Stephen Hwang, MAP 0:04
Hi, this is MAPmaking, a podcast series that brings you Canada's leading voices on the health equity issues that affect us all. I'm Stephen Hwang, Director of MAP, a research centre at St. Michael's Hospital, Unity Health Toronto. Welcome to season two of MAPmaking. We have some terrific episodes planned, and I've been really looking forward to this one in particular. Today I'm going to be talking with two health care and research giants, who were central to MAP's founding, Jeff Lozon and Ahmed Bayoumi. Jeff Lozon is a health care leader who has been at the helm of public, private, and not-for-profit organizations in Ontario, Alberta and Manitoba, including 18 years as CEO of St. Michael's Hospital in Toronto, from 1992 to 2009. During his time at St. Michael's, Jeff guided the hospital through a major financial turnaround and merger, led a team that transformed St. Michael's Hospital into one of Canada's premier teaching and research hospitals, and founded MAP, which was then known as the Inner City Health Research Unit. In 1999, Ontario's premier recruited Jeff to be the province's Deputy Minister of Health and Long-Term Care for a one-year secondment, to spearhead a new accord between the Ministry and the health-care system. In 2006, Jeff was appointed by the federal government to be the inaugural Chair of the Canadian Partnership Against Cancer. Today, Jeff is a consultant and associate professor at the University of Toronto's Department of Health Policy Management and Evaluation, and he's a sought-after speaker for his thought leadership. Jeff was recognized with the Order of Canada in 2009 for his sustained contributions to advancing health care, particularly for those experiencing disadvantage. Ahmed Bayoumi is a general internist, HIV physician and the Baxter & Alma Ricard Chair in Inner City Health at St. Michael's Hospital and the University of Toronto. Ahmed joined MAP 25 years ago, as one of our very first scientists. And since then he has led a highly impactful research program to improve the health of people experiencing marginalization, including people who use drugs, and people living with HIV. Ahmed has received numerous honors including the Canadian Society of Internal Medicine’s David Sackett Senior Investigator Award, the Society of Medical Decision Making Distinguished Service Award, and several other teaching awards. He has extensive experience in translating research to policy, and he's held numerous leadership positions at the local, regional and international level. In 2023, Ahmed was inducted as a Fellow of the Canadian Academy of Health Sciences, one of the highest honors within Canada's academic community. Ahmed, Jeff, thank you for joining me here in-person in this beautiful podcast studio at Staples Studio Corktown, and welcome to MAPmaking.

Ahmed Bayoumi, MAP 3:05
Thanks, Stephen.

Jeff Lozon 3:06
Thanks very much for having me.

Stephen Hwang, MAP 3:08
I'd love to start by setting the stage for where we are today. MAP is a world class research centre focused on health equity, and comprised of 60 scientists, investigators and postdoctoral fellows, and more than 160 staff and students. We are home to six Canada Research Chairs, and more than $100 million in active research studies. St. Michael's is now a premier academic research hospital in Canada. And MAP is its largest research centre. However, in 1998, we were just a gleam in Jeff's eye. Jeff, you founded MAP during a turbulent time for the hospital. What made 1998 the right moment to found Canada's first inner city health research unit?

Jeff Lozon 3:54
Thanks, Stephen. You know, it's a story that starts many, many, many years ago, maybe even more than a century ago, when the sisters founded the hospital to care for the sick and the poor in their terms. But in the early 1990's, the hospital had a really serious financial problem. And coming out of that financial problem, we had a restructured set of programs and we tiered them. And so we said at the top of our programs in St. Michael's Hospital will be three: the trauma program, the heart program, and an inner city health program, which we never really talked about inner city health in that same way, and we grouped together hospital departments in the Inner City Health Unit. The Inner City Health Unit was not only tiered high within the hospital priorities, but it was also expected to perform at a high level. So it had to have excellent care, excellent teaching and excellent research, but no one really knew what that research was going to look like. And you know, we hit kind of a right, the right sort of timing because the University of Toronto, which had been heavily directed towards genetic research and basic science research is beginning to open up and recognize that other types of research, epidemiological research, dry bench research, was equally important and equally relevant. So we said "we need to create a set of research programs that are devoted to the care of those in the inner city", but we really did want the unit to be anchored around an endowed chair. We found a donor in Alma Ricard, and we created the Alma & Baxter Ricard Chair for Research in the Inner City. I didn't want it to be a poor cousin, relative to trauma and heart disease, I wanted it to stand on equal footing with all of these programs that had other types of research in them. And, you know, thanks to you, and to Ahmed, and other people that have been part of it, you stand really at the top of where it could be.

