The Canadian Union of Public Employees is comprised of 500,000 employees across Canada, including 200,000 in Ontario. We represent employees in every part of the province. We are the largest health care union in both Canada and Ontario, representing in Ontario well over 50,000 hospital, nursing home, home for the aged, ambulance, home care, and municipal public health employees. We also represent employees in municipalities, social services, school boards, universities, utilities, and libraries.
In addition to public sector workers, CUPE also represents flight attendants working at the major Canadian airlines. In a very real sense, they too were on the front lines as SARS was introduced to Canada through overseas travel.
CUPE members work in many hospital and ambulance services directly affected by SARS. Fourteen CUPE members were infected with SARS. One infected CUPE member infected her twin children.
As front line providers of many of the services most affected by the SARS outbreak and as the backbone of infection control in hospitals, public health departments, and homes, we believe we can provide a front line perspective on the outbreak, the response during the outbreak, and the ongoing steps that have been taken to date to prevent another major outbreak of an infectious disease.
As a union of front line providers, we can attest that the SARS outbreak was marked by chaos and confusion, inadequate resources and planning, and a determination to place economic interests above health and safety interests. Employers and government all too often excluded the input of workers. Such an outbreak was almost inevitable given the starvation of our health care system. Worse, we have seen little that gives us hope that the necessary changes are happening.
Three CUPE paramedics became infected with SARS during the course of performing their duties. A fourth contracted it after being ordered by his employer to report to hospital and being placed in a room next to a person with SARS. Hundreds of paramedics were quarantined and well over 1,000 were exposed to SARS. In our private life, the community reacted to paramedics with fear.
We have considerable fear that SARS, or other infectious diseases, will strike again and force ourselves and our patients to relive a very ugly experience.
Chaos and confusion marked much of the response to the outbreak and inconsistencies were widespread. Front line paramedics and members of the public were endangered.
For example, there was a lack of direction for intubating in pre-hospital situations. This continued even after direction had been given for intubating in hospitals. Indeed, there was a lack of direction for pre-hospital care until at least May.
Further, while staff working in hospitals with SARS patients were directed to work in positive pressure suits while intubating, paramedics were not afforded such protection. This inequity has put paramedics and the public at risk
The province indicated we should have followed infection control manual – but paramedics in the centre of the outbreak did not see this until well into the crisis. Paramedics discovered in the midst of the crisis that a common ambulance cleaning fluid, hydrox did not eliminate viruses. Likewise, there was delay and confusion regarding the fit testing of masks. In York, it took considerable time to get disposable Bag Valve Masks. In the north and other parts of the province it took a long time just to get masks. Indeed there was a constant problem with acquiring sufficient protective materials and there was a lack of Personal Protective Equipment training. Generally, infection control procedures were weak.
The willingness of employers to involve paramedics in developing a response to the outbreak varied. Too often, front line paramedics were not involved in the central command and we were unable to get Health and Safety Committee meetings. In York, paramedics often had to rely on information provided by paramedics in the City of Toronto.
In the City of Toronto, in contrast, front line paramedics were closely involved in developing an effective response and set up a desk in the command centre through which they were able to communicate with union stewards and front line paramedics. This improved the response to SARS, allowed the union to immediately pursue problems, and helped bolster the confidence of paramedics on the front line in the fight against SARS.
With the cutback of hospital beds and resources stretched to the limit, there has been a longstanding problem in Toronto hospitals with wait times in emergency rooms. So much so that the Toronto Emergency Medical Services has recently had to devise a new system for leaving patients in hospitals to ensure that ambulance paramedics can return to service in a reasonable amount of time. As a result, during the outbreak it was not uncommon for paramedics to be required to wait for hours on end in their ambulance with a suspected SARS cases before being allowed to take the patient into emergency. Indeed, paramedics were often re-directed from a hospital unwilling to accept a suspected SARS patient.
We are not convinced that the necessary improvements that are required in infection control have been made since the outbreak. Indeed, some negative practices are deepening.
