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Mark Ungrin
Mark Ungrin

đŸ§” Excerpts from the 2006 report of Canada's SARS Commission. An inquiry into the mismanagement of SARS-CoV-1, it was the most essential read for any competent IPC / Public Health professional attempting to avoid mismanaging SARS-COV-2. So
mostly ignored. archives.gov.on.ca

Starting off moving stuff over from Twitter, so not necessarily in any particular order. Bits I've considered important over the past few years. Everyone on the planet should read at least the Recommendations - the whole Executive Summary if you have time. archives.gov.on.ca

The SARS Commission - Spring of Fear - Executive Summary - Volume 1

www.archives.gov.on.ca

The report was unambiguous about failures in SARS that must never be repeated. With 44 dead, It documented how to prevent future respiratory disease outbreaks from being as bad, or worse. Basic safeguards it would be negligent in the extreme to ignore - starting with the Precautionary Principle. đŸ«  Vol 3., Ch 8. To reiterate, this is basic knowledge from 2006. Every IPC and public health professional on the planet had free access. Note IPC's made-up "3-foot rule", and the need for respirators (even with acceptance of the general ignorance of IPC professionals around airborne transmission).

Core recommendation of the SARS Commission. There is no excuse for anyone in IPC or Public Health not being familiar with it. Even if their training ignored it (instructors burying their own past failures?), once we knew COVID is a SARS-CoV they were obligated to read it cover to cover.

Problems identified included a lack of planning. Insiders demanded more resources - it will be important to audit what was provided, what was done with them, and why - despite the call for better contingency planning - they were winging the COVID response. archives.gov.on.ca

The lack of transparency is another aspect that seems to be permanently baked into the culture of IPC and Public Health. I suspect a consequence of the toxic politics institutional medicine is famous for, with "peacetime generals" wrestling for power and authority.

One of the ways Public Health leaders and other politicians have been able to manipulate public perception of their successes and failures has been to manipulate testing and reporting of infection rates. While centralized tracking is essential, muzzling other sources of information invites abuse.

One of the things COVID has made unmistakably clear is that the Thin White Line protects senior insiders no matter what. A test for the integrity of the essential COVID inquiries will be whether those at the top are called to account, or whether excuses are made for the inexcusable.

There was nothing particularly unique about Dr D'Cunha - and that's actually the problem. The failures of leadership in Public Health can't be blamed on a few bad apples. They seem to be an unfixable part of the culture - structural issues that consistently give power to exactly the wrong people.

Poor Public Health leadership in SARS, preoccupied with turf wars and controlling information to gain power instead of doing the job and saving lives poses a key question: Why is that behaviour *so typical* of IPC / PH leaders, fighting to exclude "competitors" like OHS, science, engineering etc?

In COVID as in SARS, there has been a recurring theme of Public Health leadership that is out of its depth, but remains rigidly focused on authority and its entitlement to "own" the pandemic response and the power that comes with it, rather than focusing on knowledge, expertise and collaboration.

The Nurses' Association, as has often been the case in COVID, got it right. What has been missed - yet again - is an effective communications network, including workers, academia, and experts across disciplines. Instead, Public Health leaders focused on owning the microphone and silencing dissent.

As in SARS, so again with COVID: Public Health authorities have been largely useless in providing up to date information to clinicians and the public around airborne transmission, long COVID, spread in schools, N95s etc. PH leaders are widely perceived as more focused on their image than their job.

The failure mode of critical information (like the admission that COVID is airborne, N95s are effective, children get long COVID, etc) being quietly updated on obscure websites without any publicity has also been recapitulated in COVID. The urge to bury past mistakes overcoming the duty to warn?

The absence of both breadth and depth of critical expertise has been yet another repeated, predictable failure. Not merely diversity of training was lacking, but even *respect for diversity of training*. Combined with the sense of entitlement to control, this made COVID the Dunning-Kruger Pandemic.

