renewal of public health in canada - amazon web …...two key reports were solicited from outside...

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S A R SL e a r n i n g

Renewal ofPublic Health in Canada

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Renewal ofPublic Health in Canada

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A report of the National Advisory Committee on SARS and Public HealthOctober 2003

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This publication can also be made available in/oncomputer diskette/large print/audio-cassette/Braille upon request.

For further information or to obtain additional copies,please contact:

PublicationsHealth CanadaOttawa, Ontario K1A 0K9Tel.: (613) 954-5995Fax: (613) 941-5366

©Her Majesty the Queen in Right of Canada, 2003Cat. H21-220/2003EISBN: 0-662-34984-9Publication Number: 1210 Learning from SARS:

Renewal of Public Health in Canada

The members* of the National Advisory Committee on SARS and Public Health were:• Dr. David Naylor, Dean of Medicine at the University of Toronto (Chair)

• Dr. Sheela Basrur, Medical Officer of Health, City of Toronto

• Dr. Michel G. Bergeron, Chairman of the Division of Microbiology and of the Infectious Diseases Research Centre of Laval University, Quebec City

• Dr. Robert C. Brunham, Medical Director of the British Columbia Centre for Disease Control, Vancouver

• Dr. David Butler-Jones, Medical Health Officer for Sun Country, and Consulting Medical Health Officer for Saskatoon Health Regions, Regina

• Gerald Dafoe, Chief Executive Officer of the Canadian Public Health Association, Ottawa

• Dr. Mary Ferguson-Paré, Vice-President, Professional Affairs and Chief Nurse Executive at University Health Network, Toronto

• Frank Lussing, Past President and CEO of York Central Hospital, Richmond Hill

• Dr. Allison McGeer, Director of Infection Control, Mount Sinai Hospital, Toronto

• Kaaren R. Neufeld, Executive Director and Chief Nursing Officer at St. Boniface Hospital, Winnipeg

• Dr. Frank Plummer, Scientific Director of the Health Canada National Microbiology Laboratory, Winnipeg (ex officio)

* The Committee was materially assisted through corresponding members of the US Centers for Disease Control and Prevention and the World Health Organization.

PREFACE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The National Advisory Committee on SARS and PublicHealth was established in early May 2003 by the Minister of Health of the Government of Canada, theHon. A. Anne McLellan, in the circumstances surroundingthe outbreak of Severe Acute Respiratory Syndrome[SARS]. The Committee’s mandate was to provide a“third party assessment of current public health effortsand lessons learned for ongoing and future infectiousdisease control.”

The Minister asked the Committee to build on currentpublic health interventions, and to foster and encouragecollaboration among jurisdictions, professionals, andinstitutions. We were urged to work towards integrationof all aspects of the containment of SARS (epidemiology,management, communication, and internationalcoordination). The outbreak of SARS in the GreaterToronto Area was contained during our mandate, asexpected. Therefore, we extended this integrativeapproach to our analysis, and recommendations regardingemerging infectious diseases and public health in general.

Most of this report deals with two major elements of ourmandate: provision of a short-term assessment of lessonslearned from current public health interventions tocontain SARS, and advice regarding issues for necessarylonger-term action regarding infectious disease controland prevention.

We learned very rapidly that Canada’s ability to fight anoutbreak such as SARS was tied more closely to thespecific strengths of our public health system than to thegeneral capacity of our publicly-funded personal healthservices system. By public health, we refer to systemsthat are population-focused, and include functions suchas population health assessment, health and diseasesurveillance, disease and injury prevention (includingoutbreak or epidemic containment), health protection,and health promotion. Our analysis and ourrecommendations accordingly set out a plan for acomprehensive renewal of both the public health systemin general, and the nation’s capacity to detect, prevent,understand, and manage outbreaks of significantinfectious diseases.

The Committee went about its data gathering andanalysis in the following way.

We reviewed a broad range of source documents, research,and reports from Canada and other countries applicableto SARS, communicable disease control, and publichealth infrastructure more generally. The chair and a staffmember personally interviewed in person or bytelephone a range of informants involved in the Torontooutbreak. The Committee’s deliberations were alsogreatly assisted by one full-time policy and researchadvisor, and two part-time research/editorial associates.

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Two key reports were solicited from outside consultants.One, by Prof. Sujit Choudhry of the University ofToronto Faculty of Law, dealt with legal issues, includingthe difficult question of jurisdictional authorities. Withpermission, we borrow directly from Prof. Choudhry’sreport in this document, although it should not beassumed that he would agree in all respects with theconclusions we have drawn from it. The otherconsultancy, by the Hay Health Care Consulting Group[the Hay Group] in Toronto, entailed interviews, a survey, and an analysis of hospital service profiles, toprovide an overview of the preparedness of the GreaterToronto Area health system to respond to SARS, the gapsperceived by stakeholders, and the steps that had been or might be taken to improve responses to infectiousoutbreaks in future. We worked with the Hay Group to incorporate their findings directly into our report.Health Canada’s Office of Nursing Policy organizedroundtables with front-line health care workers; thefindings from that valuable exercise have also beenincorporated into the report.

Discourse among members involved about thirty hoursof face-to-face meetings, and a substantial amount ofelectronic and telephone traffic. We live, work, and paytaxes in several different provinces. The members of theCommittee represent a multitude of disciplines andperspectives, and several were directly involved inresponding to SARS in diverse capacities.

As noted in the Acknowledgements, our work wasinformed not only by our own experience and that ofour colleagues, but by the many non-governmental andvoluntary sector stakeholders who wrote briefs, letters,responded to requests for interviews, and providedinformation that enriched our deliberations andrecommendations. In this regard we reviewedapproximately 30 written submissions (see reportappendix for list).

We also requested preparation of extensive backgrounddocuments from Health Canada staff in the Populationand Public Health Branch. The Committee was alloweddirect and unfettered access to leading professionals inthe Branch who in turn were given explicit licence tooffer their expert opinions and advice, unconstrained bythe normal reporting hierarchy. Some senior staff draftedmaterial for the report itself. All such material was firstrevised by staff as per the Committee’s requests, thenedited or rewritten extensively by the Committeemembers.

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TABLE OF CONTENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Chapter 1 — Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Emerging and Re-emerging Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Globalization and Communicable Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16The World Health Organization (WHO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17US Centers for Disease Control and Prevention (CDC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17A “CDC North”? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Emergency Preparedness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18The State of Canada’s Public Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Federal/Provincial/Territorial Structures and Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Canada’s SARS Experience. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Learning from SARS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Chapter 2 — SARS in Canada: Anatomy of an Outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232A. A New Disease in Guangdong (November 27, 2002 - February 22, 2003). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232B. From Kowloon to Scarborough (February 23, 2003 - March 12, 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242C. SARS I: The Outbreak Begins (March 13, 2003 - March 25, 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262D. The Emergency (March 26, 2003 - April 7, 2003). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

2D.1 Information Technology and Data Sharing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282D.2 Scientific Advisory Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302D.3 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312D.4 Health Canada’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312D.5 Public Communications and Media Relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322D.6 Research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322D.7 Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 332D.8 Clinical Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2E. The Quest for Containment (April 8, 2003 – April 23, 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342E.1 Public Health’s Fight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342E.2 Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352E.3 Transmission of SARS to Protected Health Care Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362E.4 WHO Travel Advisory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

2F. Between the Waves (April 24, 2003 - May 22, 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382F.1 Hospital Infection Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382F.2 North York General Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

2G. SARS II (May 23, 2003 - June 30, 2003) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 402H. SARS and the Health Care Worker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412I. Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Chapter 3 — The Role and Organization of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433A. What is Public Health? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

3A.1 The Origins of Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433A.2 Defining Modern Public Health Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46


3B. Governance and Organization of Public Health in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473B.1 Some Constitutional and Legislative Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473B.2 Organization of Public Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 493B.3 The Challenge of Public Health in Rural and Remote Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

3C. Public Health in the Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 523D. Funding Public Health in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

3D.1 National Spending on Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553D.2 Expenditure Trends in Ontario. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 553D.3 A Modest Investment by Any Measure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

3E. International Comparisons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583E.1 United States of America. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 583E.2 United Kingdom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 623E.3 Australia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

3F. Some Reflections and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68Appendix 3.1 — US Department of Health and Human Services Organizational Chart . . . . . . . . . . . . . . . . . . . . . . . 69

Chapter 4 — Enhancing the Public Health Infrastructure: A Prescription for Renewal . . . . . . . . . . . . . . . . . . 714A. Core Elements of the Public Health Infrastructure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 714B. A New National Public Health Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

4B.1 General Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724B.2 What Does ‘National’ Mean? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734B.3 The Structure of a New Federal Agency for Public Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

4C. A Chief Public Health Officer for Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 764D. Scope of the Canadian Agency for Public Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774E. A Federal Agency with a Pan-Canadian Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

4E.1 One Agency, Many Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 794E.2 A National Public Health Advisory Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 804E.3 A National Public Health Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

4F. Funding to Strengthen Canadian Public Health Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814F.1 General Considerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 814F.2 Funding the Core Agency Functions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

4G. A New Public Health Partnership Program for Provinces and Territories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 834G.1 Level of Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 834G.2 Programmatic Funding: Some Constitutional and Legal Considerations . . . . . . . . . . . . . . . . . . . . . . 844G.3 Funding Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 854G.4 Current Program of Grants and Contributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 864G.5 Reinvigorating a National Immunization Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

4H. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Appendix 4.1 — Population and Public Health Branch: Current Organization Chart . . . . . . . . . . . . . . . . . . . . . . . . . 90

Chapter 5 — Building Capacity and Coordination: National Infectious Disease Surveillance, Outbreak Management, and Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

5A. Surveillance and Outbreak Management: Essential Functions for Public Health. . . . . . . . . . . . . . . . . . . . . . . . 915A.1 Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 915A.2 Outbreak Management and Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

5B. The Auditor General’s Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 975C. Managing Public Health Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

5C.1 Public Health qua Firefighting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985C.2 The National Emergency Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 995C.3 Focal Points for Health Emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005C.4 The Post-September 11 Environment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1005C.5 Building Surge Capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1025C.6 Crisis Communications to the Public: A Missing Link. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

5D. National Capacity and Network for Disease Surveillance & Outbreak Management . . . . . . . . . . . . . . . . . . . . 1045E. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107Appendix 5.1 — Costing of a Surveillance System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109Appendix 5.2 — Case Definitions for SARS from Health Canada and Ontario . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Appendix 5.3 — Some Steps toward Achieving Seamless Outbreak Management in Canada . . . . . . . . . . . . . . . . . . 112

Chapter 6 — Strengthening the Role of Laboratories in Public Health and Public Health Emergencies . . . 1136A. Key Activities of Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

6A.1 Diagnosis of Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1136A.2 Characterization of Micro-organisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

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6A.3 Reference Microbiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146A.4 Support to Epidemiologic Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1146A.5 Laboratory Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156A.6 Environmental Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156A.7 Chronic Disease Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1156A.8 Emergency Preparedness and Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166A.9 Applied Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166A.10 Fundamental Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

6B. The Public Health Laboratory System in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1166B.1 Front-line Laboratories (Private, Local and Hospital Laboratories) . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176B.2 Provincial Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186B.3 National Laboratories and National Laboratory Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1186B.4 International Laboratory Networks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

6C. Analysis of the Laboratory Response to SARS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1206D. The Ideal Public Health Laboratory System for Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1216E. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122Appendix 6.1 — Canadian Public Health Laboratory Network (CPHLN) Draft Terms of Reference . . . . . . . . . . . . . 123

Chapter 7 — Public Health Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1277A. The Effect of SARS on Professional Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287B. Current Supply of Public Health Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128

7B.1 Public Health Physicians. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287B.2 Public Health Nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1307B.3 Laboratory Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1317B.4 Infection Control Practitioners and Hospital Epidemiologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1317B.5 Infectious Disease Specialists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1327B.6 Epidemiologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337B.7 Other Public Health Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337B.8 Overall Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

7C. Nature of Education and Training. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337C.1 Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337C.2 Nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1347C.3 Epidemiologists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

7D. A Public Health Human Resources Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1367E. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Sources and References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Chapter 8 — Clinical and Public Health Systems Issues Arising from the Outbreak of SARS in Toronto . . . 1418A. Scope and Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1428B. Readiness of the Health System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

8B.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1438B.2 Roles and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1438B.3 Emergency Structure/Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1458B.4 Hospital Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1488B.5 Communications Structures and Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1498B.6 Surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538B.7 Health Human Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1538B.8 Psychosocial Implications of SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

8C. Services Impact and Backlog Estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1558C.1 Impacts on Emergency Department Visit/Admission Volumes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1558C.2 Surgery Volumes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1578C.3 Patient Days and Occupancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1588C.4 Elective Surgery Backlog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

8D. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Chapter 9 — Some Legal and Ethical Issues Raised by SARS and Infectious Diseases in Canada . . . . . . . . . . 1639A. General Legislative and Governance Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

9A.1 Legislation and Regulation as Components of the National Public Health Infrastructure . . . . . . . . 1639A.2 Governance Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

9B. Jurisdictional Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1669B.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1669B.2 Public Health and the Criminal Law Power. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1679B.3 Public Health and the POGG Power. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1679B.4 The International Imperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689B.5 Other Bases for Federal Legislation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1699B.6 The US Analogue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

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9B.7 Federal Legislation as Default . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1709C. Existing and Proposed Federal Legislation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

9C.1 The Proposed Canada Health Protection Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1709C.2 Federal Privacy Legislation and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1719C.3 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

9D. Provincial Legislation on Infectious Disease Outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1749D.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1749D.2 The Model State Emergency Health Powers Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1749D.3 Initial Assessment of Provincial Laws in light of the Model Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

9E. Federal Health Emergencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1769F. Ethical Issues and Lessons from the SARS Outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1789G. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Chapter 10 — Emerging Infectious Disease Research in Canada – Lessons from SARS. . . . . . . . . . . . . . . . . . . 18310A. Emerging Infectious Disease Research: A First Look at the Canadian Record on SARS . . . . . . . . . . . . . . . . . . 18410B. Outbreak Investigations and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18610C. Reflections on the Research Response to Epidemics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188

10C.1 Business as Usual. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18810C.2 Mobilization of Scientific Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18810C.3 Leadership, Organization, and Direction of Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18910C.4 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19110C.5 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

10D. Capacity for Relevant Public Health and Infectious Disease Research in Canada. . . . . . . . . . . . . . . . . . . . . . . 19310E. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Chapter 11 — Viruses without Borders: International Aspects of SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19711A. International Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

11A.1 Health Canada’s Role . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19711A.2 World Health Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199

11B. International Response to SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19911B.1 WHO Response to SARS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19911B.2 International Experiences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200

11C. Canadian-International Communication and Liaison . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20111D. Travel Advisories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202

11D.1 WHO Advisories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20211D.2 Health Canada Advisories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

11E. SARS and Travel Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20311E.1 Quarantine Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20411E.2 Quarantine Officers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20511E.3 Screening Measures and Provision of Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20511E.4 Protocols for Airlines and Cruise Ships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

11F. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207Appendix 11.1 — A Chronology of SARS Travel Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208Appendix 11.2 — SARS Screening Measures - Daily Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209

Chapter 12 — Learning from SARS: Renewal of Public Health in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21112A. Preparing for the Respiratory Virus Season. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21312B. Recommendations for Renewal of Public Health in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

12B.1 New structures for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21412B.2 New Funding for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21512B.3 National Public Health Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21512B.4 Emergency Planning, Outbreak Management and Crisis Communications. . . . . . . . . . . . . . . . . . . . 21512B.5 Surveillance/Data Gathering and Dissemination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21612B.6 Clarifying the Legislative and Regulatory Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21612B.7 Renewing Laboratory Infrastructure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21712B.8 Building Research Capacity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21712B.9 Renewing Human Resources for Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21812B.10 International Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21812B.11 Clinical and Local Public Health Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

12C. Postscript . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Appendix 1 — Interviews and Submissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221

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EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Mandate of the CommitteeThe National Advisory Committee on SARS and PublicHealth was established in early May 2003 by the Minister of Health of the Government of Canada, theHon. A. Anne McLellan, in the circumstances surroundingthe outbreak of Severe Acute Respiratory Syndrome [SARS].The Committee’s mandate was to provide a “third partyassessment of current public health efforts and lessonslearned for ongoing and future infectious disease control.”Committee members represented a multitude of disci-plines and perspectives from across Canada. Several weredirectly involved in responding to SARS in differentcapacities. We reviewed source documents, conductedinterviews, and engaged consultants to undertake surveys,additional interviews, and analyses to illuminate aspectsof the SARS experience. Advice was also sought from aconstitutional legal expert. Over 30 non-governmentaland voluntary sector stakeholders submitted helpfulbriefs and letters.

SARS in CanadaSARS is a droplet-spread viral illness, apparently caused bya novel coronavirus. Emerging in China in November 2002,SARS spread across the globe over the course of severalweeks. About 8,500 persons worldwide were diagnosedwith probable SARS during the epidemic, and there wereover 900 deaths. SARS remains a challenge to diagnoseand manage because its symptoms resemble those ofmany other respiratory infections. SARS was managedprimarily by supportive measures for those affected, withisolation and infection control precautions in hospital, as well as tracing and quarantine of contacts. Diagnosisrested on the clinical syndrome, a link to known cases ofSARS, and a process of exclusion. Available laboratorytests were not consistently helpful during the acute phaseof the illness.

Outside of Asia, Canada was the country hardest hit bySARS. As of August 2003, there had been 438 probableand suspect SARS cases in Canada, including 44 deaths.The majority of SARS cases and all deaths were concen-trated in Toronto and the surrounding Greater TorontoArea [GTA]. The toll on health care workers was high:more than 100 became ill and three succumbed.

Public health and health care workers in Ontario andBritish Columbia did an admirable job of containingSARS. Health care workers caring for SARS patients wereat heightened risk for contracting a new and dangerousdisease, and worked under physical and psychologicalstress. Lack of certainty about diagnosis and treatmentadded to the clinical challenges. SARS also placedunprecedented demands on the public health system,challenging regional capacity for outbreak containment,surveillance, information management, and infectioncontrol.

A great many systemic deficiencies in the response toSARS were identified as the Committee went about itstask. Among these were: lack of surge capacity in theclinical and public health systems; difficulties with timelyaccess to laboratory testing and results; absence ofprotocols for data or information sharing among levels of government; uncertainties about data ownership;inadequate capacity for epidemiologic investigation ofthe outbreak; lack of coordinated business processesacross institutions and jurisdictions for outbreakmanagement and emergency response; inadequacies ininstitutional outbreak management protocols, infectioncontrol, and infectious disease surveillance; and weaklinks between public health and the personal healthservices system, including primary care, institutions, and home care.

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Emerging Infectious Diseases,Globalization, and BioterrorismSARS is only the most recent example of emerginginfectious diseases—diseases that are newly identified, or that have existed previously but are increasing inincidence or geographic range. Since 1973, more than 30 previously unknown diseases associated with virusesand bacteria have emerged. Examples include: Ebolavirus (1977); Legionnaire’s disease (1977); E. coli 0157:H7-associated hemolytic uremic syndrome (1982); HIV/AIDS(1983); Hepatitis C (1989); variant Creutzfeldt-Jakobdisease (1996); and H5N1 Influenza A or avian flu (1997).West Nile virus infection is an example of a disease thathas increased its geographic range. As well, some knowninfectious diseases, such as tuberculosis, have re-emergedin vulnerable populations.

According to World Tourism Organization data, approxi-mately 715 million international tourist arrivals wereregistered at borders in 2002. Human migration has beena key means for infectious disease transmission throughoutrecorded history. However, the volume, speed, and reachof travel today have accelerated the spread of infectiousdiseases.

Compounding the challenges of dealing with emergingand re-emerging infectious diseases, is the threat of theaccidental or intentional release of biological agents ashighlighted by the intentional release of anthrax sporesin the USA in the Fall of 2001.

Public Health in Canada:Organization and JurisdictionAmong the functions of public health are healthprotection (e.g., food and water safety, basic sanitation),disease and injury prevention (including vaccinationsand outbreak management), population healthassessment; disease and risk factor surveillance; andhealth promotion. The public health system tends tooperate in the background unless there is an unexpectedoutbreak of disease such as SARS or failure of healthprotection as occurred with water contamination inWalkerton, Ontario (2000) or North Battleford,Saskatchewan (2001). An effective public health systemis essential to preserve and enhance the health status ofCanadians, to reduce health disparities, and to reduce thecosts of curative health services. Public health also playsa key role in disaster and emergency response.

Primary responsibility for public health services is at themunicipal or local level, through about 140 health unitsand departments that serve populations ranging from600 to 2.4 million people, with catchment areas from 4 to 800,000 square kilometres. The next level oforganization is provincial or territorial. At the provincial/territorial [P/T] level, staff engage in planning, administerbudgets, advise on programs, and provide technicalassistance to local units as needed. The P/T-level capacityfor coordination and technical support of local healthagencies varies sharply from one province to the next.

Two provincial models are noteworthy. British Columbiaestablished its Centre for Disease Control in 1997 to takeresponsibility for provincial-level management of infectiousdisease prevention and control, including laboratories.Quebec established the National Public Health Institute in1998 by transferring in staff from several regional publichealth departments and the ministry; it oversees the mainpublic health laboratories and centres of expertise. TheQuebec Institute has a mandate that covers prevention,health promotion, healthy living, workplace health, and chronic disease prevention as well as infectiousdisease control.

Federal activity is concentrated in the Population andPublic Health Branch [PPHB] of Health Canada. PPHB isheadquartered in Ottawa, with regional offices acrossCanada. It includes Centres for Infectious DiseasePrevention and Control, Chronic Disease Prevention andControl, Emergency Preparedness and Response, SurveillanceCoordination, and Healthy Human Development. PPHBalso oversees the National Microbiology Laboratory inWinnipeg and the Laboratory for Foodborne Zoonoses inGuelph. Other branches in Health Canada and othergovernment departments and agencies are involved withpublic health to a variable extent.

From a constitutional perspective, public health isprimarily a provincial concern. However, the federalgovernment has authority to legislate aspects of publichealth owing to its powers over, variously, the criminallaw, matters of national concern for the maintenance of“peace, order and good government”, quarantineprovisions and national borders, and trade and commerceof an interprovincial or international nature. Behind theformal division of powers is an essential tension in theCanadian F/P/T fabric: much administrative responsibilityrests with the P/T level, while revenue generation andtherefore spending capacity is concentrated at the federallevel. In the latter respect, Ottawa does not currentlymake any earmarked transfers to other governments forpublic health. PPHB instead operates a $200 million perannum program of grants and contributions directed tonon-profit and non-governmental organizations.

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Public Health Capacity and FundingThere have been many calls to strengthen public healthinfrastructure in Canada over the last decade. For example,in late 1993, given the global spread of HIV, HealthCanada organized an Expert Working Group on EmergingInfectious Disease Issues. This ‘Lac Tremblant’ groupcalled for “a national strategy for surveillance and controlof emerging and resurgent infections”, support andenhancement of “the public health infrastructure necessaryfor surveillance, rapid laboratory diagnosis and timelyinterventions for emerging and resurgent infections”,coordination and collaboration in “setting a nationalresearch agenda for emerging and resurgent infections”,“a national vaccine strategy”, “a centralized electroniclaboratory reporting system to monitor human and non-human infections”, and strengthening “the capacity andflexibility to investigate outbreaks of potential emergingand resurgent infections in Canada”. A decade later, verysimilar recommendations are repeated in our report.

In 1998, Mr. Justice Horace Krever provided a general callto improve public health in his report of the “Commissionof Inquiry on the Blood System in Canada”. An F/P/Treport on Public Health Capacity was prepared at therequest of the F/P/T Conference of Deputy Ministers ofHealth, and presented to them in June 2001. It high-lighted the weaknesses in public health infrastructureacross Canada, pointing to disparities in capacity fromone province to the next; concerns about the relative lowpriority given to longer-term disease and injury preventionstrategies; weaknesses in human resources for publichealth; and growing recruitment/retention difficulties.In 2002, the Romanow Commission recommended anational immunization strategy, a physical activitystrategy, and strengthening prevention programs. TheStanding Senate Committee on Social Affairs, Science andTechnology chaired by Senator Michael Kirby also reportedin 2002. The Senate Committee called for the federalgovernment to commit $125 million annually towardschronic disease prevention. It also cited inconsistentfunding, poor coordination among jurisdictions, and an overall lack of accountability and leadership, inrecommending additional funding of $200 millionannually to enhance public health infrastructure across Canada.

Given variation in accounting, it is difficult to generate aprecise estimate of current public health spending inCanada. We roughly estimate total public healthexpenditures in Canada (2002 - 2003) to range from $2.0 to $2.8 billion depending on the definition used.Total health spending in 2002 was $112.2 billion for the

public and private sectors combined, and $79.4 billionfor the public sector alone. Public health thereforeaccounts for 1.8% to 2.5% of total health expenditures,and 2.6% to 3.5% of public expenditures. Provincialspending clearly varies, but so do methods of accountingat the provincial level.

International ModelsAustralia and the USA are federations with constitutionaldivision of powers similar to Canada. The US Centers forDisease Control and Prevention [CDC] has an interna-tional reputation for excellence in public health. Over2,000 of the approximately 8,600 full-time equivalentemployees work outside the CDC headquarters in Atlanta;this includes postings to 47 state health departments.

Although it is best known for investigating disease outbreaks,the CDC is actually a broad public health agency; andmuch of its budget is directed to an extensive system offederal grants and transfers to states and municipalities insupport of public health infrastructure. The CDC workswith states to set and monitor standards. It oversees anational health alert and surveillance system, a nationalworkforce development and continuing education initiativefor public health practitioners and related laboratorypersonnel, and a public health information network.The CDC’s National Public Health Laboratory Systemdevelops policies and public-private partnerships forimproved and timely reporting of laboratory results.

In Australia, the federal government pays for half ofpublic health services—30% via direct expenditure and22% via transfers to states and territories. Joint publichealth activities are coordinated through the NationalPublic Health Partnership under the auspices of the federaland state/territorial health ministers. The Partnershiphas clear priorities such as: improving public healthpractice; developing public health information systems;reviewing and harmonizing public health legislation;implementing public health workforce initiatives;strengthening national public health research and devel-opment capacity; enhanced coordination of nationalpublic health strategies; and developing standards for thedelivery of core public health strategies. Federal transfersoccur through Public Health Outcome Funding Agreementsthat have targets and reporting requirements. A nationalprogram for public health education and research fundsAustralian tertiary institutions to strengthen post-graduateeducation and training.

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The USA and Australia, as well as the UK, each have acoherent chain of policy, stretching from legislation,national goals and priorities, national strategies, programsto sustain the public health infrastructure (includinghuman resources), means of reaching agreement betweenstakeholders, and specific funding programs. There aretargets with timelines and accountability mechanisms.In contrast, Canada does not have national health goals,a related strategy, or programs of federal transfers tofacilitate implementation of a national strategy.

A New Canadian Agency for Public HealthThe current federal arrangement puts public healthprofessionals inside a very large department with ahighly process-oriented culture geared to meeting thepolitical issues of the day. Vesting those functions in anarm’s-length agency would enhance the credibility andindependence of federal activities in public health, andoffer more flexibility in terms of employment andpartnerships with NGOs. An agency could also betterfoster a collaborative F/P/T culture rooted in sharedexpertise among public health professionals. The creationof an agency cannot depoliticize interactions amongjurisdictions, but it can reduce the chances that thehealth of Canadians would inadvertently be held hostagein a jurisdictional disagreement among levels of government.Among our key recommendations therefore is that theGovernment of Canada create a new Canadian Agencyfor Public Health, led by a Chief Public Health Officer of Canada.

A Canadian Agency for Public Health is arguably beststructured as a Legislated Service Agency, analogous to the Canadian Food Inspection Agency, the CanadianInstitutes of Health Research, or Statistics Canada. TheChief Public Health Officer of Canada would be the chiefexecutive of the new federal agency and report directly tothe federal Minister of Health. The Chief Public HealthOfficer of Canada would also issue an annual report on thestate of the public’s health and the public health system.

Public health agencies, centres, and institutes around the world vary in their scope. It is premature for theCommittee to recommend precisely which activities and programs should be included at this point, beyondindicating our support for a strong and integrativeorganization. A systematic review is required to establishthe scope of the new agency. A more effective approachto continuing challenges in First Nations and Inuithealth must be considered as part of any scoping process.

Centralizing the agency in a single new location wouldbe disruptive for existing staff and fail to capitalize onthe full range of opportunities for partnership in P/T andmunicipal jurisdictions. We recommend instead selectiveexpansion of activities in Ottawa, Winnipeg, and otherexisting sites, along with deliberate devolution of somecore functions to new locations across Canada. An effortshould be made to co-locate federal agency hubs withprovincial and regional centres of excellence in publichealth. Activities in these sites would thus becomemutually reinforcing, and help foster a common F/P/Tculture focused on protecting the health of Canadians.

We also recommend that, as an early priority, the newagency initiate the collaborative development of a nationalpublic health strategy. The strategy should includespecific health targets, benchmarks for progress towardsthem, and collaborative mechanisms to maximize thepace of progress. In developing a national strategy, thenew agency must not only work with P/T jurisdictionsand other federal departments and agencies, but consultwidely with stakeholders in the broader health community.The current program of transfers to NGOs should also bereviewed and aligned with the national health strategy.

The Committee further recommends the prompt creationof a National Public Health Advisory Board to advise theChief Public Health Officer of Canada on the mosteffective means to create and implement the above-notednational public health strategy. The nomination processshould build pan-Canadian collaboration by involvingexisting F/P/T networks and advisory committees.Members would be appointed to limited terms by thefederal Minister of Health.

Many core functions of the new agency can be developedsimply by transferring in current activities and capacity.Relevant core functions directly within PPHB currently costabout $187 million per annum (2002 budget). Adding inextant grants and contributions that amount to contracted-out functions, we reach $225 million as a rough estimateof spending on core functions within PPHB. About $75 million of the costs of operations in other branchesof Health Canada could also fall within a new agency’smandate, for a notional total of $300 million spent in 2002.

The Committee has recommended that the current corefunctions be expanded to include greater investments in: disease surveillance systems; health emergencypreparedness and epidemic response capacity; a majorand urgently-needed program of development of publichealth human resources; substantial augmentation ofresearch spending; enhancement of federal laboratories;

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capacity-building partnerships with provincial andhospital laboratories pending other F/P/T investments;and coverage of relatively neglected areas such asenvironmental health, mental health, injury prevention,and public health ethics.

These activities will require gradual increases in budgetfor core functions. The additional spending is projectedto reach $200 million dollars per annum within 3 to 5 years. A proportion of these new monies for corefunctions would flow to extramural partners, e.g., insupport of research programs allied with the CanadianInstitutes of Health Research [CIHR], for salaries offederal personnel seconded into P/T public healthagencies as per the CDC model, and to create newacademic, institutional, and NGO partnerships forhuman resource development.

Federal Funding to Renew PublicHealth across CanadaA stronger federal presence in public health, vested in anew agency with enhanced intramural and extramuralcapacity, would only go partway to remedying thedeficiencies evident during the SARS outbreak. Publichealth in the first instance is a local enterprise. Provincesand territories in turn must fund, support, and coordinatelocal activities through their own agencies and ministries.As a corollary, the containment of SARS was clearlydependent on local and provincial efforts in Ontario andBritish Columbia. Even greatly enhanced technicalsupport and outbreak investigation by a federal agencywill be somewhat irrelevant if the local and regionalcapacity for outbreak response is weak. The publichealth infrastructure needs strengthening at all levels,and this in turn suggests the need for earmarked federalfunding that is not currently provided.

Public health did not figure directly in the two F/P/THealth Accords reached in September 2000 and February 2003. The first Accord provided $23.4 billion in new federal funds for the six-year period from 2000-01to 2005-06. The second provided for $34.8 billion ($30.9 billion new monies) in federal funds for health for the five-year period from 2003-4 to 2007-8. Whilebillions of dollars were earmarked for personal healthservices, the two Accords together appear to include over$20 billion in non-earmarked transfers that could be used by P/T jurisdictions in part for spending on publichealth infrastructure.

The availability of these funds underscores our assumptionthat any new federal spending on public health shouldbe matched in some respects by P/T spending. But withoutearmarked federal monies for public health, P/T spendingwill be drawn, as always, to personal health services andopportunities for leverage and coordination will be lost.

As an alternative to new federal transfers, some mayargue that the federal government should simply passlegislation that imposes obligations on provinces andterritories with respect to disease surveillance or publichealth emergencies. Arguments in constitutional law canindeed be made for more federal intervention in publichealth. However, federal legislation that sought toconscript P/T personnel or unilaterally regulate theiractivities would lead to unfunded mandates and F/P/Tpolitical and legal confrontations.

Thus, following the Australian and US models, theCommittee is recommending a comprehensive set offunding arrangements and processes designed to facilitateF/P/T collaboration. The goal of these transfers is tocreate a seamless multi-tiered public health system,knitted together by inter-governmental agreements andharmonized legislation or regulation.

The Committee explicitly rejected the concepts of eitherpassive transfers without accountability or block fundingthat could become a flashpoint for F/P/T disagreement.Instead, we have endorsed a depoliticizing strategy inwhich new federal funding flows through the new agencyto P/T and municipal jurisdictions, targeting programsand activities according to agreements among publichealth professionals. The Committee firmly believes thenew agency’s impact will be strongly dependent on itsability to flow federal funds in support of front-line(local) and P/T public health agencies. Absent an abilityto fund or co-fund programs with those governments andagencies that have primary constitutional responsibilityfor public health, a new federal agency will almost certainlybe resented as an irrelevant job creation program staffedby technical experts who are better at talking to eachother than supporting serious front-line work. And absentmeaningful and earmarked federal funding, Canada’s publichealth infrastructure will remain a flimsy patchwork.

The Committee has therefore recommended threeprograms of transfers with a total value that will rise,over the course of several years, to a target level of $500 million per annum: $300 million per annum for aPublic Health Partnerships Program to build generalcapacity in public health at the local/municipal level;$100 million per annum targeted at communicabledisease surveillance and control with a particular

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emphasis on P/T level or second-line capacity; and $100 million per annum to bolster the currently under-funded National Immunization Strategy. These fundscould be combined and managed according to the Social Union Framework Agreement, thereby giving moreflexibility for federal and P/T officials to align transferswith both P/T needs and the national strategic plan forpublic health.

Communicable Disease Control andHealth Emergency ManagementHealth surveillance involves the tracking and forecastingof important health events or determinants through thecontinuous collection of relevant data, and the creationand dissemination of reports, advisories, alerts, andwarnings as needed. The 1999 and 2002 reports of theAuditor General of Canada raised serious questions aboutthe F/P/T collaborative framework for infectious diseasesurveillance and outbreak management. Although someprogress has been made, these concerns—both as regardsdetection of emerging infectious disease threats andcommunication of alerts regarding such threats—havebeen underscored by the SARS experience.

Thus, the Committee has recommended that F/P/Tgovernments urgently strengthen surveillance programs.Action would focus first on communicable diseases, andthen be extended to non-communicable diseases andrelevant population health factors. These surveillanceprograms must be coupled to short-term investments insupport of hospital infection control.

Some legal issues in surveillance also require short-termattention. The Personal Information Privacy and ElectronicDocuments Act [PIPEDA] will come into full force onJanuary 1, 2004. It is not clear if PIPEDA applies tohealth care providers. To the extent that PIPEDA doesapply, its restrictions on the non-consensual use ofhealth information could inadvertently interfere withdisease surveillance activities that pose no particularthreat to privacy. PIPEDA’s application to the healthsector accordingly requires an urgent review, culminatingin separate federal health information privacy legislation,amendments, or clarifying regulations.

F/P/T collaboration in emergency preparedness andresponse is more advanced than in health surveillanceand outbreak management. This collaboration wastriggered by tragic terrorist attacks on the USA inSeptember 2001. Since March 2002, an F/P/T Networkfor Emergency Preparedness and Response has been

working on matters such as leadership and coordination;surge capacity; training and education; surveillance anddetection infrastructure (including laboratories); supplies;and communications. We have recommended acceler-ation of support for the Network’s activities with a specialfocus on communicable disease control.

The Committee sees an urgent requirement for multi-jurisdictional planning to create integrated protocols foroutbreak management, followed by training exercises totest the protocols and assure a high degree of preparednessto manage outbreaks. To create surge capacity, the F/P/TNetwork for Emergency Preparedness and Response hasalready been working towards establishment of HealthEmergency Response Teams [HERT]. The HERT model hasbeen developed as a multidisciplinary group of clinicaland support personnel for “all hazards”. The SARSexperience highlights the need to mobilize selected groupsof skilled personnel into epidemic response teams withinthe HERT framework.

To accelerate collaborative activities in infectious diseasesurveillance and outbreak management, we haverecommended the creation of a new F/P/T Network forCommunicable Disease Control. This new F/P/T networkwould reinforce the collaborative activities of the F/P/TNetwork for Emergency Preparedness and Response.

The new F/P/T Network for Communicable DiseaseControl (and the associated funding arrangements)would be Canada’s second line of defence against ‘thenext SARS’. The new F/P/T network would createconnections not only among strengthened provincialand regional centres of excellence in infectious diseasecontrol. It could also link these P/T nodes or hubs andthe relevant centres and laboratories in the new federalagency. As noted, we recommend an approximate targetof $100 million per annum in earmarked funding insidethe new agency’s envelope for transfers to build therequired capacity at the P/T level and maintain the newF/P/T network. The flow of federal funds must be tied tointergovernmental agreements and initiatives to securestandardized business processes and a harmonizedlegislative framework for disease surveillance andoutbreak management.

Some federal funding and concerted action to ensurenational preparedness should begin as soon as possiblegiven the forthcoming winter season of upper and lowerrespiratory diseases; specific recommendations for short-term action are included in our report.

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As noted earlier, SARS has also raised concerns about thelegislative framework for health emergencies managementin Canada. Since the Fall of 2001, all jurisdictions havebeen reviewing and upgrading their emergency planningand preparedness frameworks. However, the F/P/Tlegislative frameworks for health emergencies have notbeen analyzed for comparability and interoperability. We have recommended a general intergovernmentalreview to harmonize F/P/T public health legislation, withspecific attention to public health emergencies withinextant emergency legislation.

A related concern is lack of clarity about jurisdiction whena health threat affects multiple provinces. The federalEmergencies Act (R.S. 1985, c. 22 (4th Supp.)) confers verywide powers on the federal government and can only beinvoked in the face of a truly grave national threat. Thefederal government otherwise has uncertain authority in the face of a multi-provincial outbreak. This situationis particularly problematic as the World HealthOrganization [WHO] moves to establish InternationalHealth Regulations that set expectations for memberstates as regards surveillance, reporting, and outbreakmanagement. We recommend that consideration begiven to a federal health emergencies act to be activatedin lockstep with provincial emergency plans in the eventof a pan-Canadian health emergency.

Last, the Committee determined that neither HealthCanada nor most jurisdictions and institutions havedeveloped sophisticated frameworks for riskcommunication during a public health crisis. The CDChas a comprehensive crisis communications trainingprogram that, in our view, bears close study and earlyadaptation by Canadian governments and institutions.

Public Health Partnerships ProgramWhile priority must be given in the short term toinfectious disease surveillance and outbreak managementcapacity, the broad range of public health functions alsorequires support and coordination. In many local healthunits, the same personnel help fight an outbreak one dayand inspect restaurants or deliver a health promotionseminar the next.

We accordingly recommend that a new Public HealthPartnerships Program be established under the auspicesof the Canadian Agency for Public Health. The newpartnerships program would flow funds through specificagreements with P/T public health officials, aimed atreinforcing core public health functions at the local leveland collaborative arrangements across jurisdictions. This

option is used by the USA and Australia to improve basicpublic health infrastructure. Funding for programs canbe directed at, for example, specific health protectionand disease prevention programs, information systems,laboratory capacity, training, recruitment and retention,and emergency response capacity. The programmaticoption can be combined with cost-sharing, e.g., someprograms could offer a percentage of the cost, up to adefined maximum, with the province or territory findingthe balance. Such targeted transfers with associatedaccountability mechanisms are useful ways to alignfunding and policy direction. They also reduce the riskthat existing spending would simply be displaced.

Spending through the new partnerships program wouldbe increased over several years to a target of $300 millionper annum, and aligned with the national public healthstrategy.

National Immunization StrategySince the 1990s, there has been interprovincial diversityin the publicly-funded programs and legislation pertainingto immunization and vaccination. The current arrange-ments compromise purchasing power, limit the securityof vaccine supply, and put providers in the untenableposition of having to recommend vaccines to persons/families who cannot afford them.

Four new vaccines are currently unfunded in most P/Ts—conjugate pneumococcal vaccine, conjugatemeningococcal vaccine, varicella vaccine and acellularpertussis vaccine. An F/P/T expert group proposed in2001/02 that the federal government pay for the newvaccines while P/Ts cover the costs of administration. To support their case, those involved produced documen-tation showing meaningful health and economic benefits from more complete coverage and upgrading of vaccination strategies.

The 2003 federal Budget provided only $45 million overfive years ($5 million in year one, and $10 million a yearthereafter) “to assist in the pursuit of a national immu-nization strategy.” As noted, the Committee believesthat $100 million per annum should be earmarked for amajor reinvigoration of the National ImmunizationStrategy under the auspices of the new Canadian Agencyfor Public Health. This amount would cover about 50%of the steady-state cost to P/T jurisdictions for purchasingthe new vaccines. Some of the funds should also be usedto improve tracking systems for vaccination coverage.

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Public Health Human ResourcesThe 2003 federal Budget allotted $90 million over fiveyears for health human resources, but no funds wereearmarked specifically for the public health workforce. A clear shortfall in public health human resource planningand development was recognized in the 2001 Survey ofPublic Health Capacity in Canada. The Committee foundfew definitive data on public health human resources,but those data raised concerns.

Community medicine specialists serve as medical officersof health in local public health agencies, and providespecialized expertise for the provincial and federalgovernments. Public health physicians are needed in ruralareas, the Atlantic provinces, the northern territories, and areas served by Health Canada’s First Nations andInuit Health Branch.

Experts estimate that there are approximately 12,000 publichealth nurses in Canada. The Canadian Nurses Associationestimates that Canada will be short 78,000 registerednurses by 2011. Some experts suggest that Canada isalready short 16,000 nurses. Unfortunately, informationabout the nursing workforce is not collected in a waythat makes it possible to extract definitive data on publichealth nurses.

Medical and PhD-trained microbiologists are in very high demand; current output is too low. There is also ashortage of infection control practitioners [ICP]. ICPs aremostly either nurses (88%) or laboratory technologists(10%) who learn on the job. Forty-two percent of Canadianhospitals fail to meet the current US standard of one ICPper 250 active care beds and 80% cannot attain the newCanadian standard of one ICP per 175 active care beds.Fewer than 60% of Canadian hospitals have a qualifiedphysician serving as infection control director. Canadaalso needs more epidemiologists with an orientation tofield investigation and outbreak response.

In short, on multiple levels, be it staffing for core publichealth functions or at the interface of clinical and publichealth activities, there is an acute shortage of highlyqualified personnel.

The Committee has recommended that F/P/T governmentsmove expeditiously to develop and implement a nationalstrategy to renew and sustain public health humanresources. The strategy should be based on a partnership(after the Australian model) involving governments, aca-demic stakeholders, institutional partners, and professional

associations. A budget for this purpose has been builtinto our projections for new spending by the CanadianAgency for Public Health. The strategy should not onlyaim at making Canada self-sufficient as regards publichealth personnel; it should also explicitly aim at enhancinginter-jurisdictional collaboration on a continuing basis.

Public Health Laboratories Canada’s medical laboratories are operated variously byinvestor-owned corporations, non-profit hospitals andhealth regions. All provincial governments except NewBrunswick operate public health laboratories. Ontario’sprovincial laboratory could not meet the demands forSARS testing; rapid and impressive steps were thereforetaken by laboratory workers in various hospitals inToronto to establish diagnostic capacity for the coronavirus.Unfortunately, as hospital laboratories took over testingfor SARS, the ability to monitor data at the national andeven provincial level was undercut because of poor infor-mation systems and the lack of data sharing protocols.Linkage of already-limited epidemiologic data to laboratorytest results became even more challenging.

This experience underscores our general observation thatCanadian laboratory activities in infectious diseasetesting and outbreak response are not well-coordinated or adequately linked to clinical and epidemiologic data.As recommended in the Lac Tremblant report a decadeago, Canada should initiate an active and collaborativelaboratory surveillance system to anticipate, detect andrespond to infectious disease threats.

Such a system necessitates better integration of front-linelaboratories into the public health system. Steps in thatdirection have been taken by the Canadian Public HealthLaboratory Network [CPHLN]. The CPHLN is coordinatedby the directors of the provincial and national labora-tories and some federal public health leaders. CPHLNmembership should either be extended to major hospitallaboratories or these hospitals should be incorporatedinto provincial networks represented in CPHLN. TheCommittee’s spending projections incorporate additionalsupport for provincial public health laboratories and forthe CPHLN to draw in a wider range of laboratory partners.We have also recommended an F/P/T collaborative reviewof various aspects of the public health laboratory system.

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ResearchMultiple governments and agencies have now investedmillions of dollars into SARS research. For example, theCIHR has taken a lead role in organizing the nationalSARS Research Consortium. Funding partners in theConsortium include a range of federal and provincialagencies, as well as private sector partners. The Consortiumintends to support work in diverse areas, such as diagnostics,vaccine development, therapeutics, epidemiology,databases, public health, and community impact.

However, the immediate research response to SARS wasuneven. Research into the cause of SARS, the character-ization of the agent, the development of diagnostic tests,and generation of initial clinical descriptions was conductedand communicated relatively rapidly. Research on theimmune response with the goal of developing a SARSvaccine has progressed well. Scientists in Vancouver andWinnipeg were among the leaders internationally insequencing the SARS coronavirus. This success arosefrom prior collaborative arrangements and capacity. Itunderscores the importance of support for fundamentalresearch and the need for research networks that areoperational in advance of an outbreak.

On the other hand, research on many fundamentalepidemiologic and clinical aspects of SARS has lackedcohesion. Scientists in Hong Kong were able to produceseminal epidemiologic and clinical descriptions whileresponding to a larger epidemic than Canada’s. Ourincapacity arose in part from previously-identified issuesof leadership, coordination, data collection and manage-ment, data sharing, and weak mechanisms to link epidemi-ologic and clinical to laboratory data.

The lack of capacity also reflects training and fundingpriorities, as well as problems of coordination. The CIHR’ssubmission advised that its investment in infectiousdisease research “flows primarily to support biomedicalresearch (84%), and the emphasis on biomedical researchin this field is stronger than in the CIHR’s overall portfolio(72%).” The CIHR is now attempting to build strongerclinical and epidemiologic research capacity in infectiousdiseases, but has highlighted a lack of coordination amongfederal and other agencies in developing a research agendaand capacity.

The Committee has recommended that the new CanadianAgency for Public Health and the F/P/T Network forCommunicable Disease Control must give special priorityto linking research in government and academic institu-tions with a focus on infectious diseases. It must build in

advance the teams and business processes for rapidepidemic or outbreak investigation, and therebystrengthen Canada’s ability to respond to the ‘next SARS’.

More generally, Australia, the UK, and the USA all haveembedded a strong research and science component intheir public health activities. A new Canadian agencymust therefore combine enhanced intramural R&Dcapacity with extramural funds that will allow contractingout of R&D functions through partners such as the CIHR.Parallel investments by provinces are also required.Intramural R&D activities at the F/P/T level should belinked to academic health institutions and major munici-pal health units through co-location, joint venture researchinstitutes, cross appointments, joint recruitment, inter-change, networks and collaborative research activities.

Regional and Clinical IssuesDuring the first wave of SARS in Ontario (SARS I), thegovernment declared a provincial emergency and mandatedreductions in elective and ambulatory hospital activity.Outbreak management was overseen by a ProvincialOperations Centre. Multiple institutions were involvedin caring for SARS patients. During a second wave ofSARS (SARS II) from the third week of May to the end ofthe outbreak in July, the caseload was strategicallyconcentrated in four designated institutions, andoutbreak management was overseen by a SARSOperations Centre established within the OntarioMinistry of Health and Long-Term Care.

In Ontario, confusion arose at times as to who was incharge of the outbreak response. GTA hospitals haddifficulties implementing some of the directives issued bythe provincial government. No Toronto hospital hadmade infectious diseases a program priority, and therewas no regional framework for outbreak management tocoordinate responses across institutions or health servicesectors. Occupational health and safety issues were arecurrent source of tension within institutions. Familyphysicians perceived that authorities moved slowly inadvising them on precautions to be taken in their offices,or giving them support and supplies. There were noregularized processes for sharing and compensating staffappropriately during an emergency such as SARS. In thepublic health sphere, informants criticized the lack ofcoordination across the four involved local units, theweak analytical capacity of the Ontario Public HealthBranch and its limited role in supporting or coordinatingthe outbreak responses.

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Respondents later highlighted weaknesses in systems forcommunicating infectious disease alerts from publichealth agencies to the operational levels of the healthsystem (i.e., hospitals, long-term and home care facilities,ambulance services, family physicians). The process forissuing alerts was apparently more successful in BritishColumbia, thanks to the provincial Centre for DiseaseControl. Post-SARS, clinical and public health leaders inthe Toronto area were unambiguous in supporting anintegrated and regional system of surveillance, reporting,and outbreak management for infectious diseases.

Physical plant limitations were a particular challenge forhospitals. Only 3.8% and 1.0% of Toronto/GTA acuteand non-acute care hospital beds, respectively, are insingle, negative pressure rooms. Of 28 Toronto/GTAhospitals with emergency departments, 6 lack infectioncontrol areas. About 18% of monitored intermediate/critical care beds in Toronto/GTA are equipped forinfection control. Only 30% of hospitals with autopsysuites reported that their facilities conformed to US CDCguidelines. Furthermore, in early March 2003, just priorto SARS, medical bed occupancy in Toronto/GTAaveraged 95%.

The impact of provincially-mandated restrictions onhospital activity during SARS I was largest in April, whenambulatory procedure volumes dropped 56% in the GTAhospitals and 70% in Toronto hospitals, compared toApril 2002. Levels rebounded in May. The differentstrategy used in SARS II had a much smaller impact onambulatory procedure volumes, with the GTA hospitalsonly 1% below, and Toronto hospitals 5% below theprior year. Urgent and emergency surgery volumes weremaintained. Consultants estimated that the volume ofdeferred elective surgery was over 6,600 inpatient casesand almost 18,000 ambulatory procedures. More thanhalf of the inpatient elective surgery backlog occurred inApril 2003 during SARS I. The ambulatory procedurebacklog was even more concentrated, with 85% occurringin April.

The Committee’s primary focus is on broad F/P/Tstructures, policies, procedures, and funding. However,given the very long list of issues that emerged from thespecific circumstances of the SARS outbreak, we electedto make a limited number of recommendations for theconsideration of P/T ministries of health, health regionsand hospitals, and provincial and local public healthagencies. These recommendations range over matterssuch as physical facilities in emergency departments andhospitals, regional outbreak management strategies,integrated emergency planning, improved continuing

education on infection control, and enhanced linkagesbetween public health and segments of the personalservice system (hospitals, home care agencies, primarycare).

International Aspects of SARSSARS has illustrated that we are constantly a short flightaway from serious epidemics. Strengthening the capacityof other nations to detect and respond to emerginginfectious disease is a global responsibility for a countrywith Canada’s resources and also a matter of enlightenedself-interest. The Committee has recommended that theGovernment of Canada should build health R&D activitiesinto its programs of international outreach. In particular,the new Canadian Agency for Public Health should havea mandate for greater engagement internationally in theemerging infectious disease field, and support projects tobuild capacity for surveillance and outbreak managementin developing countries.

During the SARS epidemic, WHO facilitated collaborationamong researchers, promulgated template case definitions,and issued various alerts. WHO established contact withaffected countries and offered epidemiologic, laboratory,and clinical support. It also began issuing travel advisoriesfor the first time, acting as a trans-national clearinghouseto assess the safety of international travel and, by extension,the effectiveness of outbreak management efforts indifferent countries.

In June at the WHO Global Meeting on SARS in Malaysia,it became clear that many countries had adopted theirown case definitions for SARS. The Committee believesthat further attention is needed to determine the respectiveroles of a body such as WHO and its member states indefining a new disease such as SARS.

Several Asian jurisdictions faced even greater challengesfrom SARS than did Canada. Many observers felt thatCanadian officials failed to connect closely enough withofficials in Hong Kong, Singapore, and China, and missedopportunities to learn from other countries.

Health Canada regularly transmitted information toWHO during the SARS outbreak, but data were limitedduring the early weeks of the outbreak owing to theabsence of formal reporting processes among municipal,provincial, and federal governments. Protocols for datasharing must be established not only for more effectiveoutbreak management, but to ensure that Canada canmaintain the confidence of the international communityduring an outbreak.

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Submissions to the Committee from the travel industryindicated significant gaps and inconsistencies withrespect to information on SARS available to passengersand staff. The new agency must ensure that there is aneffective communication strategy for infectious diseaseswith contact points for the travel industry.

On April 2, 2003, WHO issued a travel advisory recom-mending the postponement of all but essential travel toHong Kong and China’s Guangdong province. Previously,only individual countries had issued travel advisories.On April 23, 2003, WHO added Toronto, Beijing, andChina’s Shanxi province to the list of areas that travellersshould avoid. The advice against non-essential travel toToronto was scheduled to be in place for three weeksbefore reappraisal, but withdrawn on April 29 afterCanadian protests. Controversy about the WHO traveladvisory was augmented by inconsistency in categorizationof Toronto between WHO and the US CDC, the weakevidence for the travel advisory criteria themselves, andlimited warning from WHO of the forthcoming advisory.Assuming that WHO will continue issuing advisories,processes for developing evidence-based criteria andgiving notice to affected countries must be developed byagreement among member states.

For many years, Health Canada’s Travel Medicine Programhas issued advisories to Canadians traveling abroad onrisks such as disease outbreaks and natural disasters.Health Canada created its own scoring system to determinetravel advice concerning countries affected by SARS, butits evidentiary basis appears no stronger than the contestedWHO criteria. Moreover, travel advisories issued byCanada for Hong Kong were at times more severe thanthe WHO travel advice for Hong Kong. The Committeehas therefore recommended that Canada’s own practicesin issuing travel advisories should be revisited, ideally inthe context of a multilateral re-assessment of the basis,nature, goals, and impact of advice to travellers.

In 2002, Health Canada informed airport authorities thatit would be transferring airport quarantine responsibilitiesto the Canada Customs and Revenue Agency. Customsstaff were never trained to do the job. During the SARSoutbreak, Health Canada amended the Quarantine ActRegulations to include SARS but only a tiny contingentof quarantine officers was on hand to enforce the newregulations. Airport authorities expressed concern aboutHealth Canada’s ability to mobilize knowledgeablequarantine staff to the airports, to provide logisticalsupport, and to manage the relevant communications.In the case of cruise ships, Health Canada’s protocols forscreening, handling of suspected SARS cases, anddecontaminating ships were not released until mid-June,

after the outbreak had waned. The Committee hasrecommended that the Government of Canada ensurethat an adequate complement of quarantine officers ismaintained at all ports of entry, and that better collabo-ration with port authorities and personnel be establishedto clarify responsibilities in the event of a health threat.

Screening of incoming and outbound air passengersrelied on information cards with screening questions andsecondary assessments as needed, as well as a pilot projectusing thermal scanners in Toronto and Vancouver. As ofAugust 27, 2003, an estimated 6.5 million screeningtransactions had occurred at Canadian airports to aid inthe detection and prevention of SARS transmission.Roughly 9,100 passengers were referred for furtherassessment by screening nurses or quarantine officers.None had SARS. The pilot thermal scanner projectscreened about 2.4 million passengers. Only 832 requiredfurther assessment, and again none were found to haveSARS. In other countries, the yields for airport screeningmeasures were similarly low.

We have accordingly recommended that the Governmentof Canada should review its travel screening techniquesand protocols with a view to ensuring that travel screeningmeasures are based on evidence for public healtheffectiveness, while taking into account the financial andhuman resources required. While formal screening thusfar appears relatively inefficient and ineffective, theCommittee has recommended that the Government ofCanada provide travelers in general with informationabout where and when health threats exist, includingprecautionary measures and first steps to take in case of suspected infection. A partnership with the travelindustry would facilitate this process so that informationcould be provided at the time of bookings.

ConclusionLong before SARS, evidence of actual and potential harmto the health of Canadians from weaknesses in publichealth infrastructure had been mounting but had notcatalyzed a comprehensive and multi-level governmentalresponse. SARS killed 44 Canadians, caused illness inhundreds more, paralyzed a major segment of Ontario’shealth care system for weeks, and saw in excess of 25,000 residents of the GTA placed in quarantine.Psychosocial effects of SARS on health care workers,patients, and families are still being assessed. However,the economic shocks have already been felt not only inthe GTA, the epicenter of SARS, but across the country.

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The National Advisory Committee on SARS and PublicHealth has found that there was much to learn from theoutbreak of SARS in Canada—in large part because toomany earlier lessons were ignored.

A key requirement for dealing successfully with futurepublic health crises is a truly collaborative frameworkand ethos among different levels of government. Therules and norms for a seamless public health system mustbe sorted out with a shared commitment to protectingand promoting the health of Canadians. Systems-basedthinking and coordination of activity in a carefully-planned infrastructure are integral in public healthbecause of its population-wide and preventive focus.They are also essential if we are to be effective inmanaging public health emergencies. Indeed, Canada’sability to contain an outbreak is only as strong as theweakest jurisdiction in the chain of P/T public healthsystems. Infectious diseases are an essential piece of thepublic health puzzle, but cannot be addressed in isolation,particularly since in local health units, the same personneltend to respond to both infectious and non-infectiousthreats to community health. The Committee hasaccordingly recommended strategies that will reinforceall levels of the public health system as well as integratethe components more fully with each other.

The fiscal and strategic approaches set out in this reportare consistent with international precedents and, webelieve, the expectations of Canadians. Until now, therehave been no federal transfers earmarked for local andP/T public health activities. Public health has insteadbeen competing against personal health services forhealth dollars in provincial budgets, even as the federalgovernment has increasingly earmarked its healthtransfers for personal health service priorities. Publichealth costs are modest—perhaps 2-3% of healthspending, depending on how one defines numeratorsand denominators. The actual amount of new federalspending that the Committee has recommended wouldreach $700 million per annum by 2007 at the earliest.This is what F/P/T governments currently spend onpersonal health services in Canada between Monday and Wednesday in a single week.

The SARS story as it unfolded in Canada had both tragicand heroic elements. Although the toll of the epidemicwas substantial, thousands in the health field rose to theoccasion and ultimately contained the SARS outbreak inthis country, notwithstanding systems and resources thatwere manifestly suboptimal. The challenge now is toensure not only that we are better prepared for the nextepidemic, but that public health in Canada is broadlyrenewed so as to protect and promote the health of allour present and future citizens.

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ACKNOWLEDGEMENTS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The National Advisory Committee on SARS and PublicHealth wishes to acknowledge the contributions to ourwork by a number of individuals and teams.

Ian Green, Deputy Minister, Health Canada and ScottBroughton, Assistant Deputy Minister, Population andPublic Health Branch, gave the Committee Chairunfettered access to Health Canada officials and staffoutside of their normal reporting structures.

Many individuals in the Population and Public Healthand Health Policy and Communications Branches ofHealth Canada provided background information andsupport critical to the development of the Committee’sfinal report.

Among those who made direct contributions were: Ian Shugart, Assistant Deputy Minister, Health Policy and Communications Branch; Dr. David Mowat, Director General, Centre for Surveillance Coordination;Dr. Paul Gully, Senior Director General, Population andPublic Health Branch; Dr. Ron St John, Director General,Emergency Preparedness and Response; Dr. JudithShamian, Executive Director, Nursing Policy Office; Dr. Arlene King, Director, Immunization and RespiratoryDiseases Division; Dr. Ping Yan, Chief, Centre forInfectious Disease Prevention and Control; Dr. TheresaTam, Medical Specialist; and Claude Giroux, Senior Policy Advisor.

This senior group of Health Canada employees madethemselves available for interviews and preparedbackground materials that were very helpful to theCommittee. All were supported by large teams; somealso drew on stakeholders for input and advice. Boththese senior personnel and the Committee wish to thankall their team members and the stakeholders who assistedthem in supporting the Committee’s deliberations.

Also from Health Canada, Edith Morber, Senior PolicyAdvisor, greatly facilitated the Committee’s work withher editorial and synthetic skills and secretariat support.Sylvie Ladouceur and Carole Morris provided logisticalsupport and ensured that Committee meetings ransmoothly.

While the Committee is indebted to these and otherindividuals in Health Canada for their assistance andinput, we have drawn our own conclusions, as will beplain from some critical assessments of Health Canada’sactions, policies, and preparedness for SARS.

Independent consultants played a key role in theCommittee’s work. Saira David served as a policy andresearch advisor to the Committee, providing valuableinput. Prof. Sujit Choudhry of the University of TorontoFaculty of Law consulted extensively to the Committeeon some thorny constitutional and policy issues. Wehave incorporated his work into the report with permission,although it should not be assumed that Prof. Choudhryendorses or agrees with all the recommendations andconclusions drawn by the Committee. The Hay Group inToronto undertook a major consultancy on local/regionalclinical and public health issues. Again, we have incor-porated their outstanding work into the report, but theCommittee takes full responsibility for the findings andrecommendations.

Drs. Irfan Dhalla and Jeff Kwong, post-graduate specialtyresidents in, respectively, Medicine and CommunityMedicine at the University of Toronto, served as tirelessresearch and editorial associates. They made a majorcontribution to the Committee’s work, somehow balancingthese demands with the exigencies of residency training.

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The Committee is particularly appreciative of the front-line health care and public health professionals andadministrators who took time out of their busy schedulesto discuss their first-hand experiences combating andcontaining SARS, and their views on the lessons learned.We have generally referenced their comments withoutattribution. A few interviewees requested completeanonymity; the names of other interviewees are listed inan appendix to the report. The Committee extends itssincere thanks to them all.

This report would not have been possible without themany excellent submissions received by the Committeefrom various non-governmental and private sectororganizations. Not every stakeholder group will find allits comments or recommendations directly referenced inthe report. Similarly, to keep the number of recommen-dations to a manageable and prioritized list, not everysuggestion from the submissions has been transformedinto a Committee recommendation. However, theCommittee can warrant that all submissions had aninfluence on our deliberations and recommendations.With a few exceptions, stakeholders kindly agreed tohave their submissions posted electronically for internetaccess (see www.sars.gc.ca). We urge interested readers toaccess the important ideas and recommendations ofthese stakeholders; various of their briefs address issuesthat could not be covered in this report, and all the briefsserve as valuable resources for further study and action.

These individuals and organizations share fully in creditfor any meritorious aspects to the report. TheCommittee accepts responsibility for errors or omissions.

Dr. Julie Gerberding, Director of the US Centers forDisease Control [CDC], agreed to participate as acorresponding member and facilitated our access toinformation about the CDC's operations. On her behalf,Dr. Marty Cetron attended a Committee meeting andhelped us understand aspects of the CDC's perspectiveson SARS. Dr. David Heymann had also agreed toparticipate as Executive Director of CommunicableDiseases for the World Health Organization; but wasreassigned in July 2003 by the new WHO Director-General,Dr. Lee Jong-wook, to be his Representative for PolioEradication.

Last, the Committee was mandated to produce anaccount of key lessons learned from the outbreak of SARSin Canada, particularly as regards measures that must betaken to enhance the public health systems of our nation.We are grateful for the mandate given our members bythe Government of Canada and the Hon. Anne McLellan,Minister of Health, and hopeful that prompt action willbe taken by all levels of government, as well as relevantinstitutions and stakeholders, to ensure that the health of Canadians is protected and promoted even moreeffectively in the years ahead.

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Severe Acute Respiratory Syndrome, now known world-wide by the acronym SARS, is considered to be the “firstsevere and readily transmissible new disease to emerge inthe twenty-first century”.1

In late February, several guests at the Metropole Hotel inHong Kong had come in contact with an ill doctor whohad been involved in treating patients with an atypicalform of pneumonia in Guangdong, China. Those guestscontinued their travels in Hong Kong and on to Canada,Singapore, and Vietnam. They fell ill, and beganspreading the disease to others. Many of them died.This illness was soon identified as severe acute respiratorysyndrome or SARS. As of July 11, 2003 in its dailysummary, the World Health Organization [WHO]reported 8,437 probable cases of SARS and 813 deathsworldwide, and the toll has since risen to about 900 assome previously-ill individuals have succumbed.

Canada, like other countries, faced an intense battle tocontrol SARS. Public health and health care personnelworked tirelessly to contain the outbreak within systemsthat were often seriously inadequate to the task. Citizens were also impressively calm and cooperative,notwithstanding innumerable disruptions to theirworking lives and quarantine requirements that affectedthousands.

SARS was and remains a challenge to diagnose andmanage because its symptoms resemble those of manyother respiratory infections. Thus far, extensive researchby a WHO-coordinated international network of researchcentres has identified a novel coronavirus as thepresumed cause of SARS. The diagnostic tests available totest for the SARS coronavirus have limitations with respectto their reliability and sensitivity, and more research isneeded to enable the rapid identification andcharacterization of this new coronavirus.2

SARS is spread through close contact with an individualwho has SARS. The disease has an incubation period thattypically ranges from 2 to 10 days. Affected individualsexperience fever (>38°C) and later develop respiratorysymptoms such as cough, shortness of breath, or difficultybreathing. Overall, case fatality from progressiverespiratory failure ranges from less than 1% of cases forpersons under 24 years of age to 15% of cases for personsaged 45 to 64 years of age; in persons over the age of 65,the fatality rate can exceed 50%.3 Diagnosis rests partlyon the clinical syndrome, partly on a link to known casesof SARS, and partly on a process of exclusion. The viruscan be isolated from respiratory secretions and stool;however, it is not always detected from these sourceseven in patients with probable SARS. Serological testsbased on the body’s immune response to SARS are alsohelpful, but these tests do not begin to yield usefulinformation until a few weeks after the onset of symptoms.No vaccine or cure currently exists leaving clinicians torely primarily on supportive measures and public healthauthorities to rely on isolation and quarantine as thepredominant measures to control SARS.

Emerging and Re-emergingInfectious DiseasesEmerging infectious diseases are diseases that arenewly identified, or that have existed previously butare increasing in incidence or geographic range.4SARS is the most recent example of a new or otherwiseunknown disease. Variant Creutzfeldt-Jakob disease,discovered in 1996 and considered to be the sameagent as that causing bovine spongiform encephalitisin cattle, is another example. Since 1973, more than30 previously unknown diseases associated withviruses and bacteria have emerged. Examples include:Ebola virus (1977); Legionnaire’s disease (1977);

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INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Chapter 1S A R S a n d P u b l i c H e a l t h

E. coli 0157:H7-associated hemolytic uremic syndrome(1982); HIV/AIDS (1983); Hepatitis C (1989); andH5N1 Influenza A or avian flu (1997).5

West Nile virus infection is an example of a previouslyknown disease that has increased its geographic range.The discovery of West Nile virus in the USA in 1999 markedthe first introduction in recent history of an Old Worldflavivirus into the New World.6 West Nile virus wasdiscovered in the West Nile district of Uganda in 1937. In the last decade, human outbreaks of West Nile haveincreased in the Middle East and Europe, suggesting theevolution of a new West Nile virus variant.7 West Nilevirus arrived in Canada in 2001, found in dead birds andmosquito pools in Ontario. The first human cases ofinfection occurred in 2002. In 2002, West Nile virus wasfound in five provinces: Nova Scotia, Quebec, Ontario,Manitoba, and Saskatchewan, with Quebec and Ontariohaving confirmed cases of human infection.8 On August12, 2003, Alberta reported its first case of West Nile virus,a young woman who likely contracted the disease whilecamping in Southern Alberta.9 Federal and provincialgovernments all have action plans to reduce the spreadof the virus.

Re-emerging infectious diseases are known diseasespreviously considered under control and no longerconsidered a public health problem, but that havereappeared or are causing an increased number ofinfections.10 Some examples include: the reappearanceof epidemic cholera in the Americas in 1991; denguefever in the Americas in the 1990s; diphtheria in theRussian Federation and other republics of the formerSoviet Union in 1994; the increase in the occurrenceof meningococcal meningitis in Sub-Saharan Africasince the mid-1990s; and Yellow fever in Africa andSouth America since the mid-1980s. Tuberculosis maybe considered in this category in some respects.Tuberculosis has remained a public health problem forvulnerable populations. Its toll has increased withurban crowding and poverty in developing anddeveloped nations, with the advent of the HIVpandemic, and with the emergence of strains of drug-resistant tuberculosis bacteria.

Many of the pathogens believed to cause infectious diseasesare already present in the environment. Activities thatincrease microbial traffic between people and their environ-ments promote emergence and epidemics.11 Among thefactors precipitating the emergence and re-emergence ofinfectious diseases are: ecological changes (includingthose due to economic development and land use);human demographics and behaviour; technology andindustry; and microbial adaptation and change.

HIV provides a good example of how such factors haveled to the emergence of infectious diseases. HIV isbelieved to have had a zoonotic origin. Ecological factorssuch as deforestation and land development would haveincreased human exposure to the animal host. Socialevents such as population growth and migration played arole in increasing the opportunity for HIV transmissionto other humans. Sexual behaviour, use of illicit drugsby injection, and iatrogenic causes (e.g., the early spreadof HIV through blood transfusions and blood products)provided added advantages for the continued andaccelerated transmission of HIV.12 Bovine spongiformencephalopathy and hemolytic uremic syndrome causedby E. coli 0157:H7 (commonly known as hamburgersickness) are examples of diseases that emerged as a resultof changes in food production.13

Factors that exacerbate the emergence and re-emergenceof infectious diseases, and that present challenges indealing with outbreaks, are globalization and deficienciesin public health infrastructure.

Globalization and CommunicableDiseaseGlobalization has made our world smaller as people andgoods move more freely and more frequently around theglobe. As the world becomes more interconnected, theopportunities for rapid and effective disease spread increase.And as was seen with SARS, travel plays a pivotal role inthe rapid dissemination of disease. According to WorldTourism Organization data14, approximately 715 millioninternational tourist arrivals were registered at borders in2002 (preliminary data). Human migration has been akey means for infectious disease transmission throughoutrecorded history. However, the volume, speed, and reachof travel today have accelerated the spread of infectiousdiseases.15 The rapidity of movement from one countryto another or one continent to another falls well withinthe incubation period of virtually all infectious diseases.Disease emergence is nonetheless complex, and theconditions for a disease-causing organism must be rightin order for it to survive, proliferate, and find a way toenter a susceptible host.16 SARS, thought to be spreadthrough droplet nuclei and close physical contact, provedto be a disease easily carried to any part of the world.

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The globalization of the food (and feed) trade, whileoffering many benefits and opportunities, also presentsnew risks. Because food production, manufacturing, andmarketing are now global, infectious agents can bedisseminated from the original point of processing andpackaging to locations thousands of miles away.17

Emerging and re-emerging infectious diseases are apermanent fixture on the public health landscape at thelocal, regional, national, and international levels. Peoplewill continue to travel and migrate; goods will continueto be traded. In order to mitigate the incidence andeffects of infectious diseases, therefore, communicationat all levels and local responses to infectious diseasesmust be enhanced.

Compounding the challenges of dealing with emergingand re-emerging infectious diseases is the threat of theaccidental or intentional release of biological agents. Theevents of September 11, 2001 and the intentional releaseof anthrax spores that immediately followed in the USA,make the possibility of the accidental or intentionalrelease of a biological agent a disturbing reality and athreat to global security. International cooperation hasbeen required to prepare for such events.

Working collaboratively with international bodies is alsoa key component to dealing effectively with infectiousdiseases. Canada is in regular contact with the WorldHealth Organization [WHO] and the US Centers forDisease Control and Prevention [CDC] in its day-to-daybusiness of conducting disease surveillance.

The World Health Organization[WHO]WHO is the United Nations’ specialized agency for healthwhose objective is the “attainment by all peoples of thehighest possible level of health.” In 2001, the WorldHealth Assembly, made up of 192 member states, adopteda resolution on “Global health security: Epidemic alertand response,” in recognition of the threats to publichealth posed by epidemic-prone and emerging infections,and bioterrorism. That resolution expressed support forongoing work on the revision of the International HealthRegulations, the development of a global strategy forinfectious disease containment and the prevention ofantimicrobial resistance, and collaboration between WHOand technical partners in the area of epidemic alert andresponse. It also urged members to participate actively insurveillance activities related to health emergencies ofinternational concern, to develop and update nationalpreparation and response plans, to develop training for

involved staff, and to ensure availability of contemporaryinformation on surveillance and control of infectiousdiseases.

Within WHO, the Department of Communicable DiseaseSurveillance and Response [CSR] is responsible forrealizing this mandate. It envisages that “every countryshould be able to detect, verify rapidly and respondappropriately to epidemic-prone and emerging diseasethreats when they arise to minimize their impact on thehealth and economy of the world’s population.”

The CSR’s three strategic directions are to contain knownrisks, respond to the unexpected, and improvepreparedness. Activities include tracking emerginginfectious diseases, sounding an alarm when necessary,sharing information on emerging diseases and diseaseoutbreaks, and providing assistance to affected states inthe form of technical assistance, supplies, and in somecases, international investigations/responses.

WHO emphasizes that global surveillance and strong publichealth systems are needed to respond to emerging andre-emerging infectious diseases, and possible bioterrorismevents. As mentioned earlier, WHO is currently revising itsInternational Health Regulations which set out to “ensurethe maximum security against the international spread ofdiseases with minimum interference with world traffic.”From WHO’s perspective, the worldwide SARS outbreakhas underscored the need for these revised regulations.18

US Centers for Disease Control and Prevention [CDC]The CDC is the lead federal agency in the USA forprotecting the health and safety of its citizens, and is partof the Department of Health and Human Services. Itserves as the national focus for developing and applyingdisease prevention and control, environmental health,and health promotion and education activities withrespect to health. CDC was originally established as theUS ‘Communicable Diseases Center’ after the Second WorldWar. The continuation of the acronym CDC (minus theP for prevention) and public image of the agency as anoutbreak-fighting organization both tend to mask theextent to which CDC now serves broad public healthfunctions in the USA. The agency employs approximately8,500 employees working in 170 occupations in variouslocations, including in CDC facilities around the USA, inother countries, in quarantine offices, and in state andlocal health agencies. It is made up of 12 centres, institutesand offices, one of which is the National Center forInfectious Diseases [NCID].

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The NCID’s mandate is “to prevent illness, disability, anddeath caused by infectious diseases in the United Statesand around the world.” It accomplishes this by conductingsurveillance, epidemic investigations, epidemiologic andlaboratory research, training, and public educationprograms to develop, evaluate, and promote preventionand control strategies for infectious diseases. NCID staffwork in partnership with local and state public healthofficials, other federal agencies, medical and public healthprofessional associations, infectious disease experts fromacademic and clinical practice, and international andpublic service organizations. The NCID also worksclosely with other Centers within the CDC such as thePublic Health Practice Program Office, the Office ofGlobal Health, and the Epidemiology Program Officeamong others.

Like many other countries, the USA is in the process ofimproving its national capacities for disease surveillance,prevention, and control. It has developed a strategicplan for preventing emerging infectious diseases, thepillars of which are surveillance and response, appliedresearch, infrastructure and training, and prevention andcontrol. The CDC seeks to improve epidemiologiccapacity, surge capacity, communications, and the supplyof appropriate and adequate equipment and training.19

A “CDC North”?The experience of the SARS outbreak has renewed callsfor a Canadian version of the US Centers for DiseaseControl and Prevention to improve coordination ofpublic health across Canada, champion public healthinitiatives nationally, and direct the operations of anational disease control body. These calls are based onthe premise that public health threats such as SARS arenational issues that need a coordinated response fromboth public health and emergency response systems,with appropriate support at the federal level. They arealso based on the limitations in response capacity as wellas issues with coordination and communication thatwere highlighted during the battle to control SARS inCanada. The National Advisory Committee on SARS andPublic Health has taken a key part of its mandate to bethe assessment of options for enhancing our responsecapacity to health crises, particularly outbreaks ofemerging infectious diseases such as SARS.

Emergency PreparednessThe terrorist attacks of September 11, 2001 in the USAunderscored the necessity of local, regional, and nationalpreparedness for any emergency. New York City [NYC]saw the benefits of forward planning when a case ofexposure to anthrax, found on October 9, 2001, wassuccessfully handled. NYC was in the process ofdeveloping protocols for mass antibiotic prophylaxisagainst anthrax in 1999, and had also established anincident command structure of which NYC governmentagencies are part. This command structure includes thefollowing components: clinical response, sheltering,surveillance, environmental health, laboratory,communications, management information systems, andphysical plant operations. Each component is operatedby staff from a variety of the city’s Department of Healthprograms. NYC’s command system swung into high gearthe moment the anthrax exposure case was identified.An antibiotic distribution site was established, and workbegan on administering antibiotics and determining thesource of the anthrax and who might have been exposed.

The success of this operation was attributed to four “C’s”,i.e., clarity of mission, lines of authority, and responsi-bilities; communication; collaboration among federal, stateand local public health officials, and law enforcementofficials; and coordination of staffing and supplies.20

Federal/provincial/territorial Ministries of Health havemade progress in their emergency preparedness andresponses plans since September 11, 2001, and areworking collaboratively towards a seamless pan-Canadianhealth emergency management system. However, theSARS outbreak demonstrated that more needs to be doneto integrate the public health and emergency responsesystems in times of crisis. We cannot say, withconfidence, that the factors that contributed to NYC’ssuccessful handling of its anthrax incident were in placeto handle Canada’s SARS outbreak.

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The State of Canada’s PublicHealth System The public health system, unlike the clinical or personalhealth services system, tends to operate in the back-ground, little known to most Canadians unless there isan unexpected outbreak of disease. However, the publichealth system has many essential roles. These includehealth protection, disease and injury prevention, andhealth promotion, along with time-honoured funda-mentals such as access to safe foods, safe drinking water,and proper sanitation systems. An effective public healthsystem is essential to preserve and enhance the healthstatus of Canadians, to reduce health disparities, and toreduce the costs of curative health services. While publichealth activities may evolve as a result of changingtechnology and needs, the goals remain the same: toreduce the amount of disease, premature death, and painand suffering in the population.

Public health has the health of populations as its priority.The population approach recognizes that the health ofpopulations and individuals is shaped by a wide range offactors in the social, economic, natural, built, andpolitical environments. In turn, these factors interact incomplex ways with each other and with innate individualtraits such as sex and genetics. Such a broad perspectiveon health takes into account the potential effects of socialconnectedness, economic inequality, social norms, andpublic policies on health-related behaviours and onhealth status.

The Walkerton, Ontario E. coli outbreak in May 2000 and the North Battleford, Saskatchewan outbreak ofCryptosporidium parvum in April 2001 demonstrate howbreakdowns in infrastructure lead to public health crises.A recent comparative study of the Walkerton and NorthBattleford outbreaks conducted by Woo and Vicenteconcludes that both accidents resulted from a complexinteraction among factors at multiple levels ranging from inadequate supervision, compliancy failure, andcomplacency on the part of regulatory bodies, toprovincial budget cutbacks.21

A more cohesive, comprehensive approach to publichealth must form the basis for a sustainable public healthsystem. This means cooperation not only acrossgovernments but also within governments, and involvesthe private sector, non-governmental organizations, andthe public. This is no easy task.

Federal/Provincial/TerritorialStructures and LinkagesCanada’s Constitution provides both the federal andprovincial/territorial governments with elements oflegislative authority over health. The primary federalacts governing public health and infectious diseases arethe Department of Health Act which provides powersrelated to disease surveillance and the “protection of thepeople of Canada against the risks to health and thespreading of diseases” and the Quarantine Act. Provincialand territorial governments have regulations with respectto reportable diseases requiring special attention andmeasures. All jurisdictions have legislation governingemergencies which generally cover infectious diseaseepidemics and other situations that would present aserious public health threat.

The federal government supports health care through theCanada Health and Social Transfer [CHST] which providesprovinces and territories with cash payments and taxtransfers to apply as they see fit to their health and socialprograms. From time to time, the federal governmentalso provides funding for specific health initiatives, mostrecently primary or home care. Provincial and territorialgovernments provide funding to their respective healthauthorities predominantly through grants. In Ontario,municipalities share a 50% responsibility for the fundingof most local public health programs. In 2002, approxi-mately $79.354 billion was spent on health by the federal,provincial, territorial, and municipal governments.There is no standardized definition of public health, andit is therefore difficult to obtain a precise estimate ofwhat is spent on public health. However, in roughterms, spending on personal health services is aboutthirty-fold greater than public health spending.

Only weak mechanisms exist in public health for collab-orative decision making or systematic data sharing acrossgovernments. Furthermore, governments have notadequately sorted out their roles and responsibilitiesduring a national health crisis. Each level of government,from local to federal must collaborate if Canada is toachieve a seamless, integrated approach to public healthand to managing health crises. The SARS outbreak hashighlighted many areas where inter-jurisdictional collab-oration is suboptimal; so far from being seamless, thepublic health system showed a number of serious gaps.

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Canada’s SARS ExperienceAfter China and Hong Kong, Toronto was the regionhardest hit by SARS. As of August 12, 2003, there hadbeen 438 probable and suspect SARS cases in Canada,including 44 deaths. The majority of SARS cases havebeen concentrated in Ontario and all deaths haveoccurred in Toronto. The toll on health care workers hasbeen especially high: more than 100 fell ill withprobable SARS and three succumbed.

SARS placed heavy pressures on Toronto’s public healthand health care system. The region’s health careprofessionals, as front-line workers vital to controlling thedisease, were at heightened risk for contracting the disease,and under considerable physical and psychological stress.Many patients required intensive care, hospitals had toclose, elective procedures were cancelled, and procuringadequate types and quantities of supplies to combat thedisease was difficult. SARS also placed unprecedenteddemands on the public health system, challengingregional capacity for outbreak containment, surveillance,information management, and infection control.

While the public health and health care workers involveddid an admirable job of containing SARS and keeping itfrom spreading to the larger community, the SARSexperience highlighted weaknesses in Canada’s publichealth system. Many issues to do with the clinical systemand clinical/public health interface were also thrown intohigh relief. Aside from the lack of surge capacity to dealwith this crisis situation, problems emerged with respectto timely access to laboratory results, information sharing,data ownership, and epidemiologic investigation of theoutbreak. Communication to the public was sometimesinconsistent, and it was not always clear who was incharge of the outbreak response.

The SARS experience illustrated that Canada is notadequately prepared to deal with a true pandemic. TheOntario government has similarly emphasized thatOntario’s public health system could not have withstoodtwo simultaneous large-scale outbreaks or crises such asSARS.22 It is unlikely that most other provinces are in abetter position, and the federal capacity to support one or more provinces facing simultaneous health crisesis limited.

Having the SARS outbreaks occur in Canada’s largest citypresented many challenges. However, it may have beenfortuitous that SARS struck Toronto and not a less-advantaged region of the country. Few rural and smallurban hospitals have resident specialists in infectiousdisease; infection control officers/nurses are often part-time, and include infection control among a number ofsomewhat unrelated functions such as nursing super-vision or occupational health. In smaller jurisdictions,communicable disease investigation and control falls topublic health nurses and inspectors with at most onephysician, who may or may not be fully trained in publichealth, to provide back-up and oversight. Multi-taskingacross a wide range of activities from well baby andimmunization to community development is the rule inrural public health units, with very limited specializationof functions. How can we strengthen the public healthsystem to ensure that it can meet the unique challengesof both major metropolitan areas and smaller or ruralcommunities?

Learning from SARSThe lessons learned from SARS are critical pieces ofinformation for determining the improvements neededin Canada’s public health system. Enhancement ofsurveillance mechanisms, better coordination among thevarious levels of government and institutions for outbreakcontainment, improved public communications strate-gies, and major increases in expert human resources arejust some of the changes needed if Canada is to be betterprepared for future health crises.

SARS resulted in a tragic loss of life, grieving families andfriends, tremendous dislocation to the health system, and economic turmoil. Fortunately, SARS was onlymoderately contagious and did not turn into a full-blownpandemic. In Canada, the outbreak was primarilycentred in a major urban area with unparalleled healthcare resources. Nonetheless, it severely tested local,federal, and provincial capacity to deal with the outbreak,illuminating the strengths and deficiencies of the existingpublic health and health care systems. The knowledgegained from battling SARS should help Canada put inplace a public health system that will be capable of notonly dealing with the next outbreak, but the nextpandemic.

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There is no time for complacency. SARS has beensubdued, perhaps only temporarily, and the fall season ofrespiratory illnesses will soon be upon Canada. The workto improve the public health system and prepare theclinical services system must begin apace.

References 1. World Health Organization, “Severe Acute Respiratory

Syndrome (SARS): Status of the Outbreak andLessons for the Immediate Future,” SARS technicalbriefing, WHA 56, 20 May 2003.

2. World Health Organization Multicentre CollaborativeNetwork for SARS Diagnosis, “A MulticentreCollaboration to Investigate the Cause of Severe Acute Respiratory Syndrome,” The Lancet, Vol. 361,May 17, 2003, 1730-33.

3. SARS Conference, 17 June 2003.

4. Morse, Stephen S., “Factors in the Emergence ofInfectious Diseases,” EID, Vol. 1, No.1, Jan-March 1995;“Will it Reach On Time? Emerging and Re-emergingInfectious Diseases,” UN Chronicle, Vol.36, No.1, 1999.

5. World Health Organization, “Emerging and Re-Emerging Infectious Diseases,” WHO Fact SheetNo.97, August 1998.

6. Peterson ,L.R and Roehrig, John T., “West Nile Virus:Re-emerging Global Pathogen, EID, Vol. 7, No.4, July-Aug 2001.

7. Ibid.

8. Health Canada SARS website, http://www.hc-sc.gc.ca/pphb-dgspsp/sars-sras.

9. Globe and Mail, August 12, 2003, Page A7.

10. World Health Organization, “Emerging and Re-emerging Infectious Diseases,” WHO Fact SheetNo. 97, August 1998.

11. Morse, Stephen S., et al, “Factors in the Emergenceof Infectious Diseases,” EID, Vol. 1, No. 1., Jan-March 1995.

12. Ibid.

13. Ibid.

14. World Tourism Organization, “World Tourism 2002:Better than Expected,” Press release, January 27, 2003.

15. Wilson, Mary E., “Travel and the Emergence ofInfectious Disease,” EID, Vol. 1(2), April-June 1999.

16. Ibid.

17. Käferstein, F.K. et al., “Foodborne Disease Control: A Transnational Challenge,” EID, Vol. 3(4), Oct.-Dec. 1997.

18. Associated Press, May 27, 2003.

19. US Centers for Disease Control and Preventionwebsite, www.cdc.gov.

20. Blank, Susan, et al., “An Ounce of Prevention is aTon of Work: Mass Antibiotic Prophylaxis forAnthrax, New York City, 2001,” EID, Vol. 9 (6), June 2003.

21. Woo, Dennis and Vicente, Kim, “SociotechnicalSystems, Risk Management, and Public Health:Comparing the North Battleford and WalkertonOutbreaks,” Reliability Engineering and Systems Safety,Vol. 80, 2003.

22. Houpt, Simon, “U.S. Got lucky, SARS Experts Agree,”Globe and Mail, June 13, 2003.

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SARS IN CANADA: Anatomy of an Outbreak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Through the ages humans have relied on animals forfood, labour, companionship, and entertainment.However, our interactions with animals have infectedhumans with numerous communicable diseases. It nowappears that exotic animals in a Guangdong market—perhaps civet cats or raccoon dogs—may have given thehuman race yet another novel infectious disease: severeacute respiratory syndrome, or SARS.

Old diseases usually spread slowly. Smallpox, forexample, was a scourge in Europe for thousands of yearsbefore it finally crossed the Atlantic with ChristopherColumbus and his men. SARS, on the other hand,moved at the speed of a jet airplane. Within days of itsarrival in Hong Kong, it had circled the globe.

This chapter provides a brief overview of the SARSoutbreak in Canada. The SARS story is one in whichthousands of front-line public health and health careworkers rose brilliantly and often heroically to theoccasion to contain an outbreak, despite systems thatwere often seriously inadequate to the task. We found,not surprisingly, that individual and organizationalperspectives on the same events during the outbreakoften differed sharply. Further, although newinformation continuously emerged, it increasingly hadmore to do with retrospective second-guessing ofdecisions by individuals than with forward-lookingenhancements to the public health and health caresystems. This truncated account is designed simply toremind Canadians of how the SARS outbreak unfolded,and touches on some key issues that surface from even acursory review of four extraordinary months in thehistory of Canadian public health and health care.

We have minimized the use of names throughout theaccount for participants and interviewees. Other reviewsunderway, particularly the Ontario Public HealthInvestigation by Mr. Justice Archie Campbell, have thetime and mandate to dissect specific events in detail.Most of the salient issues are adequately framed by thefirst wave of SARS in Canada, and the account focusesmore on “SARS I”, recognizing that Mr. Justice Campbell’smandate arose in meaningful measure from eventsaround the second wave or “SARS II”. Nonetheless, wedo track the outbreak through to containment in June2003. Future historians will be able to describe theseevents with greater accuracy, a wider internationalperspective, and the benefit of longer hindsight.

2A.A New Disease in Guangdong(November 27, 2002 - February 22, 2003)

“Have you heard of an epidemic in Guangzhou? Anacquaintance of mine from a teachers’ [Internet]chat room lives there and reports that the hospitalsthere have been closed and people are dying.”

—Dr. Stephen Cunnion (posted on ProMED-mail onFebruary 10, 2003)

On February 14, 2003, the World Health Organization[WHO] reported in its weekly newsletter that an unusualacute respiratory illness had claimed five lives since theprevious November in Guangdong Province, China.Three hundred more people—about one-third of themhealth care workers—were reported to have beeninfected. Six days later, the Chinese Ministry of Healthinformed the WHO that the cause of the illness was acommon bacterium, Chlamydia pneumoniae.1

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1 Chlamydia pneumoniae is an obligate intracellular bacterium—it depends on and lives within a host cell. Most adults will be infected by C. pneumoniae at some point in their lives. Infections result in respiratory illness of varying severity, and can be effectively treated with widelyavailable antibiotics.


More than two months before, Health Canada’s GlobalPublic Health Intelligence Network [GPHIN] received aChinese-language news report of a flu outbreak inmainland China. GPHIN is an early-warning system thatcontinuously scans Internet media sources for reports ofinfectious disease outbreaks around the world. TheChinese report, published on November 27, 2002, wassent to WHO with an English header. The full report wasnever translated. Health Canada officials became awareof the new disease along with the rest of the world inFebruary 2003.

Health Canada publicized the Guangdong outbreak in itsnext FluWatch bulletin,2 which summarized influenzaactivity between February 9 and 15, 2003. The followingweek, FluWatch reported that Chinese authoritiesclaimed the Guangdong outbreak was over.

Concurrently, officials in Hong Kong reported a case ofavian influenza. On February 19, 2003, during a regularconference call with Health Canada’s Pandemic InfluenzaCommittee, federal officials recommended that allprovinces be vigilant for influenza-like illnesses inreturning travellers, particularly those returning fromHong Kong or China. Health Canada also issued writtenalerts on February 20 and 21 to the Pandemic InfluenzaCommittee, the Council of the Chief Medical Officers ofHealth, the Canadian Public Health Laboratory Network,the FluWatch network (including hospital infectioncontrol practitioners), and veterinarians, warning allrecipients to be alert for avian flu. Some representativeson the Pandemic Influenza Committee expressedconcerns that Health Canada should not be dealingdirectly with hospital infection control practitioners.

Around this time, ProMED-mail, an Internet-basedreporting system that, like GPHIN, provides early warningsof infectious disease outbreaks, was alerting its audiencethat the mysterious respiratory ailment in Guangdongmight not be caused by Chlamydia pneumoniae after all—tests found the bacteria in only two of the deceasedpatients’ tissue samples.

The combination of the two outbreaks—avian flu and themystery disease—raised concern among staff at theBritish Columbia Centre for Disease Control, and itsofficials issued the first of three broadcast e-mails onFebruary 20, informing doctors, infection control

specialists, and public health authorities to be alert forinfluenza-like symptoms in travellers returning fromChina. Toronto public health officials sent out similarinformation about severe ‘flu’ in younger adults to a listof infectious disease and emergency room physicians inToronto on February 20, and the Provincial Public HealthBranch circularized health units to the same effect onFebruary 21.

Meanwhile, the chain of events that would bring SARS toCanada began. A 65-year-old doctor who had treatedatypical pneumonia patients in Guangdong travelled toHong Kong to attend his nephew’s wedding. By the timehe checked into the Metropole Hotel, he was feelingunwell. The doctor infected at least 12 other guests andvisitors from several countries, including a 78-year-oldwoman from Canada, Mrs. K S-C.

2B.From Kowloon to Scarborough (February 23, 2003 - March 12, 2003)

Mrs. K returned to Toronto on February 23, 2003 after a10-day trip to Hong Kong. During her holiday, she spentthree nights at the Metropole Hotel in Kowloon whereshe briefly encountered the Guangdong doctor. Twodays after arriving in Toronto, Mrs. K developed a highfever, and by the time she visited her family doctor on

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2 FluWatch reports are posted on Health Canada’s website weekly during the influenza season (September to April) and biweekly during the rest of the year. Prior to Internet publication, Health Canada sends the reports by e-mail or fax to provincial and territorial FluWatch representatives, thePandemic Influenza Committee, a 250-doctor strong network of sentinel physicians, the College of Family Physicians of Canada, hospital infectioncontrol practitioners, WHO and the Pan-American Health Organization [PAHO], the CDC and several federal government departments (e.g., Department of National Defence).

D I S C U S S I O N P O I N T

The Canadian Hospital Epidemiology Committee advisedthe Committee that Canada lacks a coordinated systemto “notify acute care facilities of a global health alert,with attendant recommendations for surveillance andcontrol” if persons suspected of having a new infectiousdisease “appear in Canadian health care facilities.”Relevant information was sent out in Ontario, but thelines of accountability for alerts appear blurred, and keytarget groups commented that they had no prior warningof a new respiratory virus from Asia. Does Canada havean adequate system to detect emerging diseases world-wide or even within its borders? Once an outbreak isdetected, what kind of communication structure wouldwork best to get information to public health officials,infection control specialists, emergency departmentsand ultimately to front-line health care workers—andensure that appropriate responses are occurring?

February 28, she was also complaining of muscle achesand a dry cough. Mrs. K’s condition continued todeteriorate, and she died at home on March 5, 2003.Family members did not want an autopsy and thecoroner thought it unnecessary. On the death certificate,the coroner listed heart attack as the cause of death.

On March 7, 2003 two days after his mother’s death, Mrs.K’s 44-year old son, T C-K arrived at The ScarboroughHospital, Grace Division emergency department. Hecomplained of a high fever, a severe cough, and difficultybreathing. He shared the open observation ward of abusy emergency department for 18 to 20 hours whileawaiting admission. Only curtains separated him fromnearby patients. By the next day, Mr. T’s condition haddeteriorated sufficiently that he was admitted to theIntensive Care Unit [ICU], and eventually requiredintubation—doctors inserted a tube through his mouthinto his trachea, and attached it to a ventilator to helphis breathing.