Stephen Hwang, MAP 6:00
Ahmed, looking back, it's clear that the Wellesley merger was a turning point for the hospital. It ended up I think, being a very happy and fruitful union, but it didn't start out that way. I was wondering, what was it like for you at the time, as a Wellesley physician, ultimately coming to join St. Michael's Hospital?

Ahmed Bayoumi, MAP 6:20
So I think it's important to put our minds back to 1998. And just remember a little bit what the whole situation was like. So the hospital restructuring committee had been struck by the province, and was mandated really to look at all the hospitals, and which would stay open, quite frankly, and which should close. And they, at that time, mandated that the Wellesley should close. It wasn't actually so much a merger as really just a closure and transfer of the Wellesley, and that made a lot of people very anxious - in part because they weren't really sure what, if some of the really good things about the Wellesley would carry over. The Wellesley also was located really at the center of the gay village at a time when the HIV epidemic was very much, and still is, a very significant health problem, but at that point, there were many people dying from HIV and HIV health services really required a lot of sensitivity and attention to the needs of people living with HIV. Particularly, to address homophobia. And Wellsley, as far as I know, it's, I mean, what was said at the time, and I think it's still true, was the first hospital to have an openly gay CEO in Canada. And really had pushed very hard to address homophobia in health care and to, to build a both clinical and research program that prioritized the needs of the gay community and really reached out to that community, and to really make that community feel like they owned a part of that service, and that that research program. So there was a lot of anxiety, quite frankly, about how those services would translate over to St. Michael's. And, you know, St. Michael's had community panels at that time, and I think was very much interested in the Wellesley model, if I can say that, but hadn't quite, I think gone as far, but I think they very quickly did. And I think under Jeff's leadership, there were a couple of really strategic things that the Wellesley did. They brought over the head of the Family Practice Department, Phil Berger, who, you know, and that was a huge win for the hospital, it really shaped how people thought of the hospital is having a social justice orientation. They hired very strong people in terms of community outreach, as you know, Jim O'Neill did really amazing work in terms of reaching out to the community. And they invested in what at that time, was the Inner Health Research Unit to really show that there, as Jeff was just talking about, to really put both their commitment and money, you know, behind the idea that this research would be, not just ivory tower research, but really research that was grounded in communities and accountable to communities. But you know, St. Mike's had to prove itself, though none of those things were taken for granted. So I think it's a little bit of a long answer to your question, but I think it was an interesting time and I think those challenges actually helped to both help the researchers I think, to think about how they do the research and what it would look like, and also help the hospital to understand what a research centre that was committed to addressing marginalization would look like.

Stephen Hwang, MAP 9:45
I absolutely have to agree with you that, you know, I think that the merger, or the combination of Wellesley into St. Mike's really made St. Michael's Hospital a far better place. And a more community oriented place, and also one that was much more attuned to issues of justice and inclusion than it had been previously.

Ahmed Bayoumi, MAP 10:06
Yeah, I remember the first time that St. Mike's had a booth at Pride Day. And, you know, I think people were surprised and really, really happy and committed to that.

Jeff Lozon 10:17
Those directions were not uncontroversial given the history of the hospital. So we had to really push to make sure that that happened. And I remember drafting the first, it was a declaration of rights or something like that, for our for employees and for patients of our hospital and working really hard to make sure that the language and that the intent was, this is not a place where you're going to be judged. This is not a place where you're going to be denied service. This is a place where you're going to be welcomed, and you're going to be celebrated.

