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Uncivil society: Social and economic barriers to health equality in Canada Wylie, Lloy 2008

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Uncivil SocietySocial and Economic Barriers to Health Equality in CanadaLloy WylieWestern Regional Training Centre in Health Services ResearchBroader Study – Canadian Case� International research project - Canada, Germany and Italy. � Canada’s long experience with Multiculturalism (a policy since the 1960s) - it would be our best practices case� Unlike Europe, Canada is built on immigration� Elimination of ethnicity as an immigration criteria in 1967, shifted the origin of immigrants to Canada. � Although there are some important successes, there are some very significant challenges.December 07 Data (based on 2006 Census)Canadian Population: 31,241,030Immigrants: 6,186,950 = 20%Toronto Population: 5,072,075Immigrants: 2,320,160 = 46%Vancouver Population: 2,097,965Immigrants: 831,265 = 40%Montreal Population: 3,588,520Immigrants: 740,355 = 21%Problems / Perspectives� Decline in health status – immigrants come to Canada healthier than the average Canadian – within 5-10 years, their health status is below the average� Research shows that the responsiveness of health services in Canada to the needs of ethnically diverse communities is only moderately developed and uneven� People working in the health care system were overall more optimistic, and had a sense that over time there would be a natural progression of improvement in access. � Immigrant associations were less optimistic, systematic response needed. � A program manager in Vancouver summed up the sentiment of everyone: “there is still a lot of work to do.”Variations in Access to Care –System Barriers� Variations across the health system, ethnic groups, socioeconomic positions, make it difficult to make a definitive statement. � An immigrant association in Montreal noted that: “the major stumbling block is that the whole thing is so haphazard…You got some very good situations, some middle of the road and some real horror stories. So, you got a whole spectrum of possible answers, and it's all left to local people to somehow organize themselves to get the service that they need.”“We have been working at developing models for teaching cultural competency for social work, nursing and psychiatry for a long time… We have an international impact because people come to us from all over the world to train. But the people from Quebec don’t come…We’re well aware of the resistance in the medical community for looking at systemic knowledge, never mind cultural knowledge, and how sophisticated you have to be to actually do these things, these are very sophisticated tools.In BC they said to me, we don’t have any coloured people here so we don’t really need you. The issue I think about Quebec, I think it’s a universal issue in Canada that we do not want to talk about systemic racism, we simply do not want to talk about it, but it is there. Believe me it is there… The head of the department did not believe that culture, cultural competence, or family therapy should even exist in the curriculum of psychiatry residents.”- Service Provider in MontrealCultural Competence not a System  PriorityPhysician Access Barriers� “The issue of finding family physicians is compounded for non-English speakers, particularly trying for refugees, given the fact that many of them have been medically compromised. Reluctance to take on the whole individual who needs more than 15 minute visits.” (Vancouver).� “There are families that don't have family medicine because the doctors available in their area they say: "We are full. We cannot take any more patients." …If they have some emergency, if they have some problem, they're just running to the hospitals, and when they are to sit there, wait there, it's very difficult. It's very difficult for them. If father is working, mother is working, who's going to take the child? It's very difficult.” (Montreal immigrant association).Foreign Doctors� Foreign Credentials are not recognized for doctors� In Montreal there are 300 foreign trained doctors who have re-trained in Canada who cannot get residencies to become doctors� Institutions will hire foreign doctors who are sponsored by their home countries for hospital residencies (they get $150,000 from the home countries), rather than hire doctors who have emigrated to Canada (cost $40,000)The Continuum of Care� “it depends where you're talking about in terms of the continuum of care. I think there's certain areas of the continuum where there's better attention. And I think that's just because there may be internal champions, you know that recognize the need and support that…But even internally in the lower mainland if you look at some pockets…maybe one department uses this a lot, maybe another department doesn't.” (Vancouver)� “it would be easier if the whole system ran better, moving on with what we are doing with the population. The fact is when we are going out of our local area and our local hospital settings; we have to start each time from zero.”(Montreal)Legal Status and the IFHP � Montreal: program managers noted that a key issue for refugees was that they often needed services that they could not pay for. They also noted that this denial of access to services creates an ethnical problem for care providers. � “What are essential services, where is family responsibility for a refugee claimant, but they need more than they're allowed, or someone that doesn't have a status or whose status is ambivalent or they're in-between applying and they have to pay and they can't pay. Someone with mental health issues. There are a lot of issues around that. Because physicians and healthcare professionals feel frustrated because they're obliged to give service, ethically, but the systems in place don't always coincide. Here they're working on policies. But it really it needs a bigger initiative from the government, and a concerted effort across the board”. Vancouver Case� “I have people here with cancer, they cannot wait. You know, one guy, he arrived here, and he had a surgery before arriving, and he needed another surgery immediately. I have been advocating for him with B.C. health insurance, and ah, oh, they have to wait. So ok, you can go to an appeal to waive the waiting period. And I said ok, and I appealed for the case. But nothing happened, you know. We have cases that they are severely ill. That they need medical attention immediately, and we cannot get it because of the 3 months period of time. That would save so many lives, you know?”Language Barriers� Language barriers are seen as the most significant problem with access � “English-speaking people largely don’t realize how easy the world is when you’re communicating in your own language, versus how very very difficult it is when you’re not.” (Vancouver)Language Spoken at HomeVancouver:Non-Official Languages: 547,660(note that 70,630 of these are of the non-immigrant population)� Chinese languages: 257,610�Punjabi: 87,150�Korean: 35,925�Tagalog (Philipino): 22,365�Persian (Farsi): 19,260�Vietnamese: 15,880�Spanish: 14,255�Hindi: 11,185Montreal:Non-Official