The physician who treated Mr. T was a respirologist andintensive care specialist who astutely suspectedtuberculosis. He had not received any information aboutthe mysterious respiratory illness in Guangdong. Withtuberculosis a possibility, he isolated Mr. T, and asked therest of the family to isolate themselves at home. Hecontacted Toronto Public Health. As per the usualprotocol for tuberculosis, public health officials contactedthe family, and made arrangements for chest x-rays andtuberculosis skin tests. According to Toronto PublicHealth officials, none of the family members reportedfeeling unwell.

Many patients and staff were exposed to Mr. T before hewas placed in isolation, and two of the patients beingtreated in the Grace emergency department at the sametime would also fall ill. Partly due to hospitalovercrowding, Mr. T remained in the emergencydepartment long after doctors had authorized a hospitaladmission. While waiting for a bed to be freed up, Mr. Treceived oxygen and vaporized medications (potentiallycapable of transforming infectious droplets into aninfectious aerosol), and had numerous visitors.

The new disease spread to other countries. An Americanbusinessman who also had stayed at the Metropole Hotelflew to Hanoi, Vietnam. Feeling unwell, he visited alocal hospital on February 26, 2003 where over the nextfew days, several nurses also became ill. The hospitalcalled the local WHO office, and Dr. Carlo Urbani wassent to investigate. On February 28, he informed theregional WHO office of the respiratory disease cluster.On March 6, 2003, still unable to determine the cause ofthe Hanoi outbreak, he placed a direct call to the WHOhead office in Geneva. Dr. Urbani began to experiencesymptoms himself on March 11, and died 18 days later.His alarm helped contain the Vietnam outbreak.

Meanwhile, in Hong Kong, several dozen health careworkers at the Prince of Wales Hospital were beginningto show symptoms. Twenty-three were admitted to anisolation ward on March 11, 2003.

On March 12, 2003, WHO issued a global alert regardingthe mystery illness (soon to be called the severe acuterespiratory syndrome, or SARS) that was occurringprimarily among health care workers in Hanoi and HongKong. Physicians at several hospitals in Toronto involvedin the first wave of the outbreak later advised that theywere not informed of the alert by any level of publichealth—local, provincial, or national. The next day,these physicians discovered the WHO alert through theirown intelligence gathering.

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The SARS outbreak threw into high relief the state ofCanadian emergency departments—the point of firstcontact for the sickest patients. As the CanadianAssociation of Emergency Physicians noted in itssubmission to the Committee, there are no nationalstandards addressing emergency department design oroperation, most departments lack adequate isolationfacilities, staff may not be trained in infection controlprocedures, and “the current practice of housing largenumbers of sick admitted patients for prolonged timesin open, densely-populated emergency departments is apotential public health hazard.” These phenomenareflect not only upon the funding and organization ofemergency departments, but also the continued shortfallin ambulatory care capacity, and the need for primarycare reform.

2C. SARS I: The Outbreak Begins (March 13, 2003 - March 25, 2003)

Mr. T died on March 13, 2003. By this time, the tuberculosistests results were available and negative, and severalother family members were sick. Public health officials,in consultation with experts like Dr. Allison McGeer andDr. Andrew Simor, connected the dots. There was anunusual respiratory illness in Guangdong that hadapparently spread to Hong Kong. Mrs. K had recentlytravelled to Hong Kong. She had died at home. Soonafter, her son had developed a respiratory illness that didnot respond to the usual treatment. He too had died, andother family members were now developing symptoms.

The attending physicians recognized the need to preventfurther transmission of a disease that was unequivocallycontagious, but whose mode of transmission wasunknown. They arranged transfers of Mrs. K’s familymembers to hospitals with negative pressure isolationrooms, important in preventing transmission of airbornedisease. Sunnybrook and Women’s College HealthSciences Centre, Mount Sinai Hospital, and the TorontoWestern site of the University Health Network allaccepted family members. A granddaughter wasadmitted to the Hospital for Sick Children.

Mr. P, who had been treated in the emergency departmentbed adjacent to Mr. T on March 7, 2003 returned to TheScarborough Hospital on March 16 with respiratorysymptoms, and a fever. He was admitted into the airborneisolation room in the emergency department, andmanaged in contact and droplet precautions before beingsent to the ICU. However, his wife, who was with himin the emergency department, was not asked aboutillness until he was transferred to the ICU. Mr. P died onMarch 21; his wife and three other members of his familywere infected. His wife infected seven visitors to theemergency department, six hospital staff, two patients,two paramedics, a firefighter, and a housekeeper.

The physician who intubated Mr. P in the ICU wore amask, eye protection, gown, and gloves while performingthe procedure, but he developed SARS. Anxieties aboutthe infectivity of SARS were understandably magnified bythis incident, especially when three nurses present at theintubation were also infected. Intubation procedures, asignificant source of droplet production, would be arecurring cause of SARS transmission during the outbreak.

Another patient who was in the emergency departmentwith Mr. T on March 7, 2003 became ill on March 13, and was brought back to The Scarborough Hospital byambulance. He suffered a confirmed myocardialinfarction—a heart attack. His contact with Mr. T wasknown, but the low level of his fever, and small infiltrateon his chest x-ray were thought at the time not to becompatible with SARS. Health care workers used onlystandard infection control precautions while treating thepatient, and transferring him to York Central Hospital, afull-service community hospital north of Toronto. Hewould become the source of another SARS cluster thatultimately affected more than 50 individuals, and closeddown York Central Hospital.

While Toronto fought a spreading SARS outbreak, BritishColumbia faced a different situation. The same day Mr. Tdied, before anything was known in Vancouver about the Toronto outbreak, a man who had also stayed at theMetropole Hotel in Hong Kong arrived at the VancouverGeneral Hospital with a flu-like illness. He lived with hiswife, had not been in contact with family and friends,and went directly to the hospital when he becamesymptomatic. Infection control practitioners and theattending physician at the Vancouver General Hospitalensured that their index patient was masked, and quicklyisolated. There were no reports of secondary transmissionsfrom this case. In contrast, Mrs. K in Toronto wassurrounded by a large family and sought only ambulatorycare, and her ill son had no travel history to triggersuspicions upon his admission to hospital.

On March 13, 2003, Health Canada received notificationof the Toronto cluster, and convened the first of whatwould become daily information-sharing teleconferencesamong federal, provincial, and territorial public healthexperts. On March 14, the Ontario Ministry of Healthand Long-Term Care [OMHLTC] held a press conferencewith Toronto Public Health and Mount Sinai Hospitalspokespersons about the cluster of atypical pneumoniacases. Media outlets began to cover the emerging story avidly.

SARS continued to spread at The Scarborough Hospital,Grace Division; patients, staff, and visitors developedsymptoms consistent with the new disease. Grace closed its emergency and intensive care services onMarch 23, 2003, and began refusing new admissions and transfers from other hospitals. Outpatient clinicswere closed, and employees were barred from working atother institutions. Anyone who had entered the hospitalafter March 16 was asked to adhere to a ten-day homequarantine. The hospital implemented stringentinfection control policies including contact and droplet

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precautions such as hand washing, wearing gowns,gloves, N95 masks3, eye protection, and the use of singleor negative pressure rooms for all SARS patients.

On March 23, 2003, officials recognized that the numberof available negative pressure rooms in Toronto wasbeing exhausted. In a four-hour period on the afternoonof March 23, staff at West Park Hospital, a chronic carefacility in the city, re-commissioned 25 beds in anunused building formerly used to house patients withtuberculosis. Despite the efforts of West Park physiciansand nurses, and assistance from staff at the ScarboroughGrace and Mount Sinai Hospitals, qualified staff could befound to care for only 14 patients.

Faced with increasing transmission, the Ontario governmentdesignated SARS as a reportable, communicable, andvirulent disease under the Health Protection and PromotionAct on March 25, 2003. This move gave public healthofficials the authority to track infected people, and issueorders preventing them from engaging in activities that

might transmit the new disease. Provincial public healthactivated its emergency operations centre (better knownas MAG for Ministry Action Group).

By the evening of March 26, 2003, the West Park unitand all available negative pressure rooms in Torontohospitals were full; however, ten ill Scarborough Hospitalstaff needing admissions were waiting in the emergencydepartment, and others who were ill were waiting athome to be seen. Overnight, with the declaration of aprovincial emergency, the OMHLTC required all hospitalsto create units to care for SARS patients. Accepting a leadrole in the outbreak, Sunnybrook and Women’s would,within 48 hours, put 40 negative pressure rooms intooperation.

By March 25, 2003, Health Canada was reporting 19cases of SARS in Canada—18 in Ontario and the singlecase in Vancouver. But 48 patients with a presumptivediagnosis of SARS had in fact been admitted to hospitalby the end of that day. Many more individuals were

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0

2

4

6

8

10

23- Feb- 03

6- Apr- 03

13- Apr- 03

20- Apr- 03

27- Apr- 03

2- Mar- 03

9- Mar- 03

16- Mar- 03

23- Mar- 03

30- Mar- 03

4- May- 03

11- May- 03

18- May- 03

25- May- 03

1- Jun- 03

8- Jun- 03

15- Jun- 03

22- Jun- 03

29- Jun- 03

Onset Date

Num

ber

of C

ases

F I G U R E 1 Number of Probable Cases of SARS in Canada, February 23 to July 2, 2003(N=250), excludes 1 patient for whom onset date is unknown.

3 Respirators are designed to help prevent the inhalation of airborne particles by the user; the N95 mask is technically a respirator, and is designed tofilter 95% of particles larger than one micron. Surgical masks trap droplets produced by the user, and help prevent the transmission of virus-containing secretions. During the SARS outbreak, many patients and visitors were asked to wear surgical masks.

starting to feel symptoms, and would subsequently beidentified as SARS patients. Epidemic curves latershowed that this period was the peak of the outbreak.On March 19, nine Canadians developed “probable”SARS, the highest single-day total. Taking “suspect” and“probable” cases together, the peak was March 26, andthe three days, March 25 to 27 are the highest three-dayperiod in the outbreak.

2D.The Emergency (March 26, 2003 - April 7, 2003)

Ontario Premier Ernie Eves declared SARS a provincialemergency on March 26, 2003. Under the EmergencyManagement Act, the Premier has the power to direct andcontrol local governments and facilities to ensure thatnecessary services are provided. The same day, theprovince activated its multi-ministry ProvincialOperations Centre for emergency response, situated onthe 19th floor at 25 Grosvenor Street.

All hospitals in the Greater Toronto Area [GTA] and SimcoeCounty were ordered to activate their “Code Orange”emergency plans by the OMHLTC. “Code Orange” meantthat the involved hospitals suspended non-essentialservices. They were also required to limit visitors, createisolation units for potential SARS patients, and implementprotective clothing for exposed staff (i.e., gowns, masks,and goggles). Four days later, provincial officialsextended access restrictions to all Ontario hospitals.

Later, the Committee heard mixed opinions about whetherCode Orange was justified. Several interviewees notedthe massive number of cancelled services, and suggestedthat the collateral casualties from the suspension of healthcare activities may never be fully measured. Other harmswere more subtle, including hardship caused by restrictionson visits between families and patients hospitalized withconditions other than SARS. These informants claimedthe activation of Code Orange demonstrated a “lack ofunderstanding of the system.” They suggested that TheScarborough Hospital could have been closed andconverted into a dedicated SARS hospital, with staffsupport from other facilities, while selected otherhospitals began urgent preparations to become SARS-carecentres. The remainder of the system could then operatewith increased infection control precautions.

Other interviewees argued strenuously that the declarationof emergency and Code Orange were essential togalvanize infection control, and prevent unrecognizedexposure by hospitals in the face of great uncertaintyabout the transmissibility of SARS.

Dr. Jim Young, Ontario’s Commissioner of Public Safetyand Security, co-chaired the Provincial Operations CentreExecutive Committee, and led the Executive and ScientificAdvisory Committee in a lengthy and intense exercise toassess the pros and cons of designating one or morefacilities as “SARS hospitals.” Decision makers feared anoutbreak would over-run any one or two designated SARShospitals. The West Park experience suggested that thelogistics of staffing a SARS specialty hospital would beextremely difficult. Concentrating SARS patients in a fewinstitutions would put an enormous burden on thesehospitals, and place their clinical personnel at great risk.Patients would still go to the emergency departmentnearest them, and language in current collective agreementsconstrained the ability of the system to move staff intonew institutions. The team decided to build capacity forthe management of SARS in multiple institutions. SARSpatients were cared for at over 20 hospital sites scatteredacross the Greater Toronto Area.

2D.1 Information Technology and DataSharing

On April 1, 2003, Dr. Ian Johnson, a professor andepidemiologist at the University of Toronto, was secondedto the OMHLTC to establish a SARS surveillance system.He had formerly served as associate medical officer ofhealth for North York. Upon his arrival, Dr. Johnsonimmediately noted insufficient physical and humanresources. Dr. Johnson later told the Committee thatreporting structures were unclear, and the head office ofthe Public Health Branch was simply unable to provideoptimal support for outbreak investigation andmanagement. There were also frequent requests for datafor the provincial government’s daily press conferences.

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Ministerial leadership is needed to create system-wideoutbreak management protocols, ideally of a gradednature commensurate with the severity of an outbreak.Many Ontarians experienced adverse effects fromcancelled surgeries and delayed appointments. Ontariocould put hospitals on “Code Orange” status (or not),but did not have a coordinated outbreak protocol forhealth and long-term care facilities and community-based health care providers. Do other Canadianprovinces have such protocols in place? Are theyharmonized with each other to permit interprovincialcoordination in the event of a national outbreak? HasHealth Canada taken a leadership role in creatingtemplate protocols and facilitating their adoption?

Dr. Johnson characterized the province’s infectiousdisease tracking and outbreak management software as“an archaic DOS platform used in the late eighties thatcould not be adapted for SARS.” Several other keyinformants echoed this sentiment. In 2000, the OntarioPublic Health Branch had led a process that developed afive-year plan to upgrade information technology, but itwas not approved for funding.

This outdated software platform was assessed, and rapidlyrejected by Toronto Public Health as unsuitable for the SARSoutbreak. Toronto Public Health developed new softwaretools to deal with tracking cases and contacts; other localhealth units eventually followed suit as the outbreak spread.However, individual files for cases and contacts were main-tained on paper charts that included colour-coded Post-Itnotes. Dr. Sheela Basrur, the city’s chief medical officer ofhealth, later commented that Toronto was using nineteenthcentury tools to fight a twenty-first century disease.

Several interviewees reported that data handling protocolswere variously unclear or non-existent. Developing themduring the SARS outbreak proved to be time-consumingand frustrating. One interviewee described the situationas “a turf war” on multiple levels. Offers of assistancefrom academic clinicians were rejected; infectious diseasespecialists and hospital epidemiologists set up a separatedata system for clinical management and institutionalinfection control.

Health Canada officials were concerned that the PublicHealth Branch of the OMHLTC was, in the words of oneinformant, “completely overwhelmed”. The Committeelater learned that the personnel and infrastructuresupporting Chief Medical Officers of Health are thin inseveral provinces.

Dr. Colin D’Cunha is Ontario’s Chief Medical Officer andCommissioner of Public Health. He co-chaired theprovincial emergency team with Dr. Young. Dr. D’Cunhaadvised the Committee that Toronto Public Health wasinitially overwhelmed, and not able to generate timelydata in the first two or three weeks of the outbreak.Another informant noted that Toronto has 1,800 publichealth employees, and wondered if the city hadmaintained a large enough outbreak management andinfectious disease unit.

Dr. D’Cunha stated that protection of patientconfidentiality constrained his ability to release data toHealth Canada. Senior GTA public health physicianstook the same view of their obligations to share datawith the Ontario Public Health Branch. Health Canadainformants in turn argued that they never wantedpersonal identifiers, simply more detail to meet WHOreporting requirements. Multiple informants noted thatrelationships among the public health officials at thethree levels of government were dysfunctional.

A memorandum of understanding on data sharing wasnever finalized between the province and the federalgovernment. High-level public health officials in Ontarioand Health Canada have since given the Committeesharply divergent views on how well information flowedwith respect to both its timeliness and adequacy. It isclear that at points during the outbreak, Dr. Arlene Kingof Health Canada dealt directly with Dr. Johnson andlocal public health officials to acquire the more detaileddata necessary for discussions with WHO. Local publichealth units in turn faced pressure from the OntarioPublic Health Branch to send on data for pressconferences, for reports to Health Canada, or both.

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Provincial public health authorities are the next line ofdefence when an outbreak spreads beyond a singlemunicipal health unit or overwhelms its capacity.Ideally, they provide leadership and coordination forpublic health activities province-wide. British Columbiahas taken the additional step of building a public healthfocus for infectious diseases in the British ColumbiaCentre for Disease Control. Would Ontario have benefitedfrom a similar agency at the provincial level? How dowe build a second line of defence against outbreaks on anational basis? Ontario has also devolved public healthfunctions to municipal control; expenses are dividedequally between the provincial government and munici-palities. Did this weaken Ontario’s capacity to managemulti-jurisdictional outbreaks in a coordinated fashion?


The lack of a modern database accessible to local,provincial, and federal health authorities had adverseimpacts on the flow of information to the public andinternational agencies. The absence of appropriate andshared databases and capacity for interim analyses ofdata, also interfered with outbreak investigation andmanagement, and constrained epidemiologic and clinicalresearch into SARS. Agreements for data sharingbetween different levels of government, and the necessaryinformation technology, were apparently not in placebefore the outbreak. Who is responsible for developingsuch protocols? What kind of information systemscould help prevent future problems? How can officialsensure the confidentiality and security of patient datawhile facilitating the necessary access and analyses?

A senior public health physician, on secondment toWHO during the SARS outbreak, assessed thejurisdictional tensions bluntly after a visit to Canada inMay: “The system is sick. It’s broken.”

2D.2 Scientific Advisory CommitteeAnother group that complained about insufficent datawas the Scientific Advisory Committee [SAC], an ad hocgroup of experts that started as a “human-cellphoneconglomerate” of concerned physicians, infection controlpractitioners, and administrators from across the country.Made up of volunteers who essentially dropped whateverthey were doing to assist in the Toronto outbreak, thecommittee members worked long hours, seven days aweek. Several Toronto physicians were integral members,but when Dr. Allison McGeer fell ill, and five core memberswere forced into quarantine, Dr. Dick Zoutman, a hospitalepidemiologist and medical microbiologist from Kingston,moved to Toronto and assumed the chair. “Handcuffed”by inadequate amounts of information, Dr. Zoutmanlater commented that his group “wanted desperately toget into the epidemiology, but had no data, capacity, ortime to do so.”

The SAC was charged with developing quarantineguidelines and hospital directives covering topics such asrestricted access, isolation precautions, employee screening,and patient transfers. The directives were passed to thedirector of the Hospitals Branch of the OMHLTC and her staff, who reworded them to facilitate implemen-tation by administrators, or, as the team called it,“translation into ‘Hospitalese’.”

Preparing directives under intense pressure, the SACoccasionally lost track of draft versions in the early going,but soon devised the necessary protocols. The SAC alsohad to manage a frequently changing membership assome physicians returned to their “day jobs”. Along withoffering high praise for the SAC’s chair and members,interviewees later wondered why the committee did notinclude representatives with expertise in anaesthesia,paediatrics, or respiratory therapy. Representation fromfamily medicine came later in the outbreak, when it wasrecognized that primary care input was essential togenerate directives for physicians practising incommunity settings.

Nuances were sometimes lost and meanings blurred as directives were processed through various channels. A specialist who participated on the SAC later stated: “At times, the directives issued to the hospitals appearedto be significantly different than directives that wereagreed to by the [SAC] members and proved to be very

confusing for the hospitals.” Several clinical and admin-istrative leaders raised concerns that early directives werenot field-tested, lacked a scientific basis or were opera-tionally impossible. Dr. Jim Young noted, however, thatthe situation required “decisive action, not perfection.Every hour that we wasted was more people gettinginfected.”

A controversial directive was the requirement that healthcare workers wear fit-tested N95 masks. Neither the fit-testing (a complex operation requiring a subject to tryvarious mask designs while a bitter-tasting gas circulatesunderneath a hood), nor the appropriateness of the N95standard itself had been fully discussed by the SAC.Given that SARS was being spread primarily via droplets,some informants questioned whether N95 masks werenecessary. Others stressed that the disease should betreated as airborne until more information was available.

Notwithstanding the debate about the necessity of N95masks, fit-testing was felt by almost all to beoperationally impossible. The Provincial OperationsCentre issued the edict that health care workers shouldwear fit-tested masks, but no support was provided tohospitals to ensure this would happen. Confusingmatters further, unions such as the Ontario Public ServiceEmployees Union attempted to fulfil their safetymandates by issuing their own health alerts andrecommendations. The Ontario Nursing Association wasalarmed by the lack of fit-testing and non-compliancewith the provincial directive, and launched grievances toprotect front-line nurses.

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The Scientific Advisory Committee [SAC] was a hastily-assembled group of tireless volunteers. With over 200SARS patients in Toronto, infectious disease expertswere spread thin—and the city had only a handful ofhospital epidemiologists. Their ability to participate inSAC deliberations was limited, and when they were ableto participate in person, the entire committee was at riskof being infected with the SARS virus. Should a bodysimilar to the SAC already have been in place? The CDChas recently initiated the use of a “B [or Brains] team” toprovide scientific backup and sober second thoughts inthe midst of what is often a crisis atmosphere. Whatkind of structure should be in place in the provinces ornationally to ensure the requisite scientific support foroutbreak investigation and ‘B team’ functions? Whoshould issue directives to health care workers andinstitutions, and what kind of support should beprovided to facilitate compliance?

2D.3 LeadershipVarious interviewees acknowledged the indefatigableleaders of the emergency response, but remarked that, as one put it, “we never knew who was in charge.” Dr. D’Cunha and Dr. Young jointly led the ProvincialOperations Centre. Many interviewees noted tensionsbetween the two physicians, as well as their differingmanagement styles. In separate interviews, both Drs. Young and D’Cunha acknowledged that the dualleadership structure was less than ideal, and one personshould have been in charge. Matters were furthercomplicated as other branches of the OMHLTC helped tomanage the interactions with hospitals, long-term carefacilities, physicians, and various elements of the healthservice system. A number of physicians involved in caringfor SARS patients began actively discussing whether andhow the management of the outbreak could be handedover to a single “SARS czar”.

At the federal level, similar themes emerged. Staff at theHealth Canada Regional Office in Toronto felt they couldhave played a greater role given their proximity to the crisis,and their ability to gather intelligence locally. A pre-existing F/P/T Pandemic Influenza planning committeebecame the nidus for daily SARS teleconferences organizedby Health Canada, but representatives from Ontario weretoo busy dealing with the outbreak to join in. Severalsenior Health Canada personnel from Ottawa who cameto help in Toronto were identified for praise by inter-viewees. However, fairly or not, most informants contrastedthe response of Health Canada’s Population and PublicHealth Branch with the high standard of federal supportset by the CDC in the United States. One provincialhealth official later commented that “Tunney’s Pasture isgood for general advice, and Ottawa has a big chequebook,but the feds lack operational credibility.”

2D.4 Health Canada’s RoleAccording to Health Canada’s internal communications,on March 14, 2003, the federal government sent “sixinfectious disease and epidemiology experts to help withthe investigation of SARS cases,” with “an additionaleight experts” sent on April 1. In contrast, a provincialofficial later commented that Health Canada sent threetrainees from its Field Epidemiology Program to do aresearch project with Toronto Public Health. It appearsthat about a dozen Health Canada personnel of varyinglevels of seniority were actually on the ground in Torontofor much of the outbreak, but largely invisible. Seniorfederal personnel were closely involved in investigating a number of SARS clusters, kept other provinces andterritories prepared for SARS, and managed the internationalliaison. However, federal involvement in Ontario waslimited by the lack of a delineated role in an organizationalstructure, lack of data for outbreak investigation, andabsence of business process agreements for inter-jurisdictional collaboration.

For example, a group of field epidemiologists from HealthCanada first worked with Toronto Public Health, and thenwere moved to a OMHLTC office at 5700 Yonge Streetwhere their duties included data entry. Their mentors inOttawa objected to this deployment of skilled personnel,and the field epidemiologists were demoralized. Otherswere sent in to help on a rotation system, but this wassuboptimal. A member of the SAC commented that “theon-the-ground help from Health Canada seemed to comeon five-day contracts so there was no continuity.” Fortheir part, the field epidemiologists were critical of thelack of provincial organization, and nonavailability ofdata. On April 30, Health Canada pulled back the fieldepidemiologists from the provincial office, a move thatsome informants deemed unsupportive and ill-advised.

The federal government convened an invitational “SARSSummit” in Toronto on April 30 and May 1, 2003, settingout the framework for a national SARS strategy. Theevent helped to promote a commonality of purpose inthe struggle against SARS, although some front-line clinicaland public health physicians who had been fightingSARS at ground level later wondered why they were notinvited. Health Canada also facilitated the purchase ofapproximately 1.5 million N95 masks for the NationalEmergency Stockpile System [NESS], and sent 10,000 toToronto health officials.

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Emergency situations are inherently stressful. Publichealth crises require clear leadership at the municipal,provincial, and ultimately national levels as their scopewidens. Who should provide these differing levels ofleadership? What kind of an organizational structurewould work best? Some informants questioned theembedding of the response to SARS, a public healthcrisis, in Ontario’s general emergency managementstructures. Should there be a category of healthemergencies distinct from the general emergencymachinery at the provincial and federal levels?

2D.5 Public Communications and Media Relations

Health Canada, the OMHLTC, and Toronto Public Healthall issued regular SARS updates on their websites.Televised SARS press conferences were a daily feature ofnational newscasts—Drs. James Young, Colin D’Cunha,and Sheela Basrur became household names. Dr. DonaldLow, chief microbiologist at Mount Sinai Hospital andprofessor of medicine at the University of Toronto,emerged as one of the unofficial leaders of the SARS battle,and sometimes joined the official press conferences. Heand other infectious disease leaders also did numerousunscripted interviews.

Many observers felt that interaction with the mediabecame an end in itself during the outbreak. SeveralCommittee informants felt the impression created wasone of too many “talking heads” whose opinionssometimes diverged. Singapore, in contrast, held anevening press conference with a single spokesperson, theMinister of Health, leaving public health officials andinfectious disease experts to focus on the outbreak. Asenior physician later questioned why the media profiledthe cumulative counts of probable and suspect SARSpatients, rather than the relatively unimpressive dailyincidence statistics (as per figure 1). There appeared,however, to be no coherent communications strategyaimed at dispelling the sense of deepening crisis.

2D.6 ResearchOn March 15, 2003, WHO established an internationalnetwork of laboratories to find the agent responsible for SARS. The speed of the investigation was unpre-cedented—barely a month later, WHO announced that apreviously unknown member of the coronavirus familyhad been conclusively identified as the most likely culprit.

The first scientific papers describing SARS were publishedon the New England Journal of Medicine website on March31, 2003; one came from Hong Kong and the other fromCanada. In the following weeks, researchers from HongKong flooded the medical journals with importantanalyses—eight major publications appeared in The Lancetalone. Several more were spread between the BritishMedical Journal, Science and the New England Journal ofMedicine.

In the same period, Canadian researchers published twomore articles in the major international journals. Onewas an important breakthrough, albeit quickly repeatedin other jurisdictions—researchers from British Columbiaand Winnipeg described the genetic sequence of theToronto SARS virus in Science. Later, a team of doctorsfrom Toronto depicted the clinical features of SARS inJAMA - the Journal of the American Medical Association.

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Communications was among the issues raised in acompelling letter to the Committee, signed by thepresidents or chief executives of nine major health caregroups—the Canadian Medical Association, theCanadian Public Health Association, the CanadianNurses Association, the Canadian HealthcareAssociation, the Canadian Dental Association, theAssociation of Canadian Academic HealthcareOrganizations, the Canadian Pharmacists Association,the Canadian Association of Emergency Physicians, andthe Canadian Council on Health Services Accreditation.They wrote:

“During a crisis or emergency, the public will quicklybegin to look for a trusted and consistent source ofinformation. However, during the early days of theSARS crisis, in Toronto, there were occasions whenseveral different public health officials were beingquoted and had titles attributed to them that appeared toindicate they were responding in an acting capacity onlyand not as an “official”. This had the potential to leavean impression with the public that no one with anyauthority was in control. Establishing one individualwith authoritative credentials as the chief spokespersoncreates public confidence, and lends credibility to themessages. How the crisis or emergency is reported isjust as important as how it is actually handled. It is alsocrucial that the public, and the media have a clearunderstanding of the language of the crisis so that clear,consistent messages are communicated and received.Governments across jurisdictions must develop anemergency plan to which all parties are committedregarding leadership in communications.”


In the United States, as in Canada, responsibility foroutbreak management progresses through local andstate public health chains of command. However, theCenters for Disease Control and Prevention [CDC] isgenerally ‘invited early and often’ to become involvedwith any serious outbreak. Its credibility mitigatesjurisdictional tensions. The same cannot be said atpresent for the Population and Public Health Branch ofHealth Canada. How can we build federal capacity tosupport provincial and municipal officials in battlingdisease outbreaks? What collaborative hierarchy ofroles and responsibilities can be devised that reflects theunique nature of Canada’s federation?

While researchers in Hong Kong were busy correlatingclinical and laboratory features of SARS with epidemiologicdata, this did not occur in Toronto. The first clinicalpaper from Toronto was compiled with minimal inputfrom public health officials; its lead author was a residentphysician just two years out of medical school.

Some of Toronto’s infectious disease experts were toobusy taking care of patients to find time for research.Others were occupied by SAC deliberations. Multipleinformants praised the work done by infectious diseaseand infection control specialists who supported a widerange of activities inside and outside their homeinstitutions. They and countless health care workers rosedaily to the challenge of battling SARS, placing themselvesat risk to battle a new and contagious disease with asignificant mortality rate. As one academic physicianlater ruefully commented, “It doesn’t show up on my CV if I’m in the trenches battling SARS.” However, evenhad an appropriate database been in place, the requiredmachinery and supporting personnel may well have beeninsufficient to allow either appropriate outbreak investi-gation or the associated epidemiologic and clinical research.

On July 26, 2003, a major paper with multinationalauthorship was published in The Lancet, providing data insupport of the proposition that the new SARS-associatedcoronavirus had met the criteria to be designated thecausative agent of the new disease. Patient data wereincluded from six countries: Hong Kong, Singapore,Vietnam, Germany, France, and the United Kingdom. No Canadians appeared among the 22 authors, and noCanadian patients were included in the study sample.

2D.7 LaboratoriesWithin 24 hours of receiving the initial specimens fromSARS patients in early March 2003, the National MicrobiologyLaboratory in Winnipeg ruled out all known respiratorypathogens. The laboratory was a key member of theWHO network responding to SARS, and helped developand refine diagnostic tests for SARS. Over the course ofthe first and second outbreaks, the laboratory testedseveral thousand specimens that included blood, sputum,stool, urine, and nasopharyngeal aspirates. At one point,the laboratory was receiving 600 specimens per day, buthad sufficient surge capacity to accommodate the load.

Patient samples often arrived with no epidemiologic orclinical data—sometimes, even basic identifying datawere incorrect or missing. More disconcerting was thefinding that over 170 individuals who did not haveSARS—at least according to restrictive case definitions—tested positive for the virus. Although some results mayhave been false positives (i.e., due to imperfect tests orspecimen contamination), scientists were concerned thatmembers of this group represented an opportunity forthe virus to spread unchecked into the general community.The absence of a central database made finding theseindividuals and their contacts more difficult than itshould have been—a situation that one informant called“very frustrating and dangerous.”

In contrast, the Central Provincial Public Health Laboratoryin Toronto was unable to provide optimal support duringthe SARS outbreak. Senior physicians advised theCommittee that microbiology laboratory capacity nationallyhas eroded in recent years; and in Ontario, the CentralLaboratory was unable to keep up with the testing volumesinvolved in previous outbreaks of West Nile and Norwalkvirus. A number of infectious disease specialists suggestedthat there remains an urgent need for rapid andcoordinated laboratory testing for SARS and related viraldiseases, especially with the fall flu season approaching.

With the provincial lab overwhelmed, some hospitalssent specimens directly to the National MicrobiologyLaboratory, bypassing the usual hierarchy of referral. The Hospital for Sick Children, Mount Sinai, andSunnybrook and Women’s had strong platforms inpolymerase chain reaction technology—an elegantlaboratory testing modality that identifies micro-organisms by analyzing strands of their DNA or RNA.They became the de facto and unfunded referral centresfor Toronto SARS testing.

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Outbreak investigation and research shade together. Forexample, provisional analyses of data during an outbreakallow researchers to estimate incubation periods (thelength of time necessary to quarantine a contact), anddevise treatment protocols. Canadian researchers werehamstrung by patient care and scientific advisoryresponsibilities, a lack of data, infighting about dataaccess, limited research funds, and the need to obtainethics approvals at multiple institutions. Submissions tothe Committee by the Canadian Association of MedicalMicrobiologists, among others, have recommendedestablishing a common ethics review board for outbreaksituations, developing guidelines to ensure that outbreakdata are made available to all interested researchers (owner-ship and authorship issues should not be of primaryimportance during an emergency), and assembling a dedi-cated and experienced research team early in an outbreak.

2D.8 Clinical Challenges SARS was and remains a challenging disease to diagnoseand treat—it presents with nonspecific symptoms, it hasno hallmark abnormality on physical exam or biochemicaltesting, and there is still no unequivocally effectivetreatment. Toronto-area hospitals and clinicians had neverfaced an outbreak like SARS. Clinics designed specificallyto assess potential SARS cases were created at several sitesin the GTA to relieve the burden on emergency departments,and to help prevent further transmission. Once identified,SARS patients were cared for at numerous hospitals acrossthe city during the first wave of the outbreak.

Other countries used different strategies—in Singapore,for example, authorities concentrated all SARS patients inone hospital. Hong Kong tried to centralize SARS care ina single institution but its capacity was rapidly exceeded.In Beijing, officials ordered each hospital to establish a“fever clinic” that could assess patients at risk of havingSARS; then, in just eight days, construction workers builta thousand-bed SARS hospital on the city’s outskirts.

In Toronto, infectious disease specialists, clinical chiefs,and intensive care specialists held daily teleconferencesto discuss treatment options, and review the number ofcases at each hospital. As with any new disease, treatmentplans for SARS were designed and implemented withlittle or no evidence to back them up. Typically, a patientadmitted with SARS would receive supplemental oxygenas required, antibiotics to cover a potential bacterialinfection, and possibly—depending on the treatingphysician—ribavirin, a potent medication known to beeffective against a variety of viruses. Steroids were used

for patients with worsening respiratory symptoms, aclinical scenario that apparently corresponded to anexcessive and counterproductive inflammatory responsein the lungs.

As the doctors in Toronto gained experience, theyconcluded that ribavirin was likely causing more harmthan good. Many patients receiving it were developingtoxic side effects like red blood cell breakdown and liverdysfunction, and many patients who did not receive theantiviral medication were recovering. This information,coupled with in vitro testing (i.e., in the laboratory)showing little or no effect on the SARS coronavirus, ledCanadian physicians to stop prescribing ribavirin.Clinicians in other countries continued to use ribavirin,but in smaller doses that limited its side effects. Even inthis era of evidence-based medicine, SARS forcedphysicians to trust their instincts—and their colleagues’collective wisdom.

By the end of the first week of April 2003, 91 probableand 135 suspect SARS cases had been reported in Canada.Ten people had died.

2E. The Quest for Containment (April 8, 2003 – April 23, 2003)

2E.1 Public Health’s FightPublic health officials in York and Toronto continued totrace and quarantine contacts with good results. Theoutbreak management teams and leaders of the localpublic health units were identified by some intervieweesas those who deserve greatest credit for containing theSARS outbreak.

Nonetheless, concerns mounted that SARS was poised tospread into the community. Individuals who attended afuneral on April 3, 2003 were quarantined when somefamily members developed symptoms. An employee of alarge information technology company defied quarantine,and returned to work while symptomatic; one co-workercontracted SARS, and nearly two hundred more were sentinto isolation. A Scarborough school was closed byToronto Public Health when one student, a nurse’s child,exhibited SARS symptoms; four other schools would beclosed by local school boards as a result of SARS concernsbefore the outbreak ended. Routine screening picked upa fever in a nurse caring for SARS patients—a hurried searchto identify her fellow commuter train passengers ensued.

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The Canadian Public Health Association advised theCommittee that “current inabilities or unwillingness toshare information within the laboratory network areaggravated by the fact that three sectors—the public,private, and voluntary sectors at three levels—themunicipal, provincial, and federal levels—provide labora-tory services.” Standardized testing and coordinatedcollection/sharing of data would help inform outbreakmanagement. How should the hierarchy of referral andresponsibility be organized for laboratory testing duringoutbreaks? Who should set and police standards? Howcan we strengthen relationships between laboratoriesand clinical services, public health and governmentregulators? How do we address the supply, recruitmentand retention of medical microbiologists and virologistsin public health laboratories?

Because Toronto was the only city outside Asia to be hithard by SARS, the international media converged on thecity like never before. The attention was not only unprece-dented; it was unwanted. Despite the media attention,there was no evidence that the SARS epidemic wasspreading through the community. The Amoy Gardensoutbreak in Hong Kong, where the virus may have beentransmitted through a defective sewer system, was anexception that proved the rule—the SARS virus was spreadby either brief exposure to big doses of viral particles orclose, prolonged contact. All but a few Canadian casesoccurred in travellers, health care workers, and theirimmediate contacts. Using traditional surveillance, contacttracing, and quarantine, opportunities for communitytransmission were being identified and contained.

The number of people quarantined grew daily. Veryoccasionally, someone would refuse to enter isolation,and public health officials had to resort to legal means to enforce compliance. But this was the exception;Torontonians were generally remarkably compliant withhighly demanding strictures. Quarantined individualslost income, suffered from boredom and loneliness, andmost importantly, were fearful that they might developSARS or that they may have spread SARS to family and friends.

Committee informants commented that different publichealth units seemed to have different thresholds for theuse of quarantine. A related issue is whether public healthofficials used quarantine too frequently. Some intervieweesbelieved they did—one noted that while Beijing had2,500 cases of SARS compared to Toronto with 250, bothcities quarantined about 30,000 individuals. Beijingquarantined fewer people per SARS case because theyfocused on close contacts (e.g., household members,hospital visitors, and those who might have come incontact with bodily fluids). On the other hand, the highercaseload of probable and suspect SARS in Beijing mightactually have been a result of too-limited use of quarantine.

Perhaps the greatest scare of the Toronto outbreakoccurred on April 12, 2003 when a cluster of SARS caseswas identified in a close-knit religious community.Remarkably, it had begun with exposure back in mid-March of several members of a large extended family atthe initial epicentre—The Scarborough Hospital, GraceDivision. Over the ensuing weeks, the infection spreadquietly through the extended family and some closefriends, health care workers who cared for them, andthen into a religious group. In all, 31 cases, includingthree health care workers, were associated with thiscluster. Public health workers employed active

surveillance and quarantine to control the spread ofinfection, and unchecked community transmission never materialized.

As residents of their jurisdictions became exposed throughthe religious group cluster, public health units in thesurrounding regions of Durham and Peel joined Torontoand York in trying to stop the outbreak. The variousunits collaborated, but there was no overarching coordin-ation across jurisdictions. Hospitals later complained thatthey were sometimes contacted separately for informationabout the same patient by two public health units.Hospitals were also fielding requests for information fromthe OMHLTC Hospital Branch, the Public Health Branch,and the Provincial Operations Centre. Understandably, itappeared to those on the clinical front lines that publichealth officials were not communicating with each other.Meanwhile, in Toronto, local public health workers werenearing exhaustion—all non-SARS activity in infectiousdiseases and many other provincially-mandated programshad been suspended, and virtually all qualifiedemployees were working on SARS full time.

The monumental efforts of public health workers playeda critical role in the containment of SARS. Toronto PublicHealth, for example, investigated 1,907 separate reportsin addition to 220 cases of probable or suspect SARS,each of which involved several hours of investigativework, independent of contact tracing. A pair of paperslater published in Science provided estimates of the“infectiousness” of the SARS virus. Both papers lead onetoward the same conclusion: although SARS is onlymoderately transmissible, left unchecked it could haveinfected millions of people worldwide. Whether it wouldhave done so before mutating into a more benign formis, fortunately, still unknown.

2E.2 Primary CareAlthough most of the attention during the outbreak wasdirected toward hospitals, several instances of patientstransmitting SARS to their family doctors producedapprehension. One academic family physician voicedconcern as early as March 28, 2003: “Family physicians,just like hospitals, need precise and explicit directions forscreening patients, and for contending with suspect orprobable SARS patients who might make it past thescreening system.” They also “required full protectivegear in the unlikely event that a SARS patient did make itinto their offices.” He suggested that family physicianscould be used as sentinels—reporting cases of pneumoniato a central authority might pick up SARS clusters wherethere was no obvious epidemiologic link.

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Guidelines for family doctors were eventually issued onApril 3, 2003 via the fax and e-mail network of theOntario Medical Association. These instructions outlinedthree goals: first, to keep potential SARS patients out ofdoctors’ offices using signs, pre-recorded telephonemessages and screening questionnaires; second, to safelytreat any SARS patients that did enter the office; andthird, to protect physicians and staff from infection.Some informants later suggested that the guidelines weredifficult to implement in community-based practices.

More problematic was the lack of a system to distributethe necessary protective gear. The Ontario MedicalAssociation proposed that the fastest strategy was forfamily doctors to buy their own supplies where they could,and apply for reimbursement later. A growing number offamily physicians, however, were concerned by the lackof provincial support. On April 15, Drs. D’Cunha andYoung convened a meeting of family doctors, hospitalCEOs, and chiefs of emergency medicine at a downtownhotel. Family doctors left the meeting frustrated that theprovince had still not developed a plan to distributeprotective equipment to physicians and their office staff.On April 21, 2003, almost four weeks after the Provinceof Ontario declared an emergency, the province finallyused its vaccine distribution network to provide familydoctors with protective equipment.

2E.3 Transmission of SARS to ProtectedHealth Care Workers

On April 13, 2003, on the Sunnybrook and Women’sSARS unit, a family doctor who may have been infectedwith the SARS virus while caring for several members ofthe religious group cluster began to suffer fromincreasing shortness of breath. He was transferred to theICU. Once there, non-invasive devices were used to

assist his breathing. None worked, and doctors decidedhe required intubation. The entire ordeal (from transferto intubation) took several hours. Many health careworkers were exposed to the patient’s coughed-upsecretions or the aerosols generated by devices to assisthis breathing. Both were rich with SARS viral particles.

By the following week, 11 health care workers presentduring either the transfer or the intubation became ill.On April 20, 2003, Sunnybrook and Women’s closed itsSARS unit and its ICU. Canada’s largest trauma centrestopped accepting trauma patients. Investigators fromthe CDC were invited north to join a team attempting toshed light on how health care workers using all recom-mended precautions could have been infected. The teamconcluded that direct contact with the patient or a contam-inated environment might have led health care workersto contaminate themselves as they removed their protectivegear; alternatively, the patient’s coughing or the assistedventilation might have led to airborne spread.

The concept that minor breaches in protocol led toinfection was upsetting to some professionals who sawthese findings as a veiled criticism. The possibility thattheir own inadvertent and minor breaches in protocolcould lead to infection was disturbing to someprofessionals who saw these observations both as furtherevidence of the risks of SARS care and also as an indirectcriticism. However, most physicians and nurses had littlerecent experience with droplet precautions for a virussuch as SARS. Hospitals redoubled their efforts to trainhealth care workers covering SARS units.

Sunnybrook and Women’s continued to carry the largestvolume of SARS patients in the GTA, but many of itsphysicians with relevant expertise or experience werenow ill or in quarantine. The hospital’s administrators,clinical chiefs, and involved clinicians put out desperaterequests for support through numerous channels. OtherToronto institutions were either struggling with theirown SARS load or unwilling to help. One sister hospitaleventually sent one senior resident to help with generalmedicine coverage, freeing up on-site staff to concentrateon SARS patients.

The military sent a critical care specialist. One physicianarrived from the United Kingdom, another came fromMontreal, and the chairman of medicine at the Universityof Ottawa offered to assemble reinforcements if necessary.Further support came only after the province retained aprivate placement agency to help with recruitment, butthe agency’s pay scales for professionals would laterbecome a point of contention.

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During the SARS outbreak, several family physicianswere infected with SARS. Because most people visittheir family doctor (rather than an emergency department)when they are unwell, family doctors need protocols,protective equipment, and prompt information duringinfectious disease outbreaks. How can we bettersupport community physicians during extraordinarysituations? How can we improve communicationbetween public health officials and the primary caresector? What about other community care agencies?How do they fit into the scheme of disease surveillanceand outbreak response?

Meanwhile, in British Columbia, the transmission ofSARS to a nurse caring for SARS patients forced theclosure of a ward at the Royal Columbian Hospital nearVancouver on April 19, 2003. This was the first case ofsecondary transmission in British Columbia; the otherthree probable SARS patients in British Columbia hadcontracted the disease outside the country.

2E.4 WHO Travel AdvisoryAs the Easter and Passover holidays approached, publichealth officials braced themselves for a large spike ofcases emanating from the religious group cluster. Bothpublic health officials and clergy stressed repeatedly thatpeople under quarantine should remain home, and avoidpublic religious services. Catholic churches also institutedprecautionary measures—communion wafers were placedin hands rather than mouths, and confessions took placeoutside the usual booths. At diverse religious gatheringshandshakes were replaced with smiles.

The expected wave never occurred. By April 23, 2003,only one individual—a member of the religious group—had developed SARS in the previous two weeks. But justas confidence within the city began to grow, WHO issuedan unprecedented advisory, recommending that visitorsto Toronto postpone all but the most essential travel.The United Nations agency was concerned that “a smallnumber of persons with SARS, now in other countries inthe world, appear to have acquired the infection while in Toronto.”

Three months after WHO issued its travel advisory againstToronto, Health Canada officials remain mystified aboutWHO’s reasoning and motivation. As one Health Canadaphysician told the Committee, “The travel advisory wasan absolute stunner... We were of the belief, based on theepidemiologic data, that the outbreak was dwindling

rapidly.” Some informants have since speculated thatWHO officials were concerned about the appearance of a double standard favouring Toronto. WHO traveladvisories had already been issued for Hong Kong andGuangdong, and advice against non-essential travel toBeijing and China’s Shanxi Province was given on thesame day as the Toronto advisory.

Singapore had 189 probable cases on April 23, 2003compared with 140 for Toronto, as well as transmissionat a community market. Epidemic curves comparing theoutbreaks in Toronto and Singapore are strikingly similar(see Chapter 11). However, Singapore’s management ofthe outbreak, not least its communications strategy, wassuperbly organized and reflected a remarkable degree ofsocial solidarity that could not have been lost on WHO.The Committee has also learned that regional WHOoffices had different levels of interaction with nationsaffected by SARS, and were therefore more or less able tovouch for the containment of the outbreak.

The WHO travel advisory criteria themselves came underintense criticism—they included the presence of at least60 probable SARS cases, export of SARS to other countries,as well as community spread. Yet none of these criteriahave ever been validated as reasons for issuing a traveladvisory. For example, the absolute number of cases in an outbreak is largely a function of the size of acommunity. Issuing a travel advisory does not preventresidents of a SARS-affected area from leaving and takingSARS with them. Indeed, of the six people thought tohave spread SARS from Canada, only one was a visitorreturning home after a trip to Canada. Finally, “spreadinto the community” was never explicitly defined—if anurse with SARS infects his/her spouse, is this consideredcommunity transmission?

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Ontario is the only province that has not adopted regionaladministration of health care. The merits of regionalizationin general are subject to ongoing evaluation. However,the GTA lacks any truly regional plan for clinical servicesor health emergencies. More generally, clinical jurisdic-tions across Canada do not have defined responseteams for health emergencies that can move betweenhospitals, let alone across regions or provincial boundaries.The Canadian Medical Association has proposed a ‘gridsystem’ for personnel to support health emergencies.Should a system of health emergency response teamsbe created within and across regions and provinces?


Whether the WHO travel advisory was justified or not isdebatable. What is beyond debate is the fact that theeconomic and social impact of such advisories can bedevastating. What is the process whereby differentnations and international agencies such as WHOgenerate criteria for travel advisories, and proceed toissue them? What are the benefits and harms of traveladvisories? In the case of Canada, to what extent wasinternational confidence in our ability to manage SARSundermined by lack of coordination among jurisdictions,shortage of data, and the lack of a coherentcommunications plan?

2F. Between the Waves (April 24, 2003 - May 22, 2003)

“I can tell you definitely we are in better shapetoday than we have been in a month…Where did[the WHO] come from? Who did they see? Whodid they talk to? Did they go to our hospitals, didthey go to our clinics, did they go anywhere? Theysit somewhere, I understand Geneva, I don’t evenknow where the hell they came from, but Geneva orsomeplace and they make decisions…”

—Mayor Mel Lastman, at a press conference, April23, 2003

The WHO-issued travel advisory came just as local andprovincial health officials felt that they were winning thebattle against SARS. This perception was strengthened bymedia spokespersons, front-line clinicians, and by thefederal government. The Prime Minister also announcedthe formation of the National Advisory Committee onSARS and Public Health.

The WHO advisory, which was initially to have been in place for at least three weeks, was withdrawn on April 30, 2003 after visits to Geneva by a delegation thatincluded Ontario Health Minister Tony Clement and thePublic Health Commissioner, Dr. D’Cunha. In return,Canadian officials gave assurances to WHO that theywould intensify screening of travellers to and fromCanada to prevent export of the disease.

On May 14, 2003, WHO removed Toronto from the listof areas with recent local transmission. This was widelyunderstood to mean that the outbreak had come to anend. Consistent with the notion that the disease wascontained, the Premier of Ontario lifted the emergencyon May 17. Directives continued to reinforce the needfor enhanced infection control practices in health caresettings. Code Orange status for hospitals was revoked, andthe Ontario government announced a provincial panel tostudy the response to SARS, chaired by Dr. David Walker,dean of medicine at Queen’s University. The ProvincialOperations Centre was dismantled. The physician-in-chiefof a major teaching hospital later observed that there was“a great and understandable rush to make things normalagain after SARS I.”

By mid-May, all levels of government were presenting aunified picture to the public that SARS had been contained.Rather than presenting data about the cumulativenumber of people labelled with probable or suspect SARS,health officials began to highlight the declining numberof “active” cases and the number of new cases—figuresthat were not only more reflective of disease activity butalso less dramatic. Health Canada began to issuebulletins only weekly, and reported in its May 21, 2003update that no Canadian had experienced the onset ofsymptoms for over a month.

It appeared that the total number of cases had reached aplateau—140 probable and 178 suspect infections.Twenty-four Canadians had died, all in Ontario.

2F.1 Hospital Infection ControlStarting in late April 2003, hospitals began to ease theirinfection control precautions. Employees working outsidedesignated SARS areas were, in most hospitals, relieved oftheir obligations to wear personal protective equipmentfor all patient contact. Rules regarding the minimumdistance separating co-workers during meals were relaxed.Hospitals began increasing the number of patients allowedvisitors. Relieved that SARS had passed, staff went backto their usual routines. Hindsight would reveal thatvigilance for SARS and stringent protective measures shouldhave been maintained for at least a few more weeks.

Provincial directives required hospitals to isolate patientswith fever and respiratory symptoms in either the hospitalor the emergency department until SARS had been ruledout, but there was no recommendation for formal, hospital-based surveillance programs. The SAC had actively discussedthe need for heightened surveillance. Its functions,however, were being wound down. Public health officialsviewed syndromic surveillance as a matter for institutionalinfection control and outside their mandate; they lackedresources to implement such a program in any case.

Hospitals responded by treating all patients admittedwith community-acquired pneumonia as potential SARScases until proven otherwise. Most took special precautionswith inpatients who developed respiratory symptomssuggestive of infectious disease. Some hospitals also did“fever surveillance.” For example, at York Central Hospital,all inpatients had their temperature checked twice daily.Chest x-rays were ordered for all York Central inpatientswith fever and respiratory symptoms and they wereisolated promptly; and until SARS could be ruled out, aspecialist in lung diseases assessed and treated allpneumonia patients in isolation. Similar measures wereused in Singapore health care facilities.

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Although infection control practitioners attempted toinstitute comprehensive surveillance programs in somehospitals, such a program alone requires approximately 2full-time staff members for a 500-bed hospital, more thanthe majority of hospitals have on staff for all infectioncontrol tasks. At North York General Hospital, forexample, one full-time and one part-time infectioncontrol practitioner were responsible for 425 acute carebeds. The infection control director, Dr. BarbaraMederski, occupied the role without any salary, protectedtime, or even an office. In the absence of a directive, andwith ongoing budgetary concerns, instituting fullsyndromic surveillance was not seen by most hospitals asnecessary or feasible.

As well, hospitals were not able to access any baselinedata on rates of similar respiratory infections prior toSARS. These baseline data would have been important inassessing whether the rates of respiratory illness beingobserved were unusually high. The corollary was thathospitals lacked established surveillance networks withreal-time pooling of data and rapid expert analysis.

2F.2 North York General HospitalOn three separate occasions in April and May 2003, officialsat North York General Hospital invited experts to investigatepotential SARS cases. Those involved in adjudicating thecases were a ‘who’s who’ of leaders in the fight againstSARS. Investigations at North York at times involvedprominent infectious disease specialists, Toronto PublicHealth physicians, Health Canada personnel, and visitingexperts from the CDC. Assessment was repeatedlybedevilled by the lack of an ‘epidemiologic link’—aconnection between what, clinically, could be a patientwith SARS and a source for his or her infection.

Between April 20 and May 7, three psychiatric patientsdeveloped pneumonia. All had been on the seventh floorof North York General Hospital. One had come back tohospital through the emergency department. He wasplaced in a waiting area with a mask, but paced constantlyand, to the concern of the staff, frequently removed hismask. All three patients were isolated and managed aspotential SARS cases, although no epidemiologic link toother cases could be identified. The assessment team haddivergent views as to whether the clinical picture wasconsistent with SARS—but in the end, chiefly becausethere were no epidemiologic links to known SARS patientsand negative laboratory tests, they ruled out a new cluster.

Meanwhile, unbeknownst to the hospital administration,several elderly patients on the orthopaedic ward (4 West)had been fighting what were at first believed to be typicalpost-operative lung infections. Among them was a 96-year-old man with a fractured hip. Through means stillunknown, illness spread from 4 West over the next fewweeks to other patients and to several visitors and staff.On April 29, an intensive care unit nurse from NorthYork General was admitted to Toronto General Hospitalwith a respiratory illness. She had cared for an 88-year-oldpatient from 4 West who had been transferred to theNorth York ICU with fever, respiratory compromise, andconfusion on April 26 and subsequently died. At first, thenurses’ serology was negative for SARS, but test resultslater were positive. In hindsight, the 88-year-old wasprobably part of a growing SARS cluster on 4 West.

In mid-May physicians and nurses in the emergencydepartment assessed family members of the 96-year-oldman with symptoms suggestive of SARS, and they wereincreasingly anxious about a continuation of theoutbreak. Radiologists also expressed concerns tocolleagues about sets of suspicious x-rays. Taking theircue from public health officials and citing theepidemiologic uncertainty about how all these cases

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Infection control programs in hospitals function as aparallel system to public health efforts in the community.Infection control practitioners are responsible for trackingand managing hospital-acquired infections, educatingother health care workers, and reinforcing properprecautions. The Canadian Hospital EpidemiologyCommittee advises that systemic problems in ourcurrent health care system include “insufficient timedevoted to learning infection control practices for allhealth care providers” and “little, if any, monitoring ofinfection control practices and few consequences fornon-compliance.” The high rates of transmission tohealth care workers during SARS indicated that manyhad “limited awareness of the correct precautions and/orhow to apply them.” A recent survey found that nearly80% of Canadian hospitals do not meet the standardrecommended by the Canadian Infection Control Allianceof one infection control practitioner per 175 beds. Morethan 60% of hospitals do not have an infection controldirector with advanced qualifications (an MD or PhD) ininfectious diseases, medical microbiology, or infectioncontrol. Should Canada establish higher nationalstandards for infection control within hospital? Shouldprovinces be initiating and funding a major overhaul ofhospital infection control capacity? How should we as acountry confront the shortage in infection controlpractitioners and experts?

could be linked to each other, the hospital’s infectioncontrol director and vice president of medical affairs triedto reassure emergency physicians and nurses at a tensemeeting on May 20.

Meanwhile, St. John’s Rehabilitation Hospital had asteady flow of patients from other institutions, includinga transfer from 4 West at North York General Hospital.During the third week of May, staff at St. John’s informedsenior management that three patients were exhibitingSARS-like symptoms, and a call went out to TorontoPublic Health. The hospital immediately instituted allthe appropriate precautions. Still chasing down 30 to 40possible cases of SARS per day, personnel at Toronto PublicHealth agreed by telephone that there was a respiratoryoutbreak, but suggested that SARS was not the likelyculprit—as at North York General Hospital, no epidemiologiclink could be established. Toronto Public Health staffvisited the hospital on May 22. Discussion again focusedprimarily on establishing an epidemiologic link to thepatients. None was found.

2G. SARS II (May 23, 2003 - June 30, 2003)

“SARS I was not avoidable. We were struck bylightning. Everything after that was.”

—Dr. Richard Schabas, Chief of Staff, York Central Hospital

On May 23, barely one week after WHO had declaredToronto free of local transmission, health officialsacknowledged that SARS had not been defeated. Theprovince issued a press release announcing that fivepeople were under investigation for SARS. Anyone whohad visited St. John’s between May 9 and 20 or NorthYork General Hospital between May 13 and 23 wasordered into quarantine. North York General Hospitalimmediately closed its doors to all new admissions,except for SARS patients. By this time, SARS had alreadyspread not only within North York General Hospital butalso to patients who had been transferred from St. John’sto the Toronto General site of the University HealthNetwork, The Scarborough Hospital, General Division,and Baycrest Centre for Geriatric Care.

Despite extensive investigations by Toronto PublicHealth, Health Canada and the CDC, the exact chain ofevents leading to the second wave of the SARS outbreakremains a mystery. In fact, a definitive link between thefirst outbreak and the cases on the orthopaedic unit (4 West) has yet to be established, although officials havesuggested different possibilities. How the psychiatricpatients fit into the overall picture is also unknown, andmay never be definitively solved.

With SARS II underway, all hospitals in the GTA wereasked to resume previously abandoned infection-controlprocedures. Only four hospitals were designated as SARSfacilities. (The comparative impact of this alternativeapproach to handling the SARS caseload is analyzed inChapter 8.) These four hospitals were termed the SARSAlliance. North York General’s medical staff andadministration staff rallied and rapidly converted theirinstitution into a major SARS centre. The General site ofThe Scarborough Hospital also geared up rapidly to takeon a large caseload. St. Michael’s Hospital gradually tookon the mandate of managing complex SARS patients,consistent with its tertiary provider role. Sir William OslerHealth Centre in Etobicoke faced the greatest challengein organizing a SARS service, but ultimately providedwest-end coverage for the Alliance.

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During the SARS outbreak, Health Canada and Ontarioposted divergent definitions for probable and suspectSARS cases. Both jurisdictions revised the definitionsintermittently. Some critics argued that the Ontariodefinition put undue emphasis on close contact with aprobable or suspect SARS case, leading to a focus onspecific epidemiologic links and missed clusters ofSARS. The definition was revised on May 26 after thesecond wave of SARS had begun. The new definitionallowed for exposure to a health care setting with SARSpatients, and no longer required evidence for closepersonal contact to label a suspect case. Critics of theHealth Canada definition felt that it led to under-diagnosisof SARS by excluding cases if there was an alternativediagnosis for the relevant symptoms. On May 29, HealthCanada’s definition was revised to emphasize that thealternative diagnosis must “fully explain” the clinicalpicture. How should case definitions be constructedduring infectious disease outbreaks? Did Canada havetwo definitions of SARS—one set by the federal govern-ment apparently based on F/P/T consensus, and anotherin Ontario where the outbreak was being fought?

The SAC reconvened. In the absence of the declarationof a general provincial emergency, the OMHLTC now tooka lead role with local public health officials in coordinatingthe outbreak response. A SARS Operations Centre was setup in Ministry offices at 80 Grosvenor Street. Two assistantdeputy ministers jointly oversaw the institutional andclinical liaison functions. Dr. Jim Young brought hisconsiderable experience back to the table, and chairedmany of the meetings of the new SARS executive group.A number of physicians and administrators, mindful ofthe experience with SARS I, urged that one person begiven clear authority to be in charge of the outbreak, butthe problem of multiple leaders recurred.

Meanwhile, public health officials began, once again, themeticulous work of interviewing patients and trackingdown contacts. There was considerable fatigue and frus-tration on the front lines, but also some mitigating features.The outbreak was smaller, the virus was better understood,and the necessary precautions and routines were established.By the end of May, 48 probable and 25 suspect cases hadbeen identified in the second outbreak. Again, transmissionhad been limited primarily to hospital patients, healthcare workers, and their families. Toronto was added backto the WHO list of areas with local transmission, butWHO did not issue a travel advisory against the city.

A Clinical Advisory Team working with the Ministry putout a call for volunteers in May, and a number of Americaninfectious disease physicians and hospital epidemiologistsoffered to come to Toronto. Meanwhile, as noted above,the province retained a private health care personnelagency as sole-source provider of additional physiciansand nurses for the involved institutions. Organizedmedicine was later critical of the contract, noting thatCanadian physicians who had volunteered to help werechannelled through the agency. Other informants shruggedoff the criticism, pointing out that the agency was able todeliver qualified personnel in the face of a planning andprocess void.

As May turned into June, a few setbacks occurred. A medical student had been placed in quarantine afterpotential SARS exposure during an obstetrics rotation atNorth York General Hospital. Two days after his quarantinehad expired, he developed symptoms while working inobstetrics at Mount Sinai Hospital. Five women and theirnewborns, as well as a number of staff, were quarantined.Another incident involved 1,700 students at a highschool in Markham who were quarantined after a studentat their school fell ill.

On June 10, largely because of the tangled chain ofevents at North York General Hospital, but also becauseof mounting pressure from nursing associations andunions, opposition politicians, and the media, theProvince of Ontario announced a formal arm’s-lengthinvestigation into the SARS crisis, headed by OntarioSuperior Court Justice Archie Campbell.

2H. SARS and the Health Care Worker

On June 30, Nelia Laroza, a 51-year-old nurse at NorthYork General Hospital became the first Canadian healthcare worker to die from SARS. Hundreds of friends andcolleagues, along with the Premier of Ontario and theMinister of Health and Long-Term Care, gathered at St. Michael’s Cathedral to pay tribute. A second nurse,Tecla Lin, died on July 19, and a family physician, Nestor Santiaga Yanga, died on August 13.

Perhaps no segment of society was hit harder during theoutbreak than health care workers, a group that accountedfor over 40% of SARS infections in the Toronto outbreak.For many, the knowledge that SARS patients includedcolleagues and friends was a source of considerable stressand anxiety. And for those who were afflicted, thememories are intense. In the words of one health careprofessional hospitalized for three weeks with SARS, “I was forced at once to confront the fact that I mightnot survive the infection...I was stepping into unchartedwaters, a most unnerving adventure.”

At focus groups convened for the Committee, nurses andsupport staff expressed frustration with communicationdelays, impractical or unrealistic directives, and theinconsistent application of rewards and incentives forthose working in high-risk situations. Hospital employeesdescribed a wide range of feelings—including fear, anger,guilt, and confusion—as they struggled with personal risks,social isolation, and stigmatization of their families. Whilemost also noted a heightened sense of pride, teamwork,and solidarity, others experienced post-traumatic stressdisorder, and a minority felt they needed to change careers.

Nurses have long voiced concerns that their knowledgeand experience is not taken seriously by senior decisionmakers. At North York General Hospital, nurses allegedthat administrators ignored their warnings of an impendingsecond SARS outbreak. Nurses also expressed concernsthat the SARS unit at North York General Hospital wasoverloaded, and that suspect cases were being treated inthe emergency department with only curtains forisolation. It may not be a coincidence that North York

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nurses lacked a key advocate—the position of Chief NursingOfficer lay vacant throughout most of the SARS outbreak.At the same time, the political polarization around SARShas left lasting scars in other ways. A hospital adminis-trator who led a successful SARS team later lamented themass grievance campaigns launched by organizednursing in Ontario to protest special rewards for nursesworking in SARS units: “It was like being in a war andhaving your own soldiers shooting at you.”

Countless health care workers faced a fundamentalconflict between self-preservation, and a professionalobligation to serve the greater good. Only a smallnumber refused to treat SARS patients or work on SARSwards. Most willingly volunteered, putting theirhealth—and potentially the health of their families—injeopardy. Unlike other risks in the clinical setting, suchas transmission of HIV or hepatitis from accidental skinpunctures, SARS was acute in onset, carried an immediatemortality risk, and had no specific treatment. Perhapsmore importantly, it could be transmitted to a healthcare worker’s children by a goodnight kiss. Hundreds ofhealth care workers isolated themselves from theirfamilies during the outbreak, wearing masks at home,sleeping in the basement, taking meals alone, andwaiting to see if they would develop tell-tale symptoms.The Committee would like to salute each and every oneof them for their courage and commitment.

2I. Epilogue“In our drive to technology in the 1980s and1990s, we forgot the basics.”

—Dr. Bill Sibbald, Physician in Chief, Sunnybrookand Women’s.

We were fortunate that the SARS virus is biologicallyhandicapped. At least in the vast majority of cases, itrequires prolonged, close contact to make the short jumpfrom one human being to another. SARS has beencontained, at least temporarily—not by the genomicrevolution, not by advanced pharmaceuticals, but by old-fashioned public health measures like hand washing,infection control procedures, isolation of cases, andtracing and quarantine of contacts.

What the SARS outbreak showed, perhaps more thananything else, is the power of public health. The bestcurrent evidence is that without effective public healthmeasures, SARS would have eventually sickened millionsof people on this shrinking planet, causing not hundredsof deaths, but countless thousands. The next outbreak,however, may be even more insidious than SARS.Canada may have to deal with a deadly airborne virus, or a virus transmitted via droplets but with such a longincubation period that quarantine would be worthless.Will we be ready?

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SARS has provoked welcome discussion of the occupa-tional culture in health care. Notwithstanding popularperceptions, it appears there was only one case of inter-institutional transmission of SARS by a part-time workermoving between facilities. But casualization has otherdownsides, including attenuation of a sense of workplacecommunity and a reduced awareness of infection controlprotocols, both essential for front-line workers facedwith an outbreak such as SARS. The Canadian HospitalEpidemiology Committee also notes that hourly pay forcasual staff offers them an incentive to work while ill—a practice that, post-SARS, health care facilities haveactively discouraged.

THE ROLE AND ORGANIZATION OF PUBLIC HEALTH

Chapter 3

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The preceding chapter set out a brief chronology of theSARS outbreak as it affected Canada. The SARS experienceillustrated a variety of issues, some to do with the healthservices system, but many others to do with public healthand the interface between public health and clinical care.Except in cases of sudden threats to the health of commu-nities such as Walkerton, North Battleford, or SARS,public health operates in the background and is oftentaken for granted. Many Canadians—including healthcare professionals and administrators—accordingly haveonly a limited understanding of what public health is andhow it is organized in Canada. This chapter provides anoverview of the evolution of public health, its organizationand funding in Canada, selected comparisons with otherindustrialized nations, and some preliminary thoughtson domestic directions for change.

3A. What is Public Health?3A.1 The Origins of Public HealthMore than two thousand years ago, the authors of Greekmythology had already drawn a distinction betweencurative medicine and prevention or health promotion.Asklepios, the Greek god of medicine, was reputed tohave had two daughters, Hygiea—the goddess of preventionand wellness, and Panacea, the goddess of treatment.Other distant origins of public health surface in Greco-Roman writings associating different diseases with possiblecauses, together with prescriptions for their avoidance.

Canadians today sometimes confuse public health withpublicly-funded health care. However, until the latenineteenth and twentieth centuries, personal health carewas left for individuals to arrange. Threats to collectivehealth, in contrast, have been taken up as a matter forcommunity control or regulation wherever mechanismsof governance emerged. In Biblical times, for example,communities isolated those with leprosy as potential

sources of contagion. Urbanization in medieval Europelent momentum to concerns about sanitation and disease.The first English Sanitary Act was passed in 1388, dealingwith offal, slaughterhouses, and “corrupting of the air”.Around 1348, the Republic of Venice appointed threeguardians of public health to detect and exclude shipswith passengers affected by pneumonic plague (BlackDeath). In Marseilles (1377) and Venice (1403), travellersfrom plague-infected areas were detained for 40 days toprotect against transmission of infection; this is theorigin of the modern term Quarantine.

From the outset, public health practice has depended onhealth information, and information in turn presupposesthe existence of surveillance systems and organized data.One such source of data was the "bills of mortality"established in London, England in 1532. More than acentury after this system of death records was initiated,John Graunt published his Natural and Political Observationsmade upon the Bills of Mortality (1662), examining deathsin London by age, sex, district and social class. By 1766,the Austrian physician Johan Peter Frank had advocateda comprehensive system of health surveillance as part ofhis proposed “medical police”. In 1790, Dr. Frank arguedthat curative and preventive measures had little impacton populations where people lived in abject poverty andsqualor. This heralded a tradition of concern for livingconditions and social justice that continues today in thepublic health ethos.

In 1842, England’s Edwin Chadwick similarly describedurban squalor, lack of sanitation, and over-crowding; andhe related these to the incidence of disease and death, aswell as contrasting life expectancy in different socialclasses. His work heralded the beginning of the sanitarymovement in Britain. The motives behind the sanitarymovement were mixed as were the arguments for it bypublic health proponents. Some claimed that a moreegalitarian society would be healthier and fairer. Others

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pointed out the need for healthy labouring classes andsoldiers, and the threat of both social instability andcontagion spreading from the teeming industrial slums ofEurope. By 1850, Lemuel Shattuck’s “Report of theMassachusetts Sanitary Commission” also related livingconditions to infant and maternal mortality and morbidityrates. As the sanitary movement spread, communitiesimplemented proper disposal of waste, urban sewagesystems, and supplies of pure water for all, with a dramaticimprovement in population health.

The tool-kit of public health practice still had fewindividual-level interventions apart from measures suchas vaccination against smallpox. Nonetheless, the scienceand information supporting public health was improvingsteadily. In England William Farr started to develop theGeneral Registry Office in 1836, building on the introduc-tion of a national census in 1801 by classifying causes ofdeath. Formal medical certification of death and universaldeath registration commenced in England and Wales ayear later. John Snow—the “father of epidemiology”—published his On the Mode of Communication of Cholera in1849, famously removing the handle of the contaminatedBroad Street pump from whence cholera was spreading.Snow’s action was a landmark in public health interven-tion to contain a disease outbreak. A critical step forwardoccurred in 1856 when Louis Pasteur published hisobservations on the germ theory, allowing microbiologyto advance rapidly. In 1867, Koch published his famouspostulates for establishing a causal connection between aspecific microbe and a disease. Such connecting threadsin public health thinking have proven durable: onlyweeks before release of the present report, The Lancetpublished an article by Kuiken et al arguing that thenovel SARS-associated coronavirus satisfies a modernizedversion of Koch's postulates.1

In this country, Lower Canada established a Board ofHealth in 1832; Upper Canada followed suit a year later.Ontario passed the first provincial public health act inCanada in 1884, and other provinces soon passed similarlegislation. These acts provided for the establishment oflocal boards of health with the authority to remedyhazards to health and to appoint medical officers ofhealth. In these early years, boards often hired medicalofficers of health only when a disease outbreak struck,and dismissed them once the danger was over. Localboards of health were heavily involved in the mid-nineteenth century with quarantine and immunizationas well as combating a series of epidemics of smallpoxand cholera.

As medical science evolved, and local boards of healthprovided infrastructure for implementing inspection andregulation, local public health units in Canada took onother activities. These included pasteurization of milk,tuberculin testing of cows, oversight of isolation tocontain spread of tuberculosis [TB], management of TBsanatoria, quarantine for diverse conditions, and thecontrol of sexually transmitted diseases. The earlytwentieth century brought an increasing emphasis onmaternal and child health. Public health physicians andnurses took a leading role in developing immunizationclinics, well baby clinics, prenatal classes, postnatal visits,and education on parenting and childhood nutrition.

The activism of public health in individual- and family-level interventions was not without occasional territorialtensions. Some general practitioners voiced complaintsthat these salaried and subsidized personnel were takingaway their livelihoods and interfering with the developmentof family-based practices. The First World War none-theless saw a blush of enthusiasm for public health andthe integration of preventive medicine into clinical practice.In 1919, the Government of Canada brought togetherseveral pieces of legislation pertaining to food, drugs andcontrol of infectious diseases, and established a nationalDepartment of Health. This was the same year that theLiberal Party cautiously adopted national health insuranceas a plank in its platform, and the British ColumbiaSocial Welfare Commission began exploring the feasibilityof a state-sponsored health insurance scheme.2 But whileMedicare was several decades away, public healthmeasures were already well-established across Canada.

Following the Great War, mainstream medicine still hadfew specific remedies to palliate or cure disease. Surgicaltechniques were crude, and drugs limited to a handful ofcompounds such as digitalis for congestive heart failure,quinine for malaria, and arsenicals for syphilis. Insulinwould not appear on the clinical scene until 1923. Publichealth, meanwhile, was progressing steadily. Toxoidswere a key breakthrough in immunization strategies; atoxoid is a bacterial toxin treated to render it harmlessbut still capable of inducing immunity to the disease.On into the mid-1920s, diphtheria was the leading causeof death among children. The widespread use ofantitoxin had only a minor impact on the incidence ofthe disease. After the discovery of diphtheria toxoid, theConnaught Laboratories in Toronto produced toxoid on amassive scale and proved its effectiveness with massivefield trials of childhood immunization in Ontariostarting in 1926. The same period saw pertussis toxoidintroduced for case contacts and epidemics. Tetanustoxoid and a string of other triumphs for immunization

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and vaccination—most notably the introduction of aneffective vaccine for polio by Jonas Salk in 1956 and theeradication of smallpox—followed later.

Notwithstanding these triumphs, indeed perhaps in partbecause of them, public health was moving into a back-ground role. The growing effectiveness and technologicalsophistication of clinical medicine captured the publicimagination. After insulin came sulpha drugs andpenicillin, and then a massive armamentarium of anti-biotics, including treatments for tuberculosis. Surgicaland related techniques blossomed. Open heart surgery,dialysis, joint replacement, pacemakers, kidney trans-plantation—these and other innovations featured promi-nently in the mass media of the 1950s and 1960s. Theirmarginal yields at a population level were meaningfulbut relatively small. Increasing societal prosperity andenlightened social policy accompanying economicgrowth were great catalysts for overall improvements inlife expectancy. Across all industrialized nations, publichealth interventions also helped drive communicablediseases down the mortality lists through the middle andlatter parts of the twentieth century.

Public health, as we have already seen, was not solelyabout control of infectious diseases. Pioneers of publichealth in the eighteenth and nineteenth centuriesinvestigated the causes of, and advocated action against,nutritional (scurvy), occupational (cancer of the scrotum),and environmental (lead poisoning) diseases, and urgedmeasures to limit inequalities in health across educationand income levels. Public health practitioners remainedat the forefront throughout the twentieth century inchampioning legislative and regulatory initiatives toreduce the burden of premature and avoidable deathsand injuries along with preventable diseases.

Nonetheless, the shift in mortality and morbidity profilesaway from communicable diseases to chronic non-communicable diseases created challenges for publichealth practice. Coronary heart disease [CHD] is a usefulexample. The decline in incidence of CHD in Canada isunequivocal. The decline antedates introduction andwidespread adoption of effective agents for treatment ofdyslipidemias (e.g., high cholesterol), and the impact ofimprovements in physical activity profiles is uncertain.Some of the decline appears to be attributable to smokingcessation and adoption of healthier diets. To what canwe attribute changes in those risk factors? Familyphysicians and other clinicians are actively engaged incounselling against smoking, and provide pharmaceuticalsupports to facilitate smoking cessation, but public healthpolicy and education have also played a role throughtobacco taxes, anti-smoking advertising campaigns,

production of education materials, and product labelling.Various stakeholders from different levels of governmentsto the Heart and Stroke Foundation are active in encouragingsmoking cessation and promoting the adoption ofhealthier diets. Public health researchers unquestionablyhelped generate the epidemiologic evidence that linkedCHD to these risk factors. But even for a clear-cut casesuch as prevention of heart disease, the positive influenceof public health has been as much indirect as direct.Similar challenges arise in delineating the role of publichealth in areas such as injury prevention or, a fortiori,interventions to redress the profound and persistingvariations in health status across socioeconomic strata in Canadian society.

Not surprisingly, even within the public health community,debates occur between those with more or less expansiveviews of the mandate of public health. But there is littledisagreement on two points. First, existing levels—andallocations—of resources are suboptimal to permit thedeployment of many interventions that have the potentialto avoid premature death or disability. Second, publichealth has essential roles in areas such as health protection(food and water safety), disease surveillance, and outbreakmanagement, and these functions must be given priority.As we have seen with SARS, questions now exist as towhether the Canadian public health system is minimallyequipped and organized to deal with even a modest-sizedoutbreak of a new communicable disease.

In sum, for about a century and a half in Canada, therehas been an organized public health presence, often littlenoticed, but nevertheless contributing to a steadilyincreasing life expectancy and quality of life for Canadians.Various analyses of the improvements in health duringthe twentieth century have highlighted that modernclinical medicine is important, but broad social changesand public health measures deserve the lion’s share ofthe credit for the 25-year increase in life expectancyacross industrialized nations, including the dramaticreduction of infant mortality from 20% to less than 1%in most developed countries.3 Influential social andeconomic changes have included smaller families, higherstandards of living with better nutrition, and adequatehousing. However, public health has played a huge rolein securing safe food and water supplies, implementingpasteurization, and developing and delivering programsof vaccination and immunization. The re-emergence ofinfectious diseases, and the continued scope forprevention of the now dominant non-communicablediseases, both suggest that the yields of prudent newinvestments in public health may be substantial.

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3A.2 Defining Modern Public HealthPractice

Public health developed over the centuries as society’sresponse to threats to the collective health of its citizens,and has an enviable record of contributions topopulation health status. How do we define publichealth practice today?

Public health can be described as the science and art ofpromoting health, preventing disease, prolonging life andimproving quality of life through the organized efforts ofsociety.4 As such, public health combines sciences, skills,and beliefs directed to the maintenance and improvementof the health of all people through collective action. The programs, services, and institutions involved tend toemphasize two things: the prevention of disease, and thehealth needs of the population as a whole.5 This popu-lation focus distinguishes public health from the clinicalenterprise that is governed by the Hippocratic imperativewith its focus on the individual patient. Indeed, delineationof the boundaries of public health in this regard has beenmade explicit in Quebec’s 2001 Public Health Act, viz:“Public health actions must be directed at protecting,maintaining or enhancing the health status and well-being of the general population and shall not focus onindividuals except insofar as such actions are taken forthe benefit of the community as a whole or a group of individuals.”6

This collective approach means that, as even the briefhistory above has illustrated, public health has longincluded a regulatory function. Regulation is an effectivemeans of protecting the public from a variety of hazards,including carriers of infectious diseases, food, drugs,consumer products, pesticides, improper waste disposal,impure drinking water, recreational water, dangerousmotor vehicles, unsafe workplaces, second-hand smoke,and many others. In Canada, all levels of government—federal, provincial/territorial, and municipal—are involvedin the regulatory functions of public health.

The logic of a collective or population-based approach totraditional public health measures, such as communicabledisease control, is self-evident. But a population approachcan also be efficient in dealing with non-communicabledisease prevention. As Geoffrey Rose7 has argued, riskfactors for most diseases are typically distributed across acontinuum. A preventive strategy focusing on high-riskindividuals will deal with the margin of the problem, and has only a trivial impact on the large proportion ofdisease occurring in the majority of people who are atmoderate risk. For example, the number of cardiovascularevents arising in people with slightly raised blood pressure

or moderately abnormal blood lipids greatly exceeds thosearising in the clinically hypertensive or dyslipidemicminority. Population-based strategies that seek to shiftthe whole distribution of risk factors have the potentialto exert a much larger impact at a population level.

However, a preventive measure that brings large benefitsto the community may offer little to each participatingindividual—this is Rose’s ‘prevention paradox’.Changing health habits through individual interventioncan be difficult and inefficient; and the gradual adoptionof new norms (e.g., in diet and exercise) becomes thelogical way forward. At the same time, ethical concernsdictate that clinicians seek out and offer individualizedtreatment to the small minority of persons at greatlyelevated risk. The population approach of public healthand the individualized approach of clinical medicine arethus complementary: the opportunities for each willvary according to the disease and risk factor, and whatinterventions are available. Finding the right balance is important.

When the task of disease prevention and health promo-tion moves away from precisely identifiable risk factors,matters become even more complex. The health ofpopulations and individuals is obviously shaped by awide range of factors in the social, economic, natural,built, and political environments. These factors interactwith each other and with innate individual traits such asgenetics, sex, and age. As researchers have delineated thecomplex webs of causation that influence health-relatedbehaviours and health status, they have articulated apopulation health approach that highlights the need forinterventions such as regulation, education, communitydevelopment and social policy. The extent to whichparticular public health units or professionals embracethese tools varies, but the population health frameworkhas usefully integrated analytical perspectives in thepublic health field.

Public health practice relies heavily on intersectoralpartnerships. Public health professionals must be able towork with a range of disciplines, and form coalitions toadvocate for mitigation of health risks or implementhealth-enhancing changes in various environments. The voluntary sector is a key partner in public healthtoday. This includes non-governmental agencies (such ashealth charities and professional associations), localassociations of all kinds, community development groups,recreational associations, business groups, organizedlabour and other workplace collectivities, together withthe governmental structures which partly support andfund them. These groups may be overtly health-oriented, or may have primary interests in related areas

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such as child development and social welfare. In Canada,the voluntary sector partners with local health agencies,as well as federal and provincial/territorial [P/T] govern-ments in various programs. Joint activities include healthpromotion initiatives, and the provision of services,advocacy and community development. These partici-patory approaches are particularly important forAboriginal populations and other marginalized or hard-to-reach groups.

Over the past decade, many countries have tried todefine the essential functions of their public healthsystems. In Canada, no single accepted list exists,although a report of the national Advisory Committee onPopulation Health (ACPH) recently recommended thefollowing list of essential functions:

• Health Protection. This is a long-standing corefunction for all public health systems. The assuranceof safe food and water, the regulatory framework forcontrol of infectious diseases, and protection fromenvironmental threats are essential to the Public Healthmandate and form much of the body of current publichealth legislation worldwide. Included in this functionis the provision of expert advice to national regulatorsof food and drug safety.

• Health Surveillance allows for early recognition ofoutbreaks, disease trends, health factors, and cases ofillness which in turn allows for earlier interventionand lessened impact. Surveillance also assists in ourunderstanding of the impacts of efforts to improvehealth and reduce the impact of disease. For example,a new strain of Salmonella occurring in many parts ofthe country over a short period of time may indicatecontamination of a widely-distributed food product.

• Disease and Injury Prevention. More than a decadeago, the Centers for Disease Control and Preventionin the USA identified that as much as two-thirds ofpremature mortality was preventable through theapplication of available knowledge. Many illnessescan either be prevented or delayed and injuries can beavoided (e.g., bicycle helmet use). This category ofactivity also includes investigation, contact tracingand preventive measures targeted at reducing risks ofoutbreaks of infectious disease. It overlaps withhealth promotion, especially as regards educationalprograms targeting safer and healthier lifestyles.

• Population Health Assessment entails the ability tounderstand the health of populations, the factorswhich underlie good health and those which createhealth risks. These assessments lead to better servicesand policies.

• Health Promotion. Public health practitioners workwith individuals, agencies, and communities to under-stand and improve health through healthy publicpolicy, community-based interventions, and publicparticipation. Health promotion contributes to andshades into disease prevention (see below) by catalyzinghealthier and safer behaviours. Comprehensiveapproaches to health promotion may involve communitydevelopment or policy advocacy and action regardingthe environmental and socioeconomic determinantsof health and illness.*

The Canadian Institutes of Health Research’s [CIHR]Institute of Population and Public Health recently led agroup of opinion leaders through a process to considerthe future of Public Health, and identified some examplesfor each of these functions delineated in Table 1.

Last, public health also plays a key role in DisasterResponse. Many natural disasters not only place imme-diate demands on the health care system, but mayinvolve secondary threats to population health throughcontamination of food or water supplies or communicabledisease outbreaks.

3B. Governance and Organizationof Public Health in Canada

3B.1 Some Constitutional and Legislative Issues

Chapter 9 provides a more detailed treatment ofconstitutional and legislative issues. This introductoryoverview offers some general context.

Canada’s Constitution Act (formerly the British NorthAmerica Act of 1867) outlines the division of responsi-bilities between provinces and the federal government,and was created at a time when infectious disease andother public health concerns were everyday realities. The Act assigned responsibility for “quarantine and theestablishment of marine hospitals” to the federal govern-ment, and (s. 92) the “establishment, maintenance andmanagement of hospitals, asylums, and eleemosynaryinstitutions in and for the province, other than marinehospitals” to the provinces.

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* The more expansive aspects of health promotion occasionally draw criticism as forms of ‘health imperialism’ or ‘social engineering’.

Sections 92(13) and 92(16) of the Constitution giveprovinces responsibility, respectively, for property andcivil rights and for matters of a local or private nature.Both are relevant to the primary authority that provincialgovernments claim in Canada to pass legislationconcerning public health. Federal authority in publichealth derives from federal powers in diverse areas, suchas the criminal law, matters of national concern as regards“peace, order, and good government”, quarantine andnational borders, regulation of interprovincial trade andcommerce, and international treaty-making. Jurisdiction,in short, is mixed.

In Canada, there are federal legislative provisions for theregulation of food, drugs, and pesticides. The titles of theQuarantine Act and the Importation of Human PathogensRegulations of the Department of Health Act are self-explanatory, and these laws flow logically from theconstitutional division of powers. The Canada Health Actsets out the conditions for receipt of funding for physi-cian and hospital services, but does not cover publichealth. Indeed, only the Department of Health Act offers a

broader public health mandate, and, apart from theabove-noted regulations, its wording is more permissivethan prescriptive. It states that the Minister of Health isresponsible for “the promotion of the physical, mentaland social well-being of the people of Canada, theprotection of the people of Canada against risks to healthand the spreading of diseases, and the investigation andresearch into public health, including the monitoring of diseases.”

The uncertainty about federal powers in public health isunderscored by the state of disease surveillance. Whilethe Statistics Act and the Department of Health Act providethe Government of Canada with a mandate to collectinformation on public health risks of a pan-Canadiannature, Health Canada does not currently have a clearlegal mandate to require provinces/territories to sharehealth surveillance data with each other and the federalgovernment. As was evident in the SARS outbreak, thesetransfers occur voluntarily.8

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Essential Function Programming Examples

Population health • Population/community health needs assessment;Assessment • Health status report, system report card.

Health surveillance • Periodic health surveys;• Cancer and other disease registries;• Communicable disease reporting;• Ongoing analysis of data to identify trends or emerging problems,

(e.g., recognition of increasing syphilis cases);• Report to practitioners of increasing threat, what they need to look for, and intervention

required.

Health promotion • Intersectoral community partnerships to solve health problems;• Advocacy for healthy public policies;• Catalyzing the creation of physical and social environments to support health

(e.g., bike paths, promoting access to social networks for institutionalized seniors).

Disease and injury prevention • Immunizations;• Investigation and outbreak control;• Encouraging healthy behaviours (e.g., not smoking, healthy eating, physical activity,

bicycle helmet use);• Early detection of cancers (e.g., organized programs for breast cancer screening).

Health protection • Restaurant inspections;• Child care facility inspections;• Water treatment monitoring;• Air quality monitoring/enforcement.

T A B L E 1Examples of Programming for Essential Public Health Functions.

For the federal government to exert a stronger coordinatingand supporting role, one logical avenue is through the useof federal spending power. That is, the federal governmentcan involve itself in public health by providing condi-tional funding for public health programs or by enteringinto legal contracts to develop public health initiatives.The Population and Public Health Branch of HealthCanada currently exerts only a limited steering effectthrough its program of grants and contributions. Thesegrants and contributions are not directed to other levelsof government, but to non-profit and non-governmentalorganizations. They target areas such as children’shealth, Aboriginal peoples’ health, diabetes, HIV/AIDS,Hepatitis C, and tobacco control, among others. There isno legislative provision per se for Health Canada’s role inthese programs. Rather, they are established under thebroad rubric of the Minister of Health’s authorities in theDepartment of Health Act, and funded following Cabinetand Treasury Board decisions on policy and fundingrespectively.

Public health activities in each province and territory aregoverned by a public health act (or equivalent) and itsregulations, as well as by other specific legislation (e.g., Ontario’s Immunization of School Pupils Act). Somepublic health acts are decades old. Ontario (1983),Saskatchewan (1994), and Quebec (2002) all have modern-ized legislation, and British Columbia proposes tointroduce a new act soon. The older acts tend to bemainly concerned with infectious diseases and specific inthe powers given to public health officials, while thenewer acts are more flexible. All public health acts haveregulations; these vary from province to province. Theplanning and delivery of services is mostly devolved toregional/local structures, with responsibility usuallyassumed by elected and/or appointed boards.

Environmental health illustrates the potential jurisdictionalambiguities. The federal and P/T governments all havelegislation bearing on environmental health issues. P/Tenvironment ministries may operate water purificationfacilities and test water. Municipal governments maypass by-laws, provide many environmental services, andbe involved in enforcement. Local public health agenciesand/or P/T health ministries are responsible for advisingon human health impacts of environmental problems,for undertaking inspections and enforcement, and forinvestigations of environmental health hazards and healthevents thought to be environmentally caused. Publichealth laboratories undertake some testing, as also dovarious federal, provincial, university or contract labora-tories. Other departments of governments such as natural

resources, transportation and recreation are inevitablyinvolved. Lastly, emergency preparedness and responseauthorities, including P/T ministries of public security, willbe involved in responding to environmental disasters.

3B.2 Organization of Public HealthServices

The situation of primary responsibility for public healthservices at the municipal or local level is rooted in atradition that dates back to the time of Elizabeth I. InCanada, primary legislative authority seems to rest withthe provinces and territories, but local public healthremains the front line for battling outbreaks such asSARS. The following overview accordingly moves fromthe local to P/T to federal levels.

There are four patterns of governance of local publichealth services in Canada.

• Regional Health Authorities/Districts

This is the most common pattern, especially in theWest and increasingly in the Maritimes. Elected and/orappointed boards are responsible for the provision ofhealth services within a defined geographical area.The governance for public health is thus combinedwith that for other health services. The boards areeither elected by local residents, or appointed by theprovincial government, or a mixture of both. Thesystem is a product of the 1990s and still evolving: forexample, the number of regions and their boundarieschange frequently, there is sometimes tension betweenboards and provinces concerning powers, and therehas been a swing away from elected to appointedmembers. Despite the instability of these arrangements,they have the major advantage of promoting theintegration of clinical and public health services underunified governance that is locally responsive to somedegree. Regional structures, however, have not solvedthe problem of under-investment in public health.

• Regional/District Boards

In this case, the boards are responsible for publichealth and/or other community-based services withinan area, but do not have oversight of publicly-fundedpersonal health services. This is the pattern in parts ofNewfoundland, and until recently, in New Brunswick.

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• Quasi-municipal/County

This is the earliest pattern, and continues in Ontario.Local boards are responsible for public health andsome other community services. Boards serve eithersingle or multiple municipalities and counties, and areappointed by the involved municipalities and theprovince. In large cities, the public health board isusually a committee of city council.

• Provincial

In Prince Edward Island, services are delivered at theprovincial level.

Health Canada, through the First Nations and InuitHealth Branch [FNIHB], has a mandate from the federalparliament to provide certain public health services toFirst Nations communities on reserve. Communitieswith “transfer arrangements” with FNIHB have taken onresponsibility for some or most health services whichwould otherwise be delivered by the federal government,i.e., public health services may be delivered by thecommunities themselves. These arrangements aresupported through contribution funding provided by thefederal government.

Local service delivery across Canada is through the healthdepartments of regional health authorities or districts, or(in Ontario) through health units and municipal healthdepartments. The populations served by the relevant unitsrange from 600 to 2.4 million people, with catchment areasfrom 4 square kilometres to 800,000 square kilometres.There are approximately 139 such local/regional agenciesserving urban, rural and isolated areas, covering thepopulation of Canada, exclusive of some Aboriginalcommunities.

Each local/regional public health agency has a positionfor a medical officer of health [MOH] - a licensedphysician with post-graduate training in public health.Smaller health units find it difficult to attract medicalofficers of health or provide the full range of services. In Saskatchewan, partly for this reason, adjacent districtshave arranged to share either the medical officer ofhealth or the entire public health agency.

Each province or territory has a chief medical officer ofhealth [CMOH] or equivalent. The CMOH may also bethe director of the public health branch of the P/Tgovernment, or these may be separate positions. Thesenior public health physician sometimes also holds anAssistant Deputy Minister position. In Quebec, theAssistant Deputy Minister for public health by law is aphysician with a specialist qualification in communitymedicine. The reporting relationships of the CMOHwithin the P/T governments vary considerably, as provinceshave balanced a desire to ensure the independence of theCMOH as a health advocate with the need to integratehis or her portfolio into ministries of health.

Each province and territory also has public health staffwithin the provincial government. These staff typicallyengage in planning, administering budgets, advising onprograms, and providing assistance to local staff for seriousincidents. The British Columbia Centre for Disease Control[BC CDC] was established in 1997 to take responsibilityfor provincial-level management of infectious diseaseprevention and control, including laboratories. Divisiondirectors and other key scientific and medical staff in theBC CDC hold appointments at the University of BritishColumbia, and have protected time to enable academicactivities. A specific effort is made to ground practices inresearch evidence. The BC CDC’s budget flows throughthe provincial Health Services Authority.

Quebec established the National Public Health Institutein 1998 by transferring in staff from several regionalpublic health departments and the ministry; it overseesthe main public health laboratories and centres ofexpertise. Unlike the BC CDC, it has a general mandatethat covers prevention, community development andhealth promotion, healthy living, workplace health, andchronic disease as well as infectious diseases. The Instituteincludes the Quebec Toxicology Centre, the ScreeningExpertise Centre, and the Poison Control Centre.

Many provinces have taken steps to ensure that the localadministration of public health is not compromised byspecial interests and that provincial standards are upheld.These can be summarized as follows:

• Delivery of certain programs and services may berequired for the province to flow funds to the localhealth unit. There may be lists of core or mandatoryprograms, together with a monitoring mechanism, withor without accompanying regulations. Nevertheless,the level of service provision varies both between andwithin provinces/territories.

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• The chief medical officer of health may have thepower to intervene anywhere in the province in anemergency.

• Medical officers of health at the local level may beprovincial employees, reporting formally to the chiefmedical officer of health.

• Local boards of health may require the consent of theminister to hire and/or fire medical officers of health.

• The Minister of Health generally has the power todismiss local boards of health.

At the federal level, the most relevant organization vis-à-vis public health is the Population and Public HealthBranch [PPHB] of Health Canada. The Branch is head-quartered in Ottawa, and has regional offices acrossCanada. Its components include Centres for InfectiousDisease Prevention and Control, Chronic DiseasePrevention and Control, Emergency Preparedness andResponse, Surveillance Coordination, and Healthy HumanDevelopment. PPHB has oversight of the NationalMicrobiology Laboratory in Winnipeg and the Laboratoryfor Foodborne Zoonoses in Guelph. Other branches inHealth Canada, particularly the Health Products and FoodBranch and the Healthy Environments and ConsumerSafety Branch interact with local public health to a lesserextent. Federal agencies such as the Canadian FoodInspection Agency [CFIA] also have a role in public health.

