He was one of over 25,000 quarantined in the GTA during SARS. But only 68 were mandatory. What 'public co-operation’ means for COVID-19 planning now

Bruce England doesn't live in Ajax anymore, but he can still remember the bedroom where he was quarantined after his SARS hospitalization in 2003. The brown tweed bedspread, the light blue walls, the television on the dresser, the window that looked to the backyard, the "kill bucket" outside the door filled with bleach and water.

Every day, public health officials called to check his temperature, and once a week, he went to the hospital for a mandated checkup. Otherwise, he didn't go outside, and he didn't leave the room except to use the bathroom. "I didn't want to take a chance of infecting or passing it on," he says. He didn't want that on his conscience.

He was isolated in everything but his motivation, as it turns out. That's what a team of U.S. researchers found when they visited Toronto in late 2003 and early 2004 to study the region's response to the SARS quarantine.

Severe Acute Respiratory Syndrome (SARS) was an outbreak that primarily spread in medical facilities during two waves of infection in Ontario. Over a six-month period, 375 cases were recorded in the province, with 44 deaths.

The researchers from the Defense Threat Reduction Agency, which falls under the U.S. Department of Defense, were drawn to the GTA because of the estimated 26,000 to 30,000 people who spent time in quarantine in the York, Durham and Toronto regions. Of those thousands, only 68 were issued mandatory quarantine orders from public health officials, and only one of those orders involved the Toronto Police. With an eye to future pandemic planning, the researchers wanted to know what motivated so many people to comply, and what factors made it difficult? There was a mix of health-care workers and members of the general population in the study, and the majority said they were motivated by civic duty - a desire to protect the community, family and friends from the virus. "Fear of running afoul of the law played little role in compliance," the study noted.

"I think the most important lesson that came out of that study " was that compliance with quarantine really has to be a community effort," lead author Dr. Clete DiGiovanni said from his California home, adding that employers and government need to be key players. "People in quarantine, even though they are in quarantine so that they are away from others, they really need the help of others to comply " for any prolonged period of time."

Those who studied SARS knew there were lessons to learn - not just because Ontario was caught so unprepared, but because many believed a major pandemic was overdue.

"History has not been kind to Cassandra or Chicken Little. Those who warn of disasters have been accused through history of simply trying to scare people," the late Justice Archie Campbell wrote in an interim report of the SARS Commission. "Whether the next pandemic will be caused by H5N1 or another novel disease " it would be reckless not to prepare."

Justice Campbell, the commissioner of the years-long investigation into Ontario's response to SARS, wrote that it was "voluntary public co-operation, not legal orders or emergency powers, that won the fight against SARS."

And voluntary compliance, he wrote, would be even more essential "in a crisis the magnitude of a pandemic." That crisis is now here. The COVID-19 pandemic has changed life in Toronto in a way SARS did not, shuttering the city aside from services deemed essential. Case counts are rising, and so is the death toll, including worrying outbreaks in long-term care homes. As sunny weather brings more of the self-isolating masses outside, Mayor John Tory has pleaded with people to respect the closure of city dog parks, playgrounds and park amenities. "I don't think people yet comprehend these measures have literally life-or-death consequences," he said.

Earlier this week, Premier Doug Ford warned that a surge was coming, that little separates Ontario from the terrifying experiences of Spain and Italy.

On Friday, public health officials shared their modelling with the public, forecasting 1,600 COVID-19 deaths in Ontario by the end of April with current interventions in place. Their models show there could have been 6,000 deaths by the end of the month with no interventions, and that projected deaths could come down to 200 with "full future intervention."

Stay home, officials implore at every opportunity. Help us help our health-care system.

But keeping this many people safe through voluntary isolation is a different challenge than Toronto experienced during SARS, said Doug Hunt, the lead counsel with the SARS Commission. In both cases, the effort depends on public co-operation, which depends on confidence in leadership. People need to believe in the information they're receiving from officials, and trust that decisions are being made because of independent medical evidence, and not bureaucratic, financial or political expediency.

Hunt believes that trust exists right now. But transparency is essential. It must be enduring, which is a different challenge with this uncertain timeline. "The problem starts to grow," he said, "if any of those people who are the public face of this start to lose public trust."

Before SARS, Bruce England stood at six-foot-five, weighed 230 lbs., and as a paramedic, he could easily carry an adult down a flight of stairs. He was a paramedic supervisor in his early 50s, and one of the first health-care workers to contract the virus in Toronto.

He was unknowingly exposed to SARS when he was talking to a crew of paramedics, standing three metres away from a patient in Scarborough Grace Hospital. The symptoms hit two weeks later in late March of 2003. "SARS took everything out of me," he said.