During the outbreak Health Minister Tony Clement raised concerns about moving patients from one hospital to another. This is a valid concern. Transfers between health care facilities have a great potential to spread infectious disease and, with hospital restructuring, this is an expanding industry. Five years ago trained paramedics would have done most of these transfers. Now, fewer and fewer are done by paramedics as more and more work is handed over to for-profit transfer services. These transfer services are not regulated and the drivers are not paramedics. Their wages are much lower. Is this adequate? We are concerned about this new emerging standard.
SARS was spread to Canada through international air travel. Yet, airlines were reluctant to take the full steps necessary to protect flight attendants and passengers during the SARS outbreak.
Flight attendants were forced to deal with a lack of contingency planning by the airlines for the spread of infectious diseases through air travel. At first there was no plan to disinfect planes after travel by an individual with a suspected case of SARS. When a procedure was put in place, it was inadequate. There was no plan about how to deal with discharged SARS patients. We received no medical clearance for these passengers. Flight Attendants who were advised by Health Canada that they were “probable contacts” with SARS passengers were not quarantined.
Work refusals occurred because carriers continued to fly into SARS affected areas without providing personal protective equipment. There was inadequate protection for flight attendants. There were significant employer restrictions on the use of protective equipment for front line workers in order not to “alarm” clients.
At Air Canada the union requested protective gear and disinfection of airplanes after flights carried suspected passengers with SARS. The Union actually purchased gloves and masks for flight attendants, but Air Canada initially banned flight attendants from using them generally, except in specific cases of handling sick passengers and for cleaning the bathroom.
To add insult to injury, at the conclusion of flights from areas affected by SARS, flight attendants would open the plane doors to see airplane-cleaning staff in full protection suits. The flight attendants who had been confined to a small space for 14 hours could not even wear masks or gloves without fear of facing discipline from their employer. Staff who did not deal directly with the public, however, were under no such direction.
The airlines were all too often more concerned with image than safety. We believe the passengers would have felt safer if they saw the airlines taking pro-active steps to prevent contagion.
To help remedy this problem, the union filed a complaint against the airline with a Government Safety Officer for Human Resources Development Canada. Air Canada was trying to get out of its responsibilities and we had to push them to the wall. Eventually Air Canada was required to perform a risk assessment that indicated that there was little contingency planning.
It is responsibility of airlines for airlines to have a contingency plan for staff who may be infected or quarantined in a foreign country. However, no such contingency plan yet exists.
Finally, we have seen little, if any, improvement in infection control preparedness at major Canadian airlines.
In light of Ontario’s strong international links, we must expect that future SARS outbreaks may spread in this manner and that Toronto’s Pearson airport may well be at the forefront of such outbreaks. We saw little evidence of coordination between the provincial and federal government concerning the screening of passengers. Indeed even today the political squabbles continue and no satisfactory system is in place.
In addition to paramedics, hundreds of other City of Toronto Employees were part of the City’s response to SARS, and these were represented by CUPE Local 79, the City’s inside workers. Department of Public Health staff worked on the SARS Hotline, in case management, in contact follow-up and in epidemiology. Other City staff worked with the public in dental clinics, in social services, in building inspections and more.
These inside workers did not enjoy consultation and cooperation from management at the City of Toronto. Their concerns for their own health and safety, as well as the health and safety of the public they worked with, were routinely rebuffed. Their requests for personal protective equipment were ignored even when their jobs entailed contact with members of the public in quarantine or screening members of the public for SARS. Their attempts to hold joint Health and Safety Committee meetings were stymied.
Municipal public health departments are operating with too few reserves. When the SARS outbreak occurred workers were pulled off other vital public health duties. Food, meat, and restaurant inspections were drastically reduced. Immunizations, pre-natal nutrition, heart-health programs and food -handling training were cancelled. The well-baby program was severely curtailed and most other Department of Public Health programs were reduced to high-risk cases only. Some programs remained closed over the summer to make up for some of the department’s additional spending on SARS. We were lucky that this did not cause significant health problems.
None of the three levels of government had a computerized disease tracking system adequate for the SARS outbreak. Much of the time of public health workers was spent in complex paper tracking procedures.
Municipal homes for the aged were hard-hit by the requirements that part-time workers could only work at two-sites, or in the case of some City run homes, one site. In one home, for example, 39 of 43 part-time CUPE members worked at more than health care facility in order to make ends meet.
