Connecting with Care – Montreal

Montreal is an exhilarating and vibrant city located on an island in the St. Lawrence River. The city and the greater metropolitan region have 4 million inhabitants, with residents originating from more than 120 different nationalities. Since its foundation in 1642, Montreal has been a melting pot of cultures and is the second largest French-speaking city in the world after Paris.

Since the late 1980s, a small number of organisations across the city have been working with people who use drugs. Despite more than three decades of offering targeted services, there continues to be a significant number of unmet needs within these highly marginalised communities, especially a lack of appropriate health services.

Just outside of Montreal, in the suburb of Saint-Jérôme, the community-based organisation Centre sida Amitié (CSA) was founded in 1990 to meet the need for HIV and sexual health services outside of the urban core. After almost 30 years, CSA has developed a strong reputation for providing deep, respectful care for marginalised members of the local community.

Since their early years, the CSA’s work has grown and diversified significantly, yet a central tenet remains the close relationships forged between staff and service users. Impressively, the CSA has been able to treat 863 people for hepatitis C solely with private funding. They describe their hepatitis C model of care as a hybrid model, bringing together community-based, psychosocial and medical service providers.

 

Dr Jean Robert

When Dr. Jean Robert greets a patient and ushers them into his office for an appointment, it is hard to tell who is more excited, him or the patient. With everyone that enters his cosy office, the pair naturally catch up for some time before the conversation turns to the matter of the appointment.

When Dr. Jean Robert listens to his patients, he listens with his entire self. His way of engaging people ensures that once they enter the office, they know they are the centre of his attention. They know they will be listened to in a completely non-judgmental way, and most of all, they feel important and valued.

Dr Jean Robert sits with a patient and reviews her recent medical results. Dr Jean Robert has for many years been working to serve the community through his involvement with Centre Sida-Amitié (CSA) located in Saint-Jérôme. Dr Jean Robert has been instrumental in establishing a clinic based model of care for treating hepatitis C. CSA is entirely funded by pharmaceutical companies and receives no core funding from any government agencies. CSA has been highly affective in curing large numbers of people for hepatitis C and a few years ago reached the WHO targets. More recently, CSA has begun sharing their knowledge and expertise with frontline  organisations including Dopamine who were interested in adopting the CSA medical model.

That’s the essence of what community health is. We take a group of individuals who have hepatitis C, have HIV, are drug consumers, are on the streets, but each individual is different. At the end the day, we don’t deal with a group, but with a single person at a time because it their suffering, their blood tests, their urine tests, their well-being, their health.

Dr. Jean Robert, Centre sida Amitié

Robert Lamarche has faced many challenges in his life including long-term homelessness and severe stigma when attempting to access medical services. Robert has been a patient at Centre Sida-Amitié (CSA) for more than a decade and has developed a strong bond with Dr Jean Robert. Dr Jean Robert successfully treated Robert using the new DAA medication after earlier forms of the medication failed. CSA supported Robert to find initially temporary housing and then later secure a permant apartment. Over the years Robert has become a permanent fixture around CSA and is often involved volunteering his services.

Robert’s story

In 2001, after three years of living on the streets, Robert found himself in Saint-Jérôme and bumped into a CSA outreach worker who offered him a few apples. That small gesture was enough for Robert to feel valued. Soon after this incident, a relationship with Dr. Jean Robert and other staff at the CSA blossomed.

 

What attracted me to the CSA is that I did not feel judged at all. I received a lot of love. I trust Dr. Robert and a few people here, but not many people apart from that. I always struggled to deeply connect with people.

Robert, Centre sida Amitié

Robert had previously been told he had contracted hepatitis C, but he avoided seeking treatment. With Dr. Jean Robert’s support, Robert undertook two rounds of interferon treatment in an attempt to treat his hepatitis C. Both times were unsuccessful, and unfortunately the process was incredibly taxing on his body. Robert almost gave up hope that he would have his hepatitis C cured. However, in 2012, Robert was one of the first patients at the CSA chosen to trial the new direct-acting antiviral medication that had entered the market. While the medication has a 95% cure rate for hepatitis C, Robert was still unsure whether it would work for him.

 

His treatment involved three months of daily medication and weekly visits to the clinic, and he experienced little to no side effects. Following treatment, Robert returned for the results of follow-up tests, confirming he had been cleared of hepatitis C.

Downtown with Dopamine

Dopamine is a grassroots organisation that, for the past 25 years, has been focused on supporting and working alongside people who use drugs, their families and friends and neighbourhood residents in the Hochelaga neighbourhood of Montreal.

