LOVESICK
How a romantic vacation in the sun triggered fears of a deadly epidemic^*

The photograph, framed and displayed on a cabinet in the living room of Hilary Lomas's apartment in Hamilton, Ontario, harks back to a happier time. Five women in their late thirties to late forties (women who, at the moment the shutter clicked, might have referred to themselves sportingly as "girls"), are leaning into the gently curving trunks of an almond tree on a beach, smiling happily. Sand at their feet and an azure sea in the background. Hilary is fetching in a slim black dress. It is 1992, at a Puerto Plata resort, on the north coast of the Dominican Republic.

They are all single women, with good jobs back in Canada: Hilary, then divorced with a grown son, worked for a retail distributor. And this allowed them the freedom to travel -- several times a year. Maryann, Hilary's upstairs neighbour in Hamilton, owned a time-share overlooking the beach. What might be possible? Sand, sun, enjoying the local culture. Even romance. When they dropped in to clubs around Puerto Plata the men, mostly locals, flirted with them and, before long, a number of the women had Dominican boyfriends. Maryann ended up married, to Juan. The fellow who caught Hilary's eye was a lounge singer at the Dorado Naco resort, a slight man, twenty years her junior, named Gaspar Benjamin.

Eight years later, the repercussions of that innocent holiday time would turn Hilary Lomas's world topsy-turvy and send her community back in Canada into a panic.

On monday, December 4, 2000, the headline in The Hamilton Spectator read: "Secret TB Hunt Scours City: Victim Eluded Screening Process." The story quickly became headline news across Canada, and soon the whole country knew that, for almost two months, the Public Health Departments of Hamilton-Wentworth and several other regions had been frantically seeking out and screening hundreds of people who might have been in contact with someone identified only as "a man who'd come to the Hamilton area as a landed immigrant from the Caribbean." In a series of stories published over the next week, The Spectator's medical reporter, a young woman named Joanna Frketich, revealed that the man had arrived in December, 1999, but it wasn't until the following October that he'd been identified as carrying a potentially deadly multi-drug-resistant variety of infectious tuberculosis. During those ten months, he had at the very least infected his wife, whom, it was said, he'd married in order to immigrate. The couple had been quarantined in a TB clinic in Toronto, but before that, they'd unwittingly passed on the infection to an unknown number of other people. The exhaustive detective work needed to identify and locate those potentially infected was consuming the energies of at least a dozen public-health workers (at an estimated cost of $1.4 million).

And there was more: Frketich revealed that the mandatory medical screening by Citizenship and Immigration Canada, which should have caught and stopped the man before he immigrated, had failed.

The man was Gaspar Benjamin; his wife, Hilary Lomas.

Their story drew immediate attention to a number of serious public-health issues, not least of them our fear that dread diseases might be routinely arriving into our midst from far away. Each year, almost 700 million people fly across the world's international borders, a number that will probably rise to a billion before the decade is out. There are 100 million entries into Canada each year, including 225,000 new immigrants and 15,000 refugees; the rest are tourists, foreign business people, or Canadians returning from abroad. How can anyone possibly ensure that none of those people are carrying things far more dangerous than their souvenirs? And when somebody with a highly contagious disease does get through, how can they be identified, and what can be done to limit the damage?

In the six years after 1992, Hilary made at least a dozen trips back and forth to the Dominican Republic, sometimes with other women, sometimes alone. During a Christmas visit in 1993, she met Gaspar and their relationship took off. So, unfortunately, did her problems. In 1994, the company she worked for closed one of its divisions and laid her off, but she was less able to work anyway: a genetic kidney ailment that had plagued her since her thirties (as it did her sister, who lives in England) was getting worse. In the middle of 1994, hoping eventually to get a new kidney, she started on a dialysis program in Hamilton. But she managed to keep making her trips south whenever she could. Gaspar, at his end, seemed to be having problems too; Hilary notes that one time she observed he was taking streptomycin, which he told her had been prescribed because he had pneumonia.

