REFUGEE DIARIES: CANADA

We have received many inquires. What and who is “The CVC”.  It is just a simple concept, a health and dental  clinic that arose from a sad story , and lot of unmet healthcare needs.

In 1999 an inter-professional crew of health providers in Scarborough learned that large numbers (thousands)  of immigrants, refugees, asylum seekers and other newcomers to Canada resided and worked in our community – while being denied access to healthcare.

Some were in the 3 month wait Ontario imposes on its Landed Immigrants. Others were failed refugee claimants, sponsored persons, and homeless Canadian youth without the means to secure their health cards.

To respond to their medical needs a crew of inter-professional health providers opened medical clinics in a Church basement  in Scarborough in May 2000, to provide them free healthcare. The clinics are largely based on volunteer contributions from providers, donations, and some homelessness grant funding from the Provincial government. The medical clinics are drop in, and operate 2 evenings per week on Tuesday and Thursday, from 5 pm

The CVC

1125 Markham Rd.

Scarborough MIH 2Y5

The CVC is affiliated with a free dental clinic providing basic dental healthcare, staffed by volunteer dentists. A Paediatric Outreach Program ( POP) is staffed by paediatric residents and their supervising paediatricians from Toronto’s Hospital for Sick Children. The POP clinic operates one Saturday per month and serves the swelling ranks of uninsured children in the GTA.

This the sad story that provoked us to respond.

“Aisha”

Aisha, aged 18 years, from Grenada was attending college when she experienced another in a series of sickle cell crises and sought medical care at Scarborough’s only CHC. Her condition was beyond primary care. She was referred to the hospital emergency department. At first she refused to go, having experienced previous requests for up-front payment before receiving care. The doctor reassured Aisha that this would not happen. This was an emergency.

At the emergency department Aisha was told she had to pay $350 before they would provide care. She was told her situation was not an emergency. Not having the money, Aisha explained that her sickle cell crisis would soon leave her unconscious. It had before. Emergency department admitting staff told her that if she became unconscious, they would treat her without demanding payment first. Aisha seated herself near the triage station and waited. When she collapsed, she was taken in. After 3 days in hospital she received a bill for more than $5000.

Aisha was a sponsored youth in Canada, sent for by her father and stepmother at age 15. She had no choice in her immigration. Her parents later separated and left Canada. Her sponsorship lapsed. Aisha was left to fend for herself without health insurance. She managed to get a part-time job, find a room to rent, complete high school, and enter college in Scarborough. Her hospital bill ended her education.”

 The CVC started when someone in the crew said –

“if it Aisha’s job to fend for herself in Canada at age 17, when her sponsorship failed, to get a job, find a room, to finish high school and start College, then when she is ill, it is our job to treat  her?”

updated October 1st 2012

Mr Kenney, through a spokesperson made the following claims. The following is extracted from The Toronto Star Friday, September 28th, 2012

“…A spokesperson for Immigration Minister Jason Kenney called the doctors’ report inaccurate.

“Unfortunately, a small number of activist physicians continue to make unsubstantiated claims and use examples of individuals without disclosing their names so that the facts of these cases cannot be verified or disproved,” said Alexis Pavlich.

“The majority of the alleged cases are either factually incorrect or the real status of these individuals has been purposely altered.

Pavlich said all refugee claimants in Canada get the same access to health care as Canadian taxpayers receive through their provincial health care.

“Bona fide refugees continue to receive comprehensive health coverage, while illegal immigrants and failed asylum seekers from safe, democratic countries no longer receive health insurance that is superior to what is generally available to taxpaying Canadians,” Pavlich said.”

Allow me to disclose the name of Mr Byron Alvarez. Allow me to “substantiate”. Before he died, Mr Alvarez provided me permission to tell his story. I was his attending physician. He attended our volunteer clinic, trying to obtain care at age 40 that would either prolong, or save his life. The following is also excerpted from the Toronto Star, from an editorial, authored by me in June, 2012. My name, by the way, is Paul Caulford. I practice family medicine in Scarborough, Ontario, where I have worked for 35 years. In the article in the Toronto Star your spokesperson is quoted as describing myself and my colleagues in rather disparaging language, suggesting without using the word – we are misleading and deceiving the public. 