In sum, the provincial/territorial presence predominatesin public health, with most of the delivery of servicesoccurring locally or regionally. The local/regional agencieshave their own governance, but their activities areconstrained by P/T law, regulations, policies, directivesand conditions of funding. Various federal/provincial/territorial committees provide some elements of nationalcoordination. These include the Advisory Committee onPopulation Health and Health Security reporting to theConference of Deputy Ministers of Health, the Council ofChief Medical Officers of Health, the Canadian PublicHealth Laboratory Network, and many more technicalgroups. Domestically, the federal role, apart from specificareas of jurisdiction set out above such as quarantine atnational borders or regulation of food and drugs, hasbeen to support P/Ts and non-governmental organiza-tions with technical advice, expert resources, advancedlaboratory technology, and national surveillance andstatistics. The federal government also funds researchrelevant to public health through various channels,including the CIHR and PPHB. Last, the federalgovernment has a lead role in international liaison, aswill be discussed in Chapter 11.

3B.3 The Challenge of Public Health inRural and Remote Areas

As noted earlier, Canada was fortunate that SARS struckprimarily in Toronto with its comparatively well-developedpublic health and health care infrastructure. In manyparts of the country, capacity to battle public healththreats is limited. The risk of communicable diseases, ofcourse, is also contained by the low population densityof these same areas.

Canada’s northern territories, for example, comprise0.3% of Canada’s overall population, but 39% of itsgeographic area. In the far north, average life expectanciesare lower than for the rest of Canada, owing to higherinfant mortality rates in Nunavut and the NorthwestTerritories, higher lung cancer mortality rates in all threeterritories, and substantially higher rates of death fromunintentional injuries and suicide. The territories havehigher rates of infectious diseases such as tuberculosis andChlamydia, higher teen birth rates, and greater incidencesof smoking and other forms of substance abuse.

More generally, populations residing outside of largeurban centres tend to have lower levels of education,employment, and income. Small local hospitals cannotmaintain infection control with highly specialized staffas occurs in many urban hospitals. Rural hospitalsseldom have rooms with respiratory isolation facilities.And in local public health units, staff multi-task as amatter of course. Public health nurses provide well babyand immunization coverage one day, communitydevelopment and school visits the next. Similarly, publichealth inspectors deal with issues ranging across watersafety, restaurant and event inspections for food safety,potential rabies exposures, enteric disease outbreaks, andenvironmental hazards. In these settings, no functioncan be abandoned to combat an outbreak for more thana few days without introducing new hazards. Most ofthese remote areas have a medical officer of health, butsome positions go unfilled and others are managed bypart-time clinical physicians. Public health inspectorpositions remain unfilled for long periods, and fewsmaller health units can afford to hire personnel withgraduate training in areas such as health promotion orepidemiology. In short, Canadian geography posesspecial challenges in the organization and delivery ofpublic health services.

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3C. Public Health in theBackground

We have seen that public health moved to the backgroundas the technological capacity of clinical medicine grewthrough the latter half of the twentieth century. Inparallel, Canada moved to organize universal prepaymentof physicians’ services and hospital care, initiating fourdecades in which funding of personal health services hastaken ever greater priority over public health. Writing inthe Royal Commission report that laid the foundationsfor Canada’s universal medical care insurance system, Mr. Justice Emmett Hall and his fellow commissionersfocused on plans to improve access to physician services,and offered only a passing reference to public health:“The efforts to improve the quality and availability ofhealth services must be supplemented by a wide range ofother measures concerned with such matters as housing,nutrition, cigarette smoking, water and air pollution,motor vehicle and other accidents, alcoholism and drug addiction.”

In 1974, then Health Minister Marc Lalonde publishedan influential volume entitled A New Perspective on theHealth of Canadians.9 Lalonde argued that health statuswas influenced not only by health services and genetics orbiology, but also by environmental and lifestyle factors.While the “New Perspective” drew positive national andinternational responses, its legacy was clouded on twoscores. First, by highlighting the limits to health carebased on broad population health trends and aggregatemortality statistics, the volume understated the value ofclinical services for relevant outcomes such as disease-specific mortality, function, and quality of life. In part, itre-opened the unhelpful divide between advocates ofmore clinical spending and champions of public andpopulation health. Second, the ‘lifestyle’ terminology,with its emphasis on personal choices, was characterizedby some critics as “victim-blaming” because it down-played the social roots of unhealthy behaviours at theindividual level. The ”New Perspective” did lend momen-tum to health promotion efforts, presaged the need forintersectoral collaboration in public health, and fore-shadowed the population health paradigm that nowholds sway. However, it appears to have had little lastingeffect on federal or provincial spending in public health.

Throughout the latter half of the 1980s, when economicrecession was coupled with escalating health care costs,most provinces and territories published reviews ofhealth and health care. Nearly all of these reports sharedtwo recommendations: improved control over resources,through processes such as integration of services,alignment of incentives, regionalization, and utilizationmanagement; and an increased emphasis on preventionand health promotion. In every province, the first set ofrecommendations was operationalized; the latter receivedmuch less attention.

The scope and importance of the HIV pandemic becameincreasingly evident during the 1980s, sparking world-wide concern about infectious diseases. An expert panelof the US Institute of Medicine conducted an 18-monthstudy, culminating in 1992 in a major report—EmergingInfections: Microbial Threats to Health in the United States.10

Health Canada’s Laboratory Centre for Disease Control(later restructured inside the Population and Public HealthBranch of Health Canada) also organized an Expert WorkingGroup on Emerging Infectious Disease Issues. A multi-disciplinary group of 40 researchers and practitioners metat Lac Tremblant from December 7-9, 1993, producing adeclaration whose opening sentences were prophetic:

“The HIV pandemic has demonstrated that theworld is rapidly becoming a global community.Global interdependence, massive internal andexternal population movements, rapid transpor-tation, increasing trade and changing social andcultural patterns expose large populations to newand different pathogens and pose new threats totheir health and well-being. National boundariesno longer offer isolation or protection from infectiousdiseases, toxic chemicals and hazardous products.”

In its long list of recommendations, the group called for“a national strategy for surveillance and control ofemerging and resurgent infections,” support and enhance-ment of “the public health infrastructure necessary forsurveillance, rapid laboratory diagnosis and timelyinterventions for emerging and resurgent infections,”coordination and collaboration in “setting a nationalresearch agenda for emerging and resurgent infections,”“a national vaccine strategy,” “a centralized electroniclaboratory reporting system to monitor human and non-human infections,” and strengthening “the capacity andflexibility to investigate outbreaks of potential emergingand resurgent infections in Canada.”

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Little action was taken apart from some organizationalchanges, and most of the Working Group’s recommen-dations from 1993 remain entirely valid a decade later.Indeed, we essentially recapitulate many of them in this report.

Mr. Justice Horace Krever provided a more general call toaction in his 1998 report of the “Commission of Inquiryon the Blood System in Canada.” Krever wrote: “Publichealth departments in many parts of Canada do not havesufficient resources to carry out their duties…Continuedchronic under-funding of public health departments is adisservice to the Canadian public…It is recommendedthat the provincial and territorial ministers of healthprovide sufficient resources for public health services.”11

Krever made specific reference to the need for bettersurveillance for infectious diseases, not least those thathad contaminated the blood supply.

On September 11, 2000, the provincial premiers andfederal government reached an agreement on new fundingfor health care. This agreement provided $23.4 billion inadditional funds over a six-year period (from 2000-01 to2005-06) as set out in Table 2. There was no earmarkedfunding for public health infrastructure, although fundsfrom the Canada Health and Social Transfer [CHST]could, of course, be directed to public health by theprovinces.

At the provincial level, recent reports have begun tohighlight the need for specific investments in publichealth. For example, in June 2000, the Quebec govern-ment created the Commission d’étude sur les services desanté et les services sociaux. The Quebec report definesthe health system broadly, encompassing services toindividuals, public programs aimed at prevention, andsocial policies aimed at improving health and welfare.12

Of 36 recommendations, the first is “That prevention bethe central element of a Quebec health and welfarepolicy.” The report explicitly integrates recommendationsabout public health and preventive services with thosefocused on personal health and social services. HealthierTogether: A Strategic Health Plan for Newfoundland andLabrador was released in September 2002 and focusesextensively on a population approach to health.13 Thereport outlines only three broad goals. The first is awellness strategy, the second goal a healthy communitiesstrategy, and the third “to improve the quality, accessi-bility, and sustainability of health and community services.”Throughout the report, there are many references tohealth promotion, health protection, illness and injuryprevention, child and youth initiatives, and the non-medical determinants of health. Five-year targets arelisted in an appendix.

From a national perspective, the Commission on the Futureof Health Care in Canada14, under the direction of theHon. Mr. Roy Romanow was asked to “recommend policies”that would strike “an appropriate balance betweeninvestments in prevention and health maintenance andthose directed to care and treatment.” The Romanowreport devotes one chapter to primary care and preven-tion. His definition of primary care (“services … providednot only to individuals but also to communities as awhole, including public health programs that deal withepidemics, improve water or air quality, or healthpromotion programs designed to reduce risks related totobacco, alcohol and substance abuse”) conflates generalpractice with traditional public health activities.

Three of Mr. Romanow’s recommendations dealspecifically with public health issues. He recommends anational immunization strategy, a physical activity strategy,and strengthening health promotion and preventionprograms, focusing initially on obesity and tobacco use.Funding for these initiatives would come from a PrimaryHealth Care Transfer. The proposed Health Council ofCanada is to monitor these activities, establish commonindicators, and set benchmarks. Mr. Romanow alsorecommends that the federal government take a moreactive role in international health, focusing on publichealth initiatives and the training of health careproviders in developing countries.

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Area of funding Amount

Canada Health and Social $18.9 billionTransfer increases

Medical Equipment Fund $1.0 billion

Health information technology $0.5 billion

Health Transition Fund for $0.8 billionPrimary Care

Early childhood development $2.2 billion

Total $23.4 billion

T A B L E 2Health care funding over six years (beginning in 2000-01), as per the 2000 Health Accord.

One senior public health leader later commented:

“Sadly, the long-awaited Romanow Report did notentirely grapple with—or indeed even mention—theserious plight of public health services in Canada.Instead, it offered some suggestions for investmentsin disease prevention and health promotion, suchas the creation of a central fund for harmonizedimmunization programs and a Centre for HealthInnovation focusing on ‘Health Promotion’. Muchof the report did not sufficiently differentiate thecomplementary roles of primary care and publichealth in achieving disease prevention and healthpromotion goals. As a result, it gives the impressionthat all such activities—even health protection fromhazardous exposure, and the sort of community-based cultural change that we need to tackle theobesity epidemic—can be spearheaded from physicians’offices and ambulatory care centres.”15

The Standing Senate Committee on Social Affairs, Scienceand Technology chaired by Senator Michael Kirby releasedThe Health of Canadians –The Federal Role in October 2002after a two-year study of the Canadian health care system.16

A chapter is devoted to the argument that healthy publicpolicy must include health and wellness promotion,illness and injury prevention, public health and healthprotection, and population health strategies, and that thefederal government can and should play a leadership rolein these areas. Kirby et al focus on two areas of publichealth. The first is a National Chronic Disease PreventionStrategy that incorporates public education efforts, massmedia programs, and policy interventions targetinglifestyle behaviours such as a poor diet, lack of exercise,smoking, excessive alcohol intake, and stress. Kirby et alsuggest that the federal government should commit $125 million annually towards chronic disease prevention.The second area of focus is the deficiency in publichealth infrastructure. The Senate Committee specificallycited inconsistent funding, fragmentation and poorcoordination between jurisdictions, and an overall lack ofaccountability and leadership. Regarding health promo-tion efforts, Kirby et al mention poor coordination betweengovernment and non-governmental organizations andlow funding relative to spending on health care. TheCommittee accordingly recommended additional fundingof $200 million annually to sustain, better coordinate,and integrate the public health infrastructure as well asrelevant health promotion efforts.

The Senate Committee’s recommendations have yet to beoperationalized, notwithstanding another major re-investment in health services by the federal government.Specifically, on February 5, 2003, the First Ministers andthe federal government reached another agreement onincremental funding for health care. This agreementprovided for $34.8 billion in additional funds for healthover a five-year period (2003-4 to 2007-8). Of these,$30.9 billion represent new spending over and above theprevious Health Accord. The funding has been directedas shown in Table 3 below.

The text of the 2003 Health Accord mentions “prevention”once. In a paragraph entitled “Healthy Canadians”, theAccord acknowledges that there is a “collective responsi-bility” to deal with issues like exercise and obesity and topromote better public and environmental health.17 The2003 Accord directs health ministers to continue workingon initiatives to reduce health status disparities, and topursue a National Immunization Strategy. Funding forthese activities appears to come from the “direct HealthAccord initiatives” and “other health reform initiatives”line items. Other programs within these line itemsinclude patient safety, health human resources, andtechnology assessment.

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Area of funding Amount

Canada Health and Social $12 billionTransfer increases

Health Reform Fund $16 billion

Diagnostic/medical equipment $1.5 billion

Health information technology $600 million

Research hospitals $500 million

Direct Health Accord initiatives $1.585 billion

Other health reform initiatives $1.364 billion

First Nations and Inuit Health $1.25 billion

Total $34.8 billion

T A B L E 3Health care funding over five years (beginning in 2003-04), as per the 2003 Health Accord

The Accord proposes that health ministers develop a setof performance indicators by September 2003, andsuggests indicators for the ministers to consider. Theseindicators are divided into four groups: timely access,quality, sustainability, and health status and wellness.Although two of the suggested wellness indicators dealwith obesity and physical activity, public health activitiesare generally overlooked. For example, none of thesuggested indicators discuss vaccination rates, surveillanceof communicable diseases, disease screening, breastfeedingrates, or childhood nutrition. The 2003 federal Budgetprovides $45 million over five years for the NationalImmunization Strategy and a further $45 million for“Wellness-Sport Participation”.

The record of the last several decades is depressingly clear.Even the presence of a major new infectious disease suchas HIV was insufficient to galvanize new investments inand reorganization of public health infrastructure inCanada. Notwithstanding the drumbeat of disease preven-tion and health promotion, governments have steadilycommitted virtually all new health spending to areasother than public health. We turn accordingly to a briefexamination of the funding of public health in Canada.

3D. Funding Public Health in Canada

Tellingly, reliable information on expenditures on publichealth in Canada is not even readily available. The datapublished by the Canadian Institute for Health Information[CIHI] are not suitably disaggregated and thereforeunhelpful. The public health category includes admin-istrative spending for many other parts of the health caresystem. For example, the amount shown for Ontarioincludes the province’s contribution to the CanadianBlood Services and the operating costs of the provincialbreast cancer screening program. Some other provincesprovide no breakdown at all. CIHI intends to publishpublic health expenditures data separate from generaladministrative costs of government ministries, but thiswill not solve the problem of inconsistencies in categoriesof expenditure included in the public health envelope.

3D.1 National Spending on Public HealthFor a view of federal data, Health Canada’s “BudgetQuick Facts” document does list expenditures by branchand business line. Various branches also providedinternal estimates of expenditures on communicablediseases. Expenditures for infectious diseases inside PPHBwere calculated from budgets for individual centres.

For provinces and territories, we were able to obtaininformation on public health budgets from a fewprovinces and prorated these expenditure data to theentire country. Thus, the national estimates providedhere are fairly crude approximations. Data were notavailable for all subcategories. Data for vaccine costswere taken from a survey of provinces and territoriesundertaken by Health Canada last year; costs for thatyear were unusually high as a result of a mass campaignof meningococcal vaccination in Quebec.

Expenditures were estimated for both a narrow definitionof public health (roughly corresponding to the activitiesof official P/T and local public health organizations) and a broader definition (including activities of non-governmental organizations [NGOs] and regulatoryfunctions).

Table 4 provides a summary of estimated public healthexpenditures in Canada. Total public health expendi-tures in Canada (2002 - 2003) are estimated at $2.8 billionby the broad definition, and $2 billion by the narrowdefinition. This corresponds to per capita expendituresof $88 and $65, respectively. CIHI has forecasted 2002health expenditures of $79.4 billion for the public sectoralone and $112.2 billion for the public and privatesectors combined. Public health by the broader andnarrower definitions therefore amounts to 2.5% and1.8% respectively of total health expenditures (publicand private) or 3.5% and 2.6% respectively of publicly-funded expenditures. Public health expenditures forinfectious diseases specifically, are estimated at $787million or $25 per capita. This corresponds to 1.0% ofpublic health care expenditures.

3D.2 Expenditure Trends in OntarioWe attempted to examine public health system fundingtrends in more detail for the Province of Ontario. Ourinterest was piqued by the fact that Ontario has a set ofmandatory programs for local public health units andmeasures compliance with them. The programs representa solid foundation for public health, and thus the relation-ship between program compliance and funding seemedto offer a potential benchmark for analysis.

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Total Expenditures Per Capita As Proportion of Health ($ million) Expenditures $ Care Expenditures

Total Publicly-funded

Broad definition 2,762.4 88 2.5% 3.5%

Narrow definition 2,047.0 65 1.8% 2.6%

T A B L E 4Summary of Estimated Public Health Expenditures - Federal and Provincial/Territorial Departments of Health, 2002.

Direct Grants & Contributions Total TotalSpending for Community-based Broad Narrow

Interventions definition1,4 definition2

Federal [Health Canada] only]PPHB 186.8 200.3 387.5 225.04

Other Branches 497.93 497.9 75.05

Vaccines 25.3 25.3 25.3Subtotal 710.0 200.3 910.7 325.3

P/TOntario 443.76 - 528.310 443.76

B.C. 234.87 - 246.59 234.87

Nova Scotia 28.48 - 29.89 28.4Manitoba 43.08 - 459 43.0Prorated to Rest of Canada11 622.8 653.3 622.8Vaccines 349 349 349Subtotal 1721.7 1851.9 1721.7

Total 2431.7 200.3 2762.6 2047

Notes:1 Local public health plus regulatory functions and grants and contributions for community-based interventions2 Functions corresponding to work done by local official public health agencies3 Healthy Environments and Consumer Safety Branch [HECS], Health Products and Food Branch [HPFB], Pest Management Regulatory Agency

[PMRA], expenditures for the ‘protection & promotion of health’ business line, plus the public health portion of First Nations and Inuit HealthBranch [FNIHB] expenditures

4 Direct spending + estimated portion of grants and contributions5 Estimated public health-like expenditures by FNIHB6 includes municipal portion + provincial public health branch7 BC CDC plus Ministry and transfers to regions minus public health labs and vaccines8 Ministry plus transfers to regions (Nova Scotia: +10% for food safety and related health inspection services)9 Estimate - approximately 5% allowance for health promotion grants and regulatory work10 Addition of health promotion transfer grants + Healthy Babies, Healthy Children Program11 Prorated on a per capita cost basis by region: Manitoba for Alberta and Saskatchewan, Nova Scotia for Maritime provinces and territories,

British Columbia for Quebec. * Best available data as of May 2003.

T A B L E 5Breakdown of Estimated Public Health Expenditures by Federal and Provincial Departments of Health in Canada, 2002*($ millions)

Unfortunately, examining funding trends for the publichealth system in Ontario was problematic for several reasons.Substantial funding by municipalities is not captured byprovincial public accounts or estimates. In the transitionto the current 50:50 cost sharing with municipalities, therewas a brief period of 100% funding of local programmingby municipalities. The province has also introduced alarge and expanding Healthy Babies, Healthy ChildrenProgram. Further, non-public health budget lines appearto be embedded in the public health vote.

The Ontario Association of Local Health Agencies (alPHa)has tried to track funding for local public health depart-ments. Data were available for selected years from 1994-2002. These figures combine provincial and municipalfunding of local public health departments. Figure 1 abovesuggests that local public health funding lagged the growthin overall provincial health care spending during the periodof 1996-2001. Funding as a percentage of total healthspending increased in 2002, but remains below levelsobserved in 1994 and 1995. Per capita spending, unadjustedfor inflation, has clearly increased from 1998 through2002. The total public health budget net of revenue andexcluded items plus unorganized areas ($3.3 million) was$304.4 million in 1998 and $435.9 million in 2002. Percapita spending appears similar to Manitoba but lowerthan British Columbia; however, interprovincial comparisonsmust be drawn cautiously given limitations of the data.

Funding trend data do not addressthe broader issue of whether currentfunding is sufficient to fulfill themandate of the public health system.As noted, Ontario’s Mandatory HealthPrograms and Services offered apotential benchmark. The Programstandards and requirements arereasonably detailed and have astrong service delivery perspective.Starting in 1998, the Public HealthBranch developed a series ofindicators to facilitate local healthdepartments’ reporting on theextent of compliance with theMandatory Programs. The PublicHealth Branch annually compilesinformation from a MandatoryProgram Indicator Questionnaire[MPIQ]. Provincial averages foroverall compliance as evidenced byMPIQ results are reported to haveincreased from 70.9% to 82.6%from the period of 1998 to 2001.The extent to which the additionalfunding is responsible for risingcompliance is unclear.

3D.3 A Modest Investment by Any MeasureCIHI data report that public health and administrationtogether account for 6% of health care spending. Theinvestment in public health is clearly the smaller part ofthat percentage. Convergent validation of the estimatesdeveloped above is derived from Alberta data. As notedearlier, Alberta’s regional health authorities [RHAs] areresponsible for the delivery of both acute and chroniccare, as well as public health programs. In 1999-2000,RHA spending on “promotion, prevention, and protection”accounted for 2.9% of their budgets. This number isconsistent with our estimates that public health spendingamounts to approximately 2% of total health spending.These estimates are also in a range familiar to publichealth practitioners, i.e., between 1.5% and 3% of healthspending. Only by using the broader definition of publichealth and the smaller denominator of public spendingalone does the figure move slightly outside that range to3.5%. The good news is that, because public healthremains a very small part of total health spending, relativelymodest investments could have a transformative impact.The bad news is that there are clearly inconsistencies inpublic health programming and spending within andbetween provinces and territories, with the result thatuniform conditional transfers by the federal governmentto reinforce capacity will be difficult to operationalize.

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1994 1995 1996 1997 1998 1999 2000 2001 2002

% of Ministry of Health Per Capita

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F I G U R E 1Local Public Health Funding in Ontario —- Percentage ofMinistry of Health Spending and Per Capita Estimate

Local public health funding is based on provincial and municipal contributions to public healthdepartments in Ontario. The provincial component coincides primarily with the “Official LocalHealth Agencies” line item in Public Accounts. Data are missing for 1997 due to the time-limiteddownloading policy of the provincial government.

Overall spending targets are difficult to set as there arelimited data on spending trends and outputs, let alonehealth status outcomes. The Ontario data are consistentwith the common opinion that absolute levels of publichealth funding have generally increased, but laggedbehind spending on health care in general. This latterpoint has been supported in a submission to the Committeeby the Canadian Medical Association. Comparisons ofexpenditures across jurisdictions are also difficult, as notwo provinces seem to include exactly the same activitieswithin the public health funding envelope. For example,in several western provinces, most or all of immunization,including vaccine and delivery costs, is provided throughpublic health, whereas in Ontario and Quebec most immu-nizations are given in physicians’ offices and delivery isfunded through the medical insurance plan.

If one takes British Columbia as a benchmark, andcalculates the incremental funding required to bring allprovinces up to the per capita spending apparent forBritish Columbia, governments would need to spend anadditional $408 million per annum. But this figure isimprecise. Some services included in the British Columbiapublic health envelope may be funded through differentenvelopes in other provinces, and we have no way ofbeing certain that British Columbia’s spending in anyway represents a ‘gold standard’ for public health. Theincremental spending proposed does not consider thepotential differences in delivery costs due to geographically-dispersed populations, variable proportions of higherneeds populations, or fixed system costs that are partlyindependent of population size. We turn therefore tointernational comparisons for additional enlightenment.

3E. International ComparisonsFor comparative purposes, the Committee asked HealthCanada to obtain information on the organization,governance and funding of public health in selectedforeign countries, with an emphasis on national agencies.We have reviewed material on the USA, the UnitedKingdom, Australia, New Zealand, Sweden, Finland, andNorway. We found the organization and governance ofpublic health to be particularly informative for the USA,United Kingdom, and Australia, and review these below.

3E.1 United States of AmericaThe USA combines a large population (297 million), thehighest average per capita income on the globe, dramaticincome-related and ethno-racial health status disparities,geographic challenges that are only slightly less dauntingthan those in Canada, and a federal system of govern-ment that includes 57 separate governments at thestate/territorial/district level.

The Institute of Medicine has recently published a compre-hensive and critical review of public health infrastructurein the United States.18 As the Institute’s report high-lights, the health care context is different from otherdeveloped countries: the Department of Health andHuman Services, through its Medicare and Medicaidprograms (the latter a joint venture with the states) is thelargest insurer in the country. However, absent universalhealth care insurance, the majority of Americans obtaininsurance privately, with about 40 million uninsured,relying on a patchwork of state, local and voluntaryprograms for service. This tends to confuse the publichealth picture, as public health programs at the state andmunicipal level are often an amalgam of populationhealth and clinical prevention programs and curativecare for the indigent and uninsured populations.

The US constitution gives states primary responsibilityfor health. The federal government has a limited role inthe direct delivery of public health services, but doesprovide leadership, has some regulatory authority, andcontributes operational and financial resources. Theultimate authority for public health in the USA rests withthe Secretary of Health and Human Services. The AssistantSecretary for Health is the principal advisor to theSecretary on public health and related scientific issues.Presently, the Acting Assistant Secretary is Dr. RichardCarmona, who is also the Surgeon General. There is alsoan Assistant Secretary for Public Health EmergencyPreparedness.

The lead agency for public health activity at the federallevel is the US Department of Health and HumanServices [DHHS] (see Appendix 3.1 for an organizationalchart). The DHHS oversees several key agencies includingthe Centers for Disease Control and Prevention [CDC],referenced in the two previous chapters. Numerouscommittees in both the House of Representatives andSenate have jurisdiction over HHS activity. The roles ofDHHS include:

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Policy making: For example, the DHHS, through itsHealthy People initiative, sets goals and objectives forhealth promotion and disease prevention.

Financing public health activities: Whereas much ofthe CDC budget flows through to the states and territories,the Institute of Medicine [IOM] notes that other spendingby DHHS in the public health sphere goes not to publichealth activities as we understand them, but to personalhealth care services through Medicaid.

Public health protection: The federal government isheavily involved in this area through the Food and DrugAdministration [FDA], and the Centers for Medicare andMedicaid Services which regulates health care providersand laboratories.

Collecting and disseminating information:Numerous federal agencies collect key health data.

Capacity building for population health: The federalgovernment is expected to ensure that state and localgovernments have the resources (human, financial,organizational, etc.) to carry out their responsibilities. Inpractice, state public health agencies are chronicallyunder-funded. When states do receive additional fundsfrom the federal government, they sometimes use theseresources to reduce the proportion of state expensesdirected towards public health activities, i.e., the fundssubstitute for, rather than increase, existing state-levelpublic health spending.

Direct management of services: These allocationsinclude Medicaid, Medicare, funding of the IndianHealth Service, and some community health centres.

Faced with a constitutional division of powers similar tothat in Canada, the DHHS must work with State, Localand Tribal governments to fulfill its mission of protectingthe health of all Americans. The US Public HealthService [PHS] combines eight HHS agencies with theOffice of Public Health and Science [OPHS] that housesthe Office of the Surgeon General. The Surgeon Generaldirects the PHS Commissioned Corps—a quasi-militaryunit of 6,000 uniformed public health professionals.

The federal government has constitutional responsibilityfor preventing entry of disease into the USA and, underthe Interstate Commerce clause of the Constitution, forpreventing the interstate spread of disease. The USA has specific legislation (the Public Health Threats andEmergencies Act, 2000, also known as the Frist/KennedyAct) aimed at countering bioterrorism through theimprovement of public health infra- and infostructure at

state and local levels. Other relevant legislation governsimmunization and vaccine purchase, and includes severallong-standing “categorical” programs to fund specificnationwide programs, usually with an emphasis on thepoor or on children and youth, often in partnership withstates.

Apart from the CDC, other agencies under the umbrellaof the DHHS in the USA are listed below. The list showstheir 2002 HHS budget authority in parentheses; theseagencies may receive additional funding from non-HHSsources:

• Food and Drug Administration (US$1.3 billion)

• Health Resources & Services Administration (US$6.2 billion)

• Indian Health Service (US$2.9 billion)

• National Institutes of Health (US$23.6 billion)

• Substance Abuse & Mental Health Services (US$3.1 billion)

• Agency for Healthcare Research & Quality (US$0.3 billion)

• Centers for Medicare & Medicaid Services (US$388 billion)

• Administration for Children & Families (US$47.3 billion)

• Administration on Aging (US$1.3 billion)

The Centers for Disease Control and Prevention [CDC]was founded in 1946 to combat malaria, typhus andother communicable diseases. As noted in Chapter 1,CDC initially stood for “Communicable Disease Center.”The CDC was renamed the Center for Disease Control in1970, and added “Prevention” to its name (but not theacronym) in 1992. It is an operating division of theDepartment of Health and Human Services, and thelargest federal agency outside Washington, D.C. TheCDC has always been based in Atlanta, but over 2,000 ofthe approximately 8,600 full-time equivalent employeeswork elsewhere; this includes postings in 47 state healthdepartments, with 120 CDC employees overseas. SomeCDC staff are also members of the Commissioned Corpsof the PHS. The CDC’s current mission is “to promotehealth and quality of life by preventing and controllingdisease, injury, and disability.” The federal governmentcreated the Agency for Toxic Substances and DiseaseRegistry [ATSDR] in 1980. The director of the CDC alsoserves as the administrator of the ATSDR; the CDC andthe ATSDR submit a joint budget request.

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The CDC has 12 centres, institutes and offices. TheDirector is always a public health physician and thesenior staff are predominantly health professionals andscientists. The CDC maintains a very high public profile,and has a strong ‘corporate brand’. Its director reports tothe Secretary for Health and Human Services through theDeputy Secretary.

The CDC exerts considerable influence at state and local levels. In part this is due to the CDC’s EpidemicIntelligence Service [EIS]. The EIS was a forerunner ofsimilar programs in Canada and elsewhere. The EIS is at once a training program in field epidemiology,surveillance and disease control, and a significant part of the CDC’s ability to respond rapidly to outbreaksanywhere in the USA or abroad. It helps to ensure thatthe CDC can dispatch teams to assist or lead localinvestigations into disease outbreaks.

Many of the state and local staff were trained in the CDC EIS. Most states also have CDC staff stationed inkey state agencies.

The CDC is the clear international leader in the areas ofsurveillance systems, databases, outbreak investigation,and communicable disease epidemiology. The speedwith which the CDC and the PHS Corps can respond toan emergency infectious outbreak is unmatched globally.

The programs of the CDC are directed towards two majorfunctions. It provides infrastructure support to the statesand local health agencies. It also serves as the nationalcommand centre for health emergencies, including new or re-emerging infectious diseases and bioterrorism.The CDC engages in research, offers technical advice tomultiple nations, and helps with program developmentin the USA and around the world.

The infrastructure programs are set out below:

The National Public Health Standards Programdevelops capacity and performance standards, providesfor evaluation against these standards and providesgrants and technical assistance to state and local healthauthorities to address deficiencies. Although states arefree to reject the CDC’s performance standards, theCDC’s funding of state-level programs gives it substantialinfluence.

The Health Alert Network links all state and localhealth departments to secure communication systemsthrough the development of architecture, technicalassistance and grant-supported projects.

The Public Health Workforce DevelopmentInitiative includes a comprehensive strategy for life-longlearning for public health practitioners, and has twoarms: the Public Health Training Network and theNational Laboratory Training Network.

The National Public Health Laboratory System,beginning with standardization and enhanced testing,aims to develop policies and public-private partnershipsthat would enable improved and more timely reportingof laboratory results.

The Public Health Information Network is thearchitecture for a comprehensive system for the captureand exchange of surveillance information. It providesdesktop access to important information for publichealth practitioners.

The Public Health Emergency Fund is available forfederal action on public health emergencies.

The situation with surveillance in the USA is not dissimilarto Canada with respect to legal authority. Mandatoryreporting of infectious diseases occurs at the state or evenlocal level in the USA. Although the CDC and theCouncil of State and Territorial Epidemiologists jointlymaintain a list of nationally notifiable infectious diseases,reporting to the CDC is voluntary. On the other hand,the CDC performs a crucial role in disease surveillance,offering leadership and coordination, education, laboratorytesting, and information technology, as well as directfunding. In the last category, for example, the NationalCenter for Infectious Diseases distributed US$31.2 millionto states in 1998 through various grants for surveillance.Other CDC departments also provide funding to statesfor surveillance. In 2002, bioterrorism funding enabledthe CDC to disburse almost US$1 billion to states, ofwhich approximately US$183 million was for surveillanceand epidemiology. In short, given constitutional limitsand recent legislation that prevents the imposition ofunfunded mandates on states by federal regulators, theCDC essentially purchases a national surveillance systemthrough earmarked state-level funding and partnerships.

In the USA, the Healthy People 2010 Objectives (publishedevery ten years) contain quantifiable objectives, andprogress towards them is measured. This stands incontrast to Canada, where an overarching public healthstrategy for the nation has never been articulated.

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Essential public health services have been defined. TheCDC offers programs and funding to review state/localperformance; a framework for organizing, assessing anddeveloping public health staff care competencies; and apotential framework for new/revised public healthlegislation. Again, the contrast to Canada is striking.Direct transfers to P/T governments earmarked for publichealth do not occur in this nation, leading to inter-jurisdictional inconsistencies along with limited nationalcoordination. The federal presence in public health isalso much reduced.

The enacted CDC budget for the 2002 fiscal year (FY 2002)is outlined in the CDC’s budget request for FY 2004.Allocations for 2003 had not been formally enacted atthe time of the 2004 budget request; nevertheless, as2004 requests are generally similar both in total and bycategory to actual 2002 and expected 2003 enactments,this report presents data for 2002 only.

The CDC’s total 2002 budget of approximately US$6.5 billion excludes approximately US$1.2 billiontransferred from the CDC’s terrorism budget to theDepartment of Homeland Security for accumulation of a“strategic national stockpile” and the smallpox vaccinationprogram. The CDC receives funding via several mecha-nisms (e.g., the Labor-Health and Human Services-Education regular appropriations bill, the Veteran Affairs-Housing and Urban Development regular appropriationsbill, the Public Health and Social Services EmergencyFund, etc.). Budget details are presented by program inTable 6.

Although responsibility for public health rests with thestates constitutionally, the degree of commitment to publichealth by states and territories varies greatly. A few statesinvest heavily, and others hardly at all. State healthdepartments are usually headed by a professionally-qualified director or commissioner. However, this officialmay have responsibility not only for public health, butalso for Medicaid, professional licensing and other healthcare matters, and perhaps child welfare and some socialservices as well. In the interests of brevity, we shall notreview state-specific arrangements in detail here. Sufficeit to say that the provision of local and regional publichealth services appears more variable in the US than inCanada. While some larger cities have very effectivepublic health units, there are also several thousand local(usually county-based) agencies, many too small to beeffective or attract qualified staff. Resources areconstrained by local ratepayer interest, as a substantialportion of the funding for local agencies comes frommunicipal or country-level taxes and revenues.

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Program Expenditure Percent(US$, 000)

Birth Defects and Disabilities $89,946 1.4%

Chronic Disease Prevention and Health Promotion $746,731 11.4%

Heart Disease and Stroke $37,378Diabetes $61,683Cancer $268,627Arthritis and Other Chronic Diseases $20,812Tobacco $100,973Nutrition, Physical Activity,

and Obesity $27,505Health Promotion $15,235School Health $58,443Safe Motherhood/Infant Health $50,697Oral Health $10,814Prevention Centers $26,176Youth Media Campaign $68,388

Environmental Health $153,397 2.3%

Epidemic Services and Response $80,156 1.2%

Health Statistics $126,750 1.9%

HIV/AIDS, STD and TB Prevention $1,156,826 17.6%HIV/AIDS – Domestic $689,169HIV/AIDS – International $168,720STDs $166,534TB $132,403

Immunizations (state programs, public health clinics) $627,239 9.6%

Infectious Disease Control $348,181 5.3%

Injury Prevention and Control $149,502 2.3%

Occupational Safety and Health $275,808 4.2%

Preventive Health and Health Services Block Grant $134,958 2.1%

Public Health Improvement $148,306 2.3%

Emergency Response and Recovery $12,000 0.2%

Office of the Director $49,077 0.7%

Buildings and Facilities $296,000 4.5%

ATSDR $78,203 1.2%

Terrorism (Nonbuildings and Facilities) $1,101,439 16.8%

Upgrading State and Local Capacity $940,174Upgrading CDC Capacity $143,225Anthrax $18,040

Vaccines for Children (Medicaid, uninsured, native, etc.) $989,535 15.1%

User Fees $2,226 0.0%

Total $6,566,280 100.0%

T A B L E 6Budget for the Centers for Disease Control andPrevention, USA, 2002 (US$).

The first line for outbreak management remains at thelocal and then state level in the USA. The CDC must beinvited to offer support, but thereafter it plays particularlystrong roles in outbreak investigation and strategicadvice. The CDC’s influence and surveillance systemsalso ensure that, with few exceptions, it enters the frayearly in any serious outbreak. Just as in Canada, juris-dictional tensions occur. However, the conspicuousposition of the CDC in US outbreaks arises from its ownfirepower, its funding of activities by other governmentaljurisdictions, the role that it plays in training andcapacity-building, direct secondments of federalpersonnel into state/territorial agencies, and, not least,limits in capacity at the local or regional level.

3E.2 United KingdomAlthough the United Kingdom does not have a federalconstitution, three separate health systems are inoperation for England and Wales, Scotland, and NorthernIreland. Each is a variation on the basic model of theNational Health Service [NHS].

Britain was a pioneer in many aspects of public healthduring the nineteenth century. Its strong municipally-based public health programs were largely absorbed intothe NHS when the latter was created in 1948. Since then,public health has been closely integrated with other NHSfunctions. Furthermore, public health physicians in theUnited Kingdom have wide-ranging roles. They are notonly engaged in public health as we understand it, butalso in planning, commissioning and managing thequality of the NHS clinical services.

The basic organizational unit of the NHS is the PrimaryCare Trust. Many public health services are provided atthis level. Since April 2002, the trusts are accountable to 28 Strategic Health Authorities, each with a regionaldirector of public health. The public health directors inthe Strategic Health Authorities are charged with thedevelopment of a cross-governmental and cross-sectoralapproach to the determinants of health. Public healthpolicy informs and is informed by regional work oneconomic regeneration, education, employment andtransport. The directors give high priority to partnershipswith primary care physicians. They are accountable forhealth protection (including control of communicablediseases and environmental hazards) across the region,and play a role in emergency and disaster planning andmanagement. The public health directors are also often apoint of contact for concerns about clinical standards. In essence, serious lapses in clinical quality are regardedas tantamount to iatrogenic disease outbreaks, and may

be investigated accordingly in tandem with clinicalgovernance. Each region has its own characteristics andpublic health priorities.

Intriguingly, the Cabinet includes not only a Minister ofHealth but a Parliamentary Under Secretary of State forPublic Health, essentially a junior minister, with specificresponsibilities for a strategy to improve the health of thepublic and for policies on issues such as tobacco controland food safety. The government published a greenpaper and subsequent white paper (Saving Lives: OurHealthier Nation) setting out the government’s strategy for public health policy. In contrast to the Canadiansituation, the white paper identified five priority areas for reducing mortality and morbidity and 25 quantifiedtargets for achieving reductions in mortality and morbidityover given timescales. Work in progress is addressingtargets for addressing health inequalities and tacklingsome of the social and environmental determinants ofhealth. Public health activities are subject to nationalhealth frameworks: each Strategic Health Authoritymeasures the performance of the primary care trusts withinits boundaries, and the performance of Strategic HealthAuthorities in turn is assessed centrally. In sum, Britainis making an effort to create an accountable hierarchy ofperformance measurement in public health, a structureparallel to its innovative system of performance measure-ment for clinical or personal health services.

The UK government recently formed a Health ProtectionAgency. It drew together the Public Health LaboratoryService (including the Communicable Disease SurveillanceCentre), the Centre for Applied Microbiology andResearch, NHS staff responsible for communicable diseasecontrol and emergency planning, and units responsiblefor chemical exposures and poison control. The staff inthis agency number 2,700 in 9 regional offices. Thissecond line of defence against outbreaks is an importantinnovation to which we shall return.

The government operates other agencies designed todrive a research agenda in public health and translateevidence into action. The Health Development Agency hasan annual budget of about C$23 million. Focused onknowledge translation, the agency finances systematicreviews, gathers evidence and makes it available to publichealth authorities, advises on good public health practice,and supports the information needs of front-line publichealth workers. It has a particular interest in healthpromotion and works closely with both local public healthagencies and community groups. The Department ofHealth also funds the Policy Research Programme to helpensure that public health policy, plans, and practices arebased on reliable evidence about population needs and

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effective interventions. All of the research is directlycommissioned (costing around C$67 million per annum).More generally, the Department of Health will spendapproximately C$1.21 billion in 2002/03 through thePolicy Research Programme and NHS R&D Programme.While the NHS R&D Programme has a strong appliedclinical and health services focus, a meaningfulproportion of the research spills over to inform publichealth issues. The British Medical Research Council isfunded separately for investigator-initiated researchacross the full range of health research.

3E.3 AustraliaAustralia is similar to Canada with its vast land mass,modest population (now about 19 million), and federalsystem of government. Australia’s federation is comprisedof six states and two territories. The Commonwealth(federal) government has a broad policy leadership andfinancing role in health matters, while the states andterritories are largely responsible for the delivery ofpublic hospital and community services. Australia hasmoved back and forth with various configurations ofprivate-public mix in financing and delivering personalhealth services. Currently, it operates a nationalcompulsory tax-based system of public health insurance(known as Medicare), graduated on the basis of incomeand general taxation, that provides access to medical andhospital services for all Australians. The Commonwealthhas recently introduced a number of key policy initiativesto increase participation in parallel private healthinsurance. The Commonwealth also provides manage-ment and control of communicable diseases, and regulatesfood, therapeutic goods, and chemicals.

The Commonwealth Department of Health and AgedCare coordinates surveillance, prevention, managementand control of communicable diseases, and regulation offood and therapeutic products. However, funding ofpublic health differs from funding of hospital andmedical services. While the Commonwealth (under theAustralia Health Care Agreements) pays 75% of totalfunding for public hospital services, it pays for half of thepublic health services funding (30% via direct expenditureand 22% via payments to States and Territories). Thestates and territories contribute the remainder. Based on1999/2000 data, A$931 million was spent on core publichealth activities (less than 2% of health expenditure inAustralia).

Joint public health activities conducted by theCommonwealth and State/Territories Health Authoritiesare coordinated through the National Public HealthPartnership, a sub-committee of the Australian HealthMinister’s Conference. States and territories vary in theorganization of their public health services, with differingnumbers of local and regional public health units,variable integration with community health centres, andconsiderable variation in the role of NGOs or stand-alonefoundations.

In February 2003, all Health Ministers signed amemorandum of understanding to continue the NationalPublic Health Partnership [NPHP] for the period 2003-2007. The memorandum sets out the objectives of theNPHP, clarifies the roles and responsibilities of therespective parties to the multilateral agreement anddescribes the arrangements for implementation. TheNPHP Group is comprised of a senior representative fromCommonwealth, State and Territory Health Departments(voting members), senior representatives of the AustralianInstitute of Health and Welfare and the National Healthand Medical Research Council (non-voting members) andtwo observers (the New Zealand Ministry of Health andthe NPHP Advisory Group). The NPHP has alreadyestablished subgroups in areas such as communicablediseases and AIDS.

The Program priorities for the NPHP are clearly identified.They include: 1) improving public health practice; 2) developing public health information systems; 3) reviewing and harmonizing public health legislation;4) implementing public health workforce initiatives; 5) strengthening national public health research anddevelopment capacity; 6) improving the coordination ofnational public health strategies; 7) developing standardsfor the delivery of core public health strategies; and 8) improving Aboriginal and Torres Strait Islander health.Lessons for Canada from these collaborative arrangementswith explicit priorities are self-evident.

The Commonwealth contributes towards the capacity ofstates and territories through Public Health OutcomeFunding Agreements [PHOFAs]. Base funding is providedfor major national health priorities. PHOFAs includespecific outcome reporting requirements. This year, theCommonwealth Department of Health & Welfareprovided funds for SARS screening at airports, vaccines,and improved prevention in primary care.

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The NPHP has made substantial efforts to integrate thepreventive work of general practitioners with other primarycare services and community services. These steps shouldhelp to integrate the personal service continuum withbroader public health programming. In particular, theNPHP is working with the General Practice AdvisoryCommittee to improve the adoption of preventive andearly intervention approaches by general practitioners,thereby rationalizing the complementary role of clinicaland population strategies for prevention. Research onpopulation health issues and epidemiologic study issupported at the Commonwealth level through twomechanisms. The National Health and Medical ResearchCouncil [NHMRC] provides independent, expert adviceto government in health issues and research grants. As well, the Public Health Education and Research Programfunds Australian tertiary institutions to strengthen post-graduate education and training, including preparationof public health practitioners and research training inpopulation health.

3F. Some Reflections andConclusions

SARS is simply the latest in a series of recent bellwethersfor the fragile state of Canada’s federal/provincial/municipal public health systems. The pattern is nowfamiliar. Public health is taken for granted until diseaseoutbreaks occur, whereupon a brief flurry of lip serviceleads to minimal investments and little real change inpublic health infrastructure or priorities. This cycle must end.

Canadians have seen high-profile disease clusters arisingfrom the contamination of water supplies in Walkerton,Ontario and North Battleford, Saskatchewan. Both hadtragic effects. Last year, the nation faced an outbreak ofWest Nile virus. West Nile virus is another zoonosis, arisingfrom a reservoir of infected birds and transmitted tohumans by mosquito bites. The virus appeared in NorthAmerica in New York City in 1999, and was detected inCanada by the summer/fall of 2001. Canada recordedabout 300 confirmed cases in 2002, some with severe orfatal effects. Variant Creutzfeld Jacob Disease (the humanform of Bovine Spongiform Encephalopathy or BSE) hasalso sparked public anxieties and exacted an economic toll.

The SARS outbreak was moderate in size, in part becauseeffective actions were taken to contain its spread and alsobecause the causative agent is actually less contagiousthan some other respiratory and enteric viruses. Its socialand economic impact, however, was enormous, and itscollateral clinical consequences are still being measured.

SARS has highlighted how communicable diseases,particular those caused by hitherto unknown agents, cantap primal anxieties, prompt enormous interest on thepart of the media, and provoke some unsavoury publicresponses (e.g., incidents of harassment and scapegoatingof the Asian community in Toronto). The SARS outbreakthereby underscores the need for public health to play aleadership role in analyzing risks and communicatingeffectively about them. Yet, as the chronology in the last chapter demonstrated, neither the analytical capacitynor the communications strategies were anywhere near optimal.

Many involved have acknowledged the potential conse-quences of two public health crises happening simulta-neously. What if SARS had struck just as public healthstaff were fully engaged in coping with a bioterrorismattack or an accelerated caseload of infections with West Nile virus? In the absence of a robust public healthsystem with built-in surge capacity, every crisis forcestrade-offs—attention to one infectious disease at theexpense of others, or infectious disease prevention at theexpense of food safety, chronic disease prevention, andother public health responsibilities. In the latter respect,if Canada expends most available public health resourceson relatively rare events such as SARS or West Nile virus,we run the risk of winning a few high-profile battleswhile losing the war for health. A host of partiallypreventable non-communicable diseases continue toexact a tremendous toll on the health of Canadians,while avoidable injuries cost the nation billions of dollarsin direct health spending and indirect costs. Publichealth has much to contribute apart from containmentof communicable diseases.

The chronology in Chapter 2 highlighted the impact ofSARS in Canada’s richest and largest city in the nation’srichest and largest province. Globe and Mail columnistMargaret Wente has tartly commented: “Thanks to near-heroic efforts by public health officials, we managed tofight off a SARS fire spreading at lightning speed with anorganization about as sophisticated as an improvisedbucket brigade.”19 Support to fight the outbreak wasrequired from other jurisdictions, including scores ofvolunteers from the USA.

The capacity of other provinces varies but Ontario isassuredly not the ‘weakest link’ in the P/T public healthchain. In this respect, an F/P/T report on Public HealthCapacity was prepared for the Conference of DeputyMinisters at their request, and presented in June 2001.20

It was never formally accepted for publication anddissemination. Some of the key findings highlightpotential areas of concern for all Canadians including:

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• an overall erosion of the public health system, withsurvey respondents in key positions noting the reducedcapacity to address ongoing and emergent challengesto public health such as water quality safety andmanagement of infectious diseases;

• significant disparities in public health capacity nowexist across Canada;

• concerns that the relative low priority given to longer-term disease and injury prevention strategies isincreasing threats to the health of Canadians andundermining the sustainability of the health caredelivery system;

• a lack of written multi-year plans covering the fivecore areas of public health practice in more than halfthe jurisdictions;

• insufficient efforts in staff development and growingrecruitment/retention difficulties;

• uncertain capacity of jurisdictions to deal with morethan one emergency at a time, or to deliver some coreprograms, particularly to northern and Aboriginalcommunities; and

• limited access to health information and erodingleadership on key public health issues.

The SARS outbreak has affirmed these observations. It illustrates an urgent need to strengthen not only thefederal role, but also the P/T public health infrastructure.The effectiveness of the public health system dependscritically upon capacity at local and provincial/territoriallevels. In turn, this demands a well-trained, adequate,and fully prepared workforce, and information andsurveillance systems that can detect health threats rapidly,analyse and interpret data and communicate the resultinginformation to health care providers and the generalpublic as needed. The same infrastructure that will helpcombat the next outbreak of SARS or a similar communi-cable disease will also provide Canadians with enhancedhealth protection and preventive capacity to reduce theburden of non-communicable diseases.

The 2000 and 2003 Health Accords provided majortransfers of funds to the provinces for health spending.These transfers offer provinces a resource base that, ifthey choose, can be tapped to enhance public healthinfrastructure [PHI]. And, given the very small percentageof publicly-funded health spending directed to publichealth functions, the levels of investment that wouldhave a transformative effect on public health capacity arecomparatively small—ranging by province from tens ofmillions to the low hundreds of millions annually. Anew allocation or re-allocation equivalent to the budget

of a single mid-sized general hospital could hugelyaugment PHI for larger provinces. However, theCommittee is under no illusions about the continuingcompetitive spending pressures on provincial andterritorial governments. In the chapters that follow, weare recommending that a substantial majority of the newfederal spending on public health be directed to initiativesand programs that will create a seamless, strengthened,and collaborative F/P/T public health system.

In shaping new programs and structures, what generallessons can Canadians learn from public health systemsin other countries?

First and foremost, the US, the UK and Australia each havea coherent chain of policy, stretching from legislation,national goals and priorities, national strategies, programsto sustain the public health infrastructure (includinghuman resources), means of reaching agreement betweenstakeholders, and specific funding programs. There arequantifiable targets with timelines, and accountabilitymechanisms. In contrast, Canada does not have nationalhealth goals or strategies. Even the extant nationalindicators arising from the Health Accords are focused on the personal health care system.

Second, many countries have agencies for public healthled by a recognized expert in the field. Embeddingpublic health functions inside the usual bureaucracy mayenhance the crosswalk to other health activities, buttends to blur the professional career path for those withspecial training in the relevant disciplines, impede theagility of responses to public health emergencies, andaugment the politicization of inter-jurisdictional activity.A distinct agency can still be held to account through avariety of mechanisms, and its credibility, for better orworse, is enhanced by its distance from the usualmachinery of government. Furthermore, these agenciesin other nations help build PHI by continually andgenerously investing in the training and continuingeducation of skilled personnel. This must be a highpriority for any Canadian public health agency.

Third, the scope of public health agencies varies. Someare focused on infectious diseases alone; others have ageneral mandate. We see the rationale for single-focusagencies, and commend the work of British Columbia’sCentre for Disease Control as a provincial exemplar inthe infectious disease field. Federally, Canada already hasa Centre for Infectious Disease Prevention and Controlunder the auspices of PPHB. The Committee believesthat any new national agency must encompass a fullspectrum of public health activities through a variety ofcomponent centres, as exemplified by the USA’s CDC,

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and intriguingly, Quebec’s National Institute of PublicHealth. The scope of the agency nonetheless requirescareful assessment as we shall show in the next chapter.

Fourth, the Committee has been struck by the fact thatother federations, such as Australia and the USA, alsoface challenges from the divergent capacity of differentprovinces or states and territories. The Australian and US response is to confront the challenges of regionalpluralism with earmarked funding, mechanisms to fosterinter-jurisdictional collaboration and coordination, andagreement on explicit performance standards. Canadaneeds a more consistent public health system withmaximum inter-jurisdictional collaboration on essentialfunctions. Governments in other nations have providedexamples of steps that can be taken to meet this need forour citizens.

In seeking to foster a stronger and more integratednational public health system, the Government of Canadacan variously use legislation and regulation, provide infor-mation and advice, deliver programs itself, or make transferpayments to individuals, organizations, and other levelsof government. Each of these has a role to play.

As summarized in Chapter 9, new legislation and regulationcould be dovetailed with the recognized need for Ottawato revise and consolidate all of its public health andhealth protection legislation. A national public healthsystem would also be facilitated by a stronger nationalpresence, established arm’s-length from Health Canada butaccountable to the Minister of Health and Parliament,that would provide credible information, advice, andtechnical support to provinces and territories. The USA’sCDC is exemplary in these respects. SARS has shown thatan outbreak in one province (or nation) affects all others.Every province and territory would benefit from moreeffective support for and coordination of public healthactivities. A strong federal presence is particularly impor-tant in supporting smaller provinces faced with epidemics,and is critically important in international liaison.

Direct program delivery by the federal governmentavoids skirmishing over cash transfers and accountability,but the federal government cannot effectively deliverlocal public health services nor does it have jurisdictionto do so. As in the USA, the federal government inCanada could instead become more directly involved insurveillance in support of provinces and territories. TheCommittee is also impressed by the ability of the USCDC to maintain a highly mobile, professionally-trainedemergency response structure capable of reacting rapidlyto outbreaks of infectious disease or other healthemergencies. In an ideal world, a new Canadian agency

would support a network of expertise, have sufficientcredibility, enjoy collegial relations, and move swiftlyacross bridges of inter-jurisdictional agreements to helpin local outbreak investigations and management. Thisis one reason why, as will be elaborated in Chapter 5, weenvisage a network focused on infectious diseases alongwith a system of secondments and sharing of personneldesigned to create a culture of collaboration.

Transfers are the other policy instrument in the federaltool-kit. As noted above, the federal government currentlyoperates a program of grants and contributions throughPPHB. This system moves approximately $200 millionper annum primarily to NGOs, and aims at addressingvarious determinants of health through programs in areassuch as prenatal nutrition, Aboriginal early childhooddevelopment, healthy living, and prevention of variousnon-communicable diseases. This set of transfers shouldbe aligned with a new national public health strategy.But what is clearly needed as well is a serious investmentdirected at the support of provincial, territorial, andmunicipal public health infrastructure. To this end, boththe American and Australian examples are important.Their systems of grants and related agreements withstates and territories, incorporating clear targets andreporting mechanisms, exemplify the approach that anew Canadian agency could use to build capacity inaccordance with both a national public health strategyand the needs of specific P/T jurisdictions.

The Committee is concerned that new funding forprovinces and territories not displace current spending,and end up transferred within provincial health budgetsto become another drop in the ever-leaking acute carebucket. New funding should neither preferentially under-write those provinces that have chosen to invest at levelsmuch below others nor disadvantage provinces such asBritish Columbia and Quebec that have innovated andinvested in public health. Instead, we recommend that a new federal agency allocate these funds in such a waythat program expenditures roll up to reflect, with someallowance for year-over-year variation, approximatepopulation size, consistent with the Social UnionFramework Agreement.

The national agency should be free to set floors fordovetailed provincial activity or matching conditionsbefore a particular provincial public health branch canreceive earmarked program funds. The agency may alsochoose to underwrite all costs for particular provincial/municipal programs. What the Committee views ascrucial, however, is that there be no bulk transfer orpassive payments. The monies should be disaggregatedinto separate program grants, and different provinces

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should receive funds for different purposes to promoteachievement of a stronger and more consistent publichealth infrastructure. Overall target setting for inter-jurisdictional division of funds thereby becomes a mecha-nism whereby provinces are both assured of receiving areasonably fair share of support for their own priorities,and given incentives to set priorities for re-investment inconcert with the national agency.

Fifth, the areas of infectious disease surveillance andoutbreak management need specific support and attention.Ideally, outbreak management should be harmonizedwith other provisions for health emergencies and thesearrangements in turn dovetailed with broader strategiesfor emergency preparedness and response. To ensurethat these areas receive priority and avoid F/P/T tensions,it seems intuitively appealing to create a new networkwith earmarked funding inside the agency’s envelope forP/T contributions. This would be a uniquely Canadianapproach to reconcile some of the inter-jurisdictionaluncertainties that arise with public health not just in ourfederation, but in other federal states as well.

Sixth, Australia, the UK, and the USA all have embeddeda strong research and science component in their publichealth activities. These countries provide a solid founda-tion in epidemiology, surveillance and health statistics,to inform public health practice. The UK is the inter-national leader in its efforts to ground public healthpolicies and services in solid evidence. Canada needsmore applied public health research and evaluation,more systematic reviews and public health practiceguidelines, better training in the generation and interpre-tation of public health evidence, and better means ofstoring, maintaining and accessing the relevant knowledgefor public health practice. These issues have beenhighlighted in a document produced by the Institute ofPopulation and Public Health within the CIHR. Any newagency must have a combination of in-house capacityalongside funding to contract out R&D functions topartners such as the CIHR. The challenges go beyondpublic health and demand a review of our scientificcapacity with respect to infectious diseases research;further comments on this matter follow in Chapter 10.

Last, in one nation after another, we see efforts madeacross jurisdictions to exchange and share data andinformation. Public health practitioners were pioneeringusers of health information in the eighteenth andnineteenth centuries. More recently, public health, likethe personal health care system, has been unable to takefull advantage of innovations in information andcommunication technologies. Three levels of governmentare involved in public health, and as the SARS outbreakdemonstrated, public health must be connected to whatis happening in clinics, hospitals, and other parts of thehealth enterprise. Thus, information must move rapidlyto and from the clinical and public health frontlines.Both professionals and the media have been strongly and justifiably critical of the difficulties in sharinginformation across levels of government that becameevident in the recent outbreak of SARS. Special effortsmust be made not only to invest in informationtechnology, but also to generate the intergovernmentalagreements and information standards that will giveCanada a leading-edge public health information system.These must be an integral part of rolling out any newfunding, whether for general public health renewal, orearmarked for infectious disease surveillance and outbreakmanagement. Alongside these more informal agreements,and notwithstanding any federal legislative renewal, onecan also envisage a process to upgrade and harmonizepublic health legislation across Canada, facilitating thefunction of a truly seamless system to protect and promotethe health of our citizens, wherever they live.

These are not tall orders. They presuppose in the firstinstance only a visible and continuing commitment onthe part of all those who govern us to the principle that,whatever other differences may inevitably separate us in this sometimes-fractious federation, the health ofCanadians is paramount. Beyond that, the investment ofnew monies needed to transform public health is modestcompared to numerous other spheres of public spending,not least the personal health services sector. The singlequestion that the Committee would put to all healthministers, finance ministers, and first ministers isaccordingly simple: If not now, when?

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References1. Kuiken, Thijs, et al, “Newly discovered coronavirus as

the primary cause of severe acute respiratorysyndrome”, The Lancet, 2003, 362: 263-70.

2. Naylor, C. David, “Private Practice, Public Payment:Canadian medicine and the politics of healthinsurance, 1911-1966,” McGill Queen’s UniversityPress, Montreal, 1986: 35-37.

3. McKeown, Thomas, “The role of medicine: dream,mirage or nemesis?”, Oxford: Basil Blackwell, 1979.

4. Public Health in England, “The Report of theCommittee of Injury into the Future Development ofthe Public Health Function,” Cmnd 289, London:HMSO, 1988.

5. Report of the Premier’s Advisory Council on Health(Donald Mazankowski, Chair), “A Framework for Reform,”2001. (www.premiersadvisory.com/reform.html)

6. Public Health Act R.S.Q., 2001 c60, s5.

7. Rose, Geoffrey, “The population mean predicts thenumber of deviant individuals,” British Medical Journal,1990; 301:1031-4.

8. Wilson, Kumanan, “The complexities of multi-levelgovernance in public health”, (unpublished).

9. Lalonde, Marc (Minister of National Health andWelfare), “A New Perspective on the Health ofCanadians,” Ottawa: 1974.

10. Lederberg, Joshua, Shope, Robert E. and Oaks,Stanley C. (eds.), “Emerging Infections, MicrobialThreats to Health in the United States,” Committeeon Emerging Microbial Threats to Health, Instituteof Medicine), National Academy Press: WashingtonD.C, 1992.

11. Krever, Horace, “Commission of Inquiry on theBlood System in Canada,” Volume 3, p. 1073,released November 26, 1997.

12. Government of Quebec, “Emerging Solutions,”Commission d’étude sur les services de santé et lesservices sociaux, June 2000.

13. Government of Newfoundland and Labrador,“Healthier Together: A Strategic Health Plan forNewfoundland and Labrador.” Department of Healthand Community Services, released Sept. 10, 2002.(www.gov.nf.ca/health/strategichealthplan/pdf/HealthyTogetherdocument.pdf)

14. Romanow, Roy, “Building on Values: The Future ofHealth Care in Canada,” Commission on the Futureof Health Care in Canada, November 2002.

15. Frank, John and di Ruggiero, Erica, “Public Health inCanada: what are the real issues?”, Canadian Journalof Public Health, 2003, 94(3): 190-192, CIHR Instituteof Population and Public Health, Toronto.

16. The Standing Committee on Social Affairs, Scienceand Technology (Michael Kirby, chair), “The Healthof Canadians—The Federal Role,” Volume Six:Recommendations for Reform (Chapter 13), Ottawa,October, 2002.

17. Health Care Renewal Accord 2003. (www.hc-sc.gc.ca/english/hca2003/)

18. The Institute of Medicine, “The Future of the Public’s Health in the 21st Century,” publishedNovember 2002, National Academies Press.(www.nap.edu/catalog/10548.html)

19. Wente, Margaret. Globe and Mail, May 5, 2003, p. A15.

20. Federal/Provincial/Territorial Advisory Committee on Population Health, “Review of Public HealthCapacity in Canada,” Report to the Conference ofDeputy Ministers of Health, June 2001.

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Appendix 3.1US Department of Health and HumanServices Organizational Chart

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The SecretaryDeputy Secretary

Chief of Staff

Executive Secretary

Commissioner, Food and Drug Administration

(FDA)

Administrator, Health Resources and

Services Administration (HRSA)

Director, Indian Health Service

(IHS)

Director, National Institutes of Health

(NIH)

Administrator, Substance Abuse and Mental Health Services Adminstration

(SAMHSA)

Director, Program Support Center

(PSC)

General Counsel

Assistant Secretary for Public Health

Emergency Preparedness

Director, Center for Faith-Based and

Community Initiatives

Director, Office for Civil Rights

Inspector General

Chair, Departmental Appeals Board

Assistant Secretary, Administration for

Children and Families (ACF)

Assistant Secretary, Administration on Aging

(AoA)

Administrator, Centers for Medicare &

Medicaid Services (CMS)

Director, Agency for Healthcare Research and Quality

(AHRQ)

Director, Centers for Disease

Control and Prevention (CDC)

Administrator, Agency for Toxic Substances

and Disease Registry (ATSDR)

Assistant Secretary for Health

Assistant Secretary for Administration

& Management

Assistant Secretary for Budget, Technology,

& Finance

Assistant Secretary for Planning & Evaluation

Assistant Secretary for Legislation

Assistant Secretary for Public Affairs

Director, Intergovernmental Affairs, & Secretary’s

Regional Representatives

ENHANCING THE PUBLIC HEALTH INFRASTRUCTURE: A Prescription for Renewal

Chapter 4

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Chapters 2 and 3 have shown how and why the infra-structure that supports the delivery of public healthservices in Canada is fragile and uneven. Canadiansmust be able to rely upon public health to protect themfrom hazards to health, known and as-yet-unknown,while providing the full range of public health services.Some phenomena are predictable (e.g., “flu season”), butmost public health threats are unpredictable in their timingand location. As the SARS episode has demonstrated,they can also be unpredictable in their nature. The struc-tures and processes required to enable core public healthfunctions constitute the public health infrastructure[PHI]. This infrastructure is analogous to personal healthservices, where clinical interventions such as surgery anddrug therapy require an infrastructure of hospitals,doctors, nurses, equipment, medical schools, a pharma-ceutical industry and so on. Hence, in this chapter, weconsider the nature of the PHI and recommend strategiesfor renewing it at the federal, provincial/territorial, andmunicipal levels.

4A. Core Elements of the PublicHealth Infrastructure

The PHI schema set out below is similar to that used bythe CDC. The first three categories apply across thesystem at the local, P/T and national levels.

a. Organizational Capacity• Agreed strategies to maintain the capacity of the

public health system, to effect improvement in majorhealth issues, to set priorities and make strategicinvestments.

• Modern legislation, harmonized across jurisdictions.

• Defined essential functions, programs and services.

• An effective governance structure to ensure cleardecision making authority and public accountability, that ensures clarity of roles andresponsibilities within a systems-wide perspective, andmaximizes resources to achieve public healthobjectives.

• Visibility for, and leadership of, the public healthcommunity and effective communication with thepublic.

• Mechanisms to consult and undertake collaborativeplanning to develop national strategies for importantpublic health issues.

• Mechanisms to support non-governmentalorganizations and to consult with them.

b. The Public Health Workforce• Appropriate number of staff.

• Standards for qualifications and competencies.

• Health human resource planning for public health.

• Accessible and effective training programs in anumber of formats.

• Lifelong learning and career-developmentopportunities.

c. Optimal Business Processes and Informationand Knowledge Systems

• Defined, optimized and agreed programs and businessprocesses, including a streamlined and enhancedcapacity to assist with the management of outbreaksof disease and threats to health, including linkages toclinical systems.

• Standards and best practices.

• Research related to population and public health.

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• A central resource for knowledge translation andevidence-based decision-making, including theidentification of research needs.

• Evaluation of population and public health programs.

• An information infrastructure, including informationarchitecture, models and standards, technologytransfer, privacy and information management,development of data sources, and system development.

To these three categories one can add a fourth categoryof functions that fall naturally to the national level.These include highly technical or scarce expertise,facilities or equipment that constitute a specializedreserve or surge capacity that is best provided ororganized nationally, and formal international liaisonactivities. The federal public health function is aparticipant in the first three categories, and the providerof the fourth.

d. National Strategic Capacity• Continuing national resources

– technical assistance

– development of technical protocols and practiceguidelines

– reference laboratories

• Specialized surge capacity

– personnel

– materiel

– logistics assistance

– management and/or coordination of outbreaks andemergencies

• International

– liaison with, and reporting to/from foreigncountries and international organizations

This schema illustrates first and foremost that there areno great mysteries in the organization of an effectivepublic health system. Most of these functions are self-explanatory. Rather than elaborate on all of them here,we shall focus on a few general and critical functions.Additional detail on outbreak management, diseasesurveillance, laboratories, and health human resourcesfollows in the next chapters.

4B. A New National Public HealthFocus

4B.1 General ConsiderationsMany submissions from health stakeholders have calledfor a revitalization of the public health organization atthe national level and the creation of a professionalizedextra-governmental centre of expertise. For example, theCanadian Medical Association has recommended the“creation of a Canadian Office for Disease Surveillanceand Control as the lead Canadian agency in publichealth, operating at arm’s length from government.”The Canadian Public Health Association reported onconsultations showing “that the critical first step must beto increase current front-line public health capacity andto establish a National Public Health Agency.” TheCanadian Infectious Disease Society also favoured a“CDC North” with a specific mandate for infectiousdisease prevention and control.

We have seen above that a national agency for publichealth is a common pattern in other countries of theOrganisation for Economic Co-operation and Development[OECD]. The Population and Public Health Branch [PPHB]of Health Canada currently operates many of the corefederal public health functions for Canada. Its organiza-tion chart (see Appendix 4.1) includes multiple centres,some headquartered outside of Ottawa. In suggesting amajor restructuring of Branch activities, the Committeeintends no disrespect to the culture or accomplishmentsof Health Canada or the federal public service in general.However, the current placement of public health functionswithin a department of government puts public healthprofessionals inside a very large organization and a highlyprocess-oriented culture with a particular orientation tothe political issues of the day. One advantage highlightedby many commentators has been the transparency andenhanced credibility arising from a clearer distinctionbetween scientific advice on the one hand, and policy-making within Health Canada and Parliament on theother. A new agency could also provide expert advice toregulators in areas such as food safety, environmentalhazards, and therapeutic products.

The processes by which policy is developed and communi-cated may be suboptimal for the provision of specializedpublic health services or even advice on regulatory matters.Whereas the scientific process demands a relatively freeflow of information, governments tend to seek control ofcommunications and aim for a somewhat hierarchicalpolicy function leading towards the ultimate democraticauthority—Parliamentary debate and decision making.

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Some observers believe that one organization cannotdischarge both functions concurrently; rather, these streamsshould be brought together by building stronger bridgesbetween the distillers of evidence and the framers ofpolicy. Moreover, a service orientation and collaborativeculture are essential if the new national agency is tofulfill the mandate that Canadians rightly expect of it.These attributes are at least partially distinct from otherpolicy-making functions.

The Committee believes scientists and professionals wouldfind an arm’s-length public health agency more attractiveas a place of employment. An agency would enjoy greaterflexibility in developing cooperative or contractualarrangements with academic institutions and other privatepartners, thus facilitating research and enhancing accessto first-class talent. Agency status might also provide fora longer time horizon and greater stability of funding,with less risk of diversion of funds to other purposes.

The creation of an agency cannot depoliticize traffic amongjurisdictions, but it could reduce the chances that thehealth of Canadians would inadvertently be held hostagein a jurisdictional disagreement among levels of govern-ment. An agency standing outside government and ledby a public health professional could find new ways toengage public health professionals in the provinces andterritories, and re-energize the public health workforce.Creation of an agency would also bring the delivery ofpublic health services in line with public health in manyother countries.

By analogy, personal health services themselves aregenerally not delivered directly by federal or provincialgovernments. They are devolved to a vast number ofindividuals, institutions, and agencies. We see potentialfor better partnership with personal health serviceproviders through a new public health agency, particularlygiven the sometimes acrimonious interactions aroundhealth care at F/P/T tables in recent years. An agencywould also provide some continuity of leadership andinsulate public health functions from the lamentablyshort terms in office of senior F/P/T health officials andhealth ministers during the last decade.

4B.2 What Does ‘National’ Mean? The lexicon of Canadian F/P/T politics, and the need toreinforce public health infrastructure at all levels ofgovernment lead logically to consideration of two optionsfor a national agency. One is an F/P/T agency, accountableto federal, provincial, and territorial representatives. Thisis the model endorsed by the Council of Chief MedicalOfficers of Health. The other is a federal agency, moreclosely resembling the USA’s CDC.

We begin with F/P/T agency options. One currentexample is the Canadian Institute for Health Information[CIHI]; it has blended F/P/T funding and governance.Albeit structured as a non-profit corporation, the CanadianBlood Services [CBS] is another distinct variant. It is P/T-governed and-funded, with the federal governmentacting as the national regulator for the agency. Creatingany such agencies would involve difficult and time-consuming negotiations that could exacerbate existingtensions at F/P/T tables. CIHI has a more limited servicemandate and much smaller budget than would beencompassed by the existing public health functions.The F/P/T agency option would also blur lines ofaccountability. As Prof. Kumanan Wilson1 advised theCommittee, the CBS model has other drawbacks. It hasbeen criticized by provinces for importing the US problemof unfunded federal mandates to Canada, because itcouples national regulation to provincial supply andpayment. Even assuming new federal funds to cost-sharethe operation of a P/T-governed national agency, andfederal regulations to create consistency of operationsacross provinces, this variant seems wholly impractical.In general, the F/P/T agency option is not compatiblewith calls for clarity of roles along with renewed federaland provincial strength in public health.

SARS has nonetheless underscored for Canadians theneed for coordination of functions in areas such as diseasesurveillance, outbreak management, and emergencyresponse. These areas inescapably involve a roll up ofactivities from the municipal or regional to the provincial,interprovincial, and federal levels. We shall return tothese points in Chapter 5. For now, the Committee willsimply highlight the logical appeal of an F/P/T networkstructured to reinforce and help coordinate diseasesurveillance and outbreak management on a truly pan-Canadian basis, linked to the work of the successful F/P/Tnetwork that is already operating in the realm ofemergency preparedness and response. A new infectiousdiseases network would need earmarked funding that

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1 Interested readers can find more information on Wilson’s work on federalism at http://www.iigr.ca/publication/detail.php?publication=301 (accessed on August 21, 2003).

could flow from a federal agency to provincial centresand agencies on an equitable, transparent, and strictlymission-oriented basis. It could become a bulwark againstnew threats such as SARS. Such a network, however,requires a strong federal node that can pull its weight indisease surveillance, outbreak management, and emergencyresponse. And, for reasons given in Chapter 3, the federalgovernment must be positioned to work more generallyin support of provincial and municipal public healthprograms. To these ends, the Committee endorses thecreation of a new federal public health entity which, forease of reference, we shall term the Canadian Agency forPublic Health.

4B.3 The Structure of a New FederalAgency for Public Health

The Committee considered some options available in thecurrent machinery of government.

A Crown Corporation offers substantial independencefrom the financial and personnel controls that accompanydepartmental administration. The enabling legislationfor each Crown corporation sets out the corporation’smandate, powers and objectives. Crown corporations areaccountable to Parliament through assigned responsibleministers. The federal government retains power andinfluence over Crown corporations through: i) theappointment and remuneration of directors and chiefexecutive officers; ii) directives and regulations; and iii)approval of corporate plans and budgets. The Committeeconcludes that a Crown Corporation removes the newagency too far from Parliament and government—a point of concern given the need to ensure integration ofpublic health activity with a wide variety of departments,not least Health Canada itself.

Special Operating Agencies [SOA] are designed tobalance controls (and risk avoidance) with encouragementof innovation and initiative. SOAs support a set ofvalues—including innovation, enhanced authority at thefront line, client-centred operation, self-regulation, bettermanagement of people and accountability for results—which will lead to greater efficiency of operation andimproved service quality. SOA examples include TechnologyPartnerships Canada, Training and Development Canadaand the Canadian Heritage Information Network. SOAsare not independent legal entities, and are established on the basis of Treasury Board approval. We reject thisoption on the grounds that SOAs remain part of, andaccountable to, their home departmental organization,with preservation of all existing labour relations.

Departmental Service Organizations are operationalunits or clusters of units within a department. They areorganized to deliver services to the department’s clients.Like SOAs, they operate within a management frameworkapproved by the deputy minister and the Treasury Board,but may represent a larger share of the department’s overallactivity than a typical SOA. No separate legislation isrequired. Environment Canada’s Meteorological Serviceis the only such organization in existence. Again, thisoption does not provide the required independence oropportunity to integrate activity from multipledepartments.

Separate (statutory) agencies, also known as LegislatedService Agencies [LSA] or Departmental Corporations,provide a fourth option. Included in this category arethe Canadian Food Inspection Agency, the CanadianInstitutes of Health Research, Statistics Canada and theCanada Customs and Revenue Agency. These are mission-driven organizations established by specific legislation tomanage the organization and delivery of services withinthe federal government. They typically perform adminis-trative, research, supervisory, advisory and/or regulatoryservices of a governmental nature. Legislation sets outthe framework under which each agency will operateincluding its mandate, governance regime, powers andauthorities, and accountability requirements.

Separate agencies differ only slightly from each other.They have the following common characteristics:

• headed by a chief executive officer [CEO] reportingdirectly to the Minister;

• supported by a “Board” with members appointed bythe Governor in Council;

• subject to Ministerial direction;

• separate employer under the Public Service StaffRelations Act (e.g., increases staffing authority/flexibility);

• managed on the basis of a corporate business plan;

• focus on performance and accounting for results;

• greater financial and administrative authorities thantraditional departments, e.g., ability to enter intopartnering/licensing arrangements and can obtainnon-lapsing spending/revenue retention/re-spendingauthority; and

• oversight by the Auditor General and subject to theOfficial Languages Act, Privacy Act and Access toInformation Act and Federal Identity Programrequirements.

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As one example, the Canadian Food Inspection Agency[CFIA] has some powers/authorities that distinguish it froma “typical” department. These are listed for reference:

1. Separate employer (e.g., authority to appoint fromoutside of the public service, full control over classifi-cation, collective bargaining, pay and compensation);

2. Can set its owns fees and sell assets/services, e.g., training, accreditation, intellectual property, andretain revenue;

3. Funded through parliamentary appropriations but canspend/carryover for two years at a time;

4. Enhanced F/P/T collaboration mechanisms, in that theAgency can

a. delegate inspection/quarantine powers to P/Tpublic servants and private sector specialists;

b. enter into agreements with one or more P/Tgovernments for the provision of services; and

c. create F/P/T corporations to carry out jointactivities in a more “integrated” fashion;

5. Choice of service providers, e.g., legal, propertymanagement services; and

6. Increased contracting authority.

Even a cursory review of these characteristics underscoresthe rationale for the Committee’s recommendation thatthe new federal public health agency be structured as alegislated service agency.

The relevant legislation could be relatively skeletal with a view to timely passage. It would presumably includeappropriate and consolidated authorities to address publichealth matters where the federal government is expectedto provide leadership and action, such as national diseaseoutbreaks and emergencies, with or without additionalauthorities regarding national disease surveillance capacity.Spending authorities, however, would need to be determinedand specified, especially given the need for the Agency touse financial transfers as a means of strengtheninginfrastructure and collaboration on a truly national basis.

On the human resources side, it seems desirable for theorganization to have the authorities of a separate employerunder the Public Service Staff Relations Act to allow it toaddress unique recruitment and retention challenges inan environment of global competition for scarce scientificand public health expertise. Two other desirable featuresof agency status are the ability to use a 24-month financial

horizon, thereby escaping the perverse cycle of year-endspending that persists in Ottawa, and enhanced flexibilityin selecting providers in areas such as information tech-nology, legal services, and property management.

The new Canadian Agency for Public Health would report through its director to the Minister of Health. The Minister would be ultimately responsible for theagency, as occurs with the US CDC. The legislation wouldprovide appropriate powers for delegation of ministerialauthorities to officials. The Minister would continue togive policy direction to the agency and obtain anyinformation required to provide appropriate ministerialoversight, direction and accountability. However, weenvisage that the agency would have a strong internalpriority-setting process and a clear strategic focus in itsown right. In other words, the new agency would havemeaningful autonomy as contrasted with, say, therelationship between Finance Canada and the CanadaCustoms and Revenue Agency today.

The constituting legislation might also include legalauthorities to access and use sensitive data sourced frompublic and private sectors for public health purposes,creating a data enclave as exists for Statistics Canada.Indeed, the public health data enclave might be a ‘Swissbank’ within Statistics Canada itself. Absent such author-ity, and given problems with extant privacy legislation aswill be outlined later, the agency may have difficultiesbalancing the appropriate protection of privacy with itsperformance expectations.

As the agency would be part of the Health portfolio, theGovernment would need to clarify and establish theappropriate roles and responsibilities of Health Canada,as a department, in relation to the agency. We return tothe specific question of agency scope below.

The agency would receive an annual appropriation fromParliament, and be subject to Parliamentary scrutiny in thesame manner as for departments. That is, the AuditorGeneral of Canada would provide oversight of theagency’s financial statements and performance, includingan assessment of the fairness and reliability of theperformance information contained in the performancereport to Parliament. The Institute would also be subjectto all legislation governing departments, such as theOfficial Languages Act, Canadian Human Rights Act, Accessto Information Act and the Privacy Act.

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4C. A Chief Public Health Officerfor Canada

The Committee received a number of recommendationsfor the creation of a professionally-qualified leadershiprole in public health at the national level. This isvariously described as a Surgeon General, National PublicHealth Commissioner, Federal Chief Medical Officer ofHealth, or Chief Public Health Officer of Canada. Amongthe many stakeholder groups endorsing variations onthis theme were: the Council of Chief Medical Officersof Health, the Canadian Medical Association, theCanadian Federation of Nurses Unions, the CanadianAssociation of Emergency Physicians, the Canadian PublicHealth Association, and the Association of CanadianAcademic Healthcare Organizations.

Other countries have established similar positions. In the UK, there are Chief Medical Officers for England,Scotland, Wales and Northern Ireland; and the UK’sHealth Protection Agency is headed by a public healthphysician. In the USA, the Surgeon General and Directorof the Centers for Disease Control and Prevention areboth health professionals.

The Committee has considered different options regardingthis position. One would be to create a Surgeon Generalor ‘auditor-general for health’ who is arm’s length andapolitical. This public health watchdog could reportdirectly to the Minister as in the UK. A second and relatedoption would be to establish the position as an officer ofParliament. Officers of Parliament are generally thosewho have cross-cutting functions related broadly togovernment and governance. This does not square fullywith the public health role. In either case, the problemis that such an office would have moral authority butlittle else. An alternative option would be to create therole, but nest it within an existing or new structure. Forexample, in a new agency, a senior professional could bethe Chief Public Health Officer, analogous to the ChiefVeterinary Officer of Canada who reports to the directorof the CFIA. This is feasible, but again could leave theChief Public Health Officer in a rather awkward positionas regards independently raising issues of broad concernfor public health.

If the Chief Public Health Officer were also to be thechief executive of the new federal agency for publichealth, then he/she has a logical position of advocacyand leadership, and the tools to advance an agenda ofchange. We acknowledge potential conflicts of interestin the dual role: i.e., the Chief Public Health Officer hasan interest in ensuring that the agency is perceived to be

discharging its responsibilities effectively. However,given the visibility of the agency, appropriate ministerialoversight, and—as described below—the creation of aNational Public Health Advisory Board, this conflict canbe mitigated.

Protections for the independence of the Chief PublicHealth Officer can be devised that are analogous to thosein various provinces or territories. In urgent situationswhere the health of their respective public is threatened,a P/T health officer often has independent authority tonotify the public and advise on measures necessary forpublic protection. Specific provincial examples exist forprotection of the independence of chief health officers.In British Columbia, the Provincial Health Officer has thepower to report directly to the legislature:

If the Provincial health officer considers that theinterests of the people of British Columbia are bestserved by making a report to the public on healthissues in British Columbia, or on the need forlegislation or a change of policy or practice respectinghealth in British Columbia, the Provincial healthofficer must make that report in the manner theProvincial health officer considers most appropriate…Each year the Provincial health officer must givethe minister a report on the health of the people of British Columbia including, if appropriate, information about the health of the people asmeasured against population health targets, andthe minister must lay the report before theLegislative Assembly as soon as practical. (Health Act, ch 179, 2.3 (3) & (4))

In Manitoba, as a result of a review by the Ombudsmanof events surrounding a delay in notification of thepublic, the employment agreement between the provinceand the Chief Medical Officer of Health states:

While accountable to the Department, the ChiefMedical Officer of Health may function autono-mously when necessary in the interests of thehealth of the public. Under these circumstances,the Chief Medical Officer of Health has theauthority to issue public health advisories andbulletins, or take other actions. The Chief MedicalOfficer of Health will inform the Deputy Ministerand/or the Minister prior to such actions or as soonas practically possible, in accordance withestablished protocols. (Schedule “I”, (12))

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In short, appropriate safeguards for the independence ofthe Chief Public Health Officer of Canada can be setin place without compromising her/his accountability asan agency director.

The Chief Public Health Officer of Canada would be aleading national voice for public health, particularly inoutbreaks and other health emergencies, and a highlyvisible symbol of a federal commitment to protectingand improving Canadians’ health. She or he shouldobviously be trained and adept in crisis communications.The Chief Public Health Officer of Canada should berequired to report to Parliament on an annual basis onthe state of public health, and given authority to make aspecial report to a special parliamentary committee onany matter of pressing importance or urgency that shouldnot be deferred.

Additional duties of the Chief Public Health Officer ofCanada could include:

• to protect and advance the health of Canadians byadvocating for effective disease prevention and healthpromotion programs and activities;

• to articulate scientifically-based health policy analysisand advice to the federal minister of health and, asrequested, provincial and territorial ministers ofhealth, on the full range of critical public health andpublic health system issues;

• to provide leadership in promoting special healthinitiatives, (e.g., relating to health inequalities,childhood injuries, Aboriginal health) withgovernmental and non-governmental entities, bothdomestically and internationally; and

• to elevate the quality of public health practice in theprofessional disciplines through the advancement ofappropriate standards and research priorities.

4D. Scope of the CanadianAgency for Public Health

Public health agencies, centres, and institutes around theworld vary greatly in their scope. It is premature for theCommittee to recommend exactly which activities andprograms should be included at this point, beyondindicating our support for a strong and integrativeorganization. Instead, a systematic review of the scope ofthe new agency is needed. While there is also an optionto have two, or more, agencies, as in the UK, we endorsea unitary structure. A list of areas for inclusion follows,together with a table indicating which activities fallwithin the scope of particular centres or agencies indifferent jurisdictions.

1. infectious disease, prevention & control

2. microbiology reference laboratories

3. emergency preparedness & response

4. chemical exposures

5. poison control

6. environmental health

7. chronic disease prevention & control

8. injury prevention & control

9. perinatal & child health/human development(programs)

10. health promotion grants

11. tobacco control

12. drug control

13. screening

14. occupational health

15. food protection

16. radiation protection

17. knowledge translation

18. research

19. infostructure

20. international collaboration

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In Canada, a range of government departments andagencies engage in public health activities, including theCanadian Food Inspection Agency, Canadian Customsand Revenue Agency, Citizenship and ImmigrationCanada, Indian and Northern Affairs, and EnvironmentCanada. In each of these cases, a working relationshipexists with Health Canada. This division of roles maynot be uniformly optimal. As one example, the area ofenvironmental impacts on health has been seriouslyneglected in Canada and requires urgent investment; weenvisage this as a program of activity that must besupported by the new agency.

Specific programs within Health Canada also deal withnon-regulatory aspects of tobacco and nutrition. Oneview is that these functions should stay linked to thecorresponding regulatory activities; another would arguethat they should be rolled into the new agency. TheCommittee believes that regulation of food, pharma-ceuticals, therapeutic products, pesticides, or consumerproducts should remain outside the mandate of theagency. While its work should inform the regulation ofenvironmental hazards, and occasionally generate expertadvice for federal regulatory functions as listed, the agencywould not be expected to deal with the mechanics ofregulation. For reasons that will be outlined in the nextchapter, the Committee envisages that the Centre forEmergency Preparedness and Response would be sited inthe new agency, albeit with continued cross-linkages toother departments throughout the federal government.The new agency should create opportunities to engage inactivities that currently receive less attention in HealthCanada than might be deemed ideal, such as injuryprevention and control and mental health.

Zoonoses are of special interest to the Committee, forobvious reasons. The SARS coronavirus is simply thelatest in a growing number of viruses that are believed tohave moved from animals to humans with devastatingeffects in recent decades. Currently, the Chief VeterinaryOfficer of Canada works within the CFIA, serving asExecutive Director of the Agency’s Animal ProductsDivision, with responsibility for administration of theHealth of Animals Act. More specific responsibilities includesurveillance systems, certifying that Canada is free of theInternational Organization for Epizootics (usually knownby the French acronym, OIE) “A” list diseases, representingCanada internationally, and helping to manage veterinaryepidemics of notifiable and reportable diseases.

At risk of oversimplification, one can say that the CFIAwould consider an animal disease part of its mandate if itled to a food safety or food trade concern, or if it werelegislated to be responsible for a disease. This leads to theodd situation whereby rabies and equine encephalitis(which are human health risks, but of little food safetyconcern) are considered part of the CFIA mandatebecause of legislation, whereas West Nile virus (a humanand animal health concern but not a food safety issue) isoutside of its mandate. As outlined in a submission fromthe Canadian Veterinary Medical Association [CVMA],veterinarians collaborate across federal, provincial, andterritorial governments, and extensive lists of notifiableand reportable animal diseases are maintained andupdated. The CVMA states, “Despite the extensiveanimal disease surveillance programs, there is no directlink with public health care programs; not at the nationallevel, the provincial level, or at the local level…There is amuch clearer role for veterinarians defined in federal statutesfor animal disease control, and particularly for Reportablediseases, than seems to be the case for human health.”

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Agencies Components

BC CDC 1, 2, 4, 5, 6, 12, 15, 16, 18, 20

Quebec’s National Institute of Public Health 1, 2, 4, 5, 6, 7, 8, 9, 11, 13, 14, 18 20

New Zealand Institute for Environmental Science Research 1, 2, 4, 6, 18, 19

U.K. Health Protection Agency 1, 2, 3, 4, 5, 18

U.K. Health Development Agency 9, 17

European Centre for Disease Prevention & Control 1, 3

Finland: National Public Health Institute 1, 2, 6, 11, 18

Sweden: Institute for Infectious Disease Control 1, 2, 18

Norwegian Institute of Public Health (Folkehelseinstituttet) 1, 2, 18

U.S. Centers for Disease Control and Prevention 1, 2, 3, 7, 8, 9, 11, 12, 13, 17, 18, 19, 20

Canadian Food Inspection Agency 15

Zoonotics do have coverage within existing HealthCanada structures. These include the Food Safety andZoonotics Division within the Centre for Infectious DiseasePrevention and Control, the Laboratory for Zoonoticsand Special Pathogens at the National MicrobiologyLaboratory and the Laboratory for Foodborne Zoonosesin Guelph. Nonetheless, the new agency will clearly needto develop strong partnerships with academic veterinarymedicine and the veterinary practice community in Canada.In this respect, the Committee notes that the 1994 LacTremblant report recommended that the government ofthe day should “[a]ddress zoonoses, such that an effectivemeans of information sharing be established between allthe interested groups (i.e., veterinary medicine, AgricultureCanada, regulatory bodies, Canadian CooperativeWildlife Health Centre, public health).” Progress hasbeen made, but more is needed.

As noted above, another function that should be strength-ened and vested at least partly with a new agency is theproduction of an annual report on the health status ofCanadians, as well as other reports focused on specificaspects of population health from time to time. CurrentlyCIHI produces an annual report on the health of Canadians.This information and the related analytical capacity areessential for the new agency in setting targets and workingtowards them collaboratively with the provinces andterritories.

We have deliberately left an issue of great importance forfinal comment in this section. The health status indicatorsfor Canada’s First Nations and Inuit peoples are dramati-cally worse than those for the majority populations.These health status disparities are a national disgrace.They exist for a variety of infectious diseases as well asnon-communicable illnesses. Addressing them requires awide-angle approach to health determinants and commu-nity development that must clearly be integrally supportedand guided by the affected Aboriginal communities. Acontinuing challenge in mounting appropriate responsesis a recurring tension between the right and aspirationsof Aboriginal peoples to greater self-determination withinthe Canadian federation, and the uncertain effectivenessand efficiency of reinforcing the extant pattern of separatehealth systems for First Nations and Inuit communities.Early in its deliberations, the Committee made a strategicdecision not to move into this difficult terrain, believingthat a superficial verdict would do more harm than good,and that the field was best left to general assessmentswith a longer timeline such as the one now underway bythe Standing Senate Committee on Social Affairs, Scienceand Technology, chaired by Senator Michael Kirby. At this point, we shall say only that the scoping exercisefor the new agency must be informed by a careful reviewof public health service provision and health promotionfor First Nations and Inuit Canadians.

4E. A Federal Agency with a Pan-Canadian Orientation

Jurisdictional ambiguities and tensions have longbedevilled public health activities and programs as wellas personal health services in Canada. Chapter 9 reviewshow the federal government might work with theprovinces to clarify some of these jurisdictional ambiguitiesand strengthen its legislative role in public health as partof the omnibus review of health legislation that isunderway. However, attempts at unilateral centralizationof authority in a fragile federation with a complexdivision of powers and responsibilities are generally aprescription for conflict, not progress. Measures to createcollegiality, consensus, and commonality of purpose canlead to collaborative work that overcomes jurisdictionaltensions. Indeed, as already stated, part of the rationalefor a new agency is to remove it some distance fromF/P/T fault lines. We accordingly review here some of thefeatures of the agency that would give it a national ratherthan federal flavour and orientation. Three salientfeatures are the distribution of the functions of the newagency, creation of what we term, after the Australianprecedent, the Public Health Partnerships Program toflow funds to provinces, territories and municipalities insupport of front-line public health functions, and theappointment of a National Public Health Advisory Boarddrawing on an F/P/T nomination process.

4E.1 One Agency, Many Locations Health Canada currently operates a system of regionaloffices, with the headquarters of the Department inOttawa at Tunney’s Pasture. Few of the core functions ofPPHB are sited in these regional offices, and theirconnections to provincial and municipal health agenciesvary from one office to the next. We see little merit inspreading agency staff through these offices. On the otherhand, PPHB does have major foci outside of Ottawa.Particularly pertinent given the Committee’s mandate are the National Microbiology Laboratory in Winnipeg,Manitoba, and the Laboratory on Foodborne Zoonoses in Guelph, Ontario.

The Committee does not believe that the agency shouldbe centralized in a single new location. This wouldinvolve a transition from the current arrangement, bedisruptive for staff, and fail to capitalize on the full rangeof opportunities for partnership in P/T and municipaljurisdictions. We assume, moreover, that there will besome expansion of core functions in Ottawa, aligned

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with the funding recommendations and national publichealth strategy (see below). But the agency must be seento reach across Canada in tangible and visible ways.

There accordingly exist two logical options. One is toconcentrate on specific locations for establishing orexpanding agency functions that reflect the currentgeographical siting of PPHB. The other is to expandjudiciously some of the existing sites and deliberatelydevolve some existing or new functions to new locationsacross Canada. In this latter vision, which theCommittee endorses, an explicit effort would be made todelineate regional hubs (for example, in Vancouver,Edmonton, Winnipeg, Toronto, Quebec City and Halifax)that could each offer a specialized national resource,differentiated in support of the entire system (such asexists in Winnipeg with the National MicrobiologyLaboratory).

In the next chapter, we outline our recommendation fora national network of centres for infectious diseasecontrol, predicated on a provincial/regional hub systemas recommended by the Canadian Public HealthAssociation, and building on strengths by involving P/T,academic, and possibly other partners. Even withoutdetails about the network concept, one can imagine afully developed system in which each regional centre hastwo components, both bolstered by partnerships withlocal academic centres, the relevant municipal healthagency, and other stakeholders:

1. A regional centre focused on infectious diseasesurveillance and outbreak management, with F/P/Tfunding, networked into a national steering committee,and reporting to a director appointed under specificP/T authority (either on a single jurisdictional ormulti-jurisdictional/regional basis). Federally-fundedpersonnel could work in the P/T regional centre (or elsewhere in municipal or provincial public healthagencies) as part of a system of strategic secondmentswithin a national public health service.

