1 SPECIAL REPORT Nurses Were Sacrificed ten years after sars: where are we now? what have we learned? Ten years ago this spring, Ontario was gripped by a terror we had never known: Severe Acute Respiratory Syndrome, better known by its acronym, SARS. In this special retrospective, we relive the nightmare our members on the front lines experienced with a province and employers illequipped to handle the deadly virus, the lessons learned, and why we are hopeful our members will never be put in a similar situation again. H1N1. When ONA member Kim Campbell first heard that word in 2009, a chill went down her spine. Six years after contracting SARS while working on the front lines at North York General Hospital (NYGH) and still dealing with its horrific side effects, she knew she would be unable to relive another outbreak of an unknown virus. I didn t really realize how much SARS affected me until H1N1 came out, and I thought I cannot go through this again, I just can t, said Campbell, who spent a week recovering from SARS at Trillium Health Centre and approximately two weeks in quarantine at home. I was surprised at my reaction. I love nursing and my patients, but if it meant losing my job, that would be it for me. 1
2 SPECIAL REPORT Ten Years After SARS Kim Campbell, RN 2 Rearing its Ugly Head Campbell is just one of dozens of ONA members whose lives were turned upside down in the spring of 2003 when SARS reared its ugly head in Ontario in not one, but two waves that caught our health care system completely off guard and yielded widespread hysteria. Those on the front lines came face to face with SARS, which had made its way to Toronto from Hong Kong, as they struggled to care for sick patients while protecting themselves and their families. Many were placed in quarantine with little contact with the outside world and their families. Others became deathly ill themselves, describing severe flu-like symptoms that literally took their breath away. Most tragic of all, two members, Nelia Laroza and Tecla Lin, lost their lives caring for infected patients. By the time it was all said and done, 774 people worldwide, including 44 in Canada, died from SARS. I heard stories from nurses about driving straight home from work, stripping naked in the garage and going right into the shower because they didn t know what they were bringing home, said Susan Brickell, Bargaining Unit President for The Scarborough Hospital (then called Scarborough Hospital Grace) where the first Ontario SARS case was reported on March 7, I was taking care of HIV patients ONA President Linda Haslam-Stroud, RN, (left) and member Connie Leroux, RN, at the ONA media conference announcing our class action suit on behalf of RNs affected by SARS. in ICU when HIV was first discovered and not really knowing what it was, but you protected yourself. You re used to that as a nurse, but you don t bring it home. Bringing it home was the hard part. The disease focused heavily in the Greater Toronto Area (GTA), and hospitals such as North York General, Scarborough Hospital Grace and General Division, York Central, West Park Hospital, Toronto General Hospital, Toronto Western Hospital, Princess Margaret Hospital, Mt. Sinai, Sunnybrook, St. John s Rehab, Rouge Valley Health System, St. Michael s Hospital, Toronto East General Hospital, William Osler Health Centre, Trillium Health Centre, Humber River Regional, Lakeridge Health Corporation, Southlake Regional Health Centre, St. Joseph s Health Centre, Toronto and West Parry Sound Health Centre bore the brunt of infected patients. But we can t forget all the other ONA members across the province who were on high-alert and weren t sure how they were going to protect themselves and their patients if SARS entered their workplaces, said ONA Health and Safety Specialist Erna Bujna. We had no guarantees that it would be restricted to Toronto. Yet, these members were willing to do it. You re Scaring the Patients That seemed to be a common sentiment. I was worried at first, of course, but strangely enough, I was not afraid, said Connie Leroux, who contracted the disease from a patient and took care of her sick fellow nurses. There was no fear in the beginning. We were more than willing to take this on. That may have been not just because nurses notoriously place everyone s needs ahead of their own, but because information about the disease and its transmission was vague in the early days of the outbreak, even though the World Health Organization (WHO) declared SARS a worldwide health threat on March 15, While health care facilities followed provincial-controlled SARS directives throughout the ordeal, including ordering staff to wear personal pro-
3 tective equipment (PPE), such as respirators, gowns, goggles, gloves and hoods (for more invasive procedures); placing SARS patients in isolation; screening incoming patients for flu-like symptoms; setting up makeshift negative pressure rooms using plastic sheets to try to contain the spread; restricting visitors; and, at times, closing their doors to all admissions, those directives changed frequently, were at times confusing, and many members believe they were woefully inadequate. It was a nightmare, said Nancy Popp, who works at a GTA hospital and was quarantined after working a part-time shift at York Central where a SARS patient was identified. We were given updates daily, with the directives changing. I remember coming to work one day to find only large N95 respirators, which gapped on me. There were no smaller ones. As more and more of our members became infected, the message from the employer