Dr. Andrew Boozary is executive director of social medicine and population health at University Health Network. He’s also a primary care physician at a Toronto clinic that treats many of the marginalized patients bearing the brunt of Canada’s ongoing health care crisis.
—As told to Ali Amad
In a hospital, a code blue is the most urgent call that alerts medical staff about critical patient emergencies. Our health care system has been in a chronic state of code blue 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 at an elder care ward in a Scarborough hospital that had experienced a COVID-19 outbreak.
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’d personally treated many of those 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’d treated who weren’t alive to celebrate the holidays with their families.
I was left with so many “what ifs”: What if there were more staff 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 ward? I also remember thinking we cannot maintain the status quo that had contributed to their deaths.
Eighteen months later, little has changed in our broken health care system. We’ve all seen the headlines. Wait times of up to 20 hours in emergency rooms. Patients dying in hallways. Nurse shortages and burnouts. Increasingly frequent temporary closures of hospital units.
It’s not easy to explain why we’re facing these problems. A good place to start is by taking a look at the struggles of the individuals I treat every week. I’m one of about 200 physicians and nurses who work with Inner City Health Associates, an organization that provides health care to Toronto’s homeless and marginalized population. At a clinic in downtown Toronto, I conduct examinations and screenings of my patients, giving them specialist referrals and prescribing medications. I treat patients of all ages and backgrounds, but many encounter the same challenges.
Now think of all the marginalized patients across the country in a similar situation, stuck in emergency rooms and intensive care units because of insufficiencies in our health care system and our social safety nets. To treat these patients, health care providers must divert staff and other resources while also coping with continual pandemic waves and decades of insufficient government funding.
This has led to worse health care outcomes and preventable deaths for patients—poor and wealthy, marginalized and not—and burnout for overextended 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 of medicare in Canada, while simultaneously advocating for increased privatization of our health care system. Dr. Brian Day, medical director of the for-profit Cambie Surgery Centre in Vancouver, has been a prominent voice calling for 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 staff shortages and emergency department shutdowns. But data shows that privatization isn’t the silver bullet its supporters make it out to be.
In 2016, Saskatchewan attempted to reduce its MRI wait times with a pilot initiative that offered privately provided MRIs for those willing to pay. The pilot backfired. Instead of becoming shorter, MRI wait times increased. And what better case study for the dangers and failures of a for-profit health care model than our long-term care and retirement homes? Study after study has outlined the alarming discrepancies in death rates and health outcomes between public and private long-term care and retirement homes during the early waves of the pandemic. Residents in private facilities were consistently shown to be at greater 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 an overhaul of how we deliver health care.
Traditionally, our health care system is structured around hospitals and doctors working on their own in an urban neighbourhood or rural community. To modernize health care delivery, we must shift from this archaic and rigid structure to a more dynamic team-based approach. Instead of forcing patients to deal with our siloed health care system, which splits services into different locations or departments, each with their own procedures and red tape, teams of primary care physicians, nurses, specialists and social workers could work together in one setting or travel together as mobile units to underserved communities. Health care can then be collaboratively delivered 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 centres, community health workers tend to be locals with shared lived experiences who can act as guides and advocates for their community members. For my immigrant single-mom patient, a community health worker who speaks the same language would be an ally who can help enrol her with a family doctor and ease some of her daily life burdens.
During the pandemic, we’ve witnessed several instances of the success of team-based health care and community health workers in shoring up the gaps left exposed by our overwhelmed hospitals and primary care clinics. To name just two of many examples in Toronto alone, community health centres like Black Creek and Parkdale Queen West have regularly set up clinics in parks to provide many services for hundreds of marginalized locals over the past two years, including HIV tests, cancer screening, dental care, harm reduction, counselling and more. These efforts are the future of health care.
Along with modernizing health care delivery, we must eliminate the systemic discrimination embedded in how we fund it. Governments don’t adjust for poverty or socio-economic status when funding primary care. Doctors bill the same for each patient, regardless of the complexity of each individual case. But research has shown that there’s a link between wealth and health: the wealthier you are, the less likely you are to be sick. Rates of diabetes, cardiovascular disease and cancer all tend to be higher in less wealthy neighbourhoods. This has led to a situation where primary care clinics often establish themselves in more affluent neighbourhoods with patients who usually have simpler and less severe medical issues. There’s no incentive to take on more complex cases in poorer neighbourhoods. Without enough primary clinics to serve them in their area, marginalized and impoverished people rely on underfunded community health centres like Black Creek and Parkdale Queen West to pick up the slack.
Incorporating poverty and socio-economic status into primary care funding will eliminate this discrimination. But we first need more health equity data to highlight the discrepancies. Unfortunately, this data is largely lacking in Canada. In the early days of the pandemic, Ontario’s then–chief medical officer of health David Williams said the province wasn’t collecting race-based data related to the pandemic because all Ontarians were “equally important.” But it was precisely that data which revealed that racialized and newcomer communities experienced COVID-19 positivity rates up to five times higher than those in affluent white communities. The “universality” of our universal health care system is sadly a mirage.
These reforms require investments from all levels of government and the political will to make them happen. For those who say these investments aren’t feasible, the cost of doing nothing or maintaining the status quo far outweigh 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 per month for a patient to stay overnight in a hospital. By comparison, providing adequate permanent housing for homeless and precariously housed Ontarians has been estimated to cost only $2,400 a 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 should be woven into all our major economic and political decisions. Our governments are shirking their responsibility by largely behaving like their constituents’ health isn’t impacted by these decisions.
After that harrowing December back in 2020, I’ve been driven to push for these reforms and the meaningful change they represent. But somehow, health care reforms seemed to have been pushed aside when the next federal and provincial elections came rolling along. Marginalized communities continue to be neglected and health care resources continue to be insufficient.
If we allow the status quo to continue, the preventable deaths of so many people during our perpetual code blue crisis will have been in vain. These tragedies are our wake-up call: we’ve all been impacted by these systemic failures. Many of us have personal experience of the consequences of overburdened staff and underfunded hospitals. That’s why we need to keep applying pressure on policy-makers until they can’t ignore the systemic moral failures that are staring them in the face.
We’ve depended on the heroism of health care workers for two and a half years, but rising burnout rates and staff shortages demonstrate the obvious: this dependency isn’t a sustainable way forward.
We can’t keep failing health care workers or the patients and families they serve. We know the solutions. What we need now is societal mobilization to implement them. This isn’t about political allegiances or dollars and cents. This is about life and death. It’s about 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.