Rethinking crisis intervention at the TTC

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Op-ed in the Toronto Star by Vicky Stergiopolous and Stephen Hwang

Riding transit to work or school shouldn’t be a scary proposition, but that’s unfortunately the daily reality for far too many who take transit as a daily necessity.

This is not an issue of a subway station, or any other public space, being inherently unsafe. The issues that are plaguing our society are migrating onto the TTC. Violent incidents don’t occur in a vacuum.

The leading factors that increase the risk of violent behaviour are trauma, victimization and abuse. Inadequate income, loss of employment and lack of access to basic necessities, such as housing and food, are also key predictors. When coupled with substance use or certain mental health conditions, these stressors increase the likelihood that an individual will commit acts of violence.

Underfunding of social services, abdication of mental health supports and housing by senior levels of government, lack of supports for people who use drugs, and trauma from the pandemic are just some of the root causes that have led to the behaviours we are witnessing.

Research shows that communities that provide early years programs, supports for at-risk youth, job training and employment, and decent affordable housing as well as other measures that address the social determinants of health have lower crime rates. But you don’t need a PhD to know that people who have access to opportunities and are thriving and connected to their communities are less likely to commit a violent crime. Ensuring that our most vulnerable are safe will make everyone safer.

Il faut revoir l’intervention en cas de crise au sein de la Commission de transport de Toronto (TTC)

Article d’opinion du Toronto Star par Vicky Stergiopolous et Stephen Hwang

Prendre les transports en commun pour se rendre au travail ou à l’école ne devrait pas être une démarche angoissante; c’est pourtant la réalité quotidienne d’un trop grand nombre de personnes pour qui les transports en commun sont une nécessité quotidienne.

La question n’est pas de savoir si une station de métro ou tout autre espace public sont fondamentalement dangereux. Les problèmes qui affligent notre société se répercutent sur la TTC. Les incidents violents ne surviennent pas en vase clos.

Les principaux facteurs qui augmentent le risque de comportement violent sont les traumatismes, la victimisation et les sévices. L’insuffisance des revenus, la perte d’emploi et le manque d’accès aux produits de première nécessité, comme le logement et la nourriture, sont également des facteurs prédictifs importants. Lorsqu’ils sont associés à l’utilisation de substances ou à certains troubles mentaux, ces facteurs de stress augmentent la probabilité qu’une personne commette des actes violents.

Le sous-financement des services sociaux, le renoncement aux aides à la santé mentale et au logement de la part des ordres supérieurs de gouvernement, le manque de soutien aux personnes qui utilisent des drogues et les traumatismes causés par la pandémie ne sont que quelques-unes des causes profondes qui ont provoqué les comportements dont nous sommes témoins.

La recherche révèle que les collectivités qui proposent des programmes pour la petite enfance, des aides aux jeunes à risque, des formations professionnelles et des emplois, des logements décents et abordables, ainsi que d’autres mesures portant sur les déterminants sociaux de la santé ont des taux de criminalité plus faibles. Mais nul besoin de posséder un doctorat pour savoir que les personnes qui ont accès à des avantages, qui s’épanouissent et qui sont impliquées dans leur collectivité sont moins susceptibles de commettre des crimes violents. En garantissant la sécurité des personnes les plus vulnérables, nous assurerons la sécurité de tous.

B.C.’s drug decriminalization experiment starts today. Toronto and other jurisdictions are watching

From the Toronto Star

On Tuesday, British Columbia will begin a three-year decriminalization experiment, allowing drug users 18 and over to carry a up to 2.5 grams of opioids, such as heroin and fentanyl, as well as cocaine, methamphetamine and MDMA.

It’s an experiment that’s likely to influence drug policy across Canada.

The approach is a “monumental shift” in drug policy, says Carolyn Bennett, the federal minister of mental health and addictions, adding that it’s meant to foster “trusting and supportive relationships” rather than criminalization.

“Through this exemption we will be able to reduce the stigma, the fear and shame that keep people who use drugs silent about their use,” she told a Vancouver news conference Monday.

“And help more people access life-saving supports and treatment.”

Daniel Werb, director at the Toronto-based Centre on Drug Policy Evaluation, which helped the city with its initial request, said Health Canada appears to be “slow-walking” decriminalization in Toronto.

“My opinion is that the decision on Toronto is going to be based on whether what happens in B.C. appears, politically, to make sense,” Werb said in an interview.

The caution amid a deadly overdose epidemic is rooted, said the addictions researcher at Unity Health, in the stigmatization of drug users over a century of criminalization.

“I think it’s symptomatic of a society wide issue, which is that people don’t really care whether other people are dying of overdoses,” he said.

Can a vending machine save lives?