The perception of individual authorities abusing their power to build empires and cast themselves in a positive light instead of sharing the data that medical policy makers, scientists and the public need is another echo of SARS that remains uncorrected in COVID.

Prioritization of appearances (perhaps not coincidentally the aspect that can make hospital and public health leaders look good or bad) over the underlying reality, and the "smiles > safety" lack of a real safety culture, is also familiar. Vol 2 Ch 4: archives.gov.on.ca

This lesson clearly didn't stick.

The same "urgency of normal", with public health leaders focused on delivering the perception of victory and taking a victory lap when they had no rational basis for it - as we've seen again in COVID (celebrating Omicron, widespread infection, endemicity, etc). archives.gov.on.ca

The familiar culture of impunity in healthcare organizations, where on-the-job injuries, disability and death from COVID are swept under the rug, and hospital leaders and IPC are treated as if they are above the law. What other industry gets away with this? archives.gov.on.ca

"A disaster of the magnitude of SARS" is 44 deaths here. We're orders of magnitude past that now, and is anyone even accurately counting the workplace deaths and disabilities from COVID in healthcare? If you're wondering why there's a shortage of healthcare workers - this is a big part of it.

A deadly failure in medical leadership culture, in SARS as in COVID, was the lack of respect for non-clinical expertise, and the self-serving insistence on not merely ignoring outside input, but *excluding outsiders* from "medical" turf and authority. archives.gov.on.ca

This paragraph, written over two decades ago, could easily be copy-pasted into an inquiry report on how the response to COVID was so badly mismanaged. With experts pushed aside to reserve centre stage for medical authorities, policy was set at the deadly intersection of ignorance and overconfidence.

The big difference between SARS-CoV-1 and SARS-CoV-2 is that with SARS, the conflicts of interest held by those responsible for the initial failures were held at bay until after SARS was controlled. But COVID is ongoing, and now it's sustained by the same COIs highlighted by the SARS Commission.

If you got this far you've probably noticed the Ontario government has stopped making the report of the SARS Commission available. No doubt a perfectly innocent decision, unrelated to how embarrassing it is that they discarded it when COVID hit. đŸ«  It's here 😈: wayback.archive-it.org