CUPE members work at many of the hospitals infected with SARS, including Scarborough Hospital (Grace and General campuses), St. John’s Rehabilitation, and Lakeridge Health. Ten CUPE hospital workers were infected at work. This included support staff as well as nursing staff. One infected CUPE hospital employee infected her twin children.
A striking feature of the outbreak was how the hospitals and the provincial government set-aside the input of front line hospital workers. While in some cases, employers did draw on the knowledge and experience of front line workers, all too often the provincial government and hospitals ignored or even repelled worker involvement. By refusing to heed the information and experience of front line workers, government and employers endangered those workers and the public.
The hospitals faced a major problem with infection control. Predictably, hospital employees formed a large portion of the victims of this outbreak. Yet all too often, joint occupational health and safety committees in hospitals were downplayed or set aside. CUPE members are front line providers of nursing services and provide the backbone of infection control in hospital through housekeeping, laundry and maintenance services. Joint health and safety committees should play a significant role bringing the experience and knowledge of hospital employees to the service of creating a safe hospital environment. Unfortunately, they often did not.
As well, the Ministry of Health and the Ministry of Labour ignored key proposals from hospital employees. CUPE demanded that the hospitals move pregnant employees and require joint occupational health and safety committees to meet. Pregnant women are contra-indicated for the drugs used to treat SARS, which we understand can harm the foetus. But there was no real response to these proposals. This inaction was in stark contrast to the government’s willingness to intervene, quite crudely, in the labour market (e.g. restrictions on the number of sites employees could work at, or the selective and sometimes destabilizing introduction of danger pay).
The lack of involvement of workers in health and safety issues is not a new issue for us, nor unexpected. It reflects the hierarchical structure of hospitals and a government that wishes to restrain worker influence on health and safety.
The result is that our interest in creating a safe hospital environment, our knowledge, and our many years of experience are lost.
Without a concerted effort to change this culture in hospitals and government, we expect that future problems with infectious disease control in hospitals will also be set back by this loss.
CUPE also has a number of general concerns.
Business Before Health
Despite concerns from the unions, hospitals began to “ramp up” operations in April, just as the outbreak was spreading to other hospitals. While there may have been a number of causes of this, we note that there was a large campaign by business and every level of government to downplay the significance of the outbreak and a focus on economic activity rather than public health.
There is no doubt that the outbreak left a significant economic impact: from airlines to tourism, to entertainment, to doctors. Early in April the 12,000 person American Association of Cancer Researchers conference was cancelled. Alyse Allan of the Toronto Board of Trade stated “We have a serious economic crisis right now in the tourism industry and we have yet to understand what the ripple effect of that will be.” By May, the Toronto Board of Trade concluded that 75% of its members have had their businesses affected by SARS, and for close to half the impact was been a loss of revenue. Medical doctors faced serious reductions in their income. Ultimately, Health Minister Tony Clement estimated that SARS could end up costing Ontario a staggering $3 billion.
On April 23 the World Health Organization issued a travel advisory regarding Toronto. Premier Ernie Eves characterized this as “irresponsible” and a major campaign to reverse this decision began. Eves stated: “we are taking every step – and so is the federal government – that is possible to reverse this decision.”
Eves announces a $10 million worldwide marketing campaign and the chief spokesperson of the City of Toronto (Brad Ross) stated, “Right now the real battlefront is on the PR side of things”. The City took the unusual step of sending videos clips out via satellite to media outlets in North America, Asia, and Europe challenging the WHO advisory.
The Ontario Minister of Health, Tony Clement, traveled to the WHO in Geneva, leading the fight against the travel advisory. This we think is a telling example of a government and a Minister of Health that had lost their focus. The Minister of Health’s business is health – not tourism or business activity. In the midst of a life-threatening outbreak, this focus must be particularly sharp.
On April 29th the WHO travel advisory was removed. The Toronto Star reports that on the same day that WHO lifted its travel advisory, a document signed by the minister of Health was delivered to the Ontario cabinet that indicated that the first SARS outbreak had crippled the health system. “In the even of a major disaster in Toronto, the Ontario health system would have been brought to its knees… For surveillance and epidemiology, laboratory capacity in Ontario is now stretched beyond its ability to cover all fronts. There is a major shortage in key skills resulting in Ontario overworking existing staff and relying on transient re-located staff.”