was always the same: you broke protocol. We were restricted to where we could eat or drink. We seldom had time to go to the cafeteria. Every day we went home weighing less than we did in the morning. We were becoming dehydrated. The employer was not well equipped to handle the situation, noted Brickell, who suffered through four quarantines and acquired a milder version of the virus. I had members say, OK, I ll work in quarantine, but how am I going to buy diapers for my baby or get gas for my car? There was no answer for that. It was so hard on our nurses, said NYGH Bargaining Unit President Carolyn Edgar. They would be in full protection, dealing with critically ill patients and were in quarantine. Then an already volatile situation was made much worse on May 17, 2003 when hospitals, in response to the government s lifting of Code Orange rules to facilitate containment, began halting daily SARS screening and directed health care workers to remove their PPE because, as Edgar notes, we were told, read my lips, there is no more SARS. Unfortunately, they were dead wrong, as a cluster of five people with SARS-like symptoms hit NYGH on May 23, 2003, marking the start of the second wave. While staff were immediately directed to resume wearing PPE, for many it was too late. We didn t have to get sick, said an angry Campbell. I wore a mask and all that time, I didn t get sick and then when I took it off for a number of days, all of a sudden, I m sick. And I took it off because I was told to. We were told we were scaring the patients. SARS was an unknown at Scarborough Grace, so I could understand the confusion at that time, but it wasn t an unknown when it got to North York General. People Just Wanted it to Go Away Still, Edgar believes her hospital and others did the best they could and responded with the information they were given. She puts the blame squarely on the City of Toronto and the Ontario government. There was pressure from the City because SARS was considered such a negative influence, said Edgar. People just wanted it to go away. It wasn t helped by the fact that the WHO advised against all travel to Toronto between April 23 and 30, with tourism taking a major hit. In fact, according to the Canadian Tourism Association, cancellations due to SARS cost Ontario hoteliers $60-million for the month of April 2003 alone. I felt that Toronto was too concerned with tourism and the government listened and had no business telling us the things they did, added Campbell. They should have let people who know what they were doing handle it. I felt nurses were basically sacrificed. I blamed the government because that s where the money and the information comes from, stated Brickell, who has only been able to discuss SARS without crying in the past two years. There was so much chaos and who knows who was in charge and steering the ship. Things changed every minute; it was hard to follow. I know it was hard for the employer to keep up with the directives and get those down to the front lines. It was all being kept Read my lips, there is no more SARS. our fallen heroes NELIA LAROZA, RN Tecla Lin, RN 3
4 SPECIAL REPORT Ten Years After SARS Putting yourself at risk is one thing, putting your family at risk is quite another. Life in Quarantine: Mommy are You Going to Die? Imagine being in the same house as your family, but not being allowed to watch television with them, use the same bathroom or give them a hug? Yet, that was the reality for our members who worked in facilities where SARS patients had been admitted and were placed under quarantine some more than once as a result. These members were forced to wear masks and were limited to travelling back and forth to work. I had husbands calling me saying how could they make my wife go to work, she s quarantined, she should be at home, said Scarborough Hospital Bargaining Unit President Susan Brickell, who was quarantined four times and had to turn off the TV when her 9-year-old daughter asked her if she was going to die after watching the news. Quarantines were awful. You are not even supposed to go in your backyard, and when you run out of groceries, that s an issue. Nancy Popp, who did not contract SARS but was quarantined, was forced to stay in her bedroom until her family left each day and had to return there when they came back in the evening. She ate her meals alone. Public health wasn t calling, nor was the employer, she said. I was not provided with masks or any direction. I was basically on my own and felt very isolated. My only source of SARS news was from the television. My family was very frightened. North York General Hospital nurse Connie Leroux had three small children at home during the time of her quarantine and summed up the fear of all nurses: Putting yourself at risk is one thing, putting your family at risk is quite another. 