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This report is dedicated to those who died from SARS, those who suffered from it, those who fought the disease, and all those affected by it.
Respiratory Protection: A Fundamental Worker Safety Issue The real problem during SARS was not the N95 respirator or fit testing but deep structural contradictions in worker safety in the health care system. This included both embedded resistance within the health care system to worker safety experts and to the Ministry of Labour and Ontario’s failure to recognize, as an aspect of health worker safety, the precautionary principle that reasonable action to reduce risk, such as the use of a fitted N95 respirator, need not await scientific certainty. There were two solitudes during SARS: infection control891 and worker safety. Infection control insisted that SARS was mostly spread by large droplets which do not travel far from an infectious person. Given that case, in their view, a surgical mask was sufficient to protect health workers in most situations. Worker safety experts said workers at risk should have the higher level of protection of an N95.They said not enough is known about how SARS is spread to rule out airborne transmission by much smaller particles, and besides, hospitals are dynamic places where unforeseen events and accidents can always happen. Infection control relied on its understanding of scientific research as it stood at the time. Worker safety experts relied on the precautionary principle that reasonable action to reduce risk should not await scientific certainty.
One should be aware of the effects of droplet evaporation and the resultant diminution in size of ejected droplets. A 30 Ìm droplet dries to a 5 Ìm droplet within seconds under normal indoor air conditions. This means that a large droplet, as it evaporates, will not settle to the ground but become a free-floating entity.This has implications for the 3 foot rule, the basis for infection control precautionary measures, since it is commonly believed that large droplets ejected upon sneezing or coughing will follow Stoke’s Law and fall to ground within a 3 foot distance from the person’s face. It is evident that it is commonly believed that the 3 foot rule is a division between an unsafe and safe distance. There is no indication that the 3 foot rule takes into consideration the evaporation factor and the drift factor of airborne droplets, as discussed above. No scientific evidence is offered by WHO,DHHS-CDC,PCAH,or other medical authorities in explaining the rule. If large droplets quickly evaporate to free-floating small droplets, then the 3 foot rule applies only to droplets greater than about 50 – 100 Ìm in diameter for which there is insufficient time chance for evaporation to take effect before they fall to the ground from a height of 5–6 feet. Free floating small droplets readily go beyond the 3 foot radius. Therefore, if the majority of ejected droplets following a sneeze are evaporated to a size that is free-floating after only seconds in air, the 3 foot rule becomes illogical and not particularly helpful from a disease transmission perspective.
Precautionary Principle In The Commission of Inquiry on the Blood System in Canada, Mr. Justice Krever said: Where there is reasonable evidence of an impending threat to public health, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat.22 The importance of the precautionary principle that reasonable efforts to reduce risk need not await scientific proof was demonstrated over and over during SARS. The need to apply it better is noted throughout this report. One example was the debate during SARS over whether SARS was transmitted by large droplets or through airborne particles. The point is not who was right and who was wrong in this debate. When it comes to worker safety in hospitals, we should not be driven by the scientific dogma of yesterday or even the scientific dogma of today. We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty.
Problem 2: Lack of Preparedness: The Pandemic Flu Example When SARS hit, Ontario had no pandemic influenza plan. Although SARS and flu are different, the lack of a pandemic flu plan showed that Ontario was unprepared to deal with any major outbreak of infectious disease. Influenza22 is not only one of the oldest known diseases, it is also one of the most common,affecting an estimated 10-25 per cent of Canadians each year.23 While most recover completely, hospitalization and deaths occur in high-risk groups. An estimated 500-1,500 Canadians, mostly seniors, die every year from pneumonia related to flu. Between 250,000 and 500,000 deaths occur annually around the world.24 Three times in the last century radical new influenza strains have emerged to cause global pandemics.25 The worst was in 1918-19 when 20 to 40 million people died world-wide, including an estimated 30,000 to 50,000 people in Canada.26 Unpredictable and devastating, influenza pandemics necessitate extensive levels of preparedness if there is to be any hope of mitigating their consequences.
