Author: Samira Prasad

Lire cet article en français

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.

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.

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.

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.”

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.

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.

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.

A national research study evaluating the effectiveness of existing and emerging COVID medications has started participant enrollment in Ontario.

CanTreatCOVID research study aims to identify effective, affordable and evidence-based medications for COVID that would reduce emergency department visits and hospital stays and help people feel better faster. The long-term goal of the study is to find medications that prevent post-COVID condition, also known as long COVID.

Supported by $10 million in grants from the Canadian Institutes of Health Research, Health Canada and Public Health Agency of Canada, CanTreatCOVID partners with more than 30 organizations across six provinces: Ontario, Quebec, British Columbia, Alberta, Manitoba, and Newfoundland and Labrador. Participant enrollment in other provinces will begin soon.

The study is open to adults aged 18-49 years with one or more chronic condition(s) or adults aged 50+ years who tested positive for COVID within the last five days.

In addition to studying whether any acute treatment can prevent long COVID, CanTreatCOVID will build this adaptive platform trial to be useful for other respiratory infections and help with future pandemics.

CanTreatCOVID study is based at MAP Centre for Urban Health Solutions, Unity Health Toronto and led by Dr. Andrew Pinto, Public Health and Preventive Medicine Specialist, Family Physician, and Founder & Director of the Upstream Lab.

For more information, visit https://cantreatcovid.org/ or contact info@CanTreatCOVID.org or 1-888-888-3308.

Lire cet article en français

From Healthy Debate

Canadians’ access to primary care is worse than previously thought, according to results of the first phase of the OurCare project, one of the largest ever nation-wide surveys on primary health care. Of the nearly 9,300 survey respondents, only 77 per cent reported having a family doctor or nurse practitioner. Pre-pandemic estimates had put this number closer to 85 per cent.

Survey data have been compiled into an interactive online dashboard. The survey results mark the end of the first of three phases of the OurCare project, which aims to find the gaps and possible solutions to some of the biggest issues in primary care in Canada. The project was conceived in June 2021 as a collaboration between Tara Kiran, a family doctor and scientist with MAP Centre for Urban Health Solutions, and colleague Peter MacLeod with MASS LBP. Plans were finalized with buy-in from provincial and national health-care partners, stakeholders and the public through the Canadian Medical Association’s group, Patient Voice.

Questions covered topics ranging from timeliness and proximity to care, relationships with caregivers and willingness to receive care from a health team.

“[The survey] provides really important perspectives from the public that can help to shape the reforms that we know must come,” says Kiran. “We know that primary care is something that needs to change.”

Timely access to care was highlighted as a key issue. Walk-in clinics were used by nearly half of respondents in the past year, with one-third citing walk-in clinics as the only places they could get care.

The survey confirmed that certain demographics have even less access to primary care support. Young adults, immigrants, lower income groups and racialized people were all even less likely to have a family doctor. But access by region was the most prominent determinant of connection with a family doctor. Only 69 to 71 per cent of respondents in B.C., Quebec and the Atlantic provinces had access to a family doctor, compared with 86 and 82 per cent in Ontario and the Prairies, including Manitoba, Saskatchewan and Alberta, respectively.

More than 9,200 people completed the survey, which ran from September to October last year. The responses were then weighted to reflect Canadian demographics based on recent census data.

Kiran says that Canadians are open to doing things differently if it means they and their neighbours will ultimately receive better access to care; About 90 per cent said they would be comfortable getting support from another health team member if their doctor recommended it.

“Relationships are important – even more important than timely access to care.”

She says she was heartened to see what respondents highlighted as one of their top priorities. “Patients want to be viewed as a complete person by their health-care providers,” says Kiran. “Relationships are important – even more important than timely access to care. We know that relationships are really at the heart of good primary care, and now all of the evidence actually lines up to say that.”

Some health-care reforms, however, don’t sit well with the public. “We asked how willing you would be to use virtual-care services if the company that ran the service was receiving payments or was owned by a pharmaceutical company.” The response: 70 per cent answered “not very willing” or “not willing at all” to receive care if that was the case.

Canadians also are leery of virtual-care services selling their data; 84 per cent said they would not use virtual care if the company sells data about their health, even if identifying information were removed. “I think it just speaks to the importance of people knowing clearly how their data will be used upfront before they decide to use that service,” Kiran says.

The next step of the OurCare project involves a more in-depth review of Ontario’s primary care. A group of 36 volunteers from outside the medical community and who are representative of the demographic distributions of the province have been chosen to take part in sessions to learn the details of the primary care system.

The group has already begun meeting to cover topics such as different primary-care models, health systems, equity and access. “I think this is going to challenge experts and really help us continue to talk about the values that underlie the future primary-care system,” says Kiran. The panelists will spend more than 30 hours learning about primary care from different experts and perspectives.

