Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

https://policybase.cma.ca/en/permalink/policy14165
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-10-17
Topics
Health care and patient safety
Population health/ health equity/ public health
Text
Homeless and vulnerably housed populations are heterogeneous and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies.2 Collectively, they face dangerous living conditions and marginalization within health care systems.3 However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices.1,4,5 Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it.6 Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality.7,8 For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population.7,9 Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women.7 A generation ago, homeless Canadians were largely middleaged, single men in large urban settings.10 Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people (Box 1), immigrants, older adults and people from rural communities.13,14 For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis.15 In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors.10 Practice navigators, peer-support workers and primary care providers are well placed to identify social causes of poor health and provide orientation to patient medical homes.16,17 A patient’s medical home is “a family practice defined by its patients as the place they feel most comfortable presenting and discussing their personal and family health and medical concerns.”18 Medical care is “readily accessible, centred on the patients’ needs, provided throughout every stage of life, and seamlessly integrated with other services in the health care system and the community” (https://patientsmedicalhome.ca). Primary care providers are also well positioned to mobilize health promotion, disease prevention, diagnosis and treatment, and rehabilitation services.19 GUIDELINE VULNERABLE POPULATIONS CPD Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience Kevin Pottie MD MClSc, Claire E. Kendall MD PhD, Tim Aubry PhD, Olivia Magwood MPH, Anne Andermann MD DPhil, Ginetta Salvalaggio MD MSc, David Ponka MDCM MSc, Gary Bloch MD, Vanessa Brcic MD, Eric Agbata MPH MSc, Kednapa Thavorn PhD, Terry Hannigan, Andrew Bond MD, Susan Crouse MD, Ritika Goel MD, Esther Shoemaker PhD, Jean Zhuo Jing Wang BHSc, Sebastian Mott MSW, Harneel Kaur BHSc, Christine Mathew MSc, Syeda Shanza Hashmi BA, Ammar Saad, Thomas Piggott MD, Neil Arya MD, Nicole Kozloff MD, Michaela Beder MD, Dale Guenter MD MPH, Wendy Muckle BScN MHA, Stephen Hwang MD, Vicky Stergiopoulos MD, Peter Tugwell MD n Cite as: CMAJ 2020 March 9;192:E240-54. doi: 10.1503/cmaj.190777 CMAJ Podcasts: author interview at https://soundcloud.com/cmajpodcasts/190777-guide See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.200199 KEY POINTS
Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person’s gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care.
As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended.
Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.
Harm-reduction interventions, such as supervised consumption facilities, and access to pharmacologic agents for opioid use disorder, such as opioid agonist treatment, are recommended for people who use substances. GUIDELINE CMAJ
MARCH 9, 2020
VOLUME 192
ISSUE 10 E241 However, the social and health resources available to homeless and vulnerably housed people may vary based on geographic setting, municipal resources, housing coordination, and patients’ mental health and substance use–related care needs. In addition, many physical and mental health disorders remain undiagnosed or inconsistently treated because of missed opportunities for care, patient mistrust of the health care system or limited access to health services.3 Homeless and vulnerably housed people can benefit from timely and effective health, addiction and social interventions. Our guideline provides initial steps for practice, policy and future research, and is intended to build collaboration among clinicians, public health providers and allied health providers. Values such as trauma-informed and patient-centred care, and dignity are needed to foster trust and develop sustainable therapeutic relationships with homeless and vulnerably housed people.20,21 Scope The purpose of this clinical practice guideline is to inform providers and community organizations of the initial priority steps and effective interventions for homeless and vulnerably housed people. The guideline addresses upstream social and health needs (i.e., housing), as well as downstream health-related consequences of inadequate housing. The target audiences are health providers, policymakers, public health practitioners and researchers. Our guideline does not aim to address all conditions associated with homelessness, nor does it aim to discuss in depth the many etiologies of homelessness, such as childhood trauma, the housing market, or the root causes of low social assistance rates and economic inequality. Rather, this guideline aims to reframe providers’ approach toward upstream interventions that can prevent, treat and work toward ending the morbidity and mortality associated with homelessness. A parallel set of Indigenous-specific clinical guidelines is currently being developed by an independent, Indigenous-led team.22 This process recognizes the distinct rights of Indigenous Peoples, including the right to develop and strengthen their own economies, social and political institutions; the direct links between historic and ongoing colonial policies and Indigenous homelessness; and the need for Indigenous leadership and participation in research that is about Indigenous Peoples. Recommendations The steering committee and guideline panel members developed and approved recommendations to improve social and health outcomes for homeless and vulnerably housed people. The order of these recommendations highlights priority steps for homeless health care. We list a summary of the recommendations in Table 1 and we present our list of good practice statements in Table 2. These good practice statements are based on indirect evidence and support the delivery of the recommendations. The methods used to develop the recommendations are described later in this document. A summary of how to use this guideline is available in Box 2. Permanent supportive housing
Identify homelessness or housing vulnerability and willingness to consider housing interventions.
Ensure access of homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and/or coordinated access system (moderate certainty, strong recommendation). Evidence summary Our systematic review (Tim Aubry, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 14 trials on permanent supportive housing (PSH).30–43 Several trials across Canada and the United States showed that PSH initiatives house participants more rapidly compared with usual services (73 v. 220 d; adjusted absolute difference 146.4, 95% confidence interval [CI] 118.0 to 174.9);30 increase the number of people who maintain stable housing at 2 years (pooled odds ratio [OR] 3.58, 95% CI 2.36 to 5.43);30,40 and significantly increase the percentage of days spent stably housed.41 No trials showed a significant improvement in mental health symptoms compared with standard care.30,31,33,34,41,42 Two studies found that the mental health of PSH participants did not improve as much as that of usual care participants (e.g., mean difference –0.49, 95% CI –0.85 to –0.12).30,31 The At Home/Chez Soi trial showed small improvements in quality of life for high-needs (adjusted standardized mean difference 0.15, 95% CI 0.04 to 0.24)30 and moderate-needs (mean difference 4.37, 95% CI 1.60 to 7.14) homeless participants in patients receiving PSH.41 Youth receiving PSH saw larger improvements in their quality of life during the first 6 months (mean difference 9.30, 95% CI 1.35 to 17.24), which diminished over time (mean difference 7.29, 95% CI –1.61 to 16.18).44 No trials showed a significant improvement in substance use compared with standard care.30,33,41–43 Most trials reported no effect of PSH on acute care outcomes (e.g., number of emergency department visits and percentage of participants admitted to hospital).30,41 However, 2 trials suggest that PSH participants had lower rates of hospital admission (rate reductions of 29%, 95% CI 10 to 44) and time in hospital (e.g., mean difference –31, 95% CI –48 to –14).34,38,45 One trial found no effect of PSH on job tenure, hours of work per week or hourly wage compared with standard care.46 Participants receiving PSH may have increased odds of employment, but this depends on the severity of participant needs.46 One trial found no effect on income outcomes.46 Box 1: Indigenous homelessness Indigenous homelessness is a term used to describe First Nations, Métis and Inuit individuals, families or communities who lack stable, permanent and appropriate housing, or the immediate prospects, means or ability to acquire such housing. However, this term must be interpreted through an Indigenous lens to understand the factors contributing to this condition. These factors include individuals, families and communities isolated from their relationships to land, water, place, family, kin, each other, animals, cultures, languages and identities as well as the legacy of colonialism and genocide.11 It is estimated that urban Indigenous people are 8 times more likely to experience homelessness than the general population.11,12 GUIDELINE E242 CMAJ
ISSUE 10 The certainty of the evidence was rated moderate, because blinding of participants and personnel was not feasible in any of the trials we examined as a result of the nature of the intervention. Furthermore, several trials did not employ allocation concealment or blinding of outcome-assessment procedures, which could introduce high risks of detection and performance biases. Income assistance
Identify income insecurity.
Assist individuals with income insecurity to identify incomesupport resources and access income (low certainty, conditional recommendation). Evidence summary We identified 10 trials on income-assistance interventions, including rental assistance,47–56 financial empowerment,47 social enterprise interventions,48 individual placement and support,48,54 and compensated work therapy.52 Our systematic review showed the benefit that income-assistance interventions have on housing stability (Gary Bloch, University of Toronto, Toronto, Ont., and Vanessa Brcic, University of British Columbia, Vancouver, BC: unpublished data, 2020). Rental assistance increased the likelihood of being stably housed (OR 4.60, 95% CI 3.10 to 6.83).56 Rental assistance combined with case management increased the number of days in stable housing per 90-day period compared with case management alone (mean Table 1: Summary of evidence-based recommendations Recommendations and clinical considerations Grade rating* Recommendation 1: A homeless or vulnerably housed person Moderate certainty
Ensure access for homeless or vulnerably housed individuals to local housing coordinator or case manager (i.e., call 211 or via a social worker) for immediate link to permanent supportive housing and coordinated access system. Clinical considerations: Many jurisdictions will provide alternative housing services for specific marginalized populations, for example, Indigenous people, women and families, youth, those who identify as LGBTQ2+, those with disabilities, refugees and migrants. Strong recommendation Recommendation 2: A homeless or vulnerably housed person with experience of poverty, income instability or living in a low-income household Low certainty
Assist individuals with income insecurity to identify income-support resources and access income. Clinical considerations: Consult poverty screening tools when needed (e.g., https://cep.health/clinical-products /poverty-a-clinical-tool-for-primary-care-providers). Conditional recommendation Recommendation 3: A homeless or vulnerably housed person with multiple comorbid or complex health needs (including mental illness and/or substance use) Low certainty
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use, or multiple/complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment, and linkage to intensive case management, assertive community treatment or critical time intervention where available. Clinical considerations: Call 211 or consult primary care providers, social workers or case managers familiar with local access points and less intensive community mental health programs. Conditional recommendation Recommendation 4: A homeless or vulnerably housed person currently using opioids Very low certainty
Identify opioid use disorder.
