Water Cooler with Dr. Andrew Boozary

🤝 Meet Dr. Andrew Boozary. He’s a primary care physician, policy practitioner, researcher, and founding executive director of the Gattuso Centre for Social Medicine at the University Health Network in Toronto. He recently helped establish Dunn House, the first-ever social medicine supportive housing initiative in Canada, and his name has been floated as a possible challenger to Ontario Premier Doug Ford. We asked him about the links between housing and health care, private medicine, and what countries he thinks are getting health care right.

People who are chronically unhoused, live on average, half as long as the general public. It’s a damning health statistic. The reasons are clear: the physiological stress of unstable shelter, the inability to manage medications or follow-up, and far worse access to primary care. As a result, and through no fault of the individual, patients with no fixed address have higher rates of illnesses like diabetes, cardiovascular disease and cancer, and tend to have health care costs that are eight times higher. We cannot talk about universal health care without committing to housing as a human right. Housing policy is health policy. We either invest in homes and prevention, or we pay for it through emergency department visits, prisons, and most devastatingly, early deaths.

Dunn House has been called a “radical idea” but to me, it’s straightforward: we need to move upstream of the emergency department which has functioned as the last thread of our social safety net. When I looked at the data, one thing stood out: 234 Toronto patients accounted for more than 15,000 emergency department visits in 2019 alone. We needed to act and partner differently if we were going to interrupt the “doom loops” patients are trapped in. The UHN CEO and Board were incredible in leveraging a hospital parking lot to partner with every level of government and the United Way to build Dunn House, a permanent social medicine housing complex for UHN patients who were cycling through emergency departments, hospital wards and living in shelters or encampments. The Housing First model is evidence-based and by ensuring wraparound care with Fred Victor and Inner City Health Associates, tenants now have meaningful access to primary care, harm reduction, mental health and addictions treatment, and accompaniment from community health workers. One year in, we saw a reduction of more than 50% in ED visits, a 79% drop in hospital bed use, over $2 million in health care savings, and most importantly, people gaining back stability, relationships, and dignity. And if you haven’t had a chance to read about Jason Miles, you should. That is the true heroism in all this. 

I follow no ideology on this. But I’ll say a few things, and why I think this debate will not go away until we address the capacity challenges in our health system. I’ve experienced hallway medicine not only in caring for patients, but as a caregiver for my own family members. We need real investments and sustainable innovations in health care. I wrote in the Globe & Mail last year that Canada’s reliance on perpetual pilot projects underscores this challenge. The evidence that private equity or for-profit entities can offer a remedy for our issues simply isn’t compelling. Consider both the US and the UK: recent studies show a concerning spike in mortality rates following the entry of private equity and for-profit organizations into their healthcare systems.  I understand the urgency for change; the status quo is unsustainable. Yet, fundamentally, we need to better integrate our health and social care systems while expanding the necessary capacity for innovation if we are serious about delivering better health outcomes for everyone.

There’s no promised land. Every system has failures and blind spots. As the late Uwe Reinhardt used to remind us, you can’t simply transplant another country’s health system, or its ethics, into your own and expect it to work. You have to build on your own moral choices about who counts and who doesn’t. I think living next to a country whose health system is morally bankrupt has warped our sense of fairness in Canada. I don’t look to any single country for a silver bullet. I look to places that treat health as a collective, iterative project: where primary care is the foundation of a high-performing health system and housing, income and childcare are treated as core health infrastructure, as you see in some Nordic countries. André Picard has called Canada “the least universal health system in the world.” We insure hospitals and doctors but leave out pharmacare, homecare, and many of the supports other countries treat as basic. Years ago, I called this Canada’s “Mirage of Universality.” We talk a lot about universality in contrast to the U.S., but we have never funded it at the scale our rhetoric implies. The real question is whether a child born in the lowest-income postal code has a real chance to live, learn, work, and age in health comparable to a child in the wealthiest one. A serious health system refuses to accept those postal-code gaps as inevitable and organizes its dollars, data, and decisions around closing them.