Author: Samira Prasad

From the St. Michael’s Foundation

Dr. Dan Werb is an epidemiologist, a policy analyst and the winner of the prestigious Hilary Weston Writers’ Trust Prize for Nonfiction for his latest book, The Invisible Siege: The Rise of Coronaviruses and the Search for a Cure. We talked to Dr. Werb, who is also the executive director of the Centre on Drug Policy Evaluation at St. Michael’s MAP Centre for Urban Health Solutions.

What was it like winning the Writers’ Trust Prize for The Invisible Siege and, before that, being shortlisted for a 2019 Governor General’s Award for The City of Omens: A Search for the Missing Women of the Borderlands?

Winning the Writers’ Trust Prize was a complete and utter shock; I was absolutely convinced that there were other, more worthy books. Being nominated for the Governor General’s Award was such an honour, but very unexpected, too, because the book had an American publisher, and I didn’t know whether anyone in Canada was really paying attention to it.

How challenging was it writing about COVID-19 while in the throes of the pandemic, when there was such a lack of global vaccine distribution?

I’m an epidemiologist, not a virologist, so I must admit that when the pandemic happened, I didn’t know what a coronavirus was other than it was related to the 2002 SARS virus. I approached the book as a way to put boundaries on my own anxiety and dread. But I knew the stakes of getting the story of COVID-19 right.

On the one hand, I was writing a piece of entertainment. On the other, I was offering a real account of what happened, and conveying the illness and loss we all experienced. Meanwhile, I was frustrated by the number of people succumbing to the virus simply because market forces precluded vaccines from being distributed to under-resourced countries.

The best ways to stop people from getting infected and dying are blanketing the world with vaccines and making sure populations, everywhere, are immunized.

Yet, there’s an air of hope to The Invisible Siege.  

I set myself the task of telling readers about the science, which didn’t suddenly emerge the day the virus appeared. I focused on the early days of coronavirus research, decades ago, and its long trajectory leading to this pandemic—how we were able to create protections and blunt the force of whatever coronavirus showed up next. That’s what fills me with such hope: our capacity to deal with future virulent threats.

How can we prepare for future public health crises through what you describe as the “epidemic triangle”?

There are basically three pieces to prevention: biomedical, structural and community resilience.

The first is addressing viruses as families rather than as individual strains, and focusing on broad-based vaccines and treatments instead of individual ones.

Structural prevention, which may be the hardest, is recognizing and reversing the damage that deforestation and displacement of wild animals has brought—the ‘spillover events’ causing epidemic pathogens.

And community resilience is about acting quickly and locally to curb the outbreak of the virus. That means imposing effective public health measures and isolating people who are sick.

You also do a lot of work around public health interventions for the marginalized drug-using population at MAP Centre for Urban Health Solutions. You talk about coming up with “non-judgmental solutions” for those who use drugs and whose lives can be cut short by accidental overdose.

We’re in the midst of an overdose mortality epidemic, which has claimed about as many lives as COVID-19 over the past seven years. But unlike the case of the virus, the numbers are going up, not down, and the victims of this epidemic are overwhelmingly young people. So, there’s a real urgency to find many different ways to address this problem, such as reassessing how to control drugs and drug use, moving progressive drug policies forward and advancing life-saving interventions. If you’re a donor, you can make a massive difference in this space because there’s so much to do.

From the Globe and Mail article

In the emergency department at the Royal Alexandra Hospital in Edmonton, Dr. Louis Hugo Francescutti recently treated a patient who was homeless and was there for the 360th time.

“I’ve had others that are in the 500 range,” he said in a recent phone interview from the hospital. “I’m at work right now – I came in at 6 o’clock, and the first six patients I saw were experiencing homelessness.”

With homelessness at crisis levels in cities across the country, emergency-room doctors and nurses have become a frequent point of contact for people without shelter, who face elevated risks of injury, illness and death and often have nowhere else to turn.

The medical toll of homelessness has become so acute that hospitals are now required by the Canadian Institute for Health Information (CIHI) to track whenever a lack of shelter is mentioned in a patient’s chart.

But doctors and nurses are not obligated to ask patients about their housing status, so this information is not always making it onto those charts in the first place – meaning the picture is incomplete.

And without data, the toll of the crisis remains difficult to measure and address – and opportunities for intervention are being missed.

Under the World Health Organization’s International Classification of Diseases (ICD), which is used to track global health statistics, homelessness is coded as Z59.0.

---

One of the biggest opportunities for improvements in the Z59.0 data collection is in emergency departments – the part of the health care system that homeless patients most frequently access

The nature of emergency care – focused and brief interactions – means that housing status is less likely to get logged in those cases.