Mr Kenney, in what can only be described as thinly veiled mean-spiritedness, you rather smugly proclaimed “I don’t like being taken for a sucker,” when describing the rationale for your new legislation. 

That is where Byron’s story comes in (this is a diary from before the IFH cuts). Being 38 years old and being shot at in Guatemala ..( for political views), seeing family and friends beside you gunned down, then fleeing for your life to Canada, doesn’t get you refugee status. Working here for five years, paying taxes and volunteering with youth in your community, while trying to appeal your refugee denial, also gets you nothing — no status, no health care. Then getting cancer, well, just go away and die young man. So, that’s what he did. Turned down for lifesaving cancer treatment time and time again, Byron died, emaciated, on his apartment floor, never having taken a red cent from this country, but having given everything. What Guatemalan political thugs couldn’t accomplish, Canada did.

Byron must have been that refugee claimant “taking you for a sucker,” right Mr. Kenney? Don’t worry, he won’t do it again.

 

Sept 27th 2012, clinic

Imagine you live in a country where female genital mutilation ( FGM) is often culturally demanded, the “norm”. Your daughter is 13 years old. You disagree vehemently with her being “circumcised”. You learn that relatives are planning to take her from you and have this ritual primitive abuse performed  on her. It happened recently to another young girl in your community. She bled to death in excruciating pain.

You and your husband “borrow” enough money to get you and your daughter plane tickets to Canada. But you are pregnant and at full term, due for delivery in just 3 weeks. So you take a chance, conceal the pregnancy under bulky clothes, and you board the plane. You leave your husband, and 10 year old daughter behind. You take your 13 year old to safety, away from this most horrific and deadly abuse.

Once here you meet with Canadian Immigration officials. You explain, you ask for help. No Interim Federal Health is provided. You leave empty handed while your refugee claim is in limbo. You are due in 7 days. You have little money, and are in a shelter.

This is the new way CIC now operates. It has its “new policies” we were told when we asked.

If this was your 13 year old daughter, what would you do? Would you let her be kidnapped? Would you allow her to be painfully mutilated at age 13 so she could prove she is a virgin at marriage? Would you allow this, so she could never enjoy intimacy at any time in her life, and tear open during the delivery of her future children?

Her mother had no intention of ever fleeing, let alone when she herself is pregnant and about to deliver! But she never expected her daughter would be in this danger.

Just exactly what should we do?

September 18, 2012

Thomas is 12 months old. His mother brought him to clinic tonight from a shelter. She  fled there from spousal abuse. Until July 1st 2012 Thomas had IFH, awaiting a refugee hearing. Thomas had no say in his immigration or refugee claim his young mother initiated. He has not been eating well for a month, has a fever, and is not thriving. His mother could not afford to take him to the doctor because his IFH coverage had been cut. Thomas had infections in both ears, his tonsils are infected, and he was in discomfort.

Gabriel, from Africa, is 8, in grade 3 and has asthma. His IFH cuts mean his mother cannot afford a doctor or his asthma medications. He is coughing and wheezing more. Without treatment and care he is heading into more breathing difficulty.

Ahmed is 2. He was born with congenital defects and needs regular medical care. He is a bright and lively little fellow who has severe visual and hearing impairments. He has trouble walking, but he carries on. His parents are Canadian citizens. Ahmed was born when they were out of the country. Now that they are back, he has not received any healthcare access after 5 months. His parents are told he will not have any for some time. He cannot get the healthcare access he needs. He has a cough, and is choking and vomiting on the phlegm from his chest.

Tonight these are just 3 of 12 children under 10 years of age who are not “bogus” refugee claimants, who are in Canada legally, following process, but now denied healthcare access.

Their parents came to the clinic seeking care for their ill children, care they can now not afford. Ignoring the health needs of our most vulnerable is becoming a very dangerous situation.

Sept 13, 2012

Each day we all make choices. What to have for breakfast, what clothes to wear.

