More than 6.5 million adults in Canada lack access to primary care

First in a series of Healthy Debate articles exploring the results of the OurCare survey.

Family medicine is the front door of the health-care system. But for too many people in Canada, that front door is now closed.

Results from the OurCare national survey estimate that more than one in five Canadian adults – 6.5 million people – do not have a family physician (FP) or nurse practitioner (NP) they can see regularly for care, a situation that has become worse during the COVID-19 pandemic.

The survey was conducted between September and October last year and includes more than 9,000 responses from across the country. It’s the first phase of OurCare, a national initiative to engage the public on the future of primary care in Canada.

We found that the situation is particularly bleak in some parts of the country. In British Columbia, Quebec and the Atlantic provinces, approximately 30 per cent – almost one in three adults – reported not having a family doctor or nurse practitioner. Contrast that to 13 per cent in Ontario.

And some groups are worse off than others. Fewer adults who were racialized, lower income and in poorer health reported having a family doctor or nurse practitioner.

Thirty-five per cent of those age 18 to 29 said they didn’t have a family doctor. Some young adults may not think they need one. Indeed, 17 per cent of respondents who were without a family doctor or nurse practitioner said they weren’t looking for one, most commonly because they thought they were healthy and didn’t need one. Yet, as family doctors, we know the importance of being connected to primary care early in people’s lives.

At first glance, the numbers don’t seem as bad for older adults. But it’s a huge concern that 13 per cent of those 65 and older reported not having a family doctor – everyone in that age group needs access to primary care.

Primary care – the type of care provided by family doctors and nurse practitioners – is foundational to any well-functioning health system. Family practices are the first place you should turn when you have a new health concern. They manage ongoing health conditions and provide care to keep you well in the first place. They are the entry point into the health-care system, coordinating the care you get from others, including specialists. Without it, patients are lost and left alone to navigate a complex system.

Toronto showed ‘significant unfairness’ in controversial encampment clearings, report finds

From CBC

Toronto showed “significant unfairness” when it cleared encampments in the summer of 2021 and chose to act quickly despite there being no urgency to do so, an investigation into the controversial moves has found.

In a report released Friday, Toronto Ombudsman Kwame Addo says the city chose “speed over people” when it forcefully cleared encampments in Trinity Bellwoods, Alexandra and Lamport Stadium parks.

“Our investigation found the City displayed insufficient regard for the people it moved out of the parks,” Addo said.

“It failed to live up to its stated commitments to fairness and a human rights-based approach to housing.”

Addo’s office launched an investigation in September 2021 following the encampment clearings which saw police officers in riot gear clear the sites of residents and their supporters, and resulted in dozens of people facing charges.

The investigation focused on how the city planned the encampment clearings, engaged stakeholders and communicated with the public. It found a number of problems, including that the city treated the clearings as a “top priority” and chose expediency and enforcement despite there being no evidence to suggest the encampments were an emergency requiring an urgent response.

Addo found the city chose to clear encampments quickly rather than focusing on the needs of those living in them. As well, it said the city was aware people living there had complex mental health needs, “yet failed to include plans to address those needs.

“Encampments and supporting the people living in them are complex. But the City owes a particularly high duty of fairness to these residents,” he said.

Longtime street nurse Cathy Crowe called Addo’s report a thorough one.

“It essentially demonstrates that homeless people were treated like an infestation … the efforts were to stomp them out and never have them come back, as fast as possible,” said Crowe.

“It tells the tale of malpractice that led to violence and injury.”

Report findings ‘validating’ for advocates

Addo also found that the city failed to foster meaningful engagement with people living in them, but rather communicated in a way that was “confusing, lacked transparency and showed a lack of understanding about their reality.” 

They also did not provide any dedicated onsite staff for people living in temporary dwellings in local parks to speak with, despite the city knowing they had questions which had gone unanswered, the report adds. 

In an interim report released last July, Addo concluded that city staff rely on an outdated and inconsistent approach when it comes to dealing with unhoused people in public parks.

“I think it’s validating for a lot of people who were doing advocacy around the encampments who were struggling to get the truth out,” said Zoë Dodd, a community scholar at MAP Centre for Urban Health Solutions.

“The one thing the ombudsman talks about is harm and trauma, but it wasn’t just harm and trauma, it also led to people’s deaths.” 

Recent city data shows Toronto saw an average of more than three deaths per week among people experiencing homelessness last year, totalling 187 deaths in 2022.