By late March, Toronto public health officials were investigating 15 probable and five suspected cases, trying to get a handle on the emerging threat. They announced unprecedented measures: They were quarantining two dozen households that may have had exposure to the virus. Medical officer of health Dr. Sheela Basrur suspected hundreds would need to be isolated, and by the end of the outbreak that year, more than 22,000 people in the York, Durham and Toronto regions had been registered for quarantine. (Actual numbers were estimated to be higher, but the data is imprecise because of record keeping issues, the U.S. study noted.) Public health officials ordered quarantine for entire workplaces, schools, religious groups, people who attended certain funerals, people who visited hospitals during certain times. Public health authorities publicized places and times where exposure had been likely, asking people to call in to register for quarantine. And people did.

While England was in hospital, his wife quarantined at home. And then when he returned, he began his own period of isolation. Three public health departments were involved because he acquired SARS in Toronto, lived in Durham, and his family doctor was in York. As a result, there was different advice, and he followed it all. While most people were quarantined for 10 days, "I was locked up for a month," he says.

In their study, the American researchers found that health-care workers they spoke to "often restricted their contacts with others more strictly and for longer than required." While they were allowed to interact with family members as long as they wore masks, many took extra measures by sending their families away, or sequestering themselves in the basement. Regardless of occupation, the majority of people in the study saw quarantine as a civic duty. Health-care workers were equally motivated by the fear of the virus attacking their own families. They had seen what the virus was capable of, DiGiovanni said, and they desperately wanted to protect their loved ones.

Challenges for people in quarantine included boredom, stress, stigma, isolation, and logistics. Fear of lost income was of "paramount importance," and the "most common reason" study participants had for non-compliance.

While some employers assured their workers that pay would continue, others did not. The situation was worse for part-time, casual and self-employed workers. DiGiovanni said employers need to keep this in mind and adjust their compensation and leave policies. Governments also need to recognize this when crafting financial relief packages for their citizens, and in 2020, they need to remember that those who work in the gig economy usually lack steady wages and benefits.

While the study noted that internet grocery delivery services were "widely used" by people with computer access, England recalls there were no smartphones, and no way to transfer money digitally. He relied on family and friends from work to drop off supplies, shovel his driveway, and cut his grass. "They looked after me," he said. "I think that's why I recovered as well as I did." The majority of quarantined health-care workers in the survey experienced private support - while 4 per cent said they broke quarantine because they needed supplies.

With COVID-19, private grocery delivery services are overwhelmed. The Loblaws delivery service for downtown Toronto had no availability this week. "Please check again later," the message read Tuesday through Friday. Grocery Gateway showed a sea of unavailable time slots from now until April 23. Exceptionally high demand, they explained on their site, advising shoppers to check back every morning "as delivery times are released daily."

Doug Hunt, lead counsel with the SARS Commission, believes different levels of government have acted quickly to reassure Canadians about financial relief this time around. Whether the plans are effective, and whether there will be red tape delays are issues likely being worked through right now, he said. "The question again has to be asked, how long can that go on?"

The U.S. researchers concluded that while quarantine compliance among GTA residents "appeared high" during SARS, that sense of civic duty and social responsibility might not be as significant in other countries and cultures.

Doug Hunt remembers a meeting with U.S. Centers for Disease Control officials in Atlanta in late 2003. One of the officials said they weren't sure if there would be the same kind of public co-operation in the United States because of American traditions of "aggressive civil liberties."

"As I watched events unfold in the U.S. (this year), you can see the truth of the comment he made," he said.

Images of crowded Florida beaches and partying spring breakers were common in March. "If I get corona, I get corona," student Brady Sluder told CBS News. "At the end of the day, I'm not gonna let it stop me from partying."

He later apologized.

"Like many others, I have elderly people who I adore more than anything in the world and other family members who are at risk, and I understand how concerning this disease is for us all," he wrote on Instagram.

DiGiovanni, now retired, said messaging in the United States has been framed very personally: If we all have loved ones who are vulnerable and at risk, we should not feel immune from the responsibility of protecting them.

"That seems to be a message that is getting through with the exception of dunderheads like the person you were quoting who was frolicking in the sand and sun and immune to logic," he said.

From his home in Scarborough, Bruce England is worried that people aren't taking the advice to stay home seriously enough. Because it's not just Florida beaches that attract a crowd. When he has to venture out for medical appointments, England has noticed the city is much quieter, but there are still "more people than I think necessary." He understands why people are torn, especially those who need to be at work, and those who are hurting financially, but "if we don't get a stop to it," he said, "people are going to die."

In the course of his investigation into Ontario's experience with SARS, Justice Archie Campbell and his team interviewed around 1,000 people, including medical personnel, first responders, front-line workers, government officials, people who contracted SARS, and people who had lost loved ones. Campbell was insightful with his investigation, and prescient with his recommendations, Hunt said.

