Author: Emily Holton

HEALTHY DEBATE

By Nav Persaud, Danielle Martin, Steve Morgan, Marc-André Gagnon

COVID-19 is a terrible virus but offers a valuable lesson. Longstanding health disparities based on race have become front page news, driving home the importance of protecting everyone’s health.

Yet, a new Angus Reid Institute poll shows that many Canadians don’t have insurance that covers essential medicines and many commonly skip taking their pills because of the cost. The national survey confirms that in the midst of a global pandemic, one in four Canadian households has inadequate prescription drug coverage. Women and racialized people (“Canadians who identify as a visible minority”) are more likely to report having no insurance or partial coverage. Lower income households are more than twice as likely to be uninsured or under-insured as those with household incomes over $100,000. Women are more likely to report being uninsured or under-insured than men.

COVID-19 has made this situation dire: more than half a million Canadian houses have lost prescription drug coverage during this year of unprecedented public health and economic crises.

The interaction between race, drug coverage and COVID runs deep. For instance, having poorly controlled diabetes increases the risk of dying from the virus. One would think that every Canadian with diabetes should be all set to face down the pandemic: insulin was discovered almost a hundred years ago in Toronto; the rights to it were sold for just $1; and we have a publicly funded healthcare system. Despite that, millions continue to go without the drugs they need, like insulin.  

Accessing medicines can be the difference between life and death. Sadly, the death toll from COVID-19 in Canada has now passed 10,000. Chronic diseases like diabetes will kill more than 20,000 people this year. The number of lives saved through better access to medicine is hard to know exactly but it is likely in the thousands.

So, if we are “all in this together,” why are some riding crowded buses during a pandemic to jobs that don’t provide insurance for insulin and other life-saving medicines?

“When this pandemic started a lot of folks were talking about it being the great equalizer – we are all in the same situation. We very quickly realized this was not the case.” ~ front-line provider (focus group)

By Drs. Naomi Thulien & Amanda Noble, for Homeless Hub

In June 2020, we received funding from the Canadian Institutes of Health Research to lead a knowledge synthesis of promising mental health and substance use practices utilized during the COVID-19 pandemic with young people who were experiencing or had experienced homelessness. 

Instead of conducting a traditional knowledge synthesis by pulling together evidence found in academic journals, we wanted to hear directly from front-line providers and the young people they served. We were fortunate to work with great team of front-line clinicians, researchers, public policy influencers, and people with lived expertise in homelessness, mental health challenges, and substance use to conduct this research. 

Our final report contains survey data from 188 front-line providers across Canada and is supplemented by three focus groups – two with providers and one with young people who have experienced homelessness. We focused on three key domains: 1) pandemic impacts on mental health and substance use patterns; 2) practice adaptations; and 3) promising and transformative approaches. 

Our overall aim was to shed light on promising practice adaptations; however, the evidence we uncovered over the past five months has been less about downstream individual-level interventions and more about the need for upstream structural interventions. While there is a pressing need to understand what individual-level practice adaptations hold promise to meet the mental health and substance use needs of young people who are experiencing or have experienced homelessness (and we do expand on this in our report), it is essential that we situate this need and our response within the broader societal context in which youth exist. 

If the problem of worsening mental health and substance use during this pandemic is caused by/connected to intersecting structural inequities such as racism, insufficient housing, precarious employment, limited social connections, and poverty, and not individual “vulnerability” (a term that denotes weakness and used all too often when referring to youth experiencing homelessness), then it is logical that the proposed solutions should encompass structural interventions.

The COVID-19 pandemic has exposed and created a multitude of intersecting inequities that providers and young people are struggling to navigate. It also presents a unique opportunity to reimagine how we serve young people who are experiencing or have experienced homelessness. 

Key Messages

• We must pay special consideration to the mental health and substance use needs of young people with current and past experiences of homelessness, who are more likely than the general population to have pre-existing mental health challenges, struggles with financial hardship, and employment uncertainty.
• Providers must be careful not to inadvertently perpetuate access inequities – already common in this population – by pivoting to phone/virtual care without having a concurrent plan around addressing resource-related barriers to access.
• While it intuitively makes sense to divert young people from the shelter system – especially during a pandemic – we must ensure these young people have the social and economic supports needed not just to survive, but to thrive.

Researchers from MAP Centre for Urban Health Solutions and St. Michael’s Hospital are among 250 global experts who contributed to the recently published United Nations’ Research Roadmap for the COVID-19 Recovery.