Problem 3: Lack of Transparency38 Because there was no existing plan in place for a public health emergency like SARS, systems had to be designed from scratch. Ad hoc organizations like the Epi Unit and the Science Committee were cobbled together. Procedures and protocols were rushed into place. There was little opportunity for feedback between the local health units, hospitals and the Provincial Operations Centre that oversaw the effort to contain SARS.A lack of earlier planning and ongoing consultation meant that those working in local health units were often directed by the Provincial Operations Centre to do things for which they thought there was no clear rationale. Many people regarded the Provincial Operations Centre as a full-fledged organization. In fact, it was simply a room that functioned as an operations centre. To local public health units, it was unclear who comprised the Provincial Operations Centre, what they did, how they made their decisions and what was their legal authority for issuing directives. One physician at the Public Health Branch of the Ministry of Health described the confusion as follows: I wanted to know who was in this POC, because when I would call them, they were just saying, you know, POC and I wanted to say like, Who Are You? And, I mean, not that it was a big issue where, you know, you’d imagine major litigation or but it was, it was a huge issue on a day-to-day basis on the clinical side is how do they make these decisions, who’s making them? Another public health professional who worked with the Provincial Operations Centre described how a local Medical Officer of Health was shocked to learn that he was legally responsible for the outcome of the implementation of directives – not the Provincial Operations Centre that issued them:
One Medical Officer of Health described it as follows: An adjudication process was introduced that was designed that any listing of a new probable case had to go through a case review by the provincially selected infectious disease specialist. They were to gather all the chart information from the hospital. They would not have the epi information that was in the public health charts on whether this was a case or not – a probable or suspect case, and submit a report in writing to the POC or SOC, it was never described who they would report it to, and then we were supposed to accept this benignly. The concerns of Medical Officers of Health sometimes rose to serious levels of mistrust. Many were troubled by the fact that the adjudication process was imposed two days after the WHO travel advisory had been lifted. More will be said about the adjudication process and the classification of cases in the final report. Suffice it to say that the lack of transparency in the adjudication system led to confusion over roles and responsibilities and created the perception among some that local Medical Officers of Health were being muzzled by the province.
Problem 4: Lack of Provincial Public Health Leadership Few worked harder during SARS than Dr. Colin D’Cunha, the Chief Medical Officer of Health for Ontario and Director of the Public Health Branch in the Ontario Ministry of Health and Long- Term Care. He demonstrated throughout the crisis a strong commitment to his belief of what was in the public interest. Dr. D’Cunha is a dedicated professional who has devoted his career to the advancement of public health. However for the brief reasons that follow Dr. D’Cunha turned out in hindsight to be the wrong man in the wrong place at the wrong time. While it may be due to misunderstandings or a simple difficulty on the part of Dr. D’Cunha to communicate effectively, there is a strong consensus on the part of those colleagues who worked with him during the crisis that his highest and best public calling at this time is in an area of public health other than direct programme leadership. This general concern has undoubtedly been reflected in the government’s decision to provide him with other opportunities within his area of expertise. Because Dr. D’Cunha no longer holds the office of Chief Medical Officer of Health it might be asked why it is necessary in this interim report to deal with his leadership during SARS. The answer is that the public has a right to know what happened during SARS and that obliges me to make whatever findings I am taken to by the evidence. The story of what happened during SARS cannot be told without some reference to the difficulties that arose in respect of Dr. D’Cunha’s leadership.
As noted in this report, there was a sense in recent years that bright independent minded people were not particularly welcomed and that experts from other provinces were reluctant to come to the Ministry of Health’s Public Health Branch because of concern over what they perceived to be a difficult working environment. Anumber of Medical Officers of Health even before SARS thought there were problems with Dr. D’Cunha’s leadership. They thought that the Ontario public health community was being shut out of useful federal-provincial committee work because of the perceived difficulty of working with Dr. D’Cunha. Some senior people in the Branch developed the impression that Dr. D’Cunha discouraged the sharing of information with local public health units in the field and that he communicated the impression to Public Health Branch employees that “the field is not your friend.” As outlined below, there was a lack of positive leadership in Dr. D’Cunha’s position in relation to West Nile planning, surveillance, and management.