4 justice Archie campbell hush-hush, so I educated myself, communicated with members and basically worked 20-hour days because you can t turn off the cell phone or computer when members are in a panic. I was fearful for everything and everybody. Bujna concurs, and believes that governments and employers were focused on the financial costs of containment instead of focusing on doing whatever it takes and whatever it costs to protect workers and patient safety, noting that the voices of nurses were not being heard. And, in fact, that is one of our members biggest frustrations from those days. You would see people coming in with symptoms that didn t fit within the box of what SARS was, so they would be ruled out, agreed Leroux. But to all of us nurses, just because it doesn t fit the criteria right away doesn t mean it wasn t happening. We were voicing our concerns and were ignored. The hospital and government should have listened to the nurses because we are the ones on the front lines, added Brickell. We know what we need. We know what s going on. But they didn t. The SARS Commission That began to change when ONA members took their cause to Queen s Park in June 2003 to demand a public inquiry into the handling of the SARS outbreak. Several hundred also demonstrated outside Scarborough General Hospital that same month to demand better protection for health care workers who were treating SARS patients. At this point, let me tell you, our voices were heard, said Bujna. As a result, the government appointed Justice Archie Campbell to lead the SARS Commission of Inquiry, which considered mountains of evidence, including thousands of SARS surveys filled out by our members, before delivering a final report. His findings concluded that Ontario s hospitals are dangerous workplaces and that the province s
5 We didn t have to get sick. handling of SARS was a system failure. Campbell said that at the root of the disaster was our health care system s lack of preparation against infectious disease, the decline of public health and the malnourishment and decay of resources to protect health care workers. He described deep structural contradictions in hospital worker safety. These problems include a profound lack of awareness within the health system of worker safety, best practices and principles. Central to the problem, Justice Campbell found, were two solitudes: infection control and worker safety. Infection control relies on its best current understanding of science as it evolves over time. It is unnecessary to point out again that infection control failed to protect nurses during SARS. In the well-known debate about whether to protect workers with proper respirators, he concluded: The point is not who is right and who is wrong about airborne transmission. The point is not science, but safety. Scientific knowledge changes constantly. Yesterday s scientific dogma is today s discarded fable. 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.until this precautionary principle is fully recognized, mandated and enforced in Ontario s hospitals, workers will continue to be at risk. What We ve Done ONA has always been a driving force in trying to make Ontario workplaces safer for our members. And in the wake of the SARS tragedy, we redoubled our efforts to build what Justice Campbell described as the basic safety culture and workplace safety systems that have become expected and accepted for many years in Ontario mines and factories. As he observed, these systems were absent in hospitals battling SARS. With a long-term goal of transforming the province s health care system from occupational health and safety dinosaurs to health and safety stars, ONA has been on the forefront of the drive to heed Justice Campbell s advice to improve law, policy, funding and system capacity to protect Ontario s workers. (continued on next page) The Scars of SARS: Real Physical Damage For many members who contracted SARS, the virus may have long gone, but a multitude of health problems still remain. North York General Hospital (NYGH) nurse Kim Campbell, who was hospitalized for a week after contracting the virus, said she still suffers from shortness of breath, has severe joint problems at times and gets tired very easily. While she was able to rebuild her strength through St. John s Rehab s program for nurses who had contracted SARS, she felt pressured to return to work before she was ready. How do you say I m tired? she asked, noting that she has been on modified duties, working days since SARS. They hired someone whose mission it was to return us to work. Her colleague, Connie Leroux, was hospitalized for 10 days, being cared for by her fellow nurses. Likening the symptoms of SARS to that of a bad pneumonia, she said she also became depressed, suffered from anxiety, and was paranoid because logical thinking goes out the window. Still, both she and Campbell consider themselves lucky. Scarborough Hospital Bargaining Unit President Susan Brickell, who said her mild case of SARS felt about 10 times worse than her worst sinus infection, estimates about 10 of the more than 30 of her members who contracted SARS have never returned to work. It s a bizarre syndrome, she said. They have an array of physical, emotional and psychological problems. As nurses, we focus on the physical and pooh-pooh the rest because that s just who we are. NYGH Bargaining Unit President Carolyn Edgar noted that of the more than 40 members who contracted SARS at her hospital, approximately 10 remain off work, many suffering from a variety of lung ailments, cognitive difficulties and chronic conditions, such as fibromyalgia. There was a misunderstanding of the underlying illnesses that came as a result of SARS and some thought it was just hysteria, she said. But if you could see those nurses now, you d know it s not post-traumatic stress; it s real physical damage. 5
