A moral duty

As of this Canada Day, refugees and the physicians who treat them have been set to travel a perilous road together. Jason Kenney, Minister of Citizenship, Immigration and Multiculturalism, announced on April 25, 2012, a drastic roll back of health coverage for refugees and refugee claimants. While the stated aim is to protect public health and safety by providing refugees coverage that is “not more generous than what most Canadians receive,”¹ the reality of the changes and their consequences are much different. An equitable health care system, it is worth noting, provides each citizen with services in proportion to need and not, as the Minister implies, the same level of services for everyone.

Pre-reform benefits equated approximately to those available under most provincial social assistance programs. Post-reform changes will bear little resemblance to this, with health coverage available only for conditions deemed to be of an “urgent or essential nature” or those to “prevent or treat a disease that is a risk to public health or a condition of public safety concern.”²

What does this mean?

What will this mean for refugee patients when they walk into your office or emergency department? Citizenship and Immigration Canada recently published a brief with some extraordinary examples.³ As of Canada Day, some refugees will still be assessed for conditions like angina and diabetes. However, no refugee, even if successful in his or her application for status, will receive coverage for medications like insulin, statins, or antihypertensive medications. Refugees with poor mental health, precipitated by the very living conditions that necessitated their relocation to Canada, stand to be even more marginalized. If suicidal or suffering from posttraumatic stress disorder, they are ineligible for any therapy. Physicians will also lose funding to assess psychoses, never mind assurance that prescribed medications will be covered, unless the refugee’s condition will likely “cause harm to others if not treated.”³ A focus on emergency treatment and aggressive infectious conditions among refugees underscores a deep change in the way in which human beings are assigned value according to their social circumstances. Under the proposed changes, the health status of a refugee becomes important only to the extent that it immediately affects the health or safety of others. Neither the immediate, future, or potential well-being and welfare of the refugee, nor the effects on others and on society in the intermediate term hold any value. The refugee person in this context is no longer valued as a unique and worthy human being but is considered a “risk factor” for others. This is an insidious and deeply dehumanizing perspective.

The government is even harder on refugees who arrive from so-called safe countries. These countries have not yet been identified, but will likely include Hungary, where the Roma endure systemic discrimination, and Mexico, where many are fleeing a brutally violent “drug war.” For individuals fleeing persecution in these countries, coverage has been completely eliminated for prenatal care as well as labour and delivery. For those with acute myocardial infarction requiring emergency care, coverage has been entirely cut.

A need to be heard

To his credit, Minister Kenney has taken time to respond to public criticism, stating that despite the cuts, primary care services will remain intact. In a letter to the Ottawa Citizen, he states that asylum claimants are provided a comprehensive medical examination that “is more preventive health care than most Canadians receive on a regular basis.”⁴ This statement is misleading. He neglects to mention that this screening is only directed at diseases that threaten public—not personal—health. It does not include the routine preventive maneuvers recommended by the College of Family Physicians of Canada to enhance the health of all Canadians.⁵

This is hardly any family physician’s notion of adequate and equitable preventive care. In the same letter, Minister Kenney asserts that changes will “stop the abuse of Canada’s generous and overburdened health-care system by bogus refugees.”⁴ But when refugee claimants—“bogus” or otherwise—are left with the choice of dying at home or taking their chances at an emergency department, it is hard to imagine any physician would deny them care. With the impending cuts to primary and preventive services, it is to be expected that increasing numbers of refugees will present to emergency departments with severe and more advanced conditions. Instead of lessening the burden on the system, these changes will exacerbate already long emergency department wait times and squeeze already tight hospital and provincial health care budgets. More important, this proposed change will likely leave a large number of legitimate refugee claimants with health burdens that will considerably impede their ability to settle promptly and contribute to our society in the rich ways of their predecessors.

We as family physicians have a very important role in advocacy against these Interim Federal Health (IFH) Program changes. We are the front-line physicians. We are the ones who hear the horrific stories of persecution, torture, and, sometimes, rape. The responsibility to advocate for public policy that promotes our patients’ health is ours. The response to the proposed changes to IFH coverage by numerous contingents of family physicians and, indeed, health care professionals across Canada highlights the fact that we need and want to be heard. What are we going to tell that insulin-dependent patient with diabetes from the “wrong” country whose insulin is no longer covered? What about the pregnant woman who is not covered for routine prenatal care? Inexcusable.

The CanMEDS–Family Medicine framework for competencies in family medicine highlights and recognizes our role as health advocates.⁶ As advocates, we family physicians have the responsibility to use our expertise and influence to advance the health and well-being of individual patients, communities, and populations. We recognize the determinants of health in the populations we serve and identify larger public health issues.

The federal government needs to come clean. Minister Kenney needs to acknowledge that his IFH Program changes go far beyond cuts to enhanced benefits, in no way preserve access to appropriate primary care, and only serve to increase, not decrease, health expenditure. More important, he needs to acknowledge that denial of medical coverage to refugees, the most insecure and defenceless among us, violates the values of fairness and equity that characterize Canadians and our country’s health care system. Physicians and health care providers in Canada have mobilized. In May and June 2012, there was increased political pressure and media attention to protest these IFH Program changes. May 11 of this year marked a day of national action when physicians across Canada held protests, participated in an occupation, and issued press releases in an effort to bring public attention to this issue. On May 18, 2012, 8 national health provider associations, including the College of Family Physicians of Canada, issued a statement requesting that the planned IFH Program cuts be revised or rescinded.⁷ Even local municipalities, like the City of Hamilton, on May 16, 2012, unanimously accepted a motion to forgo changes to the IFH Program and continue to fund refugee health programs.⁸

Rather than ignoring the calls of the country’s health provider community, Minister Kenney should instead signal to the world’s most persecuted peoples that Canada remains a bastion of safety and security in a very volatile world. Let’s fight for a strong national primary health care system that includes giving some of the world’s most vulnerable people some fair breathing space. Let’s also think about how we support equitable systems for the poor and most vulnerable people in Canada. We are global citizens. We are a resource to a defined population. Treat people with dignity and compassion. If the tables were turned, we would hope and pray for the same. July 1 deserves to remain a day of celebration for the Canadians who are already here and for those who have yet to come.