Ensure access within primary care or via an addiction specialist to opioid agonist therapy (OAT), potentially in collaboration with a public health or community health centre for linkage to pharmacologic interventions. Clinical considerations: Encourage all patients taking opioid medication to have a naloxone kit. Though barriers to prescribing methadone and buprenorphine remain, be aware of new regulations that aim to facilitate OAT access and options in your jurisdiction, in particular for buprenorphine. Conditional recommendation Recommendation 5: A homeless or vulnerably housed person with substance use disorder Very low certainty
Identify, during history or physical examination, problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach, or refer to local addiction and harm-reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources such as public health or community health centre or local community services centre. Clinical considerations: In case of active opioid use disorder, facilitate patient access to OAT. Patients should be made aware of supervised consumption facility locations (Appendix 1, available at www.cmaj.ca/lookup/suppl/ doi:10.1503/cmaj.190777/-/DC1). Conditional recommendation Note: LGBTQ2+ = lesbian, gay, bisexual, transgender, questioning and two-spirited. *See Box 2 for definitions. †211 is a special abbreviated telephone number reserved in Canada and the United States as an easy-to-remember 3-digit telephone number meant to provide information and referrals to health, human and social service organizations. GUIDELINE CMAJ
ISSUE 10 E243 difference 8.58, p < 0.004).55 Compensated work therapy was found to reduce the odds of homelessness (OR 0.1, 95% CI 0.1 to 0.3).52 No income interventions showed an effect on mental health outcomes.47,52,55,56 The impact of these interventions on substance use outcomes were mixed. Provision of housing vouchers did not affect substance use over 3 years;55 however, compensated work therapy showed immediate reductions in drug (reduction: –44.7%, standard error [SE] 12.8%; p = 0.001) and alcohol use problems (–45.4%, SE 9.4%; p = 0.001), as well as the number of substance use–related physical symptoms (–64.4%, SE 8.0%; p = 0.001).52 These differences, however, tended to decline with time. No significant effects were found on overall quality-of-life, finances, health and social relations scores. Provision of housing vouchers resulted in higher family-relations score and satisfaction, and quality of housing compared with standard care.55 One trial reported that rental assistance was associated with reduced emergency department visits and time spent in hospital, but this reduction was not significantly different than in the comparator group.56 Individual placement and support was found to improve employment rates only when there was high fidelity to the model (OR 2.42, 95% CI 1.13 to 5.16).54 Financial-empowerment education and provision of housing vouchers had no effect on employment outcomes.47,55 Financial-empowerment education and individual placement and support had no effect on hourly wages.47,54 Provision of housing vouchers had no effect on monthly income.55 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Furthermore, 1 trial reported low consent rates of 47% and a 1:4 sampling ratio that further limited statistical power.52 As well, participants in the control group wanting to enter income-assistance programs after completing the study had incentives to underreport symptoms, which introduced high risk for measurement bias. Case management
Identify history of severe mental illness, such as psychotic or mood and anxiety disorders, associated with substantial disability, substance use disorders, or multiple or complex health needs.
Ensure access to local community mental health programs, psychiatric services for assessment and linkage to intensive case management, assertive community treatment or critical time intervention where available (low certainty, conditional recommendation). Evidence summary Our systematic review examined the effectiveness of standard case management, as well as specific intensive casemanagement interventions, such as assertive community treatment, intensive case management and critical time intervention among homeless and vulnerably housed populations and corresponding level of need (David Ponka, University of Ottawa, Ottawa, Ont.: unpublished data, 2020). We included a total of 56 citations, of which 10 trials reported on standard case management,51,57–65 8 trials on assertive community treatment,66–73 16 trials on intensive case management74–89 and 5 trials on critical time intervention.90–94 Box 2: How to use and understand this GRADE guideline (www.gradeworkinggroup.org) This guideline supplies providers with evidence for decisions concerning interventions to improve health and social outcomes for people who are homeless or vulnerably housed. This guideline is not meant to replace clinical judgment. Statements about clinical considerations, values and preferences are integral parts of the recommendations meant to facilitate interpretation and implementation of the guideline. Recommendations in this guideline are categorized according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system as strong or conditional recommendations. Strong recommendations indicate that all or almost all fully informed patients would choose the recommended course of action, and indicate to clinicians that the recommendation is appropriate for all or almost all individuals. Strong recommendations represent candidates for quality-of-care criteria or performance indicators. Conditional recommendations indicate that most informed patients would choose the suggested course of action, but an appreciable minority would not. With conditional recommendations, clinicians should recognize that different choices will be appropriate for individual patients, and they should help patients arrive at a decision consistent with their values and preferences. Conditional recommendations should not be used as a basis for standards of practice (other than to mandate shared decision-making). Good practice statements represent common-sense practice, are supported by indirect evidence and are associated with assumed large net benefit. Clinical considerations provide practical suggestions to support implementation of the GRADE recommendation. GRADE certainty ratings High: further research is very unlikely to change our confidence in the estimate of effect. Moderate: further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate. Low: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low: any estimate of the effect is very uncertain. Table 2: Good practice statements to support delivery of care Good practice statement Indirect evidence (reference) 1. Homeless and vulnerably housed populations should receive trauma-informed and personcentred care. 23–26 2. Homeless and vulnerably housed populations should be linked to comprehensive primary care to facilitate the management of multiple health and social needs. 27 3. Providers should collaborate with public health and community organizations to ensure programs are accessible and resources appropriate to meet local patient needs. 28,29 GUIDELINE E244 CMAJ
ISSUE 10 Of 10 trials on standard case management, 10 evaluated housing stability. Only 3 reported significant decreases in homelessness,57,62,63 an effect that diminished over time in 1 trial of a time-limited residential case management in which participants in all groups accessed substantial levels of services.57 A program tailored to women reduced the odds of depression at 3 months (OR 0.38, 95% CI 0.14 to 0.99), but did not show improvements in the women’s overall mental health status (mean difference 4.50, 95% CI –0.98 to 9.98).64 One trial reported higher levels of hostility (p < 0.001) and depression symptoms (p < 0.05) among female participants receiving nurse-led standard case management compared with those receiving standard care.60 Few studies reported on substance use, quality of life, employment or income outcomes. Findings of assertive community treatment on housingstability, quality-of-life and hospital-admission outcomes are mixed. Two trials found that participants receiving the treatment reported fewer days homeless (p < 0.01)71 and more days in community housing (p = 0.006),70 whereas 2 trials reported no effect on episodes of homelessness or number of days homeless.66,73 Further, these interventions showed an added benefit in reducing the number of participants admitted to hospital (mean difference –8.6, p < 0.05) and with visits to the emergency department (mean difference –1.2, p = 0.009).67 Most trials of assertive community treatment reported no significant differences in mental health outcomes, including psychiatric symptoms, substance use, or income-related outcomes between the treatment and control groups. Intensive case management reduced the number of days homeless (pooled standardized mean difference –0.22, 95% CI –0.40 to –0.03), but not the number of days spent in stable housing.78,80,89 In most studies, there was no major improvement in psychological symptoms between the treatment and control groups. However, 1 trial reported significantly greater reductions in anxiety, depression and thought disturbances after 24 months (mean difference change from baseline –0.32, p = 0.007), as well as improved life satisfaction (mean difference 1.23, p = 0.001) using intensive case management.86 One trial reported no significant difference in quality of life.83 Findings on substance use were mixed. Six of the 10 trials reported that intensive case management was associated with improvements in substance use behaviours.74,78,82,84,87,88 Participants receiving intensive case management reported fewer visits to the emergency department (mean difference 19%, p < 0.05) but did not have shorter hospital stays compared with control groups.85 Intensive case management had no effect on the number of days of employment, or on income received from employment; however, income received by participants through public assistance increased (e.g., mean difference 89, 95% CI 8 to 170).78,85 Critical time intervention was beneficial in reducing the number of homeless nights (mean difference –591, p < 0.001) and the odds of homelessness (OR 0.23, 95% CI 0.06 to 0.90) during the final 18 weeks of follow-up.91 Participants receiving the treatment were rehoused sooner than those receiving standard care,95 but did not spend more days rehoused.90 Adults receiving critical time intervention showed significant improvements in psychological symptoms (mean difference –0.14, 95% CI –0.29 to 0.01).90 However, findings for children’s mental health were mixed: children aged 1.5–5 years showed improvements in internalizing (ß coefficient –3.65, 95% CI –5.61 to –1.68) and externalizing behaviours (ß coefficient –3.12, 95% CI –5.37 to –0.86), whereas changes for children aged 6–10 years and 11–16 years were not significant.93 There were no significant effects of critical time intervention on substance-use,90 quality-of-life90,92 or income-related outcomes.96 Two trials reported mixed findings on hospital admission outcomes; in 1 study, allocation to critical time intervention was associated with reduced odds of hospital admission (OR 0.11, 95% CI 0.01 to 0.96) and total number of nights in hospital (p < 0.05) in the final 18 weeks of the trial.97 However, another study reported a greater total number of nights in hospital for the treatment group compared with usual care (1171 v. 912).98 The certainty of the evidence was rated low because several trials introduced high risk of detection and performance bias. Opioid agonist therapy
Ensure access to opioid agonist therapy in primary care or by referral to an addiction specialist, potentially in collaboration with public health or community health centre for linkage to pharmacologic interventions (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on pharmalogic interventions for opioid use disorder.99 Twenty-four reviews, which included 352 unique primary studies, reported on pharmacologic interventions for opioid use disorder among general populations.100–123 We expanded our inclusion criteria to general populations, aware that most studies among “general populations” had a large representation of homeless populations in their samples. We did not identify any substantial reason to believe that the mechanisms of action of our interventions of interest would differ between homeless populations who use substances and the general population of people who use substances. Reviews on pharmacologic interventions reported on the use of methadone, buprenorphine, diacetylmorphine (heroin), levo-a-acetylmethadol, slow-release oral morphine and hydromorphone for treatment of opioid use disorder. We found pooled all-cause mortality rates of 36.1 and 11.3 per 1000 person years for participants out of and in methadone maintenance therapy, respectively (rate ratio 3.20, 95% CI 2.65 to 3.86), and mortality rates of 9.5 per 1000 person years for those not receiving buprenorphine maintenance therapy compared with 4.3 per 1000 person years among those receiving the therapy (rate ratio 2.20, 95% CI 1.34 to 3.61).116 Overdose-specific mortality rates were similarly affected, with pooled overdose mortality rates of 12.7 and 2.6 per 1000 person years for participants out of and in methadone maintenance therapy, and rates of 4.6 and 1.4 per 1000 person years out of and in buprenorphine maintenance therapy.116 Compared with nonpharmacologic approaches, methadone maintenance therapy had no significant GUIDELINE CMAJ
ISSUE 10 E245 effect on mortality (relative risk 0.48, 95% CI 0.10 to 2.39).110 With respect to morbidity, pharmacologic interventions for opioid use disorder reduced the risk of hepatitis C virus (HCV) acquisition (risk ratio 0.50, 95% CI 0.40 to 0.63)112 and HIV infection.103 Adverse events were reported for all agents.100,109,119,122 Treatment with methadone and buprenorphine was associated with reduced illicit opioid use (standardized mean difference –1.17, 95% CI –1.85 to –0.49).109 Availability of buprenorphine treatment expanded access to treatment for patients unlikely to enrol in methadone clinics and facilitated earlier access for recent initiates to opioid use.117 The relative superiority of one pharmacologic agent over another on retention outcomes remains unclear; however, use of methadone was found to show better benefits than nonpharmacologic interventions for retention (risk ratio 4.44, 95% CI 3.26 to 6.04).110 The certainty of evidence ranged from very low to moderate, primarily because of inconsistency, high risk of bias and evidence from nonrandomized studies. Harm-reduction interventions
Identify problematic substance use, including alcohol or other drugs.