Toronto wants to expand drug decriminalization to cover all ages and substances

From the CBC article

Toronto updated its 14-month-old decriminalization request to the federal government Friday, clarifying it wants a Health Canada exemption to cover young people as well as adults, and all drugs for personal use.

The city’s submission, an update to its initial January 2022 request, indicates Toronto wants the federal agency to go further than the exemption it recently granted to British Columbia under the Controlled Drugs and Substances Act.

It makes clear the city wants its exemption to apply to all drugs for personal use and shield young people from criminalization, a departure from the B.C. exemption, which only applies to adults and lists a select number of substances. 

Medical Officer of Health Dr. Eileen de Villa says the submission sent to Health Canada, co-signed by the city’s police chief and city manager, is a “made-in-Toronto” model reflective of a months-long consultation process. 

“We’re talking about a matter of health and a matter of human rights, not one that really is meant to be addressed or is best addressed with a criminal justice approach,” she said in an interview. “That’s why we’re pursuing this route.” 

B.C.’s three-year exemption under the Act was granted in June and came into force Jan. 31. While that exemption caps possession at 2.5 grams, the Toronto submission does not outline a specific threshold for what constitutes personal use.

Pace of approval process has garnered criticism 

Drug use and purchasing patterns are “exceptionally diverse,” the submission said, and can vary based in part on a person’s tolerance. All trafficking and drug production would remain illegal.

Whereas the B.C. exemption only applies to people 18 and older, the Toronto model would also apply to young people. A 2019 survey conducted by the Canadian Association of Mental Health indicated around 11 per cent of Ontario students in Grades 7 to 12 reported the nonmedical use of opioids in the past year. 

Eight people aged 12 to 17 died from opioid overdoses in Toronto between 2019 to 2021, the submission said. 

“Health issues are health issues regardless of the person involved,” said de Villa. 

“That’s why we feel that this is something that does have to apply to all so that we’re sure that even the youngest members of our community are having their health issues looked at and addressed through a health lens rather than through something like a criminal justice lens.” 

The pace of the approval process has garnered criticism from drug users and advocates who say it fails to match the urgency required of an overdose crisis that has kills hundreds of people every year in Toronto. 

“They’re moving way too slowly. So, it’s nice to see movement. It’s just whenever you see a little bit of movement, I think, for me at least, it hits home just how slowly this process is going — how much we’re dragging our feet,” said Dan Werb, director of The Centre on Drug Policy Evaluation at St. Michael’s Hospital.

Decriminalization will not make the street supply any less toxic, Werb says, but it could reduce the barriers people face to accessing services that help prevent them from dying of overdoses. 

Recent overdose deaths in Simcoe-Muskoka part of an ‘ongoing trend,’ experts say

From CBC

Ontario Provincial Police sounded the alarm last week after four people in the Simcoe-Muskoka area died from suspected opioid overdoses in a span of four days.

The warning advised the public that a “highly potent and potentially fatal strain” of illicit opioid may be circulating in Simcoe County and the District Municipality of Muskoka. But experts in the region say the area has been hit hard by the opioid crisis, and four overdose deaths in a week isn’t uncommon. 

Data from the Simcoe-Muskoka health unit at the end of 2022 shows an average of 13 people in the region wind up in emergency rooms each week due to suspected overdoses.

Dr. Lisa Simon, associate medical officer of health for the Simcoe-Muskoka District Health Unit, says like other parts of the country, there has been an escalation in drug-related deaths over the last few years.

“Unfortunately, this is part of an ongoing trend we have seen for several years now of a dramatic loss of life and like these individuals, it’s often young adults,” she said.

Simon says the shift started with the introduction of fentanyl into the street drug supply in 2017, and the number of deaths continued to escalate into 2019.

“At that time, it was clearly unacceptably high levels when alarm bells were already ringing. But then the pandemic hit and the rate of opioid related harms and deaths got even higher,” she said.

Simon added 2021 saw the highest number of suspected overdose deaths on record in the region — 95 in the first six months.

The data recorded 66 confirmed and probable opioid-related deaths in Simcoe-Muskoka in the first six months of 2022. Those numbers are lower than the same period in 2021, but still substantially higher than before the pandemic.

Simon says over the last few months the region has recorded an average of three deaths per week due to drug related overdoses.