Through it all, their relationship became more serious. Hilary attempted a couple of times to have Gaspar come to Canada as a visitor, but because he had no steady job, he was never granted a visa. She then tried to sponsor him as her fiancé. This time he was denied a visa because her income wasn't high enough. So in November, 1998, she flew to the Dominican Republic, where they got married at the courthouse in San Pedro de Macoris, and promptly commenced the paperwork to get Gaspar admitted as a landed immigrant. He underwent the obligatory medical examination in September, 1999, at a clinic in Santo Domingo. In November, the all-clear was given; Hilary bought him a ticket, and on December 8 he arrived in Canada and moved in with her.

Two months after Gaspar's arrival, Hilary was told that a suitable kidney match had been found and she entered St. Joseph's Healthcare centre in Hamilton for the transplant operation. The surgery was deemed successful, but her response wasn't. She stayed in hospital for five weeks, went home for three weeks, then was back in St. Joseph's. The whole thing was becoming exhausting and discouraging. Her blood platelets were low, and she required frequent plasma-exchange procedures.

Gaspar, meanwhile, tried to pick up his musical career. He joined a Caribbean band as a singer and got gigs in Toronto and Kitchener, sometimes travelling as far afield as Montreal. Hilary, now surviving on a disability pension and savings, financed his travels, but noted the first inklings of trouble in the relationship: "I don't know how he got paid," she says, "but if he did, he never paid me back for what I gave him."

Gaspar's medical story, too, came to a head during this time. Shortly after his arrival in Canada, he'd gone for the physical examination required by immigration rules, and then, several months later, in the summer of 2000, he went for a second one. This time, a chest X-ray was taken, and when the results came back, they showed severe and long-standing damage to his lungs caused by tuberculosis. Gaspar was sent to St. Joseph's, the same hospital where Hilary had had her surgery. He was prescribed a regimen of medication and then confined to their apartment for the next three weeks. Sputum samples -- the standard way to determine definitively the presence and state of tuberculosis -- were taken from both him and Hilary. The cultures take six to eight weeks to grow, and when the results finally came back, the news wasn't good. On October 10, Hilary recalls, at about 4 p.m., the Public Health Department called, instructing her and Gaspar to pack their bags. They'd be picked up the next morning by ambulance and taken to West Park Healthcare Centre in Toronto. Their other immediate task was to put together a list, as complete as they could make it, of absolutely everybody they had been in contact with over the ten months since Gaspar's arrival in Canada.

Tuberculosis is a disease caused by a bacterium -- tubercle bacillus -- subject to airborne transmission. It is particularly transmissible in sputum, but can be coughed or even breathed into the air. You can catch it by spending time in a room, or being on an airplane, with someone who is infected. You probably won't get sick right away, but if you do, the symptoms may include coughing, a fever, and a feeling of weariness. You'll probably be quarantined and treated with a regimen of antibiotics. (These days, only a small number of cases are fatal in the developed world.) If your immune system is sturdy, you might not get sick at all, though once the bacterium enters your body, it can lie dormant forever, or spring into life at any time.

An earlier name for the disease was "consumption," and it was hugely feared, killing half of those who contracted it. The English Romantic poet, John Keats (who would die from it in 1821 at the age of twenty-five) described it as "the weariness, the fever, and the fret. . . . [Y]outh grows pale and spectre-thin and dies." In Canada, there had been no record of TB prior to the arrival of Europeans, but it quickly took hold and, for the next three centuries, was the leading cause of death among white settlers, and a disaster for native people. When the antibiotic streptomycin came into general use in 1944, it dramatically turned things around. Streptomycin and subsequent drugs were so effective, in fact, that by 1957 the death rate in Canada was one twenty-fifth of what it had been at the turn of the century. By the early 1980s, the disease was considered almost eradicated.

Yet in much of the rest of the world, particularly in impoverished places with poor public-health systems, tuberculosis never came close to being wiped out, and worldwide it is still the leading cause of death due to a single infectious agent. About three million people a year die from it and as many as one-third of the world's citizens are believed to be carrying the bug. Current hot zones include Argentina, Latvia, India's Uttar Pradesh state, Henan Province in China, and the Dominican Republic.

Canada, early on, opted for a program of protective vigilance. From the beginning, our immigration regulations included tuberculosis in a list of "mandated" diseases, which meant the government had powers to quarantine those infected and to screen any person immigrating to Canada. Under this system, would-be immigrants with TB in its active, contagious, state were to be barred from entry into Canada until they were successfully treated in their own countries; those with non-active, non-contagious TB could enter, but had then to report to local public-health authorities and be monitored.

