Race, Health Care and the Law 
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Health and Racism in Canada

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Vernellia R. Randall
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National Anti-racism Council of Canada,

 Racial Discrimination in Canada, The Status of Compliance by the Canadian Government with the International Convention on the Elimination of All Forms of Racial Discrimination (July 2002)(1)

Introduction

The Canadian government's last report to the CERD committee makes surprisingly few references to the issue of health. Health concerns have a direct and unmistakable impact on the wellbeing of racialized communities. As well as producing structural inequalities which create conditions of ill health, racism dramatically influences access to medical services and shapes the quality of encounters with the health care system.

While Canada prides itself on an internationally recognized system of socialized health care for all, it is important to keep in mind that this system has been rapidly eroding. Severe spending cuts in the health care system during the 1990s in most provinces have had a disproportionate impact on communities already marginalized by poverty, and it is well known that a disproportionate number of people of colour are poor. Recent attempts to preserve healthcare are floundering, and are compromised by a move toward greater privatization. Even at its best, the country's well-reputed medical system cannot guaranty equal treatment to all who require its services. Nor does it preclude unhealthy conditions in some communities, or assure that medical testing and treatment take into account the needs of diverse populations. The recent move toward a two-tier system will continue to assure better care only for those who can afford to pay.

Several areas of particular concern to persons of colour warrant special attention on behalf of the federal and provincial governments. For instance, Aboriginal communities are much more likely than the average Canadian population to experience poverty, violence, racism and poorer health, and to live in substandard conditions. Studies of immigrants have indