Interview by Marlene Leung, Unity Health Toronto with Dr. Nav Persaud

Dr. Alexander Augusta was a Black physician who studied medicine in Toronto in the mid-1800s after being refused admission to medical schools in the United States because of racism. Although he completed his medical training in Canada and practiced for a brief period in Toronto, he returned to America to fight for the Union in the Civil War, becoming the first African-American surgeon in the Union army. He went on to hold many distinguished and groundbreaking positions as a medical educator in the States, and, with full military honours, was buried at Arlington National Cemetery.

Dr. Nav Persaud, family physician at Unity Health Toronto and Canada Research Chair in Health Justice, recently co-authored a new paper about the remarkable life and career of Dr. Augusta. We spoke with Dr. Persaud about his interest in researching Augusta’s life in Canada and what his story can teach us about racism and the disparities that exist today in Canadian medicine.

Q: What initially sparked your interest in researching Dr. Alexander Augusta?  

Dr. Persaud: It started when I was thinking about how the history of medicine is pretty homogenous and focuses largely on the accomplishments of white men. I wondered if there were other important stories out there that had been overlooked, and that’s when I came across a book by Dr. Heather Butts (who co-authored the paper) that looked at healthcare in the U.S. during the Civil War era. That’s where I learned about Dr. Augusta.

Most of what’s written about him focuses on his time in America. Augusta’s remarkable time in Canada hadn’t been carefully examined, so that’s why we chose to focus on his decade here.

Q: This paper was published in the Canadian Medical Education Journal, why do you feel Augusta’s story is important for medical and healthcare students to know?

Dr. Persaud: Augusta’s experience here in Canada can help us understand the disparities that exist today in Canadian medicine. Even today, medical schools don’t represent the populations that they serve, and if you want to understand why, part of that means going back to Augusta’s time.

Augusta had some pretty good reasons to stay in Canada, he was barred from getting into U.S. medical schools, and people were still being enslaved in the U.S. But he decided to go back to the States and put his life at risk fighting for the Union, rather than staying in Canada. Fighting against the Confederates in the Civil War was obviously very important to him, but things weren’t easy for him here.

During his brief time here, Augusta spoke out against racism and discrimination in Canada. When there was a proposal to create a segregated colony for Black people on Ontario’s Manitoulin Island, he advocated against it, drawing parallels to the American south. He also was president of the Association for the Education of Coloured People in Canada, a group that helped ensure Black children had the necessary supplies and supports to succeed at school. It appears he never worked at a large hospital in Toronto, but after the Civil War he headed a hospital in the United States.

His story counters the very simplistic narrative of America being bad, and Canada being good. Sometimes there is this idea of Canadian exceptionalism in comparison to America, and people assume that racism wasn’t a problem in Canada and isn’t a problem today. Augusta’s life shows that it’s a much-more nuanced story than that. Obviously there was a good reason for him to come here, and racism in America was a big part of that. But there was also good reasons for him to leave Canada, and racism was one of them.

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From Unity Health Toronto

A study of emergency department (ED) visits for drug overdoses in Ontario during the COVID-19 pandemic reveals that overdoses were disproportionately higher among people experiencing homelessness.

The findings, published in Addiction, show that in Ontario from June to September 2020, when the province was reopening after wave 1 lockdown measures, weekly rates of ED visits for drug overdoses more than doubled among homeless individuals compared to the same time the year prior. Increases of this magnitude were not observed among the stably housed or those living in low-income neighborhoods.

The study shows that the impacts of the pandemic have disproportionately harmed individuals experiencing homelessness, and suggests that greater supports are needed to address the intersection of homelessness and drug use.

“These findings confirm one shameful truism of this pandemic – that vulnerable populations have been time and time again disproportionately impacted by the COVID-19 pandemic,” said Michael Liu, lead author of the study, a research coordinator at St. Michael’s MAP Centre for Urban Health Solutions, and visiting scholar at ICES.