The Simcoe Muskoka Drug Strategy — a large partnership of agencies and organizations — continues to work to address opioid related harms in the region.

Drug supply ‘incredibly unpredictable,’ expert warns

Dr. Tara Gomes, the lead principal investigator of the Ontario Drug Policy Research Network housed at Toronto’s St. Michael’s Hospital, says the Simcoe-Muskoka data mirrors what’s happening across the country.

“When we look at what’s happening with the illicit drug supply, which is that it’s incredibly unpredictable, we often see clusters of overdoses that happen,” she said, adding when a more potent fentanyl analog enters the supply, a spate of deaths can happen in a matter of days or hours.

“It might be in a particular city or region because the supply that is there at any given time might be much more potent than people are used to and it can increase the likelihood of overdose,” Gomes explained.

On the front lines of the homelessness crisis, a downtown ER tries a novel new approach

From the Toronto Star

When Dan Shaffer turned up at the St. Michael’s Hospital emergency room, it wasn’t for a medical crisis. In his early 70s, Shaffer had been evicted from his apartment and had nowhere else to go.

ER staff tried to get him into a shelter, but couldn’t. Beds, citywide, were full. They brought him to a small, warmly lit room in a side hallway, with pullout couches and reclining chairs that serve as a stopgap when someone doesn’t have a medical reason to be admitted. Staff offer food and warm clothes and add a tick to a whiteboard every time they can’t find shelter beds.

Shaffer remembers the turmoil of that night. He’d never been homeless, and was at a loss for what came next. “I’ve never been in a situation where my life was taken out of control,” he said.

Hospital staff called the city’s shelter intake line over and over that night. By the next day, they found one room at a north Toronto shelter hotel. Over the ensuing year, as Shaffer feared the remainder of his life would be stuck in the shelter system, a new outreach team from the hospital’s emergency room worked with him to find long-term, stable housing.

This is the reality inside the hallways of St. Michael’s; while Toronto hospitals have struggled with broader pressures on the health care system, their ERs are also on the front lines of the city’s mounting homelessness crisis. Carolyn Snider, the emergency room chief at St. Michael’s, says more than 4,500 homeless Torontonians came through the doors of the downtown trauma centre in the last year, about 15 per cent of them simply because there were no alternative shelter options.

Toronto turns its back on the homeless

From the Toronto Star

Toronto Council’s decision this week not to open warming centres around-the-clock to provide shelter for the city’s most vulnerable residents was beyond disappointing. It was a disgrace.

Those who objected to making the centres accessible threw up a fog of excuses — cost, staffing — and in the face of real human suffering, offered the most weakest of actions, the promise of further study and a punt to other governments.

On Wednesday, council voted 15-11 against a board of health recommendation to open the centres 24 hours until April 15. Ostensibly oncerned about the lack of funds — remember that councillors ponied up almost $50 million more for the police — council instead supported a motion to ask the federal and provincial governments for more support. And it will investigate the “feasibility of providing 24/7 drop in spaces.”

Certainly, all levels of government need to step up. But a feasibility study? What doesn’t council know? Doesn’t it know that about 100 people are turned away from temporary shelters every day?

Doesn’t it know that freezing temperatures present serious health risks to unhoused people? Doesn’t it know that unsheltered people are currently seeking refuge in public libraries, at all-night restaurants and on the TTC, and that this is one of the reasons police officers are now patrolling public transit?

Mayor John Tory, who voted against the motion to keep the centres open, has long stressed that permanent supportive housing is a better solution than temporary shelters and warming centres. That’s true, but when it comes to permanent or temporary shelter, this isn’t an either/or proposition.

Although undeniably important, permanent housing won’t be built overnight, which means temporary lodging will still be necessary. And even if there were enough homes to go around, that wouldn’t solve the problem.

Many unhoused people have experienced serious trauma — trauma that led them to the street and trauma that keeps them on the street. And transitioning to permanent housing is, for many, a further stressful experience.

15 per cent death rate, severe lesions reported in patients with mpox alongside advanced HIV: study

From CBC

During Canada’s unprecedented mpox outbreak last summer, Montreal physician Dr. Antoine Cloutier-Blais noticed a concerning trend: Patients co-infected with advanced HIV were reporting lesions across their bodies, and systemic mpox symptoms.

“It was difficult at that time to confirm that suspicion with the data we had,” he said.

Now, new research in the Lancet medical journal backs up Cloutier-Blais’ early concerns.