2. A specialized federally-funded and administeredcentre, serving as a national resource, led by a directorwithin the new federal agency, and reporting to theChief Public Health Officer of Canada.

In the best of all worlds, activity in these regional hubswould become mutually reinforcing, with the emergenceof a common culture dedicated to protecting the healthof Canadians. Regional specialty centres within the newagency might supplement some of the technical supportfunctions of P/T ministries. For example, public healthlaboratory functions could logically be rolled into a P/T

regional centre for infectious disease control. If a federallaboratory were to be developed as a specialized resourceand co-located, sharing of infrastructure and supplieswould make sense. These hubs would be ideal settings forapplied research, with both practitioners and academicsinvolved in joint research programs. They would also beexcellent settings for various types of training programs.

Last, some specialized federal resource centres may inthemselves operate on a networked basis. While thisreduces critical mass for regional hubs and F/P/T synergy,the network approach may have other advantages.

The key, in all cases, is to avoid building an empire atTunney’s Pasture and create a new culture of outreach,partnership, and excellence. As regards partnerships, anynew agency must consult widely with stakeholders in thebroader health community, including the voluntarysector and service provider associations and unions, toensure that the energy and creativity of non-governmentalorganizations [NGOs] is usefully harnessed.

4E.2 A National Public Health Advisory Board

The Committee also envisages the prompt creation of aNational Public Health Advisory Board. This Boardwould advise the Chief Public Health Officer of Canadaon the most effective means to create and implement anational public health strategy that reinforces pan-Canadian collaboration so as to protect and enhance thehealth of Canadians. The Board would be chaired by adistinguished Canadian prominent in the health sphere;its membership must reflect Canada’s geographic, culturaland linguistic diversity, as well as the range of disciplinesand stakeholders in public health. Internationalrepresentatives prominent in public health would beincluded on the Board.

To maintain appropriate and clear lines of authority, theagency and its chief executive must report to the Minister;the Board is therefore not a board of directors in the usualsense of corporate governance, but rather has an advisoryand strategic role. Nominations could be solicited fromexisting F/P/T networks and advisory committees, as wellas key stakeholders in the health sphere. In order tofacilitate pan-Canadian collaboration and integration ofpublic health functions with the broader health agenda,one option would be to stipulate that Board nominees mustbe vetted by the F/P/T Conference of Deputy Ministers ofHealth. In any case, members would be appointed tolimited terms by the federal Minister of Health, and theMinister could ask the Board for input on the performanceof the Chief Public Health Officer of Canada.

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4E.3 A National Public Health StrategyAs noted in Chapter 3, many countries have coherentstrategies with nationally-agreed health goals. Thesenations link legislation, programs, monitoring, standards,funding and accountability to a national strategy andobjectives.

Canada currently lacks an overall strategic approach tothe health field; this includes both public health andhealth care. Several stakeholder groups, including theCanadian Nurses Association and the Canadian PublicHealth Association, called for the creation of a nationalhealth strategy. This theme also emerged strongly fromfocus groups with front-line hospital staff and their unions.

Some provinces do have specific health goals. Sectorstrategies at the federal level also exist with varyingdegrees of collaboration for foci such as healthy living,cardiovascular disease, cancer and immunization. Further,provinces drawing on federal transfers and their ownrevenue bases will want to set their own public healthpriorities. However, the Committee sees overwhelmingmerit in a collaborative process to integrate existing strate-gies and forge an F/P/T consensus on goals. Canadiancitizens deserve a national health strategy that includesspecific health targets, benchmarks for progress towardsthem, and collaborative mechanisms to maximize the paceof progress. The Committee envisages a process wherebypublic health professionals from different levels of govern-ment and from major stakeholder groups should conferwith a view to developing priorities, goals and strategies.Public health professionals from Ottawa, the provinces,the territories, and various non-governmental partnersmust also pursue strategies to address the surveillanceinfo- and infrastructure, and human resources, topicsreviewed in more detail in Chapters 5 and 7. New federalfunding for public health should be explicitly tied tothese strategies and plans, with process and outcomereporting as in the Australian model, and be structured as contributions that are subject to audit (see below).

The national strategy should include provisions for acoherent response across jurisdictions to outbreaks ofcommunicable disease. Infectious disease/public healthemergency plans should be coordinated one with anotherand tested in simulation. However, the strategy must notbe limited to infectious diseases: the application ofincreased resources and new structures should facilitatethe development and implementation of a broadernational strategy to address causes of chronic diseasesand injuries. More research, more research synthesis andbetter evaluation of health promotion and other programsare all necessary as part of any effort to enhance the

effectiveness and efficiency of public health. And thesestrategies, in turn, would integrate the efforts of federal,P/T, and other stakeholders.

The Committee views communications as an integralpart of a public health strategy, not a separate, stand-alone item. The scope for public education is substantialin many areas of disease and health promotion. Forexample, a national campaign—developed in partnershipwith a number of stakeholders—could be launched toenhance public awareness of the risks of various infectiousdiseases and encourage sensible new norms in behaviour,e.g., more frequent hand washing, avoidance of workwhile in the contagious phase of a respiratory illness, useof surgical masks to prevent droplet transmission of viruses,and care during illness with a respiratory or enteric virusto prevent potential contamination of fomites (an inani-mate object that can carry disease-causing organisms) inthe work or home environment. Increased engagementof key stakeholders in communicating with the public,before and during infectious disease outbreaks offers newopportunities to inform the public through additional,innovative communications channels (i.e., employers,unions, and industry sectors directly implicated).

4F. Funding to StrengthenCanadian Public HealthCapacity

4F.1 General ConsiderationsPost-SARS, a rare consensus has emerged that more mustbe spent on public health by the federal, provincial, andterritorial governments. Submissions and observers haveprovided suggested figures: all represent significantincreases over current levels of funding. Given the manybillions of dollars of extra funding per annum flowing tothe acute care system as a result of two Health Accords,we have no hesitation in suggesting that it is time toredress the balance and invest an additional severalhundred million dollars per annum in public health.

Although Health Canada’s own operations requirestrengthening, this is not the only priority. New federalmoney must find its way to the front lines and to thoseactivities which serve to strengthen the generic capacityof local and regional public health agencies to protectand promote the health of Canadians. The Committee’sexpectation is that provinces and territories recognize—indeed, will assert—their primary responsibility for thosesame services, and also generously augment theirsupport.

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The health human resource shortfalls and urgent need tobolster public health agencies in some municipalities andprovinces make it essential that there be serious efforts ingood faith at F/P/T coordination. The worst-case scenariowould be one in which new funding served more toprompt bidding wars across jurisdictions and the movementof skilled public health personnel rather than buildingnew capacity.

Obvious targets for early investment are surge capacity todeal with infectious outbreaks and other emergencies, amajor program to build human resources in public health,reinforcement of the public health laboratory network (seeChapter 6), and creation of business process agreementsto facilitate coordinated F/P/T responses to outbreaks.Immunizations, discussed in more detail below, areanother target where money can be used quickly andwell. The list could doubtless be extended in differentdirections by different parties. Regardless, appropriateprudence in ramping-up federal funding is warranted toensure that investments meet strategic goals and thatnew federal monies do not simply displace existingpublic health commitments without much net gain.

4F.2 Funding the Core Agency FunctionsAs we saw in Chapter 3, the FY 2003 appropriation forthe US CDC was C$10.8 billion (US$7.2 billion). Use ofthis US benchmark presupposes both a strengthened corefunction in a new federal agency and enhanced flow offunds to support P/T programs, given CDC’s role in makingdiverse contributions to other levels of government. A directcomparison with federal spending in Canada is difficultgiven the fact that state and municipal public healthinfrastructure in the USA is arguably more uneven andthe per capita expenditures at the local and regional levelgenerally lower than in Canada after one discounts spendingon personal health services for recipients of social assistance.Federal expenditures on public health in Canada in anycase would need to increase several-fold to reach 1/10thof US expenditures suggested by the ratio of populations.

Another approach is to estimate the costs of strengtheningand supporting public health infrastructure in Canadaand focus on core functions already in existence or thosefunctions such as disease surveillance where a new agencymight reasonably be expected to take on a leading role.We have reviewed line-item estimates aimed at building amoderate level of infrastructure in the core agency overthe long term, but these are rough estimates and thebalance between lines would change over the years. Theseestimates did not include amounts necessary to galvanizecapacity at the P/T level, and deliberately focused onlyon “narrow-definition public health” as outlined inChapter 3, i.e., excluding the type of activities supported

by the program of grants and contributions to NGOs,universities, and other partners that is currently operatedby PPHB. (Enhancement of core activities wouldnaturally involve such partnerships; the issue here is thefunction and its incremental cost, not the mechanism.)How do these estimates roll up?

A proper national surveillance system alone could add$40 million a year, assuming that costs are borne primarilyby the federal government. However, as outlined in thenext chapter, we are assuming that surveillance of infec-tious diseases will be largely financed by the agency througha separate allocation. This estimate can thus be reducedsubstantially as regards core functions, assuming synergyin infectious and non-infectious disease surveillance. Let us peg this new cost crudely at $15 million per yearon the grounds that infectious disease surveillance systemsare a top priority in the present circumstances, and theP/T jurisdictions will themselves be co-investing in infec-tious disease surveillance. Development of the nationalhealth strategy, creation of performance standards, andpreparation of a report card to measure progress towardshealth goals could easily run $5 million a year. Enhancinghealth emergency preparedness and response, outlined in more detail in Chapter 5, adds at least $10 million per annum, rising by another $10 million if one considersthe urgent need to create epidemic response teams andother health emergency response teams to provide publichealth and health services surge capacity. Defensibleincreases in spending to enhance infectious disease capacitywithin the agency could run $50 million if the federalnodes in a new network for communicable diseasecontrol (see Chapter 5) are to be credible and supportivepartners. This includes costs of creating or improvingbusiness processes for surveillance and outbreak manage-ment, enhancement of federal laboratories, and someurgent capacity-building partnerships with provinciallaboratories until new F/P/T investments come on line.Investments in health human resources are urgentlyneeded. The agency must play a lead role in buildinghuman resources for public health, including primarytraining programs in partnership with colleges anduniversities, scholarships and bursaries, secondments,continuing education programs, and a greatly expandedfield epidemiology service. This has been projected at$25 million per annum. Health Canada’s internal invest-ment in public health research and evaluation is seriouslyinadequate, particularly if the new agency is to be a leaderin evidence-based public health practice or to partnereffectively with the Canadian Institutes of Health Research[CIHR] and other research agencies provincially and inthe non-profit sector. Another $25 million could bespent on R&D effectively in steady-state, particularly ifthe same monies go towards knowledge synthesis and

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guideline development. The coverage of areas such asenvironmental health, mental health, and injuryprevention is clearly suboptimal and taken together,could draw an extra $30 million per annum.

Not all funding needs to be new. We see opportunitiesfor public health to participate in programs alreadyannounced, such as the massive investment in the CanadaHealth Infoway, and perhaps even the 5-year $90 millionfund for health human resources planning. But the tallyabove has already taken us to $170 million per annum innew spending. Furthermore, this list assumes that thereare no new costs from institutional redesign, or new costsimposed by legislative and regulatory reforms. It assumesthat Health Canada has already invested adequately inthe existing programs that address healthy human develop-ment or chronic disease prevention and control. Bothdeal with exceedingly important areas in the publichealth portfolio—nothing less than, respectively, healthybeginnings to the lives of future generations of Canadians,and the great non-communicable scourges of our timesuch as cardiovascular disease and cancer. The list alsoassumes that if the scope of the new agency expands, the activities that are transferred in require no increasesin budgets.

In the circumstances, we are recommending that thefederal government budget for increases in core functionsof a new federal agency for public health that will rise,over the next 3 to 5 years, to a target of $200 million per annum in incremental funding beyond that alreadyspent in the “narrow” conceptualization of federal publichealth functions set out in Chapter 3.

How does this figure align with current spending? Recallfrom Chapter 3 that the core functions within PPHBcurrently amount to $187 million per annum (2002budget). Allocating a portion of extant grants andcontributions to this number, we reached $225 million asa rough estimate of core function costs in the Branchcurrently. We estimated, again crudely, that about $75million of the costs of operations in other branches ofHealth Canada could be deemed to fall within this“narrow” range of public health activities. If the agencywere simply to roll these functions together, exclusive ofvaccine costs, then it would spend about $300 millionper annum based on the 2002 budget. Thus, theproposed growth is about 60% over time to $500 millionper annum for core functions. The growth becomessmaller in relative terms if one assumes that the scope ofthe agency broadens meaningfully.

We make this recommendation in light of an urgentneed to enhance federal public health capacity, recog-nizing that it will go only a limited distance to narrowingthe major per capita spending gap when aligning similarfunctions for Health Canada and USA’s CDC. We alsotake note of the billions of dollars recently invested inpersonal health services, the staggering costs of the SARSoutbreak, and the fact that $200 million per annum isabout equal to the annual operating budget of a singlelarge community hospital. In the circumstances, it seemsminimally prudent to increase spending on core functionsover 3 to 5 years, reaching a target of an additional $200 million per annum to ensure that Canada has aneffective federal agency for public health protection and promotion.

4G. A New Public HealthPartnership Program forProvinces and Territories

4G.1 Level of FundingWe have emphasized the need for funds to flow to thefront lines where most outbreaks are contained andwhere public health does most of its good daily work inpreventing disease and protecting the health of Canadians.Ideally, to determine the necessary funding, analystswould establish a reference level for required local andP/T programs and services based on a combination ofexpert consensus, established efficacy and cost-effectiveness/cost-benefit, and comparisons with othercountries. They would then establish the gap betweencurrent reality and the reference level, and estimate thecost of closing that gap over a reasonable period of time.Such a process would be extremely time-consuming andis beyond the mandate of the Committee.

As noted in Chapter 3, incremental funding to bring allprovinces up to the spending level in British Columbiawould require an additional $408 million annually.However, the level of service in British Columbia cannotbe assumed to represent the ‘gold standard’ for publichealth service delivery. As is evident internationally withpersonal health services, the boundaries for justifiablespending on public health are highly elastic given differentcommunity or societal tolerances for health risks anddisparities. A crude $400 million figure also does notconsider the potential differences in delivery costs due togeographically-dispersed populations or differing propor-tions of higher needs populations (e.g., health status,poverty, language, education, etc.), as well as the fixedsystems costs independent of population size.

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A second approach is to consider federal support forpersonal health care. The 2003 Health Accord provides$34.8 billion in additional funds for health care over afive-year period (2003-4 to 2007-8). If public healthspending were pegged at not less than 3% of the personalhealth services spending through public channels, atleast $1 billion in new public health spending shouldhave been earmarked for public health over 5 years tokeep pace with new personal services spending. Andsince the goal is to redress the balance in some measureand build greater F/P/T capacity, the new benchmarkwould need to be well above $200 million per annum for P/T transfers.

Other estimates of necessary spending are similarly approxi-mate. We saw in Chapter 3 that the total spending onpublic health ranges from $2.0 billion to $2.7 billion,depending on whether the definition is narrow or broad.The provincial spending, based on rough estimates andprojections, is $1.72 billion, inclusive of vaccine costs. If one assumed that over several years, there should onaverage be a 50% increase in P/T/Municipal core activities,the increased spending would amount to about $850million per annum. One arbitrary point of reference isthat the federal government should cover at least 50% ofthe increased P/T spending in its role as the primary revenuecollector for Canada. This leaves half of $850 million orabout $425 million as new and earmarked federal support.Provinces vary sharply in their ability to finance additionalpublic health spending; and the proportion of federalfunding in the extant $1.72 billion fell between 1977 and2000 until the first Health Accord began reversing atrend to downloading of health costs onto P/T govern-ments. Certainly it cannot be said that Ottawa is paying50% of the existing P/T public health expenses. Thatsaid, the Committee again takes note of more than $30 billion in new federal monies to support provincialhealth spending vested in the second Health Accord.

We have therefore agreed that the total new federal contri-bution to P/T (and therefore local/municipal) publichealth funding can defensibly be set at $500 million perannum. This assumes that P/T governments themselveswill make a greater allocation to public health over thenext several years with the result that a much strongerF/P/T system will steadily emerge.

In the next chapter we shall outline how $100 millionper annum of these new federal monies should be investedin infectious disease surveillance and outbreak manage-ment through P/T or regional structures. We alsorecommend that $100 million per annum be used toreinvigorate the National Immunization Strategy (seebelow). However, not less than $300 million per annum

should be earmarked for a new Public HealthPartnerships Program to strengthen general P/T publichealth infrastructure. The logical question thenbecomes: How should the funds flow?

4G.2 Programmatic Funding: Some Constitutional and LegalConsiderations

The frustration with some of the jurisdictional issues inpublic health spurred a small chorus of informantssuggesting that the federal government should enact newpublic health legislation to create national standards inareas such as disease surveillance and notification.Others called for the acceptance of tough new rules inexchange for new federal monies. The Committeesupports the need to modernize the extant public healthnorms and legislation, and impose conditions on fundingas occurs in both the USA and Australia. However, federalspending power has both advantages and limitations.

The federal government can transfer funds to individuals,institutions (e.g., hospitals), and other levels of govern-ment (provinces, municipalities). All are legally free toaccept or decline the grant or contribution. Federal fundscan be unconditional or conditional. It is well-establishedthat conditional transfers have had the effect of influ-encing provinces to alter their policy priorities (e.g., bymaking health insurance universal). A strengthenedinfrastructure could therefore be created through the useof transfers that make provincial compliance withnational public health norms or rules a prerequisite forfederal funding. However, the provinces must agree tothe conditions. In theory, if federal spending conditionswere seen as disguised attempts to regulate provincialareas of jurisdiction, the courts might look favourably ona constitutional challenge. Moreover, the remedy in theevent of provincial non-compliance with federalconditions is political and financial, not legal.

The Committee also heard suggestions from someinformants that if the provinces did not cooperate withthe development of a national infrastructure, the federalgovernment should deal directly with municipalities andlocal health units, flowing federal funds to them inexchange for complying with federal standards onreportable diseases, timetables for reporting, etc. However,contractual obligations cannot bind third parties. A contractbetween the federal government and a municipalitywould not bind providers who report information tolocal public health officials, and municipalities generallydo not have the power to impose data standards onproviders outside the authority of the provincial publichealth branch. Furthermore, federal-municipal contracts

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could not bind provincial public health officials andinstitutions, and local public health officials are regulatedby provincial statutes, which integrate them intoprovincial public health systems.

A more useful tool that is better suited to the nature ofCanadian federalism, and the culture of collaborationthat we believe must exist in public health, is theIntergovernmental Agreement. These agreements are oftenstructured as memoranda of understanding and are “soft”policy instruments. Although they are sometimesdrafted in legal language, they lack formal legal status.Memoranda of understanding [MOUs] between govern-ments are a form of intergovernmental agreement.Intergovernmental agreements are a central feature ofCanadian cooperative federalism. These documents rangefrom the very general (e.g., the Social Union FrameworkAgreement [SUFA]) to the very detailed (which resemblecontracts). The incentive to enter into these agreementsis that they help to formalize and regularize relationsbetween levels of government. Should a dispute arise,the terms of the agreement can be reviewed and conductassessed against them. At the extreme, intergovernmentalagreements could even require that certain provisions beentrenched in provincial legislation, to make them legallybinding on provincial officials. The Supreme Court hasnonetheless stated that intergovernmental agreements donot bind provincial or federal legislatures, which remainfree to legislate in breach of intergovernmental agree-ments or to roll back legislation passed to operationalizean intergovernmental understanding. A number offederal-provincial MOUs are already in use in the publichealth sector. Consistent with practice in Australia andthe USA, we see numerous areas in public health whereMOUs could be concluded among F/P/T governments asa precondition to the flow of federal funds.

4G.3 Funding InstrumentsCurrently, the Government of Canada transfers funds toprovinces and territories as a contribution towards theprovision of insured health services on condition thatthey are provided according to the five principles laid outin the Canada Health Act. Provinces and territories fundthe provision of these insured health services, as well asother health services, including public health. In Ontario,municipal governments are also responsible for contri-buting 50% to the cost of most public health services.Federal programs include the provision of advice and in-kind service for the prevention and control of infectiousand non-communicable diseases, support for emergencyresponse, public health services for select First Nationscommunities, and grants and contributions to NGOs asoutlined earlier.

In thinking about how new funds might flow, one sees atonce that the Canada Health Act cannot practically berevised to include public health as an insured service.The types of service are distinct, and the five currentprinciples of the Act are not germane to public healthwith its population focus.

New public health funding for P/T functions might beseparately transferred to provinces and territories on anotherwise unconditional basis for general public healthpurposes. Even if there were somehow a set of indicatorsto support the broad requirement that the money bedemonstrably directed to public health, this approachwould do little to reduce disparities, augment coordination,initiate a national public health strategy, create nationalsurge capacity, or promote more uniform approaches todisease surveillance. It would also undermine Canada’sposition with international agencies such as the WorldHealth Organization that are increasingly looking tonation-states for disease prevention or control in this eraof globalization.

Another option would see tax points transferred to theprovinces and territories so that they gain greater fiscalcapacity to meet their public health needs. This has allthe disadvantages of the previous option, and because ofdifferential P/T ability to generate tax revenues, alsoaugments disparities in per capita spending, as occurredwith post-1977 personal health services spending.

Grants and contributions to local public health agencies,universities, professional associations, NGOs and otherstakeholders might be provided to promote activities thatstrengthen public health services. This will occur as partof the roll-out of many aspects of a new national strategy.It may be particularly important for the federal govern-ment to consider more direct liaison with public healthagencies in major municipalities such as Vancouver,Edmonton, Calgary, Winnipeg, Toronto, or Montreal.However, the first line of interaction should logically bewith the level of government that, constitutionally, hasprimary responsibility for overseeing public healthservices. In short, transfers to non-P/T stakeholders makesense for specific activities (e.g., aspects of health humanresource development), ideally with the full knowledgeand support of P/T jurisdictions. (Because contributionsare subject to full audit while grants are not, theCommittee urges use of contribution agreements fortransfers wherever possible.)

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Another option suggested by some was general cost-sharing, e.g., the federal government would implement aspecific formula for sharing the cost of public healthservices with the provinces and territories. This optionrequires a clear definition of the services and programs tobe cost-shared, and runs the risk of displacing, ratherthan augmenting, spending. It would not addressdisparities, coordination or surge capacity.

Two other related options are the public health capacityfoundation or a public health capacity fund. The firstinvolves transferring a lump sum to an arm’s-lengthcorporation which would disperse funds to public healthstakeholders. This would provide financial stability andallow for non-partisan solutions to specific challengesthat are not policy issues. However, this option, similarto Infoway or the Canada Foundation for Innovation, hasbeen criticized for a lack of accountability to Parliament,and has the disadvantage of failing to put public health ona continuing and stable footing. A public health capacityfund, similar to the Primary Health Care Transition Fund,would hinge on an F/P/T process to define public healthprograms to be funded. It would provide allocations toeach P/T, and each jurisdiction would then use the fundsto develop/maintain chosen activities within the overallprogram direction. This approach is more applicable todevelopmental projects, especially for information infra-structure and human resources, than to continuous fundingof infrastructure. Furthermore, it requires advance agree-ment with all provinces and territories, yet the programneeds of different P/T jurisdictions are highly variable.

Program funding, in contrast to all the foregoingapproaches, has one massive advantage. It avoids creatinganother focal point for F/P/T tensions with a visible sumof money. Program funding is unabashedly targeted tothe diverse needs of specific jurisdictions, but can simul-taneously reinforce an agreed national strategy. In essence,the Committee envisages an explicitly depoliticizingstrategy. We recommend placing the $300 million in thehands of the Canadian Agency for Public Health, andallowing a series of programmatic and ad hoc negotia-tions to unfold among F/P/T public health professionalswho have the health of Canadians, rather than thevicissitudes of re-election, as their immediate and ongoingpriority. The transfers would be structured as contributionsand therefore open to audit. As noted in Chapter 3, wealso recommend that the funds be allocated according toSUFA to avoid perverse incentives and penalties for earlyinvestments by P/Ts. A logical strategy would be tomanage the entire $500M in new public health transfersas a single sum on this basis, providing greater flexibilityto both the federal agency and P/T public health leadersin setting priorities. The earmarking of funds for an

immunization strategy and an infectious diseasesnetwork would therefore not constrain province-specificflexibility. A province might balance out greater percapita participation for front-line public health in thenew program with a lesser degree of participation in thefederal funding for provincial infectious disease control.The majoritarian provisions of SUFA also precludeblocking of necessary national norms by one or twoprovinces that have a smaller stake in one or the otherfunding stream.

This option is used by the USA and Australia to improvepublic health infrastructure. Its critical characteristic isthe ability to use funding as an instrument to directactivities according to an agreed plan. Funding forprograms can be directed at, for example, informationsystems, laboratory capacity, training, recruitment andretention, emergency response capacity, developing P/Tand local strategies and plans, among others. Theprogrammatic option might also be combined in part withcost-sharing: some programs would offer a percentage ofthe cost, up to a maximum with the province or territoryfinding the balance. This option most closely alignsfunding and policy direction, and reduces the risk ofdisplacing existing spending.

We are therefore recommending the creation of a new$300 million Public Health Partnerships Program, modelledon precedents set by the Commonwealth Government inAustralia and the US CDC. The Canadian Agency forPublic Health would flow these funds largely throughagreements with P/T public health officials, aimed atreinforcing core public health functions, collaborativearrangements, and local capacity for the full range ofcontemporary public health activity.

4G.4 Current Program of Grants andContributions

Currently, more than half of PPHB’s budget is for grantsand contributions [G&C], flowing mainly to NGOs acrossCanada. Inside this $200 million G&C envelope arewell-established programs covering a range of issues fromcommunicable and non-communicable diseases towellness and healthy living/aging. For example, amongthe programs is one to support a joint Health Canada/CIHRresearch initiative on Hepatitis C—a condition for whichthere is still no vaccine. Hepatitis C has infected anestimated 240,000 to 300,000 Canadians. Thousands ofthose infected develop chronic disease that could lead todeath from cirrhosis or liver cancer. According to Prof.Mel Krajden, prior to the joint initiative there were onlythree funded hepatitis C researchers and very limitedresearch occurring in Canada. The joint research

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initiative has catalyzed a substantial expansion inHepatitis C research across Canada, much of it inter-nationally competitive and already yielding results thatcan translate from bench to bedside. There is obviousvalue in investments of this nature and in a great manyother G&C-supported activities.

Nonetheless, the Committee has heard mixed reviews ofthe existing G&C program, in part, we surmise, becausespending on core functions has lagged and led to a senseof non-proportionality in the magnitude of transfers toNGOs. Concerns about politicization of grants andcontributions were also raised, but we have no way oftesting the validity of this innuendo. We recognize thatmany communities and community groups have bene-fited from this investment, and that it has multipliereffects through the NGO sector that are meaningful.

In her September 2001 report, the Auditor Generalcomments on the management of these programs. Her team examined a sample of 38 projects from acrossCanada under three programs. The sample was selectedbecause these projects covered the life course, wereadministered nationally and regionally, used sizableamounts of funds, and involved both grants and contri-bution agreements. Her report stated: “We are concernedabout the significant number of our project reviews thatidentified problems in the project management process.In particular, we noted that the Branch did not subjecthigh-value projects to a rigorous selection process, nordid it monitor those projects adequately…” In one ofthe program portfolios, the Auditor General noted thatthe Branch had identified problems with two of theprojects, “but had failed to take timely action to resolvethem... In the eight national and regional files on projectsunder $2 million, we found five cases that were notsubjected to an adequate selection process and yet theBranch recommended them for approval...” In anotherprogram, the Auditor General found that six of the nationalprojects were not eligible for funding based on the program’sown guidelines: “Further, there was no evidence ofcommunication with interested parties to invite projectproposals; nor was there evidence of internal or externalreview or consultation with advisors. Yet all six of theseprojects were recommended and approved for funding”(totalling $15 million). Amendments to agreements are afurther problem in that they are not subject to the sameselection process as new agreements, and can be used tobypass selection and approval processes.

The Committee believes that the grants and contributionsprograms directed at various NGOs are valuable policytools. The above-referenced concerns have more to dowith management of the funds than the intrinsic worthof the investment. However, these expenditures shouldbe reviewed to ensure that they reinforce and comple-ment the Public Health Partnerships Program, and re-allocated if there are any issues about value-added in relation to a new national health strategy.

4G.5 Reinvigorating a NationalImmunization Strategy

The Committee’s assessment of the status of the NationalImmunization Strategy offers another example of soundproposals to invest in public health that have receiveduneven and inadequate support by various levels ofgovernment. The Committee reviewed a series of docu-ments dating back to the 1990s that show substantialdiversity in the publicly-funded program and legislationpertaining to immunization and vaccination. As oneexample, not all children in Canada have received twodoses of measles vaccine because some P/Ts could notafford to institute ‘catch-up’ programs in 1996-1997.Although the benefits of adolescent hepatitis B immu-nization were recognized a decade ago, Canada tookseven years to reach national coverage because ofvariable uptake across P/T jurisdictions.

A proposal to strengthen collaboration on immunizationwas first presented to the F/P/T Conference of DeputyMinisters of Health in June, 1999. It was based on variousconcerns related to immunization in Canada, includingescalating vaccine prices, concerns about security ofsupply, safety issues with some vaccines, evidence forgrowing inequity in access to newer vaccines, and unevenelectronic recording of immunizations. Thereafter, ahighly collaborative F/P/T process led to a proposal for aNational Immunization Strategy. Those involved havenot been able to achieve support for the vision of a fully-funded strategy, in which resources to purchasevaccines and secure their delivery would be guaranteedfrom coast to coast.

At present, provinces and territories remain responsible forfinding the money to buy vaccines and deliver programs.This system continues to be criticized by expert infor-mants and stakeholders alike. We understand that somesuppliers offer provinces a package deal including variousperquisites for health promotion. The current systemcompromises purchasing power, limits the security ofvaccine supply, and puts providers in the untenable positionof having to recommend vaccines to persons/familieswho often cannot afford them.

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New vaccines are adding to the problem. Four newvaccines are currently unfunded in most P/Ts—conjugatepneumococcal vaccine, conjugate meningococcal vaccine,varicella vaccine and acellular pertussis vaccine. Theestimated bill for Canada was expected to mount fairlyrapidly to a steady-state of about $200 million per year forthese new vaccines alone. Immunization experts fromfederal, provincial, and territorial jurisdictions proposedthat the federal government pay for the new vaccineswhile P/Ts cover the costs of administration. To supporttheir case, those involved produced documentationshowing meaningful health and economic benefits frommore complete coverage and upgrading of vaccinationstrategies. However, the F/P/T focus was instead onadding money to personal health services through theHealth Accord.

The 2003 federal Budget acknowledged that immunizationhas been a remarkably effective preventive health measure.However, it provided only $45 million over five years ($5 million in year one, and $10 million a year thereafter)“to assist in the pursuit of a national immunizationstrategy.” The Budget document claimed that the “objectiveof the strategy will be to ensure equitable and timelyaccess to recommended vaccines for all Canadians in orderto reduce the incidence of specific vaccine-preventablediseases.” It further claimed that the national strategywould result in: “improved safety and effectiveness ofvaccines; enhanced coordination and efficiency of immu-nization procurement; and better information onimmunization coverage rates within Canada.” In fact,notwithstanding this lofty objective and these anticipatedresults, the financial support in the 2003 Budget isnowhere near sufficient to catalyze a nationalimmunization strategy.

The Committee believes that not less than $100 millionper annum should be earmarked for a major reinvigorationof the National Immunization Strategy under theauspices of the new Canadian Agency for Public Health.Earmarked funds could be transferred to a purchasingbody, e.g., Public Works and Government Services Canada,to purchase vaccines as agreed under the renewed strategy,so as to meet provincial and territorial needs. This wouldensure that the funds go only for the agreed-upon vaccines,consolidates purchasing power and facilitates price reduc-tions, and sets annual and national target volumes toensure that industry can meet the needs of the nation.Furthermore, other branches of Government, such asIndustry Canada, could use the vaccine investment toleverage private sector investment in vaccine research anddevelopment, as well as production in Canada. Workingfrom an F/P/T consensus enhances inter-jurisdictionalequity, by creating a “minimum agreed upon standard”

for the introduction of new vaccines. Absent suchconsolidation, P/Ts have actually ended up competingwith each other for available supply and on price asoccurred with meningococcal vaccine shortages duringoutbreaks.

Also, in the absence of immunization registries in mostjurisdictions, Canada is not in a position to providereliable and accurate information on coverage levels.Our best information is that coverage with older vaccines,fortunately, is adequate. Thus, the focus of $100 millionin incremental federal funding can be on new vaccines aswell as improving the information systems to ensure thatCanada meets an articulated health goal (and inter-national norms) as regards vaccination coverage.

4H. RecommendationsThe Committee recommends that:

4.1 The Government of Canada should movepromptly to establish a Canadian Agency forPublic Health, a legislated service agency, andgive it the appropriate and consolidatedauthorities necessary to provide leadership andaction on public health matters, such as nationaldisease outbreaks and emergencies, with orwithout additional authorities regardingnational disease surveillance capacity.

4.2 The Government of Canada should ensure thatthe scope of the Agency’s mandate covers publichealth broadly with appropriate linkages toother government departments and agenciesengaged in public health activities. TheGovernment’s scoping exercise for the newAgency must be informed by a careful reviewof public health service provision and healthpromotion for First Nations and InuitCanadians.

4.3 The Government of Canada should budget forincreases in core functions of the newCanadian Agency for Public Health that willrise, over the next 3 to 5 years, to a target of$200 million per annum in incrementalfunding beyond that already spent on corefederal public health functions.

4.4 The architects of the new Canadian Agency forPublic Health should ensure that its structurefollows a hub and spoke model whereby linksare made to existing regional centres withparticular strengths in public health specializ-ations while some other functions and new

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ones are devolved to other regions of thecountry, with a vision that these parts supportthe entire system.

4.5 The Government of Canada should create theposition of Chief Public Health Officer ofCanada. The Canadian Agency for PublicHealth should be headed by the Chief PublicHealth Officer of Canada who would reportdirectly to the federal Minister of Health andserve as the leading national voice for publichealth, particularly in outbreaks and otherhealth emergencies.

4.6 The Government of Canada should create theNational Public Health Advisory Board, andensure that nominations of board members comeforward through provincial and territorial aswell as federal channels. The mandate of theBoard will be to advise the Chief Public HealthOfficer of Canada on the development andimplementation of a truly pan-Canadianpublic health strategy.

4.7 The Canadian Agency for Public Health shouldplay a catalytic role in developing a NationalPublic Health Strategy in collaboration withprovincial and territorial governments and inconsultation with a full range of non-govern-mental stakeholders. The new Strategy shoulddelineate priorities and goals for key categoriesof public health activity along with provisionsfor public reporting across jurisdictions ofprogress towards achieving goals.

4.8 The Government of Canada should fund a newPublic Health Partnerships Program under theauspices of the Canadian Agency for PublicHealth. The Agency would thereby provideprogram funding to provinces and territories tostrengthen their public health programmingin agreed areas and in support of the NationalPublic Health Strategy. The funding for thePublic Health Partnerships Program shouldrise over 2-3 years to $300 million/annum.

4.9 The Government of Canada should incorporateinto the new Agency the current grants andcontributions programs of the Population andPublic Health Branch of Health Canada. Thesegrants and contributions should be reviewedand their uses aligned with the National PublicHealth Strategy and made complementary tothe Public Health Partnerships Program.

4.10 Through the Canadian Agency for PublicHealth, the Government of Canada shouldinvest $100 million/annum within 12 to 18months to realize the National ImmunizationStrategy whereby the federal governmentwould purchase agreed-upon new vaccines tomeet provincial and territorial needs andsupport a consolidated information system totrack vaccinations and immunizationcoverage.

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Appendix 4.1Population and Public Health Branch:Current Organization Chart

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Assistant Deputy Minister

Business Integration and Information Services Directorate

Centre for Chronic Disease Prevention and Control

Centre for Surveillance Coordination

Strategic Policy Directorate

Laboratory for Foodborne Zoonoses (Guelph)

Senior Director General

Centre for Healthy Human Development

Centre for Infectious Disease Prevention and Control

Centre for Emergency Preparedness and Response

Management and Program Services

National Microbiology Laboratory (Winnipeg)

BUILDING CAPACITY AND COORDINATION: National Infectious Disease Surveillance, OutbreakManagement, and Emergency Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Public Health is charged with protecting the health of aparticular population. Among other activities, thisrequires surveillance functions, the capacity to lead thefight against specific disease outbreaks, and the ability toparticipate effectively in a multi-modal response to majorhealth emergencies. Out of surveillance flows the abilityto issue alerts about health threats to public healthpractitioners, clinicians, health care facilities, governments,and the general public. Effective surveillance, coupled tofirst-line outbreak management, can prevent the spreadof an infectious disease and its escalation into a full-blown health emergency.

Because first-line outbreak response occurs at the local orregional level, the general renewal of public healthinfrastructure will pay dividends in better preparednessfor ‘the next SARS’. Our brief overview of SARS inCanada also has raised issues about the capacity andinterplay of P/T and federal level responses to diseaseoutbreaks, and the interface between outbreak manage-ment and broader emergency responses. Accordingly,this chapter draws together several threads.

First, we briefly introduce some of the elements ofsurveillance and outbreak management. Our overview of the basics of outbreak management is cross-walkeddirectly to the SARS experience, providing a frameworkto revisit the chronology from Chapter 2.

Second, we review the 1999 and 2002 reports of theAuditor General on issues of infectious disease surveillanceand outbreak management. These reports are prescientin the light of the events surrounding SARS.

Third, we turn to the broader issue of health emergencies.Here, there appears to be some progress in F/P/T collabo-ration, triggered in part by the terrorist attacks in theUSA on and after September 11, 2001 and recognition ofthe global challenge of bioterrorism. We highlight the

need to clarify, and where necessary improve, theinteraction of health emergency activity, specificallypublic health emergencies such as disease outbreaks, andbroader emergency preparedness and response.

Fourth and finally, we outline how new transfers by theCanadian Agency for Public Health could reinforce thenation’s second line of defence against infectious outbreaksby strengthening provincial and territorial capacity forcommunicable disease surveillance, epidemic response,and related activities in nosocomial infection control.This program of transfers would also seek to link theseP/T activities with relevant federal centres to create aseamless national network for detecting and managingemerging and existing infectious threats to public health.Some federal funding and concerted action to ensurenational preparedness should begin as soon as possiblegiven the forthcoming winter season of upper and lowerrespiratory diseases. In the medium-term, the networkmust be harmonized with the other elements of a nationalpublic health strategy, including the Public HealthPartnerships Program and funding to realize the NationalImmunization Strategy outlined in the previous chapter.

5A. Surveillance and OutbreakManagement: EssentialFunctions for Public Health

5A.1 SurveillanceExperts have written lengthy chapters on the nature ofsurveillance functions in an ideal public health system.This report is not the place to repeat those details, but abrief introduction to this oft-misunderstood field isneeded.

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Health Surveillance may be defined as the tracking andforecasting of any health event or health determinantthrough the continuous collection of high-quality data,the integration, analysis and interpretation of those datainto surveillance products (for example reports, advisories,alerts, and warnings), and the dissemination of thosesurveillance products to those who need to know.Surveillance products are produced for a specific publichealth purpose or policy objective.

Surveillance should be purposeful, economical, and action-oriented. It should not only detect emerging health risks,but include systems that allow public health officials tomonitor and evaluate progress in health protection anddisease prevention. New health risks such as bioterrorismand zoonoses, re-emergence of some diseases (e.g., multi-resistant bacteria), and globalization have fundamentallyaltered the scope and response time expected ofsurveillance programs at every level.

Surveillance uses whatever data sources will provide thenecessary information. Surveillance systems may sharedata with personal health services information systems,but the end-products are different. Most of the datacurrently available from health facilities are originallygenerated for administrative purposes. They can serve as raw material for health services management andresearch, as well as for disease and health surveillance ifprocedures for capturing and handling administrativedata are appropriately adapted.

In general, surveillance data can originate from any offour classes of source:

• Special purpose, i.e., data collected specifically for aparticular surveillance need. Special purpose datasources select the most relevant data and facilitatedetection and response, but are costly to operate andmay be difficult to maintain over the long term.

• Surveys. Usually collected for more general healthsurveillance purposes, survey data differ from otherspecial purpose data sets in that they are usually cross-sectional or ‘one-off’ and may be useful for multiplesurveillance functions, notwithstanding their lack ofspecificity.

• Administrative. As noted, data collected for admin-istrative purposes often find a secondary purpose indisease surveillance, e.g., analysis of the diagnostic fieldson hospital discharge abstracts looking for geographicclusters of a particular disease. Administrative data aregenerally lower quality, and may not always be availableon a timely basis, but are convenient to acquire andinexpensive.

• Clinical. For many surveillance purposes, this is theideal source. Indeed, new diseases and emergingclusters of known diseases are often first suspected byastute clinicians who observe unusual patterns ofillness, and work with others to initiate more systematicsurveillance. Optimum efficiency in clinical surveil-lance can only be achieved if the clinical data areaccessible electronically. This is rarely the case atpresent. The Electronic Health Record has thepotential to be a rich source of surveillance data infuture. Moreover, as submissions to the Committeehave pointed out, clinical data for surveillance need tobe assembled from a range of providers and facilities,including family physicians and other primary careproviders, emergency departments, pharmacists, andveterinarians.

We alluded in Chapter 2 to the Global Public HealthIntelligence Network [GPHIN]. While the two functionsoverlap, it is worthwhile to clarify the difference betweensurveillance and intelligence. Surveillance involvescollection and aggregation of data before they are inter-preted. In the case of intelligence, the sources of infor-mation have already been analyzed and interpreted(usually informally). Thus, an emergency physician maynotice an unusually large number of cases of bloodydiarrhoea and inform the local medical officer of health[MOH], or an MOH may post a report of an outbreak offlu-like illness with rash on an electronic bulletin board,or the GPHIN may detect news reports on influenza inAsia. The importance of intelligence is that it can alertauthorities to look for similar cases in their ownjurisdiction.

Public health is still struggling to catch up to the potentialfor effective surveillance afforded by new technologies.The problems have been not only the cost of implementingthese systems (see Appendix 5.1 for the costing of asurveillance system), but also the very slow progress ingaining consensus across jurisdictions (as will be outlinedbelow) and across programs on the architecture andstandards. Grappling with recent demands placed uponthe design of systems by privacy legislation has also beena serious challenge—one which we address in Chapter 9.As the Council of Chief Medical Officers of Health notedin their submission to the Committee, progress has beentoo slow, and “stovepipe” systems persist everywhere.

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5A.2 Outbreak Management andInvestigation

Outbreaks or epidemics are the occurrence of a disease inexcess of its expected frequency. Outbreak investigationsare a type of fast-paced epidemiologic research, under-taken to determine the cause of the outbreak and whatremedial actions are required. These investigations aretypically retrospective, occur in real time often underintense public and political pressure, begin withouthypotheses, are iterative, and are closely tied to the imple-mentation of public health measures to contain theoutbreak. Outbreak investigations also involve consider-able challenges in communication, including essentialrisk communication to the public.

Foodborne epidemics are commonly multi-jurisdictionalbecause of the wide distribution of foodstuffs from asingle source. They often require national or internationalaction. However, the investigation and management ofinfectious disease outbreaks is typically local and provincial,at least in the first instance. Other levels of governmentmay assist, and the epidemic may even be managed bynational or international bodies, but as a general rule, thefirst line of defence is local. The SARS situation is thus inmany ways a unique national and international experience,a sign-post for actual and virtual globalization. Never hasa worldwide outbreak emerged so quickly, been so widelycovered by the global media, or sparked such interactionamong different governments and international agencies.And never has a hitherto-unknown agent been investi-gated so quickly.

Again, readers can find textbooks devoted to these issues.In brief, outbreak management involves numerous steps,starting with epidemic detection and alert. Recog-nition of a new threat has different permutations andchallenges, depending upon whether the agent is knownor unknown, whether the known agent is a notifiable ornon-notifiable disease, and the extent of knowledgeabout how to contain the agent most effectively andefficiently. The special challenge in SARS was that theagent was new, its mode of transmission was initiallyunclear (e.g., droplet or airborne), and aspects of itsinfectivity (e.g., ability to survive on inanimate objects or ‘fomites’ for many hours) only emerged during thecourse of the outbreak.

Detection demands the timely upward reporting of datathrough the public health hierarchy—local, regional,provincial, national, global—and the collation andanalysis of case data at the lowest level where a cluster ofcases can be recognized. As a leading industrialized nation,Canada should be operating an exemplary surveillancesystem for new and known infectious diseases. Currently,it does not.

On occasion, cases may be scattered widely so that anoutbreak is not detectable at the local or even provinciallevel. For example, Health Canada occasionallyaggregates data showing a cluster of disease and notifies aprovince or provinces about an unrecognized epidemic ofa foodborne illness. Obviously the success of these systemsis critically dependent on timely and accurate informationflows across jurisdictions, along with data managementand analytic capacity at the appropriate levels. A smoothly-functioning laboratory network is also essential to ensurethat case characterization occurs in a timely fashion.

Once an epidemic is recognized in one country, thisintelligence can forewarn public health officials in othercountries. Health Canada publishes the CanadaCommunicable Diseases Report every two weeks; its distri-bution is primarily in electronic format. At the globallevel, there are several alert mechanisms. The GPHIN,developed by Health Canada’s Centre for EmergencyPreparedness and Response and now used by the WorldHealth Organization [WHO], scans media reports fromaround the world on the Internet. This information is fedinto the Global Outbreak Alert and Response Network[GOARN], which notifies countries about the activity andcatalyzes investigations. ProMed is an Internet alert systemwith a wide subscription base among infectious diseaseand public health practitioners. Individual clinicians andpublic health officials post unusual occurrences of infectiousdisease on ProMed. It constitutes an informal and oftenuseful back-up system to more official channels.

We saw in Chapter 2 that an early opportunity to detectSARS in China was missed by Health Canada and WHOwhen a GPHIN report in November was not fully translated.However, by February, with an apparent outbreak of avianflu in Hong Kong and an unusual respiratory outbreak inGuangdong, WHO put member countries on the alert.WHO and Health Canada alerts were picked up by theBritish Columbia Centre for Disease Control [BC CDC];the BC CDC’s dissemination of that information wasprobably responsible for the prompt isolation of the firstSARS case in Vancouver. Alerts were also issued by localand provincial public health officials in Ontario, butuptake was apparently inconsistent. In any event, the

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spread of the outbreak at The Scarborough Hospital,Grace Division was difficult to prevent given that theindex patient’s son arrived in the emergency departmentwith SARS and without a travel history.

As recognition of a new disease emerged in Vietnam andHong Kong, WHO sent out further alerts specific to SARSon March 12, 2003. In Canada, WHO alerts triggered animmediate cascade of domestic alerts. While all this wasdone promptly, SARS had already been in Canada foralmost three weeks and the outbreak was taking flight inToronto. A more effective Canadian alert system—involving both the ability to reach all levels of the healthcare system and an uptake/response capacity in thesystem—is absolutely necessary for the future.

Rapid epidemiologic assessment is essential at thebeginning of an outbreak or epidemic to define the scopeof the problem and start mobilization of containmentstrategies. In Canada at the national level, the PandemicInfluenza Committee was already in place, and it wastransmogrified into the basis for the daily F/P/T SARSconference call. These calls served a useful purposeaccording to many informants, but most participants onthe calls were not directly involved in fighting theoutbreak. Moreover, those on the front-lines wereoverwhelmed by constant demands to give and getinformation by teleconference. Again, we see thatCanada lacked back-up capacity—the ‘B-team’ functionsthat the CDC mobilizes in an outbreak. If nothing else,one might have expected rapid assessment to yield afocus on the epidemic curve for SARS with its positivemessages, rather than the cumulative case counts thatcontributed to a sense of crisis.

The next step is epidemic investigation to identify theetiology and the modes of transmission of an infectiousagent, thereby guiding appropriate measures to preventfurther transmission. An ongoing outbreak is generally ahealth emergency. Approaches to its investigation requiredifferent modes of operation, different command-and-control structures and unified leadership. Investigatorsshould be insulated from the constant demands of dataflow. This did not happen with SARS in Canada. As oneparticipant put it, “The continuous requests for infor-mation on a minute-by-minute basis, day and night—locally, provincially, and federally—hampered the effortsof a limited number of overworked staff to get on withthe job of collecting, analyzing, interpreting and dissemi-nating the epidemiologic information required to controlthis disease.” Bureaucratically-structured organizationsare not well suited to responding to an epidemic andtheir structures need to be modified for them to respondeffectively to the exigencies of rapid ‘command-and-

control’ responses. This was one of the major lessonslearned from the CDC experience with anthrax. Itunderscores why a federal agency is necessary but notsufficient for improved responsiveness in Canada.

The collective activity in epidemic investigation duringthe SARS outbreak in Toronto was embarrassingly meagre.As we have seen, no shared database was established; juris-dictions squabbled over data flow; clinicians and publichealth physicians were unable to collaborate effectivelyon investigation and research; Health Canada’s responseswere well-intentioned but the federal government’s rolewas unclear and its capacity limited as compared to theUS CDC; the provincial public health laboratory wasoverwhelmed; and the provincial public health branchwas not able to coordinate a response to an outbreak thatinvolved four distinct local health units or take a leadershiprole in epidemic investigation. For data managementHealth Canada’s web-enabled Public Health InformationSystem [ i-PHIS] was eventually put into service by theprovincial public health branch, but not by local publichealth units as it does not yet contain contact tracing andquarantine management modules. Local agencies insteadused systems built during the outbreak by each unit.

Establishing a case definition is central to diseasesurveillance and outbreak containment. The Committeehas been advised that WHO developed its case definitionto emphasize epidemiologic links because SARS, clinically,resembled so many other forms of atypical community-acquired pneumonia. As clinical and epidemiologiccharacterization of SARS continued and laboratory serologybecame available, case definitions did evolve both at WHOand elsewhere. In Canada, there were several changesthroughout the epidemic in the case definition achievedby consensus on F/P/T conference calls, but again, thiswas not a straightforward exercise (see Appendix 5.2).

The first case definition from Health Canada demandedclose contact with a suspect or probable SARS case for anepidemiologic link to be established. On March 31, 2003,the definition was revised to include “recent travel to adefined setting that is associated with a cluster of SARScases.” This was added to capture exposure to sites withinCanada, particularly in Toronto where transmission ofSARS had occurred in health care settings. The term‘travel’, however, may have added to uncertainty aboutwhether the definition was meant to apply to residentsof SARS-affected areas. Ontario, moreover, had its owncase definition (included in Appendix 5.2) that specifiedthe need for an epidemiologic link consisting of “closecontact” with a probable or suspect case. Other revisionsto the Ontario definition were made on April 29, but therequirement for “close contact” was not changed.

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On May 26, 2003, Ontario amended its definition afterthe emergence of the second wave of SARS to include“recent travel or visit within 10 days of onset of symptomsto a defined setting that is associated with a cluster ofSARS AND no other known cause of current illness.” Aspart of a general revision on May 29, 2003, Health Canadaalso amended its definition to make it clear that even avisit to a hospital with a SARS unit or other “identifiedsetting in Canada where exposure to SARS may haveoccurred” should be considered sufficient link (again seeAppendix 5.2 for details).

This inter-jurisdictional confusion, including HealthCanada’s belated recognition of the differences in defini-tions, and Ontario’s decision to post its own more specificdefinition, may have contributed to non-recognition ofclusters of potential SARS in Ontario, as public healthassessors focused on demonstrating epidemiologic links.That said, clinicians would use their own best judgementregardless of any case definition, and the Ontario definitionhas also been defended as a necessity to contain thenumber of persons who would have to be investigated.

On March 17, 2003, Health Canada, mirroring WHO,added an exclusion criterion. SARS was excluded if anotheretiology was defined for a case that otherwise met thecase definition. This tended to preclude the possibilitythat an individual might be infected with more than one agent, or that other non-infectious conditions (e.g., congestive heart failure or post-operative atelectasis)might co-exist with SARS (as was likely true on 4 West inNorth York General Hospital). On May 29, after theNorth York cluster, the definition was revised to specifythat the alternative cause must “fully explain” theclinical presentation.

The other key change on May 29, 2003 was that theprobable case definition now included a “suspect casewith radiographic evidence of infiltrates consistent withpneumonia or respiratory distress syndrome on chest x-ray.” This clarification was welcomed by Torontoclinicians, who had been frustrated with the insufficientweight given to radiological evidence.

The continued variation in case definition had internationalimplications. Differences in case definitions around theworld led to occasional misclassification of individualswho had visited Toronto, and later developed what wasclearly not SARS, as exported probable or suspect cases of SARS. And in something of a reductio ad absurdum, US authorities took transit through the Toronto Airport(in Peel Region) as constituting a visit to Toronto forpurposes of assessing exposure to a SARS-affected area.

Establishing an etiology is usually straightforward forknown agents, provided the requisite logistical arrange-ments and laboratory capacity are in place. Scientists inVancouver and Winnipeg were among the leaders inter-nationally in sequencing the SARS coronavirus, which inturn facilitated the development of serological tests forSARS. Remarkable work was also done by laboratoryworkers in various institutions in Toronto to establishdiagnostic capacity for the coronavirus, supportingclinicians on the front-lines and facilitating public healthcontainment efforts. Unfortunately, as hospital labora-tories stepped forward to take on responsibility for testingfor the SARS coronavirus, the ability to monitor data atthe national and even provincial level was undercutbecause of poor information systems and the lack of data-sharing protocols. Epidemiologic and laboratory databecame even more disintegrated, compromising epidemicinvestigation efforts.

Confirmation of cases presupposes the existence of adefinitive test to ascertain true cases. When the agent isunknown, as was true for SARS, this takes some time.More definitive testing was possible only towards the endof SARS I, with acquisition of the capability to detect thegenetic fingerprint of the coronavirus from nasopharyngealswabs, sputa, or stool, and during SARS II when serologicaltests for SARS became available.

Along with confirming apparent cases, the outbreakmanagement and investigation team must find casesand define the scope of the problem. SARS was ahuge challenge in this regard, because of the lack of anyscreening test, the similarity of the symptoms to otherinfections, and the lack of rapid confirmatory tests.Enhanced surveillance for the illness is particularly criticalat precisely that point when it appears that progresstowards containing the outbreak has been made. We haveseen already that Canada’s local responses were deficientin these respects. Part of the detection imperative alsoinvolved measures to find potential imported and exportedcases of SARS. Health Canada was pushed internationallyand nationally to implement expensive and cumbersomeairline passenger screening procedures. We return to thisissue in Chapter 11.

As data accumulate during the outbreak, the investigativeteam should be immediately generating descriptiveepidemiologic information, as well as generating andtesting hypotheses. For example, this step could havehelped to pin down more rapidly the incubation periodof SARS and attack rates in different subgroups. Aninvestigative team normally uses case-control, cohort,and experimental studies to test hypotheses about thecausative agent, its modes of transmission and possible

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interventions to contain it. Because of poor coordination,lack of standardized data collection, and substandarddata management and analysis capacity, we are onlyreaching this stage now that the Canadian outbreak hasreceded. Many valuable opportunities were lost, andCanada’s research productivity suffered as suggested inChapter 2.

Reporting of findings of epidemiologic investigationsto national and international bodies is a critical partof an outbreak investigation for several reasons. Under-standing a disease allows other jurisdictions to put inplace appropriate measures for its control and to learnfrom the experience of others. SARS has driven homethe need for timely and accurate reporting of informationon epidemics and their investigation to the nationallevel, with subsequent reporting to other countries andinternational bodies. At times during the SARS outbreak,it seemed that reports through the public health systemlagged significantly behind media reports, a situationthat did not engender international confidence.

Outbreaks are often highly visible and are conductedunder intense public, political and media scrutiny.Communications with the media, clinical personnel,governments, and the public are all extremelyimportant. We return to intra- and inter-organizationalcommunication in Chapter 8. Media demands on localand provincial public health officials were intense andtime-consuming during the SARS outbreak. Managementof communications was widely seen to be substandard, asindicated already in Chapter 2. Federal communicationswere generally reactive as Health Canada waited for thelatest press conference in Ontario, and provincial communi-cations in turn were frequently disorganized. Our percep-tion is that as the outbreak continued, various mediaoutlets themselves took on the role of public educatorsand modulators of risk communication in a commendableeffort to stabilize community perceptions of the crisis.

The control of an epidemic through public healthmeasures is the immediate purpose for epidemic investi-gations. With disease spreading, decisions on publichealth interventions need to be taken quickly and oftenwith incomplete information. The actions that are takenin controlling any epidemic have very significant costsand may be controversial or highly unpopular. In theSARS epidemic, case detection, isolation of cases, followup and quarantine of contacts, strict infection controlmeasures in hospitals, closure of hospitals, airline passengerscreening and travel advisories were the main tools usedto control the epidemic nationally and globally. Alongwith massive impacts on tourism and travel, the outbreak

had staggering costs. SARS led to direct costs throughpublic health and health care measures necessary tocontain the outbreak and treat those affected. Indirectcosts were incurred as a result of: lost productivity fromillness, quarantine, self-isolation, and related workflowdisruption; payments to health care facilities and physiciansin lieu of ordinary throughput-related revenues that wereinterrupted by SARS; salary and other compensation forthose who were quarantined or otherwise unable to carryon their normal duties of employment as a result of SARS;and service backlogs in health care and public healththat must now be cleared. The TD Bank has estimatedthe net cost of the outbreak to the national economy atbetween $1.5 billion and $2.1 billion.

The foregoing analysis may add to the impression fromChapter 2 that SARS in Canada was not an exemplar ofoutbreak management. However, so far as the Committeecan tell, all those directly involved made their very bestefforts. Countless health care and local public healthpersonnel conducted themselves in exemplary fashion.To them goes the credit for containing an unprecedentedand sudden outbreak of a hitherto-unknown andmoderately communicable disease, with a meaningfulfatality rate. Various other positive actions anddevelopments are worth noting.

In British Columbia, alerts issued by the BC CDC set thestage for the early recognition and isolation of theprovince’s first SARS case at Vancouver General Hospital.Public health surveillance measures were instituted, andan Emergency Operations Centre was opened. Therewere regular teleconferences among BC CDC experts,local medical health officers and the Provincial HealthOfficer, and active liaison with the infectious diseasecommunity. All physicians received direct communicationabout case definitions and protective measures, and awebsite was established. Additional cases of SARS inBritish Columbia were managed effectively, as weresuspect cases of SARS in other provinces.

In Ontario, despite tensions between provincial andfederal public health officials, data did flow and inter-national reporting proceeded on a regular basis. Expertsfrom local public health units and Health Canadacollaborated in cluster investigation. The federal govern-ment assisted directly with the recruitment of variouspublic health professionals such as epidemiologists,community medicine physicians, case investigators (i.e., public health nurses/inspectors) and public healthmanagers. Ultimately, an effort by all three levels ofgovernment with support from stakeholders such as theCanadian Public Health Association allowed Toronto’spersonnel needs to be met. Health Canada staff also

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worked with P/T representatives to create working groupson surveillance, infection control, clinical management,laboratory issues and public health management.

The control efforts in Toronto involved multiple jurisdic-tions, and were carried out in a blaze of publicity. Allleaders of the outbreak containment efforts worked dayand night. Local public health agencies overcame systemsdeficiencies and effectively managed an overwhelmingworkload. Volunteerism was the order of the day, asexemplified by the contribution of the Scientific AdvisoryCommittee and various clinical experts who worked atthe Provincial Operations Centre and SARS OperationsCentre in Toronto. Ontario was forced to activate its new emergency plans for the first time in the face of amysterious and dangerous virus. Anxieties at times ranhigh, but citizens in affected areas were calm andgenerally tolerant of the disruption to their lives.Compliance with quarantine and other public healthmeasures was extremely high. The Ministry of Healthand hospitals alike learned from the first wave of theoutbreak, and used a more selective approach to clinicalcare of SARS patients in the second wave. Stakeholderorganizations such as the Ontario Hospital Associationand the Ontario Medical Association made strenuousefforts to communicate with their members about SARSand to support the outbreak response. The outbreakaffected students and trainees in many disciplines whoreceive training within hospitals; it also occurred at thetime of final examinations for post-secondary institutionsand Royal College examinations for resident physicianscompleting their specialty training. Nevertheless, all theinvolved educational institutions were able to manage inways that enabled—or will allow—students to completetheir programs or examinations on schedule. Hospitalsshowed unprecedented adaptability, and the bravery of arange of health care workers, including front-line nurses,physicians, rehabilitation professionals, respiratory andlaboratory technicians, and ambulance personnel/paramedics, was little short of heroic.

These, moreover, are just a few of the success stories ofSARS in Canada. They reflect people and institutionsrising to the occasion in the face of suboptimal systemsand inadequate preparation. To paraphrase T.S. Eliot, wecan never build systems so perfect that people no longerneed to be good. But the greatest lesson of SARS inCanada is arguably that there is no excuse for toleratingsystems so imperfect that bad things happen unnecessarilyto good people.

5B. The Auditor General’sPerspective

Well before SARS appeared in Canada, the Auditor Generalhighlighted the challenges faced by the nation inoperationalizing an infectious disease surveillance systemthrough existing F/P/T processes. The Auditor General’sreports in September 1999 and September 2002 werehighly critical of the failure of the F/P/T process toestablish the needed infrastructure and concluded thatthese failings were impairing Canada’s ability to detectand respond to such outbreaks. Drawing on the reportprepared for the Committee by our legal consultant, Prof. Sujit Choudhry, the Auditor General’s findings aresummarized below.

Health Canada depends on the voluntary cooperation ofprovincial and territorial authorities, both regarding healthsurveillance (including case reporting) and responses tooutbreaks. The large body of federal, provincial andterritorial legislation that governs public health does notspell out the terms of inter-jurisdictional cooperation.Non-legal documents such as policy statements, intergovernmental agreements and memoranda of under-standing are used inconsistently to formalize the terms ofintergovernmental collaboration. Although there aredisease specific arrangements (e.g., AIDS), there is nocomprehensive F/P/T document that assigns specific rolesand responsibilities to federal, provincial and territorialgovernment actors. The lack of formal terms of cooperationimpedes rapid responses to emergency situations. Formaldocuments are clearly necessary to deal with issues suchas data sharing, data ownership, privacy, permitteddistribution of data, and the consequences of governmentalnon-compliance with these terms.

Although the situation for AIDS, influenza and entericdiseases improved between 1999 and 2002, the AuditorGeneral found that the general picture as of September2002 remained worrisome with respect to the timeliness,accuracy and completeness of data. Provinces continuedto vary in their reporting to Health Canada. For example,only 8 provinces (representing 55% of the population)reported cases of chicken pox. By 2002, an informalnational agreement existed on the list of reportable diseasesand most recent provincial lists of reportable diseases doshow substantial and reassuring congruence. However,the flow of data to Ottawa remains inconsistent. Someprovinces report diseases electronically; others do not.Provinces themselves are coping with under-reporting or non-reporting of new cases by providers. For example,a study of FluWatch in 1997-98 revealed that even with a rota of interested physicians, only 60% submitted a

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report each week. In addition, data on hospitalizationsand deaths from flu were neither timely nor accurate—a situation that has not changed and has adverse impli-cations for SARS surveillance.

An F/P/T process has been at work for several years todevelop an integrated national public health surveillancenetwork, through the Network for Health Surveillance inCanada. These committees include the Health SurveillanceWorking Group, the Communicable Disease SurveillanceSub-Group, the Canadian Public Health Laboratory Network,the National Health Surveillance Infostructure Project,and the Canadian Integrated Public Health SurveillanceProject [CIPHS]. Health Canada’s Centre for SurveillanceCoordination was set up in 2000 to provide leadershipon intergovernmental coordination. The Auditor Generalreported in September 2002 that some progress had beenmade. The Health Surveillance Working Group hadagreed that a health surveillance infostructure should bedeveloped. However, no specific timelines had been set,and the Auditor-General’s office was told that a nationalsystem would “take several to many years” to develop,particularly in the absence of targeted funding.

More recently, welcome agreement has been secured ondata elements for the core data set of communicablediseases, and progress is being made on disease-specificdata sets. The federal government has developed boththe Laboratory Data Management System and, as notedabove, i-PHIS, both components of the Canadian IntegratedPublic Health Surveillance program. These platformshave been adopted by many provinces, most recentlyOntario post-SARS. On the positive side, the federalgovernment will continue to cover the cost of softwaredevelopment and provinces are able to add specific modulesas they see fit. However, we have seen that i-PHIS lackedthe capacity to manage an outbreak, and has not beenadopted by the local public health units where the front-line work of SARS containment was done. The LaboratoryData Management System has not won consistentlyfavourable reviews even inside the Health Canada labora-tory system. Although CIPHS will allow for real-timereporting at the national level, these data will not becomprehensive in scope, because some provinces are stillnot participating. Health Canada’s aim is to pass theinfostructure development project to a federal/provincial/territorial consortium (the CIPHS Collaborative). However,some informants suggested to the Committee that alarge-scale and customized architecture was undesirable,and that the way forward should be more incremental,relying on flexible and widely-available commercialsoftware as the primary platform. Thus, both technicaland jurisdictional issues are still in play, and exacerbatedby resource constraints.

The Canadian Enteric Outbreak Surveillance Centre (CEOSC)now provides an electronic vehicle for public healthpractitioners and users, thereby allowing a growingnumber of officials to exchange and discuss informationabout enteric outbreaks in a secure environment. HealthCanada’s Health Products and Food Branch has revisedits Food Illness Outbreak Response Protocol. The Branchintends to consult with provincial and territorial govern-ment authorities in the Fall and will seek endorsement ofthe Protocol by F/P/T Deputy Ministers of Health inDecember 2003. In sum, progress continues, but it isslow and fragmentary.

5C. Managing Public HealthEmergencies

5C.1 Public Health qua Firefighting SARS can be considered as a relevant and revealing test of the resilience and the flexibility of the public healthinfrastructure to manage health emergencies of any kind. Emergency management experts advise that thesuccessful resolution of an emergency, whether in healthor otherwise, always requires preparedness, planning,efficient and well-coordinated responses, and quick andaccurate decision making by the responders.

A common metaphor for this successful emergencycontinuum is firefighting. Detection of the blaze is akinto the action of an astute nurse, pharmacist, or physicianwho detects an unusual illness or disease cluster andimmediately alerts the relevant administrators or localpublic health department. The response of firefighters isanalogous to the response by front-line public healthworkers at the local level. The analogy extends to decisionmaking about the need for support. With any largeblaze, an incident commander arrives on the scene andmust assess whether the fire is beyond the capacity of hisor her crew. If so, back-up equipment and personnel arecalled. Effective public health emergency response similarlyrequires the presence of an authority on the scene who ischarged with direct command-and-control responsibility.We expect that firefighters and fire engines from differentjurisdictions will come together seamlessly to contain anemergency. In the public health field, this seamlessnesscan only come about from effective preparedness andcoordination by public health authorities at the local,provincial, federal and territorial levels. As with fire-fighting, there must be knowledge of common operatingprocedures, compatible training and equipment and,most importantly, prior agreements for mutual assistancein emergencies requiring a sudden surge capacity.

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The public health analogy can also be extended back toprevention of fires. For example, municipal governmentsimplement building codes to require flame retardantconstruction materials. Firefighters spend considerabletime in fire safety education aimed at preventing fires andpreparing citizens to do first-line firefighting at home, ininstitutions, or in workplaces. Analogous activities arefood safety and public health inspection, immunizations,and various health promotion activities. When preventionbreaks down or is inadequate, firefighters move toemergency response mode, as do public health workers.

In the preceding sections, we saw that F/P/T collaborationhas been inadequate in the realm of disease surveillanceand outbreak management. Had the SARS outbreakmushroomed into a truly national epidemic, our lack ofpreparedness could have been disastrous. The SARSoutbreak and subsequent events in Toronto thereforeillustrate the need to address public health emergencyresponse gaps and to develop a more comprehensiveapproach to managing public health emergenciesthrough a truly pan-Canadian system.

This integrated pan-Canadian system should encompassall the tools, plans and agreements necessary to respondto SARS or to any other large scale public healthemergency. If, as we have seen, governments cannotagree on surveillance strategies during ‘business as usual’,then one can hardly expect them to work cohesively inthe heat of an outbreak.

5C.2 The National Emergency FrameworkThe federal government’s generic emergency frameworkassesses incidents on a spectrum progressing from smallto large and from the slightly consequential to thecatastrophic. Emergencies, including disease outbreaks,progress along a jurisdictional spectrum from the localresponse, up to provincial, national, continental andultimately international levels.

The federal policy for emergencies accordingly assumes ahierarchy of response moving through successive levelsof government in a mutually supportive chain. Allfederal government departments are required under theEmergencies Act and the Emergency Preparedness Act tohave their own departmental emergency plans. Thelatter legislation, proclaimed in 1988, puts a particularlyclear onus on federal ministers to be prepared for civilemergencies, and “to monitor any potential, imminentor actual civil emergency and to report, as required, toother ministers on the emergency and any measures

necessary for dealing with it.” Similar requirements existat the provincial level, where multiple P/T jurisdictionshave been reviewing and upgrading their emergencyplanning and preparedness frameworks. Plans andpreparations undertaken by the federal governmentdepartments focus on actions to assist provinces whentheir capacity to respond is exceeded, to save lives and topreserve peace, order and good government. Federaldepartments are also expected to prepare for transborderor international emergencies with appropriate policy, riskanalysis and communication strategies.

All federal departments involved in an emergency followfour key response principles: an all-hazards approach;decentralization to departments that assume commandand control; interdepartmental coordination; and federal/provincial coordination. The first three are straightforward.The all-hazards approach recognizes that while the causesof emergencies and disasters are diverse, the responsecapabilities to deal with them are frequently similar. Inthe federal government structure, emergency planningand response is decentralized to take advantage of relevantknowledge and expertise as well as command-and-controlcapacity, resources, and regulatory tools residing withindifferent departments. While some emergencies may bedealt with by a single federal department or agency, most incidents warranting a federal response require theinvolvement of a number of departments. In all cases,one department takes the lead role that assumes commandand control while others play supporting roles.

It is at the level of F/P/T collaboration and coordinationthat the gaps emerge. All provincial and territorialgovernments have constitutional responsibility for thesafety, security and well-being of their citizens. Theprovinces and territories have all created frameworks tomeet their constitutional responsibilities, and as noted,modernized these apace in many instances. However, tothe best of the Committee’s knowledge, the federal,provincial and territorial frameworks have not beenanalyzed for comparability and interoperability. Federaland provincial emergency planning must be as integratedas possible to avoid confusion and duplication of effortand to ensure a timely flow of essential information andadvice between levels of government. In other words,what happened with SARS could happen with a naturaldisaster.

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5C.3 Focal Points for Health Emergencies The federal government created the Centre for EmergencyPreparedness and Response [CEPR] in July 2000 to act asa national coordinating point for public health securitywithin Health Canada and across various levels of govern-ment in the country. This addressed the need for a moreconsistent, sustainable and integrated approach topreparing for and responding to all types of public healthemergencies in Canada. The Centre brought together mostof Health Canada’s emergency preparedness and responseprograms and created a ‘critical mass’ of resources toallow for a more cohesive and synergistic response toemergency situations from both a departmental andinterdepartmental perspective.

The CEPR mandate focuses on public health issuesarising from various threats to the safety and healthsecurity of Canadians, including:

• natural events and disasters such as floods, earthquakes,fires and highly dangerous infectious diseases; and

• human-caused disasters such as accidents or criminaland terrorist acts involving explosives, chemicals,radioactive substances or biological threats.

CEPR, in collaboration with provincial and territorialgovernments, operates the National Emergency StockpileSystem [NESS]. This system, little known to Canadians,maintains $300 million in medical services, supplies andequipment in a state of readiness for immediate distribu-tion to provinces and territories in the event of a human-caused or natural disaster. NESS contains supplies foundin medical treatment centres ranging in size from smallfield medical units right up to a large hospital, includingbeds and blankets, and pharmaceuticals. The stockpileincludes 165 emergency 200-bed hospitals that aretransportable on short notice either by truck or airplane.They are stockpiled throughout the country and can beset up in existing buildings such as schools and communitycentres. The Committee recognizes the utility of NESSand recommends that the stocks and the operatingprinciples be updated to allow for interoperability withcurrent health care facilities. As the situation with N95masks showed during the SARS outbreak, a sourcing andclearinghouse function on the part of NESS may be moreimportant than the creation of static stockpiles. We alsosee the need for F/P/T training and exercises to ensurethat personnel are familiar with the equipment in thislargely unrecognized national resource.

CEPR has integrated functions that would be carried outin most provincial settings by the Chief Medical Officerof Health, Emergency Health Director, and EmergencySocial Services Director. Not all provinces have createdparallel structures that provide a single focal point forhealth emergencies. In Ontario, the Commissioner ofPublic Security and Commissioner of Public Health sharedthe lead role in the SARS outbreak, contributing to a lackof clarity about authority. In Quebec, an all-hazardsapproach to emergency preparedness and response is ledfrom a planning hub within the Ministère de la SécuritéPublique. This hub assigns an emergency response coor-dinator to other departments who become part of anetwork for integrated information sharing and response.The Quebec model is attractive, but could also lead tosome of the same challenges as emerged in Ontario.

The Committee recognizes that health emergencies suchas major infectious disease outbreaks rapidly becomegeneral emergencies, with a panoply of concerns thatspill across multiple government departments. Thechoice of a lead official from the health department orfrom public security will depend on the specific nature ofthe threat to population health. What is needed, in anyevent, is a clear protocol for determining a lead official,appropriate expertise around that individual, and thedelegation of appropriate command-and-control authorityto the leader of the response to a public health emergency.The federal CEPR has the advantage of creating a majorfocus for health emergencies that can either take the leaditself, or connect smoothly to broader emergency responsemachinery. It was not fully tested by SARS and thestrengths and weaknesses of the model may only becomeapparent in a larger-scale crisis. The Ontario SARSexperience, in contrast, constituted a particularly difficultfirst test for that province’s new emergency machinery.Comparing notes across F/P/T jurisdictions seems prudentto determine whether current legislative, regulatory, andadministrative elements are optimally organized either toexert the required command-and-control functions in apublic health emergency, or to allow smooth interactionsbetween health departments and a command-and-controlfunction vested in another branch of government, suchas an office or department of public security.

5C.4 The Post-September 11Environment

In the immediate aftermath of September 11, 2001 terroristattacks on the World Trade Center and the anthrax bio-terrorist attacks in the United States, the federal, provincialand territorial Ministers of Health met to plan a commonresponse and to map out a strategy for strengthening thepublic health sector’s emergency prevention, detection

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and response capacities. The public health system wasrecognized as the key mechanism whereby such threatscan be prevented or contained. Our American neighbour’stragedy sparked an important degree of solidarity at theF/P/T tables that we hope will carry over, post-SARS, tothe broader goal of enhancing public health in Canada.

In October 2001, the F/P/T Deputy Ministers of Healthcreated the Special Task Force on Emergency Preparednessand Response with broad representation. In March 2002,the Special Task Force tabled 31 recommendationsgrouped under broad clusters such as: leadership andcoordination; surge capacity; training and education;surveillance and detection infrastructure (includinglaboratories); supplies; and communications. The F/P/TDeputy Ministers and Ministers of Health endorsed therecommendations of the Special Task Force, and createdthe F/P/T Network for Emergency Preparedness andResponse to develop strategies and a plan to implementthe recommendations. The Special Task Force went togreat lengths to promote the benefits of enhanced F/P/Tcoordination across virtually every area of concern.

Notably, the Task Force emphasized the importance ofbuilding on existing public health infrastructures toachieve effective emergency response coordination acrossCanada. This idea of “filling in the gaps” rather thanstarting from scratch recognizes that our public healthinfrastructure remains the best basis from which toprevent, detect, respond to and manage disease outbreaks—including terrorist actions based on chemical, biologicaland radionuclear weapons of mass destruction.

Since March 2002, the various partners in the F/P/TNetwork for Emergency Preparedness and Response havebeen working to integrate public health practices into atruly national emergency management system. Thenational emergency management system aims to supportstrategic investments in public health security; enhancecross-sectoral and cross-jurisdictional collaboration;increase information sharing; establish clear emergencymanagement protocols, roles and responsibilities; andestablish greater coordination between emergency healthand social services and public health practitioners.

The Network has already supported the federal CEPR’sefforts to develop a National Emergency TransportationStrategy that will ensure the transportation of samples,personnel, materials, supplies and medical countermeasuresin emergencies whatever they may be. The EmergencyPreparedness and Response Framework is also beingapplied to public health emergencies. The Network hasbeen involved in the development of a series of integratednational emergency response plans including the

National Smallpox Contingency Plan and the PandemicInfluenza Plan. For example, work on the NationalSmallpox Contingency Plan involved provincial andterritorial consultations that brought together over 200 individuals from a variety of professional streamsincluding public health officials, laboratory scientists,epidemiologists, emergency health services, emergencysocial services, and ambulatory services. And as we haveseen, work on Pandemic Influenza Planning formed theplatform for some successful F/P/T interactions duringthe SARS outbreak.

More generally, CEPR has been working with provinces,territories, and other federal departments to update andexpand Emergency Preparedness Training with a view toincorporating public health needs, but these activities arestill under-resourced and underdeveloped. Effectiveemergency response also requires timely communicationand passage of information among all response partners.The SARS outbreak clearly illustrated that many of thenecessary data-sharing arrangements and business processagreements have yet to be developed. The emergencyparadigm presumes that there will be sustained efforts todevelop, test and maintain interoperability amongstfederal, provincial and territorial emergency operationscentres. This includes conjoint training exercises. As acorollary, the Committee sees an urgent requirement formulti-jurisdictional planning to create integrativeprotocols for outbreak management, followed by trainingexercises to test the protocols and assure a high degree ofpreparedness to manage outbreaks.

In sum, at the time of the World Trade Center and anthraxattacks, emergency leaders in health services, social services,public security, and public health worked independentlyfrom one another in most Canadian jurisdictions. Progresshas since been made in collaboration across and withinjurisdictions. Canadian governments at all levels need tocapitalize on this momentum, and invest urgently in formal mechanisms to exchange information, sharebest practices, undertake conjoint training, integrate andtest contingency plans, and examine the interoperabilityof processes, protocols and equipment to respond tohealth emergencies.

The Committee also wishes to emphasize the need forinvolvement of non-governmental organizations [NGOs]and employers in the process of emergency preparedness.In this respect, long before the 9/11 attacks, six CanadianNGOs had agreed to share resources in an emergency andsettle up the financial implications later—an examplethat governments could emulate. Major employers havetheir own role to play. For example, during the SARSoutbreak, a major information technology company in

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Toronto took prompt action, activating an eight-pointcontingency plan to shut down operations after anemployee left quarantine and arrived at work with SARS-like symptoms. However, little is known about the stateof corporate emergency plans more generally and thedegree of interaction between major employers andpublic health units or emergency measures/public securityoffices. Communication with major employers, andespecially with enterprises involved with high volumes ofhuman traffic such as hotels, airports, and transportationproviders (e.g., VIA Rail) was suboptimal during the SARSoutbreak. These links must be strengthened as part ofemergency preparedness.

5C.5 Building Surge Capacity The outbreak of SARS has reinforced the need for surgecapacity to provide greater flexibility in health and publichealth emergency response. Developing robust surgecapacity across jurisdictions is predicated on adequateprofessional resources, a depth of skill sets and overcomingjurisdictional legislative and regulatory barriers to allow,for instance, medical practitioners and health professionalsto act outside their licensing jurisdiction in emergencies.A number of stakeholder briefs addressed this topic,including a joint communication from nine nationalhealth-related associations.

At the outset, the Committee endorses the CanadianPublic Health Association’s caveat: the concept of surgecapacity must be based on a sufficiency of capacity for‘business as usual’, thereby allowing effective redirectionof resources in time of need. The Canadian Federation of Nurses Unions and other stakeholders similarlyemphasized that surge capacity is difficult to create whenthere are shortfalls in resources for usual public healthand personal health service needs.

To create surge capacity for emergencies, the above-notedF/P/T Task Force on Emergency Preparedness and Responseendorsed the concept of establishing a national frameworkto mobilize teams of professionally-qualified firstresponders to crisis sites as requested by a provincial/territorial or international authority. The Canadian conceptis modelled after the United States’ National DisasterMedical System. The US system has included the organi-zation of over 7,000 volunteer clinical personnel intotrained response teams for quick disaster response. Forexample, the US federal government was able to placefour to five teams at the periphery of the World TradeTowers collapse within hours of the event. The Canadianconcept builds on and expands the US approach.

CEPR established the National Office of Health EmergencyResponse Teams in December 2001. Subsequently, F/P/TDeputy Ministers and Ministers of Health have unanimouslyendorsed the principles for the development of HealthEmergency Response Teams [HERT]. The National Officehas a broad mandate to oversee funding, recruitment,planning, equipment, training and education, fieldexercises, operational deployment, transportation andcoordination of the teams.

A HERT would be composed of professional healthpersonnel specially trained and certified for rapiddeployment to disaster sites across the country. EachHERT would follow a generic “all hazards” approachencompassing emergency medical response to naturalevents such as earthquakes, tornadoes and to man-madedisasters including chemical hazardous material spillsand chemical, biological, radiological or nuclear terroristattacks and, in the aftermath of SARS, infectious diseaseoutbreaks. These teams would be positioned in strategiclocations across the country, and available to assist andsupport local/provincial/territorial health authorities inthe management of emergencies.

While the HERT model has been developed as a multi-disciplinary group of clinical and support personnel for“all hazards”, the SARS experience has highlighted theneed to be able to mobilize select groups of skilledpersonnel such as quarantine officers and public healthnurses. The related concept of ‘epidemic response teams’has been endorsed by various stakeholder submissions.Nonetheless, the HERT program has the potential to be aplatform for the mobilization of personnel to address thespecific requirements of a health emergency, such as anepidemic or major outbreak of infectious disease. Theconcept is already complemented by specialized surgecapacity-building that is underway through the F/P/TNetwork for Emergency Preparedness and Response, viz.development and deployment of a Smallpox EmergencyResponse Force and Pandemic Influenza Response Teams.

The federal government would activate HERTs at therequest of the province or territory, or alternatively, inresponse to an event falling within the jurisdiction offederal responsibilities. A HERT deployed at Kananaskisin the support of the G8 Summit is an example of thelatter function.

Sponsorship of a HERT can range from local organizationssuch as a hospital or local health department to provincesand territories. Coverage for professional and legalliabilities must still be determined as part of the HERTdevelopment process, but this problem is surmountablewith appropriate funding. The Committee is aware of a

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similar provincial proposal developed by some clinicalleaders in Toronto and Hamilton after SARS, and weexpect that parallel structures may emerge in multiplejurisdictions. Again, however, the goal must be to coor-dinate activities seamlessly, rather than set up overlappingand competing teams. For example, in the currentnational framework, if a HERT is deployed for emergenciesthat do not cross provincial boundaries and do notrequire federal intervention, then upon request by theprovince or territory to the federal government, the teamwould be designated to assist the provincial response.The responsibility for all costs, equipment replacement,licensing, liability and all other factors directly andindirectly related to the use of the teams then becomes aprovincial or territorial responsibility.

Based on the SARS precedent, expedited cross-jurisdictionallicensure of healthcare personnel should be feasible tofacilitate HERT activity. One option is that the licensingauthority in the affected province should accept allqualified individuals for the purpose and duration of theemergency as long as those persons are appropriatelylicensed in at least one province/territory in Canada.The functioning of HERTs will require enthusiastic andcommitted partnerships at all levels of stakeholders fromfederal departments, provinces and territories, NGOs,regional and municipal agencies and health careorganizations, healthcare facilities, and individualprofessionals.1

5C.6 Crisis Communications to the Public:A Missing Link

Communications to the public during an emergency arecrucial, as we have seen. During the SARS outbreak,Health Canada determined at the outset to identify oneconsistent spokesperson in English and one in French.Liaison was established with the Ontario GovernmentCommunications Office and with CDC Communicationsin Atlanta. Among the other strategies were: creatingand continually updating a SARS website, establishing a24/7 1-800 public information line; briefing media; andissuing travel advisories, an activity to which we returnin Chapter 11. Federal spokespeople understandably hada lower profile than provincial and local health leadersand clinical experts, and communications strategies, aswith other elements of outbreak management, were notwell-coordinated across jurisdictions.

Health Canada’s in-house specialists have done their ownassessment post-SARS and noted the need for a clearerframework for F/P/T collaboration. Prior to SARS, anF/P/T group had in fact worked together to develop aNational Crisis Communications Strategy aimed at helpingCanadian governments plan for, and respond to, thecommunications challenges inherent in a wide range ofemergencies from natural disasters and disease outbreaksto terrorist actions. This work must move ahead promptly.

The Committee appreciates that communicating accuratedata to the public during a fast-moving outbreak can beenormously difficult, and SARS was no exception. Aparticular challenge was the lag in characterizing cases.Epidemic curves posted on the Health Canada websitewere constructed by date of onset. This is a more consistentand valid approach than tallying new cases by the datethat they came to attention. However, there is a Catch-22.If new cases are assigned back to an earlier date of onset,it can appear as if the outbreak is over prematurely. Ifnew cases are instead reported to the media as part of acumulative case count, the impression is created that theoutbreak is still snowballing when the number of newcases might actually be falling. One way around thisproblem is the use of statistical projections to control foranticipated reporting delays. The other is to report thedata from different analytical perspectives, an approachthat could cause confusion but is more comprehensiveand accurate.

These communications nuances were apparently addressed‘on the fly’ during the outbreak. The Committee hasascertained that Health Canada does not have a sophis-ticated analytical framework for risk communication.Health Canada must build expert capacity in this area.

Similar shortcomings were evident elsewhere during theSARS outbreak. Focus groups with front-line staff (seeChapter 8) suggested that even within well-establishedand close-knit organizations that had crisis plans inplace, risk communication was suboptimal during theSARS outbreak.

Peter M. Sandman was consulted by the CDC about itscrisis communications strategies, an area of increasedemphasis and investment for that organization in thewake of the anthrax attacks on the US. Sandman andJody Lanard have published various documents2 that offera useful perspective on risk communication during SARSand more generally, including a set of counterintuitive but

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1 As regards partnerships, the Canadian Pharmacists Association has highlighted the need to consider role re-definition in the face of public healthemergencies. They recommend that legislation be amended to allow pharmacists to administer vaccines in the case of pandemics or biologicalwarfare/terrorism. This could bring thousands of additional front-line health professionals into play to support epidemic response.

2 See http//www.psandman.com [Enter searchword SARS to locate several items].

compelling axioms for crisis communication. For example,they suggest that downplaying the risk of an outbreaksuch as SARS is ultimately damaging; over-reassuranceshould be avoided. Spokespeople should not concealtheir fears or downplay risks; “a fearless leader is a uselessrole model.” Intriguingly, they urge communicators tobe “at least as worried in public as you are in private.”The paternalistic assumption that the public should beblandly reassured is wrong. Instead, lay risk assessmentsshould be respected. (In the Committee’s view, a corollaryis that the risk assessments of front-line health care workersshould also be respected.) The goal of communicationshould be to teach the public what useful steps they cantake to help fight the outbreak, rather than offeringreassurances that will ring false.

Sandman and Lanard have been scathing in theirassessment of Canadian communications strategiesaround SARS, particularly in comparison to the defthandling of communications in Singapore:

“The same day WHO lifted Canada’s travel warning,the international health agency said that the worstof Singapore’s SARS outbreak seemed to be over.Singapore health ministry spokeswoman Eunice Teoresponded masterfully by moving to the fulcrum ofthe risk communication seesaw. ‘The WHO saidthe peak is over in Singapore,’ she noted, ‘but ourminister has said it is too early to tell.’”

This type of balance, in their view, ultimately generatesmore sustainable public confidence “than Canada’s angryprotests and premature celebrations. Canada’s foreignstakeholders (and in private, even its own citizens) arelikely to sit on the worried, distrustful seat of the riskcommunication seesaw, since Canada is occupying theover-reassuring, over-confident seat.”

Public opinion research commissioned by Health Canadasuggests that Canadians were actually riding the “seesaw”alongside various spokespersons, not reacting to them. A poll was taken after the WHO travel advisory whenpolitical and health leaders united to highlight the progressbeing made in containing the outbreak. Among respon-dents nationally, 62% said the SARS situation wasimproving on April 29-30, 2003, up from just 33% duringApril 25-26, 2003. In Toronto, 68% said the situationhad gotten better. Nonetheless, given the second wave ofSARS in Toronto, Sandman and Lanard’s comments aboutsitting on “the over-reassuring, over-confident seat” seemall too prophetic. The CDC now has a comprehensive

crisis communications training program3 that, in ourview, bears close study and early emulation. Nothing we have seen from any F/P/T jurisdiction to date iscomparable.

5D. National Capacity and Networkfor Disease Surveillance &Outbreak Management

Focusing on smallpox, SARS or pandemic influenza raisesthe risk of over-investing limited resources in managing arestricted range of public health emergencies rather thanengineering a system that can be flexible and responsiveas well as sustainable. This section focuses on how tobuild provincial and territorial capacity for responding tocommunicable diseases, and how to connect that capacityinto a strong network of federal, regional, and provincialhubs for disease surveillance and outbreak management.The network, in turn, must be linked to the existingF/P/T Network for Emergency Preparedness andResponse, thereby creating the multi-level protection thatCanadians need and deserve.

By way of precedent, the European Commission formed aNetwork on Communicable Diseases in 1999. It builds onthe capacity of member states and focuses on surveillanceand early warning for outbreaks with greater than nationaldimensions. The Commission has specified that communi-cable diseases should be placed progressively under EU-wide surveillance. To monitor and track develop-ments, disease-specific networks have been created. At present, these consist mainly of key laboratories inparticipating countries. Following on from discussionover a number of years about the creation of an infectiousdisease agency for Europe, the European Commission hasalso just adopted a proposal to create a European Centrefor Disease Prevention and Control by 2005. The Centrewill have a small core staff and coordinate an extendednetwork in member states. Fifteen European countriessponsor the European Program for InterventionEpidemiology Training. It is similar to Canada’s FieldEpidemiology Training Program, but also represents apotential F/P/T collaborative model. In short, if thesovereign nations of Europe have come together aroundinfectious disease surveillance and management, how canCanada allow F/P/T tensions to undermine its responseto public health threats?

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3 See http//www.cdc.gov/cdcynergy/emergency/

Chapter 4 outlined a $300 million per annum investmentfor core public health functions that would help to shore up Canada’s first line of local responses to diseaseoutbreaks and health threats, particularly when coupledwith a $100 million per annum injection of support fornew vaccines. The handling of the SARS outbreak inOntario illustrates that a different level of functionality isalso needed—a second line of defence at the provincial orregional level with surveillance, analytical, investigativeand coordinating capacity. Quebec’s National Institute of Public Health and British Columbia’s Centre forDisease Control both offer models in this respect. We focus on the BC CDC because of its primary mandatein infectious diseases.

The BC CDC was established to be the province’s focalpoint for “the prevention, detection and control ofcommunicable disease,” and a provider of specialty healthsupport and resource services. The Centre integrates fivedivisions: Hepatitis Services; Epidemiology Services;Laboratory Services; STD/AIDS Control; and TuberculosisControl. Support services include InformationManagement and Pharmacy. In April 2002, the BC CDCassimilated several new programs, including a Drug andPoison Information Centre; Food Protection Services; andRadiation Protection Services. The BC CDC works closelywith the provincial health ministry, Medical HealthOfficers, and the Provincial Health Officer. Its annualbudget of approximately $70 million includes $30 millionfor vaccinations and $40 million directed primarily tocontrol of communicable diseases. The BC CDC hascatalyzed the creation of the University of British Columbia(UBC) Centre for Disease Control in research and teachingactivities. The UBC CDC focuses on “collaborativeresearch into the surveillance, control and prevention ofcommunicable disease” and “links academia, governmentsand public health organizations in the understanding,management and prevention of infectious diseases ofpublic health significance.” The BC CDC has provensufficiently successful that its mandate is now broadeningto include other specialized areas beyond its communi-cable disease mandate.

This type of investment and structure will not be attractiveor appropriate for all provinces and territories individually.Some provinces could structure their participation in anational network as a within-province network, drawingon strengths in both public health and academe; smallerprovinces in a region may decide to pool resources andcreate a regional CDC. Transfers from the new federalagency to catalyze this second-line capacity for surveillanceand outbreak management must accordingly allow forreasonable P/T pluralism.

Estimating the required level of contributions throughthe new federal agency is not straightforward. As onesimple benchmark, approximately $40 million perannum is invested by the BC CDC, outside of vaccines,to maintain an outstanding core infectious diseasefacility for that province. British Columbia has 13% ofCanada’s population, thus roughly $280 million perannum would be required to sustain similar activityacross Canada. However, other P/T jurisdictions havealready developed some capacity analogous to the BCCDC, not least Quebec through its multidisciplinaryNational Institute of Public Health.

As well, this second line of defence could be construed asexclusively a P/T responsibility. We reject that argumentas an abdication of federal responsibility on four counts.

First, the Auditor General’s comments underscore anacute need to build surveillance capacity across Canadaas a matter of broad national interest. Multiple stake-holders urged the Committee to foster a national approachto infectious disease surveillance. The US precedentsuggests that national data and surveillance systems areonly achievable with dedicated federal funding. To thatend, the investments in the new federal agency outlinedin Chapter 4 already presumed that $25 million perannum towards surveillance would be drawn from aseparate allocation for infectious diseases.

Second, as the SARS experience demonstrated, evensubstantially enhanced firepower in a new federal agencywill do little in the absence of a well-coordinated responseto an outbreak at the provincial level. SARS has alsohighlighted the importance of enhanced nosocomialinfection control. Better linkages between public healthand the clinical sphere, and the roll-up of institutionalinfection control activities to the P/T and ultimatelynational level, will not be achieved without meaningfulfunding.

Third, if any province fails to contain an outbreakefficiently, the results for all of Canada are devastating onmultiple levels. We refer not just to the spread and tollof disease, but other impacts. The Greater Toronto Area,for example, accounts for approximately one-fifth ofCanada’s GDP, and SARS therefore had national economicimplications.

Fourth, Ottawa’s revenue-collecting and spending powersare disproportionate to its constitutional administrativemandate in the Canadian federation. This tension in thenational fabric places a constant onus on the federalgovernment to fund provincially-administered activities,particularly those that are in the broad national interest.

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On the other hand, the provinces also have revenue-generation mechanisms and access to new funds fromthe Canada Health and Social Transfer. The Committeeassumes that P/T jurisdictions would not claim theirrightful authority in a strengthened public health systemwithout taking responsibility for helping to fund it.Hence, just as the Public Health Partnerships Programwould leverage P/T investments in local public healthinfrastructure, so also do we assume that federal transfersfor prevention and control of communicable diseases atthe P/T and regional level would be matched in somemeasure by the involved P/T jurisdictions.

Weighing these factors and estimates, the Committeeenvisages that the Canadian Agency for Public Healthshould ultimately receive and earmark $100 million perannum for support of P/T capacity in infectious diseasesurveillance and outbreak containment in the form of aCommunicable Disease Control Fund. This is distinct fromand above the transfers recommended for general publichealth infrastructure and immunizations, and completesthe $500 million per annum suite of P/T contributionprograms that the Committee views as necessary for therenewal of a national public health system. We anticipatethat these transfers would start at a lower level and riseover a number of years in response to enhanced capacityarising from increases in the numbers of skilled personneland interlocking P/T investments.