“This is a population that already contends with immeasurable difficulties, and we have failed to protect them during the pandemic. There are clear policies and interventions that need to be put in place to support and protect the most vulnerable within our cities and neighborhoods,” said Mr. Liu, who is also a medical student at Harvard University and a Rhodes Scholar.

Researchers at St. Michael’s Hospital of Unity Health Toronto used data from ICES, the not-for-profit research institute, to categorize over 15.2 million Ontarians into three groups based on their housing status: individuals with a recent history of homelessness, all housed individuals, and individuals living in low-income neighborhoods.

To understand how the pandemic impacted overdoses for the people within these groups, researchers retrospectively analyzed ED data during three stages: pre-pandemic (January 5 to March 16, 2020), peak (March 17 to June 16, 2020), and re-opening periods (June 17 to September 26, 2020). The researchers used corresponding weeks in 2019 as a benchmark to measure against. They found:

• There was an overall increase in ED visits for overdoses among all three housing groups from 2019 to 2020.
• The increase was most pronounced in individuals with a recent history of homelessness. There was a 56 percent increase in ED visits for overdoses during the re-opening period of 2020 compared to the same weeks in 2019.
• Looking just at 2020, rates of ED visits per 100,000 people for drug overdoses among recently homeless individuals were 148 times higher than that of all housed individuals and 22 times higher than that of low-income housed individuals.
• ED visits for drug overdoses decreased across all groups by approximately 20 percent during the peak period compared with corresponding weeks in 2019.

“Our study shows the enormous toll that drug overdoses have taken on people experiencing homelessness during the pandemic,” said Dr. Stephen Hwang, senior author of the study and Director of MAP Centre for Urban Health Solutions at St. Michael’s Hospital.

“We need to act right now to prevent overdoses, which all too often end up causing tragic and preventable deaths,” said Dr. Hwang, who is also an internal medicine physician and Chair in Homelessness, Housing and Health at St. Michael’s Hospital.

The authors are calling for urgent public health and policy interventions to reduce the burden of drug overdoses and substance-related problems in this population, including greater access to supervised consumption facilities, fentanyl testing strips, naloxone, low-barrier opioid agonist therapies, and tailored office-based addiction treatments. The authors say the services need to be brought directly to people experiencing homelessness through mobile street teams, community-based agencies, and shelter services.

“Difficulties with substance use and homelessness are inextricably linked. Stable housing is necessary – although not sufficient – to address the unacceptably high rates of morbidity and mortality in the homeless population,” said Mr. Liu.

Les visites aux urgences dues à des surdoses de drogue sont disproportionnellement plus nombreuses dans la population des personnes sans-abri en période de pandémie : étude

Par Unity Health Toronto

Une étude portant sur les visites dans les salles d’urgence causées par des surdoses de drogues en Ontario pendant la pandémie de COVID-19 révèle que les surdoses étaient proportionnellement beaucoup plus nombreuses chez les populations de personnes sans-abri.

Les conclusions, publiées dans la revue Addiction, révèlent qu’en Ontario, de juin à septembre 2020, au moment où la province se déconfinait après la première vague de mesures de confinement, les taux hebdomadaires de visites aux urgences en raison de surdoses de drogues ont plus que doublé chez les sans-abris par rapport à la même période l’année précédente. Des augmentations de cette ampleur n’ont pas été observées chez les personnes ayant un logement stable ou vivant dans des quartiers à faibles revenus.

L’étude révèle que les répercussions de la pandémie ont nui de manière disproportionnée aux personnes sans domicile fixe et elle indique que des mesures de soutien plus importantes sont nécessaires pour faire face aux conséquences de la réciprocité entre les personnes sans domicile fixe et la consommation de drogues.

« Ces résultats confirment un triste cliché de cette pandémie, à savoir que les populations vulnérables ont été à maintes reprises touchées de manière disproportionnée par la pandémie de COVID-19 », a déclaré Michael Liu, auteur principal de l’étude, coordonnateur de recherche au Centre MAP pour des solutions de santé urbaine de l’hôpital St. Michael et chercheur invité à l’ICES.

