Right to Health

Last week, Toronto City Council made history by voting in favour of putting people’s health before their immigration status.  Canadians may be surprised to learn that the universal healthcare system they consider a shining beacon of our humanity denies healthcare services to an estimated 500,000 people in Canada, of which over 100,000 live in Toronto. A report prepared for the Toronto Board of Health outlines the health crisis for these medically uninsured individuals who reside in Toronto.

Read the full Huffington Post piece here. 

Read the report prepared by Toronto Public Health for the Board on Health on the health of the medically uninsured in Toronto here. 
Read a piece by the Wellesley Institute on this motion here. 
To see some of the council debate on this item, check out this video at 552 minutes. 

Why do so many doctors still think they are invincible to the influence of the pharmaceutical industry? Attractive, well-dressed, charismatic drug reps with pearly smiles and shiny flow charts still wait in waiting rooms. Lectures and conferences still occur where lunch is paid for by the pharmaceutical industry. Research studies are still published where investigators receive grants from drug companies and unfavourable results are still buried. Hospitals and medical clinics are still awash in brochures, pens, notepads and coffee mugs sporting names like Pfizer and Lipitor. This doesn’t even include free drug samples lining backroom shelves. How can all this still be permitted given that patients come to their doctors expecting to be offered unbiased health advice? 

Read the full Huffington Post article here.

I highly recommend checking out the documentary “Money Talks: Profits Before Patient Safety” if you’re interested in learning more. Watch it for free here: 

Hello blogosphere!

This month, I was very honoured to have my work profiled in the GTA “South Asian Generation Next” magazine. The original piece can be read here. This opportunity afforded me a lot of time to think about how we choose to represent ourselves in this world - to be true to ourselves but also to be effective in communicating our mesage. Unfortunately, word limits meant that some of the context was lost around the importance of activism, recognizing privilege and the broader immigration policy picture around refugee health cuts. I should also mention that as much as this is an honour, I am also mindful that it’s important for us to focus, not on the work of one individual, but on how we can all work together for social justice. Focusing on an individual while important for planting seeds of inspiration can also sometimes allow society to feel they are ‘off the hook’ for being personally involved in social change - this is not the goal. I also recognize that my privilege as a physician has a lot to do with why I was chosen for this article and hope that my responses work to deconstruct and not reinforce this privilege. My political and social analysis has been shaped by many friends, colleagues, fellow activists, journalists, authors and more who must also all be recognized for their contribution. I also take this opportunity to forgive the editors for the very visible spelling mistake in my name. ;) The full original responses are below - Please feel free to share and leave comments. 

—Ritika

You have been a medical doctor for close to five years. Tell us about that as well as yourself?
My professional work as a physician and my activism are intimately linked to one another the same way that health, politics and social justice are. I work as a family physician in downtown Toronto with the Inner City Health Associates. My training and clinical work has always been focused on working with individuals who are marginalized by our society in one way or another. I’ve worked predominantly with people experiencing or at-risk of homelessness as well as with immigrants, refugees and people without immigration status. Through this work, I regularly meet people who have had tremendously difficult lives. I meet people who have ended up homeless as a result of sudden job loss, people who have fled war and persecution or left their home to provide a better future for their children, people who have turned to substances as a result of childhood trauma, people who cannot access healthcare due to their immigration status and people suffering from mental illness as a result of life circumstances. I see people who are struggling to survive and others doing an incredible job surviving despite their hardships, and I see them all faced by a system that puts barriers in place to health and wellness. 

Doing this work has shown me that medicine, contrary to popular belief, is limited in its ability to impact the broader health of individuals. I often find myself prescribing medicines for ailments that could have been prevented if people had access to a living wage or social assistance rates that allowed them to be healthy and potentially return to work. Constantly coming up against these barriers to providing true health and wellness for my patients consistently fuels a deep desire to change the status quo. This is what drives me to activism to find systemic solutions to the problems that leave me helpless in the one-on-one doctor-patient encounter.

