BRIDGING THE GAPS IN HEALTHCARE

 By SHAGORIKA EASWAR

 A superhero’s cape would not be out of place for a champion of patient safety, social justice and health equity.

As such, Canada Research Chair in Health Justice is a fitting mantle for Dr Nav Persaud, who has made a name for himself for tirelessly advocating for health equity.

A scientist with MAP Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute of St. Michael’s Hospital, he is a staff physician in the Department of Family and Community Medicine at the hospital, and was named one of Canada’s Top 40 under 40 in 2017.

His mandate as Canada Research Chair in Health Justice is to conduct research and do academic work to bring us all closer to fair health outcomes.

“Right now in Canada, there are different outcomes depending on income, whether one is racialized, one’s gender, etc. Despite publicly-funded social supports and access to health supports, disparities exist.

“I am working to narrow the health gap between the highest and lowest wealth brackets, ensuring that everyone can afford the medication they need.”

It all began with his patients who couldn’t afford the meds he was prescribing. They returned to the clinic repeatedly with the same issues and he watched, helpless, as some of them ended up in the hospital with a cardiac arrest or a stroke.

“Everything I had learned at medical school was wasted if I couldn’t help my patients – but the bottom line was that for many of them medications were out of reach.”

He found this unacceptable when relatively inexpensive treatments could prevent it.

Dr Persaud knew he had to try something different.

To this end, he led the first-ever trial providing people with free access to essential medicines. In 2016, he launched the CLEAN Meds (Carefully selected and Easily Accessible at No charge Medications) study to test the effects of providing essential medicines for free to patients who were unable to afford them. Almost 800 people took part in the study through health centres in Toronto and Manitoulin Island area. 

The results from the first 12 months of the study proved beyond a shadow of doubt that access to free medication improves health outcomes. Dramatically. There was a 44 per cent increase in people taking their medications and 160 per cent increase in the likelihood of participants being able to make ends meet.

He also worked with WHO to decide which essential medicines – everything from antibiotics and pain relievers to medications for HIV-AIDS – countries should cover.

He hoped the findings would help inform public policy changes.

There has been some positive movement on that front, he says, with the federal government in favour of implementing pharmacare that would make available some medications for free. 

“But there’s pressure from pharmaceutical companies and private insurance companies to let things be as they are.”

Dr Persaud has faced-off against Big Pharma in many ways.

Questioned inappropriate ties between the pharmaceutical industry and academics.

Exposed a marketing scheme in which vouchers for brand name drugs were digitally inserted into electronic patient records to boost sales.

Campaigned for more transparency about problems with faulty medical devices that harm patients.

Revealed that a morning sickness drug didn’t meet its manufacturer’s own threshold for effectiveness. 

Stopped pharmaceutical reps from providing freebie drug samples at his family practice clinic.

“Samples are generally not for medications we’d prescribe, they are more likely to be for recently created meds. One example is an oral contraceptive that carried a higher risk of blood clots. There’s no justification for exposing a patient to that, but if it’s provided free at first, sometimes a patient wants to continue with it. That’s just bad medicine. A way to try and influence physicians.

Samples are also one of the reasons we pay more for meds – they come in small packets, so we need more, with all that extra packaging.

 “Pharmaceutical companies exist to make money and that’s not anything to be ashamed of. The problem arises when they are allowed too much power. They had the power to control the supply of vaccines and restricting them in some parts of the world as new variants emerged exacerbated vaccine inequity. 

“The first question should have been how can we determine that everyone in the world gets vaccines. This pandemic has brought to the fore the need for a non-profit that can produce essential medicines. There’s one vaccine that’s not patented that’s in the works, but it’s too small of a scale as of now and too late.”

Dr Persaud helped create the Health Justice Program, a partnership between St. Mike’s and legal clinics, which provides legal assistance to patients encountering difficulties that affect their well-being. Mould problems in rental housing, for instance.

He recently published a pandemic equitable recovery guideline with coauthors that looks at ways to address inequities exposed and worsened by COVID-19 .