Identify the most appropriate approach or refer to local addiction and harm reduction/prevention services (e.g., supervised consumption facilities, managed alcohol programs) via appropriate local resources, such as public health or community health centre or les centres locaux de services communautaires (low certainty, conditional recommendation). Evidence summary We conducted a review of systematic reviews on supervised consumption facilities and managed alcohol programs.99 Two systematic reviews, which included 90 unique observational studies and 1 qualitative meta-synthesis reported on supervised consumption facilities.124–126 For managed alcohol programs, 1 Cochrane review had no included studies,127 and 2 greyliterature reviews reported on 51 studies.128,129 Establishment of supervised consumption facilities was associated with a 35% decrease in the number of fatal opioid overdoses within 500 m of the facility (from 253.8 to 165.1 deaths per 100 000 person years, p = 0.048), compared with 9% in the rest of the city (Vancouver).124 There were 336 reported opioid overdose reversals in 90 different individuals within the Vancouver facility over a 4-year period (2004–2008).125 Similar protective effects were reported in Australia and Germany. Observational studies conducted in Vancouver and Sydney showed that regular use of supervised consumption facilities was associated with decreased syringe sharing (adjusted OR 0.30, 95% CI 0.11 to 0.82), syringe reuse (adjusted OR 2.04, 95% CI 1.38 to 3.01) and public-space injection (adjusted OR 2.79, 95% CI 1.93 to 3.87).125 These facilities mediated access to ancillary services (e.g., food and shelter) and fostered access to broader health support.125,126 Attendance at supervised consumption facilities was associated with an increase in referrals to an addiction treatment centre and initiation of methadone maintenance therapy (adjusted hazard ratio 1.57, 95% CI 1.02 to 2.40).125 Evidence on supervised consumption facilities was rated very low to low, as all available evidence originated from nonrandomized studies. There was a lack of high-quality evidence for managed alcohol programs. Few studies reported on deaths among clients of these programs.128 The effects of managed alcohol programs on hepatic function are mixed, with some studies reporting improvement in hepatic laboratory markers over time, and others showing increases in alcohol-related hepatic damage;129 however, this may have occurred regardless of entry into such a program. This evidence suggested that managed alcohol programs result in stabilized alcohol consumption and can facilitate engagement with medical and social services.128 Clients experienced significantly fewer social, health, safety and legal harms related to alcohol consumption.129 Individuals participating in these programs had fewer hospital admissions and a 93% reduction in emergency service contacts.128 The programs also promoted improved or stabilized mental health128 and medication adherence.129 Cost effectiveness and resource implications Permanent supportive housing We found 19 studies assessing the cost and net cost of housing interventions.30,41,45,130–145 In some studies, permanent supportive housing interventions were associated with increased cost to the payers, and the costs of the interventions were only partially offset by savings in medical and social services as a result of the intervention.30,41,131–134,142 Six studies showed that these interventions saved payers money.135,137,139,141,144,145 Four of these studies, however, employed a pre–post design.135,139,141,145 Moreover, 1 cost-utility analysis of PSH suggested that the provision of housing services was associated with increased costs and increased quality-adjusted life years, with an incremental cost-effectiveness ratio of US$62 493 per quality-adjusted life year.136 Compared with usual care, PSH was found to be more costly to society (net cost Can$7868, 95% CI $4409 to $11 405).138 Income assistance Two studies55,146 focused on the cost effectiveness of incomeassistance interventions. Rental assistance with clients receiving case-management intervention had greater annual costs compared with usual care or groups receiving only case management.55 For each additional day housed, clients who received income assistance incurred additional costs of US$58 (95% CI $4 to $111) from the perspective of the payer, US$50 (95% CI –$17 to $117) from the perspective of the health care system and US$45 (95% CI –$19 to $108) from the societal perspective. The benefit gained from temporary financial assistance was found to outweigh its costs with a net savings of US$20 548.146 Case management Twelve publications provided evidence on cost and costeffectiveness of case-management interventions.44,55,67,69,73,75,88,96,147–150 Findings of these studies were mixed; the total cost incurred by clients of standard case management was higher than that of clients receiving usual or standard care61,88 and assertive GUIDELINE E246 CMAJ
ISSUE 10 community treatment,67,147 but lower compared with a US clinical case-management program that included housing vouchers and intensive case management.55 Cost-effectiveness studies using a societal perspective showed that standard case management was not cost effective compared with assertive community treatment for people with serious mental disorders or those with a concurrent substance-use disorder, as it was more expensive.67 For intensive case management, the cost of supporting housing with this program could be partially offset by reductions in the use of emergency shelters and temporary residences.41 Intensive case management is more likely to be cost effective when all costs and benefits to society are considered.41 A pre–post study showed that providing this program to high-need users of emergency departments resulted in a net hospital cost savings of US$132 726.150 Assertive community treatment interventions were associated with lower costs compared with usual care.66,67,73,148,149 We identified only 1 study on the cost effectiveness of critical time intervention that reported comparable costs (US$52 574 v. US$51 749) of the treatment compared with the usual services provided to men with severe mental illness.96 Interventions for substance use We identified 2 systematic reviews that reported findings from 6 studies in Vancouver on the cost effectiveness of supervised consumption facilities;124,125 5 of these 6 studies found the facilities to be cost effective. After consideration of facility operating costs, supervised consumption facilities saved up to Can$6 million from averted overdose deaths and incident HIV cases. Similarly, Can$1.8 million was saved annually from the prevention of incident HCV infection. Clinical considerations Providers can, in partnership with directly affected communities, employ a range of navigation and advocacy tools to address the root causes of homelessness, which include poverty caused by inadequate access to social assistance, precarious work, insufficient access to quality child care, social norms that allow the propagation of violence in homes and communities, inadequate supports for patients and families living with disabilities or going through life transitions, and insufficient and poor-quality housing stock.151 In addition, providers should tailor their approach to the patient’s needs and demographics, taking into account access to services, personal preferences and other illnesses.152 Providers should also recognize the social and human value of accepting homeless and vulnerably housed people into their clinical practices. The following sections provide additional evidence for underserved and marginalized populations. Women A scoping review of the literature on interventions for homeless women (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) yielded 4 systematic reviews153–156 and 9 randomized controlled trials (RCTs)36,60,92,95,157–161 that focused specifically on homeless and vulnerably housed women. Findings showed that PSH was effective in reducing the risk of intimate partner violence and improving psychological symptoms.158 For women with children experiencing homelessness, priority access to permanent housing subsidies can reduce child separations and foster care placements, allowing women to maintain the integrity of their family unit.158 As well, Housing First programs for families, critical time interventions during times of crisis, and therapeutic communities are associated with lower levels of psychological distress, increased self-esteem and improved quality of life for women and their families.92,155 A gender-based analysis highlighted the importance of safety, service accessibility and empowerment among homeless women. We suggest that providers focus on patient safety, empowerment among women who have faced genderbased violence, and improve access to resources, including income, child care and other social support services. Youth A systematic review on youth-specific interventions reported findings from 4 systematic reviews and 18 RCTs.162 Permanent supportive housing improved housing stability. As well, individual cognitive behavioural therapy has been shown to result in significant improvements in depression scores, and family-based therapies are also promising, resulting in reductions in youth substance use through restoring the family dynamic. Findings on motivational interviewing, skill building and case-management interventions were inconsistent, with some trials showing a positive impact and others not identifying significant benefits. Refugee and migrant populations A qualitative systematic review on homeless migrants (Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020) identified 17 qualitative articles that focused on the experiences of homeless migrants.163–179 Findings indicated that discrimination, limited language proficiency and severed social networks negatively affected homeless migrants’ sense of belonging and access to social services, such as housing. However, employment opportunities provided a sense of independence and improved social integration. Methods Composition of participating groups In preparation for the guideline, we formed the Homeless Health Research Network (https://methods.cochrane.org/equity/ projects/homeless-health-guidelines), composed of clinicians, academics, and governmental and nongovernmental stakeholders. The Homeless Health Guideline Steering Committee (K.P. [chair], C.K., T.A., A.A., G.S., G.B., D.P., E.A., V.B., V.S. and P.T.) was assembled to coordinate guideline development. Expert representation was sought from eastern and western Canada, Ontario, Quebec and the Prairie provinces for membership on the steering committee. In addition, 5 people with lived experience of homelessness (herein referred to as “community scholars”180) were recruited to participate in the guideline-development activities. A management committee (K.P., C.K. and P.T.) oversaw the participating groups and monitored competing interests. The steering committee decided to develop a single guideline publication informed by a series of 8 systematic reviews. The GUIDELINE CMAJ
ISSUE 10 E247 steering committee assembled expert working groups to operationalize each review. Each working group consisted of clinical topic experts and community scholars who were responsible for providing contextual expertise. The steering committee also assembled a technical team, which provided technical expertise in the conduct and presentation of systematic reviews and meta-analyses. Finally, the steering committee assembled the guideline panel, which had the responsibility to provide external review of the evidence and drafted recommendations. The panel was composed of 17 individuals, including physicians, primary care providers, internists, psychiatrists, public health professionals, people with lived experience of homelessness, medical students and medical residents. Panel members had no financial or intellectual conflicts of interest. A full membership list of the individual teams’ composition is available in Appendix 2, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.190777/-/DC1. Selection of priority topics We used a 3-step modified Delphi consensus method (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) to select priority health conditions for marginalized populations experiencing homelessness or vulnerable housing. Briefly, between May and June 2017, we developed and conducted a survey (in French and English), in which we asked 84 expert providers and 76 people with lived homelessness experience to rank and prioritize an initial list of needs and populations. We specifically asked participants, while answering the Delphi survey, to keep in mind 3 priority-setting criteria when considering the unique challenges of implementing health care for homeless or vulnerably housed people: value added (i.e., the opportunity for a unique and relevant contribution), reduction of unfair and preventable health inequities, and decrease in burden of illness (i.e., the number of people who may have a disease or condition).181 The initial top 4 priority needs identified were as follows: facilitating access to housing, providing mental health and addiction care, delivering care coordination and case management, and facilitating access to adequate income. The priority marginalized populations identified included Indigenous people; women and families; youth; people with acquired brain injury, or intellectual or physical disabilities; and refugees and other migrants (Esther Shoemaker, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Each working group then scoped the literature using Google Scholar and PubMed to determine a list of interventions and terms relating to each of the priority-need categories. Each working group came to consensus on the final list of interventions to be included (Table 3). Guideline development We followed the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach for the development of this clinical guideline, including the identification of clinical questions, systematic reviews of the best available evidence, Table 3: Descriptions of priority-need interventions Intervention Description Permanent supportive housing
Long-term housing in the community with no set preconditions for access. Housing may be paired with the provision of individualized supportive services that are tailored to participants’ needs and choices, including assertive community treatment and intensive case management.
This guideline groups the Housing First model (a homeless assistance approach that prioritizes providing housing) with permanent supportive housing. Income assistance
Benefits and programs that improve socioeconomic status. This may include assistance that directly increases income and programs that help with cost reduction of basic living necessities.