Languages: 346,065(note that 62,500 of these are of the non-immigrant population)�Spanish: 44,670�Italian: 42,610� Chinese languages: 40,430�Arabic: 40,165�Vietnamese: 15,545�Romanian: 13,630�Greek: 13,615�Creoles: 13,490�Russian: 12,235Gendered Language Barriers� “For the paediatric care the thing that seems the most problematic is that the mother, the immigrant woman, stays home with the kids. When they have to come to the hospital she's the one who goes to see the doctor with the kids, because there is not a lot of immersions, she doesn’t learn to speak French. So it's very hard to communicate with the parents, especially the mother, when they come to the hospital. So the communication is a big issue.”Risks of Miscommunication� As one immigrant association representative in Montreal noted: � “There were cases here of false diagnoses because of incomprehension…there are also false diagnostics because of a lack of communication.”Problems with Interpreter Services� Even where there are interpretation services� trained interpreter services were not used� other staff or family members Health professionals, not patients, decide if interpretation is needed. “people sometimes arrive with their relative or they go to a hospital at emergency and they got to find a janitor for the translation, because he's the only one that speaks the language.” (Montreal)Vancouver Case� “To be honest, they weren’t even calling the interpreters, before. Because if you have a few words of a language, you say ‘ah, hi, my name is’ and ‘how are you?’…so the nurse would hear a woman say a few words in English, and she would think “oh she’s fine” and wouldn’t call the interpreter, but in fact, this woman only had a few words, and certainly didn’t understand medical terminology.”“A woman took her little boy to a hospital when he was two. Her son was being taking in for brain surgery. She didn’t have enough English to be able to understand what the doctor was telling her. To this day, she doesn’t know what the brain surgery was for. Because no-one called an interpreter, although it wouldn’t have been difficult for them to do that. People who have not lived in a system where their language is not dominant don’t know how helpless that feeling is for the parent.”VancouverAdvocacy Strategy“So it will probably be social marketing to the population saying, you know, your 13-year-old kid doesn't have to do the interpretation for you when you're talking to a doctor about sensitive matters; you have the right to an interpreter.”VancouverEthnic Differences in Access� Vancouver - Communities with a larger numbers and longer histories in Canada have better access than new immigrants. � “numbers probably creates better access. So, some of the larger groups - it's Cantonese, Mandarin and Punjabi in Vancouver and surrounding areas. So I think that those groups probably tend to have more voice. And because of the numbers, we also have more resources. … There are what we call languages of lesser diffusion… where they're having to rely on resources that are not as well trained, maybe not as accessible, so maybe appointments have to be changed - so it does change, from group to group.”Montreal - Racism“The further away you get from the European culture, the further you get towards, like say, Africa or Asia, groups that are very recent, that do not share the same value as the European traditional Canadian majority, then the resources will not be there. So health care will not be as good. So again, it has a lot to do with the time factor, and it has to do with cultural prejudices that are built into the way that Quebec and Canada perceive the population…It's in the last 20-30 years that there's been a move towards saying Canada is a multicultural society. Now, how much of that filters down to the individual citizen, some feel that way, some don't. Some don't really see Canada as a multicultural society. So there is that kind of unfortunate situation where we haven't quite made it to the 20th century yet and here we are in the new millennium.”Montreal� R1:“it is easier for some communities than others. I would say for Latin origin communities, it's very easy” R2: “yes, Italians”, � R1:“South Americans, Brazil”� R2:“Spanish community”� R1:“It is easy for European people, too”� R2:“that’s true.”…� R1:“It's not so easy for Asian people…they won’t ask very much, they won’t ask enough”� R2: “no they won’t ask enough, and they always give the impression that they are satisfied” “� R1: But you never know... It's not so easy for North African people, like Arabian, or”� R2 “Tunisian”� R1 “Egypt, Lebanese, and also Morocco. For me that just shows that it’s not only and it’s not mainly a question of language”.Economic Barriers“it’s all problems that come with the impoverishment of the population - people being less fortunate or having less access - because the problem is not necessarily income, it’s the capacity to provide for your family or to work, so, when you don’t work or when you are in an uncertain situation, this generates a series of problems in you that belong to recent immigration. But now, the conditions that we used to associate to recent immigration have a tendency to stretch out in time. So, this brings on organic and non-organic problems linked to stress, etc. But not only that - because people might have less resources, language programs are often cut for recent immigrants, and since their economic status is precarious, recent immigrants feel very uncomfortable to go take language classes when they should be working.”MontrealOrganizational  Challenges to Equitable AccessResources and Funding� Budgetary guidelines limit resources to address impact of diversity� Overall health system downsizing� Overworked staff� Project based funding—lack of sustainability� Unequal access to interpreters and culturally competent care across regions and service typesEducation, and Training� Lack of ongoing regularized intercultural training and staff time to participate� Varied levels of material adapted for a multicultural context� Lack of knowledge and sensitivity to the issues from ethnic&cultural communities� Lack of knowledge regarding new waves of immigrants� Limited recognition of the value of culture by service providers� Lack of appreciation for different cultural values Organizational ChallengesPolitical Will� Limited understanding of cultural/language competence on the impact of care� Lack of organizational and managerial commitment and awareness� Competing priorities� Need strong dedication and time to build effective partnershipsStructural Barriers� Prejudicial/discriminatory practices and attitudes� 90 day waiting period for access to services� Lack of knowledge regarding resources for referrals.� Limited capacity – data gaps, measurements� Need to address power imbalances� lack of connection between practitioners and planners� Challenges in “Multiculturalizing” a mainstream programConclusion� A long way to go still to achieve equality in access to health care services that are appropriate and comprehensive� Social attitudes play an important role� Economic Barriers also limit equitable access

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