 “Coordinated pandemic responses include efforts to return life to ‘normal’ after the immediate threat, but the COVID-19 pandemic has underscored the need to address inequities rather than resume the unfair status quo,” he wrote.

Their recommendations to address health inequities include publicly-funded childcare, support for victims of intimate partner violence, addressing racism, expanding permanent supportive housing programs and ensuring a living income. 

Asked how he would fund all these great ideas, Dr Persaud’s response is short and simple: Redistribution.

 It comes down to human rights, he says. Housing is a basic human right.

“Multiple studies have shown that people who are in stable housing are less likely to visit ER. So we can choose between paying to keep people healthy and in safe housing or paying for care.

“As for a living income, obviously that’s a large budget item. But think of the impact on children, families, on people desperate to make ends meet. Also, balance the amount that will be spent on living income against what is spent on the supports for people in precarious conditions that are in place.”

A shift in perspective can help achieve the goal, he holds.

What, then, of the oft-cited argument that universal income makes people lazy?

Ideology often plays into this, says Dr Persaud. “We’ve all heard that it’s good to put people under pressure, test their true mettle.  Teach someone to fish rather than handing out a free meal, and  so on. But how does that analogy apply to people living in poverty in Toronto? We know that living income does not make people dependent on it. There are studies that show how recipients use the extra money to pay for childcare or transport – stuff they couldn’t afford earlier – to attend programs to upgrade their skills, to climb out of survival jobs into meaningful employment.”

His father, who grew up in a relatively small farming community in Guyana, put himself through university and became an engineer. His mother’s parents had a small shop, but she trained to be a X-ray technician. Political turmoil and shrinking opportunities led them to Canada in 1979, where they faced many of the typical new immigrant struggles that others do. They worked hard to improve their circumstances and provide the best for their two sons. Dr Persaud, who was born in Canada in 1980 says he never identified as a newcomer.

“I had a happy, comfortable life, but looking back, yes, there were challenges. I didn’t view them as such at the time, but I did experience racism. I was called names I didn’t understand. But our parents provided a strong support system.”

He was in his last year at high school when he heard Stephen Hawking speak and was inspired to pursue science. After his undergraduate degree in physiology from U of T, he took a three-year break. To study philosophy and psychology at Oxford University.

He always had an interest in philosophy, he says, and wanted to understand different ways of thinking and how critical thinking could be applied to medicine.

“I realized I would never do that once I was fully immersed in a medical career. It helped that I had scholarships!”

He spent two years on a Rhodes Scholarship and another on a scholarship from Oxford, before returning to UofT to study medicine.

He met his wife at Oxford and the couple have three sons, aged five, three and two.

For them, he envisages a more fair Canada. One where opportunities are not determined by one’s last name or address. He also hopes that they will continue to fight the good fight.

“The reality is that this is an ongoing struggle. I hope that the next generation will continue to stand up for equality and justice.”

His work in health equity requires a huge commitment in terms of time and energy. With a young family come other pressures on his time.

“I am able to do what I do because I have support from colleagues and because I see the effects in my clinical practice first-hand. I see how small measures can help turn the lives around of people whose health is being harmed, who are unable to pay rent or are worried about personal safety, concerned about meeting basic needs.

“I am privileged and fortunate to have the opportunity to try and decrease the number of people coming into my clinics.”

He tells those who seek to follow him to ask themselves how passionate they are about the cause they wish to espouse.

“All of the issues I am working on take time and effort and can be frustrating. Being well-paid is insufficient motivation to keep at it.”

He points to the importance of investing in supportive relationships as it’s nearly impossible to achieve anything really meaningful by oneself.

“I learn from and connect my work with the work of others. Also, it’s really important – and something I’ve become more cognisant of recently – is to be aware of history. Of where you come from, family history, Canadian history, the history of Indigenous people. Their knowledge has benefited us all. The struggles of one community are linked to the struggles of all. Anti-Black and anti Indigenous racism is very insidious. So strive to broaden the context of your work.”

• Grant’s is proud to present this series about people who are making a difference in the community. Represented by PMA Canada (www.pmacanada.com).