On May 2 the Canadian government placed full-page ads in newspapers proclaiming that Canada has turned the page on SARS. Shortly, the Ontario Hospitals begin to relax infection control procedures, despite union concerns.
The Ontario Health Minister Tony Clement added: “Let’s face it, we had a black mark that was right beside Toronto’s name and the black mark has now been removed because of our infection control procedures.” Federal Health Minister stated: “It is controlled it is contained. Everything we have seen over the past number of weeks is evidence of that.”
But then it became known that the first outbreak had continued, unrecognized at the North York General Hospital. The WHO put Toronto back on the SARS affected list. Soon it was recognized that SARS had also spread to other hospitals, like St. John’s Rehab and the Whitby campus of Lakeridge. And again health care workers became sick. Health care workers were not pleased.
Notably, after the “second” outbreak Health Minister Clement actually asked the WHO to take “ little bit of extra time” before removing Toronto from its list of SARS affected areas. This was quite a reversal from his earlier efforts. .
For future benefit, we believe it is important for the Commission to reflect upon these developments and comment upon whether there was an undue focus on economic and business interests at the expense of public health and safety. Otherwise we may well repeat this experience.
The Health Care System Lacks Adequate Resources.
Health care has been in a continual funding crisis for some years. With staggering debt loads and most continuing to run deficits, hospitals, at the best of times, are strained to the limit. Despite an ageing population, the Conservative government has decreased health care funding as a percentage of the economy. Inadequate resources left the health care system with no reserves to deal with something like a SARS outbreak.
During the crisis the provincial government appeared to recognize that there were serious problems:  the Minister of Health and Long Term Care expressed concern about the large number of part-time nurses ;  he also expressed concern about a lack of reserves in the health care system ; and  the government’s implementation of the “new normal” for health care implicitly recognizes that there was weak infection control in our health care system. We agree with these three points, but would go further in some areas.
The disease first began to spread in Scarborough Grace hospital after a SARS victim visited the emergency room on March 7 and infected another patient. We find it completely unsatisfactory that a man with respiratory problems spent 12 hours in an observation room next to an old man. Yet given the cuts in hospital beds and the revision of hospital infection control procedures in recent years, this was almost inevitable. Indeed, given the state of Ontario hospitals, the patient could easily have lain for more than12 hours and infected more than one bedmate.
Since 1989/90 almost 18,000 hospital beds have been removed from the system – almost 1/3 of the total hospital beds. Ontario has fewer acute care beds than any other province (3.1 beds per 1,000 population compared to a Canadian average of 4.1). Ontario hospitals have a shorter length of stay compared to hospitals in other provinces. (5.8 days in community hospitals compared to 7.4 days in community hospitals in the other provinces). As we noted earlier, there are now regular ambulance offload delays because of a lack of beds and staff.
We have also seen the introduction of so-called “universal precautions” in hospitals for infection control. Given the resources available “universal precautions” (where staff are supposed to treat all patients as if they were infectious) has meant that very little in the way of precautions are actually implemented. This is exactly what seems to have happened in the outbreak. Before “universal precautions” patients presenting with respiratory ailments were isolated.
Had these resources and precautions still been in place, it would have been difficult for the infection to spread through the hospital.
Finally, The Toronto Star indicated in an editorial dated June 26, 2003 that the WHO issued two alerts describing an outbreak of an atypical pneumonia in Asia and that these reports were distributed to Toronto hospitals roughly three weeks before Che Kwai Tse showed up at Scarborough Grace hospital on March 7. We are not in a position to know why this failed to prevent an outbreak, but we do think it is a pressing issue for the Commission. Why did the warnings fail?
Are Things Getting Better?
We have seen little evidence that the changes necessary to avoid future infectious outbreaks are being made. Indeed, we see some negative changes.
We agree with comments from the provincial government that there needs to be larger reserves built into the health care system, that more full time workers are needed at health care facilities, and that infection control procedures need to be stepped up. But we have yet to see significant changes. We are very concerned about the impact of this on outbreaks in the future, perhaps the near future.