From the Toronto Star’s This Matter’s podcast

Guest: Dr. Sean B. Rourke, neuropsychologist at St. Michael’s Hospital

Smart vending machines have launched on Canada’s East coast. They’re the first of what will be 100 nationwide. But instead of dispensing chocolate or candy, these machines hold life-saving supplies like HIV tests, naloxone kits and unused needles. They’re called Our Healthbox and they’re designed to reach communities underserved by traditional health care. Today, we’re joined by Dr. Sean Rourke, a clinical neuropsychologist and scientist with MAP Centre for Urban Health Solutions at St. Michael’s Hospital, who is leading the initiative. You can learn more about OurHealthbox and whether your community is eligible for a Healthbox here.

Many Canadians welcomed virtual health care. Where does it fit in the system now?

CBC’s White Coat Black Art podcast

Having the option to speak with her doctor over the phone for basic check-ins and requests has freed up Shawna Ford’s energy for tasks she’d prefer doing.

“Normally, to go into the city, I don’t do anything the day before. I don’t do anything a few days after because it totally drains me. So having those phone appointments is amazing,” the Alberta woman, 62, told White Coat, Black Art.

“The Zoom appointments with a psychiatrist have also just freed up so much of my energy that I can use, you know, on things that I want to do,” she added. “Functional energy, I guess.”

Ford, who has diagnoses of major depressive disorder and myalgic encephalomyelitis, the latter causing extreme fatigue, still visits her doctor in person when necessary. But the pandemic-driven shift toward virtual health care has opened doors that Ford says she doesn’t want to see closed — and she’s not alone in raising concerns about access to quality virtual health care.

While British Columbia and Alberta have embraced access to virtual health care, Ontario and Manitoba have scaled back funding for services not paired with in-person doctor visits. 

“I don’t think the system has their finger on the pulse of what patients need and want, because if it did, we wouldn’t be in this predicament,” said Dr. Aviva Lowe, a Toronto-based pediatrician and lactation consultant.

‘Two classes of Ontarians’

Until December, when a new billing framework came into effect in Ontario and lowered what health-care professionals can get paid for some virtual appointments, Lowe saw patients on KixCare, a virtual, app-based health-care service for children and teens. KixCare, Lowe argues, offers a way to address health inequities by making doctors more accessible for those without a family physician or pediatrician.

“These changes have really created two classes of Ontarians when it comes to accessing virtual care,” Lowe told White Coat, Black Art host Dr. Brian Goldman.

“By that I mean there’s the group of patients who can continue to access it, and those are patients who can access it with their own doctor or with a consultation to another doctor.”

The other group are those without a regular family doctor who may now be limited in accessing health care virtually, she said.

Changes to provincial billing schemes

When the pandemic began, doctors across the country rapidly shifted their practices to phone and video calls, rather than in-person appointments. 

For many patients, it was a welcome change. A recent Western University study found that the shift reduced barriers to accessing care, particularly for people who rely on public transit, and others who may be unable to take time off work.

Governments across the country quickly implemented emergency billing codes for virtual appointments — often paid at parity with in-person appointments. 

But when the Ontario government introduced permanent billing codes for virtual appointments last year, rates paid to doctors for virtual appointments dropped in some circumstances, leading to outcry from providers.

In Ontario, doctors with an ongoing relationship to their patient — a family physician who provides regular, follow-up care, for example — can bill virtual appointments at the same rate as in-person ones, provided they see the patient in-person once every 24 months.

For services where doctors have a one-off interaction with a patient — as is the case with some virtual “walk-in” services, like Lowe’s KixCare — the rate is much lower: $15 for a phone call, or $20 when it’s over video, compared to $67 or more previously.

“I would conduct a thorough, comprehensive assessment for whatever the matter would be, which would include taking a detailed history, physical examination through a virtual platform,” said Lowe.

“It’s different than in person but, in pediatrics, observation and interaction can give us a lot of important information as to how well or how unwell a child is.”

She added that the “vast majority” of patients did not require a follow-up appointment, and she rarely referred patients to an emergency department.

Since the changes to Ontario’s doctors billing schedule came into effect, KixCare has stopped offering publicly funded appointments and instead are promoting a $29 per month subscription to access its services.

Virtual walk-in services double ER visits: study

An Ontario-based study published last month in the Canadian Medical Association Journal reported that even though in-person appointments with primary-care physicians dropped by 79 per cent in the first year of the pandemic, visits to hospital ERs did not increase due to an increase in virtual appointments.

“We did not find evidence that enrolled patients substituted emergency department visits because of less availability of in-person care,” the study’s authors wrote.

However, a separate study published in the Journal of Medical Internet Research (JMIR) — also published last month and based in Ontario — found that patients who used virtual walk-in services for one-time appointments were twice as likely to visit an ER.

Dr. Tara Kiran, a family doctor and researcher at St. Michael’s Hospital in Toronto, says while virtual appointments are convenient, having a long-term relationship with your doctor can improve survival rates while reducing costs on the health-care system. Kiran, who is also Fidani Chair in Improvement and Innovation at the University of Toronto, was a co-author of the JMIR study.

“Virtual care has its place … but I think the place in an ideal world is within a continuous relationship with the family doctor,” she said.