This guideline also groups employment programs (e.g., individual placement and support, and compensated work therapy) in this category. Case management
Standard case management allows for the provision of an array of social, health care and other services with the goal of helping the client maintain good health and social relationships.
Intensive case management offers the support of a case manager who brokers access to an array of services. Case-management support can be available for up to 12 hours per day, 7 days a week, and each case manager often has a caseload of 15–20 service users.
Assertive community treatment offers team-based care to individuals with severe and persistent mental illness by a multidisciplinary group of health care workers in the community. This team should be available 24 hours per day, 7 days per week.
Critical time intervention supports continuity of care for service users during times of transition. Case management is administered by a critical time intervention worker and is a time-limited service, usually lasting 6–9 months. Pharmacologic interventions for substance use disorder
Pharmacologic interventions for opioid use disorder, including methadone, buprenorphine, diacetylmorphine, levo-a-acetylmethadol and naltrexone.
Pharmacologic agents for reversal of opioid overdose: opioid antagonist administered intravenously or intranasally (e.g., naloxone). Harm reduction for substance use disorders
Supervised consumption facilities: facilities (stand-alone, co-located or pop-up) where people who use substances can consume preobtained substances under supervision.
Managed alcohol programs: shelter, medical assistance, social services and the provision of regulated alcohol to support residents with severe alcohol use disorder. GUIDELINE E248 CMAJ
ISSUE 10 assessment of the certainty of the evidence and development of recommendations.182 We conducted a series of systematic reviews to answer the following clinical question: Should PSH, income assistance, case management, pharmacologic agents for opioid use, and/or harm-reduction interventions be considered for people with lived experience of homelessness? Systematic reviews for each intervention were driven by a logic model. A detailed description of the methods used to compile evidence summaries for each recommendation, including search terms, can be found in Appendix 3, available at www.cmaj.ca/ lookup/suppl/doi:10.1503/cmaj.190777/-/DC1. We sought evidence on questions considering population, interventions and comparisons according to published a priori protocols.183–186 We used relevant terms and structured search strategies in 9 bibliographic databases for RCTs and quasi-experimental studies. The technical team reviewed titles, abstracts and full texts of identified citations, selected evidence for inclusion and compiled evidence reviews, including cost-effectiveness and resource-use data, for consideration by the guideline panel. The technical team collected and synthesized data on the following a priori outcomes: housing stability, mental health, quality of life, substance use, hospital admission, employment and income. Where possible, we conducted meta-analyses with random effects and assessed certainty of evidence using the GRADE approach. Where pooling of results was not appropriate, we synthesized results narratively. In addition to the intervention and cost-effectiveness reviews, the technical team conducted 3 systematic reviews to collect contextual and population-specific evidence for the populations prioritized through our Delphi process (women, youth, refugees and migrants) (Christine Mathew, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020; Harneel Kaur, University of Ottawa, Ottawa, Ont.: unpublished data, 2020).162 Additionally, we conducted 1 qualitative literature review to capture patient values and preferences, focused on the experiences of people who are homeless in engaging with our selected interventions.20 Drafting of recommendations The steering committee hosted a 2-day knowledge-sharing event, termed the “Homeless Health Summit,” on Nov. 25–26, 2018. Attendees included expert working group members, community scholars, technical team members, and other governmental and nongovernmental stakeholders. Findings from all intervention reviews were presented and discussed according to the GRADE Evidence to Decision framework.187 After the meeting, the steering committee drafted GRADE recommendations (Box 2) through an iterative consensus process. All steering-committee members participated in multiple rounds of review and revision of the drafted clinical recommendations. Guideline panel review We used the GRADE Evidence to Decision framework to facilitate the development of recommendations187–189 (Appendix 4, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.190777/-/DC1). We used GRADEpro and the Panel Voice software to obtain input from the guideline panel.190 Panellists provided input on the wording and strength of the draft recommendations. They also provided considerations for clinical implementation. We required endorsement of recommendations by 60% of panel members for acceptance of a recommendation. After review by the guideline panel, the steering committee reviewed the final recommendations before sign-off. Good practice statements We developed a limited number of good practice statements to support the delivery of the initial evidence-based recommendations. A good practice statement characteristically represents situations in which a large and compelling body of indirect evidence strongly supports the net benefit of the recommended action, which is necessary for health care practice.191–193 Guideline-development groups consider making good practice statements when they have high confidence that indirect evidence supports net benefit, there is a clear and explicit rationale connecting the indirect evidence, and it would be an onerous and unproductive exercise and thus a poor use of the group’s limited resources to collect this evidence. The steering committee came to a consensus on 3 good practice statements based on indirect evidence. Identification of implementation considerations We completed a mixed-methods study to identify determinants of implementation across Canada for the guideline (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020). Briefly, the study included a survey of 88 stakeholders and semistructured interviews with people with lived experience of homelessness. The GRADE Feasibility, Acceptability, Cost (affordability) and Equity (FACE) survey collected data on guideline priority, feasibility, acceptability, cost, equity and intent to implement. We used a framework analysis and a series of meetings (Ottawa, Ont., Jan. 13, 2020; Hamilton, Ont., Aug. 16, 2019; Gatineau, Que., July 18, 2019) with relevant stakeholders in the field of homeless health to analyze our implementation data. Management of competing interests Competing interests were assessed using a detailed form adapted from the International Committee of Medical Journal Editors Uniform Disclosure Form for Potential Conflicts of Interest194 and the Elsevier sample coauthor agreement form for a scientific project, contingencies and communication.195 These forms were collected at the start of the guideline activities for the steering committee, guideline panel and community scholars. All authors submitted an updated form in June 2019 and before publication. The management committee iteratively reviewed these statements and interviewed participants for any clarifications and concerns. A priori, the management committee had agreed that major competing interests would lead to dismissal. There were no competing interests declared. Implementation Our mixed-methods study (Olivia Magwood, Bruyère Research Institute, Ottawa, Ont.: unpublished data, 2020) looking at guideline priority, feasibility, acceptability, cost, equity and intent to implement, identified the following concerns regarding implementation of this guideline. GUIDELINE CMAJ
ISSUE 10 E249 Stakeholders highlighted the importance of increasing primary care providers’ knowledge of the process of applying to PSH programs and informing their patients about the resources available in the community. The major concerns regarding feasibility arose around the limited availability of existing services, such as housing, as well as administrative and human resources concerns. For example, not all primary care providers work in a team-based comprehensive care model and have access to a social worker or care coordinator who can help link the patient to existing services. Furthermore, wait lists for PSH are frequently long. Despite this, all stakeholders agreed that access to PSH was a priority and is a feasible recommendation. Allied health practitioners and physicians do not always agree with their new role in this area. Some feedback suggested pushback from family physicians who have limited time with patients and less experience exploring social determinants of health, such as housing or income. The initial steps outlined in this guideline would come at an opportunity cost for them. Stigma attached to the condition of homelessness was recognized as an important barrier to care for homeless populations. Many stakeholders recognized that successful implementation of these recommendations may require moderate costs to increase the housing supply, income supports and human resources. However, supervised consumption facilities, with their range of benefits, were perceived as cost-saving. Many interventions have the potential to increase health equity, if available and accessible in a local context. Many stakeholders highlighted opportunities to increase knowledge of the initial steps and advocate on a systematic level to increase availability of services. Suggested performance measures We developed a set of performance measures to accompany this guidleline for consideration by providers and policy-makers:
The proportion of adults who are assessed for homelessness or vulnerable housing over 1 year.
The proportion of eligible adults who are considered for income assistance over 1 year.
The proportion of eligible adults using opioids who are offered opioid agonist therapy over 1 year. Updates The Homeless Health Research Network will be responsible for updating this guideline every 5 years. Other guidelines This guideline complements other published guidelines. This current guideline aims to support the upcoming Indigenousspecific guidelines that recognize the importance of Indigenous leadership and methodology that will recognize distinct underlying causes of Indigenous homelessness (Jesse Thistle, York University, Toronto, Ont.: personal communication, 2020). The World Health Organization has developed guidelines to promote healthy housing standards to save lives, prevent disease and increase quality of life.196 Other guidelines specific to opioid use disorder exist,197,198 including 1 for “treatment-refractory” patients.199 In the United Kingdom, the National Institute for Health Care and Excellence has published guidelines for outpatient treatment of schizophrenia and has published multimorbidity guidelines (www.nice.org.uk/guidance). The National Health Care for the Homeless Council in the US has adapted best practices to support front-line workers caring for homeless populations.200 How is this guideline different? This guideline distills initial steps and evidence-based approaches, to both homeless and vulnerably housed people, with the assistance of patients and other stakeholders. It also introduces a new clinical lens with upstream interventions that provide a social and health foundation for community integration. Its initial steps support the vision of the Centre for Homelessness Impact in the UK, which envisions a society where the experience of homelessness, in instances where it cannot be prevented, is only ever rare, brief and nonrecurrent.201 Finally, we hope that our stakeholder engagement inspires and equips future students, health providers and the public health community to implement the initial step recommendations. Gaps in knowledge Evidence-based policy initiatives will need to address the accelerating health and economic disparities between homeless and general housed populations. As primary care expands its medical home models,27 there will be a research opportunity for more traumainformed care202 to support the evidence-based interventions in this guideline. Indeed, clinical research can refine how providers use the initial steps protocol: housing, income, case management and addiction. With improved living conditions, care coordination and continuity of care, research and practice can shift to treatable conditions, such as HIV and HCV infection, substance use disorder, mental illness and tuberculosis.203 Medical educators will also need to develop new training tools to support the delivery of interventions. Curricula and training that support the delivery of interventions, such as traumainformed and patient-centred care, will also be needed.12 Many of the recommended interventions in this guideline rely on collaboration of community providers, housing coordinators and case management. Interdisciplinary primary care research and maintenance of linkages to primary care will benefit from new homeless health clinic networks. Monitoring transitions in care and housing availability will be an important research goal for Canada’s National Housing Strategy and the associated Reaching Home program. Conclusion Homelessness has become a health emergency. Initial steps in addressing this crisis proposed in this guideline include strongly recommending PSH as an urgent intervention. The guideline also recognizes the trauma, disability, mental illness and stigma GUIDELINE E250 CMAJ