“When you admit someone to hospital, you do take a fairly complete history and describe where they live and who’s living with them,” said Dr. Stephen Hwang, a general internistand director of the MAP Centre for Urban Health Solutions at St. Michael’s Hospital in Torontoand one of the world’s leading researchers on homelessness, housing and health. “But you don’t do that in the emergency department, necessarily.”

CIHI plans to publish its first report on Z59.0 data this year, with a goal of raising awareness of the code for both physicians and researchers across the country, to get them thinking about the value of asking the question, both clinically and statistically.

From CBC

Kayla DeMong considers it a sign of success if her clients keep showing up.

DeMong is the executive director of Prairie Harm Reduction. The organization provides supports to people who use drugs, including Saskatchewan’s only supervised consumption site in Saskatoon’s Pleasant Hill neighbourhood. 

As a rule, the group doesn’t require abstinence in order to access its services, which sets them apart from some other addiction services.

“When we force people or manipulate them to seek abstinence as a part of engaging in support services, we’re just creating a cycle for them of disappointment and a lot of difficulty ahead,” said DeMong.

Advocates say that harm reduction aims to meet people where they’re at. That can mean supporting someone to continue using drugs in a supervised way amid rising overdose-related deaths. 

Some support programs, like housing and employment services, require clients to completely give up drug use before accessing them.

Not only can that create barriers to getting care and assistance, DeMong says, it also perpetuates the idea that someone lacks value because they use drugs.

“In the long run, it [abstinence] limits their ability to engage in services and create community and build relationships with positive support,” she said.

Prairie Harm Reduction’s supervised injection site provides spaces for people to use different kinds of drugs in a safer setting, and a community centre that offers access to other support services. 

Harm reduction common in medicine

There are few areas in health care that require absolute abstinence or compliance to receive care. 

“Harm reduction is something we do in medicine all the time, because if we only are going to treat good patients, we don’t treat anybody,” said Eugenia Oviedo-Joekes, a University of British Columbia scientist and Canada Research Chair in person-centred addiction care.

She says that when it comes to other chronic illnesses, such as diabetes or heart disease, patients aren’t turned away if they refuse to give up sugar or visit the gym.

“It seems that in addiction, suddenly we have this high bar for people: If you don’t stop using drugs, I’m not going to treat you,” said Oviedo-Joekes.

Focusing solely on a person’s drug addiction can also ignore conditions that may be exacerbating drug use, like past and present trauma, housing and financial insecurity, and physical and mental health issues. 

Not requiring abstinence in order to access services “means that people can walk in somewhere and, right away, someone’s there to talk to them,” said Zoë Dodd, community scholar at the MAP Centre for Urban Health Solutions at Unity Health in Toronto.

“[Harm reduction] makes space for building relationships with people and actually getting to know them, which is, I think, the biggest part of harm reduction,” Dodd said.

From Global News

A rise in the circulation of highly potent fentanyl that is increasingly being mixed with other drugs is making Canada’s street drug supply so toxic and unpredictable, tools to prevent overdoses such as naloxone are not always fully effective, experts say.

The situation has become so volatile, front-line doctors and workers say they are left to guess at what mixture of substances a person in crisis may have been exposed to, which is why they say Canada needs to move faster on measures like safe supply and drug regulation to stop the sharp rise in opioid-related deaths in Canada.

---

Tara Gomes, a scientist at Unity Health Toronto and director of the Ontario Drug Policy Research Network, says the increasing unpredictability in the drug supply in Canada poses challenges for community-based programs that help people who use drugs, as they are not set up to handle the longer-term care that may be required to aid someone overdosing from opioids mixed with benzos.

“They’re able to administer naloxone, and the person might be OK … but they are not able to be roused and people within those programs have to help monitor that person might have to stay open later or make sure there are people around because this person might need a couple of hours before they’re fully aroused and can leave the program,” Gomes said.

From the Toronto Star

People who used a virtual-only medical service — a kind of virtual walk-in clinic — during the pandemic were more likely to later go to an emergency room than patients who did appointments with their own family doctor online, a study by Toronto researchers has shown.

The study published Thursday in the Journal of Medical Internet Research explores the different outcomes between two kinds of virtual medical care during the pandemic — that given by walk-in-style clinics and that given by family doctors.

Conducted by the University Health Network, ICES, Women’s College Hospital and Unity Health Toronto, the study found that the patients who saw a physician who was not their family doctor through a virtual-only medical service were twice as likely to visit an emergency department within 30 days.

