One Thing We Know as Frontline Doctors: Pandemics End
Amid uncertainty, it’s reassuring to consider the bigger picture
The first deadly viral outbreak of the 21st century was SARS, which infected 8,437 people worldwide, including 375 in Toronto, Canada. After the crisis was brought under control, doctors who beat it looked ahead to the future pandemics they knew would be coming — and offered this guide to living through it.
Within days of the first cases of SARS arriving in Toronto in February 2003, our vibrant, cosmopolitan city was turned upside down. Hospitals, the places people usually turn to when seeking relief, suddenly became places that many people dearly wished to avoid.
Some who demonstrated signs and symptoms of SARS arrived in the hospital desperate for help, only to discover that they probably had nothing more than a cold. In other cases, people who did have SARS but who were terrified of the events happening around them tried to avoid any kind of health care. Media reports alternately frightened and reassured.
Meanwhile, the doors of the hospitals had come to resemble the security checkpoints of a military facility. Access was controlled, and entry was limited to certain points for patients and others for staff members. At our hospital, the patient entry point was through a large, permanently parked Toronto Transit Commission bus that had been set up as a screening facility. Patients would go in one door, be assessed for their SARS risk, and then go out the other door of the bus into the hospital. At the staff entrance, a large and drafty tent, we filed through in a somber line each morning, had our body temperatures checked, and received our daily supply of personal protective equipment.
A patient with a fever and a cough does not normally provoke a guarded suspicion, and certainly not fear, in doctors and nurses. During SARS, it did. Each such patient was someone who might have this potentially dangerous new illness, which had shown its capacity to transmit itself to the health care workers who came into contact with it. Hospitals that were already occupied and utilized to their limit were suddenly forced to confront an entirely new biological threat.
A total of 109 Canadian health care workers were infected, and three succumbed to the illness. Most of them had the misfortune of being exposed early in the outbreak before the full range of infection control procedures had been put in place. Meanwhile, thousands of people from all walks of life were quarantined and isolated, their family and personal lives turned upside down.
Then the outbreak ended.
No matter what, the large majority of people in the world will survive the next global pandemic, and human civilization will continue.
Looking back, it almost seems like it was a bad dream. SARS was here, and then it wasn’t. At the time, scientists and the rest of the world wondered if SARS would be the next worldwide pandemic. It wasn’t. But working in frontline health care during the outbreak did convince us of the importance of discussing the issues that arise, for health care systems and individual citizens alike, during such crises.
SARS killed relatively few people. Nonetheless, it disabled health care systems around the world, resulted in massive travel disruptions, and interfered with thousands of people’s personal liberties by way of quarantines and movement restrictions. Although the scale of illness was actually relatively small, the societal impact was massive. As such, we feel it is important to discuss what we know about these issues.
Pandemics happen, and humanity survives
Worldwide pandemics are recurring events in the cycle of human illness. They vary greatly in severity and impact, and their precise timing is unpredictable. But what we do know is that the risk of pandemic is unlikely to ever go away.
Our knowledge does give us a historically unprecedented opportunity to intervene. At the same time, there’s no point in trying to make absolute predictions about things that are inherently, to some extent, unpredictable. Instead, the key task is to consider the range of possible outcomes. The paramount question becomes this: What are the reasonable things to do given that we understand the broad strokes of the issue, but that we do not know exactly what will happen?
In many areas of our lives, it would be nice to predict the future with certainty, whether choosing among personal health options or simply picking a route to take to work in the morning. Exact predictions often cannot be made, and we judge what may or may not happen in everyday choices. We may think that one route to work will not have a traffic jam, and then it does. We may take medication to treat a problem, and it turns out to have unpleasant side effects.
That’s just the way it is. We tolerate some unknowns and ask ourselves to make reasonable decisions. A private individual should not build a hermetically sealed pandemic bunker or hoard a cache of supplies, but may consider keeping some extra food in the house.
This is the same challenge for the world’s governments, public health organizations, and any individual person in a time of pandemic. Will tough decisions be made and subsequently criticized? Absolutely, and it is useful for decision-makers as well as the public to understand that things aren’t going to work out perfectly.
The double-edged sword of what we know
We know too well that a novel virus strain can span the globe in a time frame limited only by the speed of an airliner. We are now one world with one health.
We’ve come to understand more about the development and progression of pandemics than could have been imagined a century ago. We now have the technical capacity to rapidly identify and characterize new strains of virus, share scientific information, and produce vaccines and antiviral medications. We understand how a pandemic disease spreads and how its pace may be controlled or limited.
What will this knowledge give us? In science, industry, and medicine, we have a love affair with knowledge, but this relationship delivers mixed benefits. We’ve had a century of success using antibiotics to treat human infectious diseases. Yet we constantly struggle with antibiotic resistance, and many contend that the past few decades have seen these drugs often used inappropriately. Sometimes humanity brandishes its cleverness like a great burning torch only to discover that we’ve set the house on fire.
So we must carefully consider the limitations and fickleness of knowledge. We know what public health and other responses to a pandemic are possible, but we must be mindful of the costs in social disruption and other possible consequences.
The benefits of human knowledge tend to distribute themselves to the wealthiest parts of humanity: it is easier for more affluent countries to devote resources to pandemic planning, animal health measures, disease surveillance, and stockpiling of relevant materials. For rich countries to share the fruits and products of knowledge with poor countries makes a lot of sense, but we don’t have a good track record of doing this.
The human race is greatly enthusiastic about what knowledge can do; it is less excited when knowledge tells us what we can’t do. This is our collective blind spot when it comes to our love affair with science. When the next pandemic arrives, the impact may be large and far-reaching, and we won’t be able to make it go away or prevent every single death.
Human limitations: A freedom and a reckoning
An uncomfortable reality is that, to a large degree, the next pandemic will simply run its course. Doctors, nurses, public health workers, and society will do their best to mitigate the effects, and their work has the best chance of being appropriate and effective if we understand that some things can be done, and some can’t. Our understanding of pandemics needs to include a realization that many issues are beyond our control, and a clear eye for these elements is just as important as an appreciation of what actions we can appropriately take.
We live in an era in which an unprecedented richness of science and knowledge results in society setting its expectations at the highest point. Especially in affluent countries, the consideration of a threat to human health is accompanied by the opinion that some doctor or scientist should know how to “do something,” in order to “deal with it.”
But a pandemic is never a purely medical or scientific phenomenon. It plays itself out in societies of human beings, with all our faults and foibles. The challenge is often not whether knowledge exists, but whether the human decisions to understand and use knowledge correspond well with the opportunities for meaningful action.
No matter what, the large majority of people in the world will survive the next global pandemic, and human civilization will continue. The question of how best to use our knowledge from this experience to prepare for, and respond to, the next one will likely remain an ongoing challenge of human judgment, honest communication, and commitment to delivering fair benefits to as many people as possible.
Hopefully, it will be some time before we must address the consequences of another global contagion, but the timing may not be ours to dictate. Our goal should be to truthfully say at any point, if and when a pandemic begins, that we have done what is possible and reasonable to understand its threat, to delay its occurrence, and minimize its impact upon humanity.