6 SPECIAL REPORT Ten Years After SARS We knew what we needed, but they didn t listen. The Fight for the Flag For ONA member and registered nurse Nancy Popp, it seemed like such a simple request to her employer (whom she does not wish to name): place the flag at half-mast to acknowledge the tragic passing of the first nurse to die from SARS. She had no idea the fight she was in for. After learning that her CEO was on vacation during that sad time in July 2003, Popp called her Chief Operating Officer (COO) to request the flag be lowered out of respect for nurse Nelia Laroza, but was told it would only upset the community. Unwilling to accept that reasoning, Popp called the Metro police department and fire station with the same request. While they said it was not in their policy to do so, they were supportive of Popp s request and promised to get back to her. True to their word, both quickly responded that they would lower their flags, and the firefighters even asked if Popp would consider allowing them to provide an honour guard at Laroza s funeral. Now I was really upset that the hospital would not lower its flag, Popp said. I wrote to (then) Premier Ernie Eves and told him of our struggle at work, of my request to the hospital administration, and the response of the police and firefighters to the same request. I asked for his assistance and to help us feel proud and respected. I did not expect to hear back from him. But she was wrong. On the day of Laroza s funeral, with her employer s flag still flying high, Popp called the COO one last time and was told a directive had been issued from the Premier s office advising all hospitals to lower their flags to half mast, and that her employer was in the process of doing so. A couple of weeks later, I actually received a letter from the Premier, thanking me and all the health care workers for our efforts, she said. I posted the letter at work because I wanted everyone to understand what it took to get the respect due to Nelia. Even now, 10 years later, Popp said retelling this story still brings tears to her eyes. These nurses sacrificed so much, as did many health care workers. They volunteered to take care of sick health care workers. They were heroes. They and their families deserved so much better. 6 Carolyn Edgar, RN, (left) and fellow nurses being honoured at Queen s Park for their dedication during SARS. (continued from previous page) We have made dozens of submissions, joined government committees, commented on documents, met with officials, pressed for improvements across all sectors and engaged in litigation, including launching a class action suit on behalf of RNs affected by SARS over the lack of protections. On May 7, 2009, the Ontario Court of Appeal ruled the province does not owe a private law duty of care to frontline RNs, and the following December, the Supreme Court of Canada denied an appeal of this decision. That was such an unfortunate decision because these nurses really suffered, said Edgar, while Leroux called it a slap in the face. On a more positive note, ONA has successfully negotiated with employers, filed grievances, and issued complaints to the Ministry of Labour (MOL) calling for enforcement of health and safety laws in our workplaces. We have conducted training and education of our members, developed resource materials and networks, handled complaints and guided members in their efforts to gain better protection in our workplaces. Specifically, as a result of our efforts: O The scientific community was forced to question their assumptions about the spread of infectious disease and acknowledge they may have been wrong about the airborne transmissibility of influenza. O ONA has language in the central hospital and other collective agreements for the supply of N95 respirators in the event of a pandemic, and
7 moved the government to incorporate sound occupational health and safety principles in its pandemic planning. O The MOL now has a team dedicated to the health care industry. O Under Section 21 of the Occupational Health and Safety Act (OHSA), the MOL established an advisory committee to make recommendations to the Minister on issues and trends related to the health care industry, and develop guidance notes that can assist workplace parties. O The precautionary principle has been included in the Health Protection and Promotion Act and in collective agreements around the province (although it hasn t yet been put in the OHSA). O We now have needle safety legislation and violence prevention provisions in the OHSA, and a revised CSA respirator standard that includes protection from bioaerosols, cites a health care example and lists a number of airborne diseases from which workers need protection. O Thousands of orders have been issued, there have been successful prosecutions of several hospital employers and appeals of MOL decisions have risen significantly. Where We are Today While we have made significant progress, it is not yet perfection, said ONA Health and Safety Specialist Nancy Johnson. And while many members agree more needs to be done, they report seeing significant changes on the front lines. We do more screening and people are isolated more readily, said Brickell. How effective it is, I don t know, but at least it s more effective than what we had. We communicate things better and I have commended my employer recently with the Coronavirus. Infection control notifies us much sooner and we get updates, so it s not at all a secret. And I think that helps allay the fears that are just under the surface of staff. We now have mask-fitting available to us, added Popp, who attributes the SARS tragedy for making her active in ONA. Our Joint Health and Safety Committee (JHSC) is more effective. During H1N1, the employer worked with the JHSC to develop strategies. We didn t always agree, but we were invited to the table. This was done proactively rather than the reactive process during SARS. Very good changes were made due to SARS, said Edgar. There are negative pressure rooms that deal with respiratory infections, and