The paper, a case study on mpox in individuals with advanced HIV infection, details an aggressive and serious form of the illness formerly known as monkeypox — at times involving skin cell death within lesions, nodules in the lungs, sepsis, and a high rate of death.

This form of mpox appears to be a “very severe skin and mucosal infection with high rates of sepsis and very severe lung complications,” said study author Dr. Chloe Orkin, a professor of HIV/AIDS medicine at Queen Mary University of London, in an email to CBC News.

The researchers studied a cohort of nearly 400 patients from various countries, including Canada, who caught mpox while living with HIV and low CD4 cell counts. (CD4 cells are a type of white blood cell that help fight off infections by triggering the immune system to destroy viruses and other pathogens.)

Mortality was roughly 15 per cent in individuals with advanced HIV-related disease, the researchers wrote, while the death rate for people with the most severe immunosuppression doubled to around 30 per cent, Orkin noted.

The staggering findings matter in large part due to high rates of mpox among individuals living with HIV/AIDS, who account for an estimated 38 to 50 per cent of people diagnosed with mpox.

“I think it’s an important reminder of how we must not get too complacent even in the face of low case counts, because if the virus encounters a person susceptible to such severe manifestations like people living with advanced HIV, then it can be really devastating,” said Dr. Darrell Tan, a clinician-scientist at St. Michael’s Hospital in Toronto, whose team contributed data for the Lancet paper.

Calls for more access to mpox vaccines

The takeaways of her findings, Orkin said, are that health-care workers need to be trained on the high mortality rate associated with mpox and HIV-related immunosuppression. 

“Every person with mpox should have an HIV test and every person with HIV and mpox should be tested for immunosuppression,” Orkin continued, noting those with advanced HIV infection should also be monitored carefully, given the significantly higher risk of death. 

No stick and a small carrot: Can the federal government fix health care?

From the Toronto Star

This week on “It’s Political,” we take a look at what’s plaguing the country’s health-care system, from long wait lines in emergency rooms to the lack of family doctors. What will it take to fix health care in Canada?

First, we hear directly from health professionals about the problems they’ve witnessed firsthand and the solutions they’d like to see.

Then, host Althia Raj sits down with Canada’s Health Minister Jean-Yves Duclos to discuss the federal government’s new funding arrangement with the provinces, the minister’s expectations of what the money will buy, and his stance on the increasing presence of for-profit care.

Listen here and follow or subscribe at Apple PodcastsSpotifyAmazon MusicGoogle Podcasts or wherever you listen to your favourite podcasts.

In this episode: Canada’s Health Minister Jean-Yves Duclos, Toronto Star health reporter Megan Ogilvie, former federal health minister Dr. Jane Philpott, a family doctor, dean of the Faculty of Health Sciences and director of the School of Medicine at Queen’s University, and CEO of the Southeastern Ontario Academic Medical Organization, Dr. Taylor Lougheed, a family, emergency, sport, and cannabinoid physician and chief of emergency medicine services at the North Bay Regional Hospital, longtime registered public health nurse Maureen Cava, who now works with the Safehaven Project for Community Living in Toronto, Dr. Katharine Smart, the past president of the Canadian Medical Association and a pediatrician who works in Whitehorse, Yukon, Dr. Alika LaFontaine, the president of the Canadian Medical Association and an anesthesiologist in Grande Prairie, Alberta, registered nurse Melanie Spence, who works in primary care in a community health centre in Toronto, Dr. Tara Kiran, a family doctor at St Michael’s Hospital, a scientist at the MAP Center for Urban Health Solutions, and the Fidani Chair in Improvement and Innovation at the University of Toronto. Hosted by Althia Raj.

Some of the clips this week were sourced from the CBC, Global, CTV and CPAC.

“It’s Political” is produced by Althia Raj and Michal Stein. Kevin Sexton mixed the program. Our theme music is by Isaac Joel.

Uncovering the real numbers behind who in Ontario lacks access to a family doctor

From The Globe and Mail

The number of Ontarians without a family doctor rose significantly during the first two years of the pandemic, according to the most comprehensive analysis yet of how access to primary care is deteriorating in Canada’s most populous province.

More than 2.2 million Ontarians were without a regular physician as of March, 2022, up from nearly 1.8 million in March of 2020 – a 24-per-cent increase. That means 14.7 per cent of Ontarians now rely on walk-in clinics and emergency rooms for primary care or go without it altogether, up from just over 12 per cent before COVID struck.