You have been very vocal in your criticism of cuts to refugee health care in Canada and broader changes to immigration policy. Why are these issues important to you and Canada as a whole?
The cuts to refugee health care have come to the fore because they highlight the inhumane nature of a slew of current immigration changes. As of Canada Day in 2012, people coming to Canada fleeing war, domestic violence, persecution based on their sexual orientation and various other concerns are no longer able to access essential medicines through the federal healthcare provided to them. This means diabetics no longer have this coverage for their insulin treatment and people with high blood pressure don’t have coverage for their pills. The most affected are those from a group of so-called ‘safe countries’, a list of 35 countries, from which claimants have even lost coverage for everything including emergency treatment for a heart attack, pregnancy care for a woman and check-ups for children. This group has effectively lost all access to doctors, hospitals and medicines. The Minister of Citizenship and Immigration implies that individuals from these countries are ‘bogus’ claimants even though the list includes Hungary, which has a documented history of persecuting the Roma people, who originated from India in the 11th Century. Individuals from these countries are being denied access to healthcare, fast-tracked through the system and denied the right to appeal that other claimants have, with the goal of deporting them as soon as possible. Having served many individuals from this and other countries that have been designated as safe, I have heard the stories of women fleeing sexual violence and men fleeing physical violence making these policies completely nonsensical. These cuts to the refugee health program have drawn widespread criticism from the health sector including pressure on the federal government to rescind the cuts and pressure on Ontario’s provincial government to provide coverage in the interim. 

Unfortunately, however, they go well in line with many troublesome immigration policies passed as of late. In the past few years, the government has placed a moratorium on sponsorship of parents and grandparents, instead implementing a super visa that requires family members to purchase private health insurance which is difficult and expensive to obtain. They have also decreased processing times for refugees overall, increasing the chances that their claim will be denied simply because there is not enough time to get adequate documentation from countries that may be in turmoil. They also have also legalized a decreased pay rate for migrant workers compared to workers with full status and denied them access to Employment Insurance even though they pay into it for everyone else. I think the issue of refugee healthcare cuts has really resonated with people as it’s clear that we are taking away services from some of the most vulnerable people in our society and there is no good justification for doing such a thing. It is crucial for immigrant communities like the South Asian community to be careful when the Minister seeks to divide immigrants and refugees by calling refugees ‘queue-jumpers’ ignoring the dire situations in which they arrive. There is no one line, but rather a multitude of reasons for migration and we must respect the humanity of people as well as their right to health and justice.

Tell us about the organization you work with, the Inner City Health Associates?
Inner City Health Associates is a group of physicians, primarily family doctors and psychiatrists that work with people experiencing or at-risk of homelessness in Toronto. It has a really unique model where the physicians mostly run their clinics in shelters and other community agencies where people are already accessing services and have already built trust. This is very helpful for a population that may have been poorly treated by the medical system or are unable to access regular services due to challenges such as mental illness or immigration status. We try to think beyond what is standardly considered medical care with a recognition of the social determinants of health knowing the link between income, housing and health. We work closely with social workers, case managers and other such professionals to help our patients address these basic needs knowing that often this is what will most greatly improve their health. 

I work with this group both as one of the family doctors and also as the Population Health Lead. This means I have the opportunity to take a bird’s eye view and think about what can be done to provide better care overall. I focus a lot on ensuring we are collecting data to be able to engage in continuous quality improvement. It’s really nice to see people one-on-one and have that practical experience inform the higher level work and vice versa. Part of our goal is to evaluate the success of our approach in improving the health of our population but also look at how we can decrease overall costs in the system by providing good primary care which keeps people out of hospitals and emergency rooms. We are interested in outcomes such as how many people we get connected with housing and how many people we get access to income supports beyond the standard outcomes such as diabetes control and cancer screening. 

You did your Master of Public Health at Johns Hopkins School of Public Health in the United States. What is your perspective of Canada’s health care to that of the United States? 
It has always amazed me that Canada and the US sit next to one another with such drastically different healthcare systems.  The US spends substantially more per capita on health care than any other country in the world (17.4%, with the distant second being the Netherlands at 12%, Canada spends 11.4%) and has much poorer outcomes in most arenas. This is due to a for-profit health insurance based model which treats healthcare as a market good. This means that health care services are allocated based on ability to pay instead of need, and people are often denied care when they have pre-existing conditions. The US has an estimated 50 million people without any health insurance and many others who are underinsured as the insurance companies regularly deny claims after people have sought out medical care. This is why 62.1% of personal bankruptcies in the US are due to medical bills! 

