Social Policy in Ontario

Back in 1992, Ontarians hooked on heroin were stuck in a vortex of addiction. Effective treatment was scarce — at least in the province.

Even though methadone had been around since the 1960s to treat addiction and there was compelling evidence to show it relieved intense withdrawal symptoms, it was still viewed as controversial. The idea of replacing one opioid with another raised eyebrows.

Dr. Philip Berger, a Toronto family doctor with a long history of working with the most marginalized of patients, among them people struggling with addictions, was up on the latest literature.

But trying to convince key Ontario decision-makers of the drug’s worth proved a Sisyphean task. Berger couldn’t get politicians and bureaucrats to see past the stigma of opioid-replacement therapy and make it more available. Direct lobbying didn’t work. Holding a news conference at Queen’s Park made no difference either.

That spring, flyers began appearing in parts of downtown Toronto where people with addictions were known to hang out. The notices hailed methadone as a successful treatment option and offered a peculiar suggestion on how to get it.

“If you want help or need treatment, phone Michael Decter, deputy minister of health,” they advised. His private office number was scrawled onto tear-off strips at the bottom.

The tactic worked. Twenty-five years later, Decter acknowledges the flyers, along with a resulting meeting with Berger and two patients, nudged him to increase availability of methadone, ultimately opening the door to it being accepted as a go-to addiction treatment in the province.

“Dr. Philip Berger knew how to move governments to action. He could be just enough of a thorn in your side to get your full attention but he never acted frivolously. I took him seriously because he drew attention to important issues,” Decter says.

The victory is just one of many to which Berger has contributed during his most unique 40-year medical career. His improbable trajectory has taken him from firebrand to respected senior hospital executive. Along the way, he has established himself as one of Canada’s strongest advocates for disadvantaged patients.

He has walked a fine line in going to bat for them — sometimes as part of the decision-making health-care establishment, other times as part of the rabble-rousing anti-establishment.

Berger, 67, retired this past summer from St. Michael’s Hospital. During his 20 years there, he held many leadership positions, including chief of family and community medicine, medical director of the Inner City Health Program, chair of the medical advisory committee and member of the board of directors.

Within the confines of the hospital, he had a reputation for being a skilled, hard-working, team-playing professional. He is credited with using his leadership roles to help develop a multitude of programs and services for disenfranchised patients.

But when conventional means of addressing gaps in their care didn’t work, a different Philip Berger would emerge: the radical ex-hippie in him would come out.

He would transform from administrator to street fighter when that’s what it took to get the attention of media, and policy- and lawmakers. He has bellowed into bullhorns, heckled cabinet ministers, occupied government offices, marched in protests, harangued legislative committees and held forth into many a microphone.

“He can be an agitator, some would say s— disturber, but I’m not sure you can say that in your paper,” laughs Dr. Danielle Martin, a vice-president at Women’s College Hospital and, like Berger, a prominent defender of Canada’s public health-care system.

She marvels at his ability to operate in seemingly incongruous capacities. On the one hand, he has served as a successful hospital boss, academic physician and leading medical educator at the University of Toronto. And on the other hand, he has managed to maintain his independence and call out injustices.

“Not many people can be both on the inside and the outside simultaneously. Philip has achieved that again and again in his career,” Martin exclaims.

In recognition of a “lifetime of superior accomplishments,” Berger was selected last month for induction into the Canadian Medical Hall of Fame. Laureates are national “medical heroes” whose contributions have led to “extraordinary improvements in human health.”

Berger has been honoured with a bevy of other awards over the years, including: the Order of Ontario, a Queen’s jubilee medal, and the Life Membership Award from the Ontario Medical Association (OMA).

A look back at his career shows he has been ahead of his time in shaping the delivery of care for vulnerable patients. His fingerprints are all over many programs and services that exist today — not just in Ontario, but across Canada.

Among them: HIV/AIDS treatment, needle exchanges, health care for refugees and the homeless, and public coverage of drugs for catastrophic illnesses.

“Many medical practices now considered standard were once controversial initiatives requiring courage to defend and achieve. (Berger) has defended and achieved like no one else I’ve ever met,” says former boss, St. Mike’s president Dr. Bob Howard.

Berger, who is married to a woman and has two adult children, originally planned to slow down and take life a little easier upon retiring.

