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Last Updated

24 Jun 2003

Source: New York Times, June 24, 2003

Behind the Mask, the Fear of SARS


When Trish M. Perl, a leading American epidemiologist, went to Toronto two weeks ago, she found an exhausted hospital system and workers who were both angry and overwhelmed.

Dr. Perl is one of a small number of American doctors who, in response to pleas from her Canadian colleagues, have gone to Toronto over the past several weeks to give health workers a brief respite.

She said the atmosphere at the Canadian hospital where she worked had a surreal quality, with workers in daily staff meetings facing each other in the protective gear that has become routine in the relentless battle against SARS that began in late February.

"It was eerie like you were on Mars or on a new planet," Dr. Perl said. "You sit in meetings, everyone around the table is wearing an N95 mask."

Many of those who have worked long hours battling the epidemic are testy and despondent. "They needed a break," she said.

Dr. James Brunton, chief of infectious diseases at the University of Toronto, agreed that as SARS raised havoc with the health system in Toronto, it put enormous stress on health workers.

At times, Dr. Brunton said, "half the staff has been quarantined," forcing many others to constantly work overtime. "They're not getting enough sleep, they struggle with putting on the protection gear, and they are worried about getting infected themselves."

Still, by the time she left on Saturday, Dr. Perl, who is the chief hospital epidemiologist at Johns Hopkins University, concluded that even with the problems in Toronto, Canadian health officials were much better prepared than those in the United States to deal with a major SARS outbreak.

"At Hopkins we are proud of how prepared we are," Dr. Perl said in a telephone interview from Toronto. But she said she has told many colleagues about "how much we still have to do" and can learn from the Canadian experience.

She said Canada was generally better prepared than the United States to deal with the mental health problems of health workers in a prolonged outbreak like SARS, in which the workers are at risk of becoming infected. Most workers were offered counseling, she said.

She said she was impressed, too, by the sharing of information and decisions about cases between public health officials and clinicians in Toronto.

"We do not traditionally witness this level of cooperation in the United States," Dr. Perl said.

She said the United States should adopt a system in which an experienced doctor who understands the daily workings of hospitals act as the leader in communicating to the public. American health officials were criticized during the anthrax attacks of fall 2001 for giving information seen as confusing and inadequate.

Also, Dr. Perl said, hospitals in the United States should adopt systems similar to those now in use in Toronto, in which employees' temperatures are recorded when they swipe their bar-coded employee cards.

SARS has affected a large number of doctors, nurses and other health workers in Toronto and elsewhere. Some have died. Others have lain in intensive care units for weeks, breathing only with the aid of mechanical respirators, and may yet die. The catastrophe has left many who escaped SARS "with guilt feelings and fears of catching the viral infection," Dr. Brunton said.

Dr. Perl said that of the 1,200 employees at Scarborough Grace Hospital in Toronto, where the earliest cases occurred, 70 developed SARS. As of last week, only 6 had returned to work full time, 29 were back working part time and the remaining 35 were still out. No Scarborough worker who was treated in an intensive care unit was back to work.

"We're finding that it takes quite a long time for some people to get back even if they haven't been that badly infected" because of the physical and psychological effects of the disease, Dr. Brunton said.

Some doctors have refused to care for SARS patients or resigned.

To help ease the crisis, Canadian infectious disease specialists have appealed to their American colleagues for help in caring for SARS patients and tracking the epidemic.

The Infectious Diseases Society of America sent an e-mail message to its members saying that if they wanted to go to Canada for two weeks, the Canadian government would pay their expenses and 2,000 Canadian dollars ($1,400) a day. About 300 doctors have volunteered.

Ontario health officials later this week are expected to determine how many to call. Those who go will get temporary medical licenses, malpractice insurance and work permits within 72 hours. The program got an unofficial start when individual Canadian doctors appealed to their friends who were doctors in the United States to come help.

"For a while, we had trouble convincing the government that they ought to do that," Dr. Brunton said. He went on: "That drove us crazy, as we had staff burning out, and people had arranged for these people who were willing to come up. Yet it took days for them to convince the Ministry of Health."

Dr. Perl said she came in response to pleas from two Canadian colleagues she knew from working on international committees, Dr. Allison McGeer at Mount Sinai Hospital in Toronto and Dr. Mark Loeb of McMaster University in nearby Hamilton. At first she declined, because of the obligations of her job and the reluctance of Johns Hopkins officials to let her accept, partly out of concern for her three children.

But her husband, Dr. Sylvain DeLisle, also a physician, is Canadian, and her children, ages 10 to 15, have dual citizenship. "My husband urged me to go, saying it was a civic duty and a great professional and personal opportunity, and the children were supportive," she said.

She went with two friends who are also epidemiologists: Dr. Louise M. Dembry of Yale and Dr. Tobi B. Karchmer of Wake Forest University.

"As I was hugging my little girl on leaving, I thought, What am I doing?" Dr. Perl said. "Is this a smart thing to do? I was very scared at first. I didn't know what I was getting into."

When the children called her in Toronto, "They would say, `Mommy, are you wearing your mask?' " She reassured them.

After she left, her baby sitter suddenly quit because the sitter's father told Dr. Perl that she was putting his daughter at risk of SARS. And in Toronto, Dr. Perl said she was afraid to tell anyone in the hotel what she was doing for fear of being ostracized.

Although the level of medical care in Canada and the United States is generally comparable, Canadian and American doctors cannot substitute for each other like taxi drivers changing shifts. The systems differ.

For example, Canada has fewer hospital epidemiologists than the United States, and Scarborough General Hospital, where Dr. Perl worked, had none.

The first day, Dr. Perl found that the hospital had collected the names of contacts of infected individuals but had not documented them systematically and had not prepared a graph of the dates of onset of cases information crucial to controlling an outbreak. So Dr. Perl said she began by establishing a system of disease surveillance, creating checklists for infection control and helping the hospital group patients on the wards according to the level of exposure they had with people with SARS.

By the time she left, Dr. Perl said Scarborough General Hospital's status with the health department had improved to the second-lowest level, 1, meaning it had SARS patients but no transmission in the hospital from Level 3, when transmission occurred.

She said she learned how the Canadians had solved practical problems that she had never considered in planning for outbreaks. Toronto imposed two types of quarantines one that confined people to their home, the other that allowed some hospital staff members to commute in their own cars from home to work but nowhere else, including grocery stores. So the hospital had to set up a grocery store for them in its cafeteria.

In battling infectious diseases, as in wars, some people are more courageous than others, though the effort in SARS is largely voluntary. Dr. Brunton said he observed different responses to SARS among his colleagues.

Some doctors declined to examine patients suspected of SARS. Some doctors move to the opposite side of the room when colleagues who have cared for SARS patients are present. Some who appeared to be outstanding and fearless in their usual work in the hospital suddenly collapsed in the SARS outbreak because they were worried about becoming infected or infecting their families, he said.

One radiologist in Toronto isolated himself in his office and interpreted X-ray films only if they were slipped under the closed door, Dr. Perl said.

But Dr. Brunton said he also urged certain health workers, particularly those who were pregnant or trying to start families, to stay home or not to care for patients to avoid any risk of catching SARS.

The SARS outbreak could have happened anywhere. Dr. Perl said she hoped that "if it happened in the United States, the Canadians would have come to help us."