The visits “can add to an already overwhelming strain” on emergency departments caused by staff shortages and the prevalence of viruses, says lead author Dr. Lauren Lapointe-Shaw, a general internist at Toronto General Hospital and an assistant professor at U of T.

“To add any potential demand related to these virtual appointments is suboptimal.”

Emergency departments in Ontario have been experiencing record-high wait times and some rural emergency departments have closed temporarily because of a lack of staff.

The study showed that patients who had a virtual-only walk-in appointment often had a virtual follow up and then ended up in emergency, in contrast to patients who had a virtual appointment with their family doctor and then could have an in-person follow up, possibly avoiding a hospital visit because they were able to have a physical exam.

From the CBC News article

An evolving mix of opioid cocktails and changing consumption habits mean governments must now respond more aggressively to the overdose crisis, experts say.

More than 32,000 Canadians have died of toxic drug overdoses since 2016, according to data released by Health Canada last month.

Over 3,500 people died of overdoses in the first half of 2022 (data is available only up to June). That’s almost 20 people per day, and more than half the number of people who died of overdoses during the first year of the pandemic.

The federal government has spent hundreds of millions of dollars to combat the crisis by funding community-led projects such as safe consumption sites and safe supply programs and improving access to naloxone, medication that can reverse the effects of an opioid overdose.

Fentanyl remains a driving factor in overdose deaths; Health Canada says that 76 per cent of all overdose deaths involve that opioid. But an increasing number of overdose deaths involve more than one substance.

Health Canada said just under half of the 3,556 overdose deaths that occurred in the first half of last year involved a stimulant such as cocaine or methamphetamine. At the same time, health services are increasingly warning of illicit opioids being contaminated with depressants such as benzodiazepine or “benzos.”

Tara Gomes of the Ontario Drug Policy Research Network said the two trends are likely linked.

“What we’re seeing more and more is benzodiazepines in the opioid supply. So they’re actually mixed in with the fentanyl,” she said.

That means the people who use these drugs aren’t necessarily aware that they’re taking benzo along with the opioid, she said.

But Gomes said some are intentionally using stimulants in an effort to counteract the sedative effects of an opioid and benzo cocktail.

“Oftentimes what they’re looking to do is counteract those effects, try and moderate the effects of the opioid so that they don’t get too sedated,” she said.

Benzodiazepines are dangerous when paired with an opioid like fentanyl because the added sedation increases the risk of an overdose, says Health Canada.

And the lifesaving medication naloxone does not work on benzos.

“It makes it more challenging for already burdened overdose prevention services,” Cheyenne Johnson, executive director of the British Columbia Centre on Substance Use, told CBC News.

Johnson also said a mix of opioids and benzos can also complicate substance use treatment by intensifying withdrawal symptoms. Such symptoms can include extreme anxiety, sweats and dangerous seizures.

“It makes it very complicated in terms of managing their cravings and withdrawals when there’s multiple types of potentially unknown substances like benzodiazepines” she said.

Fentanyl and benzodiazepines on their own can be used in clinical settings, but Johnson said substances never meant for human consumption are appearing in the illicit drug supply.

Xylazines, an animal sedative, and nitazenes — a synthetic opioid that is estimated to be several times more potent than fentanyl — are two such drugs, Johnson said.

“The sky is the limit on what is coming next,” she said.

Karen McDonald, head of Toronto’s Drug Checking Service, echoed Johnson’s point, saying that the illicit drug supply “is increasingly more contaminated, more toxic and less predictable.”

“[It’s a] recipe for disaster,” she said.

McDonald’s organization tests samples from the illicit drug supply to warn people who use drugs about what is being mixed in. But while the technology her organization uses is quite sophisticated, she said the illicit supply changes so fast that it feels like they’re “constantly playing catch-up.”

From The Globe and Mail article

Perhaps this year you’ve resolved to improve your health. You’re eating better. You’re exercising regularly. You’re staying hydrated, and prioritizing sleep. But have you also thought about what you can do to ensure your friends are healthy too? Your neighbours? Your surrounding environment and wildlife?

No doubt the measures you’re taking are good for you. But regardless of what any one of us does to keep fit and stay well, our risk of COVID-19 and other viruses depends heavily on how many people around us are infected and how close they are, and how much virus circulates in the air we breathe. Likewise, even assuming we have the ability and resources to do so, practising self-care can only protect us so much from countless other health threats, from environmental carcinogens to deadly heat waves to toxic work cultures that induce chronic stress and burnout.