The Roadmap seeks to address the severe health, humanitarian and socio-economic consequences of the pandemic, and to guide countries toward supporting targeted research so their responses are evidence-informed and focus on those most impacted by the COVID-19 pandemic and its collateral damage to our economies, health and wellbeing.

The Roadmap highlights 25 research priorities categorized into the five socio-economic pillars identified by the UN in a framework released in April 2020. The pillars include health systems and services, social protection and basic services, economic response and recovery, macroeconomic policies and multilateral collaboration, and social cohesion and community resilience. The MAP/St. Michael’s team focused on economic response and recovery.

Among the recommendations was for countries to invest in research that focuses on how economic recovery policies can protect all workers, ensure their well-being, and promote a resilient workforce, and how workers’ incomes and jobs can be best protected when they are sick or have caregiving responsibilities.

To arrive at these recommendations, Dr. Farah Mawani, a social and psychiatric epidemiologist and postdoctoral fellow at MAP, led a rapid scoping review of existing research on the economic impacts of COVID-19 and previous disastrous events, such as the global economic crisis of 2008 and Ebola.

“When we talk about the economic response, we’re talking about immediate measures decision-makers took to respond to the crisis,” said Dr. Mawani, citing the Canada Emergency Response Benefit (CERB) as one such measure. “And when we talk about recovery, we’re talking longer-term. It’s hard to separate them because we’re still responding to a growing crisis, but we need to have a combination of interventions, policies and programs that address the crisis response and address the longer-term needs for recovery.”

“Without research, we don’t know which of those measures are effective or not or who is being left out of various policies and programs,” she said.

Dr. Mawani and her co-authors – Dr. Patricia O’Campo, Dr. Virginia Gunn, Dr. Susitha Wanigaratne, Melissa Perri, Carolyn Ziegler, Aly Kassam, Michelle Anagnostou, Angie An and Dr. Carles Muntaner – found several gaps they identified as high-priority for future research. These gaps are important not only for decision-makers and governments, but for research funding agencies and researchers so they know what kind of research they should be funding and conducting, says Dr. Mawani.

Among the gaps, the team identified that many interventions implemented both during COVID-19 and past crises did not take an equity approach. The interventions targeted some marginalized groups, but left out disabled workers, refugees, Indigenous people and precarious workers.

“They either didn’t specify who the interventions should be targeted towards, or made general, vague statements about those who are ‘vulnerable’ without accurately framing the systemic causes of inequities or vulnerabilities,” said Dr. Mawani.

Dr. Virginia Gunn, a post-doctoral fellow at MAP Centre for Urban Health Solutions and a co-author of the Roadmap, says investing in research focused on workers in informal, non-standard, and precarious employment is important, because these workers are often covered by fewer job protections and they are often not eligible for social benefits and supports such as unemployment insurance, supplemental health benefits, or minimum wage legislation.

“These workers’ disadvantage was aggravated and magnified by the COVID-19 pandemic, further widening a range of inequities between them and workers in full-time employment,” said Dr. Gunn. “Investing in research focused on this topic will help us understand the unique needs of these workers so that we can tailor our supports.”

The Roadmap also highlighted a need for research on workers with disabilities as a result of COVID-19. Dr. Mawani says there is not enough focus on this issue currently.

“We hear about workers with disabilities who are at higher risk of serious complications due to COVID-19, which of course is really important,” says Dr. Mawani. “But what hasn’t been focused on is that COVID-19 itself is causing disabilities. What does that mean in terms of increasing disability and the impact of that on workers, job protection, workplaces, and what do countries need to do to prepare for and respond to that?”

The UN says the Roadmap was developed with a “human rights lens” and great care was taken to ensure no one was left out or left behind. The realities of racism, colonialism, sexism and ableism play a role in creating inequities and the conditions for inequities to be exacerbated during the COVID-19 pandemic, says Dr. Mawani, which is why she and her co-authors explicitly named those systems in their review. She’s pleased to see that reflected in the Roadmap.

“A lot of people shy away from naming those things. But if we don’t name them, we can’t address them.”

An area in the northeast corner of Brampton has a “shocking” 19 per cent COVID-19 test positivity rate — a rate double that of the U.S. — and is leading a list of 30 Greater Toronto neighbourhoods that are seeing alarming numbers of people testing positive for the virus, new data shows.

Peel as a whole is recording a per cent positivity of 9.8 per cent — the highest in the GTA — while neighbourhoods in northwestern Toronto, Scarborough, and southern York Region are also reporting sky-high rates, according to a first-time look at an analysis conducted by the Toronto-based non-profit ICES (formerly the Institute for Clinical Evaluative Sciences). The data covers the first week of November, the most recent time period of which per cent positivity rates are available, and is broken down by postal code to provide a detailed picture of the local severity of the pandemic.