“That, of course, gets us to the point that many people don’t have a family doctor, nurse practitioner or a primary care team, and we need to address that.”

Opinion: We need bold reform to fix family health care

Op-ed in The Globe and Mail by Dr. Tara Kiran

Access to health care should be based on need and not on one’s ability to pay. Time and again, people in Canada have reaffirmed this as a fundamental value we share.

But, as it stands, too many people don’t have access to care when they need it – especially from a family doctor. This needs to be top of mind for our elected leaders when they meet this week to discuss the future of health care funding.

This past fall, a team of researchers heard from more than 9,000 adults in Canada who responded to the OurCare national research survey about their experiences with family doctor care and what they want to see in a better system. The survey was the first phase of OurCare, a 15-month initiative to engage the public about the future of family physician care in Canada.

More than one in five people reported not having a family doctor or nurse practitioner who they can talk to when they need care or advice about their health. Extrapolated to the population of Canada, that’s more than 6.5 million people aged 18 and over who don’t have access to a family physician.

Family doctors are the gateway to the health care system. We are the first point of contact when something is wrong, we provide care for ongoing illnesses, and prevent problems from developing in the first place. When people don’t have a family doctor, everything else falls apart: Emergency departments become crowded, there are more missed or delayed diagnoses, more illnesses and immense frustration.

The problem is worse for some than others. In our survey, greater numbers of men, people with a low income and people who are racialized reported not having a family doctor. Some of the biggest differences in access to care were by region, with more than 30 per cent of respondents in Quebec and the Atlantic provinces reporting not having a family doctor, compared to 13 per cent in Ontario.

Project to Set Up 100 Harm Reduction “Vending Machines” Across Canada

From the Filter Magazine article

Vending machines are increasingly being deployed to distribute harm reduction supplies in North America. As Filter has reported, they’re being used to dispense hydromorphone in a Canadian safe supply project, and naloxone and sterile syringes in New York City, among other examples. One of their notable benefits is the level of anonymity they provide.

Now, a larger-scale effort expects to set up around 100 such machines across Canada in the next three years. Despite their being known colloquially as “vending machines,” using them is free. They’ll offer critical equipment like HIV testing kits, condoms, naloxone and syringes, as well as information—via a large touch-screen face. 

The Our Healthbox initiative is led by researchers at St. Michael’s Hospital, a site of Unity Health Toronto. Sean Rourke, a scientist at the hospital’s MAP Centre for Urban Health Solutions, is one of the experts involved.

Last year, Rourke and a team of colleagues launched the I’m Ready program, enabling people to download an app to order free, self-administered HIV test kits—which he was also involved in creating, and which are Health Canada-approved—to their homes or another location. 

If a person using the kit tests positive, they should go to a doctor for confirmation and to discuss treatment options, Rourke said, while those who test negative but may be at risk of contracting HIV should go to a doctor as well, to discuss preventative measures such as PrEP.

He never learned about Canada’s first Black doctors in medical school. He wants all students to know their names

From the Toronto Star article

It was only a few years ago that Toronto physician and researcher Nav Persaud learned the names Alexander Augusta and Anderson Abbott.

The two pioneering 19th-century doctors — the first Black people licensed to practise medicine in Canada — were never mentioned when Persaud studied at the University of Toronto, despite their connections to the university and their long lists of accomplishments.

As he learned more about them, Persaud was shocked by their invisibility in Canadian history. Then he was angry. Then he set out to rectify the injustice of their absence and ensure future students knew their names.

His efforts on that front culminated on Thursday with the unveiling of commemorative plaques, celebrating Augusta’s and Abbott’s remarkable lives and contributions to Canadian medicine.

“I hope people will be inspired,” Persaud said, prior to Thursday’s event, which was held at the University of Toronto’s Seeley Hall and jointly presented by Heritage Toronto and U of T’s Faculty of Medicine as part of Black History Month.

The plaques, which will be installed in May, are meant to “take a step towards equity,” said Persaud, a family doctor and the Canada Research Chair in Health Justice.

Augusta, an American who came to Toronto when he was denied access to medical school in the U.S., became U of T’s first Black medical student and the first Black person in Canada to receive a medical licence.

Abbott, who worked under Augusta’s supervision, became the first Black Canadian to achieve those same feats.

Announcing: Solutions for Healthy Cities Symposium, March 23, 2023

We are excited to announce that the next Solutions for Healthy Cities Symposium will be in Toronto on March 23, 2023! Join us for a full day of talks, discussion and Q&As with MAP scientists and exciting guest speakers. Connect with others who are working to implement new programs and practices in their communities, and learn from leaders in implementing equity-focused interventions.

Keynote: Dr. Ibram X. Kendi, the founding director of the BU Center for Antiracist Research and author of How to Be an Antiracist

Date: March 23, 2023, 9:30-5pm

Venue: The Symes, 150 Symes Rd, Toronto, ON

Cost: $35.00 ($39.55 incl. HST). Fee includes breakfast, lunch and reception. If this fee is cost prohibitive, please contact