There’s nothing like a global pandemic occurring amid a climate crisis to drive home the reality that our individual health depends not just on our own efforts, but on the health of our communities and ecosystem.

Yet the pandemic has demonstrated how difficult it is to shake the stubborn myth that we are masters of our own health. The phrase “we’re all in this together” quickly gave way to advice from public-health officers and politicians to “assess your own risk,” and consider using “individual public-health measures” as “a personal choice.”

The every-person-for-themselves approach to COVID-19 has driven deep social divides among people trying to protect themselves, either from infection or from a sense of threat to their freedoms. Behind all the debates about face masks, vaccines and the necessity for lockdowns and mandates lies a deeper, more fundamental question: Why should we protect or even care about the health and well-being of others (including those who don’t share our views)?

The reasons aren’t always obvious. But some doctors, researchers and academics say failing to do so could come back to bite us. If we continue to view health as an exclusively personal matter, one that does not require us to also act as stewards of our community and environmental health, it could be to our own detriment, leading to more illnesses, increased burden on our health care system, and greater social costs in the long run.

“It’s kind of a sad state of affairs that we would even ask that question,” said Lindsay McLaren, a professor in the department of community health sciences at the University of Calgary. “We are a collective and there’s no two ways about that.”

Toronto epidemiologist Dan Werb says thinking about vaccines as personal protection is a mistake.

“People regularly get vaccinated under the assumption that doing so will directly help them,” he wrote in his award-winning book, The Invisible Siege: The Rise of Coronaviruses and the Search for a Cure. “But vaccines aren’t meant to protect a person from disease – what they are meant to do is protect populations from epidemics.”

Certainly, individuals have died of COVID-19, even after being fully vaccinated. But at a population level, vaccines have prevented as many as 19.8 million deaths from COVID-19 worldwide, according to the estimates of a mathematical modelling study published in The Lancet Infectious Diseases journal in June. Even though vaccines have not reduced infections to the extent many had initially hoped, they have drastically slashed the proportion of people who require hospitalization and lowered the risk of long-COVID.

The difference between personal and population-level protection isn’t just semantics. Consider this, Dr. Werb suggested: Would you rather be the only vaccinated person in the world? Or would you rather have your entire social network, your co-workers, and everyone you encounter vaccinated, except you? (The same concept can be applied to masks, too. The benefit of wearing them is greatest when everyone wears them.)

By Jennifer Stranges, Unity Health Toronto

When Dr. Stephen Hwang joined Unity Health Toronto, he was drawn to the organization’s longstanding commitment to helping those most in need. All three of the network’s hospital sites were founded by the Sisters of St. Joseph, who were called to serve people who are disadvantaged.

“Unity Health has always been dedicated to serving people experiencing homelessness, and it’s always been an area we’ve sought to find innovative ways to provide better care,” he says.

Yet, as Hwang devoted his clinical care and research to caring for people living without permanent shelter, he noticed something else. Not only was the homeless population in Toronto growing in size, the needs of the population were growing as well. Living without shelter puts people at risk of many health challenges, but people who are homeless are also more likely to experience mental health problems and age-related decline. 

Today, caring for people who are unhoused remains a core part of the mission at Unity Health – a value that informs the basis of research, education, outreach and clinical care. The network has also continued to expand its services to meet patients and clients where they are, particularly in the areas of mental health and geriatric care. 

“Our services fill an important need for patients who often fall through the cracks,” says Hwang.

From the Toronto Star article

One of the most “morally upsetting” nights of Maggie Helwig’s life was earlier this winter.

There was a man at Toronto’s Church of Saint Stephen-in-the-Fields, near Bathurst and College Street where she’s the priest and runs a drop-in program, who was “obviously unwell” and “couldn’t even get his socks on properly.”

The shelters were full. The only thing she could do was walk him out to the encampment near the church, wake up some people there, and ask them to take him into their tent for the night.

“It was a very very cold night but the warming centre wasn’t open,” Helwig recalls.

That man this past November was welcomed into someone’s tent. But Helwig said another individual died in a tent over Christmas, when there was a cold alert and warming centres were open, but very busy. The person was not in an encampment community at the time. Their friends are trying to honour their wishes for privacy.

As Hamilton expands access to warming centres, following a public outcry over a Christmas gap in services, advocates are calling for Toronto to do the same, and highlighting that temperatures don’t need to be super cold for people to die on the streets.

As it stands now, warming centres are “generally activated” when an Extreme Cold Weather Alert (ECWA) is issued by Toronto Public Health — when the temperature is forecasted to be -15 C or colder, or -20 with the wind chill — said a city spokesperson in an email.

