Author: Samira Prasad

Op-ed in the Toronto Star, Hamilton Spectator by Dr. Nav Persaud and Dr. Stephen Hwang

As malls and coffee shops reopened after a long COVID winter, the doors have remained locked on an institution that keeps people housed: Ontario’s Landlord and Tenant Board.

The board has not returned to in-person hearings. Tenants trying to stave off eviction no longer have access to supports that were available in person, or even the reliability of being able to make their case in person.

Imagine calling into a hearing to decide whether you will be able to keep your apartment, and then getting disconnected. The stakes are extremely high for tenants appearing before the board — decisions can mean the difference between sleeping in your own bed, and scanning a list of emergency shelters to find out which ones take kids. Landlords may be seeking to secure their incomes, but they are not at risk of being on the street when a hearing concludes.

Virtual attendance can tilt hearings toward landlords. Tenants often have poorer access to high-speed internet connections and thus join by phone, especially when they need to be logged on for hours waiting for their hearing. In contrast, landlords are able to see and be seen by board staff and members. Prior to COVID, tenants were supported by board staff when they arrived at hearings, and had access to duty counsel or lawyers on site who provided timely advice and support. Tenants could easily submit pictures of mouldy or poorly maintained basements to support their claims.

Attention: Sean Weir, Executive Chair, Tribunals Ontario

April 6, 2022

Dear Executive Chair Sean Weir,

We are writing to draw your attention to the urgent need to offer the option of in-person hearings at Ontario’s Landlord and Tenant Board (LTB). Indoor settings are now open across Ontario. This includes public buildings such as libraries, community centres, universities and government offices. It also includes private sector venues such as gyms, restaurants and sports stadiums.

We are an interdisciplinary team of epidemiologists; public health specialists; primary care providers and internal medicine and family physicians. We work at or collaborate with the MAP Centre for Urban Health Solutions at St. Michael’s Hospital in Toronto, but we have affiliations and practices in a variety of settings. 

Together, we have expertise in: COVID-19 treatment and vaccination; tracking or modeling infectious disease outbreaks; housing and homelessness; and working to ensure a wide variety of environments are as safe as possible from COVID-19.

Many of us have seen the devastating effect of remote hearings for our patients. And, as a group, we want Tribunals Ontario to know that it is entirely possible to open in-person hearing spaces that meet or exceed the COVID-19 safety standards applied to the types of venues listed above.

We know the LTB used both dedicated hearing spaces in large cities and temporary venues such as church halls or hotels in smaller jurisdictions. Simple and often cost-effective measures can ensure these sites meet or exceed the COVID-19 safety standards in place across the province.

These measures are well-known and implementation is straightforward. In addition, in many public venues, they should already be in place. These measures include: the provision of well-fitted, high-quality masks; physical distancing; limiting occupancy (including in waiting areas); limiting wait times; use of portable air filters appropriate for room size; opening windows where possible; optimizing ventilation and filtration provided by HVAC systems; use of well-maintained bathroom fans that exhaust to the outside; and, hand hygiene measures. For people with cell phones, they could also be given the option to wait outside for a call until their hearing begins.

The problems with an exclusively digital approach are well known. More than a year ago, in October, 2020, legal clinics across Ontario released a report to your attention and to the Attorney General, “Ontario legal clinics’ concerns: Landlord and Tenant Board’s operations during the COVID-19 pandemic.” This report demonstrates the advantage that remote hearings often give to landlords over tenants. For example, some tenants do not have access to the necessary technology and resources such as “computers, printers, internet, phone minutes, or even a private space from which to participate in remote hearings.”

In addition, remote hearings have meant a reduction in supports for tenants, such as those provided by onsite staff such as LTB staff mediators, Legal Aid Ontario-funded tenant duty counsel, and LTB counter staff.  Although these resources remain present in the digital format, their ability to help is reduced and in some specific hearing blocks they are simply unavailable. Finally, some tenants with disabilities (visual, auditory, cognitive impairments, etc.) have difficulty participating in remote hearings as they are presently configured by the LTB.