But with the growing ease and volume of international travel, and with immigrants coming from all over the world, maintaining adequate protective measures has become an exacting task. And the existence of multi-drug-resistant (MDR) versions of TB is of particularly urgent concern. Many bacteria and viruses, including the tubercle bacillus, mutate in order to survive the antibiotic therapies with which human medicine assaults them: in doing so they produce new strains that are resistant to the drugs. For the human carrier, infection by an MDR bacterium can come about in two ways: you can pick it up from someone else who has it, or you can develop it yourself, most commonly by failing to complete the full regimen of drugs prescribed for your infection.

When West Park Healthcare, where Hilary and Gaspar were quarantined, was built in 1904, it was called the Toronto Free Hospital for the Consumptive Poor. In 1912 its name was changed to Queen Mary Hospital and it became the first institution in the world devoted exclusively to children with TB. By 1970, with the dramatic drop in the number of patients, the old hospital was closed and the present structure, a rambling lodge on park-like grounds, was put up to treat patients suffering from a variety of respiratory and long-term illnesses. The TB wing is isolated in a newer building, and can house a maximum of twenty-two patients at a time.

Essentially, there is nothing to do here but rest. Patients don't feel particularly unwell, and their treatment consists mostly of taking pills and putting in the hours. But for patients like Hilary, a gregarious person, time can sit heavily, and for a while she was the only female patient, which made her feel even more isolated. On top of that was uncertainty about how long treatment would take; three successive sputum samples have to be clear before you are declared cured.

Gaspar was allowed to go home a full three months before Hilary, and after he left she battled depression. At times, she says, she thought about sinking into her bathtub, "removing the plugs [for the dialysis] and letting it all go." She says she kept going only thanks to the encouragement of one of the nurses.

Meanwhile, the daunting task of containing a potential epidemic had already begun. Starting from the list provided by Hilary and Gaspar, the Hamilton-Wentworth Public Health Department, assisted by health units as far away as Niagara and Muskoka, followed degrees of separation, tracing a vast network of people who'd been in contact with people who'd been in contact with Hilary and Gaspar, tracking down, explaining, dealing with the inevitable fears and concerns. Health authorities ended up screening as many as 1,500 people and were able to determine, according to press reports, that ninety-two of them had been infected with multi-drug-resistant tuberculosis. (The public-health authority will not confirm the number.)

Ironically, a large part of the search happened inside St. Joseph's Healthcare centre. During Hilary's stay there for her kidney-transplant surgery and dialysis, she was constantly visiting other patients and staff, unwittingly spreading TB germs. (Before she was diagnosed with TB, Hilary had taught English as a second language and worked as a volunteer in literacy programs, for which she was given a Volunteer of the Year award.) In the end, 500 of those screened had encountered Hilary in St. Joseph's -- doctors, nurses, cleaning staff, secretaries, lab workers, people who had shared rooms with her at various times, and 250 outpatients who attended the same clinics.

Reflecting on it now, Joanna Frketich says that, given how widely public-health authorities had to spread their net and the number of people they were searching for, it's astonishing that they worked for two months without the media or the general public getting any wind of it. After the newspaper had been tipped off and the initial story had appeared, the Medical Officer of Health for the Hamilton-Wentworth region, Dr. Elizabeth Richardson, held a press conference to explain the authorities' position. No public or medical interest would have been served through publicity, she said. The main carriers had provided extensive lists of everyone they'd been in contact with, including passengers on the American Airlines flight Gaspar had taken from Santo Domingo to Toronto. If anything, the health department said, publicity would have engendered misinformation and panic, and responding to that would have overwhelmed the resources of the health workers. Frketich saw it differently. "This had broad implications for flaws in the screening process, and the public had a right to know," she says.

Wondering how it could have happened in the first place, she chased down Citizenship and Immigration officials. The system for screening immigrants from the Caribbean requires that a local doctor (in this case one working in a clinic in Santo Domingo) do a physical examination of the candidate and then send the file on to a Canadian government doctor in a regional office (in this case in Port of Spain, Trinidad). That's where medical clearance for immigration is ultimately given or refused.