But his schedule is already filling up again. He recently ran for and was acclaimed to a position on the governing council of the College of Physicians and Surgeons of Ontario, the regulator of the medical profession; works occasional shifts as a physician at homeless shelters; continues to serve as a vice-chair of St. Mike’s research ethics board; and was recently selected as an associate senior fellow at Massey College, which describes its members as “senior scholars and eminent members of society.”

Berger declined to co-operate for this story, repeatedly turning down requests for interviews about his history of activism and accomplishments.

When approached about being the subject of a profile, he scoffed at the idea, saying it was “horrifying” and caused him to feel “pangs in his stomach.” Besides, it would be boring and no one would want to read it, he grumbled.

Berger’s friends — and his foes — disagree.

Despite Berger’s sometimes combative and belligerent manner, even some targets of his prodding have come to admire him.

Describing himself as a “huge fan,” Decter says that although Berger could be a pain, he appreciates the doctor’s commitment to amplifying voices of patients who have the most trouble being heard.

“Yes, he could be difficult. He could be critical of the government, but properly critical of the government and occasionally of me,” concedes Decter, now chair of Patients Canada, an advocacy organization.

Recounting the episode with the methadone flyers, Decter says the first thing he did upon learning his phone number was plastered all over the city was call Berger. They made arrangements to meet a few days later.

The former top bureaucrat says the meeting was a big eye-opener for him.

They were joined in Berger’s office by two patients. A young couple, they confessed to Decter that they had posted the flyers with his phone number.

(Berger has only ever owned up to allowing them use his office, photocopier and staple gun. As for whose conceived of the ploy, Decter has his ideas.)

The patients told Decter they were addicted to heroin and desperate to get off the drug.

He recalls the girl — “just a really sweet kid, she looked like the kid next door” — telling him how she regularly stole clothes from high-end Yorkville stores to pay for her $10,000-a-month habit.

The patients explained how difficult it was to try to wean off the opioid. Withdrawal was physically and mentally agonizing.

“It broke my heart,” Decter says. “I learned more from them in an hour than I learned from the ministry in weeks.”

Deep into the conversation, the couple revealed the toll their addiction had taken on them: both were HIV positive from sharing needles.

Within weeks, the provincial government announced funding for a methadone clinic at the Parkdale Community Health Centre.

Decter credits Berger:

“He has stepped into some very tough situations and persuaded people, sometimes very nicely and sometimes with a range of tactics, including through posters that say call deputy Decter.”

In the years since, Berger has continued to act as a strong advocate for methadone patients. Their numbers have since soared by 400 per cent to more than 40,000.

Berger has always credited those two patients — who have never been publicly identified — for making methadone more available to Ontarians battling addictions.

Both are now dead.

That Berger did not want this profile written and that he shrugs off credit for his contributions comes as no surprise to good friend and fellow physician Dr. Rick Glazier.

“The cause and the fight are always about the welfare of others and never about himself. He is very principled that way, shunning the limelight so that the issue is what shines, not him,” Glazier says.

Without Berger’s input, this reporter was forced to slog through four-decades worth of media stories to learn more about him. Fortunately, much has been written and broadcast. He has clearly been good at getting the media involved in his many crusades.

Early articles refer to Berger as “Toronto AIDS doctor.”

When he began practising in the city in 1977, homophobia was rampant. The infamous bathhouse raids were still a few years away.

Berger was one of a small number of family doctors in the city who welcomed gay patients into their practices.

In the early ’80s, some patients began complaining of mysterious mono-like symptoms. Berger didn’t know it yet, but he was witnessing the start of the AIDS epidemic.

Berger gave dying patients his home number and was on call for the better part of a decade.

They were desperate times, he said in a 2014 story on the St. Mike’s website:

“The first 15 years of treating HIV/AIDS were defined by despair, hopelessness and fear. Five or six people who were part of my medical practice died every month. I carried around death certificates in my briefcase, for house calls.”

In 1987, Berger co-founded the Toronto HIV Primary Care Physicians Group and established the HIV Project Centre Primary Care Mentor Program.

The 38 doctors in the group couldn’t keep up with the growing number of patients, and were overworked and overwhelmed, according to old news stories.

They were highly critical of governments and health agencies for being slow off the mark, and of other doctors for refusing to step up. They held news conferences, appealing for help, and offered to teach other physicians how to care for infected patients.