"As difficult a time as this is, as bleak looking as it might be, we have such a debt of gratitude that we owe to him," Hunt said.

One of the lasting hallmarks was the emphasis on the "precautionary principle" - the idea that action to reduce risk should not wait for scientific certainty. Campbell pointed to the mixed messages around the N95 respirator during SARS. "Those who argued against the N95, which protects against airborne transmission, believed SARS was spread mostly by large droplets," he wrote. "They made this argument even though knowledge about SARS and about airborne transmission was still evolving."

"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," he continued. "We should be driven by the precautionary principle that reasonable steps to reduce risk should not await scientific certainty. Until this precautionary principle is fully recognized, mandated and enforced in Ontario's hospitals, workers will continue to be at risk."

When asked about the precautionary principle, a spokesperson with the Ministry of Health wrote that when little was known about the transmission of COVID-19, the ministry recommended "on a precautionary basis" droplet/contact and airborne precautions.

Now they say evidence is clear that it is a "droplet/contact spread virus," with "no evidence" of airborne transmission. The World Health Organization says studies suggest the virus is "mainly transmitted through contact with respiratory droplets rather than through the air."

"As this outbreak evolves, we will continue to review the scientific evidence to understand the most appropriate guidance for the health system and make updates as needed," ministry spokesperson Sonya Igneski wrote in an email.

Officials have acknowledged the province was caught off guard by the pressures on the medical supply chain during the COVID-19 pandemic. Amid concerns about supply, they have ordered more protective gear and announced federal help with N95 respirators, surgical masks, gowns, and face shields.

This week, the Ontario Hospital Association shared its concern that "many Ontario hospitals are running low on personal protective equipment, particularly masks."

A group of "medical leaders" at Michael Garron Hospital organized a personal protective equipment drive to "support anticipated shortage." Similar efforts are happening across the province. The Ontario government has a website asking people to submit their ideas and information about supplies they have.

Any issue that causes people to question the motivation behind directives can cause cracks in public trust, Doug Hunt said. He mentions Ontario's expired stockpile of millions of N95 respirators, the federal shipment of emergency medical supplies to China in February, the emerging debate about whether the public should be wearing masks, and the lack of aggressive warnings to avoid travel in early March. People need to have confidence that decisions are being made for the right reasons, he said. When officials state something emphatically, they need to be sure of what they're saying. It they're not sure, they need to say so.

While he investigated Ontario's response to the SARS crisis, Justice Archie Campbell was diagnosed with pulmonary fibrosis and, later, cancer. Those on the inquiry team remember him coming in to work with a supply of oxygen, never complaining. "Watching him write that report with the personal health burdens he had, he became one of my heroes," Doug Hunt said. "I'll never forget it."

Campbell was 65 when he died in April 2007, three months after the final report was released.

"He didn't want any other families to suffer as those families suffered," said Mario Possamai, senior advisor with the commission. "He didn't want nurses to be going through what they're going through today."

The research into the SARS response was done to "lay out a pretty detailed blueprint for how to avoid the issues," Possamai said. "I didn't think in my wildest dreams if we faced a pandemic, we would be as badly organized as we are today with respect to lab testing and N95s," he said.

As he contemplates the lessons from SARS, Doug Hunt said there are a couple of things that give him hope. There has been public co-operation so far, but "it's going to require a war footing type of resolve," he said. He is also hopeful about all the resources being poured into this problem as the world races to find a vaccine and useful antiviral medications.

From Scarborough, the now-retired Bruce England is worried about proper protection for health-care workers. When it comes to leadership, he thinks the premier and public health officials are doing a good job so far. "That's a saving grace for us now," he says.

Rick Huffman, a retired Toronto police officer who was a senior investigator with the SARS commission, says the high rate of compliance with quarantine during SARS "helped us an awful lot." Speaking from his Paris, Ont. home, he flips through the weighty final report looking for a specific passage from Campbell, where he called the public heroes for their co-operation.

"If not for them," Huffman said, "everything was going to go down the tubes."

He believes the province's experience with SARS made us better prepared to face this pandemic. If COVID-19 had happened 17 years ago, he said, "we would have been in dire, dire straits."

In his final report, Justice Archie Campbell called public support the "bedrock" of any effective emergency response. Mario Possamai believes Toronto had it in 2003, and he believes we have it now.

"I think it's one of the things that's going to help us survive this darn thing," he said.

At a daily press conference this week, Premier Ford reiterated the importance of Ontarians sticking together.

"This isn't about our government," Ford said. "We have an army behind us, an army of 14.5 million people, the hardworking people of this great province. That's what keeps me going day in and day out. That's how I know we will get through this."

Katie Daubs is a reporter and feature writer based in Toronto. Follow her on Twitter: @kdaubs