Frketich tracked down the Dominican physician, Dr. Jordi Brossa, who had initially examined Gaspar. He told her he'd sent on to Trinidad a report and an X-ray in which it was clear that Gaspar had active pulmonary tuberculosis. "He had lost ten pounds in three months," Frketich wrote, citing the doctor. He "complained of fever, and had a dry cough." Though tests of mucus from his lungs were negative for TB, "a skin test was positive and TB could easily be identified on his chest X-ray."

Frketich then called the Canadian office in Trinidad and Tobago. She was told that the doctor responsible for Gaspar's file had retired, and that they wouldn't release his name. When she contacted immigration officials in Canada, they quickly admitted an error but didn't answer her more fundamental question: Was this the sloppiness of one doctor near retirement, one mistake in an otherwise exemplary career? Or was it the problem of a system in which everybody was overworked and there were insufficient fail-safes in place?

Frketich started chasing the minister of immigration, Elinor Caplan. "Every day I called her office. Finally, on December 21, she gave a telephone interview." In it, Caplan told her that an internal review had been undertaken to establish just what had gone wrong, and promised that the results would be made public very soon.

Meanwhile, on December 18, a class-action lawsuit -- reported to be for $500 million -- was filed by a Hamilton lawyer. The plaintiffs, currently numbering sixteen, included Hilary, her son, Christopher, who is a federal civil servant living in Burlington (and who does not have TB), and a number of Hilary and Gaspar's friends. They claimed they had suffered illness and loss, and that the whole community had been put at risk, all because Gaspar Benjamin had been allowed to enter Canada infected with contagious, drug-resistant tuberculosis, and then to live here for ten months with his ailment dangerously undetected.

The defendants named were the Government of Canada, the City of Hamilton Board of Health, and the private physician who'd given Gaspar his two medical examinations in Hamilton, Dr. Margaret Krol-Szpakowski. The Canadian government was targeted, the suit stated, because its Immigration Department doctors in Trinidad had failed to catch Gaspar's illness and stop him from entering Canada. The Public Health Department, the suit alleges, failed to move "in a timely manner" once the possibility of TB was discovered. Dr. Krol-Szpakowski had also allegedly failed to take an adequate history and diagnose Gaspar's TB during his first physical, just after his arrival.

From the moment the lawsuits were filed, it became apparent the public would have to wait a long time for answers to any questions it might have. Because the matter would be before the courts, lawyers advised everyone, from the Medical Officer of Health to immigration officials, not to give interviews. For the same reason, the Immigration Department's internal review of what happened in its Caribbean office around Gaspar Benjamin has still not been made public six months later. "The lawyers are in control," explains a departmental spokesperson, René Mercier.

Gaspar was also a plaintiff in the class-action lawsuit, and this got the public buzzing. Columnists, editorialists, and call-in-show hosts were incensed that an immigrant who'd brought a deadly disease into the country should turn around and sue the very government that offered him hospitality. When I went in January to see David Smye, the Hamilton lawyer who filed the suit with his partner Jim Turnbull, at the law firm Mackesy, Smye, Turnbull, Grilli, Jones, Winward & Mahler, he suggested that the howls of protest were motivated by discrimination. "He's a landed immigrant," Smye protested, "and has all the rights you and I have."

But Smye was also concerned about what appeared to be a larger issue: credibility. Hilary may not have known that Gaspar had been ill previously and was still active with TB, but had Gaspar himself known? Or, the doctor's failure notwithstanding, should he have known? "If it turns out he knew he had TB while back in the Dominican Republic," Smye told me, "it weakens the case."

The case Smye hopes to make is that negligence had caused suffering for innocent people, and to do this he was willing to work on contingency, which means that he would not get paid unless and until he won. "We wear seat belts in our cars and have gas tanks in the right place," he boasted, "because somebody was willing to take on contingency lawsuits. People couldn't take on big institutions were lawyers not prepared to put up the money." If they win, of course, he and the other lawyers will get to keep about 30 percent of any award.