These are just a few examples. A recent report explores tenant experiences in remote hearings from March to May 2021, and details a range of hardships caused by the current format. We encourage you to read it carefully, and consider the consequences of the current situation for people’s lives. As the report makes clear, “…a tenant’s inability to participate in a hearing has potentially dire consequences – the loss of their home.”

The stakes are high for tenants at the LTB. Losing housing can directly harm health, for example, by making it difficult for people to take medications and manage diabetes. Stressors such as being evicted can directly impact mental health. Unstable housing can also make it difficult for under-housed individuals to engage in health and mental health supports.

The importance of secure housing to health and mental health outcomes is well-supported by scientific evidence. A recent study in the Canadian Medical Association Journal explores policies with the greatest capacity to improve health in the wake of the COVID-19 pandemic. Eviction prevention is one of the measures at the top of the list. Ending tenancies that might otherwise be preserved will, simply put, make people sick.

It is time to ensure that in-person hearings are made available for Ontario tenants. At many sites, this can be done very quickly. To assist, we are providing our contact information to Tribunals Ontario.

As Ontario continues to re-open in the weeks to come, we look forward to seeing the reopening of in-person LTB hearings as well. We are prepared to offer our expertise and experience to assist with this, and hope you will contact us to that end.

Sincerely,

Dr. Stephen Hwang, Staff Physician, General Internal Medicine, St. Michael’s Hospital
Research Scientist and Director, MAP Centre for Urban Health Solutions
Professor of Medicine, University of Toronto
Chair in Homelessness, Housing and Health, University of Toronto and St. Michael’s Hospital

Dr. Nav Persaud, Canada Research Chair in Health Justice
Associate Professor, University of Toronto
Staff Physician, St. Michael’s Hospital
Research Scientist, MAP Centre for Urban Health Solutions

Dr. Sean B. Rourke, Scientist, MAP Centre for Urban Health Solutions
Director, CIHR Centre for REACH Nexus
Professor of Psychiatry, University of Toronto

Dan Werb, PhD, Director, Centre on Drug Policy Evaluation
Assistant Professor, Division of Infectious Diseases & Global Public Health, UC San Diego
Scientist, MAP Centre for Urban Health Solutions

Naomi Thulien, NP-PHC, PhD, Research Scientist, MAP Centre for Urban Health Solutions
Assistant Professor, Dalla Lana School of Public Health, University of Toronto
Nurse Practitioner, Covenant House Toronto

Rosane Nisenbaum, Biostatistician, MAP Centre for Urban Health Solutions
Division of Biostatistics, Dalla Lana School of Public Health

Dr. Andrew Pinto, CIHR Applied Public Health Chair in Upstream Prevention
Director, Upstream Lab
Research Scientist, MAP Centre for Urban Health Solutions
Associate Professor, University of Toronto
Staff Physician, St. Michael’s Hospital

Dr. Ahmed Bayoumi, Staff Physician, General Internal Medicine, St. Michael’s Hospital
Professor of Medicine and Health Policy, Management and Evaluation, University of Toronto
Research Scientist, MAP Centre for Urban Health Solutions
Fondation Baxter and Alma Ricard Chair in Inner City Health, University of Toronto and
St. Michael’s Hospital

Patricia O’Campo, PhD, Executive Director, Li Ka Shing Knowledge Institute, Unity Health Toronto
Research Scientist, MAP Centre for Urban Health Solutions
Tier 1 Canada Research Chair, Population Health Interventions
Professor, Dalla Lana School of Public Health, University of Toronto

Dr. Rami Shoucri, Family Physician, St. Michael’s Hospital Academic Family Health Team
Assistant Professor, University of Toronto, Department of Family and Community Medicine
Clinical Champion, Health Justice Program

Dr. Danyaal Raza, Family Physician, St. Michael’s Hospital Academic Family Health Team
Social Accountability Faculty Lead & Assistant Professor, University of Toronto, Department of Family and Community Medicine

Dr. Kathryn Dorman, Family Physician, Addictions Medicine Program, St. Michael’s Hospital Academic Family Health Team
Assistant Professor, University of Toronto, Department of Family and Community Medicine

From the CBC News article

While the federal Liberals have pledged to make progress toward a national pharmacare program through a recent deal with the NDP, health care advocates warn those efforts are moving too slowly — putting people’s health at risk and taking a financial toll on Canada’s hospital system.