« Il s’agit d’une population qui doit déjà faire face à des difficultés incommensurables, et nous n’avons pas su la protéger pendant la pandémie. Il existe des politiques et des interventions concrètes qui doivent être mises en place pour soutenir et protéger les plus vulnérables dans nos villes et nos quartiers » a déclaré M. Liu, également étudiant en médecine à l’Université de Harvard et boursier Rhodes.

From the Toronto Star article

Toronto’s supervised drug consumption sites are seeing a record number of overdoses, while the city’s paramedics responded to more fatal overdoses in 2021 than any other recorded year — all signs that experts say point to a worsening opioid crisis both in Ontario and elsewhere.

The toll comes as front-line staff struggle with burnout and grief while navigating the unpredictability of COVID-19 and the latest Omicron wave. And a lack of swift action on the part of policy-makers to reduce opioid-related harms, some critics say, has exacerbated an already dire situation.

“The drug poisoning crisis is not getting better,” said Shaun Hopkins, manager of The Works, a supervised consumption site run by the city of Toronto. “We’re continuing to see records being set in terms of paramedic calls, deaths, overdose numbers.”

The Works saw a record 165 overdoses in December, accounting for 8.8 per cent of all visits to the site that month. It is a marked increase from December 2019, where the rate of overdoses hovered around 1.4 per cent. In January 2022, the rate of overdoses remained high at 5.6 per cent.

Paramedics in Toronto also saw a record number of opioid deaths in 2021, responding to a total of 357 fatal suspected overdose calls. In 2020, paramedics responded to 268 fatal calls. Because paramedics aren’t involved in every opioid fatality, the numbers for opioid-related deaths in 2021 may be higher, said Gillian Kolla, a post-doctoral fellow at St. Michael’s Hospital with expertise in drug policy.

Due to a data lag in Ontario, preliminary numbers of opioid-related fatalities for 2021 are only available up until June, but they hover at 1,415 deaths. In all of 2020, the province saw 2,431 deaths. British Columbia, which released its 2021 data on Monday, saw its deadliest year yet for opioid-related deaths, with 2,224 fatalities.

Op-ed by Dr. Tara Kiran published on Healthy Debate

Every day, thousands of Canadians are infected with COVID. But this isn’t March 2020. As a result of high rates of vaccination and the particulars of Omicron, the overwhelming majority of those getting COVID currently will not need hospital care. What Canadians do need to be able to ride out this wave is information, support at home and timely access to primary care.

And what primary care teams need is reliable resources to help guide us through the ever-changing thicket of research, public health guidance and tools for prevention and treatment. We need to support most people to manage on their own while also identifying and helping people who need timely interventions to keep them from becoming seriously sick.

On the ground and at the front line, it seems that information – our most valuable asset in the Omicron wave – isn’t getting through clearly.

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February 1, 2022 – As children in provinces across Canada settle back into in-person school, new research highlights how important it is to focus on helping kids recover healthy habits – particularly related to diet, physical activity, mental health and screen time.

“Our kids have now spent many months total in lockdown,” said Dr. Katerina Maximova, scientist at MAP Centre for Urban Health Solutions, St. Michael’s Hospital. “Now that many are back in school, the negative effects won’t just disappear. There’s a lot to recover from.”

Maximova gathered in-depth information on students’ lived experiences of COVID-19-related lockdowns, and how they affected kids’ mental health and lifestyle behaviours. Her research found that school closures prompted deteriorating lifestyle behaviours, mental health, and well-being of children. Disruptions led to feelings of boredom and lack of purpose, and limited opportunities for social interaction led to loneliness and an increase in screen time. Unchecked, these changes could mean an increased risk of chronic disease and mental illness in adulthood.