…Epidemiologist Dr. Farah Mawani, of MAP Centre for Urban Health Solutions at Unity Health Toronto, said the ICES data highlights how the current pandemic response is failing.

In early October, COVID-19 testing was limited just as cases were rising and in Toronto, public health dropped all contact tracing except for high-risk settings, such as schools, hospitals and long-term-care homes.

“That combination, while cases were rising, is a recipe for disaster,” Mawani said. “We are now seeing that disaster unfolding. Those are two key tools to stopping the spread.”

Sir William Osler, the Canadian doctor widely regarded as the father of modern medicine, whose name graces schools and medical institutions on both sides of the Atlantic, held racist views that have been swept under the carpet for more than a century, according to an article published in the Canadian Medical Association Journal Monday.

The article, co-authored by Toronto doctor Nav Persaud, argues that Osler continues to be lionized in medical school, a practice that whitewashes his legacy and erases his more offensive statements, which include “I hate Latin Americans,” and “What are we to do when the yellow and brown men begin to swarm over” to Canada, which he considered “a White man’s country.”

“William Osler continues to be held up as an example physicians should follow,” the article states. “As statues of once-revered individuals who participated in racist crimes are being removed around the world, we should change Osler’s place in medical curricula and explicitly address racism in medicine.”

Osler’s outsized presence in medical schools across the English speaking world overshadows the contributions made by lesser-known racialized physicians who practiced during the same era, including Black Civil War veterans Dr. Alexander Thomas Augusta and Dr. Anderson Ruffin Abbott, as well as Indigenous physicians Dr. Oronhyatekha (Burning Sky) and Dr. Peter Edmund Jones.

No hospitals are named after these doctors.

The CMAJ article states that a biographer modified a transcription of an Osler letter, replacing his use of the word “hate” for Latin Americans with “don’t care for.” The statement was ultimately not included in the 1926 Pulitzer Prize-winning biography of the doctor. The CMAJ article includes an undated illustration that depicts the doctor as an angel, complete with halo and wings, floating above Johns Hopkins Hospital in Baltimore, which he helped found.

Featured in The Globe and Mail, The Toronto Star, CBC As It Happens, and CityNews

Federal regulators have approved the first HIV self-test in Canada in a long-awaited move that experts have called critical to reaching people who don’t know they have the virus.

Health Canada granted a medical device licence on Monday to a one-minute, finger-prick blood test manufactured by Richmond, B.C.-based bioLytical Laboratories.

Canada follows dozens of other countries in greenlighting the technology, which has been endorsed by the World Health Organization as a tool to reduce the number of people with undiagnosed HIV.

The principal investigator of a study that was submitted to regulators as part of their review says the approval of HIV self-testing could “open incredible doors” to increasing access to life-extending treatments and preventing the spread of infection in Canada.

Dr. Sean Rourke, a scientist with MAP Centre for Urban Health Solutions at St. Michael’s Hospital in Toronto, says he’s working with community organizations across the country to launch a telehealth program in January that will distribute 60,000 self-tests and connect people with care.

Rourke says the need for self-testing has become even more important as a recent survey of roughly 300 front-line providers suggests the COVID-19 crisis has cut access to clinical HIV testing services nearly in half.

Dr. Katerina Maximova has been named the inaugural Murphy Family Foundation Chair in Early Life Interventions at MAP Centre for Urban Health Solutions, St. Michael’s Hospital, and the University of Toronto.

Dr. Maximova’s research and policy work focuses on children and youth, including social dimensions of health, behaviours that increase future risk of chronic disease risk, misperception of risk, and the effectiveness of early life interventions.

At MAP, Dr. Maximova will focus on solutions-oriented research to improve the early life experiences, development, and well-being of children and youth experiencing poverty.

“I am so pleased to be joining MAP and St. Michael’s,” said Dr. Maximova, “I’m also very grateful to the Murphy Family Foundation for their commitment to addressing upstream determinants of health for children and youth.”

Dr. Maximova received her PhD in epidemiology and biostatistics from McGill University. She is currently an associate professor in the School of Public Health at the University of Alberta, where she is a member of the Population Health Intervention Research Unit. She has played a major role in evaluating the impact of the APPLE Schools (A Project Promoting healthy Living for Everyone in Schools) intervention program targeting physical activity, healthy eating, and mental health of children and youth experiencing marginalization. APPLE Schools reaches more than 21,000 students annually in 75 schools across northern Alberta, British Columbia, Northwest Territories, and Manitoba. Prior to academia, Dr. Maximova spent several years with the Government of Canada working on policy issues focused on poverty in early life, ‘working poor’ families, income support for low-income families, family-friendly policies, affordable housing and homelessness.