To some who worked with him during SARS his behaviour appeared puzzling. It seemed to them that he was more preoccupied with his personal authority as Chief Medical Officer of Health than he was with working with others to get the job done. These concerns include the observation that he would make himself unavailable if he felt personally slighted by the presence of someone he considered an intruder on his own turf. His supporters on the other hand suggest that he responded appropriately by staking out the authority of his office in response to the inappropriate presence of outsiders in the management of a public health crisis that by law and by bureaucratic convention was his alone to direct entirely by himself as he saw fit. It is unnecessary to review in detail the different points of view between Dr. D’Cunha and some of his colleagues as to whether he blocked the flow of information in order to assert his status and territory in a complex turf dispute among local health units, the provincial Public Health Branch, the Hospital Division of the Ministry of Health, the federal government, and all the other governmental players necessarily involved. What is abundantly clear, despite Dr. D’Cunha’s recollection that he always shared and never withheld information, is that a contrary body of opinion is held by some who worked with him closely. Perception, in a time of crisis, is as important as fact. Many colleagues ended up with the impression that Dr. D’Cunha felt that knowledge was power and the best way to demonstrate to others that he was in charge of his own turf was to show them that he controlled the flow of information. Having regard to Dr. D’Cunha’s recollection to the contrary this impression may well be inaccurate and may simply reflect misunderstandings. The problem is that, in a crisis, teamwork is essential and any impression that impairs teamwork, whether or not the impression is accurate, can defeat the common effort.
Another knowledgeable observer, referring to Ontario’s public health response said: I think that Colin [Dr. D’Cunha] was out of his depth. I think that probably most of or all of the senior Ontario response folks were out of their depth so it is not a flaw. I think that they were well meaning and trying hard but did not have the experience to recognize the hole that they were in and to respond in this timely and aggressive and coordinated manner as would have been hoped for. Those are not character flaws but wrong people in the wrong place or not given the support they needed, one or the other. These problems together with the lack of readiness for a public health emergency forced those fighting the disease to work around Dr. D’Cunha and led to an unwieldy emergency leadership structure with no one clearly in charge. A de facto arrangement had sprung up whereby Dr. D’Cunha shared authority with Dr. Young, Commissioner of Public Safety and Security. More will be said in the final report about this arrangement. The lack of clarity as to their respective roles, together with Dr. D’Cunha’s rigid concept of his personal authority as Chief Medical Officer of Health made it difficult for him to share responsibility and work in a cooperative team fashion with others, including Dr. Young and local Medical Officers of Health in the field. These problems led in turn to Dr. D’Cunha’s increasing interest in securing the approval of the Minister’s office and his reliance on connections above because of his difficulties in working with people at his own level or below him in the hierarchy.
If there is one important lesson, it is embodied in a recommendation made by the Registered Nurses Association of Ontario at the Commission’s public hearings: Establish and maintain an effective communication network as a key component of an emergency preparedness plan. This network should link government, health providers, professional organizations, unions, higher education institutions and the public.
The same feeling was expressed within Ontario and confirmed by a federal official. As one Medical Officer of Health said: There is absolutely no respect for the Public Health Branch; we don’t turn to them for expertise or advice, we turn to our colleagues in the field; the Branch sends us internet links to Health Canada and CDC and WHO that we can find ourselves, it’s absolutely pathetic . . . a lot needs to happen before trust is restored. A lack of respect for the Public Health Branch was evident in the responses from outside Ontario and from elements of the Ontario public health system at the local level.When SARS hit, leadership was not forthcoming from a Public Health Branch that turned out to be dysfunctional.
Even when information that could be helpful to local units was generated, it was not always disseminated to the local public health units. Volunteers from the field developed a series of public health guidelines. One Medical Officer of Health noted that these guidelines were never posted nor widely distributed, leading some to wonder where they went: It was just that it became unconnected. None of the Public Health guidelines ever made it to a web site, just as an example.They never got posted . . . There were a whole series of these Public Health things that never quite officially got published . . . In many cases, they were drafts done up by the field rather than the Branch, but they did not get out on the official website.
Some regarded the lack of strategic capacity and expert leadership as a primary weakness during SARS. Dr. Richard Schabas, formerly the Chief Medical Officer of Health for Ontario, said this at the public hearings: I think the key weakness that the SARS outbreak pointed out in our public health system is a lack of strategic capacity, a lack of really expert leadership in a crisis situation at that time.We have – that capacity has been largely eroded at a provincial level over the past few years and there really was no acceptable alternative within public health.