there are processes to transfer patients to the units. There s a highly developed hot-line for staff with a message for screening. There are signs in the hospital everywhere, if you have these respiratory symptoms This is to protect the staff from patients. Our JHSC became more integrated and empowered. You can t compare it now to how it was during SARS. I would definitely feel safer today, noted Leroux. Our employer has taken necessary steps to ensure precautions are all there. Now anytime anyone comes in with respiratory symptoms, there s an assessment and if they meet the criteria, they are put into isolation. This is very good news, but ONA is aware that too many of you still face resistant employers who suggest that any identified health and safety hazards are your fault and/or your responsibility to fix. It s always thrown back at you, agreed Brickell. Why didn t you take care of yourself? Why did you make yourself contaminated? No one asks, why didn t your hospital make you wear that mask? You need to have proper infection control practitioners who understand the basics. It s not rocket science. She added that with the elimination of nursing positions across the province including 70 at her hospital alone if another virus comes along, we will have even lesser qualified people on the front lines who don t understand. Our members in the community and long-term care facilities also report they still have basic challenges getting respirators and fit-testing in their sectors, said Bujna. SUSAN BRICKELL, RN My only source of SARS news came from the TV, not my employer. 7
8 SPECIAL REPORT Ten Years After SARS I was fearful for everything and everybody. 85 Grenville St., Ste. 400, Toronto ON M5S 3A2 Tel: (416) Toll-free: Fax: (416) Copyright While ONA leaders and staff keep the pressure on government and employers to make your workplaces safe and healthy, we also need to speed up the internal responsibility system (IRS), which provides a framework to ensure compliance with occupational health and safety legislation by employers and is intended to give workers a meaningful and equal participation in decisions affecting their health. Across the province, ONA is calling on our members to elevate unresolved health and safety concerns as high as necessary and as quickly as necessary to protect workers, and call in the MOL and/or file grievances as soon as necessary when the IRS does not work. We continue to build the capacity to move the health care sector forward to the point that our members don t have to wonder if they will leave work injured or sick and bring disease home to their families, said Johnson. And when we meet resistance about the cost of occupational health and safety and the precautionary principle, we remember the personal and financial cost of the SARS response failure as it killed our members, made them and their families sick and drove Toronto s economy to its knees. Lessons Learned From the SARS tragedy, ONA has learned that our workplaces are dangerous, yet our members cannot expect the basic protections found in mines and factories. We learned that our health care system was unprepared, fragmented, poorly led and inadequately resourced, and that occupational health and safety and infection control systems that should have been working together were not. We learned not to blindly trust the science that employers and government use to fend off our demands. And we learned that if we don t step up and demand protection for ourselves, we won t get it. The biggest lesson for me was that we need to take care of ourselves and our coworkers, said Popp, who has completed an occupational health and safety program at Ryerson and is co-chair of her JHSC. I used to believe the employer would take care of me, and would never put me in harm s way. No longer do I believe this. I made a decision that I would never sit by and let nurses be treated the way we were during SARS. We need to educate ourselves because at the end of the day, it is us who are sick, injured or dying, and our families that have to deal with the consequences. The next most important message is the use of the precautionary principle, and always erring on the side of caution. It s better to be proactive than reactive. Since SARS, I ve learned not to be afraid to speak up not that I was afraid to speak up before but to realize that I know what I m talking about when it comes to safety and to not be intimidated, added Brickell. I m just not risking members when it comes to safety. I would tell our members to do whatever they have to do to protect themselves; the employer does not have a right to tell you to take off a mask. Perhaps Leroux summed it up best: We ve become an important part of decision making and we challenge upper management. While I don t know how I would feel if another virus came along, I do know the people you can count on most are the people you work with everyday on the front lines. And I love what I do. Awakened by the tragedy of SARS, we continue to make our members sacrifices matter, concluded ONA President Linda Haslam-Stroud. ONA will stay as long as necessary at the forefront of the drive to improve occupational health and legislation, policy, funding and system capacity to protect you. Motivated by our members suffering and fueled by Justice Campbell s wisdom, ONA won t give up until your safety is secure. We learned that our health care system was unprepared, fragmented, poorly led and inadequately resourced, and that occupational health and safety and infection control systems that should have been working together were not.