Children, newcomers to Ontario, and patients who live in the poorest and most racialized neighbourhoods were most likely to see their access worsen, but people from all walks of life lost their family doctors during the two-year period, the data show.

Another is that despite the worsening situation in Ontario, it still outperforms other provinces on access to primary care, according to a survey of just over 9,000 Canadians led by Tara Kiran, a family doctor and researcher at the University of Toronto whose findings jibe with those of Statistics Canada surveys.

“Ontario is, in many ways, doing the best compared to other provinces,” Dr. Kiran said. “I can only imagine what’s happening in other parts of the country.”

Compiling and comparing detailed national data on primary-care access and other key metrics is one of the goals of the federal health funding offer, which premiers accepted on Monday,despite it falling short of their demands.

Family doctor and University of Toronto researcher Rick Glazier, the other co-leader of Inspire, the network of family medicine researchers, said that although Mr. Trudeau named access to family health teams as a prioritylast week,neither the Prime Minister nor his provincial counterparts seem to grasp how dire the shortage of family doctors is about to become – especially in light of population aging and the federal government’s plan to admit nearly 1.5 million new permanent residents by 2025.

“I’m honestly not seeing the sense of urgency in expanding the interprofessional teams and building the environments that new graduates would want to work in,” Dr. Glazier said. “It’s not really as much about spending the money as changing the system.”

The Canada-Africa Mpox Partnership launches with $3 million team grant

From U of T EPIC

Researchers from the University of Toronto and Nigerian Institute of Medical Research have received $3 million from the federal government to launch an international project that will help inform the clinical and public health response to local and global epidemic of mpox (formerly known as monkeypox).

The new funding from the Canadian Institutes of Health Research (CIHR) and International Development Research Centre builds on the collaborative projects and seed funding from the mpox rapid research response launched by the Emerging and Pandemic Infections Consortium (EPIC) earlier this year.

The Canada-Africa Mpox Partnership (CAMP) brings together 68 researchers with multidisciplinary expertise from Canada, Nigeria, the U.S. and U.K. It is co-led by Darrell Tan, an associate professor in the Temerty Faculty of Medicine and infectious disease physician at St. Michael’s Hospital, a site of Unity Health Toronto, and Rosemary Audu, director of research and head of the microbiology department at the Nigerian Institute of Medical Research. Tan is also the operational co-lead of EPIC’s mpox rapid response efforts.

“Our team is honoured to receive this funding to study this previously overlooked infectious disease, and is excited to launch this work,” said Tan.

“Mpox has caused tremendous suffering, stigma and other harms in Canada and worldwide, most notably among gay, bisexual and other men who have sex with men during the 2022 outbreak. The initial support from EPIC was instrumental in allowing us to launch our research within days of the epidemic arriving in Canada and was pivotal to our securing this large grant.”

The CAMP project focuses on three main topics across diverse epidemiological, geo-social, and health system contexts: mpox transmission, treatment and vaccines.

In the first sub-project, the Mpox Prospective Observational Cohort Study, CAMP researchers are working to understand transmission from multiple angles. This will include looking at how the virus is spread between humans, including those who are asymptomatic or presymptomatic, between humans and animals, and from contaminated surfaces. A key component of this work involves mathematical modelling to study how factors like differences in size and features of sexual and social networks, health care access and vaccines might shape the differences in outbreak dynamics across regions within each country, and differences in outbreaks between the two countries.

For the second sub-project, the team is conducting a randomized controlled trial to assess the safety and effectiveness of the smallpox drug tecovirimat as a treatment for mpox. Currently, no drugs have been directly tested and shown to be effective against mpox in humans. By using the same design and measuring the same outcomes as similar trials in other countries, this trial, which also received funding support from the Public Health Agency of Canada and CIHR Canadian HIV Trials Network, will contribute to global data on the efficacy of tecovirimat.

Similar to the lack of human efficacy data on mpox treatments, there is also a need for high quality data on the safety and effectiveness of the smallpox vaccine Imvamune that is currently being offered to individuals at high-risk to protect against mpox. The last sub-project focuses on evaluating the role of the Imvamune vaccine to prevent mpox infection in humans. The team is using observational data to determine the vaccine’s safety and effectiveness, including how the effectiveness changes based on the number and timing of doses, amount of time since vaccination and patient subgroup.