The government recently announced a “supply-and-confidence” agreement that could see the Liberals stay in power until 2025 in exchange for action on several NDP priorities, including dental care and pharmacare programs.

But there’s little to suggest drug access will be a major focus in the latest federal budget expected on Thursday.

The Liberals intend to pass a Canada Pharmacare Act by the end of 2023, then task the National Drug Agency with developing a national formulary of essential medicines and a bulk purchasing plan by the end of their agreement with the NDP.

It’s “concerning” that such an open-ended timeline means building a national pharmacare program likely won’t happen until the next election cycle, said Dr. Nav Persaud, Canada research chair in health justice and a staff physician at St. Michael’s Hospital in Toronto.

“Multiple reports have detailed how including medicines in our publicly funded system would improve access, improve health, reduce the need for hospitalizations, emergency room visits, and also save billions of dollars both through direct savings, through lowering prices and through the need for health care,” he said.

“But much more important than that saved money would be the improved health, and avoided death.”

From the Toronto Star article

The days of the two-shot COVID vaccine regime appear all but over, with countries such as Israel and now the United States opening up widespread access to not just a third shot to bolster waning protection against infection, but a fourth. It’s left some experts wondering whether Canada, which worked hard to get those first two shots into arms, is now falling behind in the push to vaccinate its citizens.

The American Food and Drug Administration this week approved a fourth shot for people 50 and older in the U.S. While at least Pfizer says it has begun conversations with Health Canada, the regulatory body has yet to see an official application for that cohort to get a fourth dose from anyone.

Meanwhile, a sub-variant of highly infectious Omicron has upended what we knew about the virus — again — meaning that, at least for high-risk people, vaccination is looking less like a milestone to be achieved, and more like a process to be maintained.

That’s a message that may not yet have widespread acceptance in Canada, where 85 per cent of people have two doses but just under half have rolled up their sleeves for a third.

“I think people feel like they did their part,” says Dr. Tara Kiran, a family doctor at St. Michael’s Hospital and the Fidani Chair in Improvement and Innovation at the University of Toronto.

“They got their first and second doses, and maybe they were even on the fence, but they were like, ‘I’m going to roll up my sleeves and do it, because it’s important.’”

But when it comes to a third, or even fourth dose, that enthusiasm has tapered off, especially after a concerted push from health-care workers when Omicron landed in December, Kiran said.

Op-ed by Dr. Nav Persaud in The Hill Times

NDP Leader Jagmeet Singh and Prime Minister Justin Trudeau have each got a lot of political mileage out of past pharmacare announcements. Last week’s vague joint announcement continued the positive coverage, writes Nav Persaud.

NDP Leader Jagmeet Singh stepped over broken promises about pharmacare walking down the aisle to join Prime Minister Justin Trudeau in a confidence and supply agreement. The “marriage” vows included a new promise—not to implement pharmacare, but about “continuing progress” toward a national program by passing legislation next year and making a plan to bulk purchase essential medicines.

…This is one of two ways we will be able to see if the NDP-Liberal will really yield pharmacare. The public subsidy for private insurance plans should be rolled back or cancelled. Back in 2017, the Trudeau government indicated it would re-examine that regressive subsidy that was estimated to be worth $2.9-billion at the time. That’s right, although some naively ask how we can afford pharmacare, the current private insurance system for medicines receives a public subsidy worth well over $3-billion today.

The other test of this commitment to including medicines in our publicly funded system will be by reforming regulations patented drug pricing. Bulk purchasing will not necessarily lower the prices of patented medicines, so price ceilings need to be set and enforced with fines. Currently price ceilings in Canada are set using comparator countries like the United States that pay high prices. Plans to adopt prices paid in countries that do a better job of reigning in drug pricing were postponed in 2018 due to pressure from the pharmaceutical industry and private insurance companies.

How can we tell if industry lobbying is succeeding? Our elected leaders will wave around pharmacare blueprints but never put their work boots on. The status quo will persist and we will keep paying the price.

From CBC News Toronto

Of the thousands of opioid samples tested by Toronto’s Drug Checking Service, staff have found an increasingly toxic supply, Karen McDonald, operations manager with Toronto’s Drug Checking Service, tells CBC Toronto.