Initial allocations from this Communicable Disease ControlFund should start flowing in advance of the creation ofany new agency as part of preparedness for the winterinfluenza season. Similarly, the creation of an F/P/TNetwork for Communicable Disease Control can beginsooner rather than later to ensure that F/P/T jurisdictionalcollaboration is enhanced, and that the nation is appro-priately positioned to respond to existing and emerginginfectious diseases. We explain further in Chapter 9 howthese transfers should be tied to intergovernmentalagreements and initiatives to secure standardized businessprocesses and a harmonized legislative framework fordisease surveillance and outbreak management. For now,we refer readers to Appendix 5.3 below for a summary ofthe agreements required to promote a more seamlessapproach to outbreak management and prevent arecurrence of the inter-jurisdictional tensions evidentduring the SARS crisis.

As suggested in Chapter 4, the Communicable DiseaseControl Fund directed at infectious disease surveillanceand outbreak management could be bundled with thePublic Health Partnerships Program and NationalImmunization Strategy into a single transfer managedaccording to the Social Union Framework Agreement.

This ensures maximum flexibility for the Chief PublicHealth Officer of Canada and her/his provincial/territorialcounterparts in aligning transfers with both provincial/territorial priorities and a national strategic plan.

Although accountability for the transfers from theCommunicable Disease Control Fund would bedetermined between each P/T jurisdiction and the newfederal agency, some proportion of the $100 millionshould be reserved for networking functions. Theconcept of a second line of defence presupposes strongconnections not only among provincial and regionalcentres of excellence in infectious disease control, butalso between these P/T nodes or hubs and the relevantcentres in the new federal agency. The latter couldinclude the National Microbiology Laboratory, the Centrefor Infectious Disease Prevention and Control, the Centrefor Surveillance Coordination, and the Centre forEmergency Preparedness and Response.

This F/P/T Network for Communicable Disease Controlcould be formed quickly by connecting structures thatalready exist in some provinces (e.g., the BC CDC,relevant centres in Quebec’s National Institute of PublicHealth) to leaders from other provincial public healthbranches pending their decision on the creation ofprovincial centres of specialized expertise. Agreementsamong participating provinces and the relevant nodesand centres within the Canadian Agency for Public Healthwould be negotiated with the intent of maximizing co-location of facilities and personnel, and creating bothintegrated disease surveillance machinery and graduatedresponses to infectious disease outbreaks. The networkwould presumably include task forces or working groupsto address issues such as surveillance, outbreakmanagement and emergency response, nosocomialinfection control and hospital epidemiology, strategiccommunication, and related matters.

This new F/P/T network should seek to embody the samecollaborative culture that has apparently emerged withthe F/P/T Network for Emergency Preparedness andResponse or the Canadian Public Health LaboratoryNetwork (see Chapter 6). To that end, the communicablediseases network should be mandated and supported bythe F/P/T Conference of Deputy Ministers of Health. Itssteering committee would include designates from therelevant provincial or regional centres and leaders of therelevant federal centres.

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5E. RecommendationsThe Committee recommends that:

5.1 Under the aegis of the new Canadian Agency forPublic Health, the Government of Canada shouldbudget for a Communicable Disease ControlFund, allocating a sum rising over 2-3 years to$100 million per annum in support of provincial,territorial, and regional capacity for infectiousdisease surveillance, outbreak management, andrelated infection control activities, includingthe sponsorship of a new F/P/T network. Initialallocations from this Fund should be made tofacilitate immediate preparedness for a possiblereturn of SARS to Canada during the winterseason of respiratory illnesses and influenza.

5.2 The F/P/T Conference of Deputy Ministers ofHealth should initiate a new Network forCommunicable Disease Control that would linkF/P/T activities in infectious disease surveillance,prevention, and management. This initiativeshould be started as soon as possible, and inte-grated with the existing F/P/T Network forEmergency Preparedness and Response.

5.3 The Canadian Agency for Public Health, inpartnership with the new F/P/T Network forCommunicable Disease Control, should givepriority to infectious disease surveillance,including provision of technical advice andfunding to provincial/territorial jurisdictionsand programs to support training of personnelrequired to implement surveillance programs.The Agency should facilitate the longer-termdevelopment of a comprehensive and nationalpublic health surveillance system that willcollect, analyze, and disseminate laboratoryand health care facility data on infectiousdiseases and non-infectious diseases to relevantstakeholders.

5.4 Assuming some lag time to inception of a newAgency or F/P/T Network, Health Canada andthe provinces and territories should urgentlycommence a process to arrive at business processagreements for collaborative surveillance ofinfectious diseases and response to outbreaks.The business processes for infectious diseasesurveillance would be extended over time withsupport from the Agency’s Centre for SurveillanceCoordination and the Public Health PartnershipsProgram, to a national system for non-communi-cable diseases and population health factors.

To elaborate: the Committee envisages that the systemwould begin by collecting data on communicable diseases,and extend its ambit to non-communicable diseases aswell as relevant population health factors. The surveillancesystem must be relevant at the local level, with timelyreporting and analysis, and flexible enough to adapt tochanging needs and different local and institutionalcircumstances. Such a system must be built so thatdatabases can communicate with one another, and besufficiently ‘low tech’ to maximize uptake in hospitals(not least hospital emergency rooms where renewal andupgrading of information systems is urgently needed),clinics and public health units. The system should bemodular in both its conception and implementation, butwith data collection mechanisms and software structuredso as to permit the integration of information into alarger surveillance and public health information system.

The business process agreements for surveillance wouldcover multiple fronts, including:

a. Developing procedures for uniform and timelyreporting of identified infectious diseases, includingnew pathogens, by local authorities, provinces andterritories to Canadian Agency for Public Health. Inturn, the Agency should establish a system for rapiddetermination of diseases that must be reported on anational basis.

b. Identifying relevant surveillance tools and methods asappropriate for health professionals in other settings toinput data to the surveillance system (e.g., pharmacyidentification of increased use of antidiarrheals, earlyidentification of nursing home or other collective livingoutbreaks, role of other facilities such as schools in theevent of large community outbreaks, linkage of infor-mation systems in hospital emergency departments, etc.).

c. Developing standards for data gathering, and protocolsfor data ownership, data sharing and dissemination.

5.5 Through its own core budget and theCommunicable Disease Control Fund, theCanadian Agency for Public Health shouldsupport nosocomial infection control, includinghospital surveillance, as a priority program.Specific nosocomial infections should bedeemed nationally notifiable, and surveillancefor them supported by mechanisms for activeand passive laboratory surveillance.

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As is true for health care more generally, public healthhas under-invested in information technology for years.Other sectors such as banking and insurance make aseveral-fold higher investment in information technologyas compared to health, notwithstanding the accelerationof investment in recent years. Through Canada HealthInfoway Inc., the recent federal Budget provided $600 million in one-time only support to move aheadwith the creation of an Electronic Health Record.Comparatively speaking, the needs of surveillance havenot received much attention or funding. The presence ofa national “blueprint” for health IT, with a concentrationon the Electronic Health Record, highlights the need foran approach to health surveillance that is integrated withthe clinical systems of the future. The Committeeaccordingly recommends that:

5.6 The Government of Canada should seek theestablishment of a working group under theauspices of the Canada Health InfowayIncorporated and Health Canada and/or thenew Canadian Agency for Public Health, to focusspecifically on the needs of public healthinfostructure and potential investments toenhance disease surveillance and link publichealth and clinical information systems.

We have also highlighted the need to create collaborationbetween public health emergency capacity, particularlyoutbreak management, and the broader emergencyresponse capability of F/P/T jurisdictions. The Committeetherefore recommends that:

5.7 The F/P/T Network for Emergency Preparednessand Response, in collaboration with the newF/P/T Network for Communicable DiseaseControl, should urgently move ahead with thedevelopment of a comprehensive approach tomanaging public health emergencies through apan-Canadian system that includes:

• harmonizing emergency preparedness andresponse frameworks at the federal,provincial and territorial levels;

• developing seamless planning and responsecapacities as envisaged by the 31 recommen-dations of the Special Task Force on EmergencyPreparedness and Response;

• building an integrated F/P/T planning,training and exercising platform forresponding to all-hazard disasters, includingpublic health emergencies created by large-scale disease outbreaks;

• developing and applying a common set ofprinciples, concepts and capabilities for large-scale disease outbreaks, and

• creating the requisite linkages to majoremployers, the travel and hotel industry, andrelevant NGOs.

We return to legal issues in Chapter 9. In this context,the Committee recommends that:

5.8 Health Canada in collaboration with provincial/territorial jurisdictions should lead the develop-ment of a national legislative and policy frame-work for a measured, harmonized, and unifiedresponse to public health emergencies.

The Committee further recommends that:

5.9 F/P/T governments should develop and providetraining programs and tools to support localpublic health units and institutions in system-atically developing, implementing, and evalu-ating crisis and emergency risk communicationstrategies.

5.10 The F/P/T Conference of Deputy Ministers ofHealth should support the continued activity ofthe F/P/T Network for Emergency Preparednessand Response with a view to enhanced surgecapacities in all jurisdictions, including:

• developing an integrated risk assessment capa-bility for public health emergency response;

• assessing the National Emergency StockpileSystem [NESS] to optimize its role in supportingthe response to large-scale disease outbreaks;and

• developing and funding the Health EmergencyResponse Team concept, including a psycho-social response component, as a practical,flexible mechanism for addressing the needfor human resource surge capacity.

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Appendix 5.1 Costing of a Surveillance SystemThe costs below reflect, first, a reasonably comprehensivesystem for the surveillance of reportable infectious diseases,with the capability to link to front-line public health casemanagement systems, laboratory systems, and infectioncontrol systems. These systems only partly exist and willneed to be developed further. To satisfy the needs ofpublic health users and to meet the goals of the renewedNational Immunization Strategy, immunization and vaccineadverse event reporting modules will need to be included.It is assumed that modules for disease syndromes and formass quarantine will be included. Syndromic surveillancefor bioterrorism is listed separately.

The costs are incremental, based upon the current state ofdevelopment of surveillance infrastructure and info-structure in the Population and Public Health Branch.

A second major component is an intelligence dissemina-tion or health alert network system, not unlike thatrecommended by the Canadian Medical Association intheir submission. It would be developed gradually andwill ultimately resemble the CDC’s Public HealthIntelligence Network System. Portal-type capabilitiesallowing controlled access to a wide range of informationwill eventually be included. It would provide a fully-featured secure system for high-priority users and asimple e-mail/fax capability for general users.

Total costs are shown: this would be shared in somefashion (according to the type of expenditure, not byformula) between federal and P/T governments. Basichardware and connectivity costs are not included.

Costs are shown as average yearly costs over a five-yearperiod.

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$ millions p.a.(average, over

5 years)

CIPHS/i-PHIS

Collaborative 2.0

Updates, pilots, rollout 1.8

Modules &/or links:inspection/water 0.4non-infectious (basic) 0.5lab (link) 0.3blood-borne infections (link) 0.4influenza 0.1quarantine 0.1immunization/vaccine-preventable diseases/vaccine-associated adverse events 0.6

Lab systems development 2.0

Infection control system development 2.5

Architecture 0.4

Standards 0.7

Policy Issues (privacy, data management) 0.4

Local implementation 7.0

Subtotal 19.2

Bioterrorismarchitecture/standards 0.8public health system development 1.7feeder systems development 3.0implementation 5.0

Subtotal 10.5

Portal/Health Alert NetworkConsultation/design 0.2IM/IT development, project management 2.3Component development 0.8Implementation & operations 10.0

Subtotal 13.3

TOTAL 43.3

Five-year total: $215 million

Costing of a Surveillance System for Infectious Disease & Emergencies

Appendix 5.2Case Definitions for SARS fromHealth Canada and OntarioI. Evolution of Health Canada’s SARS Case

DefinitionMarch 16: first case definition with a probable casebeing one who meets the suspect case definition “togetherwith severe progressive respiratory illness suggestive ofatypical pneumonia”.

Comment section indicates signs/symptoms that maycharacterize severe progressive respiratory illness and that“chest x-ray changes may or may not be present”.

• First Case definition included “Close contact* with aprobable case

• Recent history of travel (within 10 days) to Asia,especially in areas reporting cases of SARS (see below)

Areas in Asia Reporting Cases of SARS China: Guangdong province, Hong Kong SAR

Vietnam: City of Hanoi

Singapore

March 17: “AND No other known cause of currentillness” was added to case definition.

March 20: “Persons under observation” is defined andadded to case definitions. Recent history of travel(within 10 days) to WHO-reported “affected areas” inAsia is added to suspect case definition (rather thanRecent history of travel (within 10 days) to Asia).

March 21: Definition of Persons “under observation” isremoved and added to website under “Public HealthMeasures”.

March 31:

• “Close contact* within 10 days of onset of symptomswith a probable case” is added to suspect casedefinition.

• “recent travel to a setting that is associated with acluster of SARS cases” is added to suspect casedefinition. This was added to capture exposure siteswithin Canada (i.e., Toronto).

Areas in Asia with Local Transmission (March 29, 2003 21:00 EST)

China, including Hong Kong Special AdministrativeRegion

Vietnam: City of Hanoi

Singapore

Taiwan [added]

April 2: “Close contact* within 10 days of onset ofsymptoms with a suspect or probable case” is added tosuspect cases definition.

May 14: Wording of Affected area changed slightly“Recent travel within 10 days of onset of symptoms to a WHO-reported “affected area” outside of Canada[previously in Asia]

• Table of Areas, OUTSIDE OF Canada listed as “AffectedAreas” (with Local Transmission of SARS) included.Case Definitions stayed the same.

May 29: Clinical criteria for a living suspect case staysthe same.

• addition of: “A person with unexplained acuterespiratory illness resulting in death after 1 November2002, but on whom no autopsy has been performed”added to suspect case definition

• Recent travel or visit within 10 days of onset ofsymptoms to a defined setting that is associated witha cluster of SARS cases changed to “Recent travel or visitto an identified setting in Canada where exposure to SARSmay have occurred (e.g., hospital [including any hospitalwith an occupied SARS unit], household, workplace,school, etc.).** This includes inpatients, employees orvisitors to an institution if the exposure setting is aninstitution.”

• link to Ontario site provided: “**The list of potentialSARS exposure sites in the Province of Ontario can beobtained at the following address:<http://www.health.gov.on.ca/english/public/updates/archives/hu_03/sars/exposure_sites_052703.pdf>”

• Probable case definition changed: “A suspect case withradiographic evidence of infiltrates consistent withpneumonia or respiratory distress syndrome (RDS) on chestx-ray (CXR).”

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• ”Exclusion Criteria strengthened”

A suspect or probable case should be excluded if analternate diagnosis can fully explain their illness.

• Areas, OUTSIDE OF Canada listed as “Areas withrecent local transmission” of SARS revised

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Chronology of Ontario SARS Case Definitions as per their website

Date Website Probable Case Definition Suspect Case Definition

April 29, 2003 http://ogov.newswire.ca/ontario/GPOE/2003/04/29/c5627.html?lmatch=&lang=_e.html

A probable case is someone who eitherhas chest x-ray findings of pneumonia orAcute Respiratory Distress Syndrome ORis a suspect case with an unexplainedrespiratory illness resulting in death, withfindings of Acute Respiratory Distresssyndrome of unidentifiable cause ANDhas had close contact with a probable orsuspect case of SARS or traveled toHong Kong, Vietnam, China, Taiwan orSingapore in the last 10 days.

No change

April 11, 2003 http://ogov.newswire.ca/ontario/GPOE/2003/04/11/c0428.html?lmatch=&lang=_e.html

A probable case is someone who eitherhas chest x-ray findings of pneumonia orAcute Respiratory Distress Syndrome ORis a suspect case with an unexplainedrespiratory illness resulting in death, withfindings of Acute Respiratory DistressSyndrome of unidentifiable cause ANDhas had close contact with a probable orsuspect case of SARS or traveled toHong Kong, Vietnam, China, Taiwan orSingapore.

A person with a history of high fever(over 38 degrees C) AND respiratorysymptoms including cough, shortness ofbreath, difficulty breathing AND no otherknown cause of current illness AND hashad close contact with a probable orsuspect case of SARS or traveled toHong Kong, Vietnam, China, Taiwan, orSingapore in the last 10 days.

May 26, 2003 http://www.health.gov.on.ca/english/public/updates/archives/hu_03/sars_stats/stat_052603.pdf

* Close contact means having cared for, lived with or had face-to-face (within 1 metre) contact with, or having had direct contact with respiratorysecretions and/or other body fluids of a person with SARS.

A person meeting the suspect casedefinition together with progressiverespiratory illness suggestive of atypicalpneumonia or acute respiratory distresssyndrome with no known cause OR aperson meeting the suspect casedefinition with an unexplained respiratoryillness resulting in death, with anautopsy examination demonstrating thepathology of acute respiratory distresssyndrome with no known cause.

A person presenting with a fever (over 38degrees Celsius) AND one or morerespiratory symptoms including cough,shortness of breath, difficulty breathing,AND one or more of the following: 1)close contact* within 10 days of onsetwith a suspect or probable case; 2) recenttravel within 10 days of onset of symptomsto a WHO reported “affected area” outsideof Canada (see WHO website for latestinformation: http://www.who.int/csr/sars/en/ ); 3) recent travel or visit within10 days of onset of symptoms to adefined setting that is associated with acluster of SARS AND no other knowncause of current illness.

Appendix 5.3Some Steps toward AchievingSeamless Outbreak Managementin CanadaEither memoranda of agreement or legislative arrangementsshould be developed among Health Canada and all P/Tjurisdictions laying out protocols covering all aspects ofthe conduct of the management of significant outbreaks,as below:

• agreement on roles and responsibilities;

• agreement on data ownership, custody, sharing; theaim should be to facilitate greater sharing of data;

• prior agreement on the use of data for publication andauthorship must be included;

• clear identification of persons responsible for (a)management of the outbreak, (b) data management,and (c) communications;

• prior agreement on the general outline of informationmanagement elements (standards, definitions, etc.),based on accepted standards, with one personresponsible for authorizing elaborations of theseelements, and enforcing their use;

• development of a shared ‘B-team’ function, withseparate teams responsible for front-line outbreakcontainment, epidemiology and data analysis, and‘sober second thoughts/hypothesis generation’;

• agreed strategy and workplan to ensure interoperabilityof all information systems concerned with infectiousdiseases in hospital and public health;

• sharing of information to be by access to a commondatabase rather than through transmission of data; and

• uniform adoption of highly flexible and interoperabledata platforms, that allow sharing of public healthinformation, capture of clinical information fromhospitals, and integration into an outbreak managementdatabase platform.

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STRENGTHENING THE ROLE OF LABORATORIES IN PUBLIC HEALTH AND PUBLIC HEALTH EMERGENCIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Laboratory issues were highlighted in briefs received fromthe Canadian Association of Medical Microbiologists, theCanadian Infectious Diseases Society, the CanadianSociety for Medical Laboratory Science, and the OntarioAssociation of Medical Laboratories. The SARS experiencehas clearly illustrated the central role that public healthlaboratories play in both public health and the healthcare system. Serving sometimes as first-line testingfacility when a novel agent emerges, and at other timesas a reference centre or ‘court of last resort’ to standardizeand improve testing procedures for unusual pathogens,public health laboratories are a key resource in infectiousdisease diagnosis, surveillance, and epidemic response.Public health laboratories also have potential functionsin chronic disease surveillance and diagnosis that couldgrow in the years ahead as more links are establishedbetween apparently non-communicable diseases and avariety of pathogens.

6A. Key Activities of LaboratoriesCanada has a wide variety of medical laboratories,organized variously under the ownership and managementof investor-owned corporations, non-profit hospitals andhealth regions, or various levels of government in theform of public health laboratories. The list of activitiesbelow applies particularly to a public health laboratory,but other types of laboratories carry out some of thesefunctions:

• Diagnosis of infections

• Characterization of micro-organisms

• Reference services

• Support to epidemiologic surveillance and epidemicinvestigation

• Participating in, conducting or coordinatinglaboratory surveillance of infectious diseases

• Environmental surveillance

• Emergency preparedness and response

• Applied research and development

• Fundamental research

While discharging these functions, public health labora-tories are integrated with the wider public health team.They play important roles in providing information forpublic health policy, training health human resources,and public health research.

A brief description of each of the key functions mayprovide the reader with a better understanding andappreciation of the role of laboratories in public health.

6A.1 Diagnosis of InfectionsThere is a public health dimension to all communicablediseases and to some related infectious disease issues(e.g., nosocomial infections and antimicrobial resistance).In Canada, diagnostic services for infectious diseases canbe provided by private laboratories, hospital laboratories,provincial laboratories or national laboratories. The mostfrequent infectious diseases, such as lower urinary tractinfections (cystitis), skin infections (impetigo, carbuncles,cellulitis), typical community-acquired pneumonias, andupper respiratory tract infections (pharyngitis, laryngitis,sinusitis), are all diagnosed using microbiological tech-niques available in private laboratories or hospital labora-tories. The role of private laboratories varies widely. Insome provinces, they mainly provide diagnostic servicesto community-based physicians. In others, they also havea significant role in providing services to hospitals, andmajor hospitals have developed public-private partnershipswith investor-owned laboratory service providers.

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Less common infections are diagnosed in laboratories ateither the provincial or national levels. In cases of newdiseases such as West Nile virus and SARS, or rare diseases such as Hantavirus and Ebola virus, the NationalMicrobiology Laboratory [NML] at times takes on the roleof front-line diagnostic laboratory. This occurs when theNML receives specimens for testing directly from healthcare institutions, a situation that arises when it is the onlylaboratory in the country able to provide the requiredtesting for reasons of economy of scale or requirementsfor high levels of containment. In many instances, this isa time-limited role as other laboratories become proficientin testing for these rare or dangerous agents, or testsbecome commercially available. The NML may also playa role in facilitating the adoption of new testing technologyby hospital or provincial public health laboratories.

6A.2 Characterization of Micro-organismsDetailed characterization of organisms is a frequentfunction of public health laboratories. There are manyimportant reasons for characterizing organisms associatedwith infection. These include gaining an understandingof a class of organisms’ susceptibility to treatments so thatappropriate treatment choices can be made, understandingthe relatedness of organisms of the same class and thuspossible common sources of infection, and determininghow an organism is causing disease and predicting risksof infectious disease outbreaks. Different types of charac-terization are generally performed by different types oflaboratories in the health care or public health system.As with other areas of public health, this function hassuffered from a lack of coordination and problems withdata sharing.

6A.3 Reference MicrobiologyReference microbiology includes activities such as confir-mation of the identification of rarer organisms, organizingand coordinating quality assurance, and proficiencytesting programs. All laboratories require some kind ofreference function. Provincial public health laboratoriesmay provide this function for laboratories in their juris-diction and the NML provides reference microbiologyservices to all provincial laboratories as well as someinternational reference activities. In the absence ofresources for developmental work at provincial laboratories,reference microbiology has been provided by someacademic hospital laboratories. Thus, Canadian referencelaboratory systems are ad hoc and not well-coordinated.

6A.4 Support to EpidemiologicSurveillance

Almost all infectious disease surveillance involves alaboratory test at some stage, as clinical diagnosis in andof itself is seldom deemed definitive. In Canada, nationalsurveillance systems for different infectious diseases haveevolved independently of each other, and are largelystand-alone. The type of laboratory testing required for agiven surveillance system determines where testing can bedone. For some infections (meningitis, Creutzfeldt-JakobDisease [CJD]), all specimens are tested at the nationallevel. For others such as influenza, initial isolation isperformed at the provincial level and a sample is referredto the National Microbiology Laboratory for sub-typing.This practice extends to many areas such as surveillanceof vaccine adverse events (now being planned), vaccinefailures or antiviral drug treatment failures.

At times, the sampling frame for surveillance is systematicand at other times it is not. For some diseases, a labora-tory result generated on the front line or in provinciallaboratories becomes part of an epidemiologic report andcontributes to a deeper understanding of a particularemerging disease or outbreak. New techniques haveallowed ‘molecular finger-printing’ of organisms toestablish their epidemiologic relationships, as in differentstrains of the SARS virus. These techniques can also beimportant in linking severity of infections to subtledifferences in viruses or bacteria that otherwise appear tobe part of the same family.

Unfortunately, these types of activities are again not well-coordinated; Canada continually loses opportunities toadvance knowledge or improve its own management ofinfectious diseases by failing to aggregate these data in acoherent laboratory-linked surveillance system. As acorollary, while there is considerable laboratory input intoinfectious disease surveillance systems, closer links areneeded to surveillance in general. The case for betterintegration of laboratory and epidemiologic activities inCanada was highlighted by multiple stakeholders, includingthe Canadian Society for Medical Laboratory Science, theCanadian Infectious Disease Society, Canadian Associationof Medical Microbiologists, and the Ontario Associationof Medical Laboratories. As well, it is clear that betterstandardization of laboratory testing would improve thecomparability of results, and mitigate either uncertaintyor the need for repeat testing.

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6A.5 Laboratory SurveillanceSome types of surveillance are primarily laboratory-based.West Nile virus is one example. The National MicrobiologyLaboratory performed all testing of dead birds andmosquitoes over the first three years; testing has sincelargely devolved to provincial laboratories. Other typesof surveillance that are primarily laboratory-based includemolecular finger-printing of foodborne organisms, anddetermination of antimicrobial resistance.

Most laboratory surveillance systems are passive, that is,they rely on submitted biologic material to make inferences.If patients with signs of a particular infection are nottested, or if they are tested in laboratories that are notpart of a surveillance network, then information is lost.Epidemiologists regard passive surveillance as flawed inthat it lacks a systematic sampling frame, clear definitionof denominators, and assurance that laboratory informationcan be integrated with standardized epidemiologic andclinical information. The outputs of a passive surveil-lance system have limited utility. Canada needs moreactive laboratory surveillance with known sampling framesand better denominator data to strengthen our ability toanticipate, detect and respond to infectious disease threats.

More timely and sensitive laboratory surveillance formany infectious diseases is entirely feasible by marryingadvances in information technology with advances inmolecular typing of organisms.

Consider the current sequence of events for a reportabledisease of national interest: a patient with a particularclinical syndrome presents to a physician. The physicianorders a laboratory test. The test is performed by a localprivate laboratory, or perhaps in a hospital laboratory.The laboratory reports the test to the attending physician,who in turn reports the case to local public health, andthis in turn is reported provincially and ultimatelynationally. This system can take from a few days up toseveral weeks before case counts cumulate to the nationallevel, and it is particularly weak for timely recognition ofmulti-jurisdictional outbreaks.

More timely detection can only be achieved throughlinking laboratories. The Canadian Public HealthLaboratory Network [CPHLN] is putting such a networkin place for enteric diseases, bioterrorism and otherevents. Although it is several years behind the UnitedStates’ PulseNet, the enteric disease surveillance system,PulseNet Canada is close to being operational.

It is ultimately possible for all provincial laboratories andsome major academic medical centres to use commontechnology platforms and typing procedures, and then belinked in real time over the Internet to provide surveillanceinformation on key infectious diseases. Multiple stake-holders encouraged the creation of this type of integratedinformation platform. Persuading laboratory stakeholdersto participate in these types of systems is a matter offinding the right inducements or mutual advantages. Asdiscussed below, a private US company, Focus Technologies,was able to gain participation of many Canadian hospitalsin a system to monitor antimicrobial resistance simply byproviding continuous feedback to the hospital labora-tories from a shared databank. Similar inducements couldfoster the creation of a national public health laboratorysystem that would serve as an integral part of a seamlessnational public health system.

6A.6 Environmental SurveillanceFood and water safety monitoring are key parts of thelaboratory surveillance system, as the Walkerton andNorth Battleford outbreaks have reminded us. This partof the system is delivered very differently in differentjurisdictions. Water testing is often devolved to the locallevel and responsibility is spread through differentministries. Similarly, food safety testing is spread acrossprovincial and federal agencies including Health Canadaand the Canadian Food Inspection Agency.

In general, food and water safety surveillance in Canadais at a fairly rudimentary state of development. The BSEsituation in Alberta has forcefully demonstrated thatfailure to adequately monitor food safety can be economi-cally catastrophic for national industries. For environ-mental monitoring, public health laboratories must beable not only to detect infectious agents, but also unusualtoxins from non-infectious sources that may or may notbe food- or water-borne.

6A.7 Chronic Disease SurveillanceWhile the public health laboratory system is largelyconcerned with infectious diseases, there are some wellestablished chronic disease surveillance systems—screening for phenylketonuria and hypothyroidism, forinstance—that may be performed by provincial publichealth laboratories. In other jurisdictions, these functionsare provided by individual hospital laboratories.

The role of public health laboratories in chronic diseasesurveillance is likely to change in the near term. Twodecades ago, few physicians would have imagined thatpeptic ulcer disease was integrally linked to infection

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with Helicobacter pylori. More and more chronic diseasesnow seem to be caused by infections or at least haveinfectious cofactors. Human papillomavirus has beenlinked to cervical cancer, and hepatitis viruses are majorcauses of hepatic cancer. At the same time, strong geneticrisk factors for chronic diseases have been identified (Brca genes for breast cancer). What may emerge is anew integrative approach to preventing chronic diseases.For example, instead of cytological screening for cervicalcancer with Pap smears, physicians and nurse practitionersmay test for Human papillomavirus and genetic factorsthat predispose to progression to cervical cancer in theface of a chronic infection. Prions may turn out to beinvolved in various chronic diseases. These developmentsagain highlight the need for a laboratory system that isintegrated with the goals of both public health andclinical care.

Unfortunately, Canada has undertaken no nationalplanning for these types of novel programs and there isvirtually no federal presence in these cutting-edge fields.The current window of opportunity will close quickly, asa variety of local screening programs and market-driventesting strategies appear. Ample room must be left forpluralism and innovation, but Canada should move aheadto develop a public health strategy that can anticipateand channel these new surveillance opportunities.

6A.8 Emergency Preparedness andResponse

Public health laboratories are tasked with preparednessand response to any infectious disease emergency or largeepidemic. Related activities include participation inplanning for emergencies (Viral Hemorrhagic FeverEmergency Response Plan, Pandemic Influenza Plan,Smallpox Plan), exercises, development of diagnostics,training and equipping other laboratories, stockpiling ofreagents, coordination of laboratory networks, provisionof surge capacity to other laboratories and participationin biologic terrorism preparedness at special events (G8Summit in Kananaskis and World Youth Day in Toronto)and finally front-line response to infectious disease inCanada and elsewhere. Many of these activities— e.g.,bioterrorism, West Nile virus, SARS—are new mandatesfor public health laboratories. And very often the newmandate is an unfunded one.

The Canadian Association of Medical Microbiologists andCanadian Society for Medical Laboratory Science bothemphasized the need for advance planning that wouldprovide the required capacity and funding for laboratoriesto deal effectively with infectious outbreaks, bioterrorism,or other workload surges.

6A.9 Applied ResearchAs technology changes and new infectious diseasesemerge, an increasingly important role for public healthlaboratories is applied research on the diagnosis anddetection of infectious diseases. This includes evaluationof new commercially-available diagnostic tests, developmentof in-house diagnostics, and research aimed at answeringspecific public health questions. As discussed in detail inChapter 10, the capacity for research in public healthlaboratories has been weak for many years and has, ifanything, eroded further in the last decade. This must be remedied.

6A.10 Fundamental Research Fundamental research is a key activity for public healthlaboratories for several reasons. First, fundamentalresearch has merit in its own right. Absent investmentsin fundamental research capacity, Canada would nothave had the technology and expertise required to isolateand sequence the SARS coronavirus so rapidly. Second,public health laboratories have unique resources andtheir research facilities can answer important scientificquestions of relevance to the health of Canadians. Third,the excitement of research opportunities will unquestion-ably help to draw talent to public health laboratories.And, as the SARS experience has so vividly illustrated,maintaining cutting-edge scientific expertise is importantin the response to emergencies.

Significant involvement in fundamental curiosity-drivenresearch is a public health laboratory function that haswithered. Most public health laboratories view basicscience research as someone else’s job. Within HealthCanada, this kind of research was actively discourageduntil research became a clear part of the mandate ofHealth Canada scientists with realignment in June 2000.These mandates must be protected and expanded in thenew Canadian Agency for Public Health.

6B. The Public Health LaboratorySystem in Canada

As noted, four levels of laboratories form the publichealth laboratory system in Canada. These are private,local and hospital laboratories, provincial public healthlaboratories, national laboratories and internationallaboratory networks. In some provinces, hospital andprovincial laboratories are integrated. These differentlevels of laboratories function as a hierarchy, althoughthere are no formal reporting relationships or require-ments. Usually, the sophistication and breadth of

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diagnostic capacity and scientific expertise increases athigher levels in the system. In an epidemic or an emer-gency, these different levels of laboratories may be supple-mented or complemented by laboratories that are primarilybased in academic institutions and whose primary role isresearch. This was clearly the case in the Toronto SARSoutbreak, where, as noted in Chapter 2, teaching hospitallaboratories took on the task of polymerase chain reaction[PCR] testing to offload the Central Provincial PublicHealth Laboratory.

The role of the different laboratory levels in surveillanceand response to an epidemic is dynamic, varying withthe disease or stage of an epidemic and with the state ofdevelopment of diagnostics. For instance, for verycommon diseases, diagnostics are usually available at thefirst contact laboratory while for rare diseases diagnostictesting may only be available at one laboratory.Commercially available diagnostic testing is more likelyto be used at the local or hospital level while in-housediagnostics are more likely to be used farther up in thehierarchy.

6B.1 Front-line Laboratories (Private,Local and Hospital Laboratories)

First-contact or front-line laboratories, which may beprivate, local or hospital-based, function primarily todiagnose infections and are not technically part of theformal public health system. However, there are publichealth obligations on them for the reporting of notifiablediseases. The use of notifiable disease legislation is a majormechanism for provincial laboratories and epidemiologyprograms to obtain data from front-line laboratories. In addition, hospital laboratories are a key part of theresponse to institutional outbreaks of infection. In front-line laboratories, specimens are mainly derived from illpatients and are submitted for a battery of specific diag-nostic tests. In general, these diagnostics focus on bacterialdiseases and in many instances traditional technologiesare used. However, the testing technology varies withthe interest, expertise and resources of the individuallaboratories. Some front-line laboratories perform aconsiderable amount of viral diagnostics as well.

Many front-line laboratory services for infectious diseaseshave been privatized to achieve cost savings. This hascreated some problems since private laboratories arereluctant to perform many labour-intensive, low-profit-margin tests. Privatization may also make it more difficultto perform certain kinds of surveillance given the scopeof new federal privacy legislation (see Chapter 9).

Front-line laboratories normally have a complement ofone or at most a few professional laboratory scientistsand a number of technologists. In major teachinghospitals, these laboratories are larger and may play amajor academic role in training and research. In smallercentres, these laboratories may be supervised by generalpathologists with very little training in microbiology.

Although local and hospital laboratories initially identifymany infectious disease outbreaks, their involvement innational surveillance systems is generally through theirrespective provincial laboratories. The hierarchical systemwhere biologic material is moved from one level in thesystem to the next for more comprehensive testing isvery cumbersome and slow. The closer to the front linethat an infection can be diagnosed, the more timely thedetection of infectious disease threats will be.

As already indicated, these front-line laboratories couldplay a much greater role in infectious disease surveillanceand outbreak detection. They could be a part of a mecha-nism for real-time sensing of infectious disease threats,and also play a key role in epidemic response. SARS wasprimarily a nosocomial outbreak, but patients come fromand return to communities; infection control cannot stopat the hospital’s walls. A further reason for greater inte-gration of front-line laboratories into the public healthsphere is that, in major academic centres, these labora-tories have significant expertise that is essential forcreating a seamless public health network.

Any move to achieve better integration and a more func-tional laboratory system will raise issues of standardizedtesting methods, information technology, data sharingand funding. These issues must be faced and can bemanaged. As one example of the necessary alignment ofincentives, Focus Technologies Inc. successfully gained theparticipation of several Canadian hospital laboratories inmonitoring antimicrobial resistance by a data-sharingscheme. Hospital laboratories provided data on anti-microbial resistance to the company at no charge butwere then able to view their institution’s antimicrobialresistance patterns in comparison to others. The companylater marketed the overall data. Focus is no longer activein Canada, but the precedent is important. Public healthauthorities and health care administrators must worktogether to create the necessary incentives for institutionalparticipation in regional, provincial, and nationalprograms.

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A start has been made on integrating front-line laboratoriesinto the public health system, specifically in the area ofmonitoring antimicrobial resistance, through the establish-ment of networks for surveillance of antimicrobialresistance. Health Canada’s Nosocomial and OccupationalInfections Section has been successful in building closelinks with leading specialists and institutions; furthernetworking is possible and has already been identified asa priority for action and funding in Chapter 5. As well,the CPHLN plans to integrate local and hospital labora-tories into an envisioned three-tiered bioterrorism responsenetwork, with local and hospital laboratories playing akey ‘sensor’ role. Thus far, these activities have progressedslowly because of a lack of resources. The fundingprograms of the Canadian Agency for Public Health(especially the Communicable Disease Control Fund) andthe proposed F/P/T Network for Communicable DiseaseControl are both mechanisms to accelerate theseinitiatives.

6B.2 Provincial LaboratoriesAll provinces have provincial public health laboratorieswith the exception of New Brunswick. In New Brunswick,the functions of a provincial laboratory are performed bytwo different hospital laboratories. Provincial laboratoriesoperate within the realm of public health, but there aremany different models. In British Columbia, the provinciallaboratory is part of the British Columbia Centre for DiseaseControl [BC CDC] with integrated infectious diseaseepidemiology and laboratory programs. In Nova Scotiaand Alberta, the provincial laboratories are merged with ahospital laboratory. In Manitoba, Saskatchewan, Quebec,Ontario and Newfoundland, organizationally and physicallyseparate laboratories exist. Some provincial laboratorieshave multiple sites within the province. These smallerlaboratories would typically have a few professionalmicrobiologists whose involvement in research anddevelopment is relatively limited.

In every province, there are different relationships withlocal academic institutions and hospital laboratories. In this “system”, the functions and services provided byprovincial laboratories vary considerably. Among thefunctions provided are reference services for local labora-tories within their jurisdiction, and primary diagnosis forcertain infections (often viral disease diagnostics arecentralized). The territories are served by provinciallaboratories under contract arrangements with Nunavutbeing served by Ontario, the Northwest Territories byAlberta, and Yukon by the BC CDC.

Provincial laboratories face a number of challenges.Their relationship with hospital and private laboratoriesacross the country is variable; it ranges from a quasi-regulatory oversight role in Quebec to collaborativerelationships or even competitive positioning in otherjurisdictions. One reason for strained relationships is that,whether owing to budget cuts to public health laboratoriesor advances in technology, hospital laboratories are nowundertaking more and more testing activities that wereonce fulfilled only by public health laboratories. Thishas led, in some circles, to a negative spiral as decisionmakers infer that public health laboratories can indeedbe safely downsized. However, the resulting loss ofcapacity to respond to emerging infectious diseases is notreplaceable by private or hospital laboratories in theabsence of a whole series of prior agreements with these entities.

The Committee’s view is that strong provincial laboratoriesremain an essential component of the public healthsystem. The Communicable Disease Control Fund andF/P/T Network for Communicable Disease Control offermechanisms for coordinated upgrading of theselaboratories, with clearer definition of their roles in thereferral hierarchy.

6B.3 National Laboratories and NationalLaboratory Networks

Within Health Canada, a number of laboratories areinvolved in infectious diseases. The primary laboratoriesare the National Microbiology Laboratory [NML] inWinnipeg, the Laboratory for Foodborne Zoonoses [LFZ]in Guelph and the National Laboratory for Retrovirusesin Ottawa. These laboratories all reside within thePopulation and Public Health Branch and would be partof the new Canadian Agency for Public Health.

These laboratories serve multiple functions includingfront-line diagnostics (for new or rare diseases), referencemicrobiology (confirming test results and qualityassurance), support to epidemiologic surveillance,conducting and coordinating laboratory surveillance,emergency preparedness and response, and applied andfundamental research.

The LFZ in Guelph focuses on the animal side of foodbornezoonotics, while the Retrovirology Laboratory specificallydeals with HIV and related viruses. The LFZ also haslaboratories in St.Hyacinthe, Quebec and Lethbridge,Alberta.

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These laboratories have testing capacity that is generallymore sophisticated than the provincial laboratories, andare staffed by a significant number of PhD or MD trainedscientists. In addition to the operations in Winnipeg, theNML provides modest support to six national referencecentres based mainly in provincial laboratories. Thesereference centres have developed for a variety of reasonsover the years; they provide specialized services not avail-able at the NML and have developed significant expertisein selected areas. For instance, the Alberta provinciallaboratory provides national reference services for strepto-coccal infections. This model of shared F/P/T expertise isentirely consistent with both the vision for the distributedfunctions of the Canadian Agency for Public Health setout in Chapter 4 and the anticipated workings of thenew F/P/T Network for Communicable Disease Control.

As part of its role, the NML plays a key role in a cluster offederal and provincial laboratories that are part of Canada’sbioterrorism response. Because of the need to providesurge capacity to the provinces and front-line responseanywhere in the world, two multidisciplinary laboratoryresponse teams have been established at the NML andequipped with portable laboratories capable of performingroutine and molecular diagnostics in high containment.One team is on call at all times and a team can be on theway to the field in as little as three hours. The CanadianAssociation of Medical Microbiologists highlighted theimportance of such rapid response teams, particularly ifthey can combine laboratory and epidemiologic expertise.The NML teams have been fully deployed only threetimes—once to New Brunswick, once to Kananaskis, andonce to Hong Kong to assist in the investigation of theMetropole Hotel and Amoy Gardens clusters of SARS cases.

Provincial and hospital laboratories have their own uniquestrengths, but do look to the NML for national leadershipin laboratory issues related to infectious diseases. TheNML provides coordination on a number of aspects oflaboratory surveillance across the country. A key develop-ment over the last two years is the establishment of anew working relationship with provincial laboratoriesthrough the CPHLN. The CPHLN’s draft terms of referenceare attached in Appendix 6.1. This body is made up ofthe directors of the provincial laboratories; the ScientificDirectors of the NML, the LFZ, and the National RetrovirusLaboratory; as well as leaders of the federal Centre forInfectious Disease Prevention and Control [CIDPC] andthe Centre for Surveillance Coordination and Response.It is functioning increasingly as a national coordinatingbody, reflecting the modus operandi that the Committeehopes can be achieved more widely in the Network for

Communicable Disease Control and beyond. Not onlyhas F/P/T collaboration in the CPHLN been strong, butits importance was endorsed by non-governmentalstakeholder submissions.

For provincial laboratory directors, the CPHLN offersopportunities both to provide input to Health Canada’sprograms and to share expertise in a national peer-to-peer network. For the NML, the CPHLN provides auseful mechanism for communicating with and learningfrom provincial laboratories, drawing on expertise that itdoes not necessarily have and implementing nationalprograms. If CPHLN continues to be successful, ultimatelyit could be a single point of contact between federal andprovincial public health laboratories for all work onissues pertaining to infectious diseases.

The NML houses and funds the CPHLN, but importantly,it is chaired by a provincial laboratory director. The CPHLNis gradually beginning to coordinate federal-provinciallaboratory programming in a number of areas, key onesbeing bioterrorism, real-time molecular fingerprinting ofE.coli and Salmonella, and food and water safety. As alljurisdictions move forward to strengthen the fabric of thenation’s public health systems, the CPHLN should inturn be strengthened and expanded. Supported by newfederal funds and linked to the new F/P/T Network forCommunicable Disease Control, it should serve asanother exemplar for how national programs can beplanned and implemented in Canada’s complex multi-jurisdictional environment.

6B.4 International Laboratory NetworksSeveral international laboratory networks have arisen fromthe need for combined firepower and rapid communi-cation among scientists in epidemic situations. Canada’snational laboratories have extensive links to theircounterparts in other countries.

Strong links to the US CDC exist for virtually all programs.This has been enormously important over the years indeveloping Canadian capacity. Canada, through theNML and Defence R&D Canada at Suffield, Alberta, is amember of the US CDC-led Laboratory Response Network,charged with responding to the threat posed by biologicaland chemical weapons and related terrorist activities.The NML is also a member of the US CDC-based PulseNet,a molecular typing network for enteric pathogens. Asnoted above, PulseNet Canada is moving forward steadily.Recently, it was agreed that the NML and the CIDPCshould create a formal liaison with the US CDC’s NationalCenter for Infectious Diseases; this is underway.

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Canada also participates in several different virologynetworks including the European Viral Diseases Networkand the International High Security Laboratory Network.The latter includes the level 4 laboratory programs fromCanada, the USA, Germany, France, Italy, the UK, South Africa, Australia, Japan, and Russia. AfterSeptember 11, 2001, the Ministers/Secretaries of Healthof the G7 countries and Mexico established the GlobalHealth Security Action Group, which includes a laboratorynetwork chaired by Canada, to respond to bioterrorism.This network’s ambit has now been expanded to includepandemic influenza.

Although the World Health Organization itself has nolaboratories, it organized an international network of morethan ten laboratories responding to SARS, including allaffected countries plus experts from some other countries.The network led to unprecedented, extensive, andgenerous sharing of data and procedures. This resultedin very rapid progress on the laboratory front. Theinternational laboratory network exemplifies some of thebest practices and precedents from the SARS experienceinternationally.

6C. Analysis of the LaboratoryResponse to SARS

The laboratory response to identifying the causative agentof SARS was one of the most visible parts of the epidemicresponse in Canada. The informal hierarchy identifiedabove has not yielded a public health laboratory system,and the extant arrangements were not well-structured forinvestigating and responding to an outbreak. Instead,Canadian biomedical laboratories are structured to supportthe diagnosis of infection in individuals. However, thesystem was able to adapt to the different demands of theSARS outbreak. The inner workings of the NML likewisewere not designed for an epidemic response, and changesin the way the NML operated were required for thenational laboratory to respond effectively.

The ‘discovery’ phase of the laboratory response consistedof ruling out known agents as the cause of SARS andidentifying the causative agent. In doing this throughthe CPHLN, agreement on the types of specimens to beobtained and specimen shipping protocols was reachedvery quickly. The network agreed that testing for knownagents would be performed at the provincial laboratories,mainly Ontario and British Columbia, allowing the NMLto focus on unknown agents. The CPHLN was also ableto provide useful advice to scientists at the NML indirections for research. These steps were taken extremelyrapidly; within two weeks, the SARS coronavirus had

been identified and the laboratory role shifted to one ofdiagnosis of coronavirus infection, development ofdiagnostic tests, and research on the agent.

As the laboratory response developed, investigations intothe cause of SARS were highly centralized at the NML.The centralization of biologic material and laboratoryresults yielded a clearer picture of all the data on causation,notwithstanding the disappointing lack of associatedclinical and epidemiologic data. A further advantage ofunified leadership was that laboratory studies werereadily coordinated, avoiding duplication and directingmaximum effort at the most important issues. However,predictably, moving specimens through the hierarchyfrom hospital laboratory to provincial laboratory tonational laboratory slowed down investigations. Onoccasion, specimens were received at the NML two tofour weeks after they were first obtained. For otherindividuals with probable SARS, reference specimens werenever received at the NML.

During the early phases of the SARS epidemic there wereseveral significant impediments to an effective laboratoryresponse. The two most important were inadequate data management and the lack of clinical and epidemi-ologic data.

Data management: The NML had no laboratory-widelaboratory information system. In spite of many yearsspent in developing a Laboratory Data Management Systemby Health Canada, the extant system could not serve theepidemic response needs. A new database had to be createdfrom scratch, and was made accessible to laboratories inthe CPHLN over the Internet. This experience highlightsthe need for software platforms that are agile, modular,and rapidly modifiable for special purposes. More oftenthan not, grand and purpose-built architectural designsin software development are overtaken by faster-movingand smaller platforms that can be customized to thechanging needs of users. The challenge, as always, is tobalance considerations of flexibility, economy, integration,and interoperability. For the future, laboratory databasesthat can communicate with one another must beestablished in public health laboratories across thecountry. If a global system cannot be achieved, then at aminimum a common information management systemfor outbreak responses should be established.

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The lack of integration of epidemiologic andlaboratory data: As Chapters 2 and 5 have alreadyhighlighted, laboratory data were not well-integrated withepidemiologic data during the SARS outbreak in Canada.This objective has still not been fully achieved, with severeadverse effects on research that will be further reviewed inChapter 10. An integrated laboratory and epidemiologicdata management system is indeed achievable, at leastfor outbreak response. Such a system should have beenin place before SARS, and must now be established assoon as possible. This shortcoming points to the generalneed for greater integration of laboratory and epidemiologicsciences in a renewed public health system.

Once the potential causative link to the new coronavirusbecame clear, the role of the NML shifted to performingdiagnostic testing, development of further diagnostictests, supporting provincial and other laboratories withtheir own diagnostics, and reporting results. The NMLinitially provided coronavirus PCR primer sequence infor-mation to the CPHLN and engineered a positive controlfor PCR testing. The plan of the CPHLN was to rapidlydevolve testing capacity to provincial laboratories.However, at the same time, provincial, hospital andacademic laboratories began developing their own testingbased on published sequences of the coronavirus andmaterial obtained from ill patients. This resulted in somechaos and duplication as individual scientists andlaboratories went their own way.

For example, several coronavirus genes from the sameTor2 isolate have been cloned and expressed multipletimes and are now being used in diagnostic tests acrossthe country. On the positive side, the agile response ofhospitals and provincial laboratories is important andencouraging. On the negative side, the development ofmultiple diagnostics is somewhat wasteful and has led tothe proliferation of diagnostic tests that, notwithstandinga common genetic platform, may not have equal sensi-tivity and specificity. Perhaps more importantly, whenmultiple laboratories are providing testing in anuncoordinated manner without sharing data, the abilityto see the whole picture of the epidemic is lost. If thisdevelopment had been anticipated, mechanisms forcoordination and reduction of duplication could havebeen put in place, along with a centralized database forall laboratory results.

This is yet another lesson from SARS. For the future,better coordination of efforts must be achieved throughextension of the CPHLN membership to major hospitallaboratories, the development of stronger provincialnetworks of laboratories, or both.

Once laboratory results of coronavirus testing becameavailable, there were some new issues around reportingof results. Although results of testing were available, therelease of results to physicians and public health unitswas at times delayed in the Ontario Ministry of Healthand Long-Term Care [OMHLTC]. We have not determinedthe extent or duration of these delays. The Committeeleaves it to the Campbell Investigation to determine theimpact of these delays, if any, on the second wave ofSARS in Toronto.

A related difficulty arose from the fact that 172 individuals,primarily from Ontario, tested positive for the SARScoronavirus, but were not classified as probable or suspectSARS. As of mid-August it is still not known if theseindividuals actually had some form of the infection, howthey acquired it, and if they produced additional chainsof transmission. Collaborative work is currently underwaywith the OMHLTC to pursue the matter. This informationwas and remains critical to determining whether therewas hidden community transmission of the SARScoronavirus and describing the full spectrum of diseasecaused by the virus.

The reporting of results to individual physicians was also problematic. For hospitalized patients who weredischarged or died, results of laboratory tests were sentdirectly to medical records and in some instances werenot seen by the physicians who cared for the patient.This illustrates the inadequacies not only of laboratoryinformation systems, but also the weak interface betweenpublic health and the health care system. In effect, nosystem exists to pull important information together intoa coherent picture of an outbreak. This situation againillustrates that the data systems and business processes inplace for managing day-to-day infectious disease problemsare ill-suited to responding to epidemics. Differentoperational procedures need to be put in place urgentlyfor an effective outbreak or epidemic response.

6D. The Ideal Public HealthLaboratory System for Canada

Ideally, Canada should have a fully coordinated andintegrated national public health laboratory system thatdelivers timely surveillance for infectious disease threats,is an active participant in infectious disease preventionprograms, and responds effectively and quickly toinfectious disease outbreaks.

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Achieving this vision depends on strong regional orprovincial public health laboratories that are closelylinked to front-line laboratories and other organizationsinvolved in public health through funding streams,collaborative agreements, common or related testingprocedures, shared or interoperable information systemsand common programming. Such a configuration wouldhelp to bring public health back into the health caresystem. These laboratories should be integrated withepidemiologic components of public health in regionalor provincial agencies, helping to reinforce the second-line of defence against public health hazards. As such,they should be supported by the new CommunicableDisease Control Fund in the Canadian Agency for PublicHealth and linked together through both the CPHLN andthe new F/P/T Network for Communicable DiseaseControl. These laboratories should also be closely tied toscientists in academic institutions. Testing for importantinfectious disease agents must be performed throughcommon testing procedures at the lowest level possiblewithin the integrated laboratory system, with results ofinterest reported to the regional and ultimately thenational level in real time through integrated informationmanagement systems.

Whenever possible, the regional laboratory would takeon leadership, coordination, and research roles in thenetwork rather than performing high volumes of testingon site. Expertise and innovation capacity should bedistributed across the network, with each regional labo-ratory developing national expertise in given areas, asoutlined earlier. The laboratory elements in the CanadianAgency for Public Health would be an integral part of thenetwork. In particular, the new federal agency must itselfmaintain world-class laboratory science capacity, and itslaboratory leaders in turn should have a mandate to buildregional public health capacity and play a major role incoordinating national surveillance and epidemic responses.

To achieve this vision, significant inducements need tobe identified for front-line laboratories to become part ofregional laboratory networks and for provincial publichealth laboratories to develop programs that fit into anintegrated national system. The Communicable DiseaseControl Fund described in Chapter 5 would supportthese aims, and the proposed F/P/T Network forCommunicable Disease Control would lend momentumto the integration of laboratory and epidemiologicfunctions.

6E. RecommendationsThe SARS experience has highlighted the importance ofpublic health laboratories in surveillance for infectiousdisease and the central role of these laboratories in theresponse to epidemics. In some respects, the laboratoryresponse to SARS went well. Its relative success was afunction of significant capacity at the national level,effective F/P/T laboratory working relationships, pre-existing functional networks, and a culture of mutualrespect and assistance among the provincial and nationallaboratories. These prerequisites for success should beemulated in other parts of the public health system. We have identified a number of challenges and issues inCanada’s public health laboratory system. The Committeeaccordingly recommends that:

6.1 The F/P/T Conference of Deputy Ministers ofHealth should urgently launch an expeditedreview to ensure that the public health labora-tories in Canada have the appropriate capacityand protocols to respond effectively andcollaboratively to the next serious outbreak ofinfectious disease. The review could be initiatedthrough the Canadian Public Health LaboratoryNetwork and engage with the new F/P/TNetwork for Communicable Disease Control assoon as the latter is operational.

6.2 Health Canada, in collaboration with the relevantprovincial/territorial authorities, should urgentlyinitiate the development of a laboratory infor-mation system capable of meeting the informationmanagement needs of a major outbreak orepidemic. The laboratory information systemmust be designed in such a way as to addressthe functional needs of laboratories, be readilyintegrated with epidemiologic information,and be aligned with data-sharing agreementsacross jurisdictions and institutions.

6.3 The F/P/T Conference of Deputy Ministers ofHealth should launch a full review of the roleof laboratories in national infectious diseasesurveillance systems, with the aim of creating amore efficient, timely, and integrated platformfor use of both public and private laboratoriesin surveillance.

6.4 The Government of Canada, through theCanadian Agency for Public Health, shouldinvest in the expansion of the Canadian PublicHealth Laboratory Network to integratehospital and community-based laboratories.This includes alignment of incentives and

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clarification of roles and responsibilities forinfectious disease control. The relevant moniescould flow from the Public Health PartnershipsProgram or the Communicable Disease ControlFund (see Chapter 5).

6.5 The Canadian Agency for Public Health shouldgive priority to strengthening the capacity ofprovincial/territorial laboratories as regardstesting for infectious diseases. The Agency shouldprovide incentives to increase the participationof provincial public health laboratories innational programs. It should support provincial/territorial public health laboratories in thecreation of provincial laboratory networksequivalent to the Canadian Public HealthLaboratory Network; these would connect inturn to the national network. The relevantmonies would flow from the CommunicableDisease Control Fund.

6.6 The Canadian Agency for Public Health shouldsupport participation and leadership in inter-national laboratory networks by our nationallaboratories, thereby building on the success ofthe international collaboration in the responseto SARS.

6.7 Health Canada, in collaboration with provincial/territorial authorities, should sponsor a processthat will lead to a shared vision for thedevelopment, incorporation, and evaluation ofleading-edge technology in the public healthlaboratory system. Among the issues that requireelucidation are the role of national systems forthe real-time surveillance of infectious diseasethrough molecular fingerprinting of micro-organisms, toxicology capacity to detect illnessescaused by the poisoning of natural environmentsand occupational hazards, and the potential forlinking genetic testing and infectious diseasesurveillance in novel programs that wouldtarget cofactors associated with thedevelopment of chronic diseases.

6.8 A national report card of performance and gapassessment for public health laboratories shouldbe developed through the Canadian Public HealthLaboratory Network and/or the F/P/T Networkfor Communicable Disease Control, allowingcomparative profiling of various provincial andnational laboratories against internationalstandards.

The Committee also takes note of human resourceshortfalls in the laboratory sphere, as outlined inmultiple stakeholder submissions. We discuss humanresource matters in Chapter 7.

Appendix 6.1Canadian Public Health LaboratoryNetwork (CPHLN)Draft Terms of Reference

1.0 BackgroundThe Canadian Public Health Laboratory Network (CPHLN)was organized in 2001 in an effort by provincial healthlaboratory directors who recognized a void in inter-provincial communication and in communication withthe National Microbiology Laboratory following thedemise of TAC, and was coincidental to the terrorism ofSeptember 11, 2001 and to the subsequent anthraxthreats. In addition to addressing concerns regardingincreased frequency and potential lethality of bioterrorismagents, the scope of the Network was expanded to includeother aspects of public health such as food and watersafety in response to water quality problems in Walkerton,Ontario and North Battleford, Saskatchewan. At present,the Network is in the initial stages of its developmentand is currently determining how best to provide leader-ship in the development of a proactive network of publichealth laboratories that will serve to protect the health of Canadians. It is also considering how to positivelyinfluence and support the broader Canadian health carerenewal initiative. The Network’s current mandate is todevelop and implement strategies to:

• Coordinate pathogen detection, infectious diseaseprevention and control;

• Conduct laboratory-based surveillance including thedevelopment of early warning systems to monitor anddetect emerging pathogens, antibiotic resistantorganisms and outbreaks; and

• Counter bioterrorist threats.

The benefits envisioned by the CPHLN include:

• A coordinated national laboratory response network;

• National standardization of laboratory procedures andquality assurance methods leading to greaterconsistency of results;

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• Expanded training available to Network participantsregarding protocols, best practices and emergingtechnologies;

• Enhanced national capability regarding the detectionof emerging pathogens, antibiotic resistant organismsand outbreaks, and the prevention and control ofinfectious diseases;

• Reduced duplication of effort; and

• Enhanced support for laboratories through increasedcollaboration.

2.0 Mission, Vision and Guiding Principles2.1 The mission of the CPHLN is to provide leadership

in public health laboratory functions through thedevelopment of a proactive network of public healthlaboratories to protect the health of Canadians.

2.2 The vision of the CPHLN is to become an action-oriented national microbiology network providingvalue-added advice and services in direct support ofthe broader Public Health System.

2.2.1 The CPHLN’s guiding principles are:

– leadership;

– stewardship;

– partnership;

– integrated management;

– value of public health surveillance andearly detection; and

– best practice.

3.0 Strategic OrientationThe following provides a graphical overview of the CPHLNstrategic orientation. For more details concerningstrategic priorities and strategic goals, refer to the CPHLNStrategic Plan.

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Strategic Goals Performance

Feedback

Strategic Priorities

Promote the growth and development of a skilled workforce for public health laboratories in Canada

Establish national laboratory network; Enhance information exchange & communications; Strengthen lab-based surveillance; Support national emergency preparedness & response; Develop and promote standards

Enhance capacity & capability of public health lab system; Support & communicate core mandate of PH labs; Promote benefits of efficient

PH laboratory services; Advocate strategies for better PH; Enhance focus on emerging issues and prevention

Foster standards development based on best practices; Develop the national reference services program

Pursue research funding opportunities; Promote the development of collaborations for better research;

Promote the improvement of training programs

Human resources planning

Formalize and sustain the national laboratory

network role of the CPHLN

Advocate for and develop

better public health infrastructure

Support and foster high quality

communicable disease reference

services

Facilitate and support leading edge science, research and training

activities

CPH

LN 2

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CPHLN 2002-2005

An action-oriented national network providing

value-added advice and services in direct support

of the broader Public Health System

F I G U R E 1 CPHLN Strategy Improved Health for Canadians

Improved Health for Canadians

4.0 Guidelines/Operating Principles4.1 The CPHLN shall work within the context of the

CPHLN Strategic Plan and reporting structure.

4.2 The CPHLN shall respect the mandates and roles ofall partners and work together in a way that willenhance their efforts.

4.3 Where appropriate and feasible the CPHLN shallcollaborate with international, federal, provincial,and territorial agencies with a bioterrorism responseor public health mandate, and participate on and/orcommunicate with related committees.

4.4 The CPHLN will facilitate the coordination ofexisting public health committees by clearlyunderstanding the roles and mandates of the variousorganizations involved in bio-terrorism response andother public health protection activities.

5.0 Governance5.1 Membership

5.1.1 The CPHLN shall be composed of no less than 13and no more than 25 members, including the chairs.

5.1.2 Members shall include the medical or scientificdirectors from the public health laboratories ineach province, except Ontario which lacks aMedical Director for the Ontario Public HealthLaboratories and will be allowed tworepresentatives, Health Canada stakeholders, the Department of Defense Research andDevelopment Canada, and the Canadian Councilof Chief Medical Officers of Health as follows:

– The Laboratory Director or designate of eachProvincial or Territorial Public HealthLaboratory (maximum thirteen designates)

– The National Microbiology Laboratory (NML),the Scientific Director General or designate,plus designates from each of the following fiveNML reference centers: Bacteriology, ZoonoticDiseases and Special Pathogens, Host Genetics andPrion Diseases, Enteric Pathogens, and ViralDiagnostics). (Six representatives)

– The Department of Defense Research andDevelopment Canada (one representative)

– The Centre for Emergency Preparedness andResponse (one representative)

– The Laboratory for Foodborne Zoonosis,Guelph (one representative)

– The Centre for Infectious Disease Preventionand Control, Ottawa (one representative)

– The Canadian Council of Chief MedicalOfficers of Health (one representative)

5.1.3 Members shall be appointed by their respectiveorganizations for a term of three years. The termis renewable for an additional term of two yearsat the unanimous discretion of the chair and vice-chair.

5.1.4 In the event that a member resigns during his orher term, a replacement for the balance of theterm shall be appointed by the representativeorganization.

5.1.5 Members shall make a commitment to be activelyinvolved in the work of the CPHLN, to makeattendance at meetings a priority and commit tofurthering the objectives of the CPHLN as definedby the strategic plan.

5.1.6 Members shall arrange to have a designate to attendmeetings in the event that they are unavailable to attend.

5.1.7 Due to the responsibilities of the CPHLN to contri-bute to the minimization bioterrorism threats tothe health and safety of Canadian, all memberswill be required to have Level II Secret Clearanceto maintain membership in the CPHLN.

5.1.8 Any designate who attends a CPHLN meeting inthe place of a member must have Level II SecretClearance.

5.1.9 Outside individuals are not permitted to attendCPHLN meetings except at the invitation of theChair and with appropriate consideration forsecurity clearance requirements.

5.1.10 Loss of membership can occur by a vote by theCPHLN membership where the consensus of thevoting members results in a vote to revoke aparticular membership. Reinstatement may occurfollowing a formal written request and a subse-quent consensus vote by the CPHLN membership.

5.2 CPHLN Leadership

5.2.1 The CPHLN shall be chaired by one CPHLNmember in good standing. The term of the chairis one year. The vice-chair from the previous yearwill be automatically appointed chair for thefollowing year.

5.2.2 The CPHLN shall have a vice-chair held by oneCPHLN member in good standing. CPHLN membersshall appoint the vice-chair for a term of one yearat which point the vice-chair takes the position ofchair for one additional term of one year.

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5.2.3 In the event that a chair should resign the vice-chair will assume the position of chair and theCPHLN will appoint a new vice-chair.

5.2.4 In the event that a vice-chair should resign theCPHLN will appoint a new vice-chair.

5.2.5 The chair or, in his/her absence, the vice-chairshall preside over CPHLN meetings.

5.2.6 The chair and vice-chair shall participate asappropriate in the delivery of CPHLN submissionsto the Council of Deputy Ministers of Healthand/or other jurisdictional bodies with abioterrorism response or public health mandate.

5.2.7 The chair and vice-chair shall work closely withthe Network Manager and, through the Secretariatstaff to further the goals and objectives of theCPHLN according to the strategic plan.

5.3 CPHLN Subcommittees

5.3.1 The CPHLN shall create committees andsubcommittees as required, to address importantpublic health laboratory issues.

5.3.2 Subcommittee members shall be nominated andapproved by the CPHLN for a term of three years(renewable). Where a subcommittee memberresigns during that term, a replacement for thebalance of the term shall be appointed by theSubcommittee and approved by the CPHLN.

5.3.3 Subcommittee members shall have laboratoryexpertise in the particular area of focus of thesubcommittee and shall represent federal, provincial,territorial or regional laboratories. Subcommitteeswill attempt representation from each jurisdictionand geographic region.

5.4 CPHLN Secretariat

5.4.1 A dedicated Secretariat shall be established at theNML in Winnipeg, to administer and facilitatethe work of the CPHLN.

5.4.2 The Secretariat will consist of a Network Managerand a Scientific Information Officer and StandardsOfficer who shall report to the Network Manager.Other staff may be hired as required to theSecretariat based on the advice of the NetworkManager, endorsement by the CPHLN membershipand availability of the required funds.

5.4.3 The Secretariat shall report to the CPHLN chairand be administered on a day-to-day basis by theScientific Director General of the NML or his/herdesignate.

5.4.4 The Secretariat shall be funded by Health Canadathrough the NML until such time as permanentoperational funds are established for the CPHLN.

5.4.5 The Secretariat will provide support to and partici-pate in CPHLN meetings as required but will notfunction as a voting member of the CPHLN.

5.4.6 CPHLN meeting agendas shall be prepared by theSecretariat, in consultation with the chair, andissued at least one week prior to meetings.

5.4.7 Minutes of CPHLN meetings shall be prepared bythe Secretariat and distributed to Network members,and other clients and partners as appropriate,within two weeks of the meeting date.

5.5 CPHLN Meetings

5.5.1 The CPHLN shall hold semi-annual meetings todiscuss and address business related to strategicpriorities, goals, objectives and initiatives; currentissues; communication flow; member relations;and funding and resource requirements, includingannual budget and operating plans).

5.5.2 Quorum for meetings shall be attendance by asimple majority of members.

5.5.3 Decisions shall be made by consensus whereconsensus is defined as general agreement, eitherverbal or by poll. When consensus cannot bereached, decisions shall be made by a simplemajority of the members present. Each memberreceives one vote.

5.5.4 No decision by the CPHLN is legally binding inanyway as the CPHLN is not established as a legalentity.

5.5.5 Minutes will be recorded by the Secretariat anddistributed to members.

5.5.6 Agenda items should be forwarded to the Secretariatno later than one month prior to the meeting.

5.5.7 The agenda and required material will be circulatedat least one week in advance of the meeting.

6.0 CPHLN Terms of Reference

6.1 Minor amendments to the Terms of Reference maybe made by the Chair subject to ratification by themembers at the next meeting of the CPHLN.

6.2 The Terms of Reference may be amended at anymeeting of the CPHLN by consensus or by vote.

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PUBLIC HEALTH HUMAN RESOURCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Public health, like other aspects of the health care system,relies on a highly skilled workforce as its most valuableresource. Although sufficient funding and an effectiveorganizational structure are necessary ingredients in aflourishing public health system, the quality of Canada’spublic health will ultimately rest on the shoulders of itspublic health workers.

Over the last decade, various task forces and academicreports have usefully addressed issues related to the supplyof health professionals and technologists. The focus ofmost of these studies, however, has been on the humanresources necessary for the provision of personal healthservices. These reports have also served as the basis forintergovernmental agreements; for example, the 2003 FirstMinisters’ Health Accord states that “appropriate planningand management of health human resources is key toensuring that Canadians have access to the health providersthey need… Collaborative strategies are to be undertakento … ensure the supply of needed health providers (includingnurse practitioners, pharmacists and diagnostic technolo-gists).” The 2003 federal Budget allotted $90 million overfive years for health human resources, but no funds wereearmarked specifically for the public health workforce.

A shortfall in public health human resource planning anddevelopment was recognized in the Survey of Public HealthCapacity in Canada, a report to the F/P/T Deputy Ministersof Health by the Advisory Committee on PopulationHealth. As we noted in Chapter 3, this report was neitherformally endorsed nor taken as a basis for action.

In this chapter, relying partly on the aforementionedCapacity report as well as expert opinion, stakeholder input,and existing sectoral surveys, we present a brief assessmentof the public health workforce in Canada. The paucity ofdata on public health human resources, analogous to thelimited data on public health spending, illustrates thatinsufficient attention has been paid to this field.

The Committee took particular note of the very widerange of stakeholders who commented on the challengesof human resources in public health. Among them werethe Association of Nursing Directors and Supervisors ofOntario Health Agencies [ANDSOOHA], Canadian HospitalEpidemiology Committee, Canadian Medical Association,Canadian Public Health Association, Canadian InfectiousDisease Society, Ontario Hospital Association, NationalSpecialty Society for Community Medicine, CanadianPharmacists Association, Canadian Association of MedicalMicrobiologists, Canadian Society for Medical LaboratoryScience, Canadian Association of Emergency Physicians,Community and Hospital Infection Control Associationof Canada, and front-line nurses and support staffinterviewed in focus groups arranged by Health Canada’sOffice of Nursing Policy.

Some human resource issues raised by stakeholders restmore in the matter of operational and institutional policy,such as the right to refuse dangerous work mentioned inChapter 9, or pay for time in quarantine. Our focus inthis chapter is on the capacity side: Does Canada haveenough skilled personnel in various public health fields,and if not, how can the nation close these gaps?

Although the major focus of this chapter is to discuss howhuman resources issues affect public health functions likehealth promotion and outbreak management, it seemedsalient to recognize the impact the SARS outbreak had oneducation, and thus the impact future public health crisescould have on health human resources. We accordinglybegin by describing how the SARS outbreak affected theeducation of health sciences students. We then present abrief review of information about the supply of publichealth professionals in Canada. Moving past the numbers,we touch on issues about education and qualifications—are our public health professionals appropriately trainedfor their work? Finally, we discuss strategies to strengthenthe public health workforce and present a set ofrecommendations.

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7A. The Effect of SARS onProfessional Education

Post-secondary institutions in Toronto and elsewhere copedwith the unprecedented and unanticipated challengesposed by the SARS outbreak. Exams proceeded as scheduled,and no student lost a year or had their program prolongeddue to SARS. Nevertheless, clinical training programs forvarious disciplines were seriously interrupted in Torontoas administrators were forced to devise and then amendpolicies on an ad hoc basis. Nursing students and educatorsin focus groups described the challenge of searching fortimely and reliable information, and the need for a bettercommunications strategy in future outbreaks. Hundredsof students and teaching staff, especially those situated in hospitals, had to deal with uncertainty and stress. Anumber of medical students and resident physicians werequarantined during the outbreak. One medical studentdeveloped SARS but recovered rapidly. In addition tointerfering with clinical education, SARS disrupted workat hospital-based research institutes and the progress ofgraduate students in those environments.

SARS had perhaps its largest impact on continuingeducation for qualified health professionals and healthresearchers. A dramatic bellwether was the cancellationon two days notice of a long-anticipated meeting of theAmerican Association for Cancer Research in Toronto.There were 16,000 registrants and local organizers hadworked for years on the event. Similar cancellationsaffected scores of other health education and researchmeetings, as part of the general decimation of theconvention and conference business in the GTA.

Issues also arose with local meetings because of increasedrisks inherent when health professionals from differentinstitutions congregate. This response was rooted less inpersonal fears of SARS itself, but rather a broader concernthat one infected individual attending a continuingeducation event could force all other attendees intoquarantine. For example, when all of Toronto’s cardiacsurgeons and others from across Canada met for a day ofcontinuing education during the second wave of theSARS outbreak, attendees worried that a catastrophicdisruption in cardiac surgery services would occur if justone attendee were infected with SARS and others wereforced into quarantine. The outbreak unquestionablylent new momentum to the use of distance-basededucational methods for health professionals.

Most resident physicians (i.e., doctors completing theirspecialty training) continued their usual work, albeit withrestrictions on inter-hospital movement. Although manyfelt understandably anxious about having to resuscitateor intubate a SARS patient, the vast majority of residentsviewed themselves as integral members of the health careteam, and willingly volunteered to care for SARS patients.Nevertheless, clinical teachers generally sought to limitthe exposure of resident physicians to SARS and took theposition that residents should be kept off primary SARSunit duty. Educators and ethicists would be well advisedto discuss the role of health professional students andtrainees in confronting risks posed by dangerousinfectious diseases, and frame guidelines for the nextoutbreak of SARS or a similar organism.

In the end, SARS had only a minimal negative impact onthe education of the next generation of nurses, doctorsand other health professionals. Some of its impacts werepresumed to be positive, as health professionals-in-trainingsaw firsthand the importance of public health andclinical infection control. However, the potential impactof a public health crisis on the health human resourcepipeline is obvious. Training institutions should heedSARS as a warning and better prepare themselves forfuture disruptions. This includes developing emergencyplans in collaboration with health care facilities that offerclinical teaching and with local public health units.

7B. Current Supply of PublicHealth Professionals

Our assessment of the state of public health humanresources in Canada is limited by sparse data. For example,public health human resources have not been wellcharacterized in either the Canadian Medical Associationor the Canadian Institute for Health Information [CIHI]databases. Sectoral studies sponsored by HumanResources Development Canada have not focused onpublic health. Other interested parties, including theF/P/T Advisory Committee on Population Health, havealso concluded that there is little quantitative informationon the state of public health human resources in Canada.

7B.1 Public Health PhysiciansThe number of doctors engaged in the practice of publichealth in Canada is difficult to quantify. Canada hasabout 400 community medicine specialists (physicianswho have completed a course of post-graduate education,passed examinations, and maintain professional compe-tence according to Royal College of Physicians and

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Surgeons of Canada standards), as well as an unknownnumber of physicians with other relevant public healthqualifications (e.g., a master’s degree, a diploma, etc.).

Approximately 135 local or regional health departmentsemploy a total of roughly 150 medical officers of health[MOH] and associate medical officers of health [AMOH].Governments also employ some of these physiciansdirectly. Table 1 shows medical officer of health positionsbased on a recent survey of Chief Medical Officers ofHealth across Canada. Simple math indicates that a largenumber of doctors have been trained in communitymedicine or public health but are not actively working inthe public health sphere—including academics, thosepractising occupational or international health, thoseengaged in clinical practice, and retirees.

Vacancy data are not particularly reliable because physiciansworking part-time or without formal qualifications occupymany of the filled positions. The National SpecialtySociety for Community Medicine points out that 8 of 37health units in Ontario do not currently employ a full-timemedical officer of health. The need for additional publichealth physicians is most acute in rural areas, the Atlanticprovinces, the territories and areas served by HealthCanada’s First Nations and Inuit Health Branch [FNIHB].Because of human resource constraints, some Canadianprovinces simply cannot require that medical officers ofhealth have formal public health qualifications. In Ontario,where specific requirements have been legislated, manyhealth units are forced to rely on acting medical officersof health, who can be hired without the full set of formalqualifications required of medical officers of health.

The Committee intends no criticism of thosephysicians without full specialist credentialsnow working as medical officers of health.These individuals are bulwarks of a strainedsystem. Instead, we wish to highlight thatCanada faces a shortage of public healthspecialist physicians with contemporaryqualifications.

Objective information on the age of themedical officer of health workforce is currentlybeing collected; preliminary results show thatup to 31% of public health physicians in MOHpositions will retire in the next 10 years.

The educational pipeline currently haslimited capacity. The usual route to publichealth specialization for a doctor is five yearsof training after medical school. However,Canada has only 11 residency positions eachyear for community medicine training. In2003, only 7 spots were offered in a pool forgraduating medical students outside Quebec.

Even more important than the limitednumber of training spots is the proportion ofcommunity medicine residents who actuallywork in public health after completing theirspecialty training. This is variously describedby the three largest programs as “most”,“very few”, and “about half”. Only a handfulof Canadian-trained physicians, therefore,enter the public health workforce each year.A few more public health physicians arerecruited from countries like the UnitedKingdom and South Africa each year butoverall, the supply pipeline remains extremely

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Province/ Ministry- MOH AMOH Population1

Territory employed

NF 1 6 0 531,145

PEI 1 0 0 140,412

NS 2 4 1 944,456

NB 1 5 0 756,368

QC 5 35 0 7,467,626

ON 11 37 11 12,109,514

MB 2 15 1 1,150,564

SK 2 10 3 1,009,225

AB 2 9 5 3,134,286

BC2 8 22 6 4,155,779

NU 2 0 0 28,955

YK 1 0 0 29,841

NWT 2 0 0 41,389

Total 40 143 27 31,499,560

1. Population figures based on Statistics Canada preliminary post-census estimatesfor 1996.

2. Data for British Columbia include 6 MOHs at the British Columbia Centre forDisease Control.

T A B L E 1Public health physicians employed in provincial or municipal positionsin Canada.

constrained. Preliminary survey results show that 83% ofpublic health physicians believe that there should bemore residency positions, and 87% support easier re-entryinto post-graduate training for doctors already practisingfamily medicine or another specialty.

Compensation is frequently cited as a barrier to recruit-ment and retention of public health physicians. Whethercompensation-related or not, interest in the specialty islimited.

In Quebec, public health physicians are able to bill theprovincial health insurance program on a sessional basisinstead of receiving a salary from the public healthdepartment. This arrangement, along with a provincialstrategy of self-sufficiency in health human resources, hasgiven Quebec many more physicians working in publichealth departments than elsewhere in the country—morethan 140 specialists are registered with the QuebecAssociation of Community Health Physician Specialists.

Relatively poor remuneration is not the only drawback toworking as a public health physician. Other potentialdisincentives are the challenges of working in a politicaland bureaucratic environment and bearing ultimateresponsibility for the health of thousands of citizens in aparticular region.

7B.2 Public Health Nurses1

Public health nurses are the single largest group ofprofessionals in the public health workforce. By mostestimates they account for almost one-third of the totalpublic health human resources. Experts estimate thatthere are approximately 12,000 public health nurses inCanada. (CIHI reports 21,334 in 2002, but this figureincludes nurses working in community health centres,day care centres, and several other settings).

The Canadian Nurses Association has noted that thenumber of registered nurses in Canada rose from 113,000in 1966 to 262,000 in 1991, but was only 253,000 in2001. The Canadian Nurses Association estimates thatCanada will be short 7,000 registered nurses by 2011 and113,000 by 2016. Some experts suggest that Canada is already short 16,000 nurses. Unfortunately, infor-mation about the nursing workforce is not collected in away that makes it possible to extract data on publichealth nurses.

Shortages are reported in rural, remote and First Nationslocations. For example, about 50% of FNIHB’s nursingpositions were reported to be unfilled two years ago.Overall, our best estimate is that the shortage of nursesfor public health positions is similar to that for othernursing specialties. Some would argue that the situationmight actually be better in public health. The hours andnature of the work and the relative independence indecision making make these positions attractive choicesfor many nurses. To quote one interview participant,“It’s easy to find applicants to recruit, especially withnurses wanting to leave the poor conditions of acutecare, and move to Monday to Friday schedules.” On theother hand, Committee informants reported that nursesare demoralized by a mismatch between funding andservice demands. One public health nurse observed that:“There is an increased expectation to do more with less.This expectation is becoming increasinglyunmanageable.”

Nursing recruitment into public health is particularlydifficult in rural and remote northern areas. Remotenorthern areas have the unique challenge of extremesocial isolation, although turnover in rural and northernareas is reportedly low. Remote areas that have retainedexperienced public health nurses for long periods nowface the challenges associated with an aging workforce.Nurses new to the north need opportunities to developthe breadth of skills and depth of knowledge needed topractice independently. Funds and mechanisms forcontinuing education are therefore an important part ofretention and career development for public healthnurses in remote areas.

In some jurisdictions, the restructuring of health systemshas resulted in the integration of public health staff andbudgets with those for patient care. Integration may alsoinclude one collective agreement for all nurses employedby the regional authority. This has contributed to identityloss for public health nurses. As one individual told theCommittee, “A frustrating by-product of regionalizationis that public health nursing has no central leadership, noone to address broad public health nursing mandates.”

A related problem is the reintroduction of “integratedpractice” or “community health nursing”, where thedistinction between traditional public health nursing andindividual care is blurred. Where a nurse is responsiblenot only for community health promotion, but also for

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1 Information for this section was obtained by Health Canada through 13 key informant interviews, 20 survey responses (from a convenience sample),and a non-exhaustive literature review. Interviews and surveys reflected input from British Columbia, Alberta, Saskatchewan, Ontario, Nova Scotiaand Newfoundland and Labrador. Urban, rural and remote perspectives were captured. Respondents included public health nurses, administrators,educators, and consultants.

home care or ambulatory clinic care, limited publichealth resources may end up diverted into other areas ofthe health care system.

The crucial work that public health nurses perform issometimes invisible. The submission by the ANDSOOHAspoke eloquently to the essential role of public healthnurses during the SARS outbreak, but these contributionshave received little public attention. Indeed, the Committeeheard repeatedly that public health nurses feel thatgovernments, the public, other health professionals, andperhaps most discouragingly, nurses in other sectors areinsufficiently aware of the contribution of the publichealth nurse.

Public health employers currently use a wide variety ofrecruitment and retention strategies to entice nurses intopublic health practice. In addition to better compensationpackages, employers use recruitment strategies such asoffering funds for continuing education, advertisingcampaigns, establishing wellness projects designed toenhance the work environment, and implementing moni-toring tools like exit interviews. In some cases, however,recruitment strategies themselves have been compromisedby budget cuts.

7B.3 Laboratory PersonnelWorking behind the front lines, laboratory personnel areessential members of the public health workforce as thepreceding chapter indicated.

Medical microbiologists are in very high demand. As withcommunity medicine, there are few residency positionsfor MD-prepared medical microbiologists, and availablespots often go unfilled. PhD-trained microbiologists arealso in short supply, and the erosion of public healthlaboratories has limited the attractiveness of this careerstream. Even were the applicant pool large enough toreplace those who retire—and most expert informantsbelieve that it is not—newly-qualified persons rarely havethe additional skills essential (e.g., epidemiology andmanagement training) for public health work. Unlikethe United States, Canada has no formalized post-doctoral program providing for medical microbiologistsinterested in a public health career.

The alignment of responsibilities and salary remains anissue. The Canadian Association of Medical Microbiologistscommented on “the lack of competitive financial remu-neration in the public health sector.” For example, inAugust 2003, the Committee noted that a provincialgovernment was advertising for a laboratory specialist to

manage a regional public health laboratory. The adver-tisement sought applicants with a knowledge of bacteriology,virology, mycology, parasitology and serology who hadan MSc or PhD from a university of “recognized standing”,demonstrated managerial experience, highly developedinterpersonal skills, and a willingness to travel. Thesalary range was $60,000 to $77,000.

PhD-trained microbiologists are critically important instaffing reference laboratories and research centres. TheCommittee did not have a detailed inventory of trainingopportunities and output of research scientists who havethe capacity to play a role in cutting-edge laboratoryactivities that will lead to better diagnostic and therapeuticcapacity for emerging infectious diseases. However, weare concerned that these highly-skilled personnel are notbeing trained, recruited, and retained in sufficient numbers.

Aside from the recurring theme of rural undersupply, thesupply of technologists is more or less adequate at present.However, this is partly a function of recent trends tomechanization and centralization of laboratory functions,but these trends have reduced the number of full-timepositions and may have ripple effects on longer-term laboursupply. The Canadian Society for Medical LaboratoryScience [CSMLS] notes that “Half of Canada’s medicallaboratory technologists will be eligible to retire by2016…Thirty per cent of medical laboratory technologistswork part time. The number of part-time positionsreflects the cutbacks in laboratory staff that have takenplace in institutional workplaces, which in turn have animpact on the ability to recruit new people into the field.”CSMLS estimates that 281 new training positions arerequired based on current demands and demographics in their discipline.

7B.4 Infection Control Practitioners andHospital Epidemiologists

Infection control practitioners—The US recommen-dation for the provision of trained hospital infectioncontrol practitioners [ICP] is one per 250 active care beds.More recently, the Infection Control Alliance (an alliancebetween the Canadian Infectious Disease Society, theCommunity and Hospital Infection Control Associationand Health Canada) has recommended a ratio of one ICPper 175 active care beds. Forty-two percent of Canadianhospitals fail to meet the former standard, and 80% cannotattain the latter. Health Canada has been consideringeven more stringent standards; these envisage one practi-tioner per 115 acute beds, and one per 250 long-termbeds. These ratios would drop further for institutionswith critical care beds. Given our hospitals' inability to

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meet the current standard, it is obvious that they will beunable to come close to the new Health Canadastandard. This suggests a massive shortfall in the numberof infection control practitioners necessary to provideoptimum infection control in the hospital sector.

Infection control practitioners are mostly either nurses(88%) or laboratory technologists (10%) who learn onthe job. Fifty-five percent are certified—usually by theCertification Board of Infection Control and Epidemiologyin the United States. Certification requires two years’experience, learning from a self-study guide and passingan examination. Continuing education is required tomaintain certification.

Health Canada was formerly involved in infection controltraining; a senior Health Canada nurse led modular trainingcourses for practitioners across the country. These courseswere well received, but Health Canada has neither offerednor been directly involved in infection control trainingcourses since 1989. There is now one formal trainingprogram in Canada—the Canadian Hospital InfectionControl Association and Centennial College partner totrain infection control practitioners in an intensive two-week course.

Hospital epidemiologists—Some physicians, usuallytrained in infectious disease, spend part or all of theirtime as medical directors of infection control programs.These individuals are known as “hospital epidemiologists”in the USA, although few have full training in epidemi-ology. Only one Canadian university, the University ofCalgary, currently offers post-graduate training in hospitalepidemiology. The number of fully-trained hospitalepidemiologists in Canada is extremely limited, and mostof them received their education in the United States. Manyphysicians working as infection control directors lack thisbackground. The advantage of hospital epidemiologytraining is that it helps to create a conjoint public healthand infection control approach.

Fewer than 60% of Canadian hospitals have a physicianserving as infection control director. Those who fill theseroles sometimes lack formal training, and others withinfection control or hospital epidemiology backgroundsare spread across multiple institutions. The reason for thisundersupply is clear—infection control activity does notcount as ‘billable time’ for physicians, and hospitals areunderstandably reluctant to divert scarce resources intounfunded programs.

Surge capacity—Severe understaffing of Toronto-areahospitals from an infection control standpoint becameclear during the SARS outbreak. As noted in Chapter 2,even if the government had ordered hospitals to conductcomprehensive syndromic surveillance after the firstwave of SARS cases, most hospitals would not have beenable to operate such a program without outside help.During outbreaks, when multiple institutions are affectedsimultaneously, the problems inherent in sharing infectioncontrol practitioners and directors among institutions alsobecome apparent.

Integration between hospitals and public healthunits—Outbreaks obviously do not confine themselvesto hospitals. Therefore, formal linkages between hospitalinfection control programs and public health units areimportant. In Ontario, for example, mandatory guidelinesrequire that an employee of the local public health unitsit on each hospital infection control committee. Informalcontacts are common, but as we shall see in Chapter 8,compliance with guidelines is variable.

7B.5 Infectious Disease SpecialistsInfectious disease specialists are physicians certified ininternal medicine or paediatrics who have taken additionalsub-specialty training in infectious disease. Most infectiousdisease physicians choose to work at academic ratherthan community hospitals. Committee intervieweesspeculated the preference for teaching hospitals might berelated to compensation. It is not uncommon for thesespecialists in teaching hospitals to be supported by avariety of salary sources to maintain a competitive income,given the relatively limited potential for generating fee-for-service revenue through patient care. In communityhospitals, infectious disease physicians are not able to billas much as other specialists. More generally, infectiousdisease specialists face the same income gap as othercognition-based medical specialties when contrasted withprocedurally-oriented specialties.

The continued challenges of older and emerginginfectious diseases, including the appearance of moreantibiotic-resistant organisms, has led more communityhospitals to search out infectious disease specialists. In the Greater Toronto Area, for example, there are now12 community-based specialists in infectious diseases ascontrasted with two a decade ago. However, this remainsa specialty that is undersubscribed and inconsistentlysupported by conventional fee-for-service billings.

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7B.6 EpidemiologistsCommittee informants were virtually unanimous in theirbelief that Canada needs more epidemiologists who cando outbreak investigation and infectious disease research.While Canada does train a modest number of epidemiol-ogists, they are drawn largely into non-communicabledisease epidemiology, including cancer and cardiovasculardisease, as well as health services research where theirobservational and analytical skills are both valuable andvalued. A prominent exception is HIV/AIDS; manyhighly-trained epidemiologists are working on controllingthis disease. Canada must draw more students into thefield of infectious disease epidemiology and providesupport and training opportunities for them. It has alsobeen argued that short courses in infectious diseaseepidemiology are an essential part of capacity buildingfor many aspects of public health practice and leadership,but are not widely available.

7B.7 Other Public Health WorkersMany other disciplines do work that is relevant to publichealth. Examples include public health inspectors, dentalhygienists, nutritionists, health promotion specialists,communication officers, sociologists, and communitydevelopment workers to name a few. Little or no infor-mation is available on the number, trends, and challengesfacing these groups, emphasizing the need for a compre-hensive inventory of the public health workforce. Indisciplines such as pharmacy and veterinary medicine,there is more reliable information on the workforce but,as indicated in submissions by national associations forboth these professions, insufficient attention has beenpaid to how their work could be integrated with publichealth priorities.

7B.8 Overall AssessmentAlthough data are scarce, the SARS outbreak made clearthat even in Toronto, where the public health infrastruc-ture is relatively strong, public health human resourcesare deficient. Indeed, one of the rate-limiting steps inthe Committee’s plan to enhance Canada’s public healthinfrastructure is the lack of qualified personnel to take onthe relevant roles and responsibilities. Several provincialand territorial ministries have vacancies in key positions.Although urban centres are currently able to fill most oftheir public health positions, problems with recruitingand retaining public health physicians were reported inall jurisdictions and public health nurses are inparticularly short supply in rural and northern areas.Anecdotal reports suggest that the situation with publichealth inspectors is only marginally better, and infection

control practitioners are in critically short supply giventhe new standards about to be released. Infectious diseaseepidemiologists are few and far between, and Canada alsolacks medical microbiologists and fully-qualified directorsof hospital infection control. Existing human resources,in sum, are insufficient to meet current and future publichealth challenges.

7C. Nature of Education andTraining

Although Canada needs more public health workers,increasing the supply alone would be a half-measure. A thorough review of public health training programs isalso needed—new entrants to the public health workforceshould be appropriately qualified, and existing publichealth workers should be provided with opportunities toacquire additional skills if necessary. We focus here onjust three of the groups reviewed above—physicians,nurses, and epidemiologists.

7C.1 PhysiciansAlthough we produce far too few public health physicians,the ones who do undergo specialty training are wellqualified. Unlike in the United States and the UnitedKingdom, all residency programs in Canada must beuniversity-based. The Royal College of Physicians andSurgeons of Canada closely monitors all specialty residencyprograms, ensuring uniformly high standards across thecountry. According to the National Specialty Society forCommunity Medicine [NSSCM], all nine fully-accreditedtraining programs for public health specialization offerrelevant didactic training plus supervised field-based experi-ence in responding to communicable disease outbreaks.

On the other hand, the nature of this outbreak experienceclearly varies. At least part of the problem in combatingSARS was that the generation of public health physicianswho had faced massive outbreaks of life-threateningrespiratory or enteric viruses is no longer practising. Anoutbreak of an enterovirus like Norwalk has a significanteffect on the health care system but does not threatenlives the way that SARS did. HIV has its own relativelydistinct epidemiology. West Nile virus is not transmittedfrom person to person, and tuberculosis is rare. Thegeneration of public health physicians who foughtoutbreaks of polio has long since retired. The publichealth physicians and hospital epidemiologists who foughtSARS have a unique experience that is shared only bysome who have fought outbreaks through internationaloutreach and training. Their experiences should bedistilled and shared widely.

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Exposure of public health physicians to hospital infectioncontrol issues varies with the site of their training andearly practice experiences. The NSSCM highlighted thatregional health authorities have offered an opportunityfor more seamless integration of the public health andclinical perspectives. Many regions have a CommunicableDisease Advisory Committee that includes representativeswith expertise in broad public health, hospital and long-term care infection control, epidemiology, andsurveillance.

Relatively few public health physicians maintain activeclinical practices while working for a public health unit.Aside from reporting mandatory diseases, even fewer clinicalspecialists and family doctors interact in a meaningfulway with their local public health units. Opinionspresented to the Committee varied as to the merits andnature of “cross-training”. Some endorsed the idea ofdual training in general internal medicine and communitymedicine. Others pointed out that specialists in commu-nity medicine have ample clinical exposure during theirpost-graduate training, including full certification infamily medicine. The NSSCM suggested that cross-trainingwould be best constructed by focusing not on publichealth specialists but on clinicians, viz. requiring familymedicine, emergency medicine, general pediatrics andinternal medicine, and infectious disease residents “tocomplete at least a one-month rotation in communicabledisease control in a local public health unit.”

The Survey of Public Health Capacity in Canada found awidespread belief that continuing education opportunitiesare lacking for public health practitioners. About half ofrespondents reported that continuing education to besomewhat or completely inadequate. Greater continuingeducation opportunities are especially needed in theareas of informatics and technology.

Limited linkages to academe add to the problems withrecruitment and retention of public health practitionersin urban areas. Among the various medical specialties,community medicine provides perhaps the fewestopportunities for active practitioners to form a workingrelationship with a university. Some community healthpractitioners hold unpaid adjunct appointments, butthere are only a few instances where public healthphysicians engage in both academic work and publichealth practice. Community medicine specialists whowork entirely within the university sector are alsobecoming rare. As Prof. Harvey Skinner, chair of publichealth sciences at the University of Toronto has written,

strengthened linkages between the academe and thepublic health sector “advance an evidence-based cultureof learning, stimulate interdisciplinary research andknowledge translation, [and] accelerate basic andadvanced training.”

7C.2 NursingTraditionally, registered nurses had to complete anadditional one-year diploma before becoming a publichealth nurse. Nursing degrees are now becoming thenorm, and diplomas have been discontinued. Mostpublic health nurses today are baccalaureate-trained, andfurther specific training in public health is no longermandatory. Instead, public health nurses learn on thejob through formal and informal in-service training.

Some experts believe that specific public health nursingtraining should be reintroduced. Public health nurseshave expressed the view that public health nursingshould be regarded as an advanced practice specialty.Acceptance of this position has apparently been hamperedby the unavailability of graduate programs in public healthnursing. When nurses with longstanding experience inthe clinical sector move to public health posts, formalretraining is appropriate, but the formal training andretraining opportunities in public health are limited.Relatively few registered nurses go on to a master’s degree in public health or similar graduate credential,and career paths in public health nursing have not been well-defined.