While there has been some recognition of the need to improve infection control procedures (the “new normal”) there has been little recognition of the need to improve cleaning in health care facilities for better infection control. Indeed, we see an increasing emphasis on downplaying and cutting hospital cleaning. Like other aspects of so-called “non-clinical” health care services, they are under attack.
The Canadian Institute for Health Information has recently revealed that hospital expenditures on support services has declined rapidly as a percentage of hospital expenditures. In the six years between 1993-94 and 1999-2000 (the most recent year for which data is reported) expenditures on support services declined from 22.1% of hospital expenditures to just 16.9%. This continues a trend of decline that dates back from at least 1976. From 1995 to 1999, there was an absolute decline in spending on hospital support services. Over that period there was an annual average decrease in spending of 1.8% for housekeeping services, and an annual average decrease in spending of 5.4% for the cleaning of laundry and linen.
Yet a high standard of hygiene should be an absolute requirement in hospitals. In the long term, cost cutting on cleaning services is neither cost effective nor common sense.
Compounding the problem, the privatization of health care support services is greatly increasing. As we see in British Columbia the end result of this is a great reduction in the wages of support staff – cutting wages in half. Not surprisingly, Scotland’s auditor general found that turnover of cleaning staff was higher among external contractors than when the work was done in house (40% versus 23% in 1998/9). The result will be a cleaning staff with less knowledge, fewer skills, and a reduced commitment to the hospital, as they seek better employment opportunities elsewhere.
In Britain, the National Health Services audit of cleaning services found that “where services are contracted out they are more likely to have failed.” The cuts and the privatization threaten the backbone of infection control in health care facilities.
In Taiwan, the Su Ih-jen, the Director of the Center for Disease Control, stated that control of nursing aides, cleaners and laundry workers in hospitals should be a key part of preventing the re-emergence of SARS.
“The SARS outbreak has revealed the impropriety of hospitals outsourcing these jobs. Take [Taipei Municipal] Yangming Hospital for example. In its outbreak, doctors and nurses fortunately were not infected,” Su said.
“However, nursing aides, who did not have proper disease-prevention outfits, roamed freely in hospitals and contracted the disease,” Su said.
“These nursing aides, cleaners and laundry workers were not the hospitals’ formal employees. The hospitals, therefore, could not efficiently manage these workers,” Su said.
Su suggested hospitals bring back under their control all outsourced jobs in order to improve infection control….Outsourcing was also cited in the Taiwan Health Reform Foundation’s review of flaws in the country’s medical system exposed by the SARS outbreak.
While the provincial government did seem to recognize during the outbreak that improvements are needed in the health care system, little has changed in terms of funding or staffing to date.
The provincial government has announced that it will cover revenue lost by hospitals as a result of SARS and has promised money to cover additional expenses brought about by SARS. But there has been no real commitment to provide the resources to improve infection control, increase the reserves of the health care system, or hire more full time workers. On July 31 the government promised $136 million for “expanded services at restructured hospitals and for priority programs.” However, this amounts to a little bit more than 1% of the government budget for just hospitals and is in line with the mid-year funding increases we have seen for some years. This will not allow significant changes.
We are not aware of any initiative to create more full time CUPE positions in health care facilities. And we note that support workers, not just RNs, work at more than one facility and can be as easily infected as any other person.
CUPE has not reached final recommendations concerning the SARS outbreak and infections. Our concerns, however, are obvious:
- In the workplace, confusion and chaos characterized much of the period of the outbreak; the input of workers was often ignored and even joint health and safety committees did not meet in many instances, seriously weakening the response to the outbreak and the confidence of staff in the protections provided.
- During the outbreak economic and business concerns too often took precedence over what should be our top priority – health and safety.
- The SARS outbreak put on public display the inadequate resources provided by governments for our cherished public health care system.
- And finally, there is little evidence that significant change is underway to deal with the problems in our health care system that were laid bare during the outbreak.
We intend to consult with our membership and consider the issues carefully. We would be pleased to share these reflections with the Commission and will provide further documentation that the Commission considers necessary.
Thank you for your consideration.
September 30, 2003 CUPE Research