Dr. Maximova has received several awards including a Career Development Award in Prevention Research from the Canadian Cancer Society Research Institute. She recently received a CIHR COVID-19 Rapid Research Grant to study the impact of prolonged school closure and social isolation on the mental health and lifestyle behaviours of elementary school children experiencing disadvantage.

About MAP Centre for Urban Health Solutions

MAP is a world-leading research centre dedicated to creating a healthier future for all. Through big-picture research and street-level solutions, our scientists tackle complex urban health issues — many at the intersection of health and equity. Internationally recognized for groundbreaking science and innovation, MAP is changing the way the world understands the health consequences of social inequality in cities. Together with our community and policy partners, we are charting the way to the world’s healthiest cities: places where people, communities, and the political, economic, social, environmental, and health infrastructures come together so that everyone can thrive. MAP is part of the Li Ka Shing Knowledge Institute of St. Michael’s Hospital and is fully affiliated with the University of Toronto. St. Michael’s is a site of Unity Health Toronto, which also includes Providence Healthcare and St. Joseph’s Health Centre.

Featured in Hospital News

As a researcher who has studied intimate partner violence for 25 years, Dr. Patricia O’ Campo knows that women experience higher rates of increased violence during epidemics — a troubling and well documented pattern. However, Dr. O’Campo discovered a puzzling gap in academic literature when the COVID-19 pandemic hit: there are no verified strategies women can utilize to promote safety and protect themselves during public health emergencies.

“There’s a lot of opinions about what women might do, but nobody has verified those strategies,” said Dr. O’Campo, Interim Executive Director of the Li Ka Shing Knowledge Institute and scientist at MAP Centre for Urban Health Solutions.

Once the COVID-19 pandemic was declared, Dr. O’Campo and her co-principal investigator, Dr. Nicholas Metheny, a Post-Doctoral Research Fellow at St. Michael’s, began exploring how to redesign the Pathways app — an earlier project which provides women in abusive partnerships with a personalized safety plan.

In a pandemic, women and children living with violence may be forced to shelter with violent partners, unable to access resources outside of the home, while dealing with a reduction in services available to them. Due to public health measures to prevent the spread of COVID-19, service agencies aren’t always able to support women face-to-face, so women experiencing violence may need to consider additional safety strategies.

To fill this gap in research, Dr. O’Campo and her team put together a list of around 35 suggested strategies and asked over 100 service providers and women with lived experience of domestic violence to rate whether the suggestions are “recommended” or “not recommended.” Some of the suggestions were rated by survey responders as having the potential to make violence worse.

“For example, we know that alcohol and substances can make an episode of violence more likely, and one of the recommendations was to hide alcohol or other substances that may make abuse worse,” she continued. “That one was rated by many women with lived experience as being something that would make violence worse.”

Other strategies that were rated as “not recommended” include trying to “keep the peace” and switching to texting or emailing instead of phone calls.

Based on the results of the rapid survey, Dr. O’Campo and her team created factsheets listing verified recommendations for women living in situations of intimate partner violence. The factsheets include tips for online and physical safety planning during public health emergencies. They are being disseminated to women and service providers to help them navigate issues that COVID-19 has exacerbated.

“There are risk factors for violence that are increasing as a result of the pandemic, and the economic pandemic that’s accompanying the infectious pandemic,” Dr. O’Campo said. “For example, an episode of unemployment highly increases household stress and therefore the risk of violence.”

The takeaway from this work, she says, is that there are strategies women can implement — that are recommended by women with lived experience and experienced service providers — to promote safety when they’re sheltering at home. These strategies, however, are not a “one-size fits all.”

“Everything should be tailored to the context in which you’re residing, but you can continue to promote safety even in this very difficult time.”

How has the COVID-19 pandemic impacted people who were released from prisons and require mental health services? What about people who rely on in-person addiction treatment to stop using opioids?

Two MAP scientists have been awarded new funding through the Canadian Institutes of Health Research (CIHR) Operating Grants: COVID-19 Mental Health & Substance Use Service Needs and Delivery to tackle their research questions.

The research and knowledge mobilization supported through these grants will help inform policy and practice in near real-time to respond to crisis-based needs. Congratulations to our researchers and their teams, whose projects are outlined below, for receiving this support.