Another impact of this process that required Dr. D’Cunha to see the data before the Science Committee saw it, and at times of refusing to allow direct reporting between Interim Report © SARS and Public Health in Ontario Problem 18: Blockages of Vital Information 145 the epidemiologists and the Science Committee, is that it left many with the belief that data was being deliberately kept from them. Some thought that control of the data enhanced Dr. D’Cunha’s ability to demonstrate to those above him that he had the information first and to show those below him that he was in charge. One member of the Science Committee described the situation as follows: I think it was, in part the data was not always there, but what was there was hidden, at least to the Science Committee, it wasn’t forthcoming even though we knew the data was there. And there was this idea that he who holds the data is powerful with the Ministry senior people, and so it was used to, you know, it was presented to them at the last minute but never to the Science Committee to deliberate on and to contemplate. So there was, you know, “I know something you don’t know” kind of mentality.
For those who did report feeling pressure to remove the equipment, the pressure came from a number of sources, even at times other health workers. And the perception of some health workers that there was pressure to discontinue using protective equipment was not restricted to those working on 4 West. Other health workers, from other areas of the hospital, made similar reports to the Commission. For example, one nurse said that there were concerns expressed about frightening others by continuing to wear the mask: We heard a lot of how it appeared to people to see us wearing masks, how it frightened them off. You know you walk into a hospital and see people with masks, people get frightened. It just seemed like they were more concerned with what we looked like to the community, how we appeared. Okay, SARS is completely under control so there is no need to worry when in fact there was still high risk to us as it later showed, there was a high risk. Because I thought it was ridiculous that they cared more about what we looked like to the general public than they cared about how we could have been exposed, and we ended up being exposed. You would hear that we want to get back into the normal, we want to get rid of these masks. That was at the first outbreak.
During a public health crisis, no health worker should be denied the opportunity to use or be discouraged from using approved protective equipment and infection control and worker safety procedures she believes are necessary to protect herself. As one physician who cared for SARS patients told the Commission: Front-line health care workers should be allowed to exercise their own kind of caution, and I understand that there would be guidelines provided. But they should have unlimited access to personal protective equipment. Let’s say if there is a next epidemic, avian flu or whatever, then health care workers should be allowed to feel safe when they come to work and not to feel that they are the guinea pigs or whatever to see if they would come down with this disease with this kind of protection. The stories of those health workers who felt they were pressured to remove protective equipment underscore the important responsibility that senior managers have to ensure a safety culture in which no one is discouraged, directly or indirectly, from protecting themselves.
In hindsight it appears likely that if the precautionary principle had been applied, and precautions had been maintained until the unexplained cases had been fully investigated and definitely ruled out as SARS, the spread of SARS could have been prevented.662 As one physician said: Answer: I think what SARS did is it humbled us and it also made us realize that even when we think we know everything, we don’t. And that diseases can, the changing nature of disease emerges gradually and we have to be very attuned to the clues that come from the ground up, not necessarily from the top to the bottom so I think humility makes the better nurse and doctor. I would always err on the side of caution. Question: And that applies to protective equipment? Answer: Yes, until they’re 
 it’s very difficult.We were told there’s absolutely nothing to worry about and then we did have something really to worry about, so I don’t know when one can ever relax, but I would, as I said, I would err on the side of caution and use the most protective equipment I could until I had an absolute assurance that a modification was safe. Especially if you’re dealing with someone’s life.
Everybody wanted it to be over, and Carolyn Abramson in the Globe said that once they 
 things changed once they lifted the travel advisory, the travel advisory was a sort of a shift in the whole psychology in the city and all of a sudden everybody now was together.When the travel advisory came down, there was the City, the Province, Health Canada, everybody 1139 SARS Commission Final Report: Volume Three © Spring of Fear Did Politics Intrude? was outraged and fighting together, and then when they got the travel advisory turned back, everybody celebrated about that and once everybody were getting back to normal and everybody was 
 that is part of why the lack of leadership. There should have been somebody who said 
 nobody questioned it. [Dr.] Jim Young went off to China to talk about our successes and how we controlled it. [Dr.] Bonnie [Henry] went with him and [Dr.] Tony [Mazzulli] went with him and nobody said, “how do you know it is over?” including myself. None of us said “well, just because,” and it is such a simple question to ask and we blew it. It is just amazing everybody blew it.