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Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government

https://policybase.cma.ca/en/permalink/policy13940
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
  1 document  
Policy Type
Policy endorsement
Date
2018-12-15
Topics
Population health/ health equity/ public health
Health systems, system funding and performance
Ethics and medical professionalism
Text
Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON This open letter is signed by the following organizations and individuals: Bathurst United Church TOPS 1. Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON 2. Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON 3. Michaela Beder, MD FRCPC, Psychiatrist, Toronto ON 4. Ritika Goel, MD, Family Physician, Toronto ON 5. Gordon Guyatt, MD FRCPC, Internal Medicine Specialist, McMaster University, Hamilton ON 6. Melanie Spence, RN, Nursing, South Riverdale Community Health Centre, Toronto ON 7. Yipeng Ge, BHSc, Medical Student, University of Ottawa, Ottawa ON 8. Stephen Hwang, MD, Professor of Medicine, University of Toronto, Toronto ON 9. Gigi Osler, BScMed, MD, FRCSC, Otolaryngology-Head and Neck Surgery, Canadian Medical Association, Ottawa ON 10. Anjum Sultana, MPH, Public Policy Professional, Toronto ON 11. Danyaal Raza, MD, MPH, CCFP, Family Medicine, Toronto ON 12. P.J. Devereaux, MD, PhD, Cardiologist, McMaster University, Brantford ON 13. Mathura Karunanithy, MA, Public Policy Researcher, Toronto ON 14. Philip Berger, MD, Family Physician, Toronto ON 15. Nanky Rai, MD MPH, Primary Care Physician, Toronto ON 16. Michaela Hynie, Prof, Researcher, York University, Toronto ON 17. Meb Rashid, MD CCFP FCFP, Family Physician, Toronto ON 18. Sally Lin, MPH, Public Health, Victoria BC 19. Jonathon Herriot, BSc, MD, CCFP, Family Physician, Toronto ON 20. Carolina Jimenez, RN, MPH, Nurse, Toronto ON 21. Rushil Chaudhary, BHSc, Medical Student, Toronto ON 22. Nisha Toomey, MA (Ed), PhD Student, University of Toronto, Toronto ON 23. Matei Stoian, BSc, BA, Medical Student, McMaster University, Hamilton ON 24. Ruth Chiu, MD, Family Medicine Resident, Kingston ON 25. Priya Gupta, Medical Student, Hamilton ON 26. The Neighbourhood Organization (TNO), Toronto, ON 27. Mohammad Asadi-Lari, MD/PhD Candidate, University of Toronto, Toronto ON 28. Kathleen Hughes, MD Candidate, McMaster University, Hamilton ON 29. Nancy Vu, MPA, Medical Student, McMaster University, Hamilton ON 30. Ananthavalli Kumarappah, MD, Family Medicine Resident, University of Calgary, Calgary AB 31. Renee Sharma, MSc, Medical Student, University of Toronto, Toronto ON 32. Daniel Voloshin, Medical Student , McMaster Medical School , Hamilton ON 33. Sureka Pavalagantharajah, Medical Student, McMaster University, Hamilton ON 34. Alice Cavanagh , MD/PhD Student, McMaster University, Hamilton ON 35. Krish Bilimoria, MD(c), Medical Student, University of Toronto, North York ON 36. Bilal Bagha, HBSc, Medical Student, St. Catharines ON 37. Rana Kamhawy, Medical Student, Hamilton ON 38. Annie Yu, Medical Student, Toronto ON 39. Samantha Rossi, MA, Medical Student, University of Toronto, Toronto ON 40. Carlos Chan, MD Candidate, Medical Student, McMaster University, St Catharines ON 41. Jacqueline Vincent, MA, Medical Student, McMaster, Kitchener ON 42. Eliza Pope, BHSc, Medical Student, University of Toronto, Toronto ON 43. Cara Elliott, MD, Medical Student, Toronto ON 44. Antu Hossain, MPH, Public Health Professional, East York ON 45. Lyubov Lytvyn, MSc, PhD Student in Health Research, McMaster University, Burlington ON 46. Michelle Cohen, MD, CCFP, Family Physician, Brighton ON 47. Serena Arora, Medical Student, Hamilton ON 48. Saadia Sediqzadah, MD, Psychiatrist, Toronto ON 49. Maxwell Tran, Medical Student, University of Toronto, Toronto ON 50. Asia van Buuren, BSc, Medical Student, Toronto ON 51. Darby Little, Medical Student, University of Toronto, Toronto ON 52. Ximena Avila Monroy, MD MSc, Psychiatry Resident, Sherbrooke QC 53. Abeer Majeed, MD, CCFP, Family Physician, Toronto ON 54. Oluwatobi Olaiya, RN, Medical Student, Hamilton ON 55. Ashley Warnock, MSc, HBSc, HBA, Medical Student, McMaster University, Hamilton ON 56. Nikhita Singhal, Medical Student, Hamilton ON 57. Nikki Shah, MD Candidate, Medical Student, Hamilton ON 58. Karishma Ramjee, MD Family Medicine Resident , Scarborough ON 59. Yan Zhang, MSc, Global Health Professional, Toronto ON 60. Megan Saunders, MD, Family Physician, Toronto ON 61. Pooja Gandhi, MSc, Speech Pathologist, Mississauga ON 62. Julianna Deutscher, MD, Resident, Toronto ON 63. Diana Da Silva, MSW, Social Worker, Toronto ON Health Care Coverage for Migrants: An Open Letter to the Canadian Federal Government Sign here - https://goo.gl/forms/wAXTJE6YiqUFSo8x1 The Right Honourable Justin Trudeau, Prime Minister of Canada The Honourable Ginette P. Taylor, Minister of Health The Honourable Ahmed D. Hussen, Minister of Immigration, Refugees and Citizenship CC: Mr. Dainius Puras, United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of health Dear Prime Minister Trudeau & Ministers Taylor and Hussen, We are writing to you today as members of the health community to urge your action on a crucial matter pertaining to health and human rights. You will no doubt be aware that the United Nations Human Rights Committee (UNHRC) recently issued a landmark decision condemning Canada for denying access to essential health care on the basis of immigration status based on the case of Nell Toussaint. Nell is a 49-year-old woman from Grenada who has been living in Canada since 1999, and who suffered significant negative health consequences as a result of being denied access to essential health care services. The UNHRC’s decision condemns Canada’s existing discriminatory policies, and finds Canada to be in violation of both the right to life, as well as the right to equality and freedom from discrimination. Based on its review of the International Covenant on Civil and Political Rights, the UNHRC has declared that Canada must provide Nell with adequate compensation for the significant harm she suffered. As well, they have called on Canada to report on its review of national legislation within a 180-day period, in order “to ensure that irregular migrants have access to essential health care to prevent a reasonably foreseeable risk that can result in loss of life”. The United Nations Special Rapporteur has pushed for the same, calling on the government “to protect health-related rights to life, security of the person, and equality of individuals and groups in situations of vulnerability”. Nell is one of an estimated half million people in Ontario alone who are denied access to health coverage and care on the basis of their immigration status, putting their health at risk. As members of Canada’s health community, we are appalled by the details of this case as well as its broad implications, and call on the government to: 1. Comply with the UNHRC’s order to review existing laws and policies regarding health care coverage for irregular migrants. 2. Ensure appropriate resource allocation, so that all people in Canada are provided universal and equitable access to health care services, regardless of immigration status. 3. Provide Nell Toussaint with adequate compensation for the significant harm she has suffered as a result of not receiving essential health care services. For more information on this issue, please see our backgrounder here: https://goo.gl/V9vPyo. Sincerely, Arnav Agarwal, MD, Internal Medicine Resident, University of Toronto, Toronto ON Nisha Kansal, BHSc, MD Candidate, McMaster University, Hamilton ON Michaela Beder, MD, Psychiatrist, Toronto ON Ritika Goel, MD, Family Physician, Toronto ON
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The Lancet Countdown on Health and Climate Change - Policy brief for Canada

https://policybase.cma.ca/en/permalink/policy14257
Date
2019-11-01
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2019-11-01
Topics
Population health/ health equity/ public health
Text
The Lancet Countdown on Health and Climate Change Policy brief for Canada 1 Finding: Exposure to wildfires is increasing in Canada, with more than half of the 448,444 Canadians evacuated due to wildfires between 1980 and 2017 displaced in the last decade. Recommendation: Incorporate lessons learned from recent severe wildfire seasons into a strengthened pan-Canadian emergency response approach that anticipates increasing impacts as the climate continues to change. Finding: The percentage of fossil fuels powering transport in Canada remains high, though electricity and biofuels are gaining ground. Fine particulate air pollution generated by transportation killed 1063 Canadians in 2015, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars. Recommendation: Develop provincial and territorial legislation requiring automakers to gradually increase the annual percentage of new light-duty vehicles sold that are zero emissions, working toward a target of 100% by 2040. Finding: Canada has the third-highest per capita greenhouse gas emissions from healthcare in the world, with healthcare accounting for approximately 4% of the country’s total emissions. Recommendation: Establish a sustainable healthcare initiative that assembles experts from research, education, clinical practice, and policy to support Canada’s healthcare sector in reducing greenhouse gas emissions and preventing pollution-related deaths, consistent with healthcare’s mandate to ‘do no harm’ and the timelines and goals of the Paris Agreement, charting a course for zero-emissions healthcare by 2050. Finding: The health of Canadians is at risk due to multiple and varied risks of climate change, including those described in this policy brief (see Figure 1). An ongoing, coordinated, consistent and pan-Canadian effort to track, report, and create healthy change is required. Recommendation: Integrate health considerations into climate-related policymaking across sectors, including in Canada’s updated 2020 Nationally Determined Contribution Commitments under the United Nations Framework Convention on Climate Change (UNFCCC) process, and increase ambition to ensure Canada commits to doing its fair share in achieving the goals of the Paris Agreement. Introduction Climate change is the biggest global health threat of the 21st century,1 and tackling it could be our greatest health opportunity.2 “The health of a child born today will be impacted by climate change at every stage in their life. Without significant intervention, this new era will come to define the health of an entire generation.”3 However, another path is possible: a world that meets the ambition of the Paris Agreement and proactively adapts to protect health from the climate impacts we cannot now avoid. This year’s briefing presents key findings and recommendations toward this path. Key messages and recommendations Health and climate change in Canada Imagine an infant born today in Canada. This child enters a country warming at double the global rate, with the average temperature in Canada having increased 1.7oC between 1948-2016.4 The North is warming even faster: areas in the Northwest Territories’ Mackenzie Delta are now 3oC warmer than in 1948.5 Climate-related impacts on health and health systems are already being felt,6 with examples outlined in Figure 1. By the time the child is in their twenties, in all feasible emissions scenarios, Canada will have warmed by at least 1.5oC as compared to a 1986-2005 reference period.4 Two scenarios are possible for the remainder of the child’s life. If GHG emissions continue to rise at the current rate (a situation referred to by the Intergovernmental Panel on Climate Change (IPCC) as