Over recent years, Hochelaga has experienced rapid gentrification, resulting in many marginalised community members having less access to services and affordable housing. Aware of the deteriorating health care situation for the community they serve, Dopamine came to the CSA to learn about their patient-centred health care model.

Dopamine outreach worker Yanick sits with Simon Chretien (not pictured) and other colleagues outside in the sun. Simon is a peer navigator working for Dopamine on the recently established Dopamed project established in January 2019. Dopamed has adopted the clinic model of care from Dr Jean Robert and his team at Centre Sida-Amitié (CSA). For many years Simon has accessed serviced at Dopamine, a community organization founded in 1994 and based in Montreal’s inner eastern suburb of Hochelaga. Dopamine is an organization that emphasises the access to services and advocacy for the local community they work with, they have a specific focus on HIV/AIDS and hepatitis prevention, as well as the prevention of other blood-borne and sexually transmitted infections. With a strong emphasis on employing those with lived experience, when Dopamine established their Dopamed they hired two peer navigators Simon and Sophie to work alongside the two doctors who work at the clinic every Tuesday.

Dopamine executive director Martin Page (Centre) talks with the organization’s two peer navigators, Simon Chretien and Sophie Lefebvre. The pair work for Dopamed, a recently established medical clinic within Dopamine’s day centres. Dopamed adopted the clinic model of care from Dr Jean Robert and his team at Centre Sida-Amitié (CSA). For many years Simon has accessed serviced at Dopamine, a community organization founded in 1994 and based in Montreal’s inner eastern suburb of Hochelaga. Dopamine is an organization that emphasises the access to services and advocacy for the local community they work with, they have a specific focus on HIV/AIDS and hepatitis prevention, as well as the prevention of other blood-borne and sexually transmitted infections. With a strong emphasis on employing those with lived experience, when Dopamine established their Dopamed they hired two peer navigators Simon and Sophie to work alongside the two doctors who work at the clinic every Tuesday. The pair have both been successfully cured of hepatitis C using the DAA medications.

In early 2019, Dopamine launched a small clinic called Dopamed, which was run out of their centre’s basement. Drawing on the organisation’s philosophy of grassroots work within their community, peer navigators Simon and Sophie were hired to work together with the doctors in the clinic. This combination of peer workers and doctors proved highly successful, and after one year, the clinic doubled its weekly operating hours.

Simon’s story

Simon has faced many challenges in his life and is acutely aware of the stigma and barriers faced by people who use drugs, especially when trying to access health care

Engaged as a peer navigator at the Dopamed clinic, Simon’s own experience informs the way he connects with people who access the clinic’s services. He has a bounce in his step and a gentle smile as he makes his way through the clinic, greeting the doctors and chatting with the community members.

Dopamine is deeply connected to the needs of their local community. Observing the need for better health care was what prompted them to reach out to the CSA and learn from their model of patient-centred health care. While the CSA and Dopamine are two distinct services, their model of collaboration to strengthen each other’s work is an example for service providers everywhere.

It’s frustrating because I’m still a human being despite the difficulties I had. What people hold as stereotypes is that this person is a human waste, that this person has never done anything good in his life. People are quickly drawn to these judgments. ‘Ah, he’s a drug addict, he’s worthless, he doesn’t respect anyone.

Simon

The success of Montreal’s many models

For Dopamine and CSA, key aspects of their models of hepatitis C care include:

  • Prioritising the needs of the local community and their reality in the moment
  • Emphasising a strong trust-based relationship between health professionals and patients
  • Viewing people as a whole and not just their health condition or life challenges
  • Bringing health care directly to the people, within a safe space
  • Finding creative ways to overcome barriers to health care access
  • Investing in strong connections and alliances with other organizations
  • Acknowledging the structural drivers of poor health, such as the criminalization of drug use and the poisoned drug supply
  • Involving people who use drugs at all stages of service development and delivery

 

From 2016 until late 2019, Know Your Status has successfully treated 488 people for hepatitis C.

Staff from Centre Sida-Amitié (CSA) discuss during a meeting. CSA is located in Saint-Jérôme and is based around the early work of clinician Dr Jean Robert who has a passion for developing strong relationships with those that he cares for. Dr Jean Robert has been instrumental in establishing a clinic based model of care for treating hepatitis C. CSA is entirely funded by pharmaceutical companies and receives no core funding from any government agencies. CSA has been highly affective in curing large numbers of people for hepatitis C and a few years ago reached the WHO targets. More recently, CSA has begun sharing their knowledge and expertise with frontline  organisations including Dopamine who were interested in adopting the CSA medical model.