For some at our clinic, the choices have recently become a little more serious, a little more devastating. For some, their choice comes down to the future of their unborn child. It comes down to the destruction of their family, their dreams, their souls.

It is not something she wants to face. There are complications that would require more in depth assessment and care. But, the withdrawal of IFH coverage from this pregnant mother ( she is not our only example), means carrying her unborn of 9 weeks to term and a safe delivery will cost money she does not have. This has her contemplating the termination of her pregnancy. She told us that the uncertainty of her refugee hearing outcome is too big a risk to take. How would she feed her children, if she is denied?

She has but a few weeks to decide. Her tears, her look away, tell us she has reluctantly made her decision.

New to Canada, from a country far across the ocean, our patient gathered her children and fled for their safety. She fled from a place where a brutal and crushing regime of political thugs disemboweled her friend, in the street, in a political protest, and left her to die. She fled to Canada because she “knew” ours was a better place, a place where her children would be safe.

What would you do? If you were this mother, just what exactly would you do to protect your children, your family? There was no time to wait the years necessary for a UN sanction as a convention refugee.

In Canada, she applied for refugee status. She received IFH back then, IFH that offered pregnancy care until her claim was heard. Her claim, now 18 months later, still awaits, still unheard. So, caught in Government delays and the confusing web of their new IFH rules, she has been “reclassified”. Her IFH no longer covers pregnancy care. It will again if her refugee claim is successful. Every cent her husband now earns goes to their rent, and food for their 2 children. She can’t take that chance, she can’t make that choice.

When you leave a brutal country laden with political thugs, with 2 children, and just the shirts on your backs, then take low paying work in Canada – there’s nothing left for “discretionary” spending, or for those “luxury” items.

Something had to go. Damn those political thugs.

Uninsured Refugee clinic Aug 21st, 2012

This week, for the first time in 13 years, we sat after clinic and wondered if we would be able to stay open? Our volunteer family doctor had finished her own office in the day, and arrived at 5 pm in the volunteer clinic. When we were finished, we counted. We had treated 34 medically uninsured patients. This was 10 more than the volunteer doctor treated in her regular OHIP practice that day. It is 20 patients more than we used to see before Bill C31 and the IFH cuts from the Federal Conservatives.

A 14 year old daughter brought her 48 year old father to clinic. They waited patiently for 2 hours to be seen. They were 2nd last. The arrived 2nd last. They had travelled by bus. Their trip took 2 hours. They went home together by bus late that night. Public transit in Scarborough is not very good.

Shanthi was the translator for her father, although her father might have managed well enough. Her English was impeccable. She and her father ( from Bangladesh), and their mother used to have IFH. It was now ineffective, despite not being expired..

Shanthi required her immunization list to be updated and transferred to a TDSB / TPH card and paper so she could attend school. Her father is diabetic. He required a blood test, a renewal of his medications, and, ongoing medical care. Together, their doctor now required $100 before treatment visits.

Our nurses and doctor were able to take care of their needs, for now. They were invited back for a follow up for her father’s diabetes.

On the way out Shanthi turned and looked at the nurse. In a soft voice, she said “Thank you”, then, she turned to the doctor, again, “Thank you”.

I noticed she was crying. She walked out holding her father’s hand.

Excerpted from an Australian Medical Research Study published in the Journal of Paediatrics, 2004.

Minister Kenney at CIC has signalled Canada will now follow Australia’s lead. Detention (without full legal process) of our children and youth refugee claimants is permitted when DCOs are soon announced. 

“” Article 37 of the Convention on the Rights of the Child states that holding children in detention shall be used as a measure of last resort and only for the shortest possible time.

The Human Rights & Equal Opportunity Commission (HREOC) expressed concern about Australia’s compliance with Convention obligations, and so conducted its own inquiry into newly arrivedchildren in detention in Australia. Detrimental effects of detention were found to be extensive in Australia, as well as in several other countries. The report of the HREOC National Inquiry into Children in Immigration Detention was tabled in Parliament on 13 May 2004. Similarly the United Nations Working Group on Arbitrary Detention (WGAD) expressed concerns about ‘the psychological impact’ of detention, its ‘automatic and indiscriminate character, its potentially indefinite duration and the absence of judicial control of the legality of detention’.