Concerningly, the negative effects were more pronounced for kids in socioeconomically disadvantaged settings.

“Pre-COVID, kids with lower socioeconomic status were already at higher long-term risk of chronic disease, including mental illness,” said Maximova. “However these findings indicate that this generation could be facing an extraordinary burden.”

The study is among the first COVID-19 research based on young kids’ first-hand reports and experience (other research is based mainly on parent views).

The findings underscore the crucial need for investments into evidence-based programs to promote health and wellness for all kids, particularly in schools in disadvantaged neighbourhoods. The APPLE Schools initiative, designed by Maximova and colleagues at the University of Alberta, is one such school-based innovation that has helped thousands of kids improve some of the health behaviours explored in this study. It impacts the lives of 21,000 students annually in 74 schools across British Columbia, northern Alberta, Northwest Territories, and Manitoba, with plans to expand to Ontario.

Read the research:

• Perceived changes in lifestyle behaviours and in mental health and wellbeing of elementary school children during the first COVID-19 lockdown in Canada (view the complimentary infographic)
• Related: “It’s very stressful for children”: Elementary school-aged children’s psychological wellbeing during COVID-19 in Canada

Aider les enfants à se rétablir après les confinements : l’importance de saines habitudes

Le 1^er février 2022 – Alors que les enfants des provinces canadiennes reprennent le chemin de l’école, une nouvelle étude souligne l’importance de les aider à retrouver de saines habitudes, notamment en ce qui concerne l’alimentation, l’activité physique, la santé mentale et le temps passé devant les écrans.

« Nos enfants ont passé de nombreux mois en confinement total », a déclaré la Dre Katerina Maximova, scientifique au MAP. « Même si de nombreux élèves sont de retour à l’école, les effets négatifs ne vont pas disparaître. Il leur faudra du temps pour s’en remettre. »

La Dre Maximova a recueilli des informations approfondies sur les expériences vécues par les élèves lors des confinements liés à la COVID-19, et sur la manière dont ils ont nui à la santé mentale et aux habitudes de vie des jeunes. Ses recherches ont révélé que les fermetures d’écoles ont entraîné une détérioration des habitudes de vie, de la santé mentale et du bien-être des enfants. Les perturbations ont suscité des sentiments d’ennui et de vide; les possibilités limitées d’interaction sociale ont conduit à la solitude et à une augmentation du temps passé devant les écrans. Si on les ignore, ces changements pourraient entraîner un risque accru de maladies chroniques et de troubles mentaux à l’âge adulte.

Il est inquiétant de constater que les effets négatifs étaient plus prononcés chez les enfants issus de milieux socio-économiques défavorisés.

« Avant l’arrivée de la COVID-19, les enfants ayant un statut socio-économique faible présentaient déjà un risque plus élevé de maladies chroniques à long terme, y compris de maladies mentales », a déclaré madame Maximova. « Ces résultats suggèrent que cette génération pourrait être confrontée à un très lourd fardeau. »

L’étude est l’une des premières recherches en temps de COVID-19 basées sur les témoignages et l’expérience des jeunes enfants (les autres recherches sont principalement basées sur les points de vue des parents).

Ses conclusions soulignent le besoin crucial d’investir dans des programmes fondés sur des données probantes pour promouvoir la santé et le bien-être de tous les enfants, en particulier dans les écoles des quartiers défavorisés. L’initiative APPLE Schools, conçue par la Dre Maximova et ses collègues de l’Université de l’Alberta, est un exemple de ce type d’innovation scolaire qui a aidé des milliers d’enfants à améliorer certains des comportements de santé examinés dans cette étude. L’initiative a une incidence sur la vie de 21 000 élèves chaque année dans 74 écoles de la Colombie-Britannique, du nord de l’Alberta, des Territoires du Nord-Ouest et du Manitoba, et bientôt de l’Ontario.