the “high emissions scenario,” or ‘RCP8.5’) temperature increases in Canada will continue after 2050, reaching 6oC relative to 1986-2005 by the time the child is in their child’s sixties.4 Globally, this degree of warming places populations at a greater risk of wildfires, extreme heat, poor air quality, and weather-related disasters. It will also lead to changes in vector-borne disease, as well as undernutrition, conflict, and migration. These impacts and others negatively impact mental health,3 including via ecological anxiety and grief.8 Climate change will not impact everyone equally, and can widen existing disparities in health outcomes between and within populations, with Indigenous populations, people in low-resource settings,28 and future generations29 disproportionately affected.30 This degree of warming has the potential to disrupt core public health infrastructure and overwhelm health services.2 Alternatively, if global emissions peak soon and quickly fall to net zero, consistent with the IPCC’s low-emissions scenario, (RCP 2.6), temperatures will remain steady from 2040 onwards.4 Measures needed to accomplish this, such as increasing clean energy, improving Figure 1: Examples of impacts of Climate Change on Health and Health Systems in Canada Indicators of climate-related health impacts and adaptation This year’s policy brief presents information on three key indicators of climate-related health impacts and adaptive responses. Additional recommendations can also be found in the 2017 and 2018 policy briefs.6,24 Wildfires Lancet Countdown data indicates that the number of daily population wildfire exposure events increased from an average of 35,300 in 2001-2004 to 54,100 in 2015-2018, not including those subjected to wildfire smoke. Canadian data supports increasing impacts: more than half of the 448,444 Canadians evacuated due to wildfires between 1980-2017 were displaced in the last decade.35 These exposures not only pose a threat to public health, but also result in major economic and social burdens. 2019 marks a crux point for humanity: choices and policies made in the lead up to the 2020 UNFCCC Nationally Determined Contribution submissions will determine whether the world follows the disastrous high-emissions scenario, or the safer low-emissions path. Children are taking to the streets to demand a livable world. It is the task of today’s political leaders and other adults to exert maximal effort within their spheres of influence in order to set a course for a healthy response to climate change. public transit, cycling and walking rates, and adhering to a plantrich diet in accordance with Canada’s new food guide, decrease emissions, and also improve health and decrease healthcare costs.30 Canada is not on track: in 2016, total Canadian GHG emissions were 704 Mt CO2e, an increase of more than 100 Mt since 1990.31 Policies and measures currently under development but not yet implemented are forecast to reduce national emissions to 592 Mt CO2e by 2030,32 79 Mt CO2e above Canada’s 2030 target of 513 MtCO2e 32—a goal which is itself too weak to represent a fair contribution by Canada to the emissions reductions necessary to meet the goals of the Paris Climate Change Agreement. The Earth as a whole is warming less quickly than Canada—but still far too fast. The IPCC and the World Health Organization have emphasized that keeping global surface temperature warming to 1.5oC is key to obtaining the best outcomes now possible for human health.33,34 To do so would require global net human-caused emissions to fall by about 45% from 2010 by 2030, reaching ‘net zero’ by 2050.34 Updated Nationally Determined Contributions to the Paris Agreement are due to be submitted by 2020: policymakers must integrate health considerations through proposed interventions. Figure 2: Number of Wildfire Evacuees in Canada 1980-2017.* Source: Wildland Fire Evacuation Database, Natural Resources Canada.35 (used with permission) *N.B. Reporting for 2017 only includes evacuations up to and including July In a mid-range GHG emissions scenario, wildfires in Canada are projected to rise 75% rise by the end of the 21st century,36 necessitating a strong adaptive response. Human health impacts of fire include death, trauma, and major burns,37 anxiety during wildfire periods,35,38 and post-traumatic stress disorder, anxiety and depression related to evacuations.39,40 Wildfire smoke also travels vast distances41 and increases asthma and chronic obstructive pulmonary disease exacerbations, with growing evidence of an association with all-cause mortality.41 Impacts on health systems can be severe: during the Fort McMurray fire hospital staff evacuated 103 patients in a matter of hours,10,42 and the 2017 British Columbia wildfires resulted in 700+ staff displaced, 880 patients evacuated, and 19 sites closed by the Interior Health Authority, at a cost of $2.7 million.12 Such devastating events also generate significant emissions, contributing to climate change, and helping to generate conditions conducive to future blazes.43 Much can be done to lessen the health impacts of wildfires. Qualitative data indicates that populations who are better-briefed on the local evacuation plan, as well as ways to lessen the risk of fire to their property, are not only more prepared but also less anxious.35,38 Building codes can be changed to help keep smoke out, primary care practitioners can ensure vulnerable patients receive at-home air filtration systems and respiratory medications prior to wildfire season,44 public health professionals can collaborate with municipal officials to maximize smoke forecast-informed outdoor and well-ventilated indoor recreation opportunities,38 and health personnel can help ensure evacuation plans are clearly communicated.45 Sustainable and healthy transport since 2000, they account for less than 4% of the energy used in transport (Figure 3). This rate of change is inconsistent with the emissions pathway required to keep today’s and future children safe. Support is therefore required for investments in public transit,47 and cycling infrastructure,48 creating win-wins for health by increasing physical activity levels and improving community cohesion, while reducing chronic disease, healthcare costs and GHG emissions.49,50 Zero emissions vehicles also reduce air pollution and are increasingly affordable: the up-front cost of electric vehicles is forecast to become competitive on an un-subsidized basis from 2024 onwards.51 British Columbia recently passed legislation requiring all new cars sold to be zero-emission by 2040.52 Other provinces would benefit from matching this ambition. Figure 3: Per Capita Fuel Consumption for Transport in Canada. Source: Lancet Countdown Transport-related pollution is harming the health of Canadians. Fine particulate matter (PM2.5) air pollution related to land-based transportation was responsible for approximately 1063 deaths in 2015 in Canada, resulting in a loss of economic welfare for Canadians valued at approximately $8 billion dollars.24 Additionally, Canada has the highest pediatric asthma rate amongst countries of comparable income level, with nitrogen dioxide (NO2) from traffic responsible for approximately 1 in 5 new cases of asthma in children.46 With transport responsible for 24% of national GHG emissions in 2017,31 decarbonizing this sector must be prioritized. Progress is entirely too slow: total fuel consumption for road transport per capita decreased 5.4% from 2013 to 2016. While per capita use of electricity and biofuels for transport increased by 600% Healthcare sector emissions Though Canadians are proud of the care they provide for one another with this country’s system of universal healthcare,53 Lancet Countdown analysis reveals an area which should give pause to all who endeavor to “do no harm”: Canada’s healthcare system has the world’s third highest emissions per capita. Previous analysis showed healthcare sector emissions to be responsible for 4.6% of the national total,54 as well as more than 200,000 tons of other pollutants, resulting in 23,000 disability-adjusted life years (DALYs) lost annually.54 Emissions from the health sector represent a strategic mitigation target in a single-payer healthcare system straining under the weight of an inexorably increasing burden of disease. While Canadian healthcare sector emissions are increasing, the world-leading Sustainable Development Unit in England reported an 18.5% decrease in National Health Service, public health and social care system emissions from 2007-2017 despite an increase in clinical activity.55 Despite healthcare being a provincial jurisdiction, there is a role for pan-Canadian sustainability initiatives to unite diverse experts spanning public health and the spectrum of clinical disciplines, economics, sustainability science and beyond. This demands health sector-wide education, consistent with existing efforts to increase environmental literacy for health professionals.56 1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet 2009;373(9676):1693-733. 2. Watts N, Amann M, Arnell N, et al. The 2018 report of The Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet 2018; vol. 392: 2479–514. 3. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet 2019; vol. 394: 1836–78. 4. Government of Canada. Canada’s Changing Climate Ottawa, Ontario,; 2019. 5. Government of the Northwest Territories. Climate Observations in the Northwest Territories (1957-2012) Inuvik * Norman Wells * Yellowknife * Fort Smith. 6. Howard C, Rose C, Hancock T. Lancet Countdown 2017 Report: Briefing for Canadian Policymakers. Lancet Countdown and Canadian Public Health Association; 2017 October 31st, 2017. 7. Rosol R, Powell-Hellyer S, Chan HM. Impacts of decline harvest of country food on nutrient intake among Inuit in Arctic Canada: impact of climate change and possible adaptation plan. Int J Circumpolar Health 2016;75(1):31127. 8. Cunsolo A, Ellis N. Ecological grief as a mental health response to climate change-related loss. Nature Climate Change 2018;8:275-81. 9. Yao J, Eyamie J, Henderson SB. Evaluation of a spatially resolved forest fire smoke model for population-based epidemiologic exposure assessment. J Expo Sci Environ Epidemiol 2016;26(3):233-40. 10. Hampshire G. Hospital heroes get patients to safety during Fort McMurray fire: 17 buses took 105 patients to safety in dramatic evacuation. CBC News. 2016. Available from: http://www.cbc.ca/news/canada/edmonton/hospital-heroesget- patients-to-safety-during-fort-mcmurray-fire-1.3574416. 11. Kirchmeier-Young M, Zwiers F, Gillett N, Cannon A. Attributing extreme fire risk in Western Canada to human emissions. Climatic Change 2017;144(2):365-79. 12. British Columbia Interior Health Authority. Wildfire Emergency Response 2017. 2018. 13. Kirchmeier-Young M, Gillett N, Zwieres F, Cannon A, Anslow F. Attribution of the Influence of Human-Induced Climate Change on an Extreme Fire Season. Earth’s Future: American Geophysical Union 2018. 14. Alberta Health. Impact of Wildfires on the Mental Health of Fort McMurray Residents: Neurotic Disorders, Daily Physician Visits within an Emergency Department 2015 vs. 2016. Alberta Health, Health Standards, Quality and Performance Division, Analytics and Performance Reporting Branch,; 2016. 15. Teufel B, Diro GT, What K, Mildrad SM, Jeong DI, Ganji A, et al. Investigation of the 2013 Alberta flood from weather and climate perspectives. Climate Dynamics 2017:2881-99. 16. Canadian Broadcasting Corporation. Alberta Flood 2013: The five people we lost. 2014. Available from: https://www.cbc.ca/calgary/features/albertaflood2013/ alberta-flood-deaths/. 17. United Nurses of Alberta. UNA Calgary office closed, many health facilities affected by southern Alberta flooding. 2013 June 21, 2013. 18. Yusa A, Berry P, J JC, Ogden N, Bonsal B, Stewart R, et al. Climate Change, Drought and Human Health in Canada. Int J Environ Res Public Health 2015;12(7):8359-412. 19. Smoyer-Tomic KE, Klaver JD, Soskolne CL, Spady DW. Health Consequences of Drought on the Canadian Prairies. EcoHealth 2004. 20. Government of Canada Agriculture and Agri-Food Canada. Impact of Climate Change on Canadian Agriculture. 2015 [Oct 22, 2017]; Available from: http:// www.agr.gc.ca/eng/science-and-innovation/agricultural-practices/agriculture- and-climate/future-outlook/impact-of-climate-change-on-canadian-agriculture/? id=1329321987305 21. Cryderman K. Drought in Western Canada is becoming an agricultural nightmare for farmers. 2018. Available from: https://www.theglobeandmail.com/ canada/alberta/article-drought-in-western-canada-is-becoming-an-agricultural- nightmare-for/. 