In a world where medical research is increasingly determined by the market for pharmaceutical products, their research addresses the needs of the lower socio-economic echelons of society. "Upon the request of several community organisations, we decided to examine the prevalence of HIV among street youth," explains Roy, a public health physician with the Montreal Regional Health Board.
Eight years ago, when Elise Roy, a physician specialising in public health, decided to conduct a cohort study on Montreal’s street youth, she approached Jean-Francois Boivin, a professor of epidemiology at McGill University, to help her design the study.
Their first study, a cross-sectional analysis, indicated that the prevalence of HIV was indeed high among local street youth. "A cross-sectional study," Boivin explains, "is a snapshot view and involves no follow-up." "It is like a photograph rather than a movie," Roy elaborates.
"We wanted to look at trends over time," states Roy. So they set up a study that would follow-up with youth every 6 months in order to examine patterns of drug use, sexual behaviour and other data related to HIV transmission. While several cross-sectional studies had been done throughout the continent, this would be the first cohort study on street youth in North America and perhaps in the world.
A cohort study would require heavy funding and no one had ventured to obtain such funding to study street youth before.
Boivin and Roy needed strategies to track down the youth and had to provide incentives to keep them involved in the study - incentives both in the form of financial rewards and in the form of much-needed health services. "All of this requires a great deal of manpower," says Boivin.
Working with street youth as research subjects required innovative approaches and a great deal of flexibility. "Sometimes a youth would show up intoxicated at an interview," says Roy, "but we just had to learn to adjust."
Street youth were not mere research subjects either. An advisory committee consulted at many stages of the project’s development included street youth. Participants in the study have been invited to attend conferences with Dr. Roy and are informed about the research findings on a regular basis.
Education as a Tool
Subjects also benefit from access to health services provided by Roy and Boivin’s staff. For example, when the researchers discovered high rates of Hepatitis B in their subjects, they implemented a vaccination program reaching over 1000 street youth.
In addition the program uses education as a tool of preventative medicine. Participants benefit from awareness campaigns that teach them to reduce high-risk behavior. "We don’t have power over the use of drugs," says Roy "so we suggest less harmful ways of using drugs." As part of the harm reduction program, cocaine injectors are encouraged to snort or sniff instead, to reduce the risk of HIV transmission.
"In general the street youth have been pretty cooperative and willing to participate in our study," says Boivin. Their main obstacle is trying to find funds. "It is an expensive project and we need to continuously convince donors that it is worth it. Every year, we wonder if we will have the funds to continue."
The worldwide recognition their work has earned, has been helpful. Their publication on mortality among street youth in the esteemed medical journal The Lancet gave prominence to their study and facilitated the fundraising process.
"The striking mortality ratio we observed highlights mental health and substance abuse as major issues that must be addressed by health professionals involved in the care of street youth," they stated in The Lancet. Their committee made recommendations to the Quebec Health Ministry and managed to obtain $1 million per year for 3 years. The money was to be shared amongst several community organisations and helped set up a clinic for street youth in Montreal. "We don’t only look at diseases such as HIV," states Boivin "we are also examining risk factors." For example his graduate students at McGill are researching factors such as prostitution and patterns of drug use.
Difficult to Compete
Currently on sabbatical leave from McGill, Boivin is studying the literature on the mental health of street youth in the United States. Asked about future plans, he replies "if I allow myself to dream, I would conduct a study on mental health in Montreal’s street youth." That is, if he can manage to find the funds for another expensive endeavour. Due to high rates of suicide and substance abuse, the study of mental health is vital in the study of street youth. There is clearly an overwhelming need. It is has not yet been done in Montreal.
For the time being, the research on street youth survives from pay cheque to pay cheque. "It is the way research goes," Boivin concedes, "we are not unique." But indeed their groundbreaking project is unique. It is in fact unacceptable that North America has had to wait so long before studying the concerns of street youth. But as Boivin admits, given the amounts of funds required, "it is difficult to compete." And sadly it is often market competition that determines the way research goes.