Watch the interview here.

From the Toronto Star article

TORONTO – When a mental health crisis call comes in to 911 in certain parts of Toronto next month, a team typically consisting of two people such as a harm-reduction worker and a nurse, or an Indigenous elder and a de-escalation expert – not police – will be the first to respond.

The mobile unit will meet with the individual in crisis and figure out what they need. Response teams will then check on the person within two days and help arrange further support, such as long-term counselling, as required.

It’s all part of a new approach to crisis intervention in Toronto that’s beginning with a pilot program launching in a few weeks.

The City of Toronto – which plans to eventually implement the program in all neighbourhoods – describes the effort as a community-led, trauma-informed alternative to traditional crisis response, with a focus on reducing harm and preventing problems from arising.

Dr. Andrew Pinto, a family physician at St. Michael’s Hospital in Toronto, said a community-led approach to helping people in mental health crises is “long overdue” and has the potential to save lives.

Pinto said it could lead to more support for those who live with mental health concerns and could prevent cases where they are harming themselves or others. In the long term, he said it can help people engage with health and social care and other resources.

Since police won’t be going to confront someone who’s in a mental health crisis, the risk of “police committing violence and actually killing somebody” could also be reduced, he said.

“I think that this type of approach can make a difference for folks. And I think that a really rigorous evaluation will help confirm (that),” Pinto said.

From the Toronto Star article

While dropping mask mandates and vaccination passports in Ontario may be a sign the worst of the pandemic is behind us, a steady stream of deaths from COVID-19 — 366 in the last month alone, according to the province’s latest data — is a reminder that the province has yet to escape the deadly virus.

The same week the province removed mandatory masking, Ontario saw 56 COVID deaths including Thompson’s, primarily in people over the age of 60. And in the three weeks since the province ended its proof-of-vaccination program, 329 people have died.

Dr. Sharmistha Mishra, an infectious disease physician and mathematical modeller at St. Michael’s Hospital, a part of Unity Health Toronto, said tracking COVID deaths is critical for understanding the pandemic — and to guide policy changes to help prevent more people from dying.

She and her team have analyzed COVID deaths and hospitalizations and found the disease disproportionately impacts those living in the province’s lowest-income neighbourhoods.

“This suggests our (COVID) interventions are working for higher-income neighbourhoods. But they are not reaching those who live in the lowest-income neighbourhoods,” she said.

This stark trend continued into the fourth and fifth waves and is apparent even when accounting for underlying health conditions, said Mishra, who holds a Canada Research Chair in Mathematical modelling and Program Science.

In Waves 4 and 5, the 20 per cent of the Ontario population who live in the highest-income neighbourhoods died of COVID at half the rate as compared to the 20 per cent of the population who live in the lowest-income neighbourhoods. This is according to data analyzed by Mishra and presented in the Ontario COVID-19 Science Advisory Table’s March 17 update.

“When you look at this data, it begs the question: for whom have we flattened the curve?,” said Mishra, noting access to testing and COVID therapeutics that can be administered out of hospital, such as monoclonal antibodies, is likely more limited for those in the province’s lower-income neighbourhoods, a point public health officials and policy-makers must consider in the months ahead.

“Deaths hold us accountable … in broad strokes they show us that we have continued to leave communities behind in this pandemic.”

From the AJMC article

Built environments can shape how active an individual is, while policy decisions made decades ago impact health disparities today. To address these critical social determinants of health, experts are calling for increased cooperation between urban planners and the public health field.

In the world of real estate, location is everything, serving as a major driving force behind both rent prices and mortgage rates. But a growing body of research highlights that when it comes to health outcomes, location may also affect disease risk, and where you reside can impact how you live.

One analysis included in the review revealed that between 2001 and 2012 in Ontario, Canada, higher neighborhood walkability was associated with a stable prevalence of overweight and obesity, and decreasing diabetes incidence. By 2012, all 3 rates were significantly lower compared with less walkable areas, where levels of obesity continued to rise.²

But geographic and population density alone does not account for this association, as destinations also influence the advantages of neighborhood walkability, explained Gillian Booth, MD, MSc, of the Department of Medicine at University of Toronto in an interview with The American Journal of Managed Care^® (AJMC^®).

