ST-JÉRÔME, QC. — Julie had no choice but to stop fighting the virus.
She’d fallen on hard times and couldn’t afford to pay $500 a month for her HIV medication. So she stopped taking it last winter.
It had been 25 years since she tested positive but the medication kept Julie’s viral load so low that it was undetectable by normal blood tests, making it untransmittable. It took just a few months off the drugs for her HIV to reappear in her bloodstream.
“I didn’t have anywhere to turn, so I figured I’d save up some money and start taking my medication again in a few months,” she said, sitting in the office of Dr. Jean Robert, one of the few doctors in Quebec who specializes in community healthcare.
“I’m back on them now. But it was a scary time.”
Dr. Robert shook his head.
“You see that?” he said, waving his arm. “The cost of your medication could have helped spread HIV. The system is actually making things more dangerous. It’s supposed to help us.”
Where do patients go when they’ve been cast away by Quebec’s healthcare network?
For those living on the margins, access to care in their time of need is nearly impossible. Being poor in this country means you’re more likely to experience trauma, housing insecurity and substance abuse disorders. It also means you have limited access to healthcare despite needing more than most people, according to the Canadian Medical Journal Association.
Medicare doesn’t cover certain prescription drugs, mental health counselling and physiotherapy, among other treatments. In Julie’s case, it meant that her HIV became transmittable for the first time in years, possibly putting others at risk of contracting it.
But there are a handful of community groups in Quebec fighting for patients who may have otherwise given up on the system. That’s where Robert and his clinic come in.
Same care, fewer resources
Once upon a time, Robert had clout within the system.
He was the head of community healthcare at Hôpital-St-Luc from 1977 to 1996, in charge of staffing, supplying and running a department that cared for sex workers and the unhoused in the heart of Montreal’s red light district. His authority was such that his own boss had to have the unit’s budget approved by Robert before he could sign off on it.
Fast forward 25 years and Robert’s practice is well beyond city limits, at a community clinic an hour’s drive north of Montreal. He provides the same care he did back then but with a fraction of the resources. His clinic, Le Dispensaire, sees over 1,000 patients a year, providing them with safe injection supplies, condoms, drug testing kits and treatment for sexually transmitted diseases.
The clinic has data to suggest its drug testing program — which allows users to check if their narcotics have been cut with fentanyl and other lethal opioids — has been effective in curbing a rise in fatal overdoses. While Quebec saw a 30 per cent jump in overdose deaths last year, the region covered by Le Dispensaire saw that number increase by just 3 per cent.
Even so, every day is a struggle to keep the clinic going.
Robert allowed Ricochet to sit in his office on July 13 as he treated patients. To respect the confidentiality of his patients, pseudonyms are used to identify them in this story.
Reggie, a ‘peace-and-love hippie’
Reggie went on a three-month bender after getting out of federal prison last March.
It was looking like he’d be back inside before long, but then he quit everything cold turkey: drinking, drugs and cigarettes. And he’s done that despite sleeping at homeless shelters and in the tall grass behind a church in St-Jérôme — the commercial hub of Quebec’s Laurentides region.
He could calm his nerves with some liquor or keep himself alert with a hit of speed, but he wants to do things right this time around. The only drug he takes is an anti-anxiolytic prescribed by Robert.
“I’ve got insomnia like a motherfucker, I’m edgy as hell,” he says. “No cigarettes, no beer, money in my pocket and I’m keeping real quiet these days. But I’m getting turned aside left and right when I try to rent an apartment.
“I can’t sleep in the church basement. There’s methamphetamines there and I don’t want the temptation. So I’ve got a tent lined up. My girlfriend wants to join me but I keep telling her not to. I want her to be happy, to rent a nice place for herself. This isn’t a life for her.”
In between anecdotes, Reggie shakes his head and smiles, laughing at the trouble he’s gotten himself into over the years.
“Goddamnit, Dr. Robert, goddamnit I messed up good,” he said. “But I look alright, right? I look like a real peace-and-love hippie with this bandana. Goes with my new philosophy, I suppose.”
Robert laughs. He’s in his late 70s, but aside from a raspy voice and bald head, the old doctor has a youthful energy to him. That he speaks slowly feels less like a byproduct of age than a desire to make sure he’s understood.
“Where’d you serve your time?” he asks.
“Cowansville,” Reggie said. “And they made me serve the whole 35 months. Goddamnit.”
Reggie takes clonazepam for his anxiety, which went through the roof when he was an inmate. Now that he’s back outside, the overpowering feelings aren’t going anywhere.
“Clonazepam, that’s my medicine and not one person is going to take it away,” says Reggie.
“I won’t, my friend, I promise,” Robert says. “You take it once before bed, right?”
“I can prescribe you another dose that you’d take at lunchtime to keep the anxiety away,” Robert says.
“I’m tired, I’m paranoid, I’m burnt out and tired of being on the streets,” Reggie says.
Robert puts up his fists, mimicking an old-timey boxer.
“I bet you solve a lot of problems with these in jail,” he says. “You may be done with prison but prison isn’t done with you. It takes a long time to get that out of your system. Give yourself some love.”