22. Ziska LH, Makra L, Harry SK, Bruffaerts N, Hendrickx M, Coates F, et al. Temper-ature-related changes in airborne allergenic pollen abundance and seasonality across the northern hemisphere: a retrospective data analysis. Lancet Planet Health 2019;3(3):e124-e31. 23. Nelder MP, Wijayasri S, Russell CN, Johnson KO, Marchand-Austin A, Cronin K, et al. The continued rise of Lyme disease in Ontario, Canada: 2017. Canadian Communicable Disease Review 2018;44(10):231-6. 24. Howard C, Rose C, Rivers N. Lancet Countdown 2018 Report: Briefing for Canadian Policymakers. Canadian Medical Association, Canadian Public Health Association, The Lancet Countdown; 2018 November. 25. a. Regional Public Health Department of Montreal. Epidemiological Investigation Heat Wave Summer 2018 in Montréal - Summary. 2019. b. Vogel MM, Zscheischler J, Wartenburger R, et al. Concurrent 2018 hot extremes across Northern hemisphere due to human-induced climate change. Earth's Future, 2019; vol. 7, 692–703. https://doi.org/10.1029/ 2019EF001189 26. Fenech A. Yes, Mr. Premier, Your Province is Shrinking! 2014 [cited 2019 Sept 20, 2019]; Available from: http://projects.upei.ca/climate/2014/02/16/ yes-mr-premier-your-province-is-shrinking/ 27. Kelleya C, Mohtadib S, Canec M, Seagerc R, Kushnirc Y. Climate change in the Fertile Crescent and implications of the recent Syrian drought. Proceedings of the National Academy of Science 2015;112 no 11: 3241–6,. 28. Berry HL, Bowen K, Kjellstrom T. Climate change and mental health: a causal pathways framework. Int J Public Health 2010;55(2):123-32. 29. Walpole SC, Rasanathan K, Campbell-Lendrum D. Natural and unnatural synergies: climate change policy and health equity. Bull World Health Organ 2009;87(10):799-801. 30. Watts N, Adger WN, Agnolucci P, Blackstock J, Byass P, Cai W, et al. Health and climate change: policy responses to protect public health. Lancet 2015;386(10006):1861-914. 31. Government of Canada. Greenhouse Gas Emissions. 2018 [June 13, 2018.]; Available from: https://www.canada.ca/en/environment-climate-change/ services/environmental-indicators/greenhouse-gas-emissions.html 32. Environment and Climate Change Canada. Canadian Environmental Sustainability Indicators: Progress Towards Canada’s Greenhouse Gas Emissions Reduction Target. 2019 [Sept 3, 2019]; Available from: https://www.canada. ca/content/dam/eccc/documents/pdf/cesindicators/progress-towards-canada- greenhouse-gas-reduction-target/2019/progress-towards-ghg-emissions- target-en.pdf 33. Ebi K, Campbell-Lendrum D, Wyns A. The 1.5 Health Report--Synthesis on Health and Climate Science in the IPCC SR1.5. 2018 2018. 34. Intergovernmental Panel on Climate Change. Global Warming of 1.5C--Summary for Policymakers. 2018 October 8, 2018. 35. Christianson A. Wildland Fire Evacuations in Canada. Natural Resources Canada; 2017. 36. Wotton M, Nock C, Flannigan M. International Journal of Wildland Fire 2010;19(3):253-71. 37. Cameron PA, Mitra B, Fitzgerald M, Scheinkestel CD, Stripp A, Batey C, et al. Black Saturday: the immediate impact of the February 2009 bushfires in Victoria, Australia. Med J Aust 2009;191(1):11-6. 38. Dodd W, Scott P, Howard C, Scott C, Rose C, Cunsolo A, et al. Lived experience of a record wildfire season in the Northwest Territories, Canada. Can J Public Health 2018;109(3):327-37. 39. McDermott BM, Lee EM, Judd M, Gibbon P. Posttraumatic stress disorder and general psychopathology in children and adolescents following a wildfire disaster. Can J Psychiatry 2005;50(3):137-43. 40. Papanikolaou V, Adamis D, Mellon RC, Prodromitis G. Psychological distress following wildfires disaster in a rural part of Greece: a case-control population- based study. Int J Emerg Ment Health 2011;13(1):11-26. 41. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical Review of Health Impacts of Wildfire Smoke Exposure. Environ Health Perspect 2016;124(9):1334-43. 42. Matear D. The Fort McMurray, Alberta wildfires: Emergency and recovery management of healthcare services. J Bus Contin Emer Plan 2017;11(2):128- 50. 43. Liu Y, Goodrick S, Heilman W. Wildland fire emissions, carbon, and climate: Wildfire–climate interactions. Forest Ecology and Management 2014;317:80- 96. 44. Barn PK, Elliott CT, Allen RW, Kosatsky T, Rideout K, Henderson SB. Portable air cleaners should be at the forefront of the public health response to landscape fire smoke. Environ Health 2016;15(1):116. 45. Maguet S. Public Health Responses to Wildfire Smoke Events. BC Center for Disease Control; 2018. 46. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO2 pollution: estimates from global datasets. Lancet Planet Health 2019;3(4):e166-e78. 47. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med 2005;29(4):273-80. 48. United Kingdom Department of Transport. Value for Money Assessment for Cycling Grants. 2014. 49. Woodcock J, Tainio M, Cheshire J, O’Brien O, Goodman A. Health effects of the London bicycle sharing system: health impact modelling study. BMJ 2014;348:g425. 50. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area. Am J Public Health 2013;103(4):703-9. 51. Willett W, Rockstrom J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 2019. 52. Zussman R. Legislation introduced to require all new cars sold in B.C. to be zero-emission by 2040. Global News Online. 2019. Available from: https:// globalnews.ca/news/5152429/legislation-introduced-electric-cars/2019. 53. Thompson N. More Canadians take pride in symbols of the country’s present than its past: survey. 2019. 54. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic- environmental-epidemiological analysis. PLoS Med 2018;15(7):e1002623. 55. National Health System Sustainable Development Unit. Reducing the use of natural resources in health and social care 2018 report. 2018. 56. Parkes M, Poland B, Allison A, Cole DC, Culbert I, Gislason MK, et al. In press-Preparing for the future of public health: Ecological determinants of health and the call for an eco-social approach to public health education. Canadian Journal of Public Health 2019. DOI: 10.17269/s41997-019-00263-8. References Organisations and acknowledgements The concept of this brief was developed by the Lancet Countdown on Health and Climate Change. This brief was written by Courtney Howard, MD; Chris Buse, PhD; Caren Rose, PhD; Andrea MacNeill, MD, MSc; and Margot Parkes, MBChB, MAS, PhD. Review was provided by Owen Adams, PhD; Ian Culbert; and Sandy Buchman, MD. Thanks to Sarah Henderson, PhD; Peter Barry, PhD; Brian Wiens, PhD; Robin Edger, LLB, LLM; Jeff Eyamie, and Ashlee Cunsolo, PhD for their assistance. Contributions and review on behalf of the Lancet Countdown were provided by Jess Beagley and Nick Watts, MBBS. THE LANCET COUNTDOWN The Lancet Countdown: Tracking Progress on Health and Climate Change is an international, multi-disciplinary collaboration that exists to monitor the links between public health and climate change. It brings together 35 academic institutions and UN agencies from every continent, drawing on the expertise of climate scientists, engineers, economists, political scientists, public health professionals, and doctors. Each year, the Lancet Countdown publishes an annual assessment of the state of climate change and human health, seeking to provide decision-makers with access to high-quality evidence-based policy guidance. For the full 2019 assessment, visit www.lancet countdown.org/2019-report . THE CANADIAN MEDICAL ASSOCIATION The Canadian Medical Association (CMA), formed in Quebec City in 1867, has led some of Canada’s most important health policy changes. As we look to the future, the CMA will focus on advocating for a healthy population and a vibrant profession. THE CANADIAN PUBLIC HEALTH ASSOCIATION The Canadian Public Health Association (CPHA) is a national, independent, non-governmental organization that advances public health education, research, policy and practice in Canada and around the world through the Canadian Journal of Public Health, position statements, discussion documents and other resources.
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Open letter to Ontario Minister of Health about the newly proposed “Consumption and Treatment Services” model

https://policybase.cma.ca/en/permalink/policy13932
Date
2018-10-31
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Date
2018-10-31
Topics
Population health/ health equity/ public health
Text
Dear Minister Elliott: We write to you as organizations concerned about the health and welfare of some of the most vulnerable Ontarians, in response to the October 22 announcement that your government plans to replace supervised consumption sites (SCS) and low-barrier overdose prevention sites (OPS) with “Consumption and Treatment Services.”1 While we welcome the stated commitment to maintain existing SCS and OPS in Ontario, we are deeply concerned that your government’s new approach to supervised consumption services is creating more barriers instead of facilitating the rapid-scale up of a diversity of much-needed supervised consumption services across the province. This is especially troubling in the context of the public health crisis in which we now find ourselves. In particular, we are concerned by the decision to impose one “Consumption and Treatment Services” model on service providers and essentially terminate low-threshold, flexible OPS. These life-saving services are part of a continuum of service models that should be made available to all people who use drugs who need them, including the most marginalized. Thousands of overdoses have been reversed using this model, and no deaths recorded at these sites. As you know, OPS were created in response to the urgent need for rapid roll-out of these vital services. A specific legal regime under a federal class exemption issued to Ontario was put in place to allow for their rapid implementation in response to the current crisis. The requirement for both OPS and SCS, including already authorized ones, to undergo a new application process for funding is sapping concerted efforts from the federal and provincial governments to respond to the overdose crisis. Not only does the new application process replicate the onerous federal exemption process for SCS (such as requiring applicants to engage in ongoing community consultations), it will also impose additional requirements including requiring applicants to provide treatment and rehabilitation services and to conduct seemingly more extensive data reporting, monitoring and evaluations — all without dedicating additional funding to allow organizations to adequately comply. Moreover, the requirement for service providers to provide treatment and rehabilitation services is not in line with harm reduction values of meeting people where they are. At the same time, the arbitrary decision to cap the number of sites at 21 without any justification means people who do not reside near existing or impending sites will be denied access to life-saving care, at a time when overdose deaths in Ontario are at an all-time high, with more than three people dying every day in 2017.2 Denying funding to new sites will undoubtedly mean more preventable overdose deaths and new HIV, hepatitis C and other infections. We agree that there are inadequate drug treatment, mental health services and supportive housing options available for people who use drugs, and providing greater support for these services is laudable. But this should not come at the expense of life-saving supervised consumption services, including low-threshold services that are varied, responsive and meet the needs of their communities. We urge you to reconsider the decision to create new hurdles for service providers to receive funding to provide supervised consumption services and to limit the number of sites to 21. We call on you to work with people who use drugs, community organizations and other health service providers to ensure greater, equitable access to SCS and OPS for the people of Ontario. Lives are at stake. Sincerely, Richard Elliott, Executive Director, Canadian HIV/AIDS Legal Network Ryan Peck, Executive Director, HIV & AIDS Legal Clinic Ontario Dr. F. Gigi Osler, President, Canadian Medical Association Michael Villeneuve, Chief Executive Officer, Canadian Nurses Association Ian Culbert, Executive Director, Canadian Public Health Association Sarah Ovens, Coordinator, Toronto Overdose Prevention Society Cc. The Honourable Doug Ford, Premier of Ontario 1 Ministry of Health and Long-Term Care News Release: Ontario Government Connecting People with Addictions to Treatment and Rehabilitation, October 22, 2018, online: https://news.ontario.ca/mohltc/en/2018/10/ontario-government-connecting-people-with-addictions-to-treatment-and-rehabilitation.html. 2 Public Health Ontario, “Opioid-related morbidity and mortality in Ontario” (May 23, 2018), online: https://www.publichealthontario.ca/en/dataandanalytics/pages/opioid.aspx#/trends.