Comparing health systems around the world, I learned that the US truly is alone as a high-income country in the system that it has. Other high-income countries, similarly to Canada, have publicly-funded health care systems, most of which actually cover more services than ours, often including medications, dental care and vision care. The US wastes a tremendous amount of money on administrative overhead paying for the bureaucracy associated with providers sending claims to multiple insurance companies, all of whom have their own administrative staff working to create bureaucratic hurdles and deny claims. Also included in this are expenses for advertising services and of course profits that come off the top. This means there is an estimated 30 cents for each dollar spent on healthcare in the US being spent on administration, rather than about 2 cents in Canada for our provincial insurance plans like OHIP. Overall, their system is completely unsustainable, but there is a glimmer of hope with places like Vermont where a bill was passed recently to institute a single payer healthcare system similar to Canada. Unfortunately, the concerns of the American healthcare system are worth paying attention to here in Canada as we often hear that the solution to our problems lies in privatization: I can tell you based on what I have seen that this is not the case.

You have often said “Health is a human right and should be made accessible to all”. Why do you think that is?
At some basic level, everyone understands that health is something sacred. It is something of utmost value and when someone is sick, they should be able to access services to make themselves well just based on their humanity. We understand at some level that in a fair and just society, the millionaire CEO running a large business and the seasonal agricultural worker picking tomatoes should all be able to access and receive high quality healthcare based on their need. In Canada, our healthcare system reminds people of the value in organizing healthcare services based on need and not ability to pay. Many people in Canada are proud of the healthcare system as something that stands for justice and equity, but I think most would be shocked to know that there are up to an estimated 500,000 people without health insurance in Canada. This is because our access to healthcare is tied to immigration status leaving many people who live and work in our communities, pay taxes, and are often in fact the backbone of our economy, without access to healthcare when they get sick. As a volunteer physician at the Volunteer Clinic for the Medically Uninsured in Scarborough, I see these individuals once they have waited for conditions to deteriorate before they have no choice but to seek healthcare, and have heard several stories of individuals who have died as a result of this lack of access. Fortunately, Toronto just recently became the first city in Canada to pass an ‘Access Without Fear’ policy meaning people in Toronto should be able to access services regardless of immigration status which will hopefully include health services. As a signatory to the Universal Declaration of Human Rights, Canada is saying that it too believes that health is a human right, and while we’re certainly doing better than the US in providing this right to our citizens, we can still do better for everyone else. 

To the many young South Asians who may want to emulate such a medical career - what advice would you want to share?
My first piece of advice would be that people should do what they feel truly passionate about, and this might not be medicine which is okay (despite what your parents may tell you). Most other health providers are not nearly recognized enough for the incredible work they do, often directly impacting the health and lives of patients much more than physicians. However, for those who are interested in medicine, it is certainly possible to work with marginalized people regardless of which specialty you choose. For those interested in systems-level thinking, I have found family medicine to be an ideal choice as it really puts you on the front lines of the healthcare system in a way that most specialties are not and also allows you to build strong ongoing relationships with patients. I would highly recommend seeking out mentors that are doing work similar to what interests you. I’ve been fortunate to find strong female mentors in medicine who are excellent clinicians, political activists as well as mothers and serve as a constant reminder to me that anything is possible! Getting exposure to the different possibilities within the medical field early on in your training is also helpful but it’s worth knowing that people do change their mind decades into their careers and it’s never too late to try something new. 

Tell us about your activism and how others can get involved. 
Activism is something I’ve been engaged in over the past five years. As a physician, I realize that I have a lot of privilege in this society and I seek to use that to positive ends, but am also careful not to reinforce it. As an immigrant woman, I hope to galvanize other women of colour who may otherwise feel uncomfortable speaking out - our voices are so greatly needed and often drastically underrepresented. I started out as a medical student simply wanting to learn more about Canada’s healthcare system and joined an organization called the Medical Reform Group which has been around since the 1970s. This led to forming a group called Students for Medicare which sought to reach students of all health professions to talk about our healthcare system and how we can ensure equitable access for all in the face of constant threats to privatize. Most recently, I’ve been involved with an organization called Health for All which works on issues related to immigration and led to the work most recently related to cuts to refugee health care but also other ongoing issues of immigration policy. I try to balance both organizing with groups as well as expressing my personal opinions through writing via outlets like Huffington Post Canada, my personal blog and Twitter. I am grateful to social media to be able to share my own perspective in a manner that is accessible by many people and encourage others to do so as well. 