Berger charged that there was a strong undercurrent of homophobia within the profession.

For years, he quietly gave out free, clean syringes to injection drug users in an effort to stem the spread of the blood-borne illness.

In 1988, he went public with what he was doing. He also announced through the media that other doctors in the Toronto HIV Primary Care Physicians Group would be joining him in giving out needles.

That didn’t go over well with police who were opposed to the harm-reduction measure. They threatened to arrest the doctors for distributing drug paraphernalia.

The defiant physicians didn’t back down.

Police eventually did.

The following year, the city opened an official needle exchange program and Ottawa announced it would help fund such efforts across the country.

Berger’s ongoing activism for patients with HIV/AIDS saw him campaign for public coverage of their pricey drugs in mid 1990s. Along with patients facing ruinous bills as high as $2,000 a month, he participated in news conferences, staged protests and wrote letters to the editor.

Soon after, the provincial government introduced a catastrophic drug plan to help patients with HIV/AIDs and other illnesses cover the crushing costs.

Berger spent seven months in Africa in 2005, leading a Canadian delegation in establishing a clinic in the small southern country of Lesotho, which was being ravaged by HIV/AIDS. Of its 2 million residents, 30 per cent were infected.

“Lesotho was dying, I don’t know how else to put it,” says Stephen Lewis, then the UN secretary-general’s special envoy for HIV/AIDS in Africa, who had turned to Ontario health officials for help.

The human rights advocate, now a professor of distinction at Ryerson University, describes how the Canadian team arrived to a scene of chaos:

“The whole health system was on its back. There weren’t medicines, there weren’t beds, there weren’t clinicians and there weren’t records.”

By the time Berger left Lesotho, the clinic was up and running, and within 18 months, 3,000 patients were in treatment. The kingdom’s government eventually took over its operation.

“I think one could faithfully say that if Philip Berger hadn’t been there, there would have been no hope of keeping all those people alive,” Lewis remarks.

On the question of what drives Berger, friends say he has always joked that it’s just the rebellious teen in him. But in more serious moments, he has admitted to detesting bigotry and abuses of power.

Experiences of anti-Semitism by generations of his family may explain why. This is the story told in previous media interviews, an obituary on his father, and by friends:

Berger’s grandfather, Joseph, left Poland in 1907 at age 15 after a teacher called him a “dirty Jew” and told him never to come back to school. He stowed away on a ship and ended up as a refugee in Estevan, Sask.

Joseph ran a little store there and occasionally donated extra blankets to the local hospital, run by the Sisters of St. Joseph.

Berger’s father, Simon, also trained to become a doctor, but upon graduating from the University of Toronto, couldn’t find an internship. It was 1943 and hospitals were rarely, if ever, hiring Jews.

A dejected Simon returned home to Saskatchewan where he bumped into the hospital’s head nun. When he told her he couldn’t get an internship, she responded: “You have got one at St. Michael’s Hospital in Toronto, I guarantee it.”

St. Mike’s was then run by the same order of nuns. Thanks to the Sisters of St. Joseph, Simon got the experience he needed there to launch his career as a dermatologist.

Berger himself was the target of much anti-Semitism growing up in Winnipeg. He was told by fellow students in his Grade 7 shop class to leave and never come back because, “We burn Jews here.”

In high school and university, there were a number of occasions that he and his friends were threatened with physical violence and taunted with jeers of “f—ing Jew.” (Berger has reportedly said he ran “like a coward” while friends got pummeled.)

Berger has always been “viscerally offended” by inequity, says Toronto family doctor Michael Rachlis, who is also from Winnipeg and counts himself as one of “at least a dozen people who would think Philip was their best friend.”

Rachlis has been involved in many of the same political battles. The pair helped lead the successful fight against extra billing of patients by physicians back in 1986. Both received death threats because of their outspokenness, Rachlis says.

Wellesley-Central Hospital sought out Berger to be its new chief of family medicine in 1994, even though he was, in many ways, a most unlikely candidate.

He had never been a hospital administrator before; in fact, he’d never even worked as a manager.

What Berger did have in abundance though was street cred. The teaching hospital was located a block away from the epicentre of Canada’s AIDS epidemic where Berger was a highly trusted advocate.

He would eventually become an “excellent administrator,” but it took some time to learn the ropes, Glazier says.