None of the critical injury864 and occupational illness865 investigations into how 146 health workers contracted SARS recommended the laying of charges. These investigations were seriously hampered by the fact that they did not begin until February 2004, leaving insufficient time for a full and thorough investigation before the expiry in March 2004 of the time for laying charges imposed by the one-year limitation period under the Occupational Health and Safety Act. In all, the Ministry received 146 occupational illness and critical injury notifications and three fatality notifications.866 Under the Occupational Health and Safety Act, employers must notify the Ministry in writing of a critical injury within 48 hours of the occurrence867 and of an occupational illness within four days.868 This timely notification allows the Ministry the opportunity to quickly investigate the events that led to the critical injury or occupational illness and to prevent its recurrence. SARS Commission Final Report: Volume Three © Spring of Fear Aftermath 864. A probable case of SARS was considered a critical injury. 865. A suspect case of SARS was considered an occupational illness. 866. There were major problems with the notification process. The Ministry told the Commission: The majority of these notifications were received after employers were ordered to do so by MOL inspectors. (Ministry of Labour, submission to SARS Commission, March 15, 2006, p. 19)
Public confidence is vital for any regulatory and enforcement ministry. In the case of the Ministry of Labour, this means that investigations into critical injuries and occupational illnesses arising from a disaster of the magnitude of SARS must be commenced expeditiously.
The Commission therefore recommends legislative amendments and policies in relation to the waiver of potential Crown privilege claims, that in such cases where charges do not result from Ministry of Labour and other investigations of deaths and critical injuries in health workplaces, the results of the investigation and the reasons for the decision not to prosecute be made public.
Respiratory Protection: A Fundamental Worker Safety Issue The real problem during SARS was not the N95 respirator or fit testing but deep structural contradictions in worker safety in the health care system. This included both embedded resistance within the health care system to worker safety experts and to the Ministry of Labour and Ontario’s failure to recognize, as an aspect of health worker safety, the precautionary principle that reasonable action to reduce risk, such as the use of a fitted N95 respirator, need not await scientific certainty. There were two solitudes during SARS: infection control891 and worker safety. Infection control insisted that SARS was mostly spread by large droplets which do not travel far from an infectious person. Given that case, in their view, a surgical mask was sufficient to protect health workers in most situations. Worker safety experts said workers at risk should have the higher level of protection of an N95. They said not enough is known about how SARS is spread to rule out airborne transmission by much smaller particles, and besides, hospitals are dynamic places where unforeseen events and accidents can always happen. Infection control relied on its understanding of scientific research as it stood at the time. Worker safety experts relied on the precautionary principle that reasonable action to reduce risk should not await scientific certainty.892
Although scientific research into SARS transmission continues, it appears that the initial dogmatic statements dismissing the possibility of airborne transmission were premature. SARS demonstrated the importance of taking precautionary approach to transmission of a new respiratory disease and to requiring the best system of respiratory protection for hospital workers. Setting aside the ongoing droplet-versus-airborne debate, the Commission heard other compelling arguments favouring a precautionary approach requiring higher levels of respiratory protection. A number of witnesses remarked that unforeseen events and accidents happen in hospitals that might inadvertently generate aerosolized particles. Experts note that even if SARS is primarily droplet-spread, no one knows when an incident might happen in a hospital to cause the inadvertent generation of aerosols.
This is not the place to enter into that acrimonious debate. Nurses are angry, with good reason, that so many got sick and that safety laws were not respected or enforced. It must noted that the experts who campaigned against the N95 and fit testing undoubtedly acted in good faith, doing what they believed was in the best interests of health workers and the health system. It would be too easy to personalize this debate and point out that some of those who most vociferously oppose the N95 and fit testing, and who were most disdainful of nurses and independent safety experts who prefer precaution, were the very people on whose watch nurses became sick despite the assurances that they were safe. Whenever someone presides over a system that fails and then leads a campaign against greater precaution, it is easy to forget that there are bigger issues at stake, more important things than arguing over who is right and who is wrong.

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