Some respondents also suggested that the educationalsystem could better equip nursing graduates for publichealth practice. The undergraduate nursing curriculumtends to focus on acute care; population and public healthcourses are limited. In addition to ensuring adequatecredit hours for public health theory and practice, traininginstitutions need to hire faculty members with publichealth expertise.

Many faculties/schools of nursing would benefit fromcloser collaboration with public health units to providemeaningful practicum experiences for nursing students.Some Committee informants remarked that curriculashould be more collaborative—public health nurses workin interdisciplinary teams, and they should train in aninterdisciplinary environment as well.

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As already suggested, opportunities for upgrading know-ledge in public health nursing are limited. Some employersfund continuing education; few fund it satisfactorily andsome do not fund it at all. Some Committee informantsreported workplace policies supportive of continuingeducation; others described an environment with rigidschedules (compromising the ability to attend courses), acomplete lack of tuition fee support, and an unwillingnessor inability among supervisors to provide the on-sitepractical experience necessary for certain qualifications.Unique challenges were identified in northern, rural andremote settings where in-person continuing education isprohibitively expensive. Keeping rural public healthnurses energized by contemporary best practices is nearlyimpossible with the current communications infrastructure.

National standards for public health nursing practicewould be helpful in establishing a set of core competenciesin the public health nursing workforce. They must beimplemented carefully to avoid compromising an alreadylimited workforce by erecting new barriers to entry. Thenecessary core competencies suggested by Committeeinterviewees include an understanding of:

• population health principles

• epidemiology and surveillance

• basic statistics

• environmental health

• informatics and data management

• program planning, management and evaluation

• adult education

• advocacy

• negotiation

• interdisciplinary practice

• injury prevention

• health promotion

• community development

• social marketing

• public policy and legislation

• research methodology and statistics

7C.3 EpidemiologistsIt was abundantly clear during the SARS outbreak thatCanada needs more epidemiologists with an orientationto field investigation and outbreak response. Canada hasmany university epidemiology programs, but most of theseare research-oriented. One exception is the University ofToronto’s Master of Health Science program—its contentis relevant to public health, and many of its enrolees arepractising health professionals looking to upgrade theirskills. However, the program constitutes a broad prepar-ation for a career in public health and does not offer thedepth or experience required for outbreak investigation.Furthermore, PhD-stream epidemiologists seem to bedrawn largely to non-communicable diseases, HIV/AIDS,and health services research.

One non-university option is the Field EpidemiologyTraining Program operated by Health Canada. Thisprogram takes in just five or six individuals per year(mainly health professionals who already have a master’sdegree in epidemiology), provides further training andthen assigns them to supervisors in the field. Undersupervision, the trainees usually have the opportunity toinvestigate outbreaks. The result has been a small butgrowing cadre of field epidemiologists who are betterprepared for leadership positions in local, provincial ornational public health agencies.

The program has tremendous potential. US experiencewith a similar program illustrates the many advantages ofa dynamic field-epidemiology training program in creatingcross-linkages among jurisdictions and strong expertise inoutbreak investigation and response, including issues ofinstitutional infection control. We believe the fieldepidemiology program should be reviewed and greatlyaugmented as part of a broad F/P/T strategy for renewalof human resources in public health. The proposed F/P/TNetwork for Communicable Disease Control, and aNational Public Health Service within the Canadian Agencyfor Public Health would provide training opportunitiesand a career path for those enrolled in this program.

Health Canada’s Skills Enhancement for Health Surveillanceprogram is a web-based distance education program aimedat front-line and supervisory workers in local healthdepartments. While not intended to substitute for master’slevel training, and still under development, it aims toprovide basic, high-quality training in epidemiology,surveillance and information management.

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7D. A Public Health HumanResources Strategy

No attempt to improve public health will succeed thatdoes not recognize the fundamental importance ofproviding and maintaining in every local health agencyacross Canada an adequate staff of highly skilled andmotivated public health professionals. Our national aimshould be to produce a cadre of outstanding publichealth professionals who are adequately qualified andcompensated, and who have clear roles, responsibilitiesand career paths. Without urgent implementation of apublic health human resources strategy, that aim cannotbe achieved.

Other nations are also grappling with this challenge. Inthe USA, partly as a result of a fragmentation of publichealth services at the local level, skills and qualificationsare suboptimal. A CDC report published in 2000 reportedthat only 44% of the public health workforce had formaltraining in public health and just 22% of local healthdepartment executives had graduate degrees in publichealth. Despite (or perhaps because of) these discouragingstatistics, the USA and several other countries we reviewedhave specific initiatives directed towards developing andsustaining the public health workforce. For example,joint initiatives between the CDC and post-graduateschools of public health target the continuing educationneeds of the United States public health workforce.

We have highlighted already that Canada faces a seriousshortage of public health physicians. However, simplycreating more training positions will not suffice.Incentives are needed that will draw medical studentsinto community medicine as a specialty training program.In turn, given the clear problem with graduates wholeave the field, there is a need to provide communitymedicine graduates with more rewarding careers inpublic health per se. Some small rural regions with fewresources will continue to find it difficult to attractqualified medical officers of health; it may be necessaryto combine health regions for public health purposes, orto have a two-tier system of medical officers of health,with senior staff acting as consultants or supervisors toseveral regions.

Medical officers of health and senior public health nursesalso need better linkages with universities. Most physicianspractising at teaching hospitals receive universityappointments—in addition to treating patients, theyteach medical students and resident physicians, and areoften supported to do research. In the public healthsphere, the teaching health unit is the teaching hospital

equivalent. This valuable concept should be embraced inevery city where the 16 Canadian health science facultiesare located. “Teaching health units” are critical if publichealth is to attract its share of exceptionally ablephysicians, nurses, epidemiologists, social scientists, andother public health workers. Analogously, in fields suchas medical microbiology, both Health Canada’s labora-tories and the British Columbia Centre for DiseaseControl have demonstrated that close links with universitydepartments are beneficial. These academic connectionsfeed a cycle of training and research opportunities thathelp to make knowledge-based workforces self-renewingand dynamic.

The available data suggest that shortages and challengesfrom insufficient training and suboptimal work environ-ments affect many constituents of the public healthworkforce. A national initiative to frame a public healthstrategy is clearly needed. Part of the exercise must be tohear out the concerns of public health practitioners in allthe relevant disciplines. Any national strategy for renewalof human resources in public health can only succeed ifdeveloped in consultation with a broad range of stakeholdersand supported by a dedicated national secretariat.Moreover, a plan on its own will do nothing—it mustattract resources and be put into action as a matter ofurgency. This is why, in budgeting for the CanadianAgency for Public Health, the Committee projected arecurring expenditure of $25 million per annum forhealth human resource renewal.

Training, professional development and continuingeducation will be prominent activities in reconfiguringthe public health workforce. Existing programs can bebolstered. The Field Epidemiology Training Program, forexample, should be significantly expanded beyond itscurrent intake of five or six trainees each year.

As outlined in earlier chapters, the Committee envisagesa system of federally-funded training placements thatwould constitute a logical career path for young Canadiansinterested in public health. A public health nurse freshfrom his baccalaureate could take a part-time Master'sdegree in Public Health with a tuition bursary whiledoing disease surveillance projects in one of the regionalnodes on the F/P/T Network for Communicable DiseaseControl. He could then spend a year doing front-linegeneral public health work in an Aboriginal communityand return to a health promotion position in Vancouver’spublic health department. A physician trained incommunity medicine could do a Field EpidemiologyPlacement, learning the essentials of outbreakmanagement as part of a mobile response team based inWinnipeg. She could go on to become an Associate

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Medical Officer in Toronto, then rejoin the federalsystem as the director of a non-communicable diseasesurveillance program in the Canadian Agency for PublicHealth. Internet-based distance education could be usedmore extensively. All of these activities would beundertaken with academic, voluntary sector, professionaland international partners, linked to and by a series offormal and informal networks, and set out in a multi-yearplan with milestones and measurement of progress.

Public health workers, like other Canadians in the workforce,want and need stimulating career paths. A NationalPublic Health Service, where interested individuals couldmove through medium-term assignments in differentdisciplines or locations, would build capacity by strength-ening individual skills and by sharing knowledge acrossjurisdictions. This movement of personnel would assistwith disease surveillance and coordination of healthpromotion. A wider range of pan-Canadian experiencesfor public health leaders would also facilitate sharing ofexperiences with new programs and systems. Canada’sF/P/T health systems are pluralistic and innovative; betterlearning across the systems would save costs, boost morale,and build collaboration. Last, in emergencies, a cadre ofindividuals familiar with change and accustomed to steeplearning curves would be ready for deployment tomunicipal and provincial public health agencies.

The Committee did review several options for improvingour public health human resources. The status quo isclearly insufficient—the public health human resourcessituation would continue to deteriorate, leavingCanadians vulnerable to a wide range of infectiousdiseases in the future, and subject to preventablemorbidity and mortality from chronic diseases andinjuries. A strategy to increase the number of publichealth workers by lowering standards was brieflyconsidered. When properly qualified persons areunavailable, one could, in theory rely upon untrainedpersons. The Committee believes this would lead to a“race to the bottom”, would negate gains made over severaldecades of gradual improvement in standards, andincrease the risk to the public’s health. Notwithstandingthese concerns, there may be valid reasons to examinecritically some of the competencies and qualificationsrequired for effective public health practice. The publichas a right to know that their tax dollars are flowing tosupport the most cost-effective approach to provision of services.

In an incremental/disjointed strategy, each F/P/T juris-diction might attempt to address issues as they arise.Education and recruitment issues, however, as well as the

inter-jurisdictional nature of public health practices,necessitate a national approach. The western provinces,for example, cannot currently meet their needs for publichealth physicians without recruiting from Ontario.

We could also recruit our public health workforcefrom abroad. While this may be suitable in selectinstances, relying on foreign recruitment is subject tofluctuations in international supply, arguably unethicalwhen we raid developing countries such as South Africathat have health human resource challenges of their own,and unlikely to meet Canadian needs in the longer-term.

All this leads us back to the view that a coherent nationalstrategy is the only way forward. A national publichealth human resources strategy should be based on apartnership (after the Australian model) involving federal,provincial and territorial governments, as well as academicstakeholders and professional associations. Under theguidance of a director and with the support of a secretariat,such a partnership must develop a strategy, implement it,and monitor its progress. The secretariat should workwith regulatory bodies, CIHI and other organizations tosupport data collection, develop better baseline informa-tion about the workforce, compare roles of public healthworkers in Canada and other countries, and evaluate theroles of different members of the public health workforce.The secretariat must also explore why certain profes-sionals choose public health practice and others do not;help define the educational standards needed to achieve,maintain and enhance competence for public health; andmake recommendations regarding public health pay scales.

Institutional infection control provides an illustration ofhow the strategy and secretariat might function. Relevantstakeholders would be pulled together into a task force toaddress this specific sector. A first phase of activity mightsee assessment of current standards and training programs,along with a more precise delineation of the supply ofinfection control practitioners and anticipated shortfalls.The next phase could be the rapid development of strate-gies to increase training opportunities and offer incentivesto nurses, laboratory technologists, and others who mightbe trained in infection control. These strategies would berolled out with support from the Canadian Agency forPublic Health and provincial/territorial jurisdictions aswell as institutional partners. Creation of continuingeducation and recertification programs could also be partof the strategy for sustaining the ICP workforce. Last, tomaintain a cycle of workforce renewal, graduate programsin infection control could be developed in a limitednumber of universities, thereby training the nextgeneration of teachers of infection control practitioners.

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Any national human resource strategy should be closelyaligned with other plans to enhance surge capacity. TheHERT concept, for example, appears best suited to full-blown emergencies. Might there also be a system ofhuman resource clusters so that redeployment of personnelwould be possible in the event of other shortfalls in localor regional response to a particular set of health threats?From the Committee’s perspective, any human resourcestrategy should not only aim at making Canada self-sufficient as regards public health personnel; it shouldalso explicitly aim at enhancing inter-jurisdictionalcollaboration on a continuing basis. A national strategycould therefore provide for more varied positions, flexibleemployment, exchanges between different job positions(both within Canada and internationally), and cross-jurisdictional continuing education.

Either through the partnership or through the creation ofa virtual national public health institute focused on educa-tion and training in public health, dedicated fundingmechanisms must be developed to support public healthworkforce development. The $25 million per annum fromthe Canadian Agency for Public Health would go somedistance to catalyzing workforce renewal. But sharedfunding will be necessary to create regional consortia andteaching health units, to augment graduate and post-graduate training positions in public health, to increase thepresence of actively practicing public health professionalsin universities, to support opportunities for advancedtraining in public health for nurses already in the workforce,and to provide scholarships and bursaries targeted at high-need areas such as First Nations and rural communities.

The strategy will depend, as noted, on more than F/P/Tcollaboration. Partnerships must be developed witheducational institutions, relevant national and provincialassociations, regulatory bodies, major municipal healthunits, industry, research agencies, rural communities,Aboriginal groups, and other stakeholders. Educationalinstitutions, in particular, would need incentives toreview curricula in relevant health disciplines to ensureadequate exposure to public health and the control ofinfectious diseases. A major step forward would bedevelopment of an 18-24 month non-thesis appliedepidemiology and public health master’s degree forhealth professionals, available in full-time and ‘executive/part-time’ formats, at multiple sites across Canada. Otherfoci for new programming include “summer schools” orshort courses in epidemiology, outbreak investigation,public health informatics, health promotion, and similartopics relevant to the practice of public health, targetingpublic health practitioners already in the workforce. We also urge the creation of a one-year public healthleadership and management program, and funding ofpost-doctoral positions in public health laboratory

science. Finally, Canadian universities, the CanadianInstitutes of Health Research, the new Canadian Agencyfor Public Health, and other federal agencies anddepartments, must play an active role in increasing theopportunities for public health workers to develop orstrengthen their research skills.

7E. RecommendationsThe Committee recommends that:

7.1 Health Canada should engage provincial/territorial departments/ministries of health inimmediate discussions around the initiation ofa national strategy for the renewal of humanresources in public health. This F/P/T strategyshould be developed in concert with a wide rangeof non-governmental partners, and include fundingmechanisms to support public health humanresource development on a continuing basis.

7.2 Health Canada should catalyze this strategy byurgently exploring opportunities to create andsupport training positions and programs invarious public health-related fields where thereare shortfalls in workforces (e.g., communitymedicine physicians, field epidemiologists,infection control practitioners, public healthnursing, and others).

7.3 The Canadian Agency for Public Health shoulddevelop a National Public Health Service, witha variety of career paths and opportunities forCanadians interested in public health. TheNational Public Health Service should includean extensive program of secondments to andfrom provincial/territorial and local healthagencies, with arrangements for mutual recog-nition of seniority and a range of collaborativeopportunities for advancement.

7.4 Educational institutions, in collaboration withteaching hospitals as applicable, should developcontingency plans to limit the adverse impacton their students and trainees from infectiousdisease outbreaks, while maximizing learningopportunities from these events. These plansshould include communications, educationregarding infection control, preparedness withappropriate protective gear, guidelines forsupport of students/trainees in quarantine orwork-and-home isolation, strategies to limit theimpact of impeded access to usual teaching andresearch sites, and guidelines for the involve-ment of students in the care of patients withserious infectious conditions.

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Sources and References Santana, S., “Containing SARS: University of Torontorises to the challenge,” AAMC Reporter, July 2003.(www.aamc.org/newsroom/reporter/july03/sars.htm)

McGugan, Susan. “Medical school on bypass during theSARS outbreak,” Clinical and Investigative Medicine, June2003, 26(3):106-7.

Advisory Committee on Population Health and HealthSecurity, Final Report of the Public Health HumanResources Task Group. June 2003.

Report to the F/P/T Deputy Ministers of Health by theAdvisory Committee on Population Health, “Survey ofPublic Health Capacity in Canada, Highlights,” March 2001.

Health Canada, Centre for Surveillance Coordination,“End-to-End Surveillance Project, Consolidated GapAnalysis,” September 2002.

National Public Health Partnership, Australia,http://hna.ffh.vic.gov.au/nphp/index.htm

US Centers for Disease Control and Prevention, PublicHealth Practice Program Office, http://www.phppo.cdc.gov/

US Centers for Disease Control and Prevention, Epidemi-ology Program Office, http://www.cdc.gov/epo/index.htm

Interviews:Dr. Cory Neudorf

Medical Officer of Health, Chief Information Officerand Vice-President, Information, Saskatoon HealthDistrict

Dr. Stephen Whitehead Associate Medical Officer of Health, Saskatoon HealthDistrict; formerly Director of Public Health,Derbyshire, United Kingdom

Ron de Burger Director of Environmental Health, Toronto CityHealth Department

Shirley Paton Chief, Nosocomial Infections, Centre for InfectiousDisease Prevention and Control, Health Canada

Dr. Richard Musto Head, Department of Community Health, University of Calgary

Dr. Rick Matthias Department of Health Care and Epidemiology,University of British Columbia

Dr. Bart Harvey Director of Community Medicine Residency Program,Department of Public Health Sciences, University of Toronto

Dr. Dick Zoutman Medical Director, Infection Control, Kingston GeneralHospital, and Vice-President, Canadian HospitalInfection Control Association

Dr. Sam RatnamDirector, Public Health Laboratory, St. John’s, Newfoundland.

Dr. Tony MazzuliPresident, Canadian Association of ClinicalMicrobiology and Infectious Disease.

Dr. Susan RichardsonPresident, Canadian Association of MedicalMicrobiologists

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CLINICAL AND PUBLIC HEALTH SYSTEMS ISSUES ARISING FROM THE OUTBREAK OF SARS IN TORONTO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Throughout its deliberations, the Committee appreciatedthe importance of understanding the response to SARSwithin a clinical and local public health context. Whilewe recognize that these matters are primarily a provincialresponsibility, viruses do not respect borders or jurisdictions,and lessons from Ontario are almost certainly applicableto other provinces. We have indicated that BritishColumbia was both fortunate and in some respects betterprepared to deal with SARS. We also speculated that hadSARS touched down somewhere other than Toronto, theresults could have been more devastating, although it ispossible that some of the jurisdictional tensions wouldhave been less.

Based on the SARS experience, this chapter discusses thesteps that key informants believe might be taken toenhance the readiness, efficiency and effectiveness of theresponse to a future outbreak. It also provides anassessment of the deferred service and disruption duringSARS and actions that might be taken in future to reducethe degree of disruption to ‘normal’ services.

This chapter draws heavily on work by the Hay Group.The Committee gave a specific mandate to theseconsultants and interacted with them on study design.Their conclusions were extraordinarily consistent withthose that arose from stakeholder submissions and fromthe Committee’s own experiences, interviews, reading,and deliberations.

The consultants used a combination of surveys, interviews,focus groups and data analysis. These activities focusedon a sample of organizations and individuals in thepublic domain significantly affected by SARS and/or whowere actively involved in the management of the response.Given the time frame available, the consultants establishedfirm schedules for participation and requested that partici-pants make themselves available. The organizations and

individuals contacted made every effort to provide inputwithin the schedule and the Committee greatly appreciatestheir efforts.

We have dealt elsewhere with the readiness of HealthCanada to respond in support of those at the local andprovincial levels fighting SARS. Health Canada’s responseswere seriously confounded and limited by the lack ofjurisdictional clarity about roles and responsibilities andthe lack of what can be termed ‘a receptor function’ inthe provincial system. However, it should be emphasizedhere that, during the consultants’ work, multiple infor-mants indicated disappointment with the role played byHealth Canada in dealing with the outbreak in Toronto.

The chapter also draws strongly on a series of roundtablesconvened by Health Canada’s Office of Nursing Policy tosolicit the perspectives of front-line nurses and supportstaff affected by the SARS outbreak in Toronto. Regulatorycolleges, professional bodies, and unions affiliated withthese two groups were also invited. Two Committeemembers attended the sessions.

In framing our perspectives and recommendations, theCommittee was also guided by input from several organi-zations. Among these were briefs from the Victorian Orderof Nurses, Ontario Association of Medical Laboratories,the Ontario Hospital Association, the Ontario Council ofTeaching Hospitals, and the Association of NursingDirectors and Supervisors of Ontario Health Agencies.

In general, a striking congruence of perspectives emergedin the responses of administrators, specialist physicians,front-line nursing and support staff, and unions repre-senting the latter groups. The chapter focuses on areasfor improvement; the consultants specifically solicitedinput on the strengths and weaknesses associated with theresponse to the outbreak and steps that might be takento improve that response in the future. Most informants

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indicated that most participants indicated that the aspectof the response that allowed the system, in the end, tosuccessfully contain the outbreak of SARS was theincredible effort made by front-line staff. This reportfocuses on opportunities for the future and thus is unableto give a full accounting of the valiant and sometimesheroic efforts of many of the public health and healthcare workers in the Greater Toronto Area [GTA] as theybattled to aid those infected and contain the spread ofthe disease.

Last, we have deliberately kept our recommendations at afairly high level of generality. This reflects considerationsof mandate, time constraints, and the existence of twoother processes to learn lessons from SARS in Ontario.We anticipate that more detailed recommendationsapplicable to the Ontario experience will be forthcomingfrom a provincial panel chaired by David Walker, Dean ofthe Faculty of Medicine at Queen’s University and fromMr. Justice Archie Campbell’s public health investigation.

8A. Scope and ApproachIn total, the consultants conducted 25 focus groups and21 interviews with organizations and individualsrepresentative of those that were most directly involvedin treating people infected with SARS and containing the spread of the disease. This included staff of ninehospitals, four public health units, Community CareAccess Centres [CCACs] in Toronto, representative primarycare providers, and officials of the Ontario Ministry ofHealth and Long-Term Care [OMHLTC].

They surveyed all acute care, rehabilitation and complexcontinuing care hospitals in the GTA regarding theirreadiness and experience with SARS. They receivedresponses from all Toronto and GTA hospitals included inthe survey1.

The survey collected activity volume data for March,April, May, and June of 2002 and 2003. The four monthsin 2003 were selected to cover the period of the SARSoutbreak. The data for the same four months in 2002were collected to provide an approximate activity baseline,with the simplifying assumption that any major changesin activity levels could be attributed to the impact of SARS.

Much of the analysis of the hospital survey activity datafocused on comparing the 2003 activity levels with thevolumes for the corresponding month in 2002. Onlyhospitals with complete data for all eight months wereincluded in the analyses.

Daily Census Summary [DCS] data were provided by theOMHLTC. These are records of the number of inpatientstreated, patient days and type of service delivered inOntario hospitals each day. These data supportcomparisons of changes in acute care hospital occupancyrates during the SARS outbreak.

Detailed, patient-specific records of inpatient and ambula-tory procedure activity for the GTA and Toronto hospitalpatients receiving care during the SARS outbreak will notbe available until late 2003. This means that there canbe no direct analysis of the impact of SARS on hospitalcase mix and specific clinical groups. However, to providesome information about the normal case mix and clinicalcharacteristics of the patients treated in Toronto hospitals,the Hay Group used the 2001/02 Canadian Institute forHealth Information [CIHI] records for Toronto hospitalsobtained previously for a benchmarking study. Thesedata were then used to estimate the expected distributionby program of Toronto hospital activity during theperiod of the SARS outbreak and to support the estimateof the volume and cost of deferred surgical activity.

The Committee had hoped to examine physician servicevolumes but approvals from the OMHLTC to access thenecessary data set had not been obtained at the time ofpreparation of this report. Researchers at the Institute forClinical Evaluative Sciences will be undertaking analysesof physician practices as part of a broader assessment ofprocess and outcome impacts from the outbreak.

As to the four roundtables convened by the Office ofNursing Policy, attendance follows:

• sixteen front-line nurses from eight organizations;

• nine participants from organizations representingnurses;

• six front-line support staff from three organizations;and

• four participants from organizations representingfront-line staff.

Participants included full-time, part-time, and casual staff from various sectors. Categories of staff included:registered nurse, registered practical nurse, infectioncontrol practitioner, nurse manager, environmental services,dietetic attendant, porter, and patient service aide.

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1 Some multi-site hospitals provided separate responses for each of their sites, while others provided a single response for the corporation.

8B. Readiness of the HealthSystem

8B.1 BackgroundKey dates in the outbreak have already been presented in Chapter 2. To recapitulate, the index patients withatypical pneumonia were seen at the Grace Site of theScarborough Hospital the week of March 10, 2003 andidentified as potential SARS cases on March 14. PremierErnie Eves declared SARS a provincial emergency onMarch 26. On or about March 28, under direction fromthe Provincial Operations Centre [POC], all GTA andSimcoe County hospitals restricted access to critically illpatients and necessary staff only. On March 29, thesehospitals were also directed to “initiate full Code Orangeemergency response plans.” The Premier lifted theprovincial emergency as of May 17, 2003.

A ‘second wave’ of SARS cases was confirmed on May 23, 2003. On May 27, the provincial governmentannounced, “four hospitals, working with all GreaterToronto Area hospitals, will use their expertise andleadership in a coordinated fight against Severe AcuteRespiratory Syndrome (SARS).” The four hospitals wereNorth York General Hospital, St. Michael’s Hospital, The Scarborough Hospital, General Division, and theEtobicoke site of the William Osler Health Centre. TheMinister stated that “We are concentrating the treatmentand expertise of SARS at four key sites around the GreaterToronto Area to ensure we quickly identify and containthe disease during this current wave of cases… This willhelp us protect the capacity of the health care system aswell as ensure that the health care system in the GTAkeeps running safely and efficiently2.” These fourhospitals are collectively referred to as the “SARSAlliance” hospitals.

For the purposes of this chapter, SARS I refers to thetimeframe of approximately March 10 to May 17, 2003.This timeframe corresponds to the initial identificationof SARS in Ontario and the response characterized by thedeclaration of a provincial emergency and oversight ofoutbreak management by the POC.

SARS II refers to the period beginning on or about May 18, 2003 and ending approximately June 30. Thistimeframe corresponds to the second cluster of SARSpatients and the date of the final new case underinvestigation. Characteristics of the SARS II response

include the SARS Alliance announced May 27 and theSARS Operations Centre [SOC] established by theOMHLTC.

8B.2 Roles and ResponsibilitiesDuring the initial stages of the outbreak, betweenapproximately March 10 and March 26, 2003, variousrespondents were unclear on the roles and jurisdictionalresponsibilities of Health Canada, the provincial Ministryof Health and the regional Public Health Units. Fromtheir perspective, it was unclear, for example:

• who was to be the contact with the World HealthOrganization [WHO];

• who was responsible for keeping the system informed;

• who had the jurisdiction/role to issue press releases;

• who was to provide advice on proper infection controlprocedures and to whom; and

• whose definitional frameworks were to be used.

Respondents observed that these issues appeared to be asource of debate between the OMHLTC and Health Canada.The province assumed responsibility for communicationwith the public initially through the Public HealthCommissioner and later through a subset of members ofthe Executive Committee of the POC. It became clearthat Health Canada had responsibility for contact withWHO. However, respondents were concerned that it wasnot until May 29 that Health Canada announced a fullalignment (or re-alignment) of its criteria for diagnosis ofSARS with those of WHO.

Respondents felt that clarity in jurisdiction and role andmore communication between Health Canada, theOMHLTC, and regional public health units would haveeliminated some of the early confusion in addressing theoutbreak. Front-line roundtable participants spoke of“fragmentation” in the system, “silos”, and “chaos”during SARS I.

Provincial GovernmentCommand and control for the operational response wassomewhat clarified when the Premier declared SARS aprovincial emergency on March 26, 2003 under theauthority of the Provincial Emergency Plans Act. Thisactivated the POC, made up of representatives from allnecessary provincial ministries. Concurrently, eachMinistry activated its own Ministry Advisory Group

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2 Ontario Ministry of Health and Long-Term Care Press Release, “Eves Government announces four hospitals to lead coordinated fight against SARS,”Toronto, May 27, 2003, Canada News Wire.

[MAG] to advise the POC and manage the emergency onbehalf of its respective Ministry. Pre-selected individualspopulated the POC and the MAGs. The consultantsinterviewed a number of individuals who had contactwith the POC during SARS I. Most indicated that themultiplicity of participants, and the advice being providedby the MAGs (most of whom had little understanding orinvolvement with SARS), led to a perception of confusionand dysfunction at the centre.

Public Health UnitsThere was also confusion regarding the roles andresponsibilities of public health units and their relation-ship to other parts of the system. The reporting relationshipof Regional Public Health Units through local govern-ments was perceived to be a source of uncertainty andconflict in their relationship with the OMHLTC PublicHealth Branch. Respondents widely reported that therewas a lack of coordination of information and overlap of roles.

Public health units and hospitals alike reported that therewas inconsistency in approach and activities across thepublic health units in the GTA. Respondents attributedthe inconsistencies to the absence of a clear linkage androle for the units in the clinical sphere, the weak link ofthe units to the OMHLTC Public Health Branch, and a lackof leadership from the OMHLTC Public Health Branch.

A number of respondents criticized the municipalreporting relationship of the regional public health units.They acknowledged that a number of the current respon-sibilities of Public Health benefit from a local emphasis(health promotion, smog alerts, etc.), but argued that areassuch as infectious diseases would benefit from a broader,provincial approach and responsibility. Health careproviders suggested that government should undertake areview of Public Health activities with the goal of redis-tributing and clearly identifying responsibilities of localpublic health units and the provincial Public HealthBranch of the OMHLTC. Respondents felt that roles,responsibilities, and accountabilities needed to be clearlydefined and understood.

HospitalsAs one CEO indicated, the management of any newinfectious disease in the absence of a scientific consensuson diagnostic criteria, etiology or treatment creates bothapprehension and new challenges for hospitals andhospital staff in responding to the illness.

None of the hospitals contacted for this study hasidentified infectious diseases as a priority program; thereis also no regional infectious disease program designatedby the OMHLTC. Further, there is no formal network ofinfectious disease specialists and there is no regionalmechanism to design or implement strategies to respondto an outbreak of infectious disease. It was reported thatinfection control specialists from hospitals have developedan informal network and some hospitals reported learningabout the outbreak through that source. A regionalinfectious disease network and strategy is clearly needed.

Many respondents indicated that being prepared requiresanticipation of a potential event and the availability of a planned response should it occur. The increasingprevalence of infectious disease outbreaks and challengesrequires that surveillance be an ongoing hospital function,and that a planned response to an outbreak be availableon both a routine and emergent basis.

Community Care Access Centres CCACs are Ontario’s clearinghouse for access to a rangeof home-based health and social services. They reportedthat the OMHLTC and hospitals did not use the expertiseof CCACs to the extent that was possible. The CCACscould have provided greater support in the discharge anddecanting of patients, particularly in the SARS Alliancefacilities that were attempting to create the capacity toaccept SARS patients. In some instances hospitals/physicians simply signed patients out without notifyingthe CCACs for tracking purposes, for arrangement ofappropriate home support, or for appropriate protectionof community workers.

Conversely, the Committee has learned that the CCACsin the GTA did not have ready access to infection controlexpertise or standardized protocols for dealing with SARS-like situations. The Victorian Order of Nurses took anumber of steps that enabled home care nurses to partici-pate effectively in the outbreak response. However, thehome care system in general was not adequately integratedor prepared for an outbreak of this nature.

During SARS II, the OMHLTC announced that theLeisureworld Brampton Woods facility would provideservices for patients, particularly from the SARS Alliancehospitals, that no longer required hospital care. Someinformants felt that the same result could have beenachieved with better outcomes (patients in facilitiescloser to home and more appropriate settings) if theMinistry had utilized the resources of the CCACs.

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Inter-Organizational InteractionRespondents reported that no system existed prior to theSARS outbreak for communication of routine infectiousdisease alerts from Health Canada to the operationallevels of the health system (i.e., to hospitals, long-termcare [LTC] facilities, CCACs, ambulance services, familyphysicians). Hospitals indicated that they had no directcommunication from Health Canada regarding SARS.

Respondents also indicated that there was a lack ofclarity regarding responsibility for alerting the variouscomponents of the health system to infectious diseaserisks when they are identified. Virtually all informantsidentified the need for a clear statement and assignmentof responsibility for providing infectious disease alerts toeach of the components of the health system including:

• regional public health units;

• family physicians;

• ambulance;

• hospitals;

• CCACs; and

• LTC facilities.

Several individuals suggested that such alerts must be ina format that is readily digestible by the different audiencesthat receive them. Further, the recipients themselvesrequire a process to receive and appropriately disseminatesuch alerts. A number of individuals identified theCoroners’ reports as an example of dissemination thatworks reasonably well: clearly labeled reports, identifyingparticular professionals who would have an interest inthe specific findings and recommendations, and a processto disseminate results.

Feedback regarding interaction with WHO was unequivocal:Health Canada has responsibility for liaison with WHOand provinces and Health Canada must collaborate tomeet our international obligations. Health Canada shouldcommunicate relevant WHO information to provincialPublic Health Branches and local public health units. IfHealth Canada is departing from international recommen-dations (as in the SARS diagnostic criteria), it must followa process that builds consensus and credibility withunambiguous explanations to all concerned.

Communication protocols regarding infectious diseasesmust include information flow in both directions: fromlocal to provincial to federal levels and from the federallevel back. Although local public health units have theresponsibility to collect infectious disease information for

reportable diseases at the individual case level, andproviders are required to report such information to thepublic health units, Public Health does not have clearenough responsibility to report this information back toproviders. Front-line workers expressed concern thatPublic Health focused on community contact tracing andquarantine to the exclusion of closer interaction withhospitals to identify how their processes and practicesmight be contributing to nosocomial infections.

Respondents believed that Health Canada should establisha surveillance role that enables it to accumulate and analyzethe locally-collected information, and establish a communi-cation process that alerts provincial public health unitsabout unusual patterns in an appropriate form fordissemination back to providers. Finally, relevant WHOinformation should be analysed in concert with thelocally collected information in the surveillance ofunusual patterns.

In sum, post-SARS, clinical and public health leaders inthe Toronto area were unambiguous in supporting anintegrated and regional system of surveillance, reporting,and outbreak management for infectious diseases. Front-line roundtable participants similarly urged the establish-ment of coordinated outbreak management under asingle authority.

8B.3 Emergency Structure/PlanningDue to the nature of the SARS emergency, there wassome initial confusion/frustration between the POC,populated by individuals prepared broadly for emergencyresponse, and the OMHLTC MAG with the contentknowledge to address the SARS emergency. The POC,which had not previously been activated, had notdeveloped a process to share responsibility. The POC andthe OMHLTC MAG ultimately amalgamated and situatedthemselves in the same physical location. Respondentsstated that this accommodation by the POC to thegreater expertise of the OMHLTC significantly improvedthe functioning of the POC. This occurred within 72hours of the declaration of the emergency.

The command-and-control structure of the POC, however,had not anticipated sharing responsibility/authority witha lead Ministry. There was perception that the roles ofthe Commissioner of Public Safety and the Commissionerof Public Health/Chief Medical Officer of Health overlapped,and it was unclear which position was ultimately respon-sible for the management of the emergency. Respondentsreported that this lack of clarity in leadership led toconfusion in the field.

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It was also noted that the various areas within eachMinistry had identified only one individual per area topopulate the POC and the MAGs; there were no alternates.This quickly proved inadequate given a 24/7 workload.Below the level of the POC and the MAG, there appearedto be little infrastructure to assist in the workings of theMAGs in support of the POC or to support the POC itself.

Further, areas of expertise were missing. Insufficient inputfrom the acute care sector meant that some of the earlydirectives demonstrated a lack of understanding of theworkings of either the health care system as a whole or theindividual components of the system. Hospital respondentsreported frustration with early directives that wereunrealistic and often not possible to implement.

Consistent with findings and recommendations inChapter 5, respondents suggested that a process beestablished to share the authority vested in the POC witha lead Ministry with content knowledge of the particulardisaster. This process should include a clear statement ofthe position/person that has ultimate authority for agiven emergency. Most recommended against a sharedresponsibility during a crisis. It was also noted that morethan one individual from each Ministry should beidentified to support the POC and the MAGs.

Several respondents also raised the question as to whetheror not a provincial emergency actually needed to bedeclared in the SARS outbreak. They felt that the POCwas a cumbersome structure for this particular emergencygiven that the response mostly required the efforts of asingle Ministry. Others noted, however, that the declarationof the emergency was necessary to provide the governmentwith the authority to make decisions and issue neededdirectives. As an alternative, informants suggested thatkey Ministries might develop their own individual emer-gency plans that provided the government with relevantauthority to act and that such Ministry-specific plansneed not involve the entire POC apparatus. If criteria foridentifying Provincial versus ‘Ministerial’ emergenciescould be set, this would allow for a more graded responserooted in sectoral expertise. Many felt that the SARSOperations Centre functioned more effectively than didthe general Provincial Operations Centre.

It was also widely suggested that both the provincial andministerial emergency plans consider closely the expertisethat would be required in various emergency situationsand identify ahead of time individuals with such expertise.As the SARS Scientific Advisory Committee demonstrated,such experts need not be employees of the provincial

government. Rather, experts from across the provincecould be identified in advance and take part in exercisesto pre-determine relevant emergency protocols.

Emergency plans should also consider compensationissues. Respondents noted that neither at the provincialnor ministerial level had emergency planning madeadvance provisions for compensation of those individualsrequired to respond to the emergency, as well as thoseaffected by the particular emergency.

Again consistent with recommendations in Chapter 5, it was also suggested that the federal government beinvolved with the emergency planning of provincialgovernments to ensure that the federal role in variousemergency situations is identified ahead of time.

Respondents identified the lack of any formal process orprevious human resource planning for recruiting or sec-onding staff to public health units in the event of an emer-gency. It was almost universally felt that there is insufficientcapacity in local public health units to address emergencysituations. Respondents were grateful that London andHamilton provided teams to assist the GTA public healthunits and noted that individuals were re-deployed internallyto provide additional focus on the SARS situation. Publichealth units reported a lack of physicians with appropriatepublic health training, and some of those with this typeof training were not available to the local units, as theyhad been seconded to the OMHLTC for the emergency.

A number of individuals suggested that there should be theability to dispatch a team of professionals to the epicentreof a major outbreak if requested to do so. Such a teamwould be specifically trained to assess the outbreak and ifnecessary identify additional resources that could be accessedto contain the situation. The services provided by this teammight range from infection control advice and specific staffeducation to actual patient care staffing. However, severalrespondents felt that sufficient health human resources donot exist for such an approach. It was suggested that anassessment of the expertise required to deal with infectiousdiseases be made and specific policies put in place toencourage the training of a sufficient number of suchprofessionals.

Many hospital respondents noted that emergencypreparedness policies and procedures are developed andtested at the level of the individual institution. Noregional policies exist and there is little evidence ofconsistency of protocols among institutions.

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There was a sense among focus group participants andinterviewees that cooperation among hospitals was inade-quate to the needs of the SARS emergency. A number ofindividual examples of sharing (non-union) staff withparticular expertise were identified as positive exceptions.Participants noted a particular need for greatercooperation among hospitals in the following areas:

• transferring/accepting non-SARS critical care patients;and

• sharing staff (and physicians) with particular expertise.

Many suggested that the absence of a pre-existing plan orapproach to cooperation among hospitals in an emergencysituation was an impediment to effective action duringthe SARS outbreak. This was identified by several respon-dents both within and external to the hospitals.

In sum, it was clear that the Toronto public healthsystem could not manage both the SARS crisis and carryon its day-to-day business. It was also clear that Torontocould not deal with more than one crisis at a time andthat the system would crash if faced with one additionallarge-scale crisis. Without a pre-existing mechanism toshare resources within the system and no surge capacity,Toronto was overwhelmed.

Managerial and front-line respondents alike urged thatall levels of government invest in front-line public healthcapacity, in addition to, and not at the expense of,existing resources and core services. Both clinical teamsand outbreak teams are needed when dealing with ahealth emergency. An adequate and consistent surgecapacity across Canada must be developed and requiresthe collaboration of provincial/territorial and municipalgovernments to ensure that investments are made andneeds met.

Code Orange is the internationally recognized code foran external disaster/emergency. Each hospital hasdeveloped its own policies and procedures to addressCode Orange situations. A number of hospitalscommented that Code Orange was not intended to dealwith an outbreak of infectious disease; nor was it themost appropriate response for all hospitals in the system.

The survey conducted as part of this study requested thathospitals state whether there were formal protocols foroutbreak management in place prior to the SARSoutbreak. Almost 90% of the acute care hospitals and78% of the non-acute hospitals reported having a formaloutbreak policy in place (Exhibit 8.1).

Two of the three Toronto hospitals that reported no formaloutbreak policy were SARS facility level 3 (the highestlevel) hospitals during the outbreak, while the third waslevel 2.

The survey also asked hospitals to provide a copy of theirprotocols for outbreak management. Eighteen facilitiessubmitted copies out of the 32 facilities that reported theexistence of such protocols.

The protocols received were of variable detail, clarity,quality and length. There are very different policies andprocedures for dealing with outbreaks of infectious diseaseamong the hospitals. In most cases, the protocols did notappear to provide sufficient information or instruction todefine how to manage severe outbreaks. Most protocolshad not been recently revised. Front-line respondentsparticularly emphasized the need for standard protocolsand practice algorithms in outbreak management.

Some respondents indicated in interviews and focus groupsthat SARS showed that many hospitals, especiallycommunity hospitals, are unprepared to deal with seriousoutbreaks of infectious disease. They have relatively weakinfection control functions and processes. Finally, somerespondents urged that basic standards of cleanliness andstandardized infection control practices and protocols bemandated across the health care system, includinghospitals, LTC, home care, and the offices ofindependent health professionals. Some suggested that

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Hospital Acute Care with Non-Acute with Location Formal Outbreak Formal Outbreak(County) Policy Policy

Yes No % Yes Yes No % Yes

Durham 4 0 100% 0 1 0%

Halton 5 0 100% 0 0

Peel 3 0 100% 0 0

Toronto 11 2 85% 7 1 88%

York 2 1 67% 0 0

Total 25 3 89% 7 2 78%

E X H I B I T 8 . 1Hospital Survey Responses re Existence of FormalProtocols for Outbreak Management

there be requirements, particularly for hospitals, toprovide continuing education on basic precautions forphysicians, nurses and other health professionals.Analogies were drawn to basic fire training required onan annual basis.

The lack of any regional hospital planning for emergencypreparedness was also heavily criticized. It was stronglysuggested that the emergency response plans of hospitalsshould include regional planning and cooperation. Suchplanning must include both inter-hospital participationand other providers and stakeholders as appropriate (i.e., CCACs, LTC facilities, Public Health, etc.).

A number of hospitals reported making use of existingnetworks, such as the Toronto East Emergency Networkand the Child Health Network, to assist with communi-cations and in some cases patient transfer.

CritiCall3 was essential for a number of required patienttransfers. Many hospitals, however, suggested that thepowers of CritiCall to enforce acceptance of patients byfacilities with open beds needed to be strengthened.Numerous situations were reported wherein hospitals had difficulty transferring patients both with andwithout SARS.

8B.4 Hospital FacilitiesThe hospital survey included questions regarding thepreparedness of the hospital facilities to accommodateSARS patients. Exhibit 8.2 shows the number of singlepatient rooms with anterooms and/or negative pressurein the GTA and Toronto acute care hospitals. Overall,3.8% of Toronto and GTA acute care hospital beds are insingle negative pressure rooms. Only 1.0% of Torontoand GTA non-acute care hospital beds are in singlenegative pressure rooms.

Toronto hospitals have the highest percent of rooms withnegative pressure (4.6% of acute beds, 1.0% of non-acutebeds). The range in the percent of acute care bedsequipped with negative pressure for individual hospitals(shown in Exhibit 8.3) is from 0% to 12%.

Of the 28 Toronto and GTA hospitals with emergencydepartments, 6 reported in the survey that they do nothave an infection control area. The hospitals withoutinfection control areas in their emergency departmentsare distributed as follows:

• two in York;

• three in Toronto; and

• one in Durham.

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3 The Ontario CritiCall Program facilitates emergency patient referrals by assisting physicians in community hospitals with access to the resources of larger tertiary care hospitals in their regions. Management of the program is provided by Hamilton Health Sciences (HHS).

Acute Hospital Location (County)

Anterooms? Negative Durham Halton Peel Toronto York Grand Pressure Total

Yes No – 8 31 7 12 58

Yes Yes 11 14 22 147 20 214

No Yes 3 13 2 140 2 160

Total Beds: 552 830 1,445 6,254 800 9,881

% Beds w/ Anterooms 2.0% 2.7% 3.7% 2.5% 4.0% 2.8%

% Beds w/ Neg. Press 2.5% 3.3% 1.7% 4.6% 2.8% 3.8%

% Beds w/ Both 2.0% 1.7% 1.5% 2.4% 2.5% 2.2%

E X H I B I T 8 . 2Hospital Survey Responses re Anterooms and Negative Pressure Rooms in Acute Care Hospitals by Hospital Location

The survey results show that 18% of monitoredintermediate/critical care beds are equipped for infectioncontrol. The percent equipped for infection controlranges from 10% in Halton to 28% in Peel.

Only 30% of hospitals with autopsy suites reported thattheir suites conformed to CDC guidelines.

All hospitals as well as front-line workers commented onthe lack of capacity to accommodate the surges indemand that often accompany emergencies. If it needsto operate regularly at 90% to 95% of capacity (as is thecase for acute medical beds), the system is unable toabsorb a large influx of patients associated with anemergency while still maintaining normal activity levels.In addition, the rest of the system lacks capacity toabsorb volume if some hospitals have to reduce volumesto deal with an emergency, as occurred during SARSwhen some hospitals’ ICUs became compromised. Somehospitals did indicate that the elective elements ofnormal activity could be temporarily suspended, if needed,to provide sufficient resources to deal with the emergentsituation. However, such interruptions would have to bebrief and accompanied by provision for catch-up capacity.

The SARS Alliance facilities noted that, with no regionaldisaster planning in place or previously identifiedmethods for cooperation between facilities, it was verydifficult to transfer non-disaster (non-SARS) relatedpatients to other facilities. The concept of designating

entire facilities as ‘level 3’ on the Ministry’s SARS scale,rather than specific units of a hospital where a breachhad occurred, led to confusion and a transient stigmati-zation of entire institutions. A number of patients wererefused, despite the transfer protocols, simply becausethey were coming from a level 3 facility.

Given the impact and potential increase in prevalence ofinfectious disease outbreaks, a number of suggestionsregarding appropriate infrastructure were also broughtforward. Specifically, respondents suggested that eachemergency room be equipped with isolation facilitieswith appropriate air handling and anterooms. They alsosuggested that the number of negative pressure rooms inhospitals be expanded. These facilities would, in theevent of an outbreak, be temporary treatment areas priorto transfer to a regional facility (or facilities) withresponsibility for caring for and isolating patients withthe infectious disease. If patients could be congregatedin regionally-designated institutions, the rest of thesystem could carry on in addressing the other health andhealth service needs of the population.

It was suggested that one or more institutions in eachregion of the province should have the necessaryinfrastructure to isolate a large number of patients in anemergency situation. These institutions would requireboth the facilities to accommodate a large number ofpatients suffering from infectious disease, and the staffrequired to treat them.

If regional programs in infectious diseases were established,the institution(s) with the facilities for addressing theoutbreak should also be the locus for the program. Manysuggested that it would be unrealistic to expect a singleinstitution to be home to sufficient infectious disease andinfection control expertise to deal with a crisis. Rather, anetwork of providers should be created that couldcollectively focus on each outbreak and realign themselvesto ensure that the needed resources are available to theregional facility in the event of an outbreak.

8B.5 Communications Structures and Processes

As noted, respondents reported that there was not aseamless and effective system prior to the SARS outbreakfor communication of routine infectious disease alertsfrom Health Canada to the operational levels of thehealth system (i.e., to hospitals, LTC facilities, CCACs,ambulance services, family physicians).

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0%

2%

4%

6%

8%

10%

12%

14%

A B C D E F G H I J K L M N O P Q R S T U V W

E X H I B I T 8 . 3Variation in Percent of Toronto and GTA Hospital AcuteBeds in Single Negative Pressure Rooms (onlyhospitals with at least 100 acute beds)

The interviewees and managerial/physician focus groupparticipants indicated that communications related toSARS came from various components of the health caresystem, with no clearly identified source and often withconflicting and/or out-of-date advice. Communicationscame from:

• Public Health Commissioner;

• Regional Public Health Units;

• Provincial Operations Centre;

• SARS Operations Centre;

• Ontario Hospital Association;

• Ontario Medical Association;

• Ministry of Health and Long-term Care;

• Public Health Branch, OMHLTC;

• Institutions Branch, OMHLTC;

• Ministry of Public Safety and Security; and

• Health Canada.

There was neither the mechanism nor the disciplinerequired to consolidate and control communicationswithin the POC. Theoretically, the POC should have beenthe single source for communications for all providers.This was not the case. Various reasons for this werepostulated; chief among them was a lack of clarity of roleand jurisdiction and a need for organizations to be seento be active in supporting their constituencies.

As noted above, the field also heavily and repeatedlycriticized both the process of issuing directives and thecontent of directives from the POC. Front-line staffemphasized that, especially early in the outbreak, itappeared that those formulating directives were notsufficiently knowledgeable about the practicality ofimplementing these practices in the clinical setting.

Criticisms also included:

• lack of clarity around who the POC was and who wasdirecting its activities;

• frustration that teleconferencing did not allow partici-pants to know who was participating in the POC, andwhether the participation was informed by science orpolitical necessities;

• length of time required to issue directives, which inturn was attributed to delays occasioned by the internalreview and approval process;

• inconsistency in directives;

• initial directives not numbered or signed; and

• lack of a pre-defined process to clarify directives.

Some of these criticisms are not entirely consistent withothers; speed in issuing directives may lead to lack ofclarity while delays led to criticisms about lack of leader-ship. Regardless, the criticisms speak to an opportunityfor improved performance.

Respondents had a mixed response to the mechanism/media used for communications by the POC. Manystakeholders expressed frustration with the length andfrequency of teleconferences. However, many also statedthat this was a timely method of disseminating quicklychanging information. After the first few days,respondents reported that the effectiveness of theteleconferences improved.

Some respondents felt that the difficulties associated withthe communications process could have been alleviatedif the OMHLTC had its own emergency preparedness planseparate from that of the POC. It was overwhelminglysuggested that regardless of the emergency situationdeclared, responsibility for communications should beidentified clearly in the various scenarios and that mechanisms be established to enforce a single communi-cations source.

Numerous comments were received highlighting theneed to ensure that all interested stakeholders receiveappropriate communications. Clearly, interested stake-holders will vary depending on the situation. However,many respondents suggested that appropriate contactsheets could be prepared ahead of any particular emergencysituation to ensure, for example, that family physiciansand local Public Health Units4 receive information at theinitiation and throughout an outbreak situation.

Finally, almost all respondents felt that a process must bein place to attempt to minimize frequent changes toinformation and conflicting information in an emergency.

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4 It is curious that initial directions from the POC were not made available to public health units. CCACs reported providing information to public healthunits that the public health units did not seem to be receiving directly.

In sum, the overwhelming sense obtained by the consultantswas that SARS demonstrated the importance of effectivecommunication during an emergency, both domesticallyand internationally. Poor communication during theSARS outbreaks may have contributed to the impositionof a travel advisory by WHO, harming Canada’s economyand reputation. The use of a myriad of spokespeoplespeaking to the media at the same time with messagesthat sometimes conflicted did nothing to instillconfidence in the public health system and underminedthe credibility of those at the helm. Respondents notedthat uneven communication to other affected sectors,such as the travel sector, created confusion and fear forboth the public and people working in those othersectors. The travel sector, severely affected by SARS,should have been kept better informed and betterutilized in disseminating information and easing publicanxiety. Pharmacists as front-line health careprofessionals also could have been better utilized toconvey important messages.

Public HealthThere was no effective mechanism for medical officers of health [MOH] to communicate amongst themselvesand to coordinate their actions during the outbreak.Conference calls among the MOH were arranged but notconsistently attended by all units. Many clinical leaderscommented that the MOH in the various regions weredisconnected from each other.

Participants also expressed frustration that communicationsfrom the public health units were non-existent orsporadic; in their view, much information was providedto Public Health, but little information came from PublicHealth. Hospitals reported receiving inquiries frommultiple public health units for the same informationregarding the same patient. When notified that the infor-mation had already been provided to a different publichealth unit, hospitals were told that the units did nothave mechanisms to share the information amongstthemselves and that it was easier to collect it again fromthe hospital.

Some hospitals anticipated that the role of Public Healthwas to consolidate, analyze and communicate back insome useful fashion the information that it was collecting.Public Health informants felt that they could not shareinformation because of confidentiality restrictions, becausethey did not have sufficient resources to share informa-tion, or simply because it was not their responsibility tocommunicate back to providers. It is unclear, thereforewhose role this was. Either expectations must be modifiedor mechanisms found to close the communications gap.

The role assumed by most public health units was focusedon front-line containment of the outbreak. As notedearlier, along with their front-line staff, several hospitalleaders had expected advice from the public health unitson infection control and quarantine procedures andenforcement; these expectations were not consistentlymet. Providers were unsure if this was or should be arole for provincial or regional level Public Health.

Confidentiality concerns raised by Public Health wereshared by health care providers who argued that they,too, have a responsibility and tradition of maintainingconfidentiality. Hence, some sharing of informationshould have been possible.

Family PhysiciansThere was no regular connection between Public Healthand family physicians during the outbreak. The role ofPublic Health in relation to physicians’ offices is notclear. Those contacted for this study indicated that theyhave no relationship with Public Health and received nocommunication from their local public health unit.Family physicians were unaware of the outbreak untilafter it had occurred and were unclear what precautionsshould be taken in their practices and unclear whoseresponsibility it was to provide them with suchinformation.

Family physicians were also largely unaware of HealthCanada infectious disease alerts. They did not knowwhose role it is to provide such alerts to family physicians.

Most family physicians reported learning of the outbreakinitially through the media. Formal communicationswith the SARS emergency infrastructure were non-existent.Initial communications (such as the location of SARSclinics) came from the media; subsequently, the OntarioMedical Association provided communications thatrespondents found useful and effective. Those activelyinvolved with a hospital received information and advicefrom the hospital. There was no direct communicationfrom Public Health to physicians’ offices.

Community Care Access CentresCCACs were not receiving any official infectious diseasecommunications from any source prior to the Torontooutbreak. Like others in the system, CCACs have nodirect relationship with Health Canada, although they domonitor Health Canada information for product alerts.It was unclear to CCACs whose role it is to alert themabout emerging infectious diseases or outbreaks.Respondents reported that Public Health and the CCACssometimes provided conflicting information to CCAC

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clients. These members of the public were accordinglyunclear if the CCACs or Public Health were the appropriatesource for information.

HospitalsNo hospital reported receiving infectious disease alertsfrom Health Canada or having a formal system in placeto receive or scan for such alerts. A number of hospitalsreported awareness of Health Canada product alerts andbulletins, but they had no formal link to Health Canada.Hospitals reported that they became aware of the TorontoSARS outbreak through the media and communicationsfrom the Public Health Branch of the OMHLTC. One CEOstated that in the UK public health is more integratedwith other elements of the health system. He had learnedthat in the UK, public health informed hospitals aboutthe emergence of a new respiratory illness from China inFebruary 2003, whereas in Toronto, hospitals did not knowabout SARS until the patients contracted the disease atThe Scarborough Hospital, Grace Division in March 2003.

Virtually all hospitals commented that throughout SARSI, it was not clear who was sending directives to thehospital. Early directives were unsigned. Later directiveswere signed by both the Commission of Public Health/Chief MOH and the Commissioner of Public Safety andSecurity. In either event, some hospitals were not initiallyclear how to get clarifications of the directives or raiseconcerns about them.

All hospitals commented on confusion arising from:

• receipt of information from different sources;

• conflicting information;

• frequent changes to information and directives;

• conflicts between directives and expertise andexperience of staff; and

• impracticality of directives in the hospital situation.

Administrators and staff at all levels expressed frustrationwith an inability to implement the directions received.The most common reasons for failing to implementdirectives were:

• unavailability of supplies identified in directives; and

• timing of receipt of directives (i.e., insufficient noticeto allow implementation).

A number of respondents felt that more input from thefront-line staff actually dealing with SARS patients mighthave improved the practicality of the directions from thePOC and the SOC.

Front-line respondents also commented on internalcommunications. They appreciated the effort made byinstitutions to communicate creatively by formal andinformal channels, but, consistent with comments inChapter 5 on risk communication, urged that spokes-people acknowledge ‘the unknowns’ rather than holdback information.

Many indicated that there is a need to strengthen therelationship and communication between public healthand hospitals. Although there is a statutory requirementthat representatives of the MOH sit on infection controlcommittees in hospitals, these individuals often lack astrong clinical background and may therefore have littleunderstanding of hospitals. As a result, they are unableto effectively liaise between the hospital and publichealth or provide useful advice to the hospital. Mosthospitals in particular felt that they had little access toregional public health officials. And when they did haveaccess, hospitals were concerned that public health staffmay not have the necessary knowledge, skills orexperience to provide appropriate advice to the hospitalsregarding infection control.

Exhibit 8.4 shows the responses from the hospital surveyregarding liaison with Public Health. While mosthospitals (89%) reported regular liaison with PublicHealth, in some instances the liaison appeared to be littlemore than the mandatory communication regardingreportable communicable diseases or having representativeson Infection Control Committees. Despite the statutoryrequirement, 35% of hospitals did not mention PublicHealth representation on committee structures whenasked to describe how they kept in contact with PublicHealth. These findings emphasize the need to ensurethat there is close liaison between local public healthunits and hospital infection control.

Also, hospitals and clinical leaders commented criticallyon the number of requests for information from PublicHealth regarding SARS patients. Hospitals reportedreceiving requests for information from more than oneregional health unit, the Public Health Branch of theOMHLTC as well as from the Ministry per se.

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8B.6 SurveillanceSurveillance emerged as another area of diffusedresponsibility. Local public health was geared towardsoutbreak containment; provincial Public Health did nottake on the role of the collection point for assemblingand facilitating the analysis of the cumulating data.There is no body with the jurisdiction at the overallsystem level to:

• accumulate and analyze information definitively orfacilitate such analysis by others;

• identify and communicate findings of the analysis ofpatterns of occurrence;

• identify and communicate alerts of unusual patterns;and

• develop contingency plans.

Although some public health units reported that theywere assisting hospitals with syndromic surveillance toidentify patients with SARS-like symptoms, hospitalsindicated that these cases were not confirmed by publichealth if an epidemiologic link to a confirmed case wasnot present. Some hospitals felt that the focus onepidemiologic links blunted their vigilance.

8B.7 Health Human Resources A number of hospitals identified insufficient numbers of specialized staff as a challenge in dealing with theoutbreak. The most commonly cited deficiencies wereinfectious disease specialists, infection control physiciansand hospital epidemiologists.

While 71% of acute care hospitals reported having accessto a physician trained for infection control, one quarterof these hospitals reported that the position was not paidand protected, leaving 46% of acute care hospitals withouta paid and protected infection control position. Only 1of 9 (11%) non-acute hospitals had a physician trainedfor infection control (this position is not paid andprotected). Collectively, the consultants' survey suggestedthat the Toronto and GTA hospitals have at most 7 FTEpaid and protected specialized infection control physicians(or 0.7 FTE positions per 1,000 acute care beds). This maybe an over-estimate based on the Committee’s own tally.The number of fully-trained hospital epidemiologists iseven lower.

These observations clearly reinforce findings from Chapter 7about the state of infection control human resources and theneed for action as regards accreditation standards or regional/ministry regulations to strengthen infection control.

Numerous individuals noted that the nature of thecollective agreements makes it virtually impossible tohave full-time employees of one institution work acrossmultiple organizations, unless each of the organizationsemploys the person directly. Sharing of staff in emergencycontravenes existing collective agreements. Front-linestaff and their organizations signaled a high degree ofdedication and a willingness to engage in planning foremergencies, along with dissatisfaction with ad hoc andpost hoc human resource practices during the SARSoutbreak.

Several hospitals identified that the high percentage ofnursing staff working part-time or casual hours throughagencies was a problem during SARS, a point echoed byfront-line focus groups. These types of employmentpractices provide a flexible workforce for the peaks andvalleys in demand inherent in hospitals, but result in staffbeing employees of several institutions simultaneously.Front-line workers highlighted the importance of a stableand permanent workforce, rather than reliance on morecostly agency personnel. Although a great deal ofpublicity centred around the potential increased risk ofinfection being transferred across organizations arisingfrom this practice, respondents were not aware of a single case of SARS transmitted from health care workers

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Hospital Hospitals Reporting Hospitals ReportingLocation Regular Liaison Public Health on(County) with Public Health Infection Control

Committee

Yes No Yes No

Durham 4 1 3 2

Halton 4 1 4 1

Peel 3 0 3 0

Toronto 20 1 13 8

York 2 1 1 2

Total 33 4 24 13

% Yes 89% 65%

E X H I B I T 8 . 4GTA and Toronto Hospital Survey Responses reRegular Liaison with Public Health

working in multiple institutions (in fact, it appears therewas only one such case). Restrictions on movement ofstaff during the outbreak may have mitigated thispotential problem. However, the challenge associatedwith such arrangements arises from:

• staff needing to be familiar with the different infectioncontrol policies and procedures of multiple organizations;

• difficulty engendering the level of commitment to an organization that is required to respond toemergencies; and

• difficulty for a hospital to secure additional shiftswhen employees have commitments to work atmultiple organizations.

There were various issues identified with compensationthroughout the SARS experience. Some hospitals reportedbeing ‘required’ to pay physicians additional stipends toinduce them to work with SARS patients. The OntarioMedical Association and the OMHLTC, working throughthe Physicians Services Committee, have developed twoprograms for physicians whose incomes were affected bySARS. These programs are the SARS Advance PaymentProgram and the SARS Income Stabilization Program.Details of these programs were made available tophysicians on the Ontario Medical Association website in a series of communications dated June 26, 2003.

In the SARS Advance Payment Program, physicians mayapply for advance payment against future billings toaddress current shortfalls in income due to service reduc-tions as a result of SARS. In this program, a physicianwhose income is less than 80% of average monthlybillings may receive payments to make up the differencebetween the earned amount and the threshold of 80% ofaverage billings. These advances will be deducted fromfuture payments. This program applies to the periodfrom March 14, 2003 to June 30, 2003.

The SARS Income Stabilization Program applies tophysicians whose incomes were reduced because ofquarantine, reductions in hospital operating capacity orreduced practice volumes in and/or outside the hospitalsetting. All physicians affected by SARS are eligible toreceive payments equivalent to the difference betweenthe amount earned and 80% of average annual billings.Physicians who worked in hospitals that were specificallytreating SARS patients are eligible for payment of thedifference between the amount earned and 100% ofaverage annual billings. Top up to 80% applies to theentire SARS emergency period. Top up to 100% appliesto the period from May 23, 2003 to June 30, 2003.

The SARS Alliance hospitals chose to provide double-timepay to those individuals working in SARS affected areas/SARS units. The OMHLTC did not sanction this action.It was heavily criticized from an equity perspective sinceother hospitals that treated SARS patients did not providethe same benefit to their staff. Further, staff were providedthe additional salary whether or not the SARS unit theyworked on actually treated SARS patients. As a result, insome cases staff treating SARS patients received no addedcompensation benefit, while others who did not treatSARS patients did receive additional compensation.

The lack of intensive care nursing professionals, and thecentralized response to this challenge, resulted in compen-sation practices that were also heavily criticized. A contractbetween the province and Med-Emerg was established toprovide critical care nursing staff to hospitals upon theirrequest. Respondents noted that the nurses employed byMed-Emerg were compensated at rates up to three timesthat of ‘regular’ hospital-based critical care nurses, causingequity concerns. Front-line representatives expressedconcern about both differential compensation and incon-sistent perquisites. Because of uneven pay scales, somehospitals felt compelled to offer their own staff the samepremium that the OMHLTC was paying to agency stafffrom Med-Emerg. Further, a number of hospitals reportedthat nurses who would otherwise have been regularlyavailable to the institution were recruited by Med-Emerg.Finally, hospitals reported limited flexibility in the staffingoffered by Med-Emerg; the hospital was unable to modifystaffing requirements and consequently, they sometimesfound themselves in the uncharacteristic position of havingtoo many staff. Despite these criticisms, as indicated inChapter 2, Med-Emerg was understood to have filledserious gaps in staffing in a very difficult period.

During the outbreak, nurses were restricted from workingin multiple institutions to control the risk of SARSmoving from one hospital to the next. This provisionserved to reduce the incomes of nurses who relied onincome from multiple organizations. Respondents notedthat the OMHLTC has not volunteered to compensatethese nurses in the same way that it has guaranteed theincomes of most physicians who work in hospitals.

These findings all highlight the need for regularizedprocesses for sharing and compensating staff duringemergencies.

Occupational health and safety concerns emerged clearlyfrom focus groups with front-line workers. Existingoccupational health and safety committees were notengaged; necessary equipment was sometimes unavailableor suboptimal, and some administrators liftedprecautions prematurely. The Committee understands

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that ambulance personnel and paramedics also hadserious concerns about protective equipment during theSARS outbreak.

8B.8 Psychosocial Implications of SARSMany respondents also discussed the significant psychosocialimplications of SARS and related stories that illustrated thepalpable fear among both health workers and the public.The impact of SARS on individuals working within thehealth system should not be underestimated. It included:

• people afraid to go to work in hospitals;

• people afraid to care for SARS patients;

• people afraid to associate with health care workers, oreven spouses of health care workers, particularly thosefrom SARS units;

• lingering resentment of colleagues who might nothave contributed what was expected;

• people feeling helpless, angry, and guilty; and

• people experiencing acute social isolation and ostracism.

Many who participated in the interviews and focusgroups suggested that the fear was engendered both bythe sensationalism of the media coverage andinconsistent information coming from the provincial andmunicipal public health officials. Front-line focus groupparticipants emphasized the need for formal crisiscommunications protocols suited to the unique needs ofeach institution and its staff (e.g., remote workers, shiftworkers). Much of the fear was simply a reasonablereaction to an unknown but extremely virulent disease.In spite of these fears, the focus groups yielded manyaccounts of heroic efforts of health workers to supporteach other and to ensure that all patients received thebest care possible.

8C. Services Impact and BacklogEstimates

All focus group participants and interviewees referred tothe impact of the SARS outbreak on hospital activityvolumes, and the challenges posed in attempting to clearbacklogs. Hospital activity data from 2002 and 2003were used to document the impact of SARS on the GTAand Toronto hospitals and to estimate the cost to thehospital system to clear the backlog.

The primary impacts on hospital service volumes werethe result of the directives to GTA and Toronto hospitalsat the end of March that required that they restrict accessto only critically ill patients. Because most surgical patients

are elective, this restriction had the greatest impact onsurgical volumes. The physical limitations on access tohospitals and the increasing public awareness of the risksof SARS in health care facilities meant that visits toemergency departments [ED] were also greatly reduced.

8C.1 Impacts on Emergency DepartmentVisit/Admission Volumes

Exhibit 8.5 shows the year-over-year percent change from2002 to 2003 in ED visits, by month and hospitallocation (GTA and Toronto).

During the first full month of the outbreak (April 2003)visits to the ED were 28% below the April 2002 levels forboth the Toronto and the GTA hospitals. After April, ED visits to the GTA hospitals recovered to levelsapproximately 15% below the prior year’s level. Visits tothe ED in Toronto hospitals increased slightly in May (to24% below the prior year), but fell to 31% below theprior year in June with SARS II. The hospitals assigned tothe SARS Alliance had a 50% reduction in their ED visitvolumes in June (after the Alliance had been established).

Exhibit 8.6 shows the overall changes in ED volumes byCanadian Triage Acuity Scale [CTAS] scores.

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-35

-30

-25

-20

-15

-10

-5

0March

-6% -6%

April May June Total

Care Hospitals, by Month

-28% -28%

-24%

-15%-16% -16%

-31%

-22%

Toronto Total

GTA Total

E X H I B I T 8 . 5Reduction in ED Visit Volumes in 2003, Compared to2002, for Toronto and GTA Acute Care Hospitals, byMonth

Overall, during the four-month period, the volumes ofED visits with CTAS score 1 (the most urgent cases)increased by 3% in the GTA hospitals and 12% in theToronto hospitals. The volumes of ED visits with CTASscore 5 (the least urgent cases) decreased by 35% in GTAhospitals and by 39% in Toronto hospitals.

As would be expected, the ED visit volumes fell the mostfor the visits that would most likely be considered to bedeferrable. There is no way to determine whether thesepatients who would normally attend and receive care in an ED received care elsewhere, e.g., in a familyphysician’s office or drop-in clinic, or went without care.Lack of access to OHIP physician service data precludedthis analysis.

For medical and mental health patients, the most commonroute of entry to the hospital is via the ED5. It would beexpected that the most critically ill patients, who requireadmission to hospital for definitive treatment, wouldcontinue to visit the ED and would continue to beadmitted as inpatients. Exhibit 8.7 shows that althoughthere was an 11.2% decrease in admissions via the ED inthe four months in 2003 compared to the same fourmonths in 2002, the decrease was exclusively due todecreases in admission of the least urgent patients.Admissions of CTAS 1 (resuscitation) patients increased by8% and admissions of CTAS 2 (emergent) patientsremained constant.

The reduction in admissions through the ED is progres-sively greater for the CTAS score 3, 4, and 5 visits. Thissuggests that the SARS outbreak and the restrictions onhospital services led to changes in inpatient admissionthresholds, and that patients who would have beenpreviously admitted were not admitted.

This study does not assess the impact of the reduction ofED visit volumes on the health of the population nor canit determine whether patients who would otherwise haveattended the ED were able to receive appropriate careelsewhere. The sustained reductions in ED visit volumesduring the outbreak suggest that the Toronto and GTAEDs have traditionally accommodated a large number ofambulatory care visits that might be handled by areformed primary care system, and that when disincentivesto visit the ED were introduced, these visit volumesdropped.

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-50

-40

-30

-20

-10

0

10

20CTAS 1

12%

3%

CTAS 2 CTAS 3 CTAS 4 CTAS 5 Total

-11%

-4%

-18%

-13%

-18%

-35%-28%

-39%

Toronto Total

GTA Total

-22%

-16%

E X H I B I T 8 . 6Reduction in ED Visit Volumes in 2003, Compared to2002, by CTAS Score, for Toronto and GTA Acute CareHospitals, by Month

-50

-40

-30

-20

-10

0

10

20CTAS 1

8.4%

CTAS 2 CTAS 3 CTAS 4 CTAS 5 Total

0.6%

-13.9%

-19.3%

-43.7%

-11.2%

E X H I B I T 8 . 7Reduction in Admissions of Patients via the ED in2003, Compared to 2002, by CTAS Score, for Torontoand GTA Acute Care Hospitals

5 In 2001/02 68% of medical admissions and 81% of mental health admissions for GTA and Toronto hospitals entered via the ED.

8C.2 Surgery VolumesThe hospital survey asked that hospitals report theirsurgical volumes (ambulatory procedures, inpatientelective cases, inpatient non-elective cases) for March,April, May, and June of 2002 and 2003. The analysespresented here compare 2003 volumes with 2002volumes for the four months.

Of all Toronto and GTA hospital ambulatory procedurecases, 98.2% are considered to be elective. When thedirectives to restrict activity to critically ill patients werepublished, ambulatory procedures and ambulatory clinicvisits would be the first services to be reduced or elimi-nated. Exhibit 8.8 shows the reduction in ambulatoryprocedure volumes from 2002 to 2003.

In April 2003, ambulatory procedure volumes dropped by56% in the GTA hospitals and by 70% in the Torontohospitals, compared to April 2002. In May 2003, GTAhospital ambulatory procedure volumes rebounded to alevel 3% above the prior year. Toronto hospital ambula-tory procedure volumes in May were only 7% below theprior year. SARS II appears to have had very limitedimpact on ambulatory procedure volumes, with the GTAhospitals only 1% below, and Toronto hospitals 5% below,the prior year. The majority of the ambulatory procedurebacklog was caused in April.

Exhibit 8.9 shows the impact of the SARS outbreak oninpatient elective surgery volumes in the Toronto andGTA hospitals. In April, the reductions in surgery weregreatest for the Toronto hospitals, but for both the GTAand Toronto hospitals, the percent reduction was not asgreat as it was for ambulatory procedures.

Although GTA inpatient elective surgery volumes for May showed a significant increase over April, they stayed13% below the level from the previous year. In June, thedrop in volumes for inpatient elective surgery for theGTA hospitals was even greater, at 21% below the prioryear. The Toronto hospitals followed a similar pattern,with inpatient elective surgery volumes 15% below theprior year in May, and then further below (24%) in June.

Thus, during the initial outbreak (in April), the drop inambulatory surgery activity was greater than the drop ininpatient elective surgery, whereas during May and June,ambulatory surgery volumes returned almost to normalwhile the volume of inpatient elective surgery remaineddepressed. One explanation is a lack of critical carecapacity in the hospitals, since complex inpatient electivecases (e.g., most cardiac surgery, most thoracic surgery,most neurosurgery, etc.) are more likely to require acritical care stay.

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-70

-60

-50

-40

-30

-20

-10

0

10March

-4% -4%


-56%

-70%

3%

-7% -5%

-23%

-1%

-16%

GTA Ambulatory Procedure

Toronto Ambulatory Procedure

E X H I B I T 8 . 8Reduction in Ambulatory Procedure Volumes from2002 to 2003 by Month and Hospital Location

-70

-60

-50

-40

-30

-20

-10

0

10March

0%

-4%


-37%

-57%

-13%-15%

-24% -26%-21% -18%

GTA Inpatient Elective

Toronto Inpatient Elective

E X H I B I T 8 . 9Reduction in Inpatient Elective Surgery Volumes from2002 to 2003 by Month and Hospital Location

The inpatient non-elective surgerypatients would be expected to fallinto the category of critically illpatients, who would be givenpriority with little reduction involumes caused by the activityrestrictions imposed as a result ofSARS. Non-elective surgeryvolumes for each of the fourmonths were generally within10% of the previous year’svolume. For the GTA hospitals,non-elective surgery volumes wereactually higher than the prior yearfor three of the four months (andonly 1% lower in May). For theToronto hospitals, non-electivesurgery volumes were higherduring SARS I, but lower duringSARS II. The higher non-electivesurgery volumes could be a resultof hospitals re-categorizingpatients from elective to non-elective, year-over-year growth involumes, or random variation.

8C.3 Patient Days andOccupancy

The OMHLTC provided daily census and bed numbers,by bed type, for GTA and Toronto hospitals for March,April, May, and June of 20036. Exhibit 8.10 shows thechange in occupancy of medical, surgical, and mental healthbeds from the beginning of March to the end of June.

The vertical bars on Exhibit 8.10 show the date that theCode Orange directive was published and the date thatthe SARS Alliance hospitals were assigned.

In early March 2003, medical bed occupancy averaged95%. High occupancy (over 90%) in medical beds isassociated with off-service placement of patients andmore frequent transfers of patients between services.This can present infection control challenges as patientsare moved from one unit to another, sometimestemporarily placed on units where the staff may beunfamiliar with their care requirements.

During SARS I, medical bed occupancy dropped to 80%.It recovered to almost 85% by mid-May, but droppedagain to 80% during SARS II.

In early March 2003, surgical bed occupancy was 88%,with a drop to 80% during the March school break. Itdropped from 85% just prior to the declaration of CodeOrange to 68% immediately following the declaration.From late April until the end of June, surgical bedoccupancy stayed between 75 and 80%.

Occupancy of mental health beds dropped from 80%prior to SARS I to 62% in mid-April. It rose to 75% bymid-May and stayed close to 75% until the end of June(when it dropped slightly to 73%). The drop in mentalhealth bed occupancy is surprising since most mentalhealth admissions (94.5%) are considered non-elective.This drop is likely related to the reduction in ED activity,since most mental health inpatients are admitted via theED. There was no way, with the available data, to assessthe impact of the reduction of mental health inpatientactivity on mental health patients (or potential patients).

The occupancy data show that the introduction of CodeOrange had the most immediate and greatest impact onsurgical beds. There was also a large occupancy reductionfor mental health beds, particularly in Toronto

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6 At the time that this report was prepared, not all Toronto and GTA hospitals had reported their occupancy data for June 2003. Only hospitals withcomplete data for all four months are included in the analyses. Data were missing for June 2003 for four acute care hospitals—Toronto East General,St. Joseph’s Health Centre, Sunnybrook and Women’s, and St. Michael’s Hospital (which was a SARS Alliance hospital).

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E X H I B I T 8 . 1 02003 GTA and Toronto Hospital Bed Occupancy for Medical, Surgical, and MentalHealth Beds by Week

community hospitals. Thereduction in occupancy for medicalbeds was not as rapid or as large.

Exhibit 8.11 shows that prior tothe establishment of the SARSAlliance the hospitals that wouldbecome Alliance members main-tained overall bed occupancy ratesbetter than the other hospitals.We speculate that this is becausetwo of the hospitals (St. Michael’sand Sir William Osler) had verylimited SARS volumes in SARS I,and the Scarborough General sitewould have taken on overloadfrom the closure of the Grace site.After the Alliance was established,overall bed occupancy in theAlliance hospitals dropped to 50%. However, this figure may besomewhat misleading. A majorcontributor to the drop in occupancy in SARS Alliancehospitals was the virtual closure of North York General Hospital.Furthermore, data from one of the four SARS Alliance hospitals,St. Michael's Hospital, were notavailable for analysis. At the sametime, the non-Alliance hospitalswere able to maintain an overalloccupancy rate of 85% duringSARS II.

Exhibit 8.12 shows that duringSARS II (and after the establish-ment of the SARS Alliance) theoverall hospital acute care bedoccupancy was approximately 80%,much lower than the above 90%rate in early March, but higherthan the 75% rate during SARS I.

The attempt to confine the impact ofSARS to the SARS Alliance hospitalsduring SARS II appears to haveinsulated the non-Alliance hospitalsfrom further large reductions inactivity, but the non-Alliancehospitals were still unable to returnto pre-SARS occupancy levels.

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E X H I B I T 8 . 1 12003 GTA and Toronto Hospital Overall Acute Care Bed Occupancy by HospitalSARS Alliance Status by Week

8C.4 Elective Surgery BacklogAs noted, most medical admissions to acute care hospitalsare non-elective and occur via the ED. The majority ofsurgical admissions are elective (as are almost all ambula-tory procedures). This analysis of the service backlog inToronto and GTA hospitals accordingly focuses on electivesurgery cases (both ambulatory and inpatient).

If Toronto and GTA elective surgery activity in March,April, May, and June 2003 had been equal to the activitylevels in the same months in 20027, then we estimatethat there would have been 6,641 additional inpatientcases and 17,828 additional ambulatory procedure cases.More than half of the inpatient elective surgery backlogoccurred in April 2003, during SARS I and Code Orange.The ambulatory procedure backlog was even moreconcentrated, with 85% occurring in April.

For purposes of calculating the cost to eliminate thisbacklog, we have assumed that all of the elective surgicalcases that could not be accommodated during the SARSoutbreak were deferred and will have to be accommo-dated some time in the future. It may not be necessaryto address the entire backlog since:

• some patients may no longer require surgery (havingopted for non-surgical treatment instead) or may nolonger be suitable candidates for the surgery;

• some patients may have sought and received theircare in hospitals outside Toronto and the GTA; and

• some physicians and patients may reassess theappropriateness of the planned surgery (given therestricted access), leading to removal of some patientsfrom the waiting lists.

Using the 2001/02 CIHI/Hay Group annual benchmarkingstudy data for Toronto and GTA hospitals, we establishedclinical program profiles for elective inpatient andambulatory procedure activity. By applying averagedirect cost per weighted case values to the weighted casedata, we estimated the direct cost of the deferred surgicalactivity to be $32.1 million.

The program areas with the estimated greatest backlog(in terms of cost) are:

• general surgery (including much of the cancer surgery,$6.3 million);

• orthopaedic surgery ($5.2 million); and

• cardio-thoracic ($5.2 million).

The analysis above is based on direct costs only. Someoverhead costs (excluded from the direct cost calculation)could be considered to be partially variable, or at leastaffected by changes in direct care volume (e.g., laundry,housekeeping, materials management). If 50% of overheadcosts were added to recognize variable overhead costs,the total estimate of the cost of deferrable surgical activitywould increase from $32.1 million to $37.9 million.However, as explained above, it is unlikely that the entirecalculated backlog will need to be cleared.

While this calculation focuses on deferred electivesurgical activity, there will be various other backlogs,such as deferred elective medical admissions and deferredambulatory diagnostic tests.

The OMHLTC has made $25 million available to hospitalsfor clearing deferred cases arising from the SARS outbreak.This funding will go some distance towards the estimatedcosts of the backlog, but not cover all estimated costs.

Funding will not be the only limiting factor on thecapacity of the Toronto and GTA hospitals to furtherincrease their activity levels to clear the backlogs. Otherpossible constraints include:

• hospital physical capacity (e.g., OR theatres, beds);

• staffing shortages (e.g., ICU nurses, respiratorytherapists); and

• impact on efficiency and productivity ofaccommodating the post-SARS “new normal” practicein Ontario hospitals.

In addition, if overtime payments are required to ensurethat staff is available to support the expanded activity,the unit costs per case will also be higher.

8D. RecommendationsA number of the issues raised by these interviews, focusgroups, surveys, and analyses have already been addressedin earlier chapters, viz. strengthening public healthinfrastructure, better F/P/T coordination, clarity aboutoutbreak management at a systems level, emergencypreparedness and response and its relationship to health

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7 We have assumed that without SARS, the 2003 activity levels would have been equal to the 2002 activity levels. This might not have been the casesince some hospitals facing funding constraints may have planned to reduce activity anyway in 2003, while others were planning for increasedactivity consistent with program expansions arising from Health Service Restructuring Commission directives.

emergencies, surveillance, systems of alerts, andcommunication challenges. However, additional issues,many specific to health care and local/regional publichealth, also emerged. The Committee’s members live,work, and pay taxes in several different provinces ofCanada. Several of us are active as administrators and/orpractitioners in the health field. As the tenor of theforegoing chapters has illustrated, we see our mandate asnational, aiming at building all levels of public healthcollaboratively. We therefore have no hesitation inoffering recommendations that bear on health care andlocal/provincial public health matters. Accordingly, theCommittee recommends that:

8.1 The CEOs of hospitals and health regions shouldensure that there is a formal Regional InfectiousDisease Network that can design and overseeimplementation of hospital strategies forresponding to outbreaks of infectious disease.These Networks should map out programs ofhospital surveillance for infectious diseases thatcross-link institutions and connect in turn to anational surveillance program so as to integratehospital and community-based information.

8.2 As part of its activities, the F/P/T Network forEmergency Preparedness and Response shouldexamine provincial and federal emergencymeasures with a view to ensuring that allemergency plans include a clear hierarchy ofresponse mechanisms ranging from the responseof a single ministry to a response from the entiregovernment, with appropriate cross-linkages.

8.3 Provincial/territorial ministries and departmentsof health should ensure that emergency plansinclude provisions for appropriatecompensation of those individuals required torespond to and those affected by the emergency.

8.4 Provincial/territorial ministries and departmentsof health should revise their statutes andregulations to require that every hospital orhealth region has formalized and updatedprotocols for outbreak management. Theseplans must include mechanisms for gettinginformation and supplies to those outside theinstitutional sector, such as primary carephysicians, ambulance personnel/paramedics,and community care providers.

8.5 The CEO of each hospital or health region shouldensure that each hospital’s protocol for outbreakmanagement incorporates an understanding ofthe hospital’s interrelationships with local andprovincial public health authorities.

8.6 The CEO and relevant clinical chiefs of eachhospital or health region should ensure thatthere is continuing education for hospital staff,particularly front-line health care workers, toenhance awareness of outbreak/infectiousdisease issues and institutional/clinicalinfection control.

8.7 Provincial/territorial ministries and departmentsof health should ensure that all key health leadersare trained in crisis communications. Hospitaland health region CEOs in turn should ensurethat clinical leaders and key administrators arealso trained in crisis communications and thatthe organization has a clear cut protocol forproviding all relevant information to staff andhearing their concerns in a timely, respectful,and participatory fashion.

8.8 Provincial/territorial ministries and departmentsof health should require through regulationand provide funding to ensure that emergencydepartments have the physical facilities to isolate,contain and manage incidents of infectiousdisease. Emergency departments should also beequipped with appropriate infostructure toenable their participation in infectious diseasesurveillance networks, including receipt of allnecessary national and international alerts.

8.9 Provincial/territorial ministries and departmentsof health should provide the necessary fundingfor renovation to achieve minimal facilitystandards for infection control in emergencydepartments.

8.10 Provincial/territorial ministries and departmentsof health should ensure that each hospital hassufficient negative pressure rooms for treat-ment of patients with infectious disease.

8.11 Provincial/territorial ministries and departmentsof health should ensure that, for emergencysituations, at least one hospital in each ‘region’of a province/territory has sufficient facilitiesand other infrastructure to serve as a regionalcentre to anchor the response to outbreaks ofinfectious disease.

8.12 Provincial/territorial ministries and departmentsof health should ensure that systems are devel-oped to ensure that providers and the publicreceive timely, accurate and consistent infor-mation and directives during an outbreak ofinfectious disease.

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8.13 Public health managers and facility/regionalhealth authority CEOs, in collaboration withrelevant unions, professional associations andindividuals, should create a process/mechanismto include front-line public health and healthcare workers in advance planning to preparefor related outbreaks of infectious diseases andother health emergencies. Occupationalhealth and safety issues should be givenprominence in this process.

8.14 Provincial/territorial ministries and departmentsof health should engage the Canadian Councilfor Health Services Accreditation to work withappropriate stakeholders to strengthen infectioncontrol standards, surveyor guidelines andtools that are applicable to emergency servicesas well as outbreak management within healthcare institutions. The standards should alsoinclude descriptors of the appropriate expertiserequired to maintain hospital infection control.

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SOME LEGAL AND ETHICAL ISSUES RAISED BY SARS AND INFECTIOUS DISEASES IN CANADA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The SARS outbreak and its aftermath have raised a numberof legal and ethical issues. We begin with legal issues, asthese are most germane to the Committee’s mandate. Anumber of provider groups, such as the CanadianHealthcare Association, the Canadian Medical Association,and the Canadian Pharmacists Association, raised theneed for specific legislative reforms. Indeed, the legalissues raised by SARS speak to the need for a thoroughreview of the broader constitutional and statutory frame-work governing infectious disease management in Canada.They include, among others: the efficacy of existingfederal and provincial legislation governing responses tocommunicable disease outbreaks; the legal relationshipsbetween local and provincial public health officials; theconstitutionality of mandatory isolation, quarantine, andtreatment orders under both federal and provincial law inlight of the Canadian Charter of Rights and Freedom’sguarantees for physical liberty and procedural fairness;workplace legislation and regulations as regards rights torefuse dangerous work and continuation of salary duringquarantine or isolation; and the legal frameworkgoverning health information privacy under the Charter,provincial privacy and health information statutes, andother legislation governing the health sector. Althoughall of these issues require eventual attention, we focushere on a narrower set of questions.

First, we revisit, following from discussion in Chapters 3and 4, some of the legal instruments available for thecreation of a national infrastructure for the detection andmanagement of infectious disease outbreaks. Second, adraft discussion document on federal legislation dealingwith national health surveillance (the Canada HealthProtection Act) has recently been circulated. We reviewthe impact of this proposed legislation, and the impact ofexisting federal legislation (the Privacy Act and the PersonalInformation Protection and Electronic Documents Act) andproposed federal legislation on the creation of a nationaldatabase for infectious disease surveillance and provider

reporting. Next, we review aspects of existing publichealth legislation in three provinces (British Columbia,Ontario and Quebec) that deal with infectious diseaseoutbreaks, and assess this legislation against the benchmarkof the US Centers for Disease Control and Prevention’s[CDC] Model State Emergency Health Powers Act. The last legal area for review is the matter of federalemergency legislation. The concluding section of thechapter returns to ethical issues and lessons learned fromthe SARS outbreak.

9A. General Legislative andGovernance Issues

9A.1 Legislation and Regulation asComponents of the National PublicHealth Infrastructure

In Chapter 4, we outlined the basic components of thepublic health infrastructure, indicating that an appropriatelegislative and regulatory framework was essential togiving Canada a stronger capacity for coordinating andmanaging a response to outbreaks such as SARS. Whatexist now are separate systems within each of the provincesand territories, as well as a federal system that operatesprimarily at Canada’s international borders. These systemsare connected by a limited number of intergovernmentalagreements, rather than through a systematic set ofintergovernmental agreements oriented around an agreedstrategic plan or through formal legal instruments thatenable the systems to operate collectively and detect andaddress common challenges.

In legal terms, we are speaking of the need for rules ofconduct (public health rules) that could guide thebehaviour of all actors in the public health system—health care providers (e.g., physicians, nurses), healthcare institutions (e.g., hospitals, laboratories), public

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health officials from all levels of government (federal,provincial and local), and private individuals potentiallysubject to quarantine and isolation orders. With respectto surveillance, examples include rules governing thefollowing: case identification (e.g., uniform criteria fordiagnosis and laboratory testing), data sharing (e.g., time-lines and procedures for reporting new cases and normsgoverning the protection of privacy), and informationdissemination (e.g., responsibility for communicating tonational and international audiences and the content ofsuch communications). National public health rules areparticularly important with respect to surveillance, becausethey facilitate the development of a real-time picture ofthe spread of infectious diseases at the national level.

Obviously, a national infrastructure also involves thecreation of new federal and F/P/T public health institutions.These have already been outlined in previous chapters.In each case, considerable effort is needed to determinehow these institutions will operate, and we have assumedin our budgetary thinking that this in itself will be anon-trivial albeit time-limited cost.

We reviewed in Chapter 4 the role of three policy instru-ments that operate on an interleaved basis—grants,contracts, and intergovernmental agreements.Given the critical nature of public health, and the needfor genuine consistency and clarity about who doeswhat, the Committee necessarily returns here to a fourthkey policy instrument—legislation and regulation.

Again in simplified legal terms, the federal Parliament ora provincial legislature may (a) enact rules, or (b) delegatethe power to make rules either to entities that are part ofgovernment (e.g., Cabinet, ministers of health) or arm’slength from government (e.g., the Canadian Agency forPublic Health, or the F/P/T Network for CommunicableDisease Control). Rules enacted by legislatures take theform of legislation, whereas rules enacted by an authorityexercising delegated powers take the form of regulations,by-laws, orders-in-council, etc. As an example, legislationcould set out processes and authority for establishing alist of reportable and notifiable diseases, and regulations orby-laws could specify the current list of relevant diseases.

The advantage of legislation is that it governs the conductof public officials and private institutions and individualswith or without their consent. But the limitation oflegislation is first, that a legislature can only enact legis-lation in areas where it has jurisdiction, and second, thatlegislation represents a visible use of power by governmentwith attendant political costs—particularly in a federationsuch as Canada where there have been tensions and

centripetal forces over many decades. As noted in earlierchapters, the constitutional division of responsibility isnot well-aligned with taxation authority in Canada, withthe result that successive federal governments have usedspending power instead of legislative authority in thehealth field.

Our recommendations thus far have followed this tradition.In effect, we are recommending that the federal govern-ment use grants as incentives for provinces, municipalitiesand health care providers to participate in a nationalinfrastructure and infostructure (e.g., setting data standardsregarding the timeliness and accuracy of information asconditions, agreeing to interoperability for outbreak surgecapacity, sharing laboratory resources, etc.), withoutseeking to establish its jurisdiction over public healthaspects of infectious disease management. This new flowof funds would be accompanied by structures to facilitatethe attainment of F/P/T consensus and the creation ofmultiple intergovernmental agreements on the parametersof a renewed and seamless public health infrastructure.However, the Committee sees a continuing issue ofgovernance and legislative authority that requiresmedium-term consideration.

9A.2 Governance Aspects In theory, public health norms could be set by the federalgovernment or by the new agency acting on the authorityof Parliament. The legislation establishing the agencycould set out a comprehensive set of public healthnorms, and/or delegate the enactment of public healthnorms to the Cabinet, the Minister of Health, or the newCanadian Agency for Public Health. The act wouldprevail over conflicting provincial public health legislation,unless challenged in the courts and struck down asunconstitutional.

An existing model for such an approach is the proposedAssisted Human Reproduction Act, Bill C-13. Bill C-13would criminalize certain conduct (e.g., human cloning).It also would permit certain “controlled activities” (e.g.,handling of sperm) to be performed only by licensedindividuals, and/or at licensed facilities, in accordancewith terms spelled out in regulations. The regulationswould lay down how “controlled activities” could takeplace, effectively regulating the work of health profes-sionals in connection with assisted human reproduction.Bill C-13 would also require licensees to report certainhealth information to a new federal agency, the AssistedHuman Reproduction Agency of Canada, which wouldmaintain a personal health information registry thatcould be used to administer and enforce the Act. Although

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there is provision in this scheme for provincial input,and for enforcement to be delegated to the provinces, theAgency would clearly be a federal agency.

A federal model would be the most efficient way to achievenational uniformity in national public health rules, buthas drawbacks that we have already indicated. Unless itsterms were closely aligned to the collaborative mecha-nisms set out elsewhere in this report, and unless it carriedwith it a funding mechanism, a federal model would runthe risk of imposing unfunded federal mandates, andspark substantial opposition from provinces. From a policystandpoint, federal uniformity may come at the expenseof provincial innovation and experimentation. Themeasures already set out in the Committee’s report shouldallow the federal government and its provincial/territorialpartners to stitch together existing uncoordinated local,provincial and federal public health systems into a nationalsystem, with attendant harmonization of existing provincialand local public health rules. A federally-imposed systemmight instead be viewed as a necessary last resort ifcollaborative and consensus-building mechanisms fail.

An alternative approach to creating system norms andrules would be for all levels of government to delegatepowers to some new steering group. In this instance,public health norms could be set either by federal,provincial and territorial governments acting collectively,or by the new Canadian Agency for Public Health. Local public health authorities would remain in place to implement national public health norms. A weakscheme of F/P/T cooperation to these ends is in place atpresent, but it is largely informal.

How could this scheme be effected? As indicated inChapter 4, the new agency would fund and facilitate the implementation of nationally-consistent norms aspart of the implementation of various initiatives throughthe Public Health Partnerships Program. New funds forthe National Immunization Strategy could flow to thesame effect.

The F/P/T Network for Communicable Disease Controlprovides another vehicle, one with joint governance tofacilitate urgent consensus-building in the realm ofdisease surveillance and outbreak management, wherefront line and provincial capacity is essential. It istheoretically possible but unlikely, that federal, provincialand territorial lawmakers would delegate powers to thenetwork, which could then regulate both provincial andlocal public health responses. On the other hand, sincethe governance structure for the new network is based onF/P/T co-decision, our expectation is that the networkwill facilitate a process of harmonization of public health

norms in federal, provincial and territorial legislation. In turn, that process could lead to legislative renewal and harmonization.

All these initiatives assume that provincial legislationwould remain in place, and would be modified as neces-sary to comply with either federal conditions or, ideally,an emerging F/P/T consensus. They assume that neitherHealth Canada nor the new Canadian federal agency haslegal authority to regulate provincial, territorial and localpublic health responses. And they assume, most impor-tantly, that SARS has brought all F/P/T governments to aunanimous view that public health matters should beseparated from other jurisdictional tensions, and regulatedcooperatively.