Ahmed Bayoumi, MAP 10:53
But you know, it wasn't just about HIV, of course, there were lots of other aspects of the Inner City Health Research Unit, as we called it back then. You know, when I, one of the other concerns I had, Stephen, you were asking about my concerns was, you know, what was I joining? Because we were really small unit at that time and certainly there was a lot of commitment from the hospital. But, but you know, I did get some advice from other people as to you know, do you do you want to go to a bigger centre that has more of a established infrastructure rather than a, a smaller one where, I guess we would use the term start-up today. We didn't use that term back then, but it really was that kind of start-up mentality. But you, you were here before me Stephen, a year or two before me, and what was it like for you was one of the very first people that, I think you were the first population health scientist was the term, right?

Stephen Hwang, MAP 11:43
Yeah. So I started at St. Michael's Hospital in 1996, a few years before the unit was founded. It was actually quite different. I think that really what, when I look back at those days, I realize, like how solitary and lonely I was, as a researcher. There was really no one else at the hospital who was doing population health or public health focused research. I was viewed, I think, as a little bit of an odd duck, like, I was interested in, and continued to be interested in research focused on people experiencing homelessness. And that was viewed as a social issue that was irrelevant to Canada, and certainly not one that you would be doing at a hospital. And I think that what I really realized looking back at is that, you know, research really is a team effort. And we realize how important it is to have mentors and colleagues and like-minded individuals to bounce ideas off and collaborate with us and prod us to develop new ideas or explore new avenues of research. But really, it was very difficult starting out because I was literally sitting there by myself in my office, kind of sitting, staring at the walls, trying to think of what kind of research I could do with very, very limited resources. So, you know, I can't tell you how dramatic the change was when we founded the research unit. And it was just so amazing to have you Ahmed, coming as a colleague, to have Rick Glazier, family medicine researcher and health services researcher, who was an early mentor to me. And really, I think, changed the way that I was able to do research, and it was just an amazing kind of breakthrough, I think. And to look back at those days, and look at where we are now. It really is kind of hard to believe how far we've come.

Jeff Lozon 13:46
Yeah, I can see, you know, like, from my perspective in the hospital, I was always worried about you guys. And I was worried that, you know, you would be alone. That you were alone, that you didn't have any people to support you. And, you know, but you guys succeeded. And you, you know, you were you were able to through your own research, and your own profile, to build and to bring others with you. After I came back from my stint as Deputy Minister, I became a bit more aware that the Ministry of Health in Ontario actually had research funds, they, you know, kind of kept them well hidden. They didn't tell anybody that they had them. But I knew we had research funds and I knew that we could actually begin to apply for those research funds as a hospital. And I think when you got, when we got the sustaining grant from the Ministry of Health through, you know, a lot of hard work by a lot of good people. Art Slutsky was a big part of that as well, he was a strong advocate for the work that was done in the research in the inner city. So when we got that it kind of stabilized things and we brought in the first, I would call outside director, Pat O'Campo, who came from John Hopkins in Baltimore. And so, you can begin to see the momentum begin to move.

Stephen Hwang, MAP 15:05
It has really been incredibly gratifying to see the growth over the years where people who want to do research in areas related to health equity and the social determinants of health are drawn to our centre. I think that it's actually an incredible asset that we're at a hospital because we are at the frontlines, and we see it every day as health care providers. But we also I think, and this is the beauty of, of our centre and our hospitals, is that we recognize that many of the roots of the illnesses we're seeing are really social and economic in etiology, in origin. And we really have to stop thinking about the answer to everything being more healthcare. And I think it's really incredibly powerful that a hospital like St. Michael's, that is so good at delivering excellent health care, recognizes the importance of going outside of its four walls, and really under addressing the social determinants of health.

Jeff Lozon 16:08
I find it totally natural that a hospital like St. Mike's, with its history, with its commitment to the community, with its commitment to academic excellence, you know, would you know, be a place for something like MAP to exist. I think it's just to me, really, really straightforward.