On January 19, Smye and Turnbull organized a press conference in co-operation with another lawyer, Michael Baker, who announced that he, not Smye and Turnbull, would now represent Gaspar, who would be suing the same defendants separately for $1.5 million. Smye and Turnbull would press on with the class action on behalf of the rest of the plaintiffs, going after, they said, $90 million. The original $500 million had been a speculative number, based on uncertainty about how many plaintiffs might eventually emerge.

When the suits were filed, the names of those involved, which had been kept out of the press until then, at last became public. Hilary, no longer anonymous, was dismayed. "When it came out in the papers about the millions of dollars, I felt terrible." She'd been talked into it, she says, by her son, Christopher, on one of his visits to West Park. They'd sat bundled against the cold on an outdoor patio in what passed for early December sunshine. "I wasn't looking to sue the government," she explains, "I just wanted to wake up the Immigration Department. They admitted a mistake had been made. The Canadian doctor in Trinidad was overworked and didn't check the papers properly." After months of reflection, however, she says she now feels a little different. She considers the misery of her past year: "Maybe I do deserve some compensation," she says.

For Hilary, now fifty-eight, release in April from the tuberculosis sanatorium after six months in quarantine has not meant an end to her troubles. Every morning, she takes the follow-up drugs, something she must continue to do for the next year and a half. Three afternoons a week, she catches a cab to nearby St. Joseph's Healthcare centre for her dialysis treatments. In the end, the kidney transplant she received last year, just before she was diagnosed with TB, didn't take. She had to stop taking all but one drug in the program of immune-suppressive pharmaceuticals required to secure the transplant, because they were incompatible with the medication she was taking to fight TB. "I knew I was going to lose it," she says, referring to her new kidney. And she did.

In addition, she has just been fitted with hearing aids, which she'll need to wear for the rest of her life to compensate for the inner-ear nerve damage caused by one of the TB drugs. She also has trouble seeing; her right eye has a cataract, a side effect, she's been told, of the one anti-rejection drug she continued to take. It's the only one of her current health problems that appears to have nothing to do with the TB.

On top of that, just before she got home from Toronto, her house was broken into. And Gaspar, whom she accuses of using up much of her money, had left.

Late in May, I chased Gaspar on his cellphone, hoping to meet him. Finally, I reached his friend, Julio Rodriguez, who instructed me to come in half an hour to Cool Shades, which he described as a place on King William Street where the Caribbean crowd hangs out.

Hamilton's once noble downtown is a little worse for wear these days and King William Street is one of the sore spots. Just where it starts to get slightly boutiquey, though, I found Cool Shades, advertising West Indian takeout, and four guys standing out in front on the street. Two of them quickly disappeared and Gaspar, a slight man with steel-framed glasses, and Julio, a stocky fellow wearing an earring and a black baseball cap, stepped forward. Julio did all the talking and seemed like Gaspar's agent or manager until I figured out that Gaspar really doesn't speak very much English. "Who do you represent and what do you want?" Julio demanded, steering us in the direction of a Tim Hortons coffee shop a block away. When I told him, he began to feel me out about whether Saturday Night might consider paying them for an interview. "How bad does your editor want this story?" Julio asked.

Julio Rodriguez is part of the class-action suit. A friend of Gaspar's before he immigrated to Canada in 1993, he became infected with TB when they resumed their association in Hamilton. He didn't become ill, but recites the common information: he'll have to be monitored; the chance of his becoming active is 5 percent. Some of the infected people are being given preventive antibiotics designed to kill the bacillus before it can become active. But TB specialist Dr. Lori Whitehead, who is based in St. Joseph's Healthcare centre, explained that there can be side effects (the antibiotics can be toxic to the liver) so they are given judiciously, "only to those whose risk of developing active tuberculosis outweighs the risk of liver damage or other side effects."

Julio, nevertheless, emphasized how his life has changed. "I have no job. When the publicity came out, the place I was working [as a welder] told me not to come back in."

Gaspar nodded; he has his own tale. For him, his music career has been brought to a standstill. "I was the best singer in Hamilton," he joked. Since he got out of the TB hospital, his mates in the band have disappeared. "We are each other's only friend," declared Julio, putting his arm around Gaspar. Just then, a petite woman hurried by toting a gym bag. She offered an effusive, flirty kind of hello, and was gone. "She's a public-health nurse," said Julio. "They're the only people who'll talk to us," added Gaspar.