The Committee accepts that all of these endeavourscould be undermined if provinces and territories refuse toparticipate collaboratively. Hard decisions must be takenin the early days of the network, for example, as towhether the majority rules or whether a new norm mustbe adopted unanimously. As described in Chapter 5, anF/P/T process has been underway with respect to diseasesurveillance for many years, and has made only limitedprogress on a range of important issues. Accordingly,one might ask: What is the fall-back position if thesenew investments fail to secure progress?

In this regard, an obvious option is ‘federal default’.“Default” public health norms would be set by thefederal government, with advice from the new agency.Provincial rules would apply if they were “substantiallysimilar” or “equivalent” to the national public healthnorms, thereby permitting provincial innovation andexperimentation while ensuring national standards. Thefederal legislation would presumably include a list ofnotifiable diseases and terms for information sharing thatwould allow the federal government to meet its nationalas well as international obligations. Local public healthauthorities would remain in place to implement thenational norms. Examples of federal legislation that setout a federal default position that does not apply inprovinces with equivalent or substantially similar schemesinclude the Tobacco Act, the proposed Assisted HumanReproduction Act, the Personal Information Protection andElectronic Documents Act, and the Canadian EnvironmentalProtection Act. The effect of this model is to permitprovincial statutes to prevail over federal law in the eventof overlap—a reversal of the norm whereby federal lawprevails over provincial law in areas of overlapping jurisdiction. The courts have not considered theconstitutionality of these provisions.

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Federal default legislation charts a middle path that bothensures the creation of a national minimum and permitsprovincial variation. However, because the federallegislation would impose legal obligations on provincialand local public health officials, this strategy would stillengender provincial/territorial opposition unless sufficientprogress was made through the new funding mechanisms,strategies, and networks to permit the emergence of aconsensus on ‘template’ provincial legislation and associatedfederal responsibilities that would be encompassed in thefederal default provisions. On the other hand, ifinsufficient progress is made despite the investment ofhundreds of millions of dollars, we believe Canadianswould expect the federal government to get on with thetask of creating a clearer framework for its own role andthe corresponding default legislation for F/P/T interactions.

In all of this discussion, the question remains: Settingaside the various political and practical issues that havebeen given point above, does the federal governmenthave a constitutional basis for legislating in the publichealth sphere?

9B. Jurisdictional Issues9B.1 BackgroundAs noted in Chapter 3, the Canadian Constitution’s fewexplicit references to health-related matters grant bothlevels of government jurisdiction. The Constitutionconfers jurisdiction over “hospitals” and “asylums” onprovinces, and jurisdiction over “quarantine” and “marinehospitals” on the federal government. Since the goal ofthe drafters of the Constitution in 1867 was to create twolevels of government with non-overlapping areas ofjurisdiction, these provisions can be interpreted as dividingjurisdiction over public health, with the provincesgoverning local public health matters, and the federalgovernment attending to public health risks that arise atCanada’s international borders (hence the references toquarantine and marine hospitals).

Over time, court decisions have placed many aspects ofhealth care regulation within provincial jurisdiction. Thecourts have held that provinces possess jurisdiction overpublic health, including legislation for the prevention ofthe spread of communicable diseases, and sanitation.The provinces have exercised this jurisdiction to engagein health surveillance (including reporting and tracking),outbreak investigations, quarantine, isolation, andmandatory treatment. Moreover, the courts have grantedprovinces jurisdiction over a variety of related areas: drugaddiction (including legislation for involuntary treatment),mental health (including legislation for involuntary

committal), the medical profession (including the practiceof medicine), workplace health and safety, the regulationof foods for health reasons, the safety and security ofpatients, and hospitals. The Supreme Court has statedthat provinces enjoy jurisdiction over “health care in theprovince generally, including matters of cost and efficiency,the nature of the health care delivery system, and priva-tization of the provision of medical services,” as well as“hospital insurance and medicare programs.”

These areas of provincial jurisdiction are well-established.The central basis of provincial jurisdiction is the provincialpower to regulate “property and civil rights”. This powerhas been interpreted very broadly by the courts toencompass rights that individuals possess under thecommon law of tort (e.g., the right to bodily integrity,which is at issue in medical negligence, assault, andbattery), contract, and property. Any public health lawthat infringes upon these common law rights falls withinprovincial jurisdiction.

Despite the broad powers of the provinces to regulatepublic health, federal involvement has also been clearlysanctioned by the courts. Indeed, the Supreme Court hassaid that “subjects related to ‘health’ do not exclusivelycome within either federal or provincial competence,”and that “Parliament and the provincial legislatures mayboth validly legislate” with respect to health.

The firmest basis of federal jurisdiction over the manage-ment of infectious disease outbreaks is the federal powerover “Criminal Law” although a good argument forfederal jurisdiction can also be made on the basis of thefederal power to legislate for the “Peace, Order, and GoodGovernment” of Canada (the POGG power). To many,criminal law instruments—consisting traditionally of acriminal prohibition, police enforcement, prosecutionsbefore the courts, and criminal sanctions—would appearto be unsuitable for the information-gathering andtreatment goals that would underlie a national infra-structure for infectious disease surveillance. This harkensback to the eighteenth century concept of public healthpractitioners as the ‘medical police’, introduced inChapter 3! The POGG power, which has been interpretedto permit the federal government to address issues with“national dimensions”, appears to be a more appropriatevehicle for federal involvement. However, the impor-tance of the criminal law power relative to federal juris-diction is a function of Canada’s constitutional history.

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9B.2 Public Health and the Criminal Law Power

Although the Constitution assigns the federal governmentbroad powers, such as the POGG power and the power toregulate “trade and commerce”, most of these powerswere historically interpreted extremely narrowly by thecourts. By contrast, the federal criminal law power hasbeen interpreted very broadly, and as a direct consequence,became the constitutional basis for a wide variety offederal legislation. Thus, the federal criminal law poweris the constitutional basis for a wide range of statutesoutside the traditional criminal law context, includingthe former Combines Investigation Act, the Competition Act,the Canadian Environmental Protection Act, and healthlegislation such as the Food and Drugs Act, the HazardousProducts Act, the Tobacco Act, and Bill C-13, the proposedAssisted Human Reproduction Act. The response of theSupreme Court to the federal government’s extensive useof the criminal law power has been in many cases toextend its scope even further.

The focus of previous applications of the federal criminallaw power to health-related issues has been on productsthat pose a risk to human health. However, through thecriminal law power, Parliament has already regulatedthreats to human health posed by other individuals (e.g.,the Criminal Code prohibitions on assault and murder).By analogy, Parliament might govern individuals whojeopardize human well-being because they havecontracted an infectious disease.

The Supreme Court has stated that “[t]he scope of thefederal power to create criminal legislation with respect tohealth matters is broad,” and has laid down a three-parttest for determining whether a federal law falls withinthe scope of the federal criminal law power: (a) Does thelaw prohibit an activity? (b) Are there penal consequencesfor contravening that prohibition? and (c) Is the prohibi-tion motivated by a criminal law purpose?

Put another way, from a public policy standpoint, theprincipal limitation of the criminal law power is that itrequires the creation of criminal offences. Criminal lawoffences are usually part of the traditional model ofcriminal law regulation, which consists of (a) prohibitedconduct that is (b) clearly stated in statute, and (c) enforcedthrough ex post criminal prosecutions, (d) before thecriminal courts. This model is unsuitable for publichealth laws.

However, the Supreme Court has recently upheld underthe criminal law power statutes that tie criminal prohibi-tions to extensive regulatory regimes, in the firearms andenvironmental protection contexts. These schemes are afar cry from the traditional model of criminal law, and maybe designed to pre-empt the need for criminal prosecutions.An example of a criminal law statute regulating healthcare that contains an extensive regulatory regime is BillC-13, the proposed Assisted Human Reproduction Act(discussed in more detail above).

Public health legislation, of course, has different goalsthan the traditional concerns of the criminal law.However, to be a criminal law, a law must be enacted forone of the following reasons: “public peace, order,security, health or morality.” Public health laws areclearly enacted for a “health” purpose. Moreover, theSupreme Court has recently loosened up the test evenfurther, now only requiring the law to have been enactedto further “fundamental values”, a standard that a publichealth law would no doubt meet.

A potential advantage of predicating federal legislationon the criminal law power is that strictly intra-provincialactivity may be regulated. In contrast, the nationaldimensions branch of the POGG power (discussed below)enables federal legislation to regulate interprovincialactivity. The leading example here is the Criminal Codeitself, which of course governs crime within any singleprovince. The Food and Drugs Act and Bill C-13 alsoprohibit intra-provincial activity.

On the other hand, courts reviewing federal legislationwill examine if it is a disguised attempt by the federalgovernment to regulate areas of provincial jurisdiction(e.g., the practice of medicine). Thus, the legislationwould need to be crafted with a view to avoiding thoseareas where the federal government has no claim toconcurrent jurisdiction.

9B.3 Public Health and the POGG PowerTwo branches of the federal government’s Peace, Orderand Good Government [POGG] power are relevant topublic health and infectious diseases: (a) the “emergency”branch, which gives the federal Parliament jurisdiction to enact laws that would normally lie in provincialjurisdiction, on a temporary basis, in times of nationalcrisis; and (b) the “national dimensions” branch, whichgives the federal Parliament jurisdiction to enact laws inareas of concern to Canada as a whole.

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The emergency branch of the POGG power sets aside thedivision of powers during emergencies, conferring“command-and-control” authority on the federal govern-ment. It is applicable to public health, since the courtshave referred to epidemics and pestilence as health-relatedsituations in which it could be invoked, but the thresholdis very high, and therefore it has no applicability in mostsituations. More critically, the emergency branch of thePOGG power can only be exercised for the duration ofthe emergency. Thus, the emergency branch of thePOGG power could not serve as the constitutional basisof mandatory reporting for a national surveillance systemand other components of a national public healthinfrastructure.

The national dimensions branch of the POGG power hasintuitive appeal. It is what, in non-legal terms, mostinformants have invoked when speaking to the Committeeof the legislative imperative facing Canada in the publichealth sphere. This branch of the POGG power has beenused very infrequently by courts to uphold federallegislation, but holds potential as the basis for renewingfederal public health regulation, particularly with respectto infectious disease management. The test for thenational dimensions branch is (a) the area to be regulatedmust have a singleness, distinctiveness and indivisibilitythat clearly distinguishes it from matters of provincialconcern; and (b) the area to be regulated must have ascale of impact on provincial jurisdiction that isreconcilable with the division of powers.

The courts have articulated a number of principles ininterpreting the national dimensions branch of the POGGpower that bear on potential public health legislation.The Supreme Court has invoked the idea of “provincialinability” that, taken literally, suggests that the POGGpower permits the federal government to act where theprovinces cannot. But the better view is that the POGGpower permits the federal government to act alone inareas where provinces could conceivably legislate but areunwilling to do so. Two such situations are (a) inter-jurisdictional spillovers, and (b) federal-provincial collectiveaction problems. Each of these potentially applies toinfectious disease surveillance and outbreak management.A spillover is a situation where a province’s failure toadequately regulate an activity has negative effects inother provinces, in federal territories, or in other countries.According to the Supreme Court, the federal Parliamentcan legislate if “provincial failure to deal effectively withthe intra-provincial aspects of the matter could have anadverse effect on extra-provincial interests” (italics added).This requires little explanation in the context of SARS.

Collective action situations arise where (a) public policyproblems straddle the divide between federal and provincialjurisdiction, and require a coordinated federal-provincialresponse, and (b) the cooperative scheme would beineffective in every part of the country if one provincewere to decline to participate. Arguably, the ongoingfailure of the federal government and the provinces toagree on a system of national surveillance (discussed inChapter 5) is an example of just such a federal-provincialcollective action problem.

The key limitation of the national dimensions branch ofthe POGG power is the need for the area to be regulatedto be relatively narrow and confined, so as to not intrudetoo severely on provincial jurisdiction. This raises signifi-cant design issues for national public health legislation.

9B.4 The International ImperativeSARS has driven home the international dimension ofinfectious disease control and, in the view of theCommittee’s legal consultant, strengthens the constitu-tional case for a federal public health law under thenational dimensions branch of POGG: the SupremeCourt has held that where an international treatystipulates that a policy matter straddles the dividebetween provincial and federal jurisdiction, the case forfederal jurisdiction is much stronger. At present, inter-national public health treaties that address infectiousdisease management are narrow in scope. The WorldHealth Organization’s [WHO] International HealthRegulations impose a range of binding legal obligationson WHO member states to stem the international spreadof infectious disease.

These International Health Regulations were underrevision prior to SARS, and are being reviewed again inlight of this outbreak. Draft proposals have not beenreleased yet to the public. However, a WHO discussiondocument suggests that the revised International HealthRegulations require member states to operate a nationalsurveillance system:

Rapid identification of urgent national risks thatmay be public health emergencies of internationalconcern would require that each country have anational surveillance system that feeds data fromthe periphery to the central governments in a veryshort time. … Further, the system should be able toanalyse such data rapidly and facilitate quickdecisions.

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WHO’s emphasis on the importance of accurate andcomprehensive national data, collected on a real-timebasis without regard to provincial boundaries, wouldserve to strengthen the claim of federal jurisdiction inCanada. Moreover, in another document, WHO proposesthat the revised International Health Regulations laydown the following “minimum core requirements” fornational surveillance systems. Timely, accurate andcomplete data are of central importance:

Detection and reporting: Unusual and/or unexpecteddisease events or public health risks in all communitiesshall be detected and all available essential informationshall be immediately reported to the appropriate publichealth response level (e.g., emergency room, villagehealth care worker, etc.).

Response - the first public health response level:The first level shall have the capacity to verify the reportedevent or risk and to begin implementing preliminarycontrol measures immediately. Each event or risk shallbe assessed immediately and if found urgent all availableand essential information shall be immediately reportedto the designated national focal point.

Response - national/international level: All reportsof urgent events or risks shall be assessed at the nationallevel within 24 hours. If the event/risk is assessed asmeeting any of the following parameters for public healthemergencies of international concern, WHO must benotified immediately through the national focal point:

• A serious and unusual or unexpected event.

• A significant risk of international spread.

• A significant risk of international travel and/or trafficrestrictions on the free movement of persons,conveyances or trade goods.

WHO also stipulates that an additional design feature ofnational health surveillance systems should be a “singlecontact point” in a national health surveillance system tocommunicate information to WHO on a 24/7 basis. Thisinternational reporting structure would only reinforcethe need for a national infrastructure in which allinformation is collected at a single point. Again, thissupports the case for federal jurisdiction.

9B.5 Other Bases for Federal LegislationThe federal government enjoys jurisdiction over“Quarantine and the Establishment and Maintenance ofMarine Hospitals.” This power is the constitutional basisof the federal Quarantine Act. The scope of the power isunclear, as it has not been the subject of constitutionallitigation. Originally, it was thought to be limited tomaritime quarantine, given the juxtaposition of“quarantine” and “marine hospitals”. Although themeans for international travel have expanded, it is stillthought to be confined to quarantine at entry into andexit from Canada. New regulations under the QuarantineAct have already been issued in response to SARS (see alsoChapter 11). Whether this Act could be extended on thebasis of interprovincial travel is unknown.

The final basis for federal jurisdiction over public health isits power to regulate trade and commerce. This provisiongives the federal government the power to regulate inter-provincial and international economic activity, up to andincluding the prohibition of interprovincial trade. Subjectto the Charter, this might permit the federal governmentto ban the importation of items that carry infectiousdiseases (if diseases were carried by animals or produce,for example).

9B.6 The US AnalogueThe Committee asked the CDC to advise on whether ithad jurisdictional power to investigate an outbreak on itsown cognizance, or whether CDC involvement occurssecondary to a request for assistance by a state or territory.We also asked what powers the US federal governmenthas to become involved on its own cognizance, absent aninvitation from the affected state or states. The CDCresponded as follows:

“As a matter of policy, CDC generally requests state healthdepartment authorization to conduct activities withintheir borders. CDC requests this authorization whetherthe activity involves one state or several, whether CDCstaff presence is actual or ‘virtual’, and whether theinvitation to participate comes from within the state orfrom an outside agency or organization. This policy isbased upon the Constitutional relationship between thefederal and state governments. While states are reservedthe ‘police powers,’ i.e., the authority of all state govern-ments to enact laws and promote regulations to safeguardthe health, safety, and welfare of its citizens within itsborders, the federal government retains authority toregulate matters of interstate commerce.”1

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9B.7 Federal Legislation as DefaultThe early passage of a federal law that imposed unfundedobligations on the provinces and territories, or swept asideprovincial authority over public health matters, would runcounter to the collaborative framework that underpinsour recommendations. The Committee’s optimistic viewis that if health surveillance and outbreak managementwere left to health professionals working in Health Canadaand the provincial/territorial ministries of health, agree-ment would be reasonably rapid and comprehensive.Such issues can and should be insulated from the ebband flow of F/P/T relations through the creation of theCanadian Agency for Public Health and the F/P/TNetwork for Communicable Disease Control.

The need for federal legislation could be vitiated not onlyby the piecemeal assembly of a system of national rulesthrough mechanisms described, but by intergovernmentalinitiatives to upgrade and harmonize legislation. To thatend, we believe the federal government should embarkon a time-limited intergovernmental initiative with aview to renewal of the legislative framework for diseasesurveillance and outbreak management in Canada,ideally extending to broader health emergencies from thelatter as a starting point.

Only if these initiatives fail to produce a national systemof public health norms and rules would we recommendthat the federal government move towards legislationalong the lines of the ‘federal default’ provision set outabove. Our assumption is that many provinces will be inagreement with the thrust of these legislative reformsand the goal of creating a national system, and that thedefault legislation would therefore apply only to thoseprovinces that have not undertaken the necessarymodernization and harmonization.

Our hesitation arises not just from a deep-seated (andperhaps naïve) belief in collaborative fiscal federalism,but also from two other observations.

First, outbreaks are fought at the local level. SARS wasnot contained by Health Canada; it was contained bylocal public health agencies and health care institutions.With our vast geography and cultural heterogeneity,Canada cannot be managed as regards infectious diseaseslike Hong Kong or Singapore.

Thus, a federal law may be ineffective if general andmore harmful than helpful if unduly prescriptive.

Second, and as a corollary, we do not believe that thefederal government could commandeer provincial andmunicipal public health officials to administer a federalpublic health statute. Politically, the concept of comman-deering provincial and local public health officials todeliver federally-framed public policy without their consentstrikes at the very idea of federalism. Federal laws doconfer on provincial officials’ broad grants of discretion,and/or grants of discretion subject to express criteria, andthe Supreme Court has upheld federal laws employingboth approaches. Here, however, we are considering afederal public health statute that would impose duties on provincial and local public health officials (e.g., aduty to share disease surveillance information with theircounterparts in other provinces and with federalofficials). The most obvious example of a federal statuteimposing duties on provincial officials is the CriminalCode, which imposes an enormous number of such dutieson provincial officials, ranging from the police andCrown Attorneys all the way up to provincial AttorneysGeneral. Precedents for federal regulation imposingduties on provincial officials also exist outside theCriminal Code. In past provincial challenges to theconstitutionality of federal laws, the imposition of dutieson provincial officials was not itself an issue. Thus, thisissue has not been squarely addressed by the SupremeCourt. The overwhelming majority of arrangements forco-administration or co-management, however, havebeen established on a consensual basis, on the groundthat provincial governments are not subordinate to thefederal government.

9C. Existing and ProposedFederal Legislation

9C.1 The Proposed Canada HealthProtection Act

Health Canada recently released proposals for a newCanada Health Protection Act. Health protection iscurrently governed by eleven federal statutes. HealthCanada has deemed the existing scheme unsatisfactoryon several grounds. The process of legislative revisionhas been underway since 1998. Public consultations willcommence this Fall, ending at the earliest in December2003, and may potentially extend until March 2004.Based on these consultations, Health Canada will draftlegislation that will be ready for public distribution in2005, at which point it would proceed through thelegislative process.

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The goal of the revision is to repeal and replace fourstatutes—the Food and Drugs Act, the Hazardous ProductsAct, the Quarantine Act, and the Radiation Emitting Devices Act—with a single statute, the Canada HealthProtection Act.

The discussion document sets out procedures to deal withcommunicable diseases in relation to persons entering andexiting Canada, as well as relevant safeguards to ensurecompliance with the Charter of Rights and Freedoms.Given the federal government’s constitutional authorityover interprovincial travel, the discussion documentsuggests that the provisions governing quarantine wouldalso be applicable to movement across provincial andterritorial boundaries in Canada, albeit with some modifi-cations. However, the document does not advance anyfurther claims to federal jurisdiction on this basis.

The discussion document also suggests that the CanadaHealth Protection Act “could articulate a role for thefederal government to work with other public authoritiesinside and outside Canada to ensure a national frameworkfor coordinated public health-related surveillance.” Morespecifically, Health Canada could, “in cooperation withother interested parties,” create a national healthsurveillance system. Health surveillance and researchactivities would include:

• developing, supporting and participating in nationaland international networks;

• promoting the use of standard techniques, analyticaltools, models, definitions and protocols;

• ensuring surveillance of health events which includeseveral jurisdictions;

• initiating programs to respond to emerging or priorityissues;

• establishing, maintaining and operating informationexchange systems; and

• undertaking national surveys.

The Act would authorize the Minister of Health to enterinto agreements with provinces regarding these matters,including agreements regarding the delegation ofenforcement powers to provincial officials.

Thus, the discussion document leaves intra-provincialpublic health regulation to existing provincial publichealth systems. The creation of a national infrastructurewould be on a negotiated and cooperative basis, withintergovernmental relationships being governed by

federal-provincial agreements. These agreements wouldbe formal documents spelling out the terms of cooperation,which would be accessible to the public, and whosecontents could be prescribed by legislation.

The measures suggested in the proposed Canada HealthProtection Act to both formalize and make more trans-parent the intergovernmental approach to nationalsurveillance are commendable. In particular, the provisionfor enforcement agreements between the federal andprovincial governments would be a positive development.They are consistent with, and provide legal authority for,mechanisms such as those recommended in this report.Unfortunately, the document makes reference to neitheran agency nor a network of the type proposed inChapters 4 and 5. At the very least, the agency optionmight be given prominence for reasons already outlined.

9C.2 Federal Privacy Legislation andPublic Health

Any national system of health surveillance would entailthe collection of vast amounts of personal healthinformation. As a consequence, it would potentiallytrigger the operation of privacy legislation governingboth the private and public sectors.

PIPEDA: The Personal Information Privacy andElectronic Documents Act (PIPEDA) is a new law thatregulates the collection, use and disclosure of “personalinformation” by a range of non-governmental entities,including corporations, associations, partnerships, tradeunions, and private individuals. It is not clear where andhow PIPEDA applies to health care providers. To the extentthat PIPEDA does apply, provisions in the law appeardesigned to safeguard provider reporting obligationsunder federal and provincial law. However, PIPEDA maystill impede surveillance because of its tight restrictionson the non-consensual collection of information. Weelaborate below.

PIPEDA began to come into force on January 1, 2001,and currently only applies to the federally-regulatedprivate sector (airlines, banking, broadcasting, etc.), aswell as to interprovincial information transfers (e.g.,communication of personal health information to privateinsurers from providers) and international informationtransfers. But it will apply to all entities that fall withinits scope on January 1, 2004.

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The basic rule of PIPEDA is the need for an individual toconsent to the collection, use, and disclosure of her/hispersonal information. The principal target of PIPEDA isprivate enterprise. However, PIPEDA has generatedcontroversy in the health sector because its definition ofpersonal information includes “personal health infor-mation”, which it defines as follows:

(a) information concerning the physical or mentalhealth of the individual;

(b) information concerning any health service providedto the individual;

(c) information concerning the donation by theindividual of any body part or any bodily substanceof the individual or information derived from thetesting or examination of a body part or bodilysubstance of the individual;

(d) information that is collected in the course ofproviding health services to the individual; or

(e) information that is collected incidentally to theprovision of health services to the individual.

This extremely broad definition of health informationcovers any health information about an individual,however that information is acquired. Other informationacquired incidentally in the provision of health services—e.g., an individual’s name, address, or health cardnumber—would also be covered.

If PIPEDA applies to the non-profit health sector, itpotentially places into question the legality of a widevariety of existing or potential information-sharingpractices. The Canadian Healthcare Association, forexample, has argued that it might make difficult themeasuring of outcomes and quality of care. The CanadianPharmacists Association has suggested that PIPEDA couldimpede providers from submitting insurance claims onbehalf of patients. Stakeholders have also suggested thatthe consent requirement could impede communicationbetween members of a health care team treating a patient(Canadian Medical Association) or among differentproviders (Ontario Ministry of Health and Long-TermCare). The Canadian Institutes of Health Research hasraised concerns that certain of PIPEDA’s provisions wouldimpose too onerous a burden on researchers.

These concerns suggest that PIPEDA was not drafted withsufficient attention to the particular issues facing thehealth sector. The Government of Canada has not clearlyaddressed these concerns in recent months—a situationthat has done little to build confidence in the ability ofthe federal government to legislate prudently in the

public health field. Major stakeholders have called forlegislation that would apply to the health sector insteadof PIPEDA, or regulations to PIPEDA to clarify its appli-cation to the health sector. These concerns are urgent,because the Act will soon be fully in force.

To these concerns we add the fact that PIPEDA may impedeprovider reporting in a system of infectious diseasesurveillance. These obstacles could arise not only withrespect to any new reporting obligations imposed byfederal legislation, but also in connection with existingreporting obligations under provincial legislation.

A fuller treatment of these issues can be found in thereport prepared for the Committee by Prof. Choudhry.Three points suffice here. First, providers may be partlyinsulated by the fact that PIPEDA focuses on commercialactivity, and the information at issue must be collected,used, or disclosed “in the course of” such activity.However, non-profit providers that enter into commercialcontracts involving the transfer of personal health infor-mation (e.g., hospitals contracting with investor-ownedlaboratories and pharmacies) might trigger the operationof PIPEDA with respect to those relationships. Second, it appears that the form of the consent required underPIPEDA may vary, with sensitive information requiringexpress consent. PIPEDA specifically refers to “medicalrecords” as sensitive information. Third, PIPEDA doesallow for non-consensual disclosure if the disclosure isrequested “for the purposes of enforcing any law ofCanada, a province or a foreign jurisdiction” or “for thepurpose of administering any law of Canada or a province.”These exceptions would likely extend to reportingrequirements under provincial or federal public healthlegislation provided those laws impose a reportingobligation. Non-consensual disclosure is also permitted“because of an emergency that threatens the life, healthor security of an individual.” This could apply toinfectious disease reporting in an outbreak, but not inordinary disease surveillance.

If a reporting obligation under existing provincial lawconflicts with PIPEDA, PIPEDA would prevail. A provincecannot “opt out” of PIPEDA unless the federal governmentconcludes that it has enacted legislation that is “substan-tially similar” to PIPEDA. Because PIPEDA is not yet fullyin force in the provinces, the question of how the federalgovernment will approach the issue of whether provinciallaws are substantially similar has not yet been considered.However, the Privacy Commissioner has interpreted“substantially similar” to mean that provincial legislationmust provide protection for privacy that is “equal orsuperior” to that provided in PIPEDA.

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In conclusion, PIPEDA could raise significant difficultiesfor collection of information for disease surveillancepurposes under public health legislation, particularlyunder provincial legislation, and its impact on providerreporting of infectious diseases requires clarification.

Privacy Act and the proposed Canada HealthProtection Act. Once health information is passed onto a new federal agency, or the federal government, itmight become subject to the federal Privacy Act or theproposed privacy measures set out in the Canada HealthProtection Act draft discussion document.

Identifiable personal health information is informationthat identifies an individual or can reasonably be expected(through data linking) to identify him/her. This informa-tion is at issue in infectious disease surveillance. Theproposed Canada Health Protection Act would grantHealth Canada the power to collect identifiable personalhealth information. A national system of infectiousdisease surveillance centred either on Health Canada oran independent agency would similarly require alegislative basis for the collection of identifiable personalhealth information.

The proposed Canada Health Protection Act usefully setsout the principles that should govern the collection anduse of identifiable information. Informed consent is thepresumptive norm based on disclosure of the purposesfor which the information is being collected. The non-consensual collection, use and disclosure of identifiablepersonal health information are subject to necessity riders.They are permitted if, and only if, (a) such non-consensualuse is necessary in order to promote a legitimate publichealth objective, (b) the objective cannot be achievedwith non-identifiable personal health information, and(c) the public interest in public health outweighs anyharm to the particular individual(s) concerned. Thecollection, use and disclosure of identifiable personalhealth information must infringe upon privacy intereststo the least extent required to achieve the public healthobjective. This proportionality principle has severaldimensions: collecting or disclosing as little identifyinginformation as is required in order to achieve the publichealth objective; conversion to de-identified data as soonas possible and limiting access to identifiable personalhealth information; prohibiting the use of identifiablepersonal health information to make decisions about anindividual in other contexts (e.g., with respect todisability benefits, income tax credits, etc.); and takingprecautions by those to whom Health Canada disclosesinformation to prevent improper use or further disclosurefor an unauthorized purpose.

The Privacy Act now in force does not fully satisfy theseprinciples. As noted in Chapter 4, a new federal agencyfor public health would be subject to the Act if so desig-nated through regulation. The consent provisions areweaker than those envisaged in the new act, and there isno specific test of necessity for the collection, use, ordisclosure of personal information. Non-consensualdisclosure is permitted “for the purpose for which theinformation was obtained …or for use consistent withthat purpose,” or “for any purpose in accordance with anyAct of Parliament or any regulation.” Thus, the importanceof the objective, the necessity of using identifiableinformation, and the weighing of the benefits obtainedagainst the damage done to the individual are neitheridentified nor considered. The Privacy Act does notimpose any legal obligation to use those measures whichare the least invasive of privacy, such as de-identification,access on a need-to-know basis, etc.

The proposed Canada Health Protection Act discussiondocument also speaks to the issue of communication ofidentifiable personal health information between differentgovernments. It suggests that Health Canada may collectand use such information provided to it by other govern-ments without an individual’s consent, when that infor-mation is provided by another government “performinga public health function”, and if that other governmentwas authorized by law to receive the information withoutconsent in the first place. Non-consensual disclosure by Health Canada to other governments or publicinstitutions would be permitted in a narrower range ofcircumstances—i.e., when consent would be impracti-cable or would defeat the legislative objective, and thepublic health interest would outweigh any prejudice tothe individual.

The proposed federal act accordingly is contingent insome respects on the provincial laws surrounding privacyand health information. Inconsistencies in provinciallegislation, in turn, will lead to variability in what iscommunicated to the federal government. It is thesetypes of concerns that led the Advisory Council onHealth Infostructure to call in its Final Report (1999) forthe harmonization of provincial and federal privacylegislation.

9C.3 Summary Two key pieces of federal privacy legislation fall on eitherside of a divide. One is too sweeping and restrictive,while the other does not conform to protective principlesthat have been articulated in the proposed CanadaHealth Protection Act. Federal privacy legislation mustbe amended to properly accommodate a national system

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of infectious disease surveillance. It is not clear if PIPEDAapplies to health care providers. To the extent thatPIPEDA does apply, it threatens to undermine providerreporting obligations under federal and provincial law,because of its tight restrictions on the non-consensualcollection of information. The impediments posed byPIPEDA to federal reporting obligations could be easilyhandled through appropriate statutory language. However,if applicable, PIPEDA would prevail over provincialpublic health statutes. Moreover, provinces do not havethe ability to “opt out”. The potential difficulties posedby PIPEDA to public health and disease surveillance arepart of a larger set of concerns regarding PIPEDA’sapplication to the health sector. PIPEDA’s application tothe health sector requires an urgent review, culminatingeither in separate federal health information privacylegislation, or amendments to PIPEDA.

On the other hand, the non-consensual collection, useand disclosure of identifiable personal health informationby the federal government, or by federally-created agencies,should comply with the principles of necessity andproportionality. The Privacy Act falls short of thoseprinciples. The proposed Canada Health Protection Actwould comply with those principles, except with respectto the treatment of data communicated to the federalgovernment by the provinces where the inconsistenciesin provincial privacy legislation lead to concerns.

On both counts, then, as Canada moves to implement astronger national system of disease surveillance, federallegislation dealing with health information privacy mustbe reviewed and either amended or its applicabilityclarified.

9D. Provincial Legislation onInfectious Disease Outbreaks

9D.1 Background A large number of statutes and regulations set out thelegal framework within which provincial public officials,health care professionals, and private individuals operateto manage disease outbreaks. In the wake of SARS, onequestion that must be asked is whether this legal frame-work provides public health officials with the tools totackle infectious disease outbreaks, while at the sametime respecting the rights to privacy and physical libertyof persons subject to public health legislation.

A recent report prepared for Health Canada entitled “ACompendium of the Canadian Legislative Framework forthe Declaration and Management of Infectious Diseases”collects and summarizes the relevant provisions undervarious provincial laws. The Committee asked Prof.Choudhry to measure the public health legislation ofBritish Columbia, Ontario and Quebec against the CDC’sModel State Emergency Health Powers Act. Although theModel Act may itself contain deficiencies, it was apotential benchmark and springboard for analysis.

9D.2 The Model State Emergency HealthPowers Act

The CDC recently released a Model State EmergencyHealth Powers Act that provides a template for statelegislatures to use in modernizing and updating theirpublic health legislation. The Model Act was formulatedas part of a broader attempt to examine public healthinfrastructure in the United States in the wake of theterrorist attacks of September 11, 2001. Even prior toSeptember 11, a leading academic study had concludedthat state public health laws were badly in need of revision,because they did not reflect contemporary understandingsof disease surveillance, prevention and response; did notaccord sufficient weight to individual privacy and liberty;were often fragmented (with multiple laws in place withinstates applying different norms to different diseases); anddid not require planning in advance of public healthemergencies (including mechanisms for communicationand coordination within and between states, and theclear allocation of responsibilities).

The legal consultant’s review focused on provisions inthe Model Act dealing with disease reporting andinformation sharing with other jurisdictions. Therelevant provisions are summarized below.

• Who Must Report: The Model Act imposes reportingobligations on “health care providers”, which includesboth institutions (hospitals, medical clinics andoffices, special care facilities, medical laboratories) andpersons (physicians, pharmacists, dentists, physicianassistants, nurse practitioners, registered and othernurses, paramedics, emergency medical or laboratorytechnicians, and ambulance and emergency medicalworkers) that provide health care services. Thedefinition is non-exhaustive—i.e., it could apply toother individuals and institutions not listed in theModel Act who provide health care services. Coronersand medical examiners also owe reporting obligations.

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• Triggering Event For Report: Reporting must take placein “all cases of persons who harbor any illness orhealth condition that may be potential causes of apublic health emergency.” The Model Act does notrequire that the person suffer from the illness, andtherefore may include persons who have merely beenexposed to or infected with an illness. However, theModel Act does require that the person actuallyharbor the illness; a “reasonable suspicion” or theprospect that the person “may” harbor the illness donot appear to be sufficient.

• Reportable Diseases: The reporting obligation extendsto “any illness or health condition that may bepotential causes of a public health emergency.”Reportable diseases include, but are not limited to, alist of biotoxins issued by the US federal government,and any illnesses or health conditions designated bystate public health authorities. A public healthemergency—a key concept in the Model Act—isdefined as follows:

an occurrence or imminent threat of an illness orhealth condition that:

(1) is believed to be caused by any of the following:(i) bioterrorism; (N.B.: bioterrorism is also

defined);(ii) the appearance of a novel or previously

controlled or eradicated infectious agent orbiological toxin;

(iii) a natural disaster;(iv) a chemical attack or accidental release; or(v) a nuclear attack or accident; and

(2) poses a high probability of any of the followingharms:(i) a large number of deaths in the affected

population;(ii) a large number of serious or long-term

disabilities in the affected population; or(iii) widespread exposure to an infectious or

toxic agent that poses a significant risk ofsubstantial harm to a large number ofpeople in the affected population.

• When Report Must Be Made: The report must be madewithin 24 hours.

• To Whom Report Must Be Made: The report must bemade to “the public health authority”, which is thestate public health authority or any local publichealth authority.

• What Information Must be Reported: The report mustinclude: the specific illness or condition; the name,date of birth, sex, race, occupation, and home andwork addresses of the patient; the name and addressof the person making the report, and any otherinformation required to locate the patient for follow-up.

• Information Sharing with Other Jurisdictions: The ModelAct requires a state public authority to notify federalauthorities if it “learns of a case of a reportable illness orhealth condition, an unusual cluster, or a suspiciousevent that may be the cause of a public healthemergency.” The scope of the information that isshared is limited by a test of necessity—that is, it mustbe “information necessary for the treatment, control,investigation and prevention of a public healthemergency.”

9D.3 Initial Assessment of ProvincialLaws in light of the Model Act

We review below the differences observed between theModel Act and the public health laws of British Columbia,Ontario, and Quebec.

Who must report: The Model Act imposes reportingobligations on a wide range of individuals andinstitutions within the health sector. Legislation inBritish Columbia, Ontario and Quebec generally followsthis pattern, albeit through slightly different means.Ontario’s legislation is most similar to the Model Act, inthat it exhaustively enumerates who is under a reportingobligation. British Columbia, by contrast, imposes aduty on “any person”. While this latter provision hasthe benefit of flexibility and adaptability to an ever-changing landscape of institutional and individualproviders, it comes at the expense of clarity andaccountability. Quebec’s law (which was recentlyenacted) raises a different sort of concern—the onlyhealth professionals with reporting obligations arephysicians. Nurses and other health professionals whomight be the first to identify a case of infection appear toowe no reporting obligation. As well, hospitaladministrators do not appear to be under a duty toreport, notwithstanding their overall responsibility forthe institutions which they manage.

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Triggering Event: The triggering event for the reportingobligation under the Model Act is that a person “harbor”an illness, which includes persons who have been infectedwith and who suffer from the illness. In British Columbia,only physicians are obliged to report cases of infection;other reporting obligations apply if an individual issuffering from or has died from a communicable disease.It would appear that other health care providers need notreport instances of infection. Similarly, in Ontario, onlyphysicians and hospital administrators appear to be underan obligation to report instances of infection. Laboratoriesmight be required to report instances of infection,depending on the information yielded by a test. Quebec’sbroad language, requiring reporting in the case of asuspicion “of a threat to the health of the population”would presumably extend to infections.

List of Reportable Diseases: The Model Act is written againstthe backdrop of September 11, 2001 and, as a consequence,is focused on public health emergencies, particularlythose arising from bioterrorism. In this respect, it is nota good model for a general purpose public health statute.British Columbia, Ontario and Quebec appear to requirethe reporting of largely similar diseases vis-à-vis oneanother. One problem is that triggering events are some-times undefined. For example, in Ontario a “communicabledisease outbreak” is undefined, as is a “disease outbreakor occurrence” in British Columbia. Although the lack ofdefinition promotes flexibility, the lack of clear definitionmight lead to over- or under-reporting.

When Report Must Be Made: The Model Act requires reportingwithin 24 hours, presumably because of its focus onemergent biological threats. Within British Columbia,there are specific reporting obligations ranging from 24 hours to 7 days. Quebec has a uniform, province-wide standard of 48 hours. Ontario and Quebec both useimprecise language, such as “as soon as possible” and“promptly”, which impedes clarity and accountability.

To Whom Report Must be Made: The Model Act requires thatall reports be made to the state public health authority,to facilitate data centralization. The overwhelmingmajority of reporting obligations in British Columbia,Ontario and Quebec require information to be sent tothe medical officer of health (British Columbia, Ontario)or the public health director (Quebec). As a consequence,public health laws in these provinces also facilitate datacentralization.

What Information Must be Reported: All three provincialacts provide reasonably detailed delineation of whatmust be reported.

Duty to Share Information with Other Jurisdictions: TheModel Act requires that federal officials be notified in theevent of a public health emergency. Although provinciallaws govern non-emergency situations, they nonethelessshould contain some obligation on the part of provincialofficials to report information to their provincial andfederal counterparts. According to the informationcontained in “A Compendium of the Canadian LegislativeFramework for the Declaration and Management ofInfectious Diseases,” no such obligations exist. This doesnot mean that such communications do not occur inpractice.

In conclusion, provincial public health laws measure upreasonably well against the CDC state template. Somevariation is probably attributable to the emergent focusof the Model Act. However, some standardization across provinces with respect to timelines and legalobligations to share data with federal and provincialcounterparts should be considered in the context of theintergovernmental review of public health legislationrecommended above.

9E. Federal Health EmergenciesChapter 5 alluded to the federal Emergency PreparednessAct (R.S. 1985, c. 6 (4th Supp.)) proclaimed in 1988. That legislation delineates wide-ranging obligations onministers to ensure that their departments take action to“develop policies and programs for achieving an appro-priate state of national civil preparedness for emergencies.”It also specifies a responsibility for liaison with provincesand a coordinating role for the federal government. Itsdesign dovetails with the federal Emergencies Act (R.S. 1985,c. 22 (4th Supp.) that received assent in 1989 and replacedthe problematic War Measures Act.

The Emergencies Act describes various categories of emer-gencies. The most salient is the subcategory of publicwelfare emergency that includes “an emergency that iscaused by a real or imminent...disease in human beings,animals or plants...that results or may result in a dangerto life or property, social disruption or a breakdown inthe flow of essential goods, services or resources, so seriousas to be a national emergency.” It defines a “nationalemergency”, in turn, as “an urgent and critical situation …that seriously endangers the lives, health or safety ofCanadians and is of such proportions as to exceed thecapacity or authority of a province to deal with it.”

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The federal government’s effectiveness in coordinatinghealth emergencies on a national basis is arguablycompromised by the lack of specific legislation. During atruly national health emergency, Health Canada has twovastly different options for asserting a ‘command-and-control’ function necessary for a national response.Officials refer to these with some frustration as ‘thesledgehammer’ and the ‘tackhammer’. The former option,implementation of the Emergencies Act, can only beinvoked if a high threshold is crossed as noted above.The Emergencies Act confers very wide powers on thefederal government and has not been invoked since itspassage. The latter option essentially involves “requesting”collaboration from public health partners.

The Canadian Medical Association has argued in a detailedsubmission that emergency managers require a publichealth legislative platform that lies between these twoextremes and facilitates a coordinated response at all levelsof government for public health emergencies. Theypropose a specific ‘Health Emergencies Act’ with gradedincreases in federal responsibility and jurisdiction as thescope and scale of an emergency spreads. Based on theirbrief and a confidential technical document, the Committeeinfers that the proposal involves provincial/territorialconsultation at every stage and provincial/territorial consentfor a claim of jurisdiction only for lower level healthemergencies. The Committee agrees with some informantswho have suggested that the threshold for non-consensualfederal jurisdiction in the Canadian Medical Associationscheme should be shifted ‘upwards’, but this modificationdoes not invalidate the underlying concept.

As the level of government uniquely charged withprotecting the national interest, the federal governmenthas the strongest legitimacy to act alone when aninfectious disease outbreak potentially has interprovincialand/or international dimensions. Moreover, it enjoys acomparative institutional advantage in regulating matterswith an interprovincial or international dimension.Conversely, provincial public health officials enjoy thegreatest legitimacy in responding to outbreaks that arelargely local in impact. A graded approach to federalintervention would complement, rather than replace,existing provincial, territorial and municipal publichealth structures, helping again to stitch them togetherinto a national system.

Earlier in this chapter, we signaled our discomfort withthe idea that a federally-appointed public health officialcould commandeer provincial/territorial and local publichealth officials for matters such as disease surveillance.However, in a public health emergency, where suchpowers would be exercised only temporarily and thenonly after an assessment that the gravity of the situationposed a clear danger to the health of Canadians thatcould not otherwise be managed, the basis for thoseobjections is blunted.

As currently proposed, the Canada Health Protection Actdoes not include any discussion of health emergencies.In part, this is because the proposed act adheres to afairly narrow understanding of federal jurisdiction, i.e., jurisdiction over international and interprovincialmovement of persons, whereas public health emergenciesmight encompass a broader range of circumstances. The Canadian Medical Association proposal allows formovement into provincial jurisdiction by the federalgovernment in the event of a truly grave emergency. Theconstitutional basis for federal emergencies legislationwould be the emergency branch of the POGG powers.

The Committee believes that the Canadian MedicalAssociation proposal has merit and recommends that, aspart of the legislative renewal process already underway,two steps be taken. First, the intergovernmental initiativein public health legislation should consider extant emer-gency legislation in the light of public health emergencieswith a view to harmonization as appropriate acrossprovinces and territories. Second, consideration shouldbe given to a federal health emergencies act to be activatedin lockstep with provincial emergency acts in the eventof a pan-Canadian health emergency. We leave to therelevant experts whether this falls under the proposedCanada Health Protection Act, under legislation toestablish the new Canadian Agency for Public Health,both, or a separate legislative initiative.

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9F. Ethical Issues and Lessonsfrom the SARS Outbreak

The SARS outbreak posed a number of ethical challenges.Decision makers were required to balance individualfreedoms against the common good, fear for personalsafety against the duty to treat the sick, and economiclosses against the need to contain the spread of a deadlydisease. Decisions were often made with limitedinformation and under short deadlines.

A working group of the University of Toronto Joint Centrefor Bioethics undertook to draw the ethical lessons fromthe challenges of and responses to SARS in Toronto2.The working group identified five general categories ofethical issues arising from the SARS experience:

• Public health versus civil liberties: There are timeswhen the interests of protecting public health overridesome individual rights, such as the freedom of move-ment. In public health, this takes its most extremeform with involuntary commitment to quarantine.

• Privacy of information and the public’s need to know:While the individual has a right to privacy, the statemay temporarily suspend this privacy right in case ofserious public health risks, when revealing privatemedical information would help protect public health.

• Duty of care: Health care professionals have a duty tocare for the sick while minimizing the possibility oftransmitting diseases to the uninfected. Institutionsin turn have a reciprocal duty to support and protecthealth care workers to help them cope with thesituation, and to recognize their contributions.

• The problem of collateral damage: Restrictions on entryto SARS-affected hospitals meant that people weredenied medical care, sometimes for severe illnesses.There were also restrictions on visits to patients inSARS-affected hospitals. Decision makers faced dutiesof equity and proportionality in making decisions thatweighed the potential harm from these restrictionsagainst benefits from containment of the spread ofSARS through rapid and definitive intervention.

• Global interdependence: SARS underlines theincreasing risk of emerging diseases and their rapidspread. It points to a duty to strengthen the globalhealth system in the interests of all nations.

The Joint Centre working group suggests that an ethicalframework be developed that would address the fiveissues noted above, and that would ensure that Canada isbetter prepared to deal with future health crises involvinghighly contagious diseases.

Four of these points bear brief elaboration.

Civil Liberties: During both SARS outbreaks, health carepractitioners, patients and families were asked to placethemselves under ten-day quarantines in their homes inorder to reduce the risk of exposure of an infectiousdisease to the community. Other strategies used duringSARS were widespread availability of disposable masks,self-surveillance and work-home quarantine (i.e., limitingcontacts to those necessary for duties in the health caresetting), and restrictions on assembly of groups. Althoughthe Health Protection and Promotion Act3 gives officials thepower to force non-compliant individuals into quarantine,this was used only once during the outbreak.

Applying the principle of reciprocity, society has a dutyto provide support and other alternatives to those whoserights have been infringed under quarantine. Intriguingly,after returning from quarantines, some health carepractitioners reported feeling disconnected from thecurrent state of the organization4. Focus groups withfront-line workers also revealed that some in quarantinewished to continue participating in the battle againstSARS by contacting patients and families to providesupport and answer questions, or by helping withcontact tracing.

Privacy: Disease reporting during an outbreak carries therisk of a breach of confidentiality. Boundaries of privacyvary from person to person. Some believe that there is arisk of privacy infringement only if confidentiality is notmaintained and a social stigma or loss of employmentensues from the breach. The other view is that a privacyinfringement is wrong regardless of whether any harmoccurs as a result5. In either event, under the ethical valueof proportionality, officials must use the least intrusivemethod to obtain their goal. Legislation such as the HealthProtection and Promotion Act prohibits the release ofpersonal information except in very specific circumstanceswhere there is a public good to be served or added protectionobtained by releasing an individual’s name.

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During SARS, Toronto Public Health named only twonames—that of the deceased index case for Toronto andher deceased son, and this was done with the informedconsent of the surviving family members, based on theirunderstanding that this extraordinary step was necessaryfor the protection of public health. An unknown numberof people had attended a funeral visitation at the homeof the deceased index case, and public health authoritieshad no way of contacting these people individually toadvise them that they had been exposed and to watch forsymptoms and remain in isolation for ten days. Most ofthe remaining family members were already hospitalizedand too ill to provide sufficient detail. Two probable SARScases identified themselves to Toronto Public Health as adirect result of this announcement. Both were healthcare workers who could have spread the virus furtherwith disastrous results. These details illustrate the knife-edge on which these decisions rest.

Duty of care: Health care providers constantly weighedserious health risks to themselves and their families againsttheir obligation to care for patients with SARS. A substantialpercentage of the probable SARS cases involved front-lineproviders. Nurses and physicians were at particular risk.Overall, it appears that 168 people or about 40% of thoseinfected were health care workers. The Canadian MedicalAssociation Code of Ethics calls on physicians to“consider first the well-being of the patient6,” while theCanadian Nurses Association Code of Ethics for nursingstipulates that “nurses must provide care first andforemost toward the health and well-being of the person,family or community in their care7.” Other health careprofessions in Canada have considered or adopted similarcodes. SARS has taught us, however, that this ethicalduty must be balanced by a countervailing duty: not toplace others at risk by coming to work while ill andpotentially contagious. What remains unclear are thelimits to this duty: What is the point at which the duty ofcare is balanced by a right to refuse dangerous tasks?How is the duty of care modified by the occupationalcircumstances and professional obligations of differenthealth care workers?

Just as health care practitioners have a duty to care for thesick, health care organizations clearly have a reciprocalduty to support and protect their workers. This meantproviding the necessary safety equipment and appropriateeducation regarding the use of such equipment, providinginformation on risks and the need for precautionarymeasures and ensuring a safe working environment.Notwithstanding the enormous efforts that many insti-tutions made with respect to internal communicationand safeguards for health care workers, serious tensionsarose with respect to occupational health and safety.

Many of these were avoidable, as they arose fromdirectives around N95 masks and fit-testing which wereeither more stringent or interpreted more stringently,than necessary. Health care organizations did offer avariety of psychological supports to their staff, but manyof these measures were instituted after SARS, rather thanduring the outbreak itself. What also emerged veryclearly was that health care workers under siege in anemergency such as SARS greatly valued and deservedstrong support from community and political leaders aswell as co-workers and administrators.

Collateral effects: The ethical trade-offs posed by thecollateral effects of caring for SARS patients were numerous.For example, the Catholic Health Association of Canadanoted in its submission the serious impact on manypatients, friends, and families from restricted visitinghours. Decision making was particularly challenging incritical care units8. The principle of equity required thatdecision makers balance controlling the spread of thedisease on the one hand, and the rights of non-infectedpatients to access medical care, particularly urgentservices on the other. The enormous human toll of thedisruption to the system lies just beneath the statistics inChapter 8. Countervailing this impact is the very reallikelihood that the uncontained spread of SARS couldhave killed thousands. Such trade-offs make it verydifficult to apply any ethical Procrustean bed inhindsight to the decisions made. However, an ethicalframework of some type may be useful for future decision makers.

To this list the Committee would add two other issues.

First, the Canadian Association of Medical Microbiologistshas noted the ethical challenges that arose in undertakingresearch during the SARS outbreak. Issues arose that cutacross individual institutions and agencies, necessitatingunprecedented coordination of expedited ethical reviews ofresearch protocols and outbreak investigation proposals.

Second, scientific credit and collaboration also poseethical challenges during an outbreak. For example,while many academic clinicians were fighting the SARSoutbreak in Toronto, research scientists were testing thesamples that were flooding the National MicrobiologyLaboratory in Winnipeg. They collaborated with theBritish Columbia Centre for Disease Control andgenomics experts salaried by the British Columbia CancerAgency to sequence the Toronto strain of the coronavirus.The University of British Columbia subsequentlypurchased a full-page advertisement during the outbreakto claim credit for the discovery. We thus had thesituation where some academics were fighting a battle for

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all of Canada against a new infectious agent, and otherswere consumed with offering scientific advice to bringthe outbreak under control, while others capitalizedbrilliantly on the availability of specimens and data tothe benefit of all, winning scientific kudos in the process.How does one apportion a fair distribution of scientificcredit in these difficult circumstances? Guidelines areneeded to facilitate collaborative research and researchpublications during infectious disease outbreaks,particularly in a relatively small academic communitysuch as that which exists in Canada.

A related ethical issue that arose from SARS is the seekingof patents on the SARS-associated coronavirus. Researchersin the United States, Canada and Hong Kong9 have appliedfor patents on the coronavirus and its gene sequence.The US CDC and the British Columbia Cancer Agencypublicly acknowledged taking this course of action toensure that the virus and the sequence remain in the publicdomain (it is important to note that the sequences werepublished in Science magazine in early May, 2003)10. A news item in the June 20, 2003 edition of The Lancetreported that the US National Institute of Allergy andInfectious Diseases is making a SARS genome “chip”available to researchers around the world, free of charge,in an effort to spur research. The “chip” contains the29,700 DNA base pairs of the SARS coronavirus designedfrom data from institutes in the US, Canada, and Asiathat had sequenced the complete SARS coronavirusgenome.

While this is a positive development, the patenting oforganisms and genes such as SARS remains an issue andhas raised myriad concerns11,12. The current patentsystem in Canada was not designed to address questionsof DNA patenting and the commercialization of thehuman genome. Generally, raw products of nature arenot patentable. However, a patent may be granted to theentire process of discovering and isolating, in thelaboratory, strings of DNA that were not obvious before,rather than to a gene as it exists in nature. In order topatent a gene, a sequence or other similar material, theinventor must modify or identify the novel geneticsequences. The product of the sequence must be modifiedand the function in nature must be explained. Thesematters have been given point in Canada by the narrowdecision (5-4) of the Supreme Court, in December 2002,to reject the patent of the Harvard ‘Onco-mouse’, notbecause of any primary principled objection to the concept,but because extant Canadian patent legislation did notcontemplate such a claim. Patents had previously beengranted in Canada for unicellular organisms; thus, there

is ample precedent in Canada for patenting the genomeof a virus. However, the ramifications of these practicesare important, particularly where public funding or publichealth issues are concerned. This issue falls outside theCommittee’s mandate, but underscores the continuinguncertainty and concerns from a number of quartersabout the patenting of organisms and genes in general.The Committee urges continued vigilance and debateconcerning the application of the Patent Act and thecorresponding frameworks surrounding the patent processto the unique challenges of patenting micro-organismsand other living entities.

9G. RecommendationsIn light of the foregoing issues, the Committeerecommends that:

9.1 The Government of Canada should embark on atime-limited intergovernmental initiative witha view to renewing the legislative frameworkfor disease surveillance and outbreak manage-ment in Canada, as well as harmonizing emer-gency legislation as it bears on public healthemergencies.

9.2 In the event that a coordinated system of rulesfor infectious disease surveillance and outbreakmanagement cannot be established by thecombined effects of the F/P/T Network forCommunicable Disease Control, the Public HealthPartnerships Program, and the above-referencedintergovernmental legislative review, theGovernment of Canada should initiate thedrafting of default legislation to set up such asystem of rules, clarifying F/P/T interactions asregards public health matters with specificreference to infectious diseases.

9.3 As part of Health Canada’s legislative renewalprocess currently underway, the Government of Canada should consider incorporating inlegislation a mechanism for dealing withhealth emergencies which would be activatedin lockstep with provincial emergency acts inthe event of a pan-Canadian health emergency.

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9.4 The Government of Canada should launch anurgent and comprehensive review of theapplication of the Protection of InformationPrivacy and Electronic Documents Act to thehealth sector, with a view to setting outregulations that would clarify the applicabilityof this new law to the health sector, and/orcreating new privacy legislation specific tohealth matters.

9.5 The Government of Canada should launch acomprehensive review of the treatment ofpersonal health information under the PrivacyAct, with a view to setting out regulations orlegislation specific to the health sector.

9.6 The Canadian Agency for Public Health shouldcreate a Public Health Ethics Working Group todevelop an ethical framework to guide publichealth systems and health care organizationsduring emergency public health situations suchas infectious disease outbreaks. In addition tothe usual ethical issues, the Working Groupshould develop guidelines for collaboration andco-authorship with fair apportioning of author-ship and related credit to academic participantsin outbreak investigation and related research,and develop templates for expedited ethics reviewsof applied research protocols in the face of out-breaks and similar public health emergencies.

9.7 F/P/T departments/ministries of health shouldfacilitate a dialogue with health care workers,their unions/associations, professionalregulatory bodies, experts in employment lawand ethics, and other pertinent governmentdepartments/ministries concerning duties ofcare toward persons with contagious illnessesand countervailing rights to refuse dangerousduties in health care settings.

REFERENCES1. Personal communication: Morris GD. Centers for

Disease Control and Prevention’s Public HealthInfrastructure. Prepared August 2003.

2. Singer P, Benatar SR, Bernstein M, Daar AS, DickensBM, MacRae SK, Upshur REG, Wright L, Shaul RZ,“Ethics and SARS: Learning Lessons from the TorontoExperience,” June 18, 2003, submitted to NationalAdvisory Committee on SARS & Public Health. Seehttp://www.utoronto.ca/jcb/SARS_workingpaper.asp

3. R.S.O. 1990, c. H-7.

4. Maunder R., et al, “The immediate psychological andoccupational impact of the 2003 SARS outbreak in ateaching hospital,” Canadian Medical AssociationJournal, 2003: 168:1245-1251.

5. Kass N., “An Ethics Framework for Public Health,”Public Health Matters, 2001: 91(11):1776-1782.

6. Canadian Medical Association, Code of Conduct(www.cma.ca).

7. Canadian Nurses Association, Code of Conduct, page 10(www.cna-nurses.ca/pages/ethics/ethicframe.htm).

8. Bernstein M, Hawryluck, L., “Challenging beliefs andethical concepts: the collateral damage of SARS,”Critical Care, 2003: 7: 269-271.

9. Gold, Richard, “SARS genome patent: symptom ordisease?,” The Lancet, 2003: 361(9374) 2002-2003.

10. Stagg-Elliott, Victoria, “SARS spurs race for a cure—and for patents, AMNEWs, May 26, 2003.

11. Ibid.

12. Ministry of Health and Long-Term Care, Governmentof Ontario, Canada, “Ontario Report to Premiers:Genetics, Testing & Gene Patenting: Charting NewTerritory in Healthcare,” January 2002.

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EMERGING INFECTIOUS DISEASE RESEARCH IN CANADA – Lessons from SARS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The Canadian experience with SARS reminds us that theinvestigation of an epidemic is research—research conductedat a feverish pace. Chapter 5 outlined how the researchconducted during an outbreak is essential to effectiveresponse measures and ultimate control of the epidemic.Unfortunately, with a few notable exceptions, Canadiangovernments and public health institutions did not heedthe warnings of the 1994 Lac Tremblant declaration andbuild the necessary research capacity for emerginginfectious diseases. Research and evaluative capacity inpublic health more generally was not sustained duringthe budget roll-backs of the 1990s, as deficit-cuttingreductions in federal transfers limited provincial andmunicipal spending.

A more fundamental problem, however, is one of cultureand commitment. Quebec’s National Institute of PublicHealth and the British Columbia Centre for DiseaseControl [BC CDC] have supported research, and HealthCanada’s realignment in 2000 provided tangible supportfor in-house science capacity. However, the Committeeperceives that public health agencies and governmentshave often regarded research capacity as academic,irrelevant, and discretionary rather than the core publichealth function that it is. F/P/T governments have signifi-cantly increased health research funding across Canadain recent years, but the absolute levels of investmenthave favoured either investigator-initiated fundamentalresearch or R&D activities that are amenable to short-termeconomic pay-offs through private partnerships. TheCommittee strongly supports ongoing and greater invest-ments in “curiosity-driven” research; as discussed below,critical capacity for epidemiologic investigation andoutbreak response is built in part by nurturing the relatedand fundamental science. Similarly, we recognize thatthe private sector is not only a major investor in researchbut plays the key role in commercializing beneficialdiscoveries made with public sector support. However,

these types of investments are not aligned with theunique modalities of research and evaluation that areembedded in core public health functions.

A related challenge is the profoundly multidisciplinarynature of effective research targeting an outbreak orepidemic. Many disciplines are needed: e.g., epidemiology,biostatistics, mathematics, medical microbiology, clinicalmedicine, laboratory science, health systems research,social sciences, and health policy. All must be engagedfor the response to be optimally effective. For example,our review of the SARS outbreak in Canada has alreadyillustrated how the ability to do etiologic or diagnosticresearch requires good epidemiologic and clinical dataalong with laboratory research capacity. A shortfall inone dimension cannot be covered by strength in another.

The need to value and support a research culture inpublic health arises from more than its positive impacton our ability to understand and control outbreaks ofinfectious disease; our standing in research affects howother nations see Canada and its public health system.Science—a system for solving problems and addressingunknowns—is the organizing principle for outbreakmanagement and epidemic response. If other nations loseconfidence in the scientific capacity and leadership inour public health system, it can have a lasting negativeeffect on how other countries choose to interact withCanada, be it through tourism, trade, academic and culturalexchanges, or through multilateral bodies such as theWorld Health Organization [WHO]. Last, beyond researchand evaluation focused on infectious diseases, publichealth must have a strong scientific foundation and acapacity for critical self-evaluation through generationand application of evidence-based programming.

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10A. Emerging Infectious DiseaseResearch: A First Look at theCanadian Record on SARS

Experience with other emerging infectious diseases—HIV,Hepatitis C and West Nile virus, to name but three—haslong since highlighted deficiencies in how Canadianresearch is organized to respond to emergency situationsand significant new infectious disease threats. Manyexperts believe that a slow and poorly-coordinated researchresponse had an adverse effect on Canada’s measures tocontrol HIV and Hepatitis C, with resulting adverseimpacts on the health of Canadians and enormous directand indirect costs. With West Nile virus, we have not as yet been able to generate a clear epidemiologic pictureof the extent of the problem in humans and the severityof health risks involved. The seasonal nature of thedisease means that research capacity must be poised andready to respond as cases appear. Our current levels andmodes of organizing and funding public health researchmake this difficult.

Earlier chapters have already indicated that the researchresponse to SARS in Canada was uneven: some aspectswere performed well; others were not. Research into thecause of SARS, the characterization of the agent, thedevelopment of diagnostic tests, and generation of initialclinical descriptions were all conducted and communicatedrelatively rapidly. Research on the immune responsewith the goal of developing a SARS coronavirus vaccinehas progressed well. On the other hand, research onmany fundamental epidemiologic aspects of SARS,including research on the spectrum of disease and suchquestions as the duration of viral shedding and theperiod of infectivity, has lacked cohesion. Even now weremain unable to address many of these questions. As adeveloped country with an acclaimed health care system,Canada has no excuse for its inability to develop anepidemiologic analysis of SARS. The Canadian performance,as already indicated in Chapter 2, contrasts sharply withHong Kong. Scientists in Hong Kong were able toproduce seminal epidemiologic and clinical descriptionswhile responding to a larger epidemic than Canada faced.Our incapacity arose in part from previously-identifiedissues of leadership, coordination, data collection andmanagement, data sharing, and weak mechanisms to linkepidemiologic and clinical to laboratory data. It alsoreflects lack of research capacity and advanced planning.

The Canadian research response to SARS as of earlyAugust is summarized in Table 1. The issues listed undereach type of research are a non-exhaustive summary ofthe research questions that needed answers. At first

glance, the performance appears reasonable. However,these research activities arguably address only a minimaland essential set of issues. Our preparedness for the nextrespiratory virus season, when SARS could reappearinsidiously amidst thousands of Canadians with coughand fever of a more benign nature, would be enhancedby garnering answers to many other questions.

In Table 2, the Canadian performance is compared to theinternational research response. Again, this assessmentwas compiled to the end of July 2003. Although othervaluable publications have since appeared, this is a contextwhere timeliness of research is critical. The numbers ofpublications and the impact factor of publications aredetailed. The impact factor is one measure, albeitdecidedly imperfect, of the uptake of scientific publications.It tallies how often on average papers are cited whenpublished in the journal in question. High-quality andmore topical papers tend to be published in higher-impactjournals, such as Science, Nature, the Journal of the AmericanMedical Association, the New England Journal of Medicine,The Lancet, and the British Medical Journal. AlthoughCanada has contributed 20% of the published worldliterature on SARS, many of these publications are injournals with low impact—they have limited influenceon thinking and global knowledge. In addition, there isdouble counting of reports that were published simulta-neously in the Canada Diseases Weekly Report and theUS Morbidity and Mortality Weekly Report. Overall, theimpact of Canadian research ranked ahead only of China,notwithstanding the fact the indexing services do not listChinese language publications and they were accordinglyassigned an arbitrary weight approximating zero.

The weakness in some areas may speak to the importanceof interdisciplinary linkages as highlighted earlier. Wenoted, for example, that the performance in some aspectsof diagnostic work was undercut by weaknesses incollecting epidemiologic and clinical data and integratingthese data with laboratory work. The weak performancein research on pathogenesis may be a result of Canada’sfailure to develop a large cadre of clinician scientists, thefact that some clinician-scientists who had a directopportunity to study SARS were utterly consumed withmanaging clinical aspects of the outbreak, and inadequatelinkages between clinicians and basic scientists. We turnnext to a brief comparison of the research response toSARS with what could or should have been done.

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Type of research Issues Addressed Canadian Enabling or Limiting FactorsPerformance*

Emergent Research

Epidemiology and • Incubation period ++public health • Attack rates ++

• Routes of transmission +++• Mortality rates ++• Infection control issues +++• Effectiveness of quarantine, +

travel advisories, passenger screening

Etiologic and • Identification of causative agent. +++Diagnostic • Most appropriate specimens +

source and timing.• Sensitivity, specificity of +

different diagnostic tests

Clinical • Spectrum of disease ++• Clinical manifestations +++• Therapy of disease +• Long term sequelae +

Pathogenesis • Mechanisms of disease causation ++• Animal models +++• Genetics of susceptibility to disease ++

Virology • Basic biology –• Genome sequencing +++• Protein characterization +++

Immunobiology • Correlates of protective immunity ++ These studies are underway.• Vaccine development ++

Post Event Research

Health Systems • Cost effectiveness of interventions +Research • Unintended consequences +

of interventions• General Health Economics +

Social and economic • Individual impacts of the epidemic +and interventions.

• Behavioural research +• Societal impacts of the epidemic +

and interventions

Policy • Lessons learned ++ These are currently in progress.• Public health implications ++

* +++ Indicates Canadian scientists completed research on the issue, which has been communicated scientifically as well as publicly. For mostsub-categories of emergent research, this would be considered an adequate or better response.

++ Indicates research work is in progress.+ Indicates research projects are being planned.– Indicates no current work in progress or that there is no longer the ability to do the work.

T A B L E 1A Preliminary Summary of the Canadian Research response to SARS as of early August 2003

Problems in data management and sharing, as well as poor linkage of laboratory andepidemiologic data, limited and are still limitingour ability to do these types of studies.

Work was complicated by changing casedefinitions, changing classification of cases andlimited integration of clinical and epidemiologicdata with laboratory data.

An initial clinical descriptive paper waspublished, plus an analysis of critically illpatients; but little work on other aspects thus far.

Some opportunities lost because of slowness toengage basic scientists or limited number of clinicianscientists. More opportunities remain unexploited.

Existing collaborative networks facilitated genomeand protein work.

The type of research is not essential early in theepidemic response and is appropriatelycommencing now. However, the lack of linkedand comprehensive data will impede the quality ofthese studies for some time.

CIHR has a future competition planned in these areas.

10B. Outbreak Investigations and Research

Chapter 5 outlined how outbreak investigations andresearch interconnect. The research response to anepidemic such as SARS has several phases, including theidentification, characterization, response, monitoring and post-event phases. Ideally clinical, epidemiologic,laboratory and social science research tools are used in anintegrated and coordinated fashion in each phase. Thesephases are not entirely sequential. Each phase of theresearch response brings different questions and thus therequired research response may be different in terms of

resources or expertise. Functionally in Canada, eachphase had and has different mechanisms for leadership,direction, organization, and funding. Some aspects ofresearch are required for emergency response, whileothers are better suited to answering longer-termquestions of equal import but less urgency.

In the identification phase the questions are: What arethe manifestations of infection? What is causing theoutbreak or epidemic? How is the causative agenttransmitted? When does transmission occur? The causeof any epidemic is not known when cases first beginoccurring. An epidemic caused by a known agent usuallyrequires, in the initial identification phase, competent

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Canada United Hong Kong China United SingaporeStates Kingdom

Epidemiology Publications 6 2 3 10 2 2and Public Health

Mean Impact Factor 3.4 15.0 16.3 0.1 18.0 0.0

Etiology and Publications 2 2 2Diagnostic

Mean Impact Factor 15.0 9.0 0.0

Clinical Publications 8 2 13 15 6

Mean Impact Factor 10.5 6.5 10.1 0.3 4.5

Virology Publications 2 1 3 9 1

Mean Impact Factor 11.5 23.3 17.5 0.2 13.3

Immunobiology Publications 4

Mean Impact Factor 0.6

Social and Publications 7 1 1Economic

Mean Impact Factor 1.3 23.3 0.8

Policy Publications 1 1

Mean Impact Factor 13.3 6.6

Totals 24 8 21 40 4 9

Percent 20.5 6.8 17.9 34.2 3.4 7.7

Impact Factors/ 5.9 14.9 11.4 0.4 11.0 21.7Publication

* Impact was calculated by averaging the 2001 Institute for Scientific Information [ISI] impact ranking of journals in which a given country’sresearch was published. The analysis is based on publications listed in the US National Library of Medicine as of July 30, 2003. Journals forwhich the ISI has no impact factor ranking, such as Chinese language publications and the Morbidity and Mortality Weekly Report [MMWR] andthe Canada Diseases Weekly Report [CDWR] were given an impact factor of 0.001 in calculating means.

T A B L E 2Numbers and Impact Ranking of Canadian SARS Research Reports as of Early August, 2003

public health laboratories to test for known agents, inaddition to epidemiologic and clinical research resources.An epidemic caused by a new agent, such as SARS, requiresmore robust laboratory research capacity. The SARScoronavirus was identified quickly with traditional tech-nology. Advanced proteomics, genomic and genetictechnologies were employed after identification to charac-terize the agent; such technologies may have been neededin the first instance to identify a more fastidious organism.Fortunately, these capacities were in place and opera-tional well before an event such as SARS: Canada hasconsiderable strengths in multiple academic centres ingenomics and proteomics, and the National MicrobiologyLaboratory [NML] fulfilled its function appropriately as anational reference laboratory. These responses alsodepended on existing collaborative relationships. For thefuture, Canada should develop and sustain a strongnational network of fundamental and applied scientistscapable of rapid research responses to the next outbreakof a novel infectious agent within our borders.

In the characterization phase, research turns to thedevelopment of diagnostic tests, determining the spectrumof disease, assessing the extent of infection, and delin-eating the mechanisms of disease pathogenesis. We nowhave effective diagnostic tools in Canada. Indeed, multiplesites have been active in developing and enhancingSARS-specific diagnostic technologies. However, theCanadian research response has yet to generate meaningfuldata on the spectrum of disease, the extent of infection,and understanding of mechanisms of disease pathogenesis.The international public health community was lookingto Canada for answers to questions of global significance,and our response was inadequate.

Bringing an epidemic under control requires effectivepublic health and clinical action. Research on theresponse to an epidemic is important to understandingthe effectiveness of interventions and refining orabandoning them. The interventions used in theresponse to SARS—antiviral treatment, quarantine andisolation, suspension and redirection of hospital activity,travel advisories, screening of travelers—all wereemployed empirically. Adverse effects ranged from directdrug toxicity for patients treated with antiviral drugs, toloss of income and psychosocial consequences for thosein quarantine. At a macro-level, the consequencesranged from modest inconveniences (longer airport line-ups) to very serious health threats (delayed health services)for hundreds of thousands. There were also nationaleconomic impacts that affected millions of Canadians.There were and still are few data on which to basejudgements about the relative benefits of any of theseinterventions.

Some caused adverse effects without any benefit. For example, during SARS there was a laudable attemptto conduct an emergency clinical trial of ribavirin.However, before this could be mobilized, ribavirin becamethe “standard of care” for SARS and a trial was no longerthought to be “ethical”. Unfortunately, ribavirin use inSARS patients had a high rate of adverse events. Later invitro research showed no activity of the drug on the SARS coronavirus. The suspension of elective services inhospitals and quarantining of thousands of individuals,as occurred in Ontario, had obvious adverse impacts.

All these decisions were made in the face of crisis condi-tions and the pressing need to contain a serious outbreak.Careful evaluation of the effectiveness of the relevantpublic health and clinical measures should not imply anyadverse verdict on the judgement of those who usedthem. Science progresses by turning today’s truths intotomorrow’s mistakes. Evaluation in hindsight is alwayseasier than decision making under duress. But that is allthe more reason why evaluation should occur to informfuture decision making. It needs to be conducted now,so that potential future epidemics can be dealt with usinginterventions with the least unintended negative effects.

Finally, passenger screening was implemented at substantialcost to the public health system and travel advisories wereissued with severe economic effects. In the end, werethere any positive health effects from these measures?We need to know their impact with certainty andcommunicate the results.

Monitoring the effectiveness of response through enhancedsurveillance becomes important as an outbreak comesunder control. This is the phase of research we are in now.As already noted, enhanced surveillance will be extremelyimportant nationally and for other jurisdictions in thenorthern hemisphere as we enter the next respiratoryvirus season.

Once an epidemic is over, various types of post-eventresearch can be undertaken. The biomedical, clinical,epidemiologic and public health research activities initi-ated during the initial phases of outbreak response mustbe moved to completion. For SARS, there is a continuingneed for more long-term fundamental research into thebasic biology of the virus, with a view to designing moreeffective therapies and developing a vaccine. “Lessons-learned exercises” are another type of evaluative researchfocused on system improvement. This report is anexample of one such exercise. Parallel work for Ontario

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is underway with the Walker Panel and CampbellInvestigation; an expert panel chaired by Prof. Sian Griffithsand Sir Cyril Chantler of the UK is similarly providing athird-party assessment of the SARS outbreak response inHong Kong.

Assessing the long-term sequelae of SARS and its overallhealth impacts are some of the other types of researchthat are required. Many questions remain unanswered.Do patients affected with SARS all recover full respiratoryfunction? How many patients and health care workerssuffered lasting psychosocial harms? What exactly wasthe economic impact of SARS on institutions and thevarious segments of the Canadian economy? In this posthoc phase of research, more usual research processes maybe appropriate.

10C. Reflections on the ResearchResponse to Epidemics

10C.1 Business as UsualCanada has generally produced research on emerginginfectious diseases through the academic model. That is,research is initiated and carried out by one or a fewinvestigators who have an interest in a question; it isfunded through peer review, and communicated throughpeer-reviewed channels. These normal processes forplanning, approving, funding, conducting, analyzing andcommunicating research are ill-suited to meet the earlyresearch needs of an epidemic response. Changes mustbe made during an epidemic investigation, just as changesin the health system’s hierarchical structures must bemade for effective outbreak management.

Peer review, of course, remains the overall gold standardfor what science is performed and where it is published(and thus noticed). Peer review has its failings and critics;however, to paraphrase a similar tag about democracy, itis the worst system for assessing science—except all theothers. The basis for this system is to ensure that thehighest quality, most important research is performedand that it is verified by other scientists. During anepidemic, the necessity of timely response means thatformal peer review is not practicable. This does notmean that quality should be sacrificed. High qualityscience in the course of an epidemic can be assured byhaving teams of scientists who are normally full partici-pants in the peer-reviewed processes—competitive grantingand publishing in peer-reviewed journals—in place torespond to emergency research needs. Furthermore, thisteam must have processes for dynamic interchange andcritical evaluation of each other’s ideas on a rapid timeline.

In short, strong leadership by excellent scientists, coupledwith internal and external informal peer discussions ofexperiments and findings, can ensure that emergencywork remains high quality.

10C.2 Mobilization of Scientific ResourcesIn order for scientific resources to be mobilized, theyneed to exist and be organized in a fashion that permitsrapid (less than a day) deployment. Canada needs acadre of cutting-edge scientists in the public health,clinical, and biological spheres of infectious diseases, whocan and will drop everything on short notice and applytheir skills to the solution of the health threat at hand.To be cutting-edge and prepared, they must be activelyengaged in research and part of the overall Canadianresearch community on a continuing basis.

This in part is a key role for government science. Strategicinvestments in government public health sciencecapacity—such as the NML and the BC CDC—wereimportant factors in Canada’s ability to respond to SARS.However, networks based in academe and the privatesector are also needed to broaden and deepen ourresponse capacity. These research networks cannot beabout subsidizing ”business as usual”, or providingretainers to purchase the goodwill of a set of academicsin hopes that they may elect to help out in a nationalemergency. Funds should flow to build specific capacitiesand establish delineated obligations—such an apparatusmust be established in advance with clear ground rules.Hospitals and universities are useful partners, but theprimary connections must be with individual scientistswho want to be part of a research response team.Furthermore, epidemic research needs to be organized sothat it can react in any or several areas of the country ata given time, and provision must also be made forurgently mobilizing scientific resources from outside thehealth sector.

The US Centers for Disease Control and Prevention [CDC],for example, co-opted US coronavirus experts shortlyafter the virus was linked to SARS. Similarly, in thelaboratory investigation of SARS, the NML linked toacademic institutions, provincial agencies and the privatesector. This resulted in the first full-length genomesequencing of the SARS coronavirus by a collaborativeteam from the Michael Smith Genome Sciences Center,the BC CDC, and the NML. Government investment inbasic science capacity over the last several years createdresearch strength that could be drawn into action.However, the timely assembly of such collaborations canonly occur if there is already a degree of connectedness,

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trust and scientific respect. The middle of an epidemic isnot the time to be establishing new linkages andcollaborations.

Overall, the SARS experience argues that capacity forcutting-edge science in government is needed, and itneeds to be fully connected to and integrated withacademic and private sectors through interchanges, jointappointments, collaborations and formal and informalnetworks. Fostering these linkages should be an integralpart of the workplan for a new Canadian Agency forPublic Health and the F/P/T Network for CommunicableDisease Control. The network should give specialpriority to linking research in government and academicinstitutions with a focus on infectious diseases, therebybuilding the teams and business processes for rapidepidemic investigation that will strengthen Canada’sability to respond to the ‘next SARS’.

While some aspects of laboratory research on SARS inCanada were a source of national pride, we have alreadyoutlined that more could have been done. Reports oninterim laboratory results were not produced and communi-cated as often as they could have been. Effective linkageof laboratory research at the national level to the clinicaland epidemiologic research efforts at the provincial andlocal level never really happened. Academic linkagestended to be geographically limited.

Mobilization of epidemiologic and public health researchwas particularly weak. As noted earlier, the researchcapacity in provincial public health agencies varies, butwith some exceptions, is very limited. Indeed, littlescientific capacity exists in most local and provincialagencies. The Committee sees an acute need for strongeracademic linkages and in-house research capacity forpublic health agencies at the provincial/territorial leveland in major municipalities. Supporting such linkagesand capacity should be a funding priority in the transferprograms from the Canadian Agency for Public Health.

Health Canada’s capacity in these areas is also limited.The Centre for Infectious Disease Prevention and Control,the main part of the Population and Public HealthBranch responsible for surveillance and epidemiologicresearch on infectious disease, employs only 12 medicalepidemiologists and public health practitioners and 9 PhDepidemiologists. Their research productivity varies inpart because of competing demands on their time, and in part because the current structures do not lend them-selves to academic partnerships.

Connections between the academic sectors in epidemiologyand public health and local, provincial and nationalcounterparts have in some cases been eroded. The expiryof initiatives such as Public Health Research Educationand Development [PHRED] in Ontario has resulted in thecollapse of teaching public health units. As a result, inToronto during the height of the epidemic, the academicpublic health sector was not drawn into needed epidemicresearch, and as yet has produced very little research inthese areas. To pick up a theme from Chapter 7, publichealth units and public health practitioners in majorcentres need to be integrated into the academic sector in much the same way that teaching hospitals partnerwith universities and community colleges. The cross-fertilization will improve training opportunities, createmore varied and attractive career paths, build a strongresearch culture in public health, and facilitate the rapidemergence of teams of investigators who can participatein epidemic investigation.

In the latter stages of the SARS outbreak, large researchcoalitions did begin to emerge in Canada. These includethe SARS Research Network in Toronto and the SARSAccelerated Vaccine Initiative in British Columbia. TheCanadian SARS Research Consortium was initiated in lateMay 2003 to “coordinate, promote and support SARSresearch in Canada and develop international linkagesand partnerships to control and eradicate SARS.” Theconsortium was catalyzed by the Canadian Institutes ofHealth Research [CIHR] to deal with the immediate threatposed by SARS. If it proves successful, the Canadian SARSResearch Consortium could become a model and evolveinto a more permanent structure to address newly emerginginfectious diseases in Canada. The funding partnersinclude the CIHR, Genome Canada, Health Canada,GlaxoSmithKline, the Michael Smith Foundation forHealth Research, the Ontario Research & DevelopmentChallenge Fund [ORDCF], Fonds de la recherche en santédu Quebéc [FRSQ], the Protein Engineering Network ofCentres of Excellence [PENCE], and CANVAC (theCanadian Network for Vaccines and Immunotherapeutics).The Consortium intends to work in diverse areas, such asdiagnostics, vaccine development, therapeutics, epidemi-ology, databases, public health and community impact.

10C.3 Leadership, Organization, andDirection of Research

The usual consensus-building processes for scientificcollaboration are difficult to follow in the face of an out-break and the required research response. Furthermore,assuming that F/P/T public health research capacity iscreated within public agencies and institutions, jurisdic-tional tensions could still emerge and impede the research

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response to the next major outbreak. These concernssuggest the need for clarity about scientific and researchleadership in epidemic research responses.

This is not a straightforward matter. Researchers are notoften skilled in management. Moreover, managementskills are necessary but not sufficient for the discharge ofa leadership role in a crisis. Attempted research leadershipalso sometimes runs afoul of research ‘followership’, i.e., researchers resist being organized and steered at thebest of times. They have a healthy scepticism aboutauthority, and highly-specialized expertise that is unlikelyto be matched by a particular leader. Leadership of ascientific team accordingly derives from competence,respect, interpersonal and communication skills, andmutual trust as much as it does from the authority givento someone in a particular position. This is doubly sowhen the scientific team is a network of individualsoutside a hierarchical organization, in which participantshave the latitude to choose their collaborators and theirresearch foci. Furthermore, decisions need to be made ina timeframe that may not allow consensus building.

During the SARS epidemic, effective overall leadership onresearch was lacking, particularly in the epidemiologyand public health sphere. Multiple public health unitswere involved but coordination was limited and staff wereconsumed with fighting the outbreak. The provincialpublic health branch did not have sufficient in-houseresearch capacity or highly-developed academic linkages.As noted in Chapter 2, scientific firepower was marshalledin an advisory committee to support the executive teamthat oversaw the provincial emergency in Ontario, butthis group did not have the time, data, or clear mandateto coordinate the relevant epidemic research. In future,research leadership for outbreak investigation must bedetermined well in advance, along with a tentative set ofmanagerial structures to move a research agenda forward.

One such structure, as noted earlier, is the creation of aconnection between the outbreak management team andthe research response team—a B-Team as pioneered bythe CDC. This would be a group whose task it was tothink critically about the scientific questions, generateideas for research, and offer sober second thoughts onthe overall direction of an outbreak response.

More generally, the research structures themselves neednot mirror the command-and-control apparatus neededfor effective management of the outbreak per se; but theywill be more hierarchical than normal in research. Putanother way, the scientific team must have a quarterbackand a play book that all will use, albeit temporarily untilpost-event research brings the more free-flowing processesof normal science on stream.

Those normal scientific processes involve redundancy,repetition and uncoordinated replication, and competition.These processes, with their centripetal tendencies andcreative anarchy, have paid huge dividends for society.However, they are too slow, unpredictable, and expensivefor outbreak research. This underscores the need, outlinedearlier, for two synergistic elements in the research response:a strong scientific presence in publicly-managed and -accountable institutions, and funds flowing throughstructures that draw non-governmental partners into anetwork with a clear set of research responsibilities.

For example, in the early stages of the SARS outbreak,laboratory research was relatively well-coordinatedbecause it was centralized. As the health care and academicsectors became engaged and testing for the coronavirusbecame more widely available, laboratory activity becamemore fragmented. The ability to track laboratory resultsdisappeared. Central data management was not maintained.Indeed, although many stakeholders called for action, itwas not clear who, if anyone, had the authority to insiston better coordination of data management.

The epidemiologic, clinical, public health and social scienceresearch efforts were even more fragmented. Health Canadaattempted to direct some of the epidemiologic and publichealth research by developing research protocols andproviding funding and direct support. However, progresshas been frustratingly slow. The CIHR demonstratedsubstantial agility and provided some welcome leadershipthrough a special SARS competition, in May. However,some of the individuals who were best placed to addressthe central questions were already deeply engaged infighting the outbreak and hardly in a position to writeelegant grant applications. An accelerated grantingcompetition may be worthwhile for slower-moving out-breaks or for rapid post-event research, but was criticizedby a number of informants as misplaced in the midst ofcontinuing efforts to contain a fast-moving outbreaksuch as SARS.

Some mechanism for ongoing coordination of SARSresearch is still needed, as pressing questions remainunanswered. The Canadian SARS Research Consortiumand the SARS Accelerated Vaccine Initiative are twoexamples of efforts to coordinate the research effort.However, these coordinating bodies are operating underno particular authority, and a wide range of other activityis now underway without formal cross-linkages, networking,or coordination. Research on the development of diag-nostic tests is illustrative. Diagnostic research can onlybe done if there is access to clinical specimens. These areonly available in any quantity in a few institutions that

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may or may not be interested and willing to providethem to researchers. The amount of material is limitedso that not every demand for material can be met.

There are also serious organizational and ethical issues inhow diagnostic specimens can be drawn into a coordinatedresearch effort. Some researchers have suggested thatCanada create a national SARS database to facilitateresearch, pulling together relevant clinical, epidemiologic,laboratory, and, where applicable, pathological data.This would be novel and ideal. However, individualresearchers do not have control over data that accumulateduring the response to an outbreak. The data are nowheld in many different institutions and agencies; they aresubject to constraints of confidentiality arising from theiracquisition as part of a local public health investigationor clinical encounter.

As well, in usual circumstances, those who generate data“own” the data and decide what is to be done with them.These researchers are under no obligation, except perhapsa moral one, to make data available to others who maybe able to use it better. The same applies to biologicmaterials. These practices must change during provincialand national emergencies, and perhaps more generally.

Thus, a fundamental question that Canada needs toanswer is: Who “owns” the various streams of preciousscientific data that emerge during an outbreak? Duringthe Health Canada SARS conference in Toronto on April 30/May 1, 2003, it was suggested that the idea of“ownership” of data during an outbreak should bepermanently replaced by “stewardship”. Operationalizingthis idea will be challenging, but is worthy of pursuit.

As a corollary, how can the confidentiality of the affectedpatients and their contacts be safeguarded in any dataamalgamation process? Some informants believe thatconfidentiality and privacy concerns can be readily man-aged by having each group or institution in a data steward-ship consortium agree on a protocol for “anonymizing”the data, and then using common non-nominal identi-fiers to create the means for linking data from multiplesources. On the other hand, we noted in Chapter 9 thatthe Privacy Act and The Personal Information Protection andElectronic Documents Act and related provincial laws arenot well suited to disease surveillance, outbreak investi-gation, and applied research in the face of infectiousdiseases. In this regard, an epidemic caused by a newagent presents some unique issues. In broad brushstrokes,the US approach has been to consider public health

investigations somewhat differently than planned researchactivity with respect to some of these ethical issues.More thinking about the ethical and legal dimensions ofpublic health research and outbreak investigation isneeded. The rights of the individual must be balancedagainst the public good of disease surveillance and epidemicresearch that will safeguard the population’s health.

In sum, for future emerging infectious disease threats,some process for coordinating the research effort nationallyneeds to be in place. A restructured national public healthsystem should have this role, along with the authoritiesto direct and coordinate research, establish nationaldatabases and research platforms, ensure that appropriateethical and privacy safeguards are in place, and provideresources to fund epidemic response research.

10C.4 FundingWe have already seen that the usual peer-reviewedmechanisms for funding research are not suited to theimmediate initial phases of epidemic research. Certainresearch activities must be carried out regardless of flawsin study design. An outbreak is not the time to allow“the best to become the enemy of the good”; a responsemust occur. The initial funding for research conductedon SARS was not peer-reviewed in the formal sense andwas provided entirely by affected health care institutionsor directly by governments. The quality of the work was ensured by pre-existing capacity and networks ofscientists who provided real-time informal peer review.Subsequently, the peer-reviewed granting agenciesresponded to SARS research needs and began fundingSARS research in a relatively rapid timeframe. However,at this point we have largely lost the ability to performclinical research on the pathogenesis of SARS.1

It appears that the CIHR was able to hold an acceleratedcompetition in part because of a quirk in their financesfor fiscal year 2003-2004. The CIHR and other agenciesneed to have the capacity to respond to new threatsrapidly through the creation of special funding envelopes.It is surprising that the Canadian Food Inspection Agency[CFIA], as an agency with a legislative mandate similar tothe CIHR, is able to roll funds over on a 24-month basiswhile the CIHR is not. Extending this administrativepolicy to CIHR would clearly improve the CIHR’sflexibility in responding to emerging infectious diseasesand other fast-breaking research issues.

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1 It is arguable that, funding aside, pathogenetic research was impeded by a dearth of clinician scientists and the pressures they were under in fightingthe outbreak.

Canada’s investment in infectious disease research andspecial funding for SARS is detailed in Table 3. To date,the Government of Canada has invested or committedabout $6.7 million (Health Canada has spent about $2 million on research, the CIHR has announced or heldcompetitions for $2.7 million and the Minister of Healthhas reallocated $2 million for SARS research to the NML)on SARS research. This does not account for what hasbeen spent directly by health institutions and provincialgovernments in responding to SARS. The investmentseems small in relation to a problem that infected morethan 400 people, killed 44, resulted in thousands inquarantine, shut down the health care system in Toronto,

had huge direct and indirect costs, and probably affectednational economic indices. It is especially small when oneconsiders that $20 million have been allocated for adver-tising campaigns to enhance tourism in Ontario post-SARS.

In recognition of the unusual nature of SARS and theimportance of research, some novel funding initiativeshave developed. British Columbia’s SARS AcceleratedVaccine Initiative has made $2.6 million available forSARS vaccine development. The Ontario Research andDevelopment Challenge Fund announced $10 million tocreate an Ontario infectious diseases network. Part of thefunding will be to match the support for Ontario-basedscientists who are successful in obtaining CIHR funds forSARS research.

All these initiatives are commendable, but the capacity of the research community to respond is limited. Thecreation of scientific capacity is a long-term process. It involves coordination of support across post-secondaryinstitutions, granting councils, and the health charities,together with an ongoing demand for highly-skilledpersonnel and a career path that makes a particular fieldattractive. Furthermore, as the Canadian Veterinary MedicalAssociation [CVMA] highlighted, capacity-buildinginvestments must be extended in new directions. Giventhe importance of zoonoses, the CVMA questions why“virtually nothing” is spent to predict which diseases inanimal populations may jump to human communities,and to prevent such cross-species transmission. Thiscapacity-building must involve the private sector as wellas the public sector. For example, Canada’s Research-based Pharmaceutical Companies suggest that industry isprepared to invest not only in biomedical investigationbut broader health research, including social sciences.

In sum, targeted competitions on a short timeline willsimply flow more money to already-overloaded investi-gators or subsidize second-rate research unless a maturescientific community with appropriate breadth and depthexists and is ready to respond to requests for proposals.A careful balance must be struck across three areas offunding: open competitions to support investigator-drivenscience; targeted competitions that seek to support, prefer-entially, work in specific areas; and mission-orientedresearch with a strongly applied focus (as occurs duringoutbreak investigation).

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All Infectious Special Allocations Diseases for SARS

(C$ millions) (C$ millions)

CIHR2 71.5 2.7

NSERC 2.8

Genome Canada3

Canada Foundation 24for Innovation

Networks of Centers of Excellence4

Health Canada – 13 3National Microbiology Laboratory (internal and external funding)

Health Canada – Center 5 1for Infectious Disease Prevention and Control (internal and external funding)

Health Canada – 5Laboratory for Food Borne Zoonoses (internal and external funding)

Provincial Unavailable 12Governments

Total 120+ 17.7

T A B L E 3Canadian Spending On Infectious Diseases Researchand SARS Research To Date

2 CIHR submission to the National Advisory Committee on SARS and Public Health, July 28, 2003.3 Genome Canada currently has a competition for applied genomics in health which will invest in infectious diseases.4 Two networks are funded, the Canadian Bacterial Diseases Network [CBDN] and the Canadian Network for Vaccines and Immunotherapeutics. CBDN

funding as a National Centre of Excellence [NCE] is coming to an end. Two NCEs, the Protein Engineering Network of Centres of Excellence [PENCE]and the Mathematics of Information Technology and Complex Systems [MITACS] have funded SARS research projects.

10C.5 CommunicationsScientific communication changes substantially in epidemicsituations and is fundamentally different from normalprocesses and procedures. Public communications issueswere detailed in Chapter 5. This section considers communi-cation of scientific information within the scientificcommunity, to public health officials, and to the media.

In a non-epidemic situation, research is communicatedthrough peer-reviewed channels—scientific conferencesand scientific journals. This process is slow, but valuablebecause it serves to validate results. Communicationswith the public happens in most instances after someform of peer review and communication to other scientists.During the SARS epidemic, communications amonglaboratory scientists nationally and internationally wereeffective and efficient through the use of internationalconference calls and the Internet. An important innovationwas the impromptu network of laboratories and supportingweb page rapidly put in place by WHO. This resulted in a very early exchange of ideas, results, reagents andprotocols and significantly speeded up identification ofthe coronavirus and confirmation of its link to SARS.The framework for international communication andcollaboration came together in less than two weeks. This successful process should be studied, codified,strengthened, and replicated wherever necessary.

Nationally, communication of laboratory results was facili-tated through dissemination of a summary of laboratoryresults from the NML. The frequency of production waslimited by a weak capacity for analysis at the NML. Otherlimitations in communication involving laboratories wereoutlined in Chapter 6. On balance, however, informationmoved reasonably well.

The same cannot be said for communication about theepidemiologic aspects of the science. Global epidemiologyand public health networks did not develop until muchlater in the epidemic. Nationally, although HealthCanada made significant efforts to obtain and communicateinformation on the epidemiology of SARS, shortcomingsin data management and analysis meant that very littlein the way of epidemiologic information was generatedto communicate. Thus, the issue may be more one ofcontent than communication capacity.

As was true internationally, teleconference calls and theInternet were the basic communication tools usednationally by researchers. Teleconferences were effectivebut highly inefficient. Individuals who were key playersin the response at all levels spent many hours every day

on conference calls. From the Health Canada perspective,since the relevant individuals from the most affected areaswere stretched so thinly that they were too busy to partici-pate, this led to the Kafkaesque situation where callsinvolved discussion among regions that were unaffected.Consideration needs to be given to how to improve theefficiency of communication during emergency response,starting with the creation of adequate local and regionalactivity so that communications can be sustained whilethe response to an outbreak is underway.