A big realization for me has been that we live in a particular system that has oppression and injustice built into it as the default setting and that if we don’t work to actively move towards a more equitable society, it is unlikely to happen on its own. I’ve also realized that working to bring about change can seem intimidating but is actually pretty easy. If you are concerned about something, coming together with a group of individuals can be a very powerful thing. This can mean something as simple as writing letters to your local city councillor pertaining to a neighbourhood issue like a public park or it can mean organizing large-scale demonstrations relating to global climate change. Although many of us have come to this country as migrants, we have to be empowered enough to speak out and move towards a more just and equitable society - if we all decide to do this, the possibilities are endless.

On November 13th, 2012, my friend and colleague, Dr. Tomislav Svoboda, was arrested while protesting the removal of bike lanes on Jarvis St. in Toronto. He did this knowing the risks because he considered them worthwhile to make a statement about the need for bike infrastructure and the link to public health and safety. I joined him this morning in a press conference presenting this view. 

This is what I said:

1. Canada and the US are 10x behind countries like Denmark, Germany & Sweden in our bike usage - (1 in 10 of their trips are by bike, 1 in 100 of ours). Countries with less bike infrastructure have more injuries and when asked why people do not cycle more, SAFETY is cited as a common reason. 

2. Last month, a study in the American Journal of Public Health looking at cyclists in Toronto and Vancouver found:
- Major streets with parked cars and no bike infrastructure are the worst for injuries 
- Simple bike lanes reduce the risk of injuries by 50% 
- Bike lanes with a physical barrier reduce the risk of injuries by 90% 
- This is not new information. Similar results have been seen in multiple studies.

3. Since 2006, there are over 1000 collisions with cyclists on record each year in the City of Toronto and on average 2 cyclists killed each year (likely underestimates). In 2012, 57 people in Toronto were admitted to hospital with injuries from cycle collisions, and three were killed. The families of these individuals live their lives knowing that these deaths could have been prevented with better bike infrastructure. 

4. When the Jarvis bike lane was installed, bike traffic went up 3-fold, collisions on average decreased by 23%, with a minor increase in travel time for motorists only at peak rush hour of only a few minutes 

5. In response to all this evidence, in 2012, NY added 33km of bike lanes, Montreal added 35km of bike lanes, Chicago added 53km of bike lanes, but Toronto had a net removal of 2km of bike lanes. We are completely out of line with the evidence and the broader trend in North America. 

As a physician, a public health professional but also as both a Toronto cyclist and motorist, I call on our public officials to support a substantial increase in bike infrastructure in Toronto. This is not about bikes vs. cars, it is a matter of public health and public safety. 

For the public statement released by physicians from St. Michael’s Hospital and to see a written version of Tomislav Svoboda’s remarks, click here.

If you’d like to get involved with this issue, check out Cycle Toronto. 

Media coverage from the press conference:
http://torontoist.com/2013/01/physicians-call-for-more-bike-lanes-more-quickly/
http://www.citynews.ca/2013/01/16/doctor-protests-removal-of-jarvis-bike-lanes/
 

Watch a video from the press conference: 

If you are a frontline healthcare or social service provider in Ontario, Quebec, BC or Alberta, you may find these flowcharts I created helpful to decode refugee health cuts.

Download Ontario flowchart here: http://health4all.ca/IFHCutsFlowchartOntario
Download Quebec flowchart here: http://health4all.ca/IFHCutsFlowchartQuebec

It’s a sad day for refugees looking to Canada for protection. Today, Jason Kenney and the Conservative government announce a controversial list of countries that will determine who does and does not get access to healthcare in this country. This ‘Designated Countries of Origin’ or so-called ‘safe countries’ list singles out refugee claimants from certain countries fast-tracking their claims and denying almost all coverage for health care services, even in the case of a child with an emergency.