“He had never been a leader, other than in protests, and had never been an academic so there was a steep learning curve,” Glazier says, adding that Berger started off by not consulting colleagues on big decisions, “thinking he knew best.”

When he realized no one was following him, he overcorrected by consulting excessively.

Says Glazier: “He would spend an hour and a half on the phone most nights, consulting with me, consulting with the dean, consulting with everyone, everywhere. He calmed down in later years but was still highly consultative.”

In 1997, the Health Services Restructuring Commission recommended that the Wellesley close and that most of its programs — including its large HIV/AIDS one — move to St. Mike’s.

The proposal ignited a firestorm of opposition, including numerous protests, a court challenge and a “Staying Alive” campaign launched by supporters, including the hospital’s board of directors.

Opponents perceived St. Mike’s, a Catholic hospital, to be anti-gay and feared LGBTQ patients would face discrimination. Leaders of AIDS organizations warned that patients with HIV/AIDS would be judged as sinners.

Berger was among those who fought against the Wellesley’s closure but when the court battle was lost, he saw the writing on the wall.

In the midst of the unrest, St. Mike’s then president Jeff Lozon quietly tapped Berger to become the hospital’s next head of family medicine.

“He was by far and away the preferred candidate. St. Mike’s had a big commitment to the inner city and Philip was an urban health inner city doctor,” Lozon says.

But with emotions running high, the board of the Wellesley issued an edict, forbidding staff and physicians from communicating with anyone at St. Mike’s.

That made a job interview difficult.

“I couldn’t be seen going to the Wellesley and Philip couldn’t be seen going to St. Mike’s, so we had these almost clandestine meetings at the back of the Pickle Barrel on Yonge St.,” Lozon says.

Berger did his due diligence before accepting the job, says Lozon, who subsequently became deputy health minister and now runs his own health-care consulting firm. He studied the ethics guide of the Catholic Health Alliance of Canada to ensure he was comfortable with it.

“He read it from front to back and could quote from it. I think the one thing the guide really provided him was comfort that St. Mike’s did have a preferential option for the poor,” Lozon says.

The secrets to Berger’s success, according to friends and former colleagues, include working in settings that share his progressive values, carefully choosing his battles, doing his homework, and being fearless and relentless.

“When Philip digs is teeth into something, he doesn’t let go. If he finds something out there that is unjust, he will battle it to the end,” says Dr. Meb Rashid, medical director of the Crossroads Clinic for Refugee Health Care at Women’s College Hospital.

Rashid and Berger teamed up in 2012 to form Canadian Doctors for Refugee Care after the then federal Conservative government cut health coverage for refugee claimants.

Berger took some getting use to, Rashid says, recounting the first of what would be almost nightly phone conversations for the next four years:

“He said, ‘I have an idea. It worked in the ’70s. Here’s what we are going to do. We are going to go occupy a federal government building.’”

Rashid recalls thinking at the time, “‘Who is this man?’ This was well outside the scope of most physicians.”

But three weeks later, Rashid found himself participating in a sit-in at the office of then Natural Resources Minister Joe Oliver. He and Berger had hoped a dozen doctors would join them; 90 people showed up.

Berger’s next idea was to interrupt ministerial announcements to protest the cuts. That one really made Rashid squirm.

“I hated it. I remember saying it was ridiculous because the person shouting down the government official would look like an idiot. Philip said, ‘That might be true, but you never see doctors doing this.’”

Across the country, doctors crashed government photo-ops. Berger himself heckled then federal minister of state for sport Bal Gosal during a Pan Am Games announcement at Nathan Phillips Square.

“It was not intuitive to me that this would have been a successful advocacy strategy,” Rashid says. “But Philip knows what buttons to press. In terms of political advocacy, he’s got very keen instincts.”

They co-ordinated nationwide demonstrations and public forums, gathered signatures on petitions, wrote op-eds and called news conferences.

They also participated in a charter challenge against the government. Berger coached Rashid who was cross-examined for seven hours, advising him to study as though he were preparing for a med-school exam:

“One of the things I learned from Philip was that you have to do your homework. He preached that you have to absolutely be true to the facts. Don’t embellish or cut corners because you will be caught out for that.”

They won the legal challenge and the Liberal government last year restored the health coverage to 100,000 refugees.

