SARS swept through Toronto in March, 2003 with the impact of a major natural disaster. Unlike other natural disasters like Hurricane Katrina, however, this perfect storm landed on the doorstep of Ontario’s health care system. In the end, 44 people died and nearly 330 people became seriously ill with the virus. Many of the victims were health care practitioners.

In the wake of SARS, a number of lawsuits were launched on behalf of individuals or families who contracted the virus. All this litigation is still before the courts. Various inquiries were initiated as well, the most prominent being the provincial government’s Commission to Investigate the Introduction and Spread of SARS in Ontario – or the Campbell Commission, as it’s more widely known – headed by Justice Archie Campbell, a well-respected judge of the Ontario Superior Court.

Entitled “Spring of Fear”, Justice Campbell’s report was released amid a flurry of media attention, but most of the media interest subsided after a few days. There should be no doubt however about the report’s longterm importance and implications.

The full five-volume, 1,200 page report contains a detailed analysis of Ontario’s experience with SARS and makes several recommendations for improving infection control, worker safety and patient care. It also sounds a number of warnings for the future.

During SARS there was a general understanding that it was an unexpected, unknown illness that could not have been anticipated or prevented. However, Campbell comments in his report that today, “there is no longer any excuse for governments and hospitals to be caught off guard, no longer any excuse for health care workers not to have available the maximum reasonable level of protection through appropriate equipment and training, and no longer any excuse for patients and visitors not to be protected by affective infection control practices”. Thus, the bar has been raised for hospitals to respond effectively to infectious disease outbreaks.

In the final instalment of his report Campbell deals specifically with the issue of responsibility. He concludes that SARS was able to take hold because of systemic weaknesses in worker safety, infection control and public health. “The evidence throws up no scapegoats,” he says. He also finds that the hospitals involved in the SARS crisis were not to blame and recognizes that the outbreak could have happened in almost any hospital in the province. He commends the doctors, nurses and other health care workers who worked on the front lines, putting their lives at risk to help others. He concludes that, ultimately, SARS was stopped by health care professionals, scientists and specialists who were prepared to take strong measures, which were successful in the end.

One of Campbell’s recommendations is for better worker safety. Hospitals are described as dangerous places, like mines or factories. Campbell found that infection control and worker safety disciplines generally operated as separate silos during the SARS crisis. He emphasizes the need for effective cooperation to establish a strong safety culture. He also calls for more aggressive investigations and prosecutions under workplace safety legislation by the provincial Ministry of Labour. In response to these recommendations, we can assume the Ministry of Labour will respond vigorously to disease outbreaks in the future, with increased surveillance and possible prosecutions of health care institutions.

The Campbell Commission Report is clearly not light reading. However, those involved in infection control need to pay close attention to it and to the recommendations made within. The clear message from the report is that more work is needed to improve infection control in Canada.

You can access the Campbell Report at: