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Opinion: It is possible to end chronic homelessness if we act now

By Dr. Stephen Hwang, MAP Director


As a physician and researcher on homelessness, I’m a witness to the intersecting health crises that affect people who don’t have adequate housing. COVID-19 is only one of them. For years, my colleagues and I have treated infections and overdoses, chronic diseases, injuries and mental health issues among people experiencing homelessness. We have been applying Band-Aids, addressing only the most visible symptoms of a continuing crisis.

The pandemic has forced us to confront the consequences of having allowed homelessness to persist in our cities for far too long. Canadians living on low incomes in crowded conditions have been disproportionally affected by COVID-19. In Toronto alone, more than 500 people experiencing homelessness have been infected with the coronavirus. As case numbers rise and the colder months move us indoors, adequate shelter is more important than ever.

We have seen rapid action on homelessness over the past six months that would have been previously unthinkable. Municipal and provincial governments, health care and service providers, public-health and community agencies have undertaken extraordinary and costly emergency efforts to prevent COVID-19 from spreading rapidly in shelters and encampments. Empty hotels have been quickly turned into temporary housing. Facilities to allow people to safely self-isolate have been created in a matter of weeks. Cities are committing to build new modular housing for people experiencing homelessness.

And now, in last week’s Throne Speech, the federal government announced a new aspiration – to entirely eliminate chronic homelessness in Canada. We must seize this once-in-a-generation opportunity to move beyond short-term, crisis solutions and make lasting change, meet the needs of our communities and end chronic homelessness in our cities. It’s possible, necessary and the right thing to do.

Unity Health physician who worked in Sierra Leone during Ebola helps build model to project local COVID-19 numbers

Infectious disease physician Dr. Sharmistha Mishra experienced the early days of the COVID-19 pandemic as a flashback. Everywhere she looked were echoes of Ebola and her work in Sierra Leone.

She saw the crucial role nurses play as the main connecters to the patients. She saw the fear, heightened this time because the disease was at our doorstep. She saw a grounding principle of her practice come to life once again: we will always know more tomorrow than we do today.

“As Infectious Disease practitioners, we live in the world of uncertainty,” said Dr. Mishra, who is also a scientist at MAP Centre for Urban Health Solutions and a mathematical modeler. “That’s part of our training, and that’s so much of what an epidemic is. We can transfer knowledge from other epidemics but there is always an adaptive nature to our approach.”

To prepare for that uncertainty, hospital leadership approached Dr. Mishra in February with a question she, as a mathematical modeler and infectious disease specialist, was uniquely suited to tackle: Can we project how the pandemic will unfold in the hospital’s two acute care sites, St. Joseph’s and St. Michael’s?

In the end, the work by Dr. Mishra and her team, published today in CMAJ Open, would be described by leaders as an ‘eerily accurate’ depiction of how the surge unfolded at the two sites.

Though mathematical models were common in the beginning of the pandemic – and still are – they were made with a provincial, national or global lens. None, before Dr. Mishra’s, was tailor made to Unity Health to help with a local response.

“Our leadership wanted to be as data-driven as we could about this and that’s what they want going forward,” she said. “We want science to drive our response, and that’s what we did in the first wave.”

The project started with the team trying to determine the simplest model that would capture how this disease could spread. This would help them predict how many COVID patients would potentially be admitted, and how many would have severe enough symptoms to be in intensive care.

Her team then set out to find data that could inform the model and project the answer to their initial question. They pulled existing studies, historical data on pandemics, the hospitals’ data on admissions and bed capacity, and health administrative from ICES to understand what the catchment areas of the two sites looked like.

The biology of COVID-19 and how long the virus could be passed on also informed their modelling. They estimated its severity rate and the percentage of people that needed to be hospitalized. The Decision Support team, and Infection Prevention and Control helped the scientists pull numbers and ensure the model made sense for the network.

“The data was changing day by day,” Dr. Mishra recalled. The first iteration of their model was built in four days. Then the team took another three weeks to nail down the science and offer more robust scenarios for the hospital to plan its approach.

The most reliable projections in mathematical models are those based on the most recent data. The projections the team made based on the prior two or three weeks would fit the next two or three weeks, and so on.

“A key lesson in this exercise was that we had to constantly recalibrate because so many things were changing,” Dr. Mishra said. “If we had used only early data, our projections would have been very different.”

The modelling helped the hospital respond quickly and plan patient flow accordingly. Dr. Mishra said there’s always ways for modelling to improve, and she feels ready to have an even better approach for a second wave of the disease.

“We now know some more of the nuances that affect COVID-19 risk, like congregate settings, age groups, and social determinants of health. I feel like we’re in a much better place now to be more adaptive in our modelling as well as our response.”

Dr. Mishra also hopes her team’s work can be used by other hospitals to project their own numbers. Everything they’ve created is open source and generalizable.

“That’s another similarity from my work in Ebola that I’ve seen with COVID-19: everything has become less about the individual and more about the collective.”

COVID-19 testing site for Indigenous people to open in Toronto

“We saw in the first wave how there were gaps in the ability of non-Indigenous services to meet the needs of the Indigenous community. That’s why we need our own agencies to do it. We need to use our own community networks and relationships to make sure that Indigenous people have Indigenous specific pathways.”

Dr. Janet Smylie, Director of Well Living House

A COVID-19 testing site is opening up for Indigenous people in Toronto, just in time for the cold and flu season. 

“There’s not much trust for some Indigenous folks in our health care system because of discriminatory practices or blatant racism,” said Steve Teekens, executive director of Na-Me-Res, an emergency shelter and housing organization.

“We have a vacant building here and one of our managers thought this would be a fabulous idea to offer it up as a COVID testing facility for Indigenous people.” 

Canada’s COVID-19 Immunity Task Force invests almost $3M in two major MAP projects

Two MAP scientists have been awarded nearly $3 million in federal grants in support of research projects focused on improving our understanding how COVID-19 affects people experiencing homelessness, as well as children and families.

The funding is part of a $12.4 million funding announcement from Canada’s COVID-19 Immunity Task Force (CITF), in collaboration with the Canadian Institutes of Health Research (CIHR).

The COVENANT Study (COVID-19 Cohort Study of People Experiencing Homelessness in Toronto), led by MAP Director Dr. Stephen Hwang, received $1.9 million in funding. This study will reveal the patterns and trajectory of COVID-19 in the homeless population, and will help policy-makers and service providers better understand what works to prevent, detect and manage COVID-19 in this high-risk group.

The TARGet Kids! COVID-19 Study of Children and Families, led by MAP scientist Dr. Jonathon Maguire and Dr. Catherine Birken from the Hospital for Sick Children (SickKids), received $975,000 in funding. The study will answer important questions about COVID-19 community transmission, risk factors for infection, and disease severity among children and families. This study is also funded by Fast Grants, the St. Michael’s Hospital AFP Innovation Fund, and the St. Michael’s Hospital Foundation.

The Government of Canada launched the COVID-19 Immunity Task Force (CITF) in late April 2020 to track the spread of the virus in both the general population and priority populations in Canada. The Task Force also aims to shed light on immune responses to SARS-CoV-2 in a diversity of communities, age brackets, populations, and occupational groups across the nation. To generate this information, the Task Force is drawing on experts from universities and hospitals across Canada and working closely with provincial and territorial public health officials.

Dr. Naomi Thulien receives St. Michael’s Hospital career award

Dr. Naomi Thulien has received the Lucy Boguski Career Award in Transitioning Youth Out of Homelessness.  

The primary purpose of this four-year award is to help build a program of research dedicated to transitioning youth out of homelessness. The award was created at St. Michael’s Hospital and Thulien is the inaugural recipient.  

Thulien is an affiliate scientist at St. Michael’s Hospital MAP Centre for Urban Health Solutions and an assistant professor at the McMaster University School of Nursing. These funds will allow her to devote more time to research, including the supervision and mentorship of graduate students with a keen interest in understanding how to sustain youth exits out of homelessness.  

“I am committed to conducting community-based research that advocates for equitable social and economic inclusion for young people who have experienced homelessness,” says Thulien. “I am also really excited to be supervising four promising graduate students this fall. All will be conducting critical qualitative health research with young people who are experiencing or have experienced homelessness.”

Closing the gender pay gap in medicine: An action plan

Closing the gender pay gap in medicine in Canada requires a multipronged approach to overcome systemic bias, including payment and hiring transparency, changes to medical education, better parental leave and more, as outlined in an analysis article in CMAJ (Canadian Medical Association Journal).

Read the CMAJ paper

In Ontario, male family physicians earn 30% more, and male specialists earn 40% more than their female counterparts on average.

“The gender pay gap exists within every specialty and also between specialties, with physicians in male-dominated specialties receiving higher payments,” write Dr. Tara Kiran, St. Michael’s Hospital of Unity Health Toronto, Toronto, Ontario, and Dr. Michelle Cohen, Queen’s University, Kingston, Ontario. “The gap in not explained by women working less but, rather, relates more to systemic bias in medical school, hiring, promotion, clinical care arrangements, mechanisms used to pay physicians and societal structures more broadly.”

Research from the United States and the United Kingdom indicates that the pay gap persists after adjusting for physician age, specialty, number of hours worked and other factors. In Canada, the proportion of female physicians has grown from 11% in 1978 to 43% in 2018, but women make up only 8% of Ontario’s highest billing physicians.

“Women in medicine face discrimination throughout their careers,” the authors write. “This discrimination is rooted in the history of women’s exclusion from the profession, along with the institutional legacies of sexism in medical schools, clinical care arrangements, health organizations and the fee system itself. In the early stage of their careers, the ‘hidden curriculum’ both subtly and overtly encourages women trainees to enter specific, often lower-paid, specialties.”

Provincial and territorial governments, institutions and faculties of medicine, professional associations, clinical leaders and individual physicians all have a role to play.