Ahmed Bayoumi, MAP 16:27
Yeah. So I think there are a couple of things that people assume when they hear hospital-based research centre. One is that, that it is not community focused, and that there's still a divide between hospital and community. And I think that's been a critical element of MAP from its earliest days, was really thinking about how we defined community, what do we mean, when we say that word? How do we ensure that our research is accountable to communities? So not just partnering with communities, but going further to actually think about issues of accountability. Which is actually, you know, I think, a higher level of commitment to working with communities than just partnership. And even now, it you know, it's been a, I continue to learn how to do that, quite frankly. So you know, even now, it's about how do we think about the community setting priorities and the community being integrally involved in every step of the research process? And so it's a journey, right, and but I think one of the, one of the really important aspects of MAP has been that we, we've actually been on that journey. And I think, because of the hospital's commitment to working with communities, I think we are thinking about those things in ways that other centres are only starting to think about. We have, of course lots to learn from many people, but I think there is the space to think about those issues at MAP that is really important and distinct.

Stephen Hwang, MAP 17:57
Yeah, I think one of the other interesting, like, evolutions in our identity is actually in our name. So we started out as the Inner City Health Research Unit, which is a term that I think is very specific to, you know, the downtown core. But then we changed our name, ultimately to the Centre for Urban Health Solutions. First of all, recognizing that the issues that we seek to address around health equity are not geographically constrained, but are seen throughout urban areas. And also that we wanted to move beyond just describing problems and to actually coming up with interventions, both policies and programs that would address them. And then more recently, our name change to MAP which really, just, I think reflects our desire to map or plan out a path to a healthier future for all, but also our increasingly national and international reach.

Jeff Lozon 18:55
I think it's a really good example of how you can start out with an idea, but the idea that evolves and takes on a life of its own, if it's a good idea, and it's well supported and done in the right sort of way. So I think of the original types of issues that, you know, we talked about with, you know, people accepting the homeless, coming into the emergency department and treating them, you know, with kindness and compassion and with equity, you know, that was kind of like a big breakthrough, because, you know, there's lots of places where they couldn't go and be treated and cared for. And, you know, then, you know, you just kind of evolve, the problems evolve, and the science evolves, and the approach to evolves. And, you know, I don't think we ever anticipated that we'd have medical geographers doing solution based work inside MAP and that sort of thing. So, you know, I think it's a testament to the people that have, have run it and continue to run it and direct it. That you are always finding new frontiers of places that where you could do that, and also new approaches to it. So it's been a big success story driven by the people that have provided leadership.

Ahmed Bayoumi, MAP 20:05
Yeah I think, I think one of the other things that MAP has done really well, is to think about what methods are the best to ask for a specific question. So, rather than being a research centre that's focused on getting people together, who have a certain type of expertise, we get people together who are interested in a certain type of issue. And that means we have qualitative researchers, we have quantitative researchers. You know, I started my career as a pure quantitative researcher, but I do lots of work now that's qualitative work with lots of qualitative researchers. It's because that's the best way to answer some of the really important questions that we have, you know, and the interaction between the numbers and the stories is often more powerful than either one alone, you know. And now we're talking about lots of things like complexity and systems approaches and really trying to think about, because really, when we're thinking about some of the problems that we are talking about, they are really hard problems, right? They are deeply rooted in the systems of care, but also the economic systems, the political systems that that we live in. And so to, you know, to focus on something like compassionate care in the emergency department, it's really important for that encounter, but it doesn't address the system, right? And so, as we've grown as a, as a centre you know, one of the really fascinating things to me to see is how we've also grown in terms of the ways we start to think about, and hopefully start to research these questions more. But as you know, the growth has always been there, and it continues to be there.

Jeff Lozon 21:45
So I'd be interested to know, what would you see the next 10 years looking like?

Ahmed Bayoumi, MAP 21:50
Well, I mentioned before this, this idea of looking at systems. You know, I would hope that we really start to do that in a serious way. And so we have, we have lots more data available to us than ever before. With electronic data now, it's the cost of collecting data has come down a lot. So I would hope that we build upon that, not just in terms of the data, but also the methods that we use to analyze that data and really start to think about how the different pieces of the puzzle interact with each other to create health outcomes. I hope that we also continue to think about the community involvement, as I said before. And really think about, you know, asking communities, what their priorities are, but then also helping, working with communities to find the research questions themselves, working with, we now have committee members that we're hiring to help analyze the data. We involve community members in the knowledge translation, when we have results, to bring that back to the communities. But there's a lot we have to do still in terms of having people live experiences as researchers, there are many barriers, some within the hospital some without, to do that better. And so I think that's an area where there still is room to grow, and still areas to define what we can do better and how, and think about how we can address those.