They chat for a few more minutes and Robert wishes him well as Reggie heads back into the world.
“You’re alright, doctor. You’re even pretty good I’d say.”
Community healthcare works, but government won’t fund it
The push for community healthcare began in the early 1970s, when a McGill University study found an alarming link between poverty and death in Montreal.
People in the working-class enclave of Pointe-St-Charles were dying of cancer, diabetes and heart disease at an alarming rate when compared to the rest of Montreal. If you lived in the neighbourhood in 1970, you were three times more likely to die of complications from diabetes than if you lived elsewhere in the city. The death rates for strokes, cancer, accidents and heart disease were about twice the city average as well.
So the university and local activists got together to launch Quebec’s first-ever community clinic. Today, after nearly 50 years of austerity governments, healthcare reforms and scorched earth budgets, the clinic still stands.
But that isn’t the norm in Quebec anymore.
“The model popped up in places all over in North America in the 1970s, but many of those clinics have gone by the wayside,” says Erin Strumpf, a professor of economics at McGill University.
“They were created by people who were really passionate, really creative and really devoted. But that’s also one of the reasons they collapsed. People retire, they get old, they move on, and you can’t clone them.
“Often, the strength was the people and not the system. You need exceptional people to run these clinics but those people are, by definition, exceptional. They’re hard to find.”
The clinic in Pointe-St-Charles influenced the creation of the CLSC — a system of free government-run clinics that brought doctors and nurses together with social workers and other professionals. Robert was there at the peak of the movement.
“There were about 100 clinics doing some version of the community model in the 1980s. It was something to behold,” he said. “Now, I can’t think of more than a few.
“The problem, at its core, is that healthcare has become a political object and sickness is an industry. The system entrusts healthcare to political organizations. People in politics can be devoted and well intentioned but there’s just one problem: their job is to win elections. They can’t come up with 10-year plans because they can only see as far as the next election.”
Robert allows for at least one major exception in provincial politics — Claude Castonguay. The former health minister was instrumental in taking healthcare away from the clergy during Quebec’s Quiet Revolution in the 1960s and creating a system of community clinics.
Of course, in his later years, Castonguay would advocate for more privatization of the system but Robert says the health minister had vision while in office.
“Sadly, the people who followed him — even in the same party — they slowly dismantled the CLSC system,” Robert says. “Doctors would say, ‘We’re not civil servants, we won’t work with social workers.’ Budgets had to be balanced, accountants took over the management of healthcare. But people aren’t numbers to be punched into a system.”
Strumpf says the trend in Quebec has been to centralize healthcare, something that’s happened regardless of which government has been in power.
The last major round of reforms came under Liberal Health Minister Gaétan Barrette, who dissolved regional agencies and cut 1,300 managerial jobs across the province. His plan did little to curb overcrowded emergency rooms, wait times for surgery or lower costs across the network.
It also caused an upheaval among those who worked under Barrette. Ten members of the McGill University Healthcare Centre’s board of directors resigned to protest the minister’s reforms. He was widely criticized by patient advocates, doctors’ unions and other civil servants.
Castonguay told the Montreal Gazette that Barrette’s reign was a “total failure,” comparing his centralized approach to something out of an Eastern Bloc dictatorship.
“Of course, for the people on the front lines, it will always feel like centralizing healthcare ignores what they see on the ground every day,” said Strumpf. “But the flip side is that what the workers see may not be borne out by data collection on a massive scale. It could be but a more centralized approach can gather and analyze data to better use resources.
“Of course, I say it could, but that’s not always the case.”
Since the Coalition Avenir Québec formed a government in 2018, they haven’t deviated from the essential structure of Barrette’s healthcare network. Of course, any move in policy would have been complicated by the pandemic, but the reality today is much the same as it was before the CAQ took office.
Julie, a mother
Julie recounts the way she learned of her HIV diagnosis in 1996.
“They told me over the phone and basically just hung up,” she said. “It was incredibly cold. I was overcome by shock and grief and there was no one to help walk me through the process.”
Making matters worse, Julie’s husband had also contracted the virus and, after her son was born, he also tested positive for HIV.
When he told his first girlfriend about his health, she broke up with him and told their classmates. He was bullied and beaten and had to be moved to a new high school.
Tears stream down Julie’s face as she recounts that chapter in her life.
She cries at Robert’s office because she feels comfortable with him. Robert wants her to experience a more human approach to healthcare, and there is no rush to get her out the door. That might explain why she’s been coming to him for nearly 20 years.
There are happy stories. The clinic’s walls are adorned with art donated from their patients as a thank-you for being treated with dignity. From stained glass to impressionist paintings, the variety of work is impressive.
Photos of patients with diplomas line the hallway that leads to Robert’s office. Each person who has completed hepatitis C treatment gets one.
“We’re lucky to have each other,” Robert says, tapping one of the framed pictures. Back in the office, Julie had one final request for her doctor. Could he prescribe patches to help her quit smoking?
“Absolutely! Happy to hear you’re giving it a shot.”
He wrote the script down and she was on her way.
“Thank you, Dr. Robert.”