Dr. Douglas MacPherson tries to put the outbreak of MDR tuberculosis into perspective. "The medical crisis was contained, two people were quarantined in a tuberculosis hospital, others who were infected have been identified, some put on preventive drugs, all will be watched." MacPherson, who's director of St. Joseph's Regional Parasitology Laboratory and an associate professor in the Department of Pathology and Molecular Medicine at McMaster University, is more concerned about the larger context: the ways our present age and travel technologies increase our risks from migrating infections. His personal stake in the matter is huge. Since February, he's added a new job to his resumé: Health Canada's director of quarantine, travel, and migration health -- one of the top jobs in the business of keeping Canadians safe from nasty diseases.

He reminds me that despite its frightening reputation, TB is still not a huge threat to Canada's health: "Only two thousand cases per year in a population of over thirty million." The subtext of this reassurance, however, is that while TB might be frightening, there are far worse things to worry about. And whether we can identify, contain, and treat diseases is an open-ended question. For the last couple of years MacPherson has represented Canada in multinational discussions on new ways of dealing with the health and infectious-disease implications of twenty-first century global travel and movement. So far, they haven't got much past the stage of identifying the problem.

"Eighty years ago, when it took three weeks to cross the ocean by steamer ship," MacPherson muses, "if you had a contagious, infectious disease, it would have been likely to express itself before you arrived. A hundred years before that, when a journey took six weeks to three months, any disease would not only kill you, it probably killed half the people on the ship and you had a pretty good idea what was happening. But now, you can bury your grandmother in the Congo, jump on an airplane, get to Pearson, and less than twenty-four hours later be off to some place in Saskatchewan well within the incubation period of Ebola."

Indeed, in early February, within a week of MacPherson taking on his new job, a thirty-two-year-old woman from the Democratic Republic of Congo became violently ill twenty-four hours after arriving in Hamilton via Toronto's Pearson International Airport and Newark, New Jersey. For a week she lay in intensive care under isolation. Doctors, MacPherson among them, tried to calm media speculation that the mysterious illness she suffered from might be Ebola. They weren't vindicated until the samples they'd sent to the National Microbiology Laboratory in Winnipeg came back negative.

Asked if he was surprised that Gaspar Benjamin slipped through the system of surveillance, MacPherson says, "I'm not surprised from the operational point of view. There is a process and regulations and there are people involved. I'm not sure that the operational design is what failed here, primarily. What I do know is that ten years ago or so there were about 80,000 immigrants coming into Canada and thirty immigration physicians doing the screening. Today, there are eleven physicians [for 225,000 immigrants]."

As of the end of June, the situation is still far from being resolved. The Immigration Department has commenced (but not finished) an audit of its medical-screening system by which it examines the health of all would-be immigrants. A spokesman would only say that, in the Gaspar Benjamin case, it was either "a fluke or human error." But because of the lawsuits there has been no public elaboration. As for the lawsuits themselves, statements of defence have not yet been filed, and therefore the suits have not yet been certified by an Ontario Superior Court judge, something, according to Jim Turnbull, that could still take months. Hilary says wistfully that she hopes everything might be settled out of court.

On a sunny day in June, I pick her up at the bus terminal in Toronto. She must return to West Park Healthcare Centre every three months for the next year and a half to see her doctor and get a ninety-day supply of drugs, which she carries back to her local hospital in Hamilton. Though she's been assured she no longer has active or contagious TB, the bacillus itself is hard to kill. Her Hamilton doctor has given her the bad news that because of this she might not be able to go ahead with a new kidney transplant. The good news is that she could soon be able to start doing her dialysis at home. Another bit of even better news is that, to date, none of the people infected by Gaspar and Hilary has become active or contagious. As for Gaspar, he's now on welfare, unable to find a job. "He's coming 'round more often," Hilary says, "and we're friends. I still feel very responsible for him and I still love him."

We make it to the front doors of the hospital. Would I like a tour, she asks? Twenty minutes later we're putting on masks to cover our noses and mouths and being admitted behind the heavy doors of the infectious TB wing. It's quiet. Very quiet. Hilary shudders a little bit, perhaps thinking of what might have been.

* Thanks to Larry Krotz for allowing us to post this story.

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