Formal publication of results also changed during SARS.Researchers had the unusual experience of finding thateditors of the most respected journals were lobbying forsubmissions and offering turn around in a matter of daysfor review and publication of electronic papers. Trendstoward rapid e-publication that were already in the offingmay have been accelerated by SARS.

During an epidemic, research is conducted in a fishbowl.This meant that during the SARS epidemic, preliminaryscientific results were widely reported in the press moreor less as the findings were produced. This resulted inconsiderable pressure on Canadian scientists, and shapedscientific communications in subtle ways. For example,modest and reasoned differences in viewpoints amongexperts concerning causative agents appeared to be black-and-white disagreements when selected sound-bites wereaired or quotes chosen for use by print media. Honestdifferences should be shared with the public, but theCommittee perceives that there was clear scope for bettercoordination of how scientists communicated withdecision makers and the public.

10D. Capacity for Relevant PublicHealth and Infectious DiseaseResearch in Canada

As one indicator of research spending on infectiousdiseases, the CIHR now has an annualized commitment of$71.4 million to this broadly-defined field. This invest-ment might be considered “over-invested”5 if viewedsolely with an eye to the relative burden of disease. Theproblem, of course, is that the CIHR’s overall budget on aper capita basis continues to lag hugely behind the USNational Institutes of Health. Compared to the USA,spending by our national health research agency on infec-tious diseases represents a substantial under-investment,and many other areas of health research have presumablyfallen even further behind. The CIHR’s spendingincludes 11 randomized controlled trials for a total of$3.88 million, and the HIV Clinical Trials Network for

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5 CIHR submission to the National Advisory Committee on SARS and Public Health, July 28, 2003.

$4.2 million; 527 operating grants for $52.6 million; 91 career awards for $5.56 million; and 181 individualtraining awards for graduate students and post-doctoralfellows for a total of $4.30 million. As an example of under-investment in infectious diseases research, the CIHRcurrently has no funded projects on West Nile disease.

Epidemiologic and public health research on infectiousdiseases is considerably under-invested. “CIHR’s invest-ment in infectious disease research flows primarily tosupport biomedical research (84%), and the emphasis onbiomedical research in this field is stronger than in theCIHR’s overall portfolio (72%).”6 Furthermore, there areno specific CIHR investments in emerging infectiousdiseases, although the Institute of Immunology andInfectious Diseases is planning a special initiative in thisarea. According to a brief inventory by the CIHR, “NSERCprovides about $2.8 million in operating support per yearin areas ranging from studies into fundamental biology ofpathogens, through to more applied studies of vaccinesand antimicrobials, agricultural practice, and food safety.As well, “the Canadian Foundation for Innovation hasinvested close to $24 million in infrastructure and equip-ment in the area of infection and parasitic diseases.”Two federally-funded networks of centres of excellenceare relevant: the Canadian Bacterial Diseases Networkand the Canadian Network of Vaccines and Immuno-therapeutics [CANVAC]. There is no network focused on viral diseases. “Genome Canada has funded threelarge projects relevant to human infectious disease, onCryptococcus, Candida albicans, and viral proteomics.”

Other relevant federal investments include the NationalResearch Council’s Institute of Biodiagnostics located inWinnipeg and its Institute of Biological Sciences, locatedin Ottawa. The latter has developed an effective vaccinefor Group C meningococcal disease.

According to the CIHR, “A ballpark estimate for federalinvestment in infectious diseases research would be $100 million per year. However, as in most other areasof science, there is little coordination between agenciesin how those funds are invested or in developing afederal research agenda.”

We have noted above that essential capacity for leadingand performing the needed research in response to anepidemic must reside in government-funded publichealth institutions. How robust is the capacity for thistype of research in public health institutions? TheCommittee perceives that, with a few exceptions, the

overall research capacity in provincial public health islimited. Ontario has seen a decline in the number oflaboratory scientists in its provincial laboratory; analyticalcapacity in the provincial public health branch wasnotably limited during SARS. British Columbia, Albertaand Quebec have strength in some areas, but no otherprovinces have internationally-competitive laboratoryresearch capacity in the public health realm.

The situation is worse in the epidemiologic and publichealth fields. The Committee’s assessment is that, withthe possible exception of Quebec’s National Institute ofPublic Health, no province has broad public healthresearch capacity within its public sector. British Columbiahas strength in specific areas through its Centre forDisease Control. Manitoba at one time had a productiveepidemiologic research unit but it has largely disintegratedowing to lack of targeted support. We detailed earlier theloss of Ontario’s PHRED program and the lack of linkagesbetween health units and universities or communitycolleges. The same malaise that has led to profoundshortages in human resources for public health hasundermined research capacity in the field.

Recognizing the capacity issues, the CIHR has recentlyfunded five new strategic training initiatives in infectiousdiseases. This is a positive step, but CIHR’s record showsthat its absolute increases in support for biomedicalscience have meaningfully outstripped expansion acrossthe other three “pillars” combined—those being clinicalinvestigation, health services research, and populationand public health research. This asymmetric growth inCIHR spending is partly a capacity problem in areas otherthan biomedical research, but also reflects the CIHR’sdifficult mandate of meeting research needs for allimaginable stakeholders. It is very unclear whether theseparate CIHR Institutes can address the capacity forpublic health research, particularly in epidemiology andthe social and behavioural sciences.

10E. Recommendations Some aspects of the research response to SARS wentexceedingly well in Canada; other aspects did not. Thereasons for these failings can be summarized briefly asfollows. Governments have not consistently recognizedthat research is a core public health function, andsupported it. Canada’s considerable new investment inresearch has not adequately targeted public health andepidemiologic research, nor has there been substantialthinking about creative partnerships and programs to

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6 CIHR submission to the National Advisory Committee on SARS and Public Health, July 28, 2003.

build public health research capacity. Furthermore,support for clinician scientists has been limited. Canadianresearch structures and procedures are not designed for thetype of research response that is required in an epidemic.The actual capacity for key types of research in publichealth institutions has been constrained by: the weakresearch and evaluation culture in multiple levels ofgovernments; limited career paths for public health prac-titioners in various disciplines at the federal, provincial,and local levels; a lack of programs and opportunities toprepare personnel from multiple disciplines for publichealth research in general and investigation of emerginginfectious diseases in particular; and pressure on existingpersonnel such that research and evaluation activities, iffunded at all, must be squeezed in between other pressingwork demands. Finally, there are no mechanisms fornational leadership, coordination and direction ofepidemic research.

To prepare for future SARS outbreaks, which could be asclose as the next respiratory virus season, Canada needsto take stock and complete some important SARS-relatedresearch projects as quickly as possible. We also need tomake longer-term changes. Although SARS was only amoderate-sized outbreak, it highlighted a number ofdeficiencies in our research response that could havebeen extraordinarily damaging had the agent been evenmore infectious or dangerous. We now have the oppor-tunity—indeed, an obligation—to address the structural,procedural and capacity issues that prevented a moreeffective research response to SARS in this nation.

The Committee accordingly recommends that:

10.1 The Canadian Agency for Public Health shouldearmark substantial funding to augmentnational capacity for research into epidemio-logic and laboratory aspects of emerginginfectious diseases and other threats to popu-lation health. This enhanced national publichealth science capacity should be stronglylinked to academic health institutions throughco-location, joint venture research institutes,cross appointments, joint recruitment, inter-change, networks and collaborative researchactivities.

To this end, in the notional core budget for the CanadianAgency for Public Health outlined in Chapter 3, weforesaw new spending rising to $50 million per annumon infectious disease capacity, including research elements,and another $25 million in general public health R&Dfunctions. Some of these activities would be in-house;

many would be initiated in collaboration with academicpartners, provinces and territories, major municipal healthunits, and research agencies, particularly the CIHR.

10.2 The Canadian Agency for Public Health, inpartnership with provincial and territorialgovernments and through the F/P/T Networkfor Communicable Disease Control, shoulddirectly invest in provincial, territorial, andregional public health science capacity.

The $100 million earmarked for ‘second-line’ capacity,including the operation of the F/P/T Network forCommunicable Disease Control, is the logical source offunding for this purpose. Options include directedfunding flows to existing provincial/territorial bodies orthe creation of joint F/P/T regional institutes. Themandate of these bodies would be to provide publichealth research services to the provinces and territories.

10.3 The F/P/T Network for Communicable DiseaseControl, in partnership with the CIHR and theCanadian research community, should developclear protocols for leadership and coordinationof future epidemic research responses.

10.4 The Canadian Agency for Public Health andthe F/P/T Network for Communicable DiseaseControl should ensure that epidemic responseteams initiated as part of the Health EmergencyResponse Team [HERT] concept, provide notonly surge capacity for outbreak containmentper se, but also a mobile “B-team” and investi-gative infrastructure, including epidemiologists,programmers, and analysts.

10.5 The Canadian Agency for Public Health, inpartnership with provincial/territorial govern-ments, should develop clear rules, reinforcedby intergovernmental agreements, on thesharing of information, the establishment ofnational databases, and the use of biologicmaterials for research in response to epidemics.

10.6 The Canadian Agency for Public Health, incollaboration with the CIHR, should establish a task force on emerging infectious diseases torecommend research priorities and fundingmechanisms. The Agency, in collaborationwith the CIHR and other national researchfunding bodies, should support the developmentof special funding mechanisms and processesfor fast-tracking research related to epidemicsof infectious diseases.

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10.7 The Canadian Agency for Public Health, inpartnership with research agencies andprovincial/territorial governments, shouldwork with universities to improve researchtraining opportunities in infectious diseasesand outbreak management for the full rangeof involved disciplines. This capacity-buildingfocus should be a priority within the broaderhealth human resource strategy of the Agency(see Chapter 7).

10.8 The Government of Canada should strengthenits R&D functions in international healthoutreach, with particular emphasis on emerginginfectious diseases on a global basis.

In this respect, as suggested in the brief discussion ofethics in Chapter 9, the Committee believes that Canadahas an obligation to be more engaged in outreachactivities that will help build research capacity in lessdeveloped nations. These investments should havepositive long-term impacts on the health of populationsin those nations, and thereby complement conventionalforms of assistance provided by the CanadianInternational Development Agency and other agencies.We return to this issue in Chapter 11.

10.9 The Government of Canada should fosterworkable public-private partnerships with thebiotechnology, information technology, andpharmaceutical industries for shared researchinterests in the realm of emerging infectiousdiseases, including new vaccines, antiviralcompounds, immunotherapies, and diagnostictechnology.

10.10 The Canadian Agency for Public Healthshould spearhead discussions on the issues ofintellectual property, copyright and patentingfrom public health inventions.

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VIRUSES WITHOUT BORDERS:International Aspects of SARS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The SARS outbreak illustrates Marshall McLuhan’sprediction that the world would become a ‘global village’.It took smallpox centuries just to cross the Atlantic; a fewweeks after arriving in Hong Kong from Guangdong, SARShad already spread to 30 countries on five continents. As of July 2003, the direct clinical toll of SARS wasalready about 8,500 probable SARS cases and more than800 deaths worldwide. The global economic and socialtoll has been nothing short of staggering.

The story of SARS in Canada has had internationaldimensions from the outset. In both Ontario and BritishColumbia, SARS was imported by Canadians returningfrom Asia. Conversely, it appears that only three individ-uals developed SARS after leaving Canada, with onwardtransmission only by one person who went to thePhilippines.

In this chapter we focus on three key internationalaspects of the SARS outbreak. First, we see again thatCanada must have the reporting systems, collaborativemechanisms, and resources in place for other members ofthe family of nations to be satisfied that we can meet ourobligations to contain outbreaks. Second, SARS was thefirst instance in which the World Health Organization[WHO] issued travel advisories. Not only were theevidentiary foundations for WHO intervention weak, butthere are more general concerns about the basis for andeffect of travel advisories, including Health Canada’s ownpractices in this regard. Third, the federal governmentneeds to review its measures for disease screening andhealth-related support at ports of entry to Canada.Airport screening measures, in particular, appear to havelittle yield.

11A. International Background11A.1 Health Canada’s Role

“National boundaries no longer offer isolation orprotection from infectious diseases, toxic chemicals,and hazardous products.”

—Lac Tremblant Declaration, 1994

As noted in Chapter 3, in 1992 the Institute of Medicine—a division of the National Academies of Sciences in theUnited States—released a report describing the growingconcerns about the resurgence of infectious diseases.1A little less than two years later, Health Canada’s LaboratoryCentre for Disease Control convened a three-day meetingat Lac Tremblant. Forty leading scientists gathered todiscuss and debate the Institute of Medicine report andconsider its implications for Canada. Their conclusionswere reflected in the “Lac Tremblant Declaration,” thatrecommended the development of national strategies forthe surveillance and control of new and resurgentinfectious diseases. These recommendations recognizedthe ongoing emergence of infectious diseases in Canada,such as Lyme Disease (1975), Legionnaires’ disease (1976),HIV/AIDS (1981), E. coli O157:H7 (1983), hepatitis C(1989), and Hantavirus (1993).

Although some within the federal government acceptedthe pressing need for a national plan, the availableresources were insufficient to allow a comprehensiveapproach. The Institute of Medicine report and the LacTremblant meeting did contribute to the development ofthe Office of Special Health Initiatives, organized withinthe Laboratory Centre for Disease Control at HealthCanada. Focusing on global mobility and its implicationsfor infectious disease spread, the Office of Special HealthInitiatives developed the Travel Medicine and MigrationHealth programs and the Montebello Process, which

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offered advice to other government departmentsconcerning screening of immigrants for infectiousdiseases. After a Health Canada reorganization in 2000,these activities were incorporated into the new Centre forEmergency Preparedness and Response.

Through its membership in WHO, Canada accepted theobligation to report nationally on only a few diseases(e.g., plague, yellow fever and cholera). As noted inChapter 9, WHO has been updating its regulations and isdeveloping new standards for surveillance and control ofcommunicable disease. Even in the absence of suchinternational standards, however, multiple observers hadalready identified a threat to the domestic control ofinfectious diseases from the lack of a truly national surveil-lance and reporting system. SARS has now sharply illus-trated the international realities that make it untenablefor each province or territory to choose when and whatinfectious disease data to report to other jurisdictions,including the federal government. Measures alreadyrecommended throughout this report should, if adopted,rapidly remedy this situation.

International CollaborationsCollaboration among nations is beneficial to Canada inpart by ensuring that the nation has intelligence onemerging disease trends so that citizens and our healthsystems can be informed and act accordingly. HealthCanada works closely with WHO in the area of infectiousdiseases. Canadian representatives sit on the advisoryboards of WHO’s Communicable Diseases cluster and theGlobal Outbreak Alert and Response Network [GOARN].WHO relies extensively on Health Canada’s Global Public Health Intelligence Network [GPHIN]*, a uniqueearly-warning system mentioned in several previouschapters. GPHIN continuously scans Internet mediasources for reports of infectious disease outbreaks aroundthe world. Three Health Canada staff members areseconded to WHO to provide technical advice, support,and training opportunities, but not explicitly to improveliaison. As well, Health Canada’s Population and PublicHealth Branch [PPHB] includes a number of WHOCollaborating Centres, enabling alliances to improveepidemiologic and laboratory response to internationalissues.

Health Canada has close ties with the US Centers forDisease Control and Prevention [CDC], and the two bodieshave engaged in many collaborative programs over theyears. Health Canada plays an important role in inter-national working groups, such as those that have recentlybeen created to prepare for the possibility of deliberatetransmission of infectious diseases (i.e., bioterrorism).The federal Minister of Health or one of her delegatesalso represents Canada in other international forums—the Asia Pacific Economic Cooperation forum, forexample, recently hosted a meeting of health ministersin Thailand to discuss SARS. Finally, to assist developingcountries, Canada provides technical advice and supportthrough Health Canada and to a lesser extent, throughthe Canadian International Development Agency [CIDA].As noted in Chapter 10, except in HIV/AIDS, CIDA’shealth portfolio is modest and includes no involvementin emerging infectious diseases. We believe thatCanada’s international outreach on emerging infectiousdiseases should be strengthened, thereby providingmeaningful support to developing nations and uniquelearning opportunities for those preparing for careers inpublic health.

Other international collaborations that have developedas a result of individual contacts and interests amongHealth Canada staff include the Caribbean EpidemiologyCentre, and joint surveillance of enteric pathogens insome Central and South American countries facilitatedthrough the Pan American Health Organization [PAHO].

Unfortunately, Health Canada lacks an overarchingstrategy for international collaboration and has notprioritized international activities. Recognizing thisweakness, PPHB has been collating its internationalactivities over the past six months to inform strategicdevelopment. A deficiency that will need to be addressedas part of this process is the lack of an emerging infectiousdiseases strategy with strong international elements.SARS has illustrated that our borders do not protect usfrom disease and that we are constantly a short flightaway from serious epidemics. Strengthening the capacityof other nations to detect and respond to emerginginfectious disease is important from the point of view ofenlightened self interest as well as a global responsibilityfor a country with Canada’s resources.

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* A partnership between WHO and Health Canada, the GPHIN is a unique, early-warning, Internet-based system that provides preliminary public healthinformation about global health risks on a real-time, 24/7 basis. From multiple information sources, including global media outlets, GPHIN gathersand disseminates relevant public health information on disease outbreaks. Basic reports are processed by a computer and then human analystsreview each report for relevance and accuracy. From approximately 18,000 total monthly reports received, approximately 3,000 are accessed byWHO, which selects the most urgent for verification with the affected country. GPHIN reports approximately 40% of the outbreaks known to WHO.In addition to infectious disease reports, GPHIN covers environmental contaminants, natural disasters, nuclear safety, product recalls and safety,therapeutics, and bioterrorism. Identified news is electronically disseminated to users, who include government and public health officials in Canadaand around the world.

11A.2 World Health OrganizationIn 1948, the United Nations created the World HealthOrganization. With 192 member countries, WHO’sgovernance structure includes the World Health Assembly(all member states), an Executive Board (32 health experts),and a Secretariat (3,500 staff) headed by a Director-General.In addition to the headquarters in Geneva, WHO operatessix regional offices. The organization’s global budget isabout US$1 billion; a portion of this derives from annualcontributions from member countries. Canada’scontribution for 2003 was over US$10 million.

Over the last half century, WHO has generally focused on infectious diseases commonly found in developingcountries—malaria and tuberculosis, for example. WhileWHO has engaged in global surveillance of these diseasesand has directed specific responses (e.g., immunizationcampaigns), until recently it lacked the ability to respondto and manage outbreaks. Prior to 2000, WHO employeda relatively passive approach to the international notifi-cation of outbreaks of infectious diseases by memberstates. Data from developing nations were often severalyears old before their release. Even more importantly,when affected by outbreaks that could potentially haveinternational economic impact (e.g., a reduction intourism), countries sometimes failed to notify WHO.

The combination of the 1992 Institute of Medicine report on emerging infectious diseases with outbreaks ofpneumonic plague in India in 1994 and Ebola in theCongo in 1995 prompted WHO to develop a strategy formore proactive responses. It had (and still has) specifiedonly that plague, yellow fever, and cholera must bereported to WHO by member nations. While formalsurveillance efforts are only now being expanded, thepartnership with Health Canada to create the GPHINrepresented WHO’s first step towards a worldwide earlywarning system for outbreaks. As noted, GPHIN providesglobal surveillance capacity and bypasses the traditionallyslow passage of information from local agencies to nationalgovernments and then to WHO. WHO also establishedthe GOARN, a collaboration of over 118 institutions thatresponds to WHO requests for rapidly mobile teams ofexperts in infectious disease control within 24 hours of arequest by a member state. GOARN has demonstrated itsability to deploy relatively large international teams ofepidemiologists, clinicians, statisticians, and logisticspersonnel in response to outbreaks such as Ebola virus inGabon and Uganda, severe influenza in Madagascar, andplague in Algeria. Last, during the SARS epidemic, WHOhas begun issuing travel advisories for the first time,acting—without explicit authorization by member states—as a trans-national clearinghouse to assess the safety ofinternational travel and, by extension, the effectiveness

of outbreak management efforts in different countries.The Committee heard some concern expressed about asituation in which nations such as Canada are expectedto ‘report to’ the WHO, and what this precedentportends for member states more generally.

11B. International Response to SARS

11B.1 WHO Response to SARSWHO issued an unprecedented global health alert onSARS on March 12, 2003. By this time, SARS had alreadyspread from Hong Kong and Guangdong province ofChina to Viet Nam, Singapore, Thailand, and Canada.

Very early in the outbreak, WHO established contact withaffected countries and offered epidemiologic, laboratory,and clinical support. By March 17, 2003, WHO wascoordinating an international multi-centre effort thatunited 11 laboratories in ten countries to identify thecausative agent and develop a diagnostic test. Meanwhile,GOARN teams in Hanoi and Hong Kong were collectingclinical and epidemiologic data as well as helping managethe outbreak; Canada participated actively in the GOARNeffort in Hong Kong. Through its regional office inManila, WHO established logistics bases and supplychains to ensure the rapid provision of protectiveequipment and medicines.

SARS provided a new challenge for WHO’s CommunicableDisease Surveillance and Response group—it was a non-focal, multi-country outbreak of a hitherto-unknowndisease. As we learned in Chapter 6, close internationalcollaboration on laboratory and epidemiologic aspectswas successfully brokered by WHO primarily throughteleconferences. It also established a secure web page tofacilitate international collaboration.

WHO first issued case definitions for SARS on March 15, 2003. At that time, a suspect case was anyonewith fever and respiratory symptoms such as cough orshortness of breath. A probable case was someone withclose contact with a person diagnosed with SARS and ahistory of travel to a SARS-affected area, or a suspect casewith x-ray findings of pneumonia. These definitionswere refined over the following weeks to more accuratelydetect and exclude cases. Revised definitions issued onMay 1 required the fulfillment of four criteria for asuspect SARS case: fever; cough or shortness of breath;an epidemiologic link (close contact with a suspect orprobable case; recent travel or residence in an area wherelocal transmission has occurred); and the absence of analternative diagnosis. A probable SARS case had all the

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features of a suspect case plus x-ray, laboratory, or autopsyfindings consistent with SARS. WHO was forced tomaintain a clinical/epidemiologic definition because novalidated, widely available laboratory test for SARS hadyet been developed.

We have previously reviewed various criticisms of theSARS case definitions. Even the symptoms that wereincluded in the definition may not have been the mostappropriate; an evaluation of the criteria looking specifi-cally at the clinical presentations of Hong Kong patientswas published in the British Medical Journal on June 21,and it found that the WHO criteria would miss nearly75% of cases when applied to people presenting early intheir course of illness. A further concern has been thatthe WHO case definition did not distinguish betweenToronto, as a so-called “SARS-affected area,” and specificexposure sites that were publicized by both provincialand federal public health officials. As noted in Chapter5, this sometimes led other countries to treat individualswho had visited Toronto or even transited throughToronto’s Pearson Airport as potential SARS cases. Otherprovinces and territories worked with the more specificHealth Canada definition rather than viewing everyonefrom the Greater Toronto Area [GTA] with respiratorysymptoms and a fever as a possible SARS case.

Criteria for a new disease inevitably must evolve as infor-mation about the disease cumulates. Some confusion wastherefore inevitable. However, WHO’s criteria meant thatrecords of exported cases used in the WHO assessment forthe Toronto travel advisory included individuals whowould not have met the Canadian case definition. Rapidcontact with countries diagnosing “cases” from Canadausually led to an understanding on both sides. Moregenerally, discrepancies between the WHO definition andthose used by individual countries were a recurrentsource of confusion in the media.

Only in June at the WHO Global Meeting on SARS inMalaysia did it become clear that many countries hadadopted their own case definitions. Surprisingly, thispractice was sanctioned by WHO itself. The Committeebelieves that further attention is needed to determine therespective roles of a body such as WHO and its memberstates in defining a new disease such as SARS.

11B.2 International ExperiencesWhile the focus in Canada was on the domestic SARSsituation, several Asian countries faced even greaterchallenges in containing their outbreaks. Each outbreakwas ultimately controlled through isolating cases, tracing and quarantining contacts, and maintainingvigilance in surveillance efforts. Although SARS seemed

to affect the same populations—mainly health careworkers, hospital patients, and household contacts—irrespective of country, there were several key differencesin how the outbreaks were managed in the variousjurisdictions.

Singapore’s experience is illuminating as its outbreak was similar in magnitude to that faced in Toronto (see Figure 1). Singapore is a city-state with a populationof just over four million, comparable to the GTA. InSingapore, a single hospital was designated as the “SARShospital,” caring for all SARS patients. This hospitalliaised with public health in a seamless operation toperform all contact tracing within 24 hours of suspect orprobable SARS cases being admitted—a clear contrastwith the situation in Toronto.

Those who were placed under quarantine in Singaporereceived compensation either directly or indirectly fromthe government. In Canada, only certain employeeswere eligible for benefits, while those who were self-employed or who did not qualify for benefits sufferedfrom lost income. In Singapore, quarantine orders wereissued by a private security company with twice daily callsby videophone. The very few violations that occurredresulted in the use of electronic tracking bracelets. In Toronto, public health staff struggled with massivehuman resource shortages; at times, they were able to callquarantined individuals only once every three days.

Singapore also benefited from strong leadership with asingle point of command-and-control. In fairness, Singaporeas a city-state is organized in a much less complex fashionthan Canada, where three levels of government wereinvolved in the SARS outbreak. Nonetheless, Dr. TonyTan, Singapore’s Minister of Health, was clearly in charge.He held daily press conferences each morning, where heshared not only facts but also uncertainties and potentialworst-case scenarios, along with actions that Singaporeanscould and should take to protect themselves and others.In Canada, multiple public health officials, clinicians,and politicians appeared at various times on newsbroadcasts, variously generating anxiety with mixedmessages or over-reassuring the public.

Singapore also conducted active surveillance for feversand pneumonias among all hospital inpatients, searchingfor any cases that may have been missed. We believe thatthe ineffectiveness of such programs in Toronto hospitalscontributed to SARS II. Differences in human resourceswere also evident: Singapore’s 1400-bed Tan Tock SengHospital had 40 staff carrying out active surveillance,while most hospitals in the GTA, as noted in Chapters 7and 8, had insufficient staff for ordinary infection control,let alone comprehensive syndromic surveillance.

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11C. Canadian-InternationalCommunication and Liaison

LiaisonLiaison with, and transmission of information to andfrom other countries and international organizations areimportant functions in the public health system at alltimes. These tasks are crucial when a public health crisisemerges. Soon after SARS arrived in Canada, HealthCanada and the Atlanta-based CDC exchanged one staffmember to act as liaison officers. This arrangement lastedseveral weeks and greatly facilitated interactions betweenthe two bodies. Similarly, a staff person from theCommunicable Disease Surveillance Centre of Englandand Wales was posted to Health Canada’s EmergencyOperations Centre in Ottawa for a week-long stint.

However, the bulk of SARS cases were in Asia, and expertsthere were gaining invaluable experience. Many observersfelt that Canadian officials failed to connect closely enoughwith officials in Hong Kong, Singapore and China. Oneexception occurred when WHO asked scientists from theNational Microbiology Laboratory [NML] and theWorkplace Health and Public Safety Program to providetechnical advice to Hong Kong, specifically at AmoyGardens, an apartment block where hundreds of residents

were infected through a defective sewage system, andalso at the Metropole Hotel, the epicentre of the outbreakin Hong Kong. Overall, however, Canada missed out onvaluable opportunities to learn from other countries. In contrast, those involved in managing the Singaporeoutbreak followed the Canadian situation closely.Provincial and municipal representatives from Canadavisited Beijing when the Chinese government extendedan invitation in the lull between SARS I and SARS II, andHealth Canada officials visited Singapore only after theglobal outbreak was essentially over.

CommunicationAlthough Health Canada regularly transmitted informationto WHO during the SARS outbreak, it was unable tosupply as much detail as was formally requested.2 Theabsence of formal reporting processes between municipal,provincial, and federal governments contributed greatlyto deficiencies in data acquisition and sharing. Someexperts told the Committee that Canada was simply unableto maintain the confidence of WHO due to incompleteaccounting of the outbreak and control measures as wellas obvious inter-jurisdictional tensions.

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F I G U R E 1Statistically estimatedSARS infection curves ofaffected areas (exceptfor People’s Republic ofChina).

y axis: expected numberof daily new infections,calculated from theSARS epidemic curvesby dates of onset ofsymptoms published bythe World HealthOrganization; x axis:dates of new infectionsSource: Ping Yan, Health Canada

Health Canada officials have stated that they repeatedlyasked the Province of Ontario for more detailed informationregarding the cases of SARS. A document outlining theinitial proposed data elements and the reason for collectingthe information was sent to the Ontario Ministry ofHealth and Long-Term Care [OMHLTC] on April 5, 2003.Besides Health Canada, both WHO and the otherprovinces and territories within Canada were requestingdetailed information. The federal perspective is thatOntario continued to submit incomplete data during thefirst part of the outbreak, and federal officials often gainednew information from Ontario’s daily press conferencerather than through intergovernmental channels. Asnoted in Chapter 2, the perspective from the Public HealthBranch of OMHLTC is sharply different. During thesecond phase of the SARS outbreak, it is clear that thedisagreements over data flow had largely abated.

The accounts of SARS in Chapters 2 and 5 have demon-strated that the local public health units and the provincialPublic Health Branch were overwhelmed by the enormousworkload during the SARS outbreak. Simply creating therequisite agreements for sharing data is not enough;capacity must be built at all levels of the public healthsystem to permit a more coordinated response tooutbreaks with adequate analysis and reportage.

Although Health Canada designated spokespeople inEnglish and French for SARS, the problem of mixed messagesoccurred federally as well as provincially. For example, theCanadian Embassy to the United States later complainedabout the multiple and at times divergent messages comingfrom Health Canada and the Department of ForeignAffairs and International Trade. They suggested that thedepartments find a way to centralize incoming andoutgoing information, including press releases.

Submissions to the Committee from the travel industryalso raised concerns about communications on SARS,indicating significant gaps and inconsistencies withrespect to information on SARS available to passengersand staff. Airports were overburdened with calls fromthe public looking for health-related travel informationyet they could not get a coordinated message on SARSfrom health officials. Some airports and transport carriersretained the services of a medical expert to educate staffon infectious diseases, both to help them do their jobsand to quell their concerns and fears.

The role of the travel industry in communications effortsshould also be recognized. Airports indicated that theyprovided communications equipment and services toHealth Canada, provided updates to the airport communityby way of bulletins and video records, and also organizedand hosted meetings for stakeholders. A number of travelindustry stakeholders have called for the establishmentof a communication strategy for infectious diseaseswhich includes contact points for the travel industry.

11D. Travel Advisories11D.1 WHO AdvisoriesOn April 2, 2003, WHO issued a travel advisoryrecommending the postponement of all but essentialtravel to Hong Kong and China’s Guangdong province.This was the first time the international agency had everissued such an advisory; previously, only individualcountries had issued travel advisories.

On April 23, 2003, WHO added Toronto, Beijing, andChina’s Shanxi province to the list of areas that travellersshould avoid. The advice against non-essential travel toToronto was scheduled to be in place for three weeksbefore reappraisal. As we noted in Chapter 2, the reactionof Canadian officials was swift and angry, with politiciansand public health officials from multiple levels of govern-ment travelling to Geneva to provide documentationthat Toronto’s outbreak was under control and to requestthat WHO remove the travel advisory. On April 29, lessthan a week after the initial announcement, WHO liftedits Toronto advisory.

Recognizing the threat of an emerging infectious disease,WHO apparently felt a need to support and protect lessdeveloped countries. The SARS global health alert waspredicated on the risk of transmission of the disease tocountries that would not have the infrastructure to copewith SARS, and the advisories reinforced this warning.However, the effects of the travel advisories have beenprofound on the economies of targeted countries.Canadians were particularly frustrated by the differencein concurrent categorization of Toronto by the CDC andWHO, with WHO issuing a more severe warning. Somehave suggested that WHO should confine itself toinforming countries of the epidemiologic situation inmember countries and not issue travel advisories.

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The controversies surrounding the WHO travel advisorywere augmented by the content of the travel advisorycriteria and the communication process leading up to theannouncement of the advisory. The criteria seem arbitraryand were developed during the outbreak without aformal consultation process or serious scientific debate.The criteria referred to “prevalent cases” (which apparentlyincluded persons with SARS still in isolation), categor-ically assessed as more or less than 60, more or less than5 new cases per day on a three day rolling average, andlocal transmission. The export of SARS to other countrieswas also considered.

None of these criteria has ever been validated as reasonsfor issuing a travel advisory. The 60-case threshold hasbeen described as arising “out of the blue”. One seniorHealth Canada official who acted as the liaison withWHO and criticized the criteria, was under theimpression that the criteria were still in draft form evenas WHO used them to impose the advisory on Torontoand other regions. There are conflicting accounts as towhether warning was given in a telephone call about theimpending travel advisory in a conversation amongWHO, PAHO, and Health Canada staff about the“affected area” criteria. In any event, within 24 hours ofthat conversation, a travel advisory had been issued.While there were some brief recriminations betweenpublic health officials, one positive effect of the advisorywas to create a welcome unity of response among alllevels of government.

The Committee can find little rationale for the criteria orthe timing of the WHO travel advisory. If WHO is tocontinue issuing advisories, clear criteria and a processfor notice must be developed by agreement amongmember states.

11D.2 Health Canada AdvisoriesIn Canada, travel advisories are issued by Health Canada’sTravel Medicine Program, which assesses the risk forCanadians travelling abroad through information obtainedfrom WHO, GPHIN, the Department of Foreign Affairsand International Trade, and other sources. Three levelsof advisories are used: routine advice (i.e., no advisory),defer all non-essential travel, and defer all travel. Thissystem has existed for many years, and advisories havebeen issued on outbreaks of new and known diseases, aswell as natural disasters and hazards, such as bushfires in Australia.

During the SARS outbreak, the major concern was theextent of community spread and the risk that communityspread might pose to the Canadian traveller. In addition,as it became clear that hospitals were sources of transmis-sion of SARS, Health Canada became concerned thatCanadian travellers with pre-existing medical conditionsmight have to seek medical care in seriously affectedSARS countries, thereby incurring the risk of exposure.

Health Canada used information from WHO on affectedarea status, and combined this with information collectedby GPHIN and other sources to produce a score that wasthen translated into an advisory. In this scoring system,Health Canada used WHO’s categorical labels that werebased on the transmission pattern in a particular city orprovince. These were translated into numbers andaveraged for a country, and then an advisory for thecountry would be generated.

The Committee can find no evidence to suggest thatHealth Canada’s own scoring system has a much firmergrounding than the WHO criteria. By using the WHO“affected area” definitions, Health Canada incorporatedcriteria into its travel advisories that it criticized whenWHO applied them to Toronto. This system was usedthroughout the outbreak, and led to the issuance oftravel advisories for other jurisdictions such as HongKong. As one can see in the Table 1, the travel advisoriesissued by WHO and Health Canada diverged, with theCanadian advisories at times more severe than those ofWHO. This and other conflicts between WHO andHealth Canada advisories sparked an expression ofconcern by the Department of Foreign Affairs andInternational Trade. Canadian missions abroad also werequestioned as to the reason why travel advisories fromCanada differed to those of WHO.

In short, while many Canadian officials have beencritical of WHO over the lack of evidence for its traveladvisory criteria, Canada’s own practices should berevisited, ideally in the context of a multilateral re-assessment of the basis, nature, goals, and impact ofadvice to travellers.

11E. SARS and Travel IssuesAs early as March 15, 2003, WHO issued an emergencytravel advisory warning travellers and airline crews to bealert for symptoms consistent with SARS, and theyoutlined basic procedures for airlines in the event that apassenger or aircrew member became symptomatic in-flight. Later, after its annual World Health Assembly

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meeting in May, WHO’s SARS Resolution urged memberstates to apply their guidelines regarding internationaltravel.

11E.1 Quarantine ActUnder the Quarantine Act and Regulations, the federalgovernment exercises its responsibility to help protectCanadians from diseases which might pose a threat topublic health through the international movement ofpeople, goods and conveyances (e.g., airplanes, ships,vehicles, etc.). The Quarantine Act and Regulations givequarantine officers at Canadian ports of entry and exit theauthority to require that a person suspected of having adisease listed in the Act or another dangerous disease

undergo a medical examination and to detain that personif necessary. The Act lists four contagious diseases:cholera, plague, yellow fever and smallpox. In keepingwith WHO’s urging that member nations take thenecessary steps to address the SARS outbreak, HealthCanada has amended the Quarantine Act Regulations.The amendments include adding SARS to the QuarantineAct’s Schedule of infectious and contagious diseases;prescribing an incubation period for SARS (20 days);providing quarantine officers with the authority to compelairline carriers on relevant incoming and outgoing flightsto distribute SARS health information and questionnairesto all persons on board; and extending the list of airportswhere an aircraft arriving in Canada must report, beforelanding, cases of illness or death on board the aircraft.

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T A B L E 1Comparison of travel advice against Hong Kong by WHO and Health Canada

Date WHO Health Canada

25 March Recommends no travel restriction to any destinationincluding Hong Kong.

Recommends that people planning to travel to Hong Kongshould defer all travel until further notice.

2 April As a measure of precaution, WHO recommends thatpersons traveling to Hong Kong consider postponingall but essential travel. This recommendation appliesto travelers entering Hong Kong, not to passengersdirectly transiting through the Hong Kong internationalairport.

Recommends that people planning to travel to Hong Kongshould defer all travel and alternate routing be considered,when possible, if a traveler is transiting through HongKong.

13 May Recommends that people planning to travel to Hong Kongshould defer all travel and recommend alternate routingbe considered, when possible, if a traveler is transitingthrough Hong Kong.

15 May Based on the evidence that the SARS situation hadpeaked and is confined to certain well defined areas inHong Kong, Health Canada recommends to defer allelective or non-essential travel to Hong Kong.

23 May Removes the recommendation that people shouldpostpone all but essential travel (i.e., no travel restriction).

30 May Due to the continued concern about limited spread ofSARS Health Canada recommends to defer all elective ornon-essential travel to Hong Kong.

16 June Due to the continued concern about limited spread ofSARS Health Canada recommends to defer all elective ornon-essential travel to Hong Kong.

23 June Hong Kong removed from the list of areas with recentlocal transmission, i.e., the chain of human-to-humantransmission is considered broken, thus eliminating therisk of infection for both local residents and travelers.

No further mention of any travel restriction against Hong Kong.

11E.2 Quarantine OfficersIn 2002, Health Canada informed airport authorities thatit would be transferring airport quarantine responsibilitiesto Canada Customs. Customs staff were never trained todo the job. When SARS arrived, Canada had only a tinycontingent of quarantine officers prepared to screenpassengers arriving from Asia. A few Health Canadanurses were rapidly trained and dispatched to Torontoand Vancouver to act as quarantine officers by March 18.Later, more officers were deployed to international airportsin Montreal, Calgary, and Ottawa. The responsibilities ofthe quarantine officers have traditionally includedassessing passengers and cargo from aircraft, ships, trains,cars, etc., and detaining any person or object suspectedof being infected.

During the SARS outbreak, the handful of quarantineofficers performed screening, handed out information totravelers, and responded to requests from flight crews,customs, and immigration officers for assistance in theassessment of sick persons on aircraft. Normally inMarch, 12 to 14 flights arrive from Asia daily, and withthe average capacity on each flight being 315 passengers,over 27,000 passengers required screening each week.With the drop in tourism due to SARS during April andMay, the volume was reduced to about 19,000 per week.In any case, the quarantine officers were quickly over-extended and eventually needed additional assistance,which was provided by local public health authoritiesand Health Canada’s regional First Nations and InuitHealth Branch office.

Airport authorities made submissions expressing concernabout Health Canada’s ability to mobilize knowledgeablequarantine staff to the airports, to provide logisticalsupport, and to manage communications to their ownstaff, the airports, air carriers, and the public. Airportauthorities clearly felt that Health Canada quarantinestaff were sent into the situation with limited briefingand little or no supporting materials.

11E.3 Screening Measures and Provisionof Health Information

Screening of incoming air passengers was started as aninitial response to prevent importation of SARS.(Appendix 11.1 provides a chronology of airport screeningin Canada.) Passengers from Asia were “visually screened”and greeted with yellow Health Alert Notices providinginstructions on how to self-monitor for SARS symptoms;

they were also required to provide contact information toallow public health officials to trace them in the eventthat a fellow passenger was diagnosed with SARS. Posterswith pertinent information about SARS were placed instrategic locations around the airports.

On March 27, 2003, WHO recommended that areas withlocal transmission of SARS institute measures to screendeparting travelers. Health Canada responded byproviding cherry-coloured Health Alert Notices identicalto those being provided for incoming travelers.

In May, as part of the understanding that led WHO torescind its travel advisory, the federal government agreedto institute further exit screening of air travelers. Theinformation cards for both arriving and departing travelerswere revised to include a set of screening questions* in aneffort to detect symptomatic individuals. Anyone whoanswered “yes” to any of the questions was interviewedby Health Canada screening nurses; and any possible SARScases would be promptly isolated and transferred to healthfacilities for further evaluation. WHO also suggested thatthe use of thermal scanners be considered. One machinewas graciously loaned to Canada by Singapore, and othersacquired as part of a pilot project to test the technology.These machines were installed in Toronto and Vancouverto detect travelers with fever.

In submissions to the Committee, airport authorities inboth Vancouver and Toronto were critical of HealthCanada’s organizational ability and operational capacityin managing travel screening. The Vancouver InternationalAirport Authority submission to the committee noted, forexample, that Health Canada officials repeatedly referredto a “contingency plan” that “had never progressedbeyond the draft stage and appeared to (have been)abandoned.” They also noted that the language barriersof many travelers were not appropriately addressed;information should have been provided in Chinese aswell as English and French.

As of August 27, 2003, an estimated 6.5 million screeningtransactions occurred at Canadian airports to aid in thedetection and prevention of SARS transmission. Roughly9,100 passengers were referred for further assessment byscreening nurses or quarantine officers. None had SARS.Over 3.2 million arriving passengers were screened usingyellow cards; compliance was close to 100% because ofthe mandatory review by Customs officials. Over990,000 outbound passengers were screened at Toronto’sPearson international airport using cherry cards. Audits

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* Do you have a fever? Do you have one or more of the following symptoms: cough, shortness of breath or difficulty breathing? Have you been incontact with a SARS-affected person in the last 10 days?

conducted by Health Canada staff demonstrated thatthere was also a high rate of compliance with cherrycards; over 90% of departing international passengersindicated that they had received the cards and had beenasked health-related questions at check-in by airline staff.

The pilot thermal scanner project included most inboundand outbound international passengers at Toronto’sairport, and all passengers on inbound flights from Asia,as well as a sample of three outbound internationalflights daily at Vancouver’s airport. Almost 2.4 millionpassengers were screened by late August, the vast majorityin Toronto. Only 832 required further assessment, andagain none were found to have SARS. More detailedstatistics are provided in Appendix 11.2.

In other countries, the yields for airport screeningmeasures were similarly low. An evaluation of airportscreening in Beijing revealed that despite screening over275,000 travelers between April 24 and June 20, only0.2% were determined to have fever. None had SARS. In Singapore, 30,000 passengers were screened each day,with about 60 of those assessed further. Again, none hadSARS. Only in Hong Kong did airport screening yieldany SARS cases—after screening millions of travelers withthermal scanners, two SARS cases were found.

These results are not surprising. Screening for a raredisease like SARS in a large population (i.e., millions oftravelers) is both difficult and ineffective with an extremelylow likelihood of actually detecting cases. Also, travelscreening fails to detect those who may be incubating thedisease—these individuals would still be symptom-free.Screening healthy people for infectious diseases shouldbe based on certain premises: that a disease is present inthe general population, that it can be detected by screeningmeasures, and that there is a high risk of transmission byasymptomatic individuals. None of these conditions weremet by SARS. In the absence of such features, screeninghealthy people is expensive, possibly highly intrusive, andcan create a false sense of security or needless anxieties.

The claim that screening bolsters business confidence hasbeen promoted by various countries at internationalforums. Given the available data, screening appears to bemore about conformity than logic or evidence, with nocountry prepared to take the first step of abandoningthese measures. Furthermore, any measures implementedat airports should theoretically be replicated at ports andat land border crossings. In Canada, with 18 land bordercrossings with the US, this was impossible. Instead,replicating the CDC's action, information cards wereprovided to an estimated 200,000 vehicles per monthentering Canada.

Formal screening may be difficult to justify, but provisionof timely and practical health information to travelers ismuch less expensive and based on the defensible assump-tion that the vast majority of persons are rational andwell-intentioned, and can make intelligent risk assessments.The benefit of providing health information to travelershas been demonstrated in at least one anecdotal report ofa person who arrived in British Columbia from anaffected area and was subsequently diagnosed as havingSARS. He developed symptoms one to two days afterarrival, isolated himself as instructed on the yellowHealth Alert Notice, and was admitted to hospital whereisolation precautions were strictly followed. There wasno secondary spread from this case.

11E.4 Protocols for Airlines and CruiseShips

At one point early in the SARS outbreak, a traveler whoexhibited SARS-like symptoms arrived in Vancouver;Health Canada invoked the Quarantine Act to stop theaircraft from departing until it had been properly decon-taminated. However, Health Canada officials were unableto advise the airline as to the requirements for adequatedecontamination because they were still unsure of thecause of SARS. Protocols for aircraft and airlines were notdeveloped until the end of April. These outlined theappropriate cleaning agents and protective measures tobe used when decontaminating an aircraft that hadcarried a potential SARS case. Health Canada’s protocolsfor screening, handling of SARS cases, and cleaning cruiseships were released in mid-June.

Related problems encountered during the SARS outbreakwere jurisdictional disagreements between federal andlocal officials, as well as between local health authorities,with regards to airports and ports situated within thegeographic boundaries of local health units. For example,University of British Columbia [UBC] Hospital in Vancouverwas designated as the facility for SARS patients; however,the airport was located in the suburb of Richmond andtherefore part of a different health region. Travelers withSARS-like symptoms were allegedly examined in theparking lot to determine whether they should be transportedto the UBC Hospital or to the local Richmond Hospital.

In all these instances, business processes can bedeveloped to anticipate difficulties and ensure the fasterimplementation of containment, decontamination, orreferral protocols.

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11F. Recommendations Having regard to the international issues reviewed above,the Committee recommends that:

11.1 The Government of Canada should take thelead, along with an international consortiumof committed partners, in the detection ofglobal emerging diseases and outbreaks. Thisshould be done through enhancements to theGlobal Public Health Intelligence Network andsimilar programs.

11.2 The Canadian Agency for Public Health shouldhave a mandate for greater engagement inter-nationally in the emerging infectious diseasefield, including the initiation of projects tobuild capacity for surveillance and outbreakmanagement in developing countries.

11.3 The Canadian Agency for Public Health shouldbe the institution responsible for direct commu-nication with the World Health Organization,the US CDC, and other international organiza-tions and jurisdictions. The Agency shoulddisseminate within Canada information receivedfrom international organizations and jurisdic-tions on global health threats, and in turn, itwould inform the World Health Organizationand other jurisdictions of relevant Canadianevents. During outbreak situations, the Agencywould perform the role of liaising betweenCanadian and international organizations andjurisdictions to maximize mutual learning.

11.4 The Government of Canada should review itstravel screening techniques and protocols witha view to ensuring that travel screening measuresare based on evidence for public health effec-tiveness, while taking into account thefinancial and human resources required for theirimplementation and sustained operation. TheGovernment of Canada should also initiate amultilateral dialogue with other nations thatare currently engaged in SARS travel screeningto determine whether and when some or all ofthese measures should be modified ordiscontinued.

11.5 The Government of Canada should seek thesupport of international partners to launch amultilateral process under the auspices of theWorld Health Organization that would setagreed-upon standards of evidence for theissuance of travel advisories and alerts bymember states. The multilateral processshould also seek to determine the role of WHO

in issuing travel advice, and to establish aprocedure for providing advance notice forpossible alerts and advice. The notice processshould provide a mechanism for consultationwith and a response by the target country.

11.6 The Government of Canada should ensure thatan adequate complement of quarantineofficers is maintained at airports and otherports of entry, as required. Fully trained andinformed quarantine officers should beavailable at airports to deal with healththreats, to provide information to and educateairport staff, customs officials, and airlinepersonnel concerning the recognition of illnessand measures to be taken to contain risk.Close collaboration with airport authoritiesand airline personnel to clarify responsibilitiesin the event of a health threat is necessary.

11.7 The Government of Canada should ensure thatincoming and outgoing passengers are providedwith health information about where and whenhealth threats exist, including any precautionarymeasures to take, how to identify symptoms ofthe disease, and what first steps to take in caseof suspected infection. A partnership with thetravel industry would facilitate this process sothat information could be provided at the timeof bookings. The current Health Canada website containing information for travelersshould be made more prominent and itsexistence promoted.

11.8 All federal/provincial/territorial/municipalresponse plans should include port/cruiseship-and airport/airplane-specific protocols forinfectious diseases as well as protocols foremployee protection guidelines and decontam-ination of aircraft, ships, and/or facilities.Jurisdictional issues concerning travel and healthneed to be resolved through the plan. The planshould be developed with input and buy-infrom local health officials, response agencies,ports, airports and the relevant companies inthe shipping and airline industries.

References 1. Institute of Medicine, “Emerging Infections: Microbial

Threats to Health in the United States”, January 1,1992. Accessed on Aug 4 2003 athttp://www.iom.edu/report.asp?id=4572.

2. World Health Organization, Weekly EpidemiologicRecord, 2003, 78 (14): 102-105.

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Appendix 11.1A Chronology of SARS Travel ScreeningChronology - SARS Screening (2003)February 24 SARS arrives in Canada carried by individual returning from Hong Kong

March 12 WHO issues global alert on “mysterious virus-pox” epidemic in China

March 13 Health Canada notified of several cases of atypical pneumonia in Ontario

March 18 Quarantine Officers deployed. HC begins distribution of “Health Alert Notices” to travelers arriving in & returning to Canada from Asia at Pearson and Vancouver airports

March 21 Yellow health information cards distributed to major airports in Canada

March 24 HC deploys personnel to Dorval for increased screening of incoming passengers

March 27 WHO recommends SARS-affected areas with known transmission to institute measures to identifyinternational passengers with symptoms. Also issues recommendations to airlines regarding suspectedcases in-flight

April 3 Distribution of cherry cards for passengers departing Pearson on international flights implemented –expands to Toronto Island Airport and train stations April 7

April 9 In-flight distribution of Yellow cards and contact forms begin on 9 airlines with flights from Asia

April 23 WHO travel advisory in place for Toronto, lifted April 30

May 7 Thermal scanner on loan from Singapore operational at Pearson

May 14 Toronto removed from WHO’s list of areas with local transmission. Returned to list May 26 and removedagain on July 2

May 16 Distribution of revised Yellow health alert cards (with questions) begins at Toronto and Vancouver forinternational travellers on all Asian airlines bringing passengers into Canada and Air Canada (flightsfrom Asia)

May 16 Distribution of revised Cherry cards (with questions) for outbound flights begins at Toronto for 5international airlines. Six Thermal Scanners set up in Vancouver airport for all incoming internationaltravelers (subsequently reduced to 5 due to malfunctioning equipment)

May 23 Six Thermal scanners set up in Toronto Pearson airport for all incoming and outgoing internationaltravelers

June 2 Start distribution of Cherry cards for all outbound international airlines from Toronto

June 6 Yellow card screening in place for all international flights into Toronto and Vancouver and at 18 land-border crossings from the U.S.

June 10 HC’s protocol for cruise ships posted online

June 12 Amendments to the Quarantine Act and Regulations come into effect

June 14 Yellow card screening in place for all international flights arriving in Toronto, Vancouver, Calgary, Montreal and Ottawa

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Measure LocationDaily Report Cumulative Report

CommentsScreened Further

Assessed Results Screened FurtherAssessed Results

CherryCards -

outboundToronto 10,074 7 all cleared 992,720 792 all cleared

All international flights flying from all terminalsnow using "Cherry Card" process.

Yellow Cards -inbound

Toronto 15,217 33 all cleared 1,091,709 3,158 all cleared

All international flights arriving daily in Toronto(70+ airlines), Vancouver (100+ airlines),Ottawa (13+ airlines), Calgary (20+ airlines),Dorval and Mirabel (23+) have yellow-cardscreening in place. Vancouver data to dateonly reports Asian airline arrivals. We arecompiling past records to update thisinformation for all airlines.

Scanners(pilot

project)

Toronto 25,291 4 all cleared 2,051,141 791 all cleared

2 companies operating: FLIR (3) and ThermalImaging Inc (3), all static:• Terminal 1 (2 machines - inbound and

outbound)• Terminal 2 (2 machines - inbound and

outbound)• Terminal 3 (2 machines - inbound and

outbound)• Hrs of operation per airline schedules.

Shifts covering 8:30 a.m.- 9:00 p.m.

Vancouver 4,714 1 all cleared 310,745 41 all cleared2 companies operating: Mikron (3) FLIR (3):• 1 FLIR machine is hand-held.• Hrs of operation per airline schedule. Shifts

covering 7:00 a.m.-11:00 p.m.

TOTAL ALLCARDS 39,973 97 all

cleared 4,195,847 8,268 allcleared

TOTAL ALLSCANNERS 30,005 5 all

cleared 2,361,886 832 allcleared

Scanner leases have been extended to Sept. 16th.

Video

All airlines(with the

exception ofAir Canada

and PhilippineAirlines) areshowing the

video.

7 of 9 airlines from SARS-affected areas flying into Toronto & Vancouverhave copy of video

Videos were sent to Air Canada on July 31.Videos were sent to Philippine Airlines on July7th. We have received confirmation from AirCanada that they will start showing the videosbeginning August 9. Philippine Airlinesreceived their copies via the Canadian Consuloffice in late July. They expect to be playingthem by mid-August.

LandBorders

Approximately200,000 vehi-cles per monthare receivingyellow cardsat 18 land-

bordercrossings

GRANDTOTAL ALLSCREENINGMEASURES =

5,753,185

5,753,185 represents the total passenger screening transactions: some people will have been screened twice (with cherry/yellow cards and then withthermal temperature scanners)

Vancouver 4,118 24 all cleared 1,137,526 2,111 all cleared

Vancouver 2,774 16 all cleared 282,425 888 all cleared

Vancouver 6,602 15 all cleared 629,599 1,103 all cleared

Ottawa 1,188 2 all cleared 61,768 236 all cleared

Yellow CardSubtotal 29,899 90 3,203,027 7,476 all cleared

August 8-12 audit findings of 1,302 passengers:93% of people surveyed (1,210) at Pearsonresponded they received a cherry card. 80%responded they had been asked health-relatedquestions at check-in. Follow-up with airlinesnot fully complying.

Appendix 11.2SARS Screening Measures - Daily Report August 27, 2003 (end-of-day)

LEARNING FROM SARS: Renewal of Public Health in Canada. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

SARS has demonstrated the speed with which a dangerousnew disease can emerge and spread around the planet.The seriousness of the outbreak and the challenges thatarose in containing SARS are widely and rightly regardedas signposts for the need to strengthen Canada’s publichealth systems.

In fact, the evidence of actual and potential harm to thehealth of Canadians from weaknesses in public healthinfrastructure has been mounting for years without atruly comprehensive and multi-level governmentalresponse. Canada has faced the HIV epidemic, watercontamination in Walkerton, Ontario and NorthBattleford, Saskatchewan, and threats to the safety ofCanadian blood supplies from HIV and Hepatitis B andC. The events of September 11, 2001 and the relatedanthrax attacks on our US neighbour heralded thepossibility of bioterrorism within our borders. Recently,one part of the country has faced economic hardshipcaused by fears of the spread of BSE from cattle tohumans, while others are trying to stem the spread ofWest Nile virus from birds to humans. And as this reportgoes to press, a new public health crisis is unfoldingaround a meat packing plant in Aylmer, Ontario.

All these events have represented tangible threats to thephysical and economic well-being of Canadians. Allthese threats emphasize the need for a seamless publichealth system. At minimum, Canadians expect that thenation’s public health systems should be fully preparedto deal with emergencies caused by infectious diseases,accidental or intended, and consistently be able toprotect them from mass contamination of water or food.These minimal expectations are not being met.

As a disease outbreak, SARS was relatively small.Nonetheless, the disease killed 44 Canadians, and causedillness in a few hundred more. The response to theoutbreak paralyzed a major segment of Ontario’s healthcare system for weeks, and saw more than 25,000 residentsof the Greater Toronto Area placed in quarantine.Psychosocial effects of SARS on health care workers,patients, and families are still being assessed, but theeconomic shocks have already been felt. Estimates basedon volumes of business compared to usual seasonalactivities suggest that tourism sustained a $350 millionloss, airport activity reduction cost $220 million, andnon-tourism retail sales were down by $380 million. It seems entirely possible that the direct and indirectcosts of SARS could reach $2 billion.

As Canada recovers from this extraordinary set of events,the National Advisory Committee on SARS and PublicHealth has been weighing what lessons might be learnedfrom the outbreak of SARS in Canada. The foregoingchapters indicate that there was much to learn—in largepart because too many earlier lessons were ignored. Weare confident that related work by other individuals andgroups—including the Senate Standing Committee chairedby the Hon. Michael Kirby, the expert panel in Ontariochaired by Dr. David Walker, and the public healthinvestigation by Mr. Justice Archie Campbell—will lead tomany lessons beyond those drawn here. Those ongoingassessments, however, must not be used by governmentsas an excuse for inaction and delay.

Before recapitulating the recommendations from earlierchapters, some themes and issues from the body of thisreport may be worthy of review.

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Our first theme is that the single largest impediment todealing successfully with future public health crises is thelack of a collaborative framework and ethos amongdifferent levels of government. If the experience of SARSin Ontario were to be repeated in a jurisdiction with fewerresources and a smaller base of highly-skilled and dedicatedpersonnel, or in the face of a more virulent infectiousdisease, the consequences could be disastrous. Canadiansexpect to see their governments collaborate responsibly inthe face of a serious threat to the health of the population.The rules and norms for a seamless public health systemmust be sorted out in advance of a health emergency,with a spirit of partnership and shared commitment tothe health of the citizenry, not on an ad hoc basis in themidst of the battle to contain a viral outbreak.

Systems-based thinking and coordination of activity in acarefully-planned infrastructure are not just essential in acrisis; they are integral to core functions in public healthbecause of its population-wide and preventive focus. To repeat an observation from an earlier chapter: theCommittee does not seek to build public health systemsso perfect that people no longer need to be good. But webelieve Canadians should demand a set of interlockingpublic health systems sufficiently strong that bad thingsdo not happen needlessly to good people. The case for acollaborative and coordinated approach to public healthis arguably even more acute than in our still-fragmentedpersonal health services systems. Weakness in healthprotection or disease control in one jurisdiction willrapidly affect many other jurisdictions. To that end, theCommittee has recommended strategies that will strengthenall levels of the public health system as well as integratethe components more fully with each other.

The Committee appreciates that F/P/T relations are notstraightforward in Canada (or any other federation). That,in large part, is why we have proposed new structuresand funding mechanisms that aim to remove publichealth from the jurisdictional cross-fire. The Committeenonetheless strongly urges current and futuregovernments to view public health as a ‘constructive-engagement zone’ in F/P/T relations for several reasons.

First, public health threats have generalized impacts. Thesuccess of Ontario and British Columbia in containingSARS spared the rest of the country. We cannot afford tohave any weak links in a pan-Canadian chain of healthprotection and disease control.

Second, public health costs are modest—perhaps 2-3% ofhealth spending, depending on how one defines numeratorsand denominators. The actual amount of new federalspending that the Committee has recommended wouldreach $700 million per annum by 2007. This is whatF/P/T governments currently spend on personal healthservices in Canada between Monday and Wednesday in a single week.

Third, the Committee’s recommendations for new fundingare oriented to supporting all jurisdictions. Until now,there have been no federal transfers earmarked for localand provincial/territorial [P/T] public health activities.Public health has instead been competing against personalhealth services for health dollars in provincial budgets,even as the federal government has increasingly earmarkedits health transfers for specific health service priorities.About 75% of the new federal spending that we haverecommended will flow to support local and provincial/territorial public health activities. This includes $300 million per annum for front-line public healthactivities under the new Public Health Partnerships Program,$100 million per annum to support P/T purchase of costlynew vaccines under a reinvigorated National ImmunizationStrategy, and $100 million in a Communicable DiseaseControl Fund to support second-line defences at the P/Tlevel and link P/T and federal centres of excellence insurveillance, prevention, and containment of infectiousthreats to health. Furthermore, the new CanadianAgency for Public Health would make significant newinvestments in health human resources, research, andsurveillance for non-communicable diseases—all ofwhich will have direct benefits for P/T jurisdictions.

Fourth and finally, the fiscal and strategic approaches setout in this report are entirely consistent with internationalprecedents and, we believe, the expectations of Canadians.Similar programs of transfers for public health to statesand territories exist in Australia and also operate underthe auspices of the Centers for Disease Control andPrevention [CDC] in the USA. Public health authoritiesin the European Community are building capacity tocoordinate health protection and facilitate networkingamong national foci for disease control. With theglobalization of health threats and growing importanceof international collaboration in disease control, theCommittee urges F/P/T governments to coalesce aroundpublic health as a pan-Canadian priority.

We turn back now to the Committee’s recommendations.

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The first section consists of a series of recommendationsthat require urgent attention by governments as part ofpreparation for the winter season and the associatedincreases in the incidence of respiratory viral illnesses.They are largely self-explanatory.

The sections thereafter recapitulate recommendationspresented in the body of the report. Arguments in supportof each recommendation were given in the relevantchapter. For brevity, we do not repeat the rationale forthe recommendations or elaborate on them below.

While the Committee is providing its advice and recom-mendations to the federal Minister of Health, publichealth broadly and health emergencies more specificallyare national issues that require pan-Canadian collaborationand involvement. No one level of government has soleresponsibility over all aspects of public health. And,given the roles and experiences of various Committeemembers, we believed it would be a dereliction ofresponsibility for us to focus very narrowly on federalissues. Therefore, by necessity, we present recommendationsor sub-recommendations that apply to jurisdictions inaddition to or other than the federal government.

Among these are recommendations that deal with thepersonal health services sector and aspects of local publichealth arrangements where P/T jurisdiction is relativelyclear. Most of these were first set out in Chapter 8. The information and evidence bearing on those recom-mendations was carefully collected, albeit primarily fromone large province. We repeat these recommendations inthe hope that they may be useful to all P/T jurisdictions.

A further caveat is that many of the recommendationsapply to public health broadly. Infectious diseases are anessential piece of the public health puzzle, but cannot beaddressed in isolation, particularly since in local healthunits, the same personnel tend to respond to both infec-tious and non-infectious threats to community health.Furthermore, the success of health emergency planningand outbreak management is dependent upon a broadand solid public health foundation. Implementation ofthese recommendations should therefore greatly enhancethe capacity of Canada’s public health systems to respondto infectious diseases or other health emergencies, whilesimultaneously renewing the general public healthinfrastructure and its ability to protect and improve thehealth of Canadians.

12A. Preparing for the RespiratoryVirus Season

As Canada recovers from SARS, preparations must beginfor the next respiratory virus season. SARS may or maynot re-emerge; however, even if it does not, the publichealth system and the health care system will be forcedto respond to many false alarms. While many of theinitiatives needed to renew the public health system willrequire months or years of hard work, there are someareas that, in the Committee’s view, require attentionover the next three months.

• A national manual for the investigation and control of SARS outbreaks should be completed. Parts of thismanual exist in Health Canada guidelines, and inOntario and British Columbia directives and guide-lines. A coordinated and detailed package needs to beavailable to hospitals and public health units acrossthe country. Health Canada funding and a secretariat,as well as P/T cooperation and collaboration, will be necessary.

• In addition to a comprehensive technical manual foroutbreak containment, Health Canada should coor-dinate the development of an educational packageabout routine practices, SARS, and SARS surveillancefor the coming winter season that can be distributedto hospitals, programs and institutions involved ineducating health professionals, and various professionalassociations and stakeholder groups for use in trainingfront-line staff.

• The F/P/T Conference of Deputy Ministers shouldimmediately designate lead public health officials todevelop guidelines for federal, provincial, local, andinstitutional roles and responsibilities during anoutbreak of SARS or similar agent. This work wouldbe antecedent to more comprehensive and longer-term development of intergovernmental agreementson public health roles and responsibilities. It shouldspecify the roles of institutions and various levels ofgovernment in both domestic and internationalelements of responding to SARS.

• Real-time alert systems for SARS and similar respiratoryillnesses need to be created and coordinated. Thisincludes: mechanisms for rapid reporting of activitywithin Canada to Health Canada, mechanisms for infor-ming Canadians rapidly of developments in other juris-dictions, and mechanisms for prompt communicationof the evolving scientific data from Canada and otherparts of the world. The alert systems must extend toall health care facilities and, to the greatest extentpossible, should also reach primary care providers.

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• National recommendations on surveillance for SARSshould ideally be completed by mid-October. Primarycare providers require guidelines for assessment andreferral of respiratory illnesses, given the high volumeof such patients in their offices during the wintermonths. Definitive diagnoses will generally be made inemergency departments and hospitals. Hence, forclarity of responsibility, surveillance planning shouldbe led by the Nosocomial and Occupational InfectionsSection within the Centre for Infectious DiseasePrevention and Control [CIDPC] with input fromother key divisions. The surveillance strategy shouldinclude recommendations for appropriate laboratorytesting for SARS and other viral pathogens, a manualof definitions and procedures, and a software programfor data entry at the hospital level for reporting tolocal public health units.

• The National Microbiology Laboratory, through theCanadian Public Health Laboratory Network, shouldestablish guidelines for the necessary laboratorycapacity across the country. Provincial ministries ofhealth should coordinate provincial and hospitallaboratory resources to ensure that adequate capacityfor SARS and other viral testing is available by mid-November, and that clinicians are educated as to whatspecimens are needed, how they should be sent, andthe timeframe for reporting of results.

• Health Canada should work ahead of the HealthEmergency Response Team [HERT] framework to create,organize, and resource two national epidemic responseteams. Their roles, responsibilities and reportingstructure need to be negotiated with the provincesand territories, with due consideration given to theneeds and responsibilities of the local public healthunits and other institutions or agencies that the teamswould be sent to assist.

• A full research evaluation and publication of the effec-tiveness of passenger screening on the detection of‘importation and exportation’ of SARS should becompleted as soon as possible. Health Canada shouldshare these results with other jurisdictions that areperforming passenger screening antecedent to themultilateral dialogue on passenger screeningrecommended below.

• International technical liaison offices, at a minimumwith the World Health Organization [WHO] and theUS CDC, should be established for the NationalMicrobiology Laboratory and the CIDPC. Protocolsfor the exchange of liaison officers during epidemicsmust be negotiated.

• Health Canada should coordinate an open scientificmeeting late in the Fall, with objectives that include:updating Canadians on the science of SARS, discussingplans for SARS surveillance for the winter season, and reviewing the roles of travel advisories andpassenger screening.

12B. Recommendations forRenewal of Public Health in Canada

12B.1 New structures for Public Health • The Government of Canada should move promptly

to establish a Canadian Agency for Public Health, alegislated service agency, and given it the appropriateand consolidated authorities necessary to provideleadership and action on public health matters, suchas national disease outbreaks and emergencies, with or without additional authorities regarding nationaldisease surveillance capacity.

• The Government of Canada should ensure that thescope of the Agency’s mandate covers public healthbroadly with appropriate linkages to other governmentdepartments and agencies engaged in public healthactivities. The Government’s scoping exercise for thenew Agency must be informed by a careful review ofpublic health service provision and health promotionfor First Nations and Inuit Canadians.

• The architects of the new Canadian Agency for PublicHealth should ensure that its structure follows a huband spoke model whereby links are made to existingregional centres with particular strengths in publichealth specializations while some other functions andnew ones are devolved to other regions of the country,with a vision that these parts support the entire system.

• The Government of Canada should create the position of Chief Public Health Officer of Canada.The Canadian Agency for Public Health should beheaded by the Chief Public Health Officer of Canadawho would report directly to the federal Minister ofHealth and serve as the leading national voice forpublic health, particularly in outbreaks and otherhealth emergencies.

• The Government of Canada should create theNational Public Health Advisory Board, and ensurethat nominations of board members come forwardthrough provincial and territorial as well as federalchannels. The mandate of the Board will be to advisethe Chief Public Health Officer of Canada on thedevelopment and implementation of a truly pan-Canadian public health strategy.

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• The F/P/T Conference of Deputy Ministers of Healthshould initiate a new Network for CommunicableDisease Control that would link F/P/T activities ininfectious disease surveillance, prevention, and manage-ment. This initiative should be started as soon aspossible, and integrated with the existing F/P/T Networkfor Emergency Preparedness and Response.

• The Canadian Agency for Public Health should createa Public Health Ethics Working Group to develop anethical framework to guide public health systems andhealth care organizations during emergency publichealth situations such as infectious disease outbreaks.In addition to the usual ethical issues, the WorkingGroup should develop guidelines for collaborationand co-authorship with fair apportioning of authorshipand related credit to academic participants in outbreakinvestigation and related research, and develop templatesfor expedited ethics reviews of applied researchprotocols in the face of outbreaks and similar publichealth emergencies.

12B.2 New Funding for Public Health• The Government of Canada should budget for increases

in core functions of the new Canadian Agency forPublic Health that will rise, over the next 3 to 5 years,to a target of $200 million per annum in incrementalfunding beyond that already spent on core federalpublic health functions.

• The Government of Canada should fund a new PublicHealth Partnerships Program under the auspices of theCanadian Agency for Public Health. The Agency wouldthereby provide program funding to provinces andterritories to strengthen their public health programmingin agreed areas and in support of the National PublicHealth Strategy. The funding for the Public HealthPartnerships Program should rise over 2-3 years to$300 million/annum.

• Through the Canadian Agency for Public Health, the Government of Canada should invest $100 million/annum within 12 to 18 months torealize the National Immunization Strategy wherebythe federal government would purchase agreed-uponnew vaccines to meet provincial and territorial needsand support a consolidated information system totrack vaccinations and immunization coverage.

• Under the aegis of the new Canadian Agency forPublic Health, the Government of Canada shouldbudget for a Communicable Disease Control Fund,allocating a sum rising over 2-3 years to $100 millionper annum in support of provincial, territorial, andregional capacity for infectious disease surveillance,

outbreak management, and related infection controlactivities, including the sponsorship of a new F/P/Tnetwork. Initial allocations from this Fund should bemade to facilitate immediate preparedness for apossible return of SARS to Canada during the winterseason of respiratory illnesses and influenza.

12B.3 National Public Health Strategy• The Canadian Agency for Public Health should play a

catalytic role in developing a National Public HealthStrategy in collaboration with provincial and terri-torial governments and in consultation with a fullrange of non-governmental stakeholders. The newStrategy should delineate priorities and goals for keycategories of public health activity along withprovisions for public reporting across jurisdictions ofprogress towards achieving goals.

• The Government of Canada should incorporate intothe new Agency the current grants and contributionsprograms of the Population and Public Health Branchof Health Canada. These grants and contributionsshould be reviewed and their uses aligned with theNational Public Health Strategy and made complemen-tary to the Public Health Partnerships Program.

12B.4 Emergency Planning, OutbreakManagement and CrisisCommunications

• The F/P/T Network for Emergency Preparedness andResponse, in collaboration with the new F/P/T Networkfor Communicable Disease Control, should urgentlymove ahead with the development of a comprehensiveapproach to managing public health emergenciesthrough a pan-Canadian system that includes:

– harmonizing emergency preparedness and responseframeworks at the federal, provincial and territoriallevels;

– developing seamless planning and response capacitiesas envisaged by the 31 recommendations of theSpecial Task Force on Emergency Preparedness and Response;

– building an integrated F/P/T planning, training andexercising platform for responding to all-hazarddisasters, including public health emergenciescreated by large scale disease outbreaks;

– developing and applying a common set of principles,concepts and capabilities for large scale diseaseoutbreaks; and

– creating the requisite linkages to major employers,the travel and hotel industry, and relevant NGOs.

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• Health Canada in collaboration with provincial/territorial jurisdictions should lead the developmentof a national legislative and policy framework for ameasured, harmonized, and unified response to publichealth emergencies.

• As part of Health Canada’s legislative renewal processcurrently underway, the Government of Canada shouldconsider incorporating in legislation a mechanism fordealing with health emergencies which would beactivated in lockstep with provincial emergency actsin the event of a pan-Canadian health emergency.

• F/P/T governments should develop and providetraining programs and tools to support local publichealth units and institutions in systematicallydeveloping, implementing, and evaluating crisis andemergency risk communication strategies.

• The F/P/T Conference of Deputy Ministers of Healthshould support the continued activity of the F/P/TNetwork for Emergency Preparedness and Responsewith a view to enhanced surge capacities in alljurisdictions, including:

– developing an integrated risk assessment capabilityfor public health emergency response;

– assessing the National Emergency Stockpile System[NESS] to optimize its role in supporting theresponse to large-scale disease outbreaks; and

– developing and funding the Health EmergencyResponse Team concept, including a psychosocialresponse component, as a practical, flexiblemechanism for addressing the need for humanresource surge capacity.

12B.5 Surveillance/Data Gathering and Dissemination

• The Canadian Agency for Public Health, in partnershipwith the new F/P/T Network for Communicable DiseaseControl, should give priority to infectious diseasesurveillance, including provision of technical adviceand funding to provincial/territorial jurisdictions andprograms to support training of personnel required toimplement surveillance programs. The Agency shouldfacilitate the longer-term development of a compre-hensive and national public health surveillance systemthat will collect, analyze, and disseminate laboratoryand health care facility data on infectious diseases andnon-infectious diseases to relevant stakeholders.

• Assuming some lag time to inception of a new Agencyor F/P/T Network, Health Canada and the provincesand territories should urgently commence a process toarrive at business process agreements for collaborative

surveillance of infectious diseases and response tooutbreaks. (This work dovetails with the above-notedSARS surveillance initiative for the Fall of 2003). Thebusiness processes for infectious disease surveillancewould be extended over time with support from theAgency’s Centre for Surveillance Coordination and thePublic Health Partnerships Program, to a nationalsystem for non-communicable diseases and populationhealth factors.

• The Government of Canada should seek the establish-ment of a working group under the auspices of theCanada Health Infoway Incorporated and HealthCanada and/or the new Canadian Agency for PublicHealth, to focus specifically on the needs of publichealth infostructure and potential investments toenhance disease surveillance and link public healthand clinical information systems.

12B.6 Clarifying the Legislative andRegulatory Context

• The Government of Canada should launch an urgentand comprehensive review of the application of theProtection of Information Privacy and ElectronicDocuments Act to the health sector, with a view tosetting out regulations that would clarify the applica-bility of this new law to the health sector, and/or creatingnew privacy legislation specific to health matters.

• The Government of Canada should launch a compre-hensive review of the treatment of personal healthinformation under the Privacy Act, with a view tosetting out regulations or legislation specific to thehealth sector.

• The Government of Canada should embark on a time-limited intergovernmental initiative with a view torenewing the legislative framework for disease surveil-lance and outbreak management in Canada, as well asharmonizing emergency legislation as it bears onpublic health emergencies.

• In the event that a coordinated system of rules forinfectious disease surveillance and outbreak managementcannot be established by the combined effects of theF/P/T Network for Communicable Disease Control,the Public Health Partnerships Program, and theabove-referenced intergovernmental legislative review,the Government of Canada should initiate thedrafting of default legislation to set up such a systemof rules, clarifying F/P/T interactions as regards public health matters with specific reference toinfectious diseases.

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12B.7 Renewing Laboratory Infrastructure• The F/P/T Conference of Deputy Ministers of Health

should urgently launch an expedited review to ensurethat the public health laboratories in Canada have theappropriate capacity and protocols to respond effectivelyand collaboratively to the next serious outbreak of infec-tious disease. The review could be initiated throughthe Canadian Public Health Laboratory Network andengage with the new F/P/T Network for CommunicableDisease Control as soon as the latter is operational.

• Health Canada, in collaboration with the relevantprovincial/territorial authorities, should urgentlyinitiate the development of a laboratory informationsystem capable of meeting the information managementneeds of a major outbreak or epidemic. The laboratoryinformation system must be designed in such a way as to address the functional needs of laboratories, bereadily integrated with epidemiologic information,and be aligned with data-sharing agreements acrossjurisdictions and institutions.

• The F/P/T Conference of Deputy Ministers of Healthshould launch a full review of the role of laboratoriesin national infectious disease surveillance systems,with the aim of creating a more efficient, timely, andintegrated platform for use of both public and privatelaboratories in surveillance.

• The Government of Canada, through the CanadianAgency for Public Health, should invest in theexpansion of the Canadian Public Health LaboratoryNetwork to integrate hospital and community-basedlaboratories. This includes alignment of incentivesand clarification of roles and responsibilities forinfectious disease control. The relevant monies couldflow from the Public Health Partnerships Program orthe Communicable Disease Control Fund.

• The Canadian Agency for Public Health should givepriority to strengthening the capacity of provincial/territorial laboratories as regards testing for infectiousdiseases. The Agency should provide incentives toincrease the participation of provincial public healthlaboratories in national programs. It should supportprovincial/territorial public health laboratories in thecreation of provincial laboratory networks equivalentto the Canadian Public Health Laboratory Network;these would connect in turn to the national network.The relevant monies would flow from theCommunicable Disease Control Fund.

• The Canadian Agency for Public Health should supportparticipation and leadership in international laboratorynetworks by our national laboratories, thereby buildingon the success of the international collaboration inthe response to SARS.

• Health Canada, in collaboration with provincial/territorial authorities, should sponsor a process thatwill lead to a shared vision for the development,incorporation, and evaluation of leading-edgetechnology in the public health laboratory system.Among the issues that require elucidation are the roleof national systems for the real-time surveillance ofinfectious disease through molecular fingerprinting ofmicro-organisms, toxicology capacity to detectillnesses caused by the poisoning of naturalenvironments and occupational hazards, and thepotential for linking genetic testing and infectiousdisease surveillance in novel programs that wouldtarget cofactors associated with the development ofchronic diseases.

• A national report card of performance and gap assess-ment for public health laboratories should be developedthrough the Canadian Public Health LaboratoryNetwork and/or the F/P/T Network for CommunicableDisease Control, allowing comparative profiling ofvarious provincial and national laboratories againstinternational standards.

12B.8 Building Research Capacity• The Canadian Agency for Public Health should

earmark substantial funding to augment nationalcapacity for research into epidemiologic and laboratoryaspects of emerging infectious diseases and otherthreats to population health. This enhanced nationalpublic health science capacity should be strongly linkedto academic health institutions through co-location,joint venture research institutes, cross appointments,joint recruitment, interchange, networks and collabo-rative research activities.

• The Canadian Agency for Public Health, in partnershipwith provincial/territorial governments and throughthe F/P/T Network for Communicable Disease Control,should directly invest in provincial, territorial, andregional public health science capacity.

• The F/P/T Network for Communicable Disease Control,in partnership with the CIHR and the Canadianresearch community, should develop clear protocolsfor leadership and coordination of future epidemicresearch responses.

• The Canadian Agency for Public Health and the F/P/TNetwork for Communicable Disease Control shouldensure that epidemic response teams initiated as partof the Health Emergency Response Team [HERT]concept, provide not only surge capacity for outbreakcontainment per se, but also a mobile “B-team” andinvestigative infrastructure, including epidemiologists,programmers, and analysts.

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• The Canadian Agency for Public Health, in partnershipwith provincial/territorial governments, shoulddevelop clear rules, reinforced by intergovernmentalagreements, on the sharing of information, theestablishment of national databases, and the use ofbiologic materials for research in response to epidemics.

• The Canadian Agency for Public Health, in collaborationwith the CIHR, should establish a task force on emerginginfectious diseases to recommend research prioritiesand funding mechanisms. The Agency, in collaborationwith the CIHR and other national research fundingbodies, should support the development of specialfunding mechanisms and processes for fast-trackingresearch related to epidemics of infectious diseases.

• The Canadian Agency for Public Health, in partnershipwith research agencies and provincial/territorialgovernments, should work with universities to improveresearch training opportunities in infectious diseasesand outbreak management for the full range of involveddisciplines. This capacity-building focus should be apriority within the broader health human resourcestrategy of the Agency.

• The Government of Canada should strengthen itsR&D functions in international health outreach, withparticular emphasis on emerging infectious diseaseson a global basis.

• The Government of Canada should foster workablepublic-private partnerships with the biotechnology,information technology, and pharmaceutical industriesfor shared research interests in the realm of emerginginfectious diseases, including new vaccines, antiviralcompounds, immunotherapies, and diagnostictechnology.

12B.9 Renewing Human Resources forPublic Health

• Health Canada should engage provincial/territorialdepartments/ministries of health in immediate discus-sions around the initiation of a national strategy forthe renewal of human resources in public health. ThisF/P/T strategy should be developed in concert with awide range of non-governmental partners, and includefunding mechanisms to support public health humanresource development on a continuing basis.

• Health Canada should catalyze this strategy by urgentlyexploring opportunities to create and support trainingpositions and programs in various public health-related

fields where there are shortfalls in workforces (e.g.,community medicine physicians, field epidemiolo-gists, infection control practitioners, public healthnursing, and others).

• The Canadian Agency for Public Health should developa National Public Health Service, with a variety of careerpaths and opportunities for Canadians interested inpublic health. The National Public Health Serviceshould include an extensive program of secondmentsto and from provincial/territorial and local healthagencies, with arrangements for mutual recognition ofseniority and a range of collaborative opportunitiesfor advancement.

• Educational institutions, in collaboration with teachinghospitals as applicable, should develop contingencyplans to limit the adverse impact on their studentsand trainees from infectious disease outbreaks, whilemaximizing learning opportunities from these events.These plans should include communications, educationregarding infection control, preparedness withappropriate protective gear, guidelines for support ofstudents/trainees in quarantine or work-and-homeisolation, strategies to limit the impact of impededaccess to usual teaching and research sites, andguidelines for the involvement of students in the careof patients with serious infectious conditions.

12B.10 International Issues• The Government of Canada should take the lead,

along with an international consortium of committedpartners, in the detection of global emerging diseasesand outbreaks. This should be done through enhance-ments to the Global Public Health Intelligence Networkand similar programs.

• The Canadian Agency for Public Health should have amandate for greater engagement internationally in the emerging infectious disease field, including theinitiation of projects to build capacity for surveillanceand outbreak management in developing countries.

• The Canadian Agency for Public Health should be theinstitution responsible for direct communication withthe World Health Organization, the US CDC, andother international organizations and jurisdictions.The Agency should disseminate within Canada infor-mation received from international organizations andjurisdictions on global health threats, and in turn, itwould inform the World Health Organization and otherjurisdictions of relevant Canadian events. During out-break situations, the Agency would perform the role ofliaising between Canadian and international organiza-tions and jurisdictions to maximize mutual learning.

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• The Government of Canada should review its travelscreening techniques and protocols with a view toensuring that travel screening measures are based onevidence for public health effectiveness, while takinginto account the financial and human resourcesrequired for their implementation and sustainedoperation. The Government of Canada should alsoinitiate a multilateral dialogue with other nations thatare currently engaged in SARS travel screening todetermine whether and when some or all of thesemeasures should be modified or discontinued.

• The Government of Canada should seek the support ofinternational partners to launch a multilateral processunder the auspices of the World Health Organizationthat would set agreed-upon standards of evidence forthe issuance of travel advisories and alerts by memberstates. The multilateral process should also seek todetermine the role of WHO in issuing travel advice,and to establish a procedure for providing advancenotice for possible alerts and advice. The noticeprocess should provide a mechanism for consultationwith and a response by the target country.

• The Government of Canada should ensure that anadequate complement of quarantine officers is main-tained at airports and other ports of entry, as required.Fully trained and informed quarantine officers shouldbe available at airports to deal with health threats, toprovide information to and educate airport staff, customsofficials, and airline personnel concerning the recognitionof illness and measures to be taken to contain risk.Close collaboration with airport authorities and airlinepersonnel to clarify responsibilities in the event of ahealth threat is necessary.

• The Government of Canada should ensure thatincoming and outgoing passengers are provided withhealth information about where and when healththreats exist, including any precautionary measures totake, how to identify symptoms of the disease, andwhat first steps to take in case of suspected infection.A partnership with the travel industry would facilitatethis process so that information could be provided atthe time of bookings. The current Health Canada website containing information for travelers should bemade more prominent and its existence promoted.

• All federal/provincial/territorial/municipal response plansshould include port/cruiseship- and airport/airplane-specific protocols for infectious diseases as well asprotocols for employee protection guidelines anddecontamination of aircraft, ships, and/or facilities.Jurisdictional issues concerning travel and health needto be resolved through the plan. The plan should bedeveloped with input and buy-in from local health

officials, response agencies, ports, airports and therelevant companies in the shipping and airlineindustries.

12B.11 Clinical and Local Public HealthIssues

• F/P/T departments/ministries of health should facilitatea dialogue with health care workers, their unions/associations, professional regulatory bodies, experts inemployment law and ethics, and other pertinentgovernment departments/ministries concerning dutiesof care toward persons with contagious illnesses andcountervailing rights to refuse dangerous duties inhealth care settings.

• The CEOs of hospitals and health regions shouldensure that there is a formal Regional InfectiousDisease Network that can design and oversee implemen-tation of hospital strategies for responding to outbreaksof infectious disease. These Networks should map outprograms of hospital surveillance for infectious diseasesthat cross-link institutions and connect in turn to anational surveillance program so as to integratehospital and community-based information.

• As part of its activities, the F/P/T Network for EmergencyPreparedness and Response should examine provincialand federal emergency measures with a view to ensuringthat all emergency plans include a clear hierarchy ofresponse mechanisms ranging from the response of asingle ministry to a response from the entire govern-ment, with appropriate cross-linkages.

• Provincial/territorial ministries and departments ofhealth should ensure that emergency plans includeprovisions for appropriate compensation of thoseindividuals required to respond to and those affectedby an emergency.

• Provincial/territorial ministries and departments ofhealth should revise their statutes and regulations torequire that every hospital or health region has formal-ized and updated protocols for outbreak management.These plans must include mechanisms for gettinginformation and supplies to those outside theinstitutional sector, such as primary care physicians,ambulance personnel/paramedics, and communitycare providers.

• The CEO of each hospital or health region shouldensure that each hospital’s protocol for outbreakmanagement incorporates an understanding of thehospital’s interrelationships with local and provincialpublic health authorities.

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• The CEO and relevant clinical chiefs of each hospitalor health region should ensure that there is continuingeducation for hospital staff, particularly front-line healthcare workers, to enhance awareness of outbreak/infectious disease issues and institutional/clinicalinfection control.

• Provincial/territorial ministries and departments ofhealth should ensure that all key health leaders aretrained in crisis communications. Hospital and healthregion CEOs in turn should ensure that clinicalleaders and key administrators are also trained in crisiscommunications and that the organization has a clearcut protocol for providing all relevant information tostaff and hearing their concerns in a timely, respectful,and participatory fashion.

• Provincial/territorial ministries and departments ofhealth should require through regulation and providefunding to ensure that emergency departments havethe physical facilities to isolate, contain and manageincidents of infectious disease. Emergency departmentsshould also be equipped with appropriate infostructureto enable their participation in infectious diseasesurveillance networks, including receipt of all necessarynational and international alerts.

• Provincial/territorial ministries and departments ofhealth should provide the necessary funding forrenovation to achieve minimal facility standards forinfection control in emergency departments.

• Provincial/territorial ministries and departments ofhealth should ensure that each hospital has sufficientnegative pressure rooms for treatment of patients withinfectious disease.

• Provincial/territorial ministries and departments ofhealth should ensure that, for emergency situations, atleast one hospital in each ‘region’ of a province/territoryhas sufficient facilities and other infrastructure toserve as a regional centre to anchor the response tooutbreaks of infectious disease.

• Provincial/territorial ministries and departments ofhealth should ensure that systems are developed toensure that providers and the public receive timely,accurate and consistent information and directivesduring an outbreak of infectious disease.

• Public health managers and facility/regional healthauthority CEOs, in collaboration with relevant unions,professional associations and individuals, should createa process/mechanism to include front-line public healthand health care workers in advance planning to preparefor related to outbreaks of infectious diseases and otherhealth emergencies. Occupational health and safetyissues should be given prominence in this process.

• Provincial/territorial ministries and departments ofhealth should engage the Canadian Council forHealth Services Accreditation to work with appropriatestakeholders to strengthen infection control standards,surveyor guidelines and tools that are applicable toemergency services as well as outbreak managementwithin health care institutions. The standards shouldalso include descriptors of the appropriate expertiserequired to maintain hospital infection control.

12C. PostscriptThe SARS story as it unfolded in Canada had both tragicand heroic elements. The toll of the epidemic wassubstantial, but thousands in the health field rose to theoccasion and ultimately contained the SARS outbreak inthis country. The Committee emphasizes that in drawinglessons from the SARS outbreak, our intent has been notto ‘name, shame, and blame’ individuals, but rather tomove and improve systems that were suboptimal. Thechallenge now is to ensure not only that we are betterprepared for the next epidemic, but that public health inCanada is broadly renewed so as to protect and promotethe health of all our citizens. It is to these latter ends thatthe Committee’s recommendations have been offered.We believe the recommendations represent a reasonablycomprehensive and affordable starting point for strength-ening and integrating public health at all levels in Canada.As our colleagues in government contemplate theserecommendations, the Committee commends to themthe vision of Benjamin Disraeli (1804-1881) who, onintroducing his Public Health Act to British Parliament in 1875, remarked that public health was the foundationfor “the happiness of the people and the power of thecountry. The care of the public health is the first duty ofa statesman.” Less eloquently, the Committee in closingrepeats the simple question we put earlier to all healthministers, finance ministers, and first ministers: If notnow, after SARS, when?

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INTERVIEWS AND SUBMISSIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

As part of the Committee’s fact finding phase, it conductedinterviews with front-line health care providers andadministrators, as well as personnel from variousorganizations and levels of government involved inmanaging the SARS outbreak. The Committee also putout a call for submissions to health care associations,non-governmental organizations, and relevant industrystakeholders. The call for submissions offered these

groups an opportunity to relay their experiences withSARS, the lessons they learned from the outbreak, andtheir views on how the public health system needs to be improved.

The following are lists of individuals that were interviewedand submissions that were received.

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Interviewee Affiliation Date

Dr. Ian Johnson Dept. of Public Health Sciences, UofT June 3

Dr. Mary Vearncombe Director, Infection Control, SWCHSC June 6Dr. Anita Rachlis Infectious Disease Consultant, SWCHSCDr. Andrew Simor Infectious Disease Consultant, SWCHSC

Prof. Sujit Choudhry Faculty of Law, UofT June 13

Prof. Harvey Skinner Dept. of Public Health Sciences, UofT June 16

Dr. Mark Cheung General Internal Medicine, SWCHSC June 16

Mr. Doug Hunt Counsel to Public Health Investigation June 17, Mr. Justice Archie Campbell Investigator under the Public Health Act July 11,

August 18

Mr. Frank Lussing CEO York Central Hospital June 18(Committee member)

Mr. Malcolm Moffatt CEO St. John’s Rehabilitation

Dr. Ronn Goldberg Radiologist-in-chief, North York June 19General Hospital

Ms. Janet Beed VP, COO – Toronto General Hospital June 20Ms. Janet Davidson President, Toronto East General

Dr. Raziel Gershater Radiologist, North York General Hospital June 24

I N T E R V I E W S

Appendix 1S A R S a n d P u b l i c H e a l t h

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Mr. Bill Tholl CEO, CMA June 24Dr. Dana Hanson President, CMADr. Isra Levy Director of Public Health, CMA

Dr. Denise Werker WHO CDS, Geneva June 25,Dr. Arlene King Director of Immunization and Respiratory June 26

Diseases, Population and Public Health Branch, Health Canada

Ms. Pegeen Walsh Special Advisor to Regional Director General June 25Health Canada-Ontario/Nunavut Region

Dr. Bob Lester Executive VP - SWCHSC June 25

Dr. James Young Commissioner of Public Safety June 26

Dr. Rob Horvath Assistant Director, Emergency Services, North York General Hospital July 1

Dr. John Frank Scientific Director, Institute for Population July 2and Public Health, CIHR

Dr. David Mowat Director-General of the Centre for July 3Surveillance Coordination, Population and Public Health Branch, Health Canada

Dr. Don Low Microbiologist-in-Chief, Mt. Sinai Hospital July 3Dr. Allison McGeer Director, Infection Control, Mt. Sinai Hospital

(Committee member)

Dr. Richard Schabas Chief of Staff, York Central Hospital July 3

Dr. Colin D’Cunha Commissioner of Public Health, OMHLTC July 7

Dr. Kumanan Wilson General Internal Medicine, UHN & Institute July 7of Intergovernmental Relations, Queen’s University

Mr. Gerry Dafoe CEO, CPHA July 8Dr. David Mowat Health Canada

Ms. Gail Paech Assistant Deputy Minister - Long-term Care, July 8OMHLTC

Mr. Phil Jackson Director, Health Information and Science Branch, OMHLTC

Dr. Paul Gully Senior Director General, Population July 9and Public Health Branch, Health Canada

Dr. Mona Loutfy Infectious Disease Consultant, SWCHSC/ July 10North York General

Mr. Tom Closson CEO, UHN July 11Dr. Michael Gardham Director, Infection Control, UHNMs. Gillian Howard VP Public Affairs, UHN

SubmissionsAssociation of Canadians Academic Health Care Organizations

Association of Nursing Directors and Supervisors of Ontario Health Agencies

British Columbia Ministry of Health Planning

Canada’s Research-Based Pharmaceutical Companies

Canadian Association of Emergency Physicians

Canadian Association of Medical Microbiologists

Canadian Coordinating Office for Health Technology Assessment

Canadian Council on Health Services Accreditation

Canadian Federation of Nurses Unions

Canadian Healthcare Association

Canadian Hospital Epidemiology Committee

Canadian Infectious Disease Society

Canadian Institutes of Health Research

Canadian Medical Association

Canadian Pharmacists Association

Canadian Public Health Association

Canadian Society for Medical Laboratory Science

Catholic Health Association of Canada

Community and Hospital Infection Control Association of Canada

Council of Chief Medical Officers of Health

Greater Toronto Airports Authority

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Dr. Bill Sibbald Physician in Chief, SWCHSC July 11

Dr. Phillip Ellison Family Medicine, UHN July 15

Dr. Barbara Mederski Director of Infection Control, July 15North York General Hospital

Ms. Bonnie Adamson CEO, North York General Hospital July 23

Ms. Bonnie Adamson CEO, North York General Hospital July 31Dr. Keith Rose VP - Medical Affairs,

North York General Hospital

Group of Nine National Associations1

National Specialty Society for Community Medicine

Ontario Association of Medical Laboratories

Ontario Council of Teaching Hospitals

Ontario Hospital Association

Ontario Medical Association

Royal College of Physicians and Surgeons of Canada

Vancouver International Airport Authority

VIA Rail Canada

Victorian Order of Nurses

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1 Canadian Medical Association, the Canadian Public Health Association, the Canadian Nurses Association, the Canadian Healthcare Association, the Canadian Dental Association, the Association of Canadian Academic Healthcare Organizations, the Canadian Pharmacists Association, the Canadian Association of Emergency Physicians, and the Canadian Council on Health Services Accreditation.