Actions to close the pay gap include:

  • Transparent data, including reporting of physician payments by gender and other demographic characteristics
  • Antioppression training for leadership
  • Addressing gender bias in medical schools and medical curricula
  • Standard, fair, and transparent hiring and promotion practices
  • Actively seeking and encouraging women for leadership roles
  • Better maternity and parental leave programs

“[W]ork to address gender pay equity in medicine cannot be done in isolation,” write the article’s authors. “The medical profession should remain mindful of the relative privilege of physicians in society and support advances for women struggling in precarious, lower-paid work; solutions for the medical profession should not exacerbate broader societal income inequality. Efforts to close the gender pay gap in medicine should embrace efforts to measure and reduce pay gaps related to other intersecting forms of discrimination, including race and disability.”

Listen to the CMAJ podcast interview with Drs. Kiran and Cohen

Opinion: The end of the HIV crisis is within our grasp. We must apply the pandemic spirit to achieve it

By Sean Rourke and Bill Flanagan


Imagine having easy access to a home self-test for COVID-19. With instant results, you’d be able to make informed decisions about your health and decide whether you should stay in or go to work. Research teams around the world are devoting resources to making this a reality, in the hopes of helping to stop the months-old pandemic in its tracks. In the meantime, many Canadian jurisdictions are offering medically administered swab tests with quick turnaround times in accessible ways.

But this inspiring efficiency is in sharp contrast to how the HIV epidemic has been handled in Canada, where the rate of new HIV infections continues to rise – even as the numbers consistently decline in countries such as the United States, the United Kingdom, Australia and Japan.

The difference: Canada has not yet approved or implemented a full range of HIV testing options, including self-testing; we have not yet ensured linkage to care for all; and universal and free access to treatment is not consistently available across our country.

About 15 per cent of people living with HIV in Canada are undiagnosed: They have HIV but do not know it because they have not been tested. There is also a significant proportion of people who are diagnosed with HIV but are not in care. Recent estimates from the U.S. Centers for Disease Control indicate that about 80 per cent of new HIV infections result from gaps in testing and treatment.

This suggests that if more Canadians had access to home self-tests, and were then provided with effective treatment – which can allow people with HIV to live almost normal lifespans, and in almost all cases can entirely suppress the virus so that there is no risk of transmitting it to sexual partners – the reduction in spread could in effect end the HIV epidemic in this country.

COVID-19’s impact on racialized communities

Black, Indigenous and other racialized people make up about half of Toronto’s population, but 83 per cent of the city’s COVID-19 cases says MAP scientist Dr. Andrew Pinto.

In the below interview, he spoke with CTV News about how systemic racism has affected racialized populations during the pandemic.

Most family doctors unaware of centralized intake services available in Toronto

What good are Ontario’s many health services if patients get lost in a maze of telephone numbers and waiting lists trying to access them? That was the dilemma the Toronto health region began tackling ten years ago, when it started introducing centralized intake services to act as a single point of entry for patients or doctors navigating Ontario’s complex healthcare system. A patient could call one of several centralized access lines to find a service that meets their needs, such as programs for senior’s supports, mental health and addictions, or diabetes services. Or, their family doctor can use it to refer them to that service.

Now a new study is exploring how well it works.

The study, published in Healthcare Policy, looked at how often family doctors are using central intake services and also whether family doctors were more likely to be aware of the program if they worked in an inter-professional team setting like a Family Health Team or Community Health Centre.

The study, which surveyed nearly 250 primary care physicians in Toronto, found that most family doctors are not aware of the centralized intake services available in the city. This creates a barrier between patients and the help they need. We spoke with Dr. Tara Kiran, family physician at St. Michael’s Hospital Academic Family Health Team and lead author of the study, about how the findings could improve the system.

U of T prof earns Tier 1 Canada Research Chair in Indigenous health

“Health information is actually an extension of our sacred kin lines – of the blood and genetic memory that’s held in our DNA. It’s an observation about our health that’s rooted in blood memory. That’s a huge and awesome resource. We can use this to plan and develop thriving communities.”

Prof. Janet Smylie sees a change in the conversation about systemic racism.

The recently appointed Tier 1 Canada Research Chair in Health believes she is the first Indigenous person with kin and land ties to what is now known as Canada. She hopes to use the platform to advance the conversation even further.

“First Peoples in Canada receive second class healthcare services that for the greater part have been designed using non-Indigenous models and approaches,” says Smylie, a University of Toronto professor at the Dalla Lana School of Public Health and the Department of Family and Community Medicine at the Faculty of Medicine.

She is pleased about the award but prepared for the work ahead, which blends her medical and research background. From health care to research, it is all “relational.”

“I have the privilege and opportunity to develop those relationships with patients and carry that into my public health research and in Indigenous communities. Relationality, from my perspective, as a Métis woman is foundational to Indigenous social systems. The key, in my mind, is to never underestimate how important those relationships are,” she says.