Dr. Andrew Boozary is executive director of population health and social medicine at University Health Network. He is also a primary care physician at a Toronto clinic that treats many of the underserved patients who are most affected by Canada’s current health care crisis.
— As told to Ali Amad
In a hospital, a Code Blue is the most urgent call that alerts medical staff to critical patient emergencies. Our healthcare system has been in a chronic Code Blue state for years.
In December 2020, I came face to face with the tragic consequences of this systemic failure. Canada was in the midst of another deadly wave of the pandemic that winter, so I decided to volunteer in an elderly care ward at a Scarborough hospital that had experienced an outbreak of COVID-19.
Nothing in my years as a doctor could have prepared me for what I witnessed. By the end of the outbreak, 80 patients had died. I had personally treated many of these patients, but could do nothing to save them. I remember driving home after a long shift on Christmas day and all I could see in my mind were the faces of the people I had treated who were not alive to celebrate the holidays with their families.
I was left with so many “what ifs”: What if more staff were available to treat them? What if there was better ventilation and more adequate personal protective equipment to prevent the rapid spread of COVID-19 in the room? I also remember thinking that we cannot maintain the status quo that had contributed to their deaths.
Eighteen months later, little has changed in our failing healthcare system. We’ve all seen the headlines. Waiting times of up to 20 hours in emergency rooms. Patients dying in the corridors. Shortage and exhaustion of nurses. Increasingly frequent temporary closures of hospital units.
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It is not easy to explain why we face these problems.. A good place to start is by taking a look at the struggles of the people I deal with each week. I am one of about 200 doctors and nurses who work with Inner City Health Associates, an organization that provides health care to Toronto’s homeless and underserved population. At a clinic in downtown Toronto, I perform exams and evaluations on my patients, refer them to specialists, and prescribe medications. I treat patients of all ages and backgrounds, but many face the same challenges.
Now think of all the marginalized patients across the country in a similar situation, trapped in emergency rooms and intensive care units due to the inadequacies of our health system and our social safety nets. To treat these patients, health care providers must divert staff and other resources, all the while coping with continuing waves of pandemics and decades of insufficient government funding.
This has led to worse health care outcomes and preventable deaths for patients (poor and rich, marginalized or not) and burnout in overworked and underpaid nurses and personal support workers. These problems existed before COVID-19, but the stresses caused by the pandemic have exacerbated their impacts.
Some have described the pandemic as the death knell for Medicare in Canada., while also advocating for further privatization of our healthcare system. Dr. Brian Day, medical director of the for-profit Cambie Surgery Center in Vancouver, has been a leading voice calling for the privatization of Canada’s health care for years. Earlier this month, Ontario Health Minister Sylvia Jones said her government was considering privatization as a solution to worsening staffing shortages and emergency department closures. But the data shows that privatization is not the panacea that its supporters claim.
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In 2016, Saskatchewan attempted to reduce wait times for its MRIs with a pilot initiative that offered privately provided MRIs to those willing to pay. The pilot failed. Instead of getting shorter, MRI wait times increased. And what better case study for the dangers and failings of a for-profit health care model than our nursing and long-term care homes? Study after study has outlined the alarming discrepancies in mortality rates and health outcomes between public and private nursing homes and long-term care during the first waves of the pandemic. Residents in private facilities were consistently shown to be at higher risk of dying from COVID-19.
Instead of scrapping Medicare and taking the dangerous and inequitable path of charging people money to save their lives and take care of their health, we should reform our current system. This begins with a review of how we provide health care.
Traditionally, our health system is structured around hospitals and doctors working on their own in an urban neighborhood or rural community. To modernize healthcare delivery, we must move from this archaic, rigid structure to a more dynamic, team-based approach. Instead of forcing patients to deal with our isolated health system, which divides services into different locations or departments, each with its own procedures and red tape, teams of primary care doctors, nurses, specialists and social workers they could work together in one setting or travel together as mobile units to underserved communities. Health care can then be delivered collaboratively in a much more time- and cost-efficient approach that benefits providers and patients.