“There may also be instances when the city decides to open warming centres independent of ECWA “out of an abundance of caution due to colder nighttime temperatures and forecasted wind chill values. For example, warming centres were open and accessible from December 23 at 7 p.m. until noon on December 28,” the spokesperson added.

The city is “aware of unconfirmed reports of the death of a person experiencing homelessness on or about Christmas Eve,” they said.

“The cause of death of people experiencing homelessness, and discovered outside at any time of year, is determined by the Office of the Chief Coroner of Ontario and only communicated to the next of kin.”

“Toronto used to do a lot more,” said Helwig of warming centres.

“Before the pandemic there actually was a whole network of warming centres all over the city.”

Now there are just three, all walk-ins, and they were “very crowded” over Christmas when they were open during the extreme cold temperatures.

Some of them closed because of the pandemic, some have become part of the 24 hour respite system, but what’s needed is a “low barrier flexible winter space,” she said.

“The need is just growing, and growing in every area all the time.”

The city of Hamilton announced on Wednesday expanded warming centre hours until the end of March, following public pressure.

Dr. Stephen Hwang, director of MAP Centre for Urban Health Solutions, said his team conducted a study in 2019 that showed about 70 per cent of injuries due to cold happen when the weather is warmer than -15 C.

“I don’t believe there’s evidence to support -15 as being the correct threshold. I suspect that it’s driven more by resource constraints than by anything else,” he said in an interview with the Star. There’s a need for shelter beds. But “on nights where it’s cold, there should be enough warming centres available that people can at least get out of the cold,” he added.

From The Globe and Mail article

Allan Carpenter shuffles into the doctor’s office and gets down to business.

The 65-year-old patient and his long-time physician, Gordon Arbess, have plenty to talk about, even though they see each other for a check-up every second week.

Mr. Carpenter’s back and hip are so sore he worries he’ll end up in a wheelchair. He is anxious about getting to all his medical appointments, including a coming visit with an orthopedic specialist. He’s had HIV since the late 1980s, and he recently beat throat cancer.

“We do have a team of people that are trying to help you,” Dr. Arbess says, soothing his patient’s nerves, “and I know how much you’ve gotten out of it. But I know some days it’s difficult for you to get to these appointments. I get it. I hear you.”

For Canadians without a family doctor, the thought of having a physician guide – a “captain of my ship,” as Mr. Carpenter calls Dr. Arbess – is appealing in itself. But Mr. Carpenter is fortunate to have more than a captain. He has a whole crew.

His clinic east of downtown Toronto is part of the St. Michael’s Hospital Academic Family Health Team, a five-site organization with more than 200 staff, including nurses, dietitians, pharmacists and social workers, as well as clerical staff to support about 80 doctors and 36 medical residents.

This model, which Ontario calls the Family Health Team, is widely considered by health-system experts to be the best way to deliver primary care, especially for patients like Mr. Carpenter with multiple complex medical conditions. Family doctors also favour the team approach because it helps them stave off burnout by sharing the workload. The Canadian Medical Association has named “expanding team-based care” as one of its top recommendations for solving the country’s health care crisis.

Despite that, Ontario hasn’t opened a new Family Health Team in a decade, in part because of the cost.

---

Ontario began overhauling its primary-care system in the early 2000s. The new models paid family doctors working in groups mostly for the number of patients they enrolled in their practice, a departure from the traditional fee-for-service approach where doctors are paid for every discrete episode of care they deliver.

The alternative models blended capitation payments – which are annual payments to doctors for every patient on their roster – and fee-for-service to different degrees. The approach was supposed to encourage long-term relationships with patients and give physicians time to deliver comprehensive care to older, sicker patients who might have four or five health concerns to discuss at a single visit.

Doctors had to join one of the new payment models, the most popular of which is called a Family Health Organization, or FHO, if they wanted to be a part of a Family Health Team, or FHT. What set the FHTs apart was that the provincial government paid the salaries of the dietitians, pharmacists, social workers and other health professionals who rounded out the team.

There are currently 181 Family Health Teams in Ontario, the last of which opened in 2012.

In many ways, the reforms succeeded. Doctors flocked to the new patient enrolment models, leading to a 43-per-cent increase between 2006-07 and 2015-16 in the number of Ontarians who said they had a family doctor.

Patient care improved, too, said Tara Kiran, a University of Toronto primary-care researcher and physician at the Family Health Team where Allan Carpenter is a patient. She and her research colleagues found that FHT patients received better diabetes monitoring and visited the emergency department less often than patients at non-team practices, although emergency-department use increased for both groups over time.