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Drawing on lessons from the 2003 outbreak of Severe Acute Respiratory Syndrome, city and provincial experts promise new screening measures, emergency plans to treat patients from home and tough laws detailing what health workers must do.

Rules still under government debate could ban travel, fix prices and order health-care professionals to provide necessary services in the event of a pandemic.
"I think what puts us ahead of folks who haven't dealt with SARS is that it really has made the potential pandemic more real. We at least have a framework for what we might see with pandemic flu," says Dr. Susan Poutanen, primary author of the first two scientific papers on SARS, published in The New England Journal of Medicine during the Canadian outbreak.

Toronto was the only city outside Asia where people died of SARS. The disease infected 375 people in the city, Canada's largest, and killed 44, prompting a scathing public inquiry and angry lawsuits.

And it could be only a matter of time before Toronto has to cope with bird flu too, as the H5N1 avian influenza virus spreads out of Asia to infect birds in Europe and Africa. Experts agree it will one day reach North America too.

The virus does not easily infect humans -- it has killed just over 100 people in three years -- but scientists fear it could mutate into a pandemic strain that could kill tens of millions.

LONG-DISTANCE CARE

Ontario's influenza plan aims to free up overwhelmed hospitals by providing telephone and Internet home care to less vulnerable patients.
Late last year, the provincial government proposed legislation that would broaden its power to ban travel and order health workers to provide services if a pandemic struck.

But Ontario's Bill 56, which is still being debated, has drawn criticism from doctors who fear they will be jailed or fined if they refuse to work.

"My initial response when I think about (avian influenza) is that I'd like to run away from it all and protect my family, and that's the sense I get from my colleagues," said Connie Leroux, a nurse who contracted SARS from a patient at a Toronto hospital. "However, I also have a very strong sense of responsibility to our community and our patients, so I'm not sure how many of us would actually leave -- including myself."

Poutanen, an infectious disease consultant at Toronto's Mount Sinai Hospital, named surveillance and diagnosis as key areas where Toronto learned from SARS.

"Surveillance for fever and respiratory illnesses ... has gone from essentially nothing to an Ontario-wide suggestion that all hospitals search (them) out," she said.

Hospitals in the province of 12.5 million will question anyone who arrives with a respiratory illness, even isolate them until the symptoms are deemed noninfectious.

In 2003, hospitals overlooked a single case of SARS, setting off a second deadly wave of the disease and landing thousands in quarantine.

One of those quarantined was Leroux. Now 35 and diagnosed with depression, anxiety and post-traumatic stress, Leroux says she followed guidelines for both protective attire and contact with her family.

"It was very clear to me that (my husband) and two children were at high risk of contracting it as well because I had just seen them and was quite contagious at the time," she said in an interview.

Leroux's family did not contract SARS, but they spent 10 days in isolation, while she was quarantined for a month. The nurse is now one of 53 suing the provincial government for negligence during the crisis.

TRUMPING MOTHER NATURE?

A public inquiry blamed a "broken" public health care system in its interim report, calling it "unprepared, fragmented, poorly led ... inadequately resourced."

"SARS was contained only by the heroic efforts of dedicated front line health care and public health workers and the assistance of extraordinary managers and medical advisers," Justice Archie Campbell wrote in 2004.

Ontario that year committed C$2.4 million ($2 million) in new health spending and created an emergency management unit to coordinate the province's response to crises like SARS.

"The fundamental problem with SARS was that we took for granted our ability to trump Mother Nature," said Allison Stuart, the unit's director. "We don't have a pill for everything, and we learned that lesson very quickly."