An integral part of this team-based approach is an investment in more community health workers. Typically trained and employed by community health centers, community health workers tend to be locals with shared life experiences who can act as guides and advocates for members of their community. For my single immigrant mother patient, a community health worker who speaks the same language would be an ally to her who could help her enroll her with a family doctor and ease some of the burdens of her daily life.
During the pandemic, we have seen multiple success stories of health care and community health workers teaming up to close the gaps left exposed by our overwhelmed hospitals and primary care clinics. To name just two of many examples in Toronto alone, community health centers like Black Creek and Parkdale Queen West have regularly set up clinics in parks to provide many services to hundreds of underserved locals over the past two years, including HIV testing, screening cancer, dental care, harm reduction, counseling and more. These efforts are the future of health care.
Along with the modernization of health care delivery, we must remove the systemic discrimination embedded in the way we fund it. Governments do not adjust for poverty or socioeconomic status when funding primary care. Physicians bill the same for each patient, regardless of the complexity of each individual case. But research has shown that there is a link between wealth and health: the richer you are, the less likely you are to get sick. Rates of diabetes, cardiovascular disease, and cancer tend to be higher in less affluent neighborhoods. This has led to a situation where primary care clinics are often set up in more affluent neighborhoods with patients who generally have simpler, less serious medical problems. There is no incentive to take on more complex cases in poorer neighborhoods. Without enough primary clinics to serve them in their area, marginalized and impoverished people rely on underfunded community health centers like Black Creek and Parkdale Queen West to pick up the slack.
Incorporating poverty and socioeconomic status into the financing of primary care will eliminate this discrimination. But first we need more health equity data to highlight discrepancies. Unfortunately, this data is largely lacking in Canada. In the early days of the pandemic, then-Ontarian Health Chief Medical Officer David Williams said the province was not collecting race-based data related to the pandemic because all Ontarians were “equally important.” But it was precisely those data that revealed that communities of color and newcomers experienced COVID-19 positivity rates that were up to five times higher than those of wealthy white communities. The “universality” of our universal health system is, unfortunately, a mirage.
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These reforms require investments from all levels of government and the political will to carry them out. For those who say these investments are not feasible, the cost of doing nothing or maintaining the status quo far outweighs the costs of these investments that will dramatically improve health outcomes and create a more equitable society. It costs the province $6,600 a month for a shelter bed and between $10,000 and $20,000 for a patient to spend the night in a hospital. By comparison, it has been estimated that providing adequate permanent housing for homeless and precariously housed Ontarians costs only $2,400 per month per person.
But reforming our health care system shouldn’t be about the bottom line. Access to high-quality health care is vital to a well-functioning society that treats all its members with respect and dignity. Health considerations must be woven into all of our major economic and political decisions. Our governments are evading their responsibility by behaving largely as if the health of their constituents is unaffected by these decisions.
After that harrowing December in 2020, I felt compelled to push through these reforms and the significant change they represent. But somehow, the health reforms seemed to have been sidelined when the next federal and provincial elections came around. Marginalized communities continue to be neglected and health resources remain insufficient.
If we allow the status quo to continue, that means the preventable deaths of so many people during our perpetual Code Blue crisis will have been for nothing. These tragedies are our wake up call: we have all been affected by these systemic failures. Many of us have personal experience of the consequences of overstaffed staff and underfunded hospitals. That’s why we must keep putting pressure on policymakers until they can’t ignore the systemic moral failings that are facing them.
We have relied on the heroism of healthcare workers for two and a half years, but rising burnout rates and staffing shortages demonstrate the obvious: this reliance is not a sustainable way forward.
We cannot continue to fail healthcare workers and the patients and families they serve. We know the solutions. What we need now is the social mobilization to implement them. It’s not about political allegiances or dollars and cents. This is about life and death. This is the kind of society we want to create and impart to future generations. It’s about what matters most to us: the health and well-being of our loved ones and fellow human beings.