To be sure, Berger is not universally loved.

His strong opinions rub some the wrong way. A letter to the editor and opinion piece, both authored by him and published in the Star earlier this year, raised the hackles of some in his profession.

In the Jan. 27 letter, Berger was harsh in his criticisms of a group of doctors planning to overthrow the board of the OMA and threatening work action:

“The coup leaders have failed on every count of responsible leadership with their rancid policies, feckless judgment, boundless self-righteousness and skin thinner than Donald Trump’s. They hide their perhaps legitimate concerns about income under the pious garb of claiming the dispute is about their patients’ welfare. Yet their threats to reduce or withdraw services make such claims risible.”

Berger slammed them again in the Feb. 10 opinion piece:

“The public will not be fooled by such sanctimonious declarations and moral cover for what lies at the heart of the dispute between government and doctors — physician incomes. And higher wages for doctors will do nothing to remedy the flaws in our health care system.”

In response, Berger came under attack on the 10,000-plus member Facebook group, Ontario Doctors Discussion Forum:

“He might understand how patients are suffering if he looks beyond his downtown Toronto well-staffed centre . . . If all that fails invite him to shut the hell up,” wrote Hemant Shah, a gastroenterologist at the Toronto General Hospital and a district director on the OMA board.

Contacted by the Star, Shah said he had no comment.

Toronto family physician Dr. Mark Linder posted a letter to Berger on the forum in which he wrote:

“So, in the spirit of debate and free speech, please know that you have presented yourself to the world as a patronizing, sanctimonious prig. Your odious self-righteousness almost immediately and automatically discounts all your arguments.”

Linder did not respond to requests for comment.

Berger’s willingness to take on the group has won him admiration in other quarters, especially among young doctors he has mentored and who are following in his activist footsteps.

When Berger was clearing out his office last summer, he removed from the wall a treasured possession — a 37-year-old poster for the Ian Adams Defense Fund.

(Adams is a former investigative reporter and novelist. Social justice activists raised money for his legal defence in 1980 when the courts took the unusual step of ordering him to release identities of sources. Adams is also the author of a powerful 1967 Macleans story, “The Lonely Death of Charlie Wenjack,” about a 12-year-old Ojibwe boy who died of exposure and hunger after running away from an Ontario residential school. The story has been in the news again recently because it was the source of inspiration for the late Gord Downie’s last album, graphic novel and animated film, Secret Path.)

As if passing the mantle, Berger gave the poster to protege Dr. Nav Persaud. It now hangs in the younger family doctor’s office at St. Mike’s.

“If I could accomplish one-tenth of what he has accomplished, I would be very proud,” Persaud says.

The young doctor is already making a name for himself by taking on the Goliath of Big Pharma. Persaud has made headlines for exposing conflicts of interest and flawed scientific evidence.

He says Berger has been an invaluable source of guidance and support in navigating such battles:

“He said there are risks and there are people who are going to object to what you are doing and there are going to be repercussions for you later on. But you have to make a decision about what sort of career you want to have and what sort of life you want to live.”

Physicians are privileged and benefit from being members of institutions such as St. Mike’s and the University of Toronto, Persaud says Berger has taught him.

“That carries with it some responsibilities. When we see something going wrong, we need to speak up, especially when disadvantaged or marginalized people are affected,” Persaud says.

Dr. Joshua Tepper, another St. Mike’s family doctor, describes how he sought out Berger for advice when he was a first-year resident at another hospital. Tepper had some ideas on how to better serve patients but needed some direction on how to move them forward.

“Whether you agreed with him on a particular issue, Philip paved the way for many of us in understanding that physicians have an important role not just inside the exam room but outside,” says Tepper, who is also president of Health Quality Ontario, the provincial agency that monitors the performance of the health system.

He notes that the role of physician-as-advocate is recognized today as being so important that medical school students and residents are taught about it. In fact, Berger taught such a class at U of T.

But back when Tepper was in school — he graduated in 2000 — there was no such formal instruction.

“When I was training you relied on role models and pioneers like Philip to guide you.”

Even though the senior doctor has now formally retired, Tepper expects he will continue to be a force for good.

“He has such energy and passion, such a willingness to call out what he sees wrong in society, I can’t believe . . . we won’t hear his strong voice and social conscious in the future on important issues.”