Stephen Hwang, MAP 23:17
Yeah, I absolutely agree with you on that, those are really key issues. I think that the only thing that I would add is that, you know, I think will in the next 10 years, we'll strive to continue to do really, you know, high impact, excellent research, that we will at the same time be focusing on how we can translate our expertise and our knowledge into policy impact, because so much of what we want to see in terms of change is not at the individual level, it's not about just changing how one patient gets treated. It's about how we create policies that systematically advantage or disadvantage certain groups, and how we need to develop evidence informed policies that that create a more equitable community. I don't know if there's any last words that you'd like to share?

Ahmed Bayoumi, MAP 24:14
I think, you know, what people might not appreciate if they're not at St. Mike's is just how central issues of inner city health are to the mandate and, and the identity of the hospital. And so, and I think that's, that's grown over time. But, you know, as poverty has persisted, and homelessness has persisted, as the opioid crisis has taken off, we've only become more and more relevant. And we are really seen now I think as the go to place for research on issues of marginalization and issues that relate to inner city health. I've heard from so many people that we are their preferred place to come now for employment, so we actually have the opposite problem of having too many people who want to work here.

Jeff Lozon 25:02
Think of how far you guys have come from the time I remember when the financial problem with the hospital occurred. It was like serious discussion about actually closing the emergency department, getting rid of family medicine, making the hospital a referral hospital only, you know. And then on the other extreme, there was people who said, well, we should no longer be a teaching hospital, we know should no longer do heavy surgical, you know, interventional cases, because we can't afford to do that. And we just kind of rejected the either/or tyranny and took the both/and approach. And, and it worked out, but I think, this same extent that you know, the hospital supported inner city health programs, and then the Inner City Health Research Unit, I mean, you have become a definitional part of St. Michael's Hospital. You helped define that hospital for what it is today.

Ahmed Bayoumi, MAP 25:54
Well, thanks.

Stephen Hwang, MAP 25:55
Thank you.

Ahmed Bayoumi, MAP 25:56
I mean, I think we defined each other. It's always been this, this relation- I mean, I think that, that it's a very helpful dialogue.

Stephen Hwang, MAP 26:04
Yeah, I just actually have to say that looking back, just the steadfast support of the hospital's leadership, yourself Jeff, and others, over the years has really been instrumental to our success. I think that you can't, I just can't say enough about how much that that commitment and support has meant. This has been a really wonderful discussion. Jeff Lozon, Ahmed Bayoumi, thank you so much for being with me here today to have this discussion. And thank you for all that you've done over the years.

Ahmed Bayoumi, MAP 26:38
Thank you. It's been great.

Jeff Lozon 26:39
Yeah, this has been really a lot of fun. So thank you very much for inviting me.

Stephen Hwang, MAP 26:43
You've been listening to MAPmaking. MAP is a St. Michael's Hospital research centre dedicated to creating a healthier future for all. Learn more at maphealth.ca. I want to acknowledge the sacred land on which MAP and St. Michael's Hospital operate. This land is the territory of the Huron-Wendat and Petun First Nations, the Seneca and most recently, the Mississauga of the Credit First Nation. We are grateful to have the opportunity to work in the community on this territory. We are also mindful of broken covenants, and the need to strive to make right with all our relations. This podcast is produced by Emily Holton with associate producer Samira Prasad. I want to acknowledge and thank the St. Michael's Foundation and our incredible donors as well as Staples Canada for their support and commitment to MAP's work. We partnered with the team at Staples to create Even the Odds, an initiative to raise awareness of inequity in Canada and to help build vibrant healthy communities. You can learn more at staples.ca/eventheodds. I'm Stephen Hwang. Thank you for listening. Take good care, and we'll see you next time.