Children are particularly vulnerable to psychological trauma resulting from long periods of insecure residency, exposure to harsh treatment, confinement, deprivation and exposure to unstimulating environments. Such experiences create additional vulnerability in children and adolescents due to their incomplete biopsychosocial development, dependency, inability to understand certain life events51 their underdevelopment of coping skills52 and their experiences of past separation. Detention has been found to undermine parental capabilities with children experiencing suboptimal parenting as a consequence of the stresses of their confinement and creating further difficulties when families are finally resettled.

Being unaccompanied or separated from family members, whether in detention or in the community creates further stresses for children. Unaccompanied minors, mostly adoles- cents, lack social support groups, relatives and other natural mentors. Additionally, fear of being returned to their country of origin whilst awaiting refugee determination status may be psychologically damaging. Many unaccompanied adolescents hold TPVs, making them vulnerable to repatriation and impairing their capacity to feel settled and secure. Preliminary research amongst ( some refugees) reveal that the social deprivations experienced are associated with increased levels of psychological disability. Decreased health service utilization has also been reported as a result of uncertainty and fear associated with status. Unaccompanied and separated children in particular should be provided with appropriate protection and care due to the greater risk of psychological and health problems than their accompanied peers. Providers should be aware of the specific experiences of children who have previously been in detention….”

AUGUST 17TH CLINIC, 2012 — raising the risk of death and disability in Canadian infants.

Women not provided professional healthcare during their pregnancy are far more likely to experience serious negative outcomes. So is the unborn child they carry. The risk of prematurity, death to mother, and complications such as eclampsia and newborn death are up to 7 times higher when Mom and baby have no healthcare.

Again, this week, a continuing stream of women at all stages of pregnancy arrived in clinic with rejected IFH, deprived access to healthcare for their pregnancies and unborn. This included Amy, 2 months away from delivery. “Desperate”, best describes her emotions. The expiry date on her IFH papers was in the future. When we contacted Blue Cross, the newly appointed ( by the Conservative Feds) insurance carrier that oversees IFH requests and claims ( we have to stop clinic and phone for each patient) we get nothing but rejections. Amy could not afford the fee her doctor was now charging.

The obstetricians we called to help her were either full, or charged. Amy needed every cent to try to cover the delivery / hospital fees. She was in a panic.  A lot of handwringing and discussion ensued. We decided the best pathway for a good outcome would be for us, with the Midwives who give us time, to provide the remainder of her antenatal care, provide her with her pregnancy medical records, and refer Amy through the local ER when she went into labour. What else can we do?

In 1998, a US analyses ( where there are 40 million uninsured) determined the cost to their society of “raising” a damaged newborn, in the NYC area, delivered with prematurity complications from an unattended pregnancy, exceeded $500,000 by age 20. The cost of healthcare for the same pregnancy and delivery, including 24 hours in hospital was $6000.

Do the math. Frankly, we expect better from those who govern us. Irrational, harmful, and very expensive  decisions, all based on biased ideology have no place in the Legislatures of a modern democracy built on fairness and compassion.

The Federal Conservatives have repeatedly told us their new hardline refugee policies will save us all money. Really? Pray tell.

AUGUST 16TH 2012.

Our numbers of uninsured refugees needing healthcare continue to grow. Tonight’s volunteer free clinic saw more and more patients with rejected Interim Federal Health. In their midst, was a sponsored person, denied healthcare.

Carlos is 47. He came to Canada from South America, via the USA ,when he was 42. He resided in the USA for many years with a valid residency permit. He came here to live with his wife and their 3 children.

Carlos is sponsored by his wife. She has a job, is a Canadian citizen. Carlos is here legally. He desperately wants to work. He cannot – at least legally. Immigration has repeatedly denied him a work permit – for more than 4 years.  This means he cannot earn the money he needs to buy his diabetic treatments, or to see a doctor.  Instead, he receives a small social assistance cheque.