Booth is a scientist at the MAP Centre for Urban Health Solutions within the Li Ka Shing Knowledge Institute of St. Michael’s Hospital in Toronto, and coauthor of the aforementioned studies.

Factors outside of design, density, and destinations affect neighborhood-specific health outcomes, and can even negate the benefits of living in highly walkable areas, she stressed.

Based on their research, Booth and colleagues found those living in areas with low levels of traffic-related air pollution reaped greater benefits from walkability with regard to hypertension and diabetes risk.

“But if there [were] really high concentrations of air pollution, the benefit of walkability was completely eliminated, because air pollution itself is a risk factor for diabetes,” she said. “It’s not enough to just build [environments] right.”

Apart from pollution, additional influences can sway the extent to which individuals take advantage of walkability and the neighborhood’s capacity to enact environment-level improvements. Safety, sidewalk conditions, crime rate, and transportation options all function to encourage or dissuade walking, regardless of a space’s design.

“We always have to think about where people live and the neighborhood environment as a whole, and what makes the neighborhood healthy and what doesn’t,” Booth said. “There’s a lot of interest now into, not only how do we make healthier designs, but about how do we make more equitable decisions in terms of where to invest.”

Lire cet article en français

Op-ed in the Toronto Star by Dr. Nav Persaud

Pharmacare announcements have not made people healthier before. The confidence-and-supply agreement between the Liberals and NDP promises only a plan for pharmacare by 2025. So we will hear more announcements about pharmacare, but will medicines ever be included in our publicly funded health system?

Money is the reason dental care was promised but pharmacare was not. Pharmacare will save billions of dollars by reducing the price for each pill. The current patchwork system ratchets up drug prices as private insurance companies, which provide employer-based plans enjoyed by around 60 per cent of Canadians, take a percentage of each claim. So high drug prices are incentivized in Canada where medicines are less expensive in countries such as New Zealand, Australia and the United Kingdom.

Lower prices were supposed to arrive in Canada. Five years ago the Trudeau government promised to tackle high prices for patented drugs by using prices in countries like New Zealand to set price ceilings. Implementing this change was supposed to be a step toward pharmacare. Five years ago then-Health Minister Dr. Jane Philpott said “Canadians are going to see that we are going to be able to save [them] in the order of billions of dollars per year.”

L’annonce du programme d’assurance médicaments ne garantit pas une baisse des prix

Article d’opinion du Dr Nav Persaud dans le Toronto Star

Les annonces faites au sujet de l’assurance médicaments n’ont jamais amélioré la santé de la population. L’accord de confiance entre les libéraux et le NPD ne prévoit qu’un plan pour l’assurance médicaments d’ici 2025. Nous continuerons de recevoir des annonces concernant l’assurance médicaments, mais posons-nous la question : les médicaments seront-ils un jour pris en charge par notre système de santé publique?

Pour des raisons financières, on a promis des soins dentaires, mais pas l’assurance médicaments. En réduisant le prix de chaque comprimé, l’assurance médicaments permettrait d’économiser des milliards de dollars. L’actuel système fragmenté fait grimper le prix des médicaments. Les compagnies d’assurance privées, qui fournissent les régimes d’employeur dont profitent environ 60 % des Canadiens, prélèvent un pourcentage sur chaque demande de remboursement. Le Canada favorise donc les prix élevés des médicaments, alors que les médicaments sont moins chers dans des pays comme la Nouvelle-Zélande, l’Australie et le Royaume-Uni.

Une baisse des prix était censée se produire au Canada. Il y a cinq ans, le gouvernement Trudeau avait promis de s’attaquer aux prix élevés des médicaments brevetés en utilisant les pratiques de pays comme la Nouvelle-Zélande pour fixer des prix plafonds. La mise en œuvre de ce changement était censée être une étape vers l’instauration de l’assurance médicaments. Il y a cinq ans, la ministre de la Santé de l’époque, la Dre Jane Philpott, avait déclaré : « Les Canadiens vont constater que nous sommes en mesure de leur faire économiser des milliards de dollars par an. »