your post-traumatic stress. Like I said, a whole city feels the same way. I remember all this very clearly. People are talking about it. Schools are sending emails back to parents, passing along information and reassurance. My wife is a teacher, and she’s getting a lot of questions from parents. In 2003, we were sleepy. In 2020, we’re not.
Henry: It was a hard time. One of my colleagues, her mother died in hospital, mostly alone. People couldn’t get in to visit her. But we had to put in these restrictions to minimize the people coming through the hospitals. And that’s part of the first lesson again: control the infections at the hospitals. We’re doing better. I know there’s a lot of talk in Toronto about protective equipment being more available and nurses wearing it. That’s good. That’s an ongoing symbol of the stress and the distress of Toronto’s experience.
But another thing — and this is really, really, really important — was figuring out who’s in charge. The health sector is complex, nowhere more in this country than Ontario. There were many fiefdoms in Ontario. They didn’t talk to each other. At the time, there were 37 different health units in Ontario. They didn’t have a common IT system to share information. In Ontario, there was no central provincial agency. British Columbia has one, and it was a very different scenario in B.C. in 2003, but they had the B.C. Centre for Disease Control. The BCCDC gave common messaging and scientific information. We didn’t have that in Ontario. We had to pull together a scientific committee from people who were already exhausted from their daily tasks. When you have an unknown virus — at first we didn’t even know it was a virus! — that’s making health-care workers sick and killing people, there wasn’t help rushing in. There was so much fear. We needed help. Public Health needed help. We needed help with contact tracing. With infection control. We needed to provide support and advice, and we needed front-line personnel to help in the hospitals. And the rest of Canada and the world said, oohhh .... we’re gonna let you guys handle that. We’re gonna support you, but from here. They didn’t want to send their infection-control people and risk losing them or having them bring it back home with them. There was a lot of fear, but I think we’ve come a long way on that and recognizing where central messaging can come from.
Gurney: As SARS went on, as it became identified and you began closing hospitals to contain the infection, how did your role and work evolve? What did you get pulled into?
Henry: We created a management system. We had different operational people working with different parts of the challenge, and I was the operational leader, with oversight of them. I worked directly under the late Sheela Basrur, who was the public face of the response. My job was to give her the information to coherently speak to the public about what was going on and also make sure we were doing all the things we needed to do. We were managing the sick, contacting those in quarantine and checking on them, making sure that they were taking their temperature and that they had food and medications and masks. We effectively quarantined a large number of people. We had a team doing epidemiology, tracing where people had had contacts or become infected. We also were tracking SARS itself. We didn’t know how long it took people to get sick, the incubation period. It was about 10 days, but we didn’t know that and had to figure it out. We needed to figure out if it was transmitted from person to person by anything other than droplets. It wasn’t, mostly — mostly droplets. But, in Hong Kong, it was probably through aerosolized feces traced back to the plumbing. We established a hotline for information and for people to assess their risk. The public was worried. We talked to them and told them what we could.
I talked to many groups. I was liaison to the families of those who died. I talked with them as they were in crisis. I talked with imams to determine how we could safely do burial rituals for someone who had died of this. I talked with a rabbi about postponing the shiva for the patriarch of a Jewish family that had passed away, so we could protect the rest of the family. Things you never realized or expected. We had to talk with school boards. We organized community meetings in many different areas to talk with schools. Many schools closed not necessarily because of risk from SARS but because of staff concerns. There was a lot of fear. People in Toronto felt that they were kept informed, but often people outside of Toronto were projecting their fear, including from the U.S. And then the WHO travel warning came out of the blue. It made people feel like they had been lied to.
Gurney: I know you are incredibly pressed for time right now, but if you’ll indulge me one last question — as the crisis ground on, and your duties changed and you’re suddenly discussing burials with religious leaders, how did you have to adapt? What changed for your organization?
Henry: Well, after the first month or so, we finally got some help. More personnel arrived. But common suffering builds strong bonds. The small original group of us, we stay in touch, still, regularly. We got into a cycle of knowing what we had to do and doing it. And, as new issues arose, we dealt with them. It took a long time for us to recover from that. It took years. And not just Toronto Public Health. The organization totally reorganized itself because of SARS. We have a much stronger liaison unit with acute-care facilities to maintain the flow of information. Now we have Public Health Ontario. There wasn’t something like that in 2003. It’s amazing. And, federally, there’s Public Health Canada and a public-health officer for Canada. That position was created because of SARS.
There are processes for aligning the work we’re doing, for sharing resources, all across the country. That’s completely different from 2003.
This interview has been condensed and edited for length and clarity.