Read the full Huffington Post article here.
Healthy Debate version here.  

Today at 10:30am, Jason Kenney announced the following countries as “safe”: Austria, Belgium, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Slovak Republic, Slovenia, Sweden, UK, USA.

Resources:
Canadian Association of Refugee Lawyers press release:
http://www.carl-acaadr.ca/node/50
Canadian Council for Refugees, Amnesty International Canada joint press release: http://ccrweb.ca/en/bulletin/12/12/14
CIC Announcement re Initial DCO List:
http://www.cic.gc.ca/english/department/media/releases/2012/2012-12-14.asp

A few nights ago, I watched the North American premiere of the film ‘Just the Wind’ at the Toronto International Film Festival. The film’s raw depiction of the experience of racism and oppression experienced by the Roma people left me deeply disturbed. The family portrayed in this film lives in a poor, rural area of Hungary facing daily discrimination and harassment while attempting to maintain the semblance of normalcy. They hear of the violent murder of a neighbouring Roma family perpetrated by strangers who arrived in the night and killed the family, children and all, in cold blood with shotguns. The film is based on a series of racist murders committed against the Roma people in Hungary in 2008-2009. Such violent attacks continue today. 

Read the full article here. 

See below for an interview with a Roma refugee family in Canada: 

On April 25, Jason Kenney, our Minister of Citizenship, Immigration and Multiculturalism, announced cuts to Canada’s refugee health insurance, to go into effect the day before Canada Day. What followed has been an unprecedented mobilization across the country denouncing these cuts.

Arguments have been made on multiple bases: the unfairness and cruelty of these cuts, the harm to the health of individual refugees, the public health issues that affect others in Canada and the increased costs which will be borne from unnecessary preventable disease complications. Many have also noted that these cuts to refugee healthcare fit in with this government’s ongoing attack on migrants, be it the halt on family sponsorships, the decrease in pay for temporary foreign workers, the lowered acceptance rates for refugees or the ongoing marginalization of undocumented people.

Read the full article here. 

Resources:
A flowchart and a table that explain the refugee health cuts for frontline workers. 
A blog being kept by the Volunteer Clinic for the Uninsured in Scarborough.
A monitoring tool for healthcare workers to document adverse outcomes of the cuts.  

In a shocking move, the Canadian government is cutting access to health care for refugees across Canada starting on June 30. Health groups are loudly denouncing cuts to the Interim Federal Health Program (IFHP) that provides temporary healthcare to refugees and asylum seekers in Canada.

Disregard for health and human rights
If these cuts are implemented, all refugees will lose access to essential medications, and thousands designated as coming from ‘safe countries’ will be denied healthcare services altogether, even in the case of life-threatening conditions such as heart attacks. These cuts highlight the current government’s utter disregard for health and human rights and they will leave refugees, an already vulnerable group, struggling harder for survival.

As a group of health care workers and allies who work with migrant communities, we see cuts to the IFHP as fundamentally unjust and part of a larger pattern. Over the past few years, we have seen progressively harsher immigration restrictions as Jason Kenney, our Minister of Citizenship, Immigration and Multiculturalism, seeks to fundamentally transform Canada’s immigration system.

Read the full piece here. 

To learn more about Health for All, a migrant justice organization with many health providers, check out the website here. 

In a time of government austerity and popular opposition, we have grown accustomed to the sight of people taking to the streets. But physicians demonstrating en masse? Now that’s not something you see every day! The action began on May 11, and it hasn’t stopped yet.

That day, 90 physicians occupied the office of Conservative MP Joe Oliver in Toronto in response to proposed cuts to healthcare for refugees, and were joined by others taking action across the country.

These cuts to the Interim Federal Health Program (IFHP), will deny access to essential medicines for all refugees, and almost all healthcare for many. This means that diabetics will no longer receive insulin, while others will go without blood pressure medications. Those deemed to be from so-called “safe countries” will be denied care even in life-threatening situations such as heart attacks or suicide attempts. These cuts will lead to increased suffering, and possibly even death, for a population that is already vulnerable.

Read the full article here.