Carlos now needs insulin. His blood sugar has elevated to the point where it is dangerous, potentially life threatening, and certainly life shortening. The pills we are giving him have failed. He cannot afford a doctor to provide care. His eyesight is deteriorating. We have a donation of 3 months of insulin. We gave it to him this evening. We taught Carlos how to inject himself.  When it runs out – then what? If he drifts into a coma, he will need the ER, and likely stay in hospital for days. Our ER’s are already overcrowded. Our hospital’s have bed shortages. We are trying to find a way to get more insulin, to keep his health going, to prevent a hospital visit. We have 3 months supply. We are looking for an eye physician willing to assess Carlos. We prefer he not develop diabetic blindness.

Who thinks a scenario like this up? Who forces a man of 47 who can and wants to work to take social assistance? Who denies him life saving prevention and healthcare, and drives him instead into the ER for care 200 times more expensive than simple insulin?

When those opposed to providing basic health coverage to refugee claimants and other medically uninsured say words like – ” no healthcare for bogus newcomers”, or ” I won’t be taken for a sucker”, do they mean Carlos? Do they realize their words are lethal to a father of 3 children? Is this how they would want to be treated if in his shoes? Are we mad?

I am afraid that one day we will wake up, and realize how severely Canada has deteriorated. I fear that then, it will be too late for all of us.

Ontario is one of 3 Provinces imposing a 3 month wait for health coverage for its landed immigrants – 80,000 per year. A lot can and does go wrong in those 3 months.

Tem was 8 years old when he came to Canada in 2008. Two weeks later he required urgent life saving medical care. He was medically uninsured, in Ontario’s 3 month wait.

Tem’s father was granted admission to Canada from the Darfur refugee camp in 2000, 1 month before Tem was born. His mission was to arrive ahead, and meet the requirements Canada set down to allow the rest of his family to join him. He worked 2 and sometimes 3 jobs for 8 years to save the funds Ontario required. Finally, in 2008, he succeeded. His 2 sons and wife landed as immigrants. Ontario imposed its 3 month wait for their healthcare.

Tem was born in Sudan with severe and lethal heart malformations. He received life saving surgery when he was 3, in the Darfur region where he resided in the refugee camp. Cardiovascular surgeons from Europe came to Sudan to do free open heart surgery. They patched Tem’s tiny heart with a temporary fix. He would need definitive corrective surgery before he was 8 or he would die. Blood was flooding backwards, damaging his lungs.

Two weeks after arriving in Canada, Tem developed a severe pneumonia. His deformed heart was failing under the added strain. He was short of breath, febrile, septic and dehydrated. His father took him to the ER. He was told he needed to pay $500 just for Tem to be assessed. There would more cost for treatments.

Not able to pay, Tem’s family brought him to the clinic. After treatment for pneumonia, and then the gracious generosity of a cardiovascular surgeon at Sick Children’s, Tem survived. His heart is now repaired. His family now live in an apartment in a southern Ontario town where his father works. Tem is a soccer player now with his school team.

The courage and resolve of Canada’s newcomers never ceases to inspire us. They defy and survive death from war and starvation in their home lands, and for Tem, what war and starvation in Darfur could not accomplish, Canada nearly did.

Ironically it was Ontario’s Provincial NDP Government, under Bob Rae, who imposed this regressive and dangerous policy. The NDP’s current leader, Andrea Horvath is in a position to reverse this social injustice that has harmed and impoverished Canada’s newcomers to Ontario. We call on her to do so. The Liberal’s to date have refused.

We and the OMA have presented the financial data to the McGuinty Government proving that providing primary healthcare for medically necessary conditions in the 3 months will save money. The current policy is more expensive, produces ill health and longer hospital stays, and impairs acculturation ( see Kaufman et al, Academic Medicine 2000).

Why is it so difficult for Ontario do the right thing by the newcomers it invites to sustain its future? What is stopping it? What information does it have to support its policy? The OMA and our organization have offered evidence the policy is ill conceived.

It is way past time for Ontario to step out of the past, and into the future of healthcare – for the good of  everyone’s health.

PC