After the group has been primed with all the information, it will meet in-person in February to discuss possible solutions. “This is a really exciting step that I think is going to help us go deeper than we could with the survey.” On Feb. 12, the group will present its final recommendations. Matthew Anderson, CEO of Ontario Health, is among the health-system leaders who will attend.

The third and final phase of the project will assemble local community round tables made up of volunteers from marginalized backgrounds who will focus on the unique needs of underserved communities. The local community round tables are expected to meet in the spring.

Un sondage NosSoins souligne le manque d’accès aux soins primaires

Tiré de Healthy Debate

L’accès de la population canadienne aux soins primaires est plus difficile qu’on le croyait, selon les résultats de la première phase du projet NosSoins, un des plus grands sondages jamais réalisés à l’échelle nationale sur les soins de santé primaires. Des quelque 9 300 répondants au sondage, seuls 77 % ont déclaré profiter des services d’un médecin de famille ou d’une infirmière praticienne. Les estimations prépandémiques avaient placé ce chiffre autour de 85 %.

Les données du sondage ont été compilées dans un tableau de bord interactif en ligne. Les résultats du sondage marquent la fin de la première des trois phases du projet NosSoins, qui vise à trouver des lacunes et des solutions possibles à certains des plus grands problèmes en matière de soins primaires au Canada. Le projet a été lancé en juin 2021 dans le cadre d’une collaboration entre Tara Kiran, médecin de famille et scientifique du Centre MAP pour des solutions de santé urbaine, et son collègue Peter MacLeod du MASS LBP. Les plans ont été achevés avec l’adhésion de partenaires provinciaux et nationaux du secteur de la santé, de parties prenantes et du public par le truchement du groupe Voix des patients à l’AMC de l’Association médicale canadienne.

Les questions portaient sur des sujets comme la rapidité et la proximité des soins, les relations avec les dispensateurs de soins et la volonté de recevoir des soins de la part d’une équipe de santé.

« [Le sondage] fournit des perspectives très importantes de la part du public qui peuvent contribuer à façonner les réformes qui, nous le savons, doivent être mises en place, a déclaré la docteure Kiran. Nous savons que les soins primaires sont un secteur qui doit être amélioré. »

From The Globe and Mail article

There are many reasons why hospital emergency departments have been under unprecedented strain lately, but new research shows that the shift by family doctors to virtual care since the start of the pandemic is not one of them, according to the president of the Ontario Medical Association.

In a study by the Ontario Medical Association, published in the CMAJ (Canadian Medical Association Journal) on Monday, researchers found primary care physicians’ transition to virtual care was not associated with increased emergency department visits by their patients.

“There are other reasons why emergency departments are overwhelmed. It’s not because doctors have pivoted to a hybrid model and are now seeing their patients virtually as well,” OMA president Rose Zacharias said.

The study adds to growing research on the impact of virtual care, which has taken off in Canada since doctors were driven to restrict in-office visits early in the pandemic to reduce COVID-19 transmission. Many doctors began offering appointments by phone or video call.

Meanwhile, in the past year, emergency departments have struggled to keep up with demand, Dr. Zacharias said. But this has been the result of multiple factors, including burnout among health care professionals, a backlog in care, and patients showing up in greater numbers and sicker after a period of public-health restrictions, she said.

As well, there is a shortage of doctors and nurses in Ontario, with more than one million people in the province lacking a family doctor in the first place, she said, explaining the latest findings show patients who did have family doctors were not turning to emergency departments because of a decline in the availability of in-person care.

---

While the researchers did not study the reasons for this, lead author Lauren Lapointe-Shaw suggested a couple of potential explanations. Patients tend to use virtual walk-in clinics for new, acute problems, many of which require a physical exam of some kind, such as abdominal pain, she said. She suspects in many cases, patients may be redirected to an emergency department for that physical exam, since virtual walk-in clinics do not have a bricks-and-mortar facility where patients can be assessed in person.

Another potential reason may involve the relationship and trust between patient and doctor, said Dr. Lapointe-Shaw, who is a general internist physician at Toronto’s University Health Network and assistant professor at the University of Toronto. Patients may have less confidence in doctors they meet for the first time virtually and who do not examine them physically, and so are more likely to visit an emergency department for a second opinion, she said.

Her co-author Tara Kiran, a family doctor at St. Michael’s Hospital and Fidani Chair of Improvement and Innovation at the University of Toronto, emphasized the need to integrate virtual-care options into family care in a way that strengthens continued relationships between health care professionals and patients. That includes the increased use of asynchronous messaging, such as e-mails via a secure platform, which is highly desired by patients but not currently widely used, she said.

It’s important to avoid using virtual care in a way that fragments the continuity of patients’ care, Dr. Kiran said.

“A strong relationship between one physician and a patient has been shown time and again to have better outcomes for patients, even lower costs for the system,” she said.