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Proposed UN Convention on the rights of older persons

https://policybase.cma.ca/en/permalink/policy13925
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
  1 document  
Policy Type
Policy endorsement
Last Reviewed
2020-02-29
Date
2018-07-25
Topics
Population health/ health equity/ public health
Text
Dear Minister Freeland: We are a national consortium of experts who serve and advocate for the needs and rights of older people. We are delighted by the recent appointment of a new Minister of Seniors, and send our congratulations to the Honourable Filomena Tassi. We are also encouraged by our Government’s commitment to support the health and economic well-being of all Canadians, and heartened by your promise to listen to, and to be informed by feedback from Canadians. It is in this spirit that we are writing today regarding the need for Canada to provide support and leadership with a goal of developing and ratifying a United Nations (UN) Convention on the Rights of Older Persons. In the context of massive global demographic shifts and an aging population, insightful and careful reflection by the leaders of our organizations has led to universal and strong support for the creation and implementation of a UN Convention to specifically recognize and protect the human rights of our older persons. A UN Convention on the Rights of Older Persons will:
enshrine their rights as equal with any other segment of the population with the same legal rights as any other human being;
categorically state that it is unacceptable to discriminate against older people throughout the world;
clarify the state’s role in the protection of older persons;
provide them with more visibility and recognition both nationally and internationally, which is vitally important given the rate at which Canadian and other societies are ageing;
advance the rights of older women at home and as a prominent factor in Canada’s foreign policy;
have a positive, real-world impact on the lives of older citizens who live in poverty, who are disproportionately older women, by battling ageism that contributes to poverty, ill-health, social isolation, and exclusion;
support the commitment to improve the lives of Indigenous Peoples; members of the LGBTQ community, and visible and religious minorities; and,
provide an opportunity for Canada to play a leadership role at the United Nations while at the same time giving expression to several of the Canadian government’s stated foreign policy goals. We have projected that the cost and impact of not having such a Convention would have a significant negative impact on both the physical and mental health of older Canadians. The profound and tragic consequence would have a domino effect in all domains of their lives including social determinants of health, incidence and prevalence of chronic diseases, social and psychological functioning, not to mention massive financial costs to society. There is recognition of this need internationally and ILC-Canada, along with other Canadian NGOs and organizations have been active at the UN to help raise awareness of the ways a UN Convention on the Rights of Older Persons would contribute to all countries. Changes have already been implemented by our Government that are consistent and aligned with a UN Convention, such as improving the income of vulnerable Canadian seniors, funding for long term care and support for community based dementia programs. These initiatives are all in keeping with support for a Convention on the Rights of Older Persons. They are also reflective of our country’s commitment to engage more fully with the United Nations and provide Canada the stage to demonstrate leadership on a vital international issue. It is an opportunity to champion the values of inclusive government, respect for diversity and human rights including the human rights of women. Scientific evidence demonstrates that human rights treaties help to drive positive change in the lives of vulnerable groups of people. In many countries in the world, older people are not adequately protected by existing human rights law, as explicit references to age are exceedingly rare. Even in countries like Canada, where there are legal frameworks that safeguard older people, a Convention would provide an extra layer of protection, particularly if the Convention has a comprehensive complaints mechanism. Older adults need to be viewed as a growing but underutilized human resource. By strengthening their active role in society including the workforce, they have tremendous capacity, knowledge, and wisdom to contribute to the economy and general well-being of humankind. We are requesting you meet with our representatives, to discuss the vital role of a UN Convention on the Rights of Older Persons and the role your government could play in improving the lives of older people in Canada and around the world. The fact that Canada is ageing is something to celebrate. We are all ageing, whether we are 20 or 85. This is a ”golden opportunity” to showcase Canada as a nation that will relentlessly pursue doing the “right thing” for humanity by supporting a UN Convention that ensures that our future is bright. Please accept our regards, and thank you for your attention to this request. We await your response. Sincerely, Margaret Gillis, President, International Longevity Centre Canada Dr. Kiran Rabheru, Chair of the Board, International Longevity Centre Canada Linda Garcia, Director, uOttawa LIFE Research Institute cc: The Right Honourable Justin Trudeau Prime Minister of Canada The Honourable Filomena Tassi Minister of Seniors The Honourable Jean Yves Duclos Minister for Families, Children and Social Development Ambassador Marc-Andre Blanchard Permanent Representative to Canada at the United Nations The Honourable Ginette Petitpas Taylor Health Minister Margaret Gillis President International Longevity Centre Canada Dr. Kiran Rabheru Chair of the Board, International Longevity Centre Canada Linda Garcia, PhD Director LIFE Research Institute Dr. Laurent Marcoux President Canadian Medical Association Andrew Padmos, BA, MD, FRCPC, FACP Chief Executive Officer Dani Prud’Homme Directeur général FADOQ Peter Lukasiewicz Chief Executive Officer Gowling WLG Dr. Dallas Seitz, MD, FRCPC President, CAGP Dr. Frank Molnar President, Canadian Geriatrics Society Dr. David Conn Co-Leader Canadian Coalition for Senior’s Mental Health Claire Checkland Director - Canadian Coalition for Seniors’ Mental Health Joanne Charlebois Chief Executive Officer, Speech-Language & Audiology Canada Claire Betker President Canadian Nurses Association Janice Christianson-Wood, MSW, RSW Title/Organization: President, Canadian Association of Social Workers / Présidente, l’Association canadienne des travail- leurs sociaux François Couillard Chief Executive Officer/Chef de la direction Ondina Love, CAE Chief Executive Officer Canadian Dental Hygienists Association Jean-Guy Soulière President/Président National Association of Federal Retirees /Association nationale des retraités fédéraux Sarah Bercier Executive Director Laura Tamblyn Watts National Initiative for the Care of the Elderly Dr. Keri-Leigh Cassidy Founder Fountain of Health Dr. Beverley Cassidy Geriatric Psychiatris Seniors Mental Health Dalhousie University Dept of Psychiatry Jenny Neal and Janet Siddall CO Chairs, Leadership Team Grandmothers Advocacy Network (GRAN) Kelly Stone President and CEO Families Canada Dr. Becky Temple, MD, CCFP, CCPE President, CSPL Medical Director Northeast, Northern Health Medical Lead Privilege Dictionary Review, BCMQI J. Van Aerde, MD, MA, PhD, FRCPC Clinical Professor of Pediatrics - Universities of Alberta & British Columbia, Canada Associate Faculty - Leadership Studies - Royal Roads Univ, Victo- ria, BC, Canada Past-President - Canadian Society of Physician Leaders Editor-in-Chief / Canadian Journal of Physician Leadership Dr. Rollie Nichol, MD, MBA, CCFP, CCPE Vice-President, CSPL Associate Chief Medical Officer, Alberta Health Services Dr. Shannon Fraser, MSc, FRCSC, FACS Secretary / Treasurer, CSPL Chief General Surgery Jewish General Hospital Linda Gobessi MD FRCPC Medical Director Geriatric Psychiatry Community Services of Ottawa Ottawa Vickie Demers Executive Director / Directrice générale Services communautaires de géronto- psychiatrie d’ Ottawa Geriatric Psychiatry Community Services of Ottawa Ging-Yuek Robin Hsiung, MD MHSc FRCPC FACP FAAN Associate Professor Ralph Fisher and Alzheimer Society of BC Professor Director of Clinical Research Director of Fellowship in Behavioural Neurology UBC Hospital Clinic for Alzheimer and Related Disorders Division of Neurology, Department of Medicine University of British Columbia Adriana Shnall Senior Social Worker Baycrest Health Sciences Harinder Sandhu, D.D.S., Ph.D Professor and Past Director Schulich Dentistry & Vice Dean, Schulich School of Medicine & Dentistry Western University Dr. Christopher Frank, Chair of Geriatric Education and Recruitment Initiative Jennie Wells, MD Associate Professor, University of Western Ontario Department of Medicine Chair/Chief Division of Geriatric Medicine Parkwood Institute Laura Diachun, MD Program Director, Undergrad Geriatric Education University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Sheri-Lynn Kane, MD Program Director Internal Medicine Dept of Medicine Education Office Victoria Hospital Niamh O’Regan, MB ChB, Assistant Professor, University of Western Ontario Parkwood Institute Michael Borrie, MB ChB, FRCPC Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Parkwood Institute Jenny Thain, MRCP (Geriatrics) Assistant Professor, University of Western Ontario Department of Medicine, Division of Geriatric Medicine Victoria Hospital Peter R. Butt MD CCFP FCFP Assoc. Professor, Department of Family Medicine, College of Medicine, University of Saskatchewan Mamta Gautam, MD, MBA, FRCPC, CCPE Dept of Psychiatry, University of Ottawa Psychiatrist, Psychosocial Oncology Program, The Ottawa Hospital President and CEO, PEAK MD Inc. Dr. Shabbir Amanullah Chair, ICPA Arun V. Ravindran, MBBS, MSc, PhD, FRCPC, FRCPsych Professor and Director, Global Mental Health and the Office of Fellowship Training, Department of Psychiatry, Graduate Faculty, Department of Psychology and Institute of Medical Sciences, University of Toronto Sarah Thompson, MD, FRCPC Geriatric Psychiatrist Seniors’ Mental Health Team Addictions and Mental Health Program Louise Plouffe, Ph.D. Director of Research, ILC Canada (retired) Kimberley Wilson, PhD, MSW Assistant Professor, Adult Development & Aging, Department of Family Relations & Applied Nutrition, University of Guelph Andrew R. Frank M.D. B.Sc.H. F.R.C.P.(C) Cognitive and Behavioural Neurologist Medical Director, Bruyère Memory Program Bruyère Continuing Care Ottawa, Canada Diane Hawthorne Family Physician BSc, MD, CCFP, FCFP Dr. Ken Le Clair Prof Emeritus Queens University and. Lead Policy Physician Consultant to Ontario. Seniors Behavioral Support Initative Queens University
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