Lisez l’étude scientifique (en anglais) :

• Perceived changes in lifestyle behaviours and in mental health and wellbeing of elementary school children during the first COVID-19 lockdown in Canada (regardez l’illustration informative)
• Document associé : « It’s very stressful for children » : Elementary school-aged children’s psychological wellbeing during COVID-19 in Canada

From the Toronto Star article

Physicians and outreach workers at St. Michael’s Hospital are seeing an alarming rise in the number of homeless individuals coming to the emergency department seeking shelter and suffering from severe cold-related injuries, including frostbite, painful foot infections and life-threatening hypothermia.

Hospital staff say the crisis has escalated in the last two weeks due to a critical lack of space in the city’s shelter system, hit hard by the Omicron variant.

At St. Michael’s Hospital’s emergency department, about 20 per cent of its patient visits are by patients experiencing homelessness, said Dr. Carolyn Snider, chief of emergency medicine at the hospital, a part of Unity Health Toronto. And while the ER does see an increase in the number of underhoused individuals seeking care in the winter, the recent spike caused by Omicron hitting the shelter system alongside frigid temperatures is different, she said.

“We’re seeing more patients. They’re staying longer because there is nowhere else to send them. And they’re coming in sicker, with more cold-related injuries.”

Hospital staff are seeing cases of “trench foot” in underhoused patients. The serious condition is caused when feet are cold and wet for too long. “Their socks are wet, their feet have been in the cold and snow, and their skin is macerated from that,” Snider said, adding that if left untreated patients can get serious infections.

Dr. Stephen Hwang, director of the MAP Centre for Urban Health Solutions, said the recent experiences of St. Mike’s staff offer a window into what is happening in the shelter system and points to the immediate need for more warming centres and more shelter beds.

He noted that some city shelters experiencing a COVID outbreak are directed to not accept new clients for public health reasons, a decision that may be causing additional harm. According to SSHA, some locations can continue accepting clients with appropriate protections and under guidance from Toronto Public Health. And while in some cases shelters may need to close for a short time, “all efforts are being dedicated to ensure access to safe indoor spaces for people in need,” SSHA said.

Hwang, a physician at the hospital and a researcher who studies homelessness and health, said given the current shelter pressures and extreme cold, he hoped city staff would see the importance of offering a person shelter from the cold. “The need for more shelter beds right now in the city, we are seeing it from a health-care perspective. But we know people in the community are seeing it every day as well. We are all very concerned.”

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From Global News Radio

Hayley Thompson, project manager of Toronto’s Drug Checking Service (launched by MAP’s Centre for Drug Policy Evaluation) explains how the free service works by analyzing unregulated drug samples, and why it’s important in the absence of a regulated drug supply.

Listen to the full interview here

Pourquoi les services de contrôle des substances sont essentiels dans le cadre de la crise des opioïdes

De Global News Radio

Hayley Thompson, gestionnaire de projet du Drug Checking Service de Toronto (lancé par le Centre for Drug Policy Evaluation du MAP) explique comment fonctionne ce service gratuit qui analyse des échantillons de drogues non réglementées, et pourquoi il est important en l’absence d’un système réglementé d’approvisionnement de drogues.

Lire cet article en français

From CP24 News

Amid a bitter cold spell, MAP Director Dr. Stephen Hwang speaks with CP24 about the lack of shelter beds in the city and a ‘housing first’ approach to end homelessness.

Watch the full interview here

Les personnes en situation d’itinérance ont besoin d’aide

De CP24 News

En pleine vague de froid, le directeur du MAP, le Dr Stephen Hwang, s’entretient avec CP24 du manque de lits d’hébergement dans la ville et de l’approche du « logement d’abord » pour mettre fin à l’itinérance.

January 25, 2022 – A new report captures and explores people’s experience of overdose – what happened, where, and how others responded to help. Based on surveys with almost 250 people as well as in-depth interviews with 17 people who inject drugs, the report highlights how unwelcoming Ontario’s health-care system can be for people who use drugs.

Of the people interviewed, most who went to hospital after an overdose reported negative experiences with health-care providers, including experiences of stigma and discrimination from hospital staff. Only one person received medication to manage their withdrawal symptoms. Nobody was offered Opioid Agonist Therapy (medications to reduce cravings for opioids) or a referral to a substance-use treatment program.

“It is critical that people who have experienced an opioid overdose are offered supports and treatment for opioid withdrawal in the emergency department, when admitted to hospital, or when leaving detox,” said co-author Dr. Ahmed Bayoumi, a scientist at MAP Centre for Urban Health Solutions and physician at St. Michael’s Hospital. “Our results indicate gaps in these practices in Toronto, and that’s unacceptable.”

The study’s survey recruited 249 people who inject drugs from four Toronto harm-reduction programs. It found that most people who inject drugs have experienced more than one overdose in their lifetime, likely due to the high frequency of fentanyl use in the context of an unregulated, toxic drug supply. Concerningly, almost one-third of people surveyed had experienced two or more overdoses in the six months before completing the survey.

“It is very common for people to experience multiple overdoses due to the toxicity and unpredictability of the drug supply,” said Sarah Greig, manager of the Moss Park Consumption and Treatment Service and one of the report co-authors. “We need new options for people – like safer supply and buyer’s clubs – while also improving the care people are receiving in the health care system.”

The overdoses often occurred when people were alone at their own home, with someone else at home, or at a friend’s home. Most people who overdosed were given naloxone, often by a friend. People who overdosed described receiving help from a friend, family members, strangers, or harm reduction workers if they overdosed in an supervised consumption site.

Only about one-third remember paramedics being called after an overdose.

“We have a lot of research to show that due to criminalization and negative past experiences with police and health care providers, people will often only call paramedics as a last resort,” said co-author and MAP postdoctoral fellow Dr. Gillian Kolla. “Decriminalization of drug use is one measure that may help.”

The authors say that Canada must move quickly to implement more and better harm reduction and treatment options, and to integrate them into housing and shelter programs. Responses must also focus on measures to prevent overdoses from occurring in the first place, through safer supply programs, compassion or buyer’s club models, and the introduction of a regulated drug supply. Additionally, decriminalization and legalization (beyond safer opioid supply programs) need to be at the forefront of dialogue on interventions to address the crisis of drug poisonings, due to the documented harms from criminalization on people who use drugs.

The report authors also note a link between people who overdosed two or more times and the experience of multiple forms of oppression, related to the history and continuing experiences of colonialism in Canada, anti-Black racism, and experiences of homelessness. Culturally safe supports are urgently needed for racialized and Indigenous people who inject drugs.

The report is the second release from the Impacts of Overdose study, co-led by Bayoumi, Kolla, and Dr. Kathleen Kenny of the University of Manitoba. The first report focused on impacts of overdose on front-line harm reduction workers.

From the CTV News Toronto article

Half of Ontarians who died of an opioid overdose in the early stages of the pandemic had interacted with the health-care system in the month before their deaths, a new report shows.

And one in four had seen a doctor, gone to an emergency department or been discharged from hospital just a week prior, the research shows.

“That represents such an important missed opportunity for us to make sure that our health-care system is serving the needs of people who use drugs and helping connect them to the services that they need to help prevent these fatal overdoses,” said Dr. Tara Gomes, an epidemiologist with Unity Health and investigator with the Ontario Drug Policy Research Network who co-authored the study.

The report, titled “Patterns of Medication and Healthcare Use among People who Died of an Opioid-Related Toxicity during the COVID-19 Pandemic in Ontario,” was released Tuesday by Unity Health and the Ontario Drug Policy Research Network. Public Health Ontario, the chief coroner’s office and ICES, the non-profit health research organization, contributed to the report.

The authors are calling for a safer drug supply, expanded access to low-barrier treatment in health-care settings, affordable, supportive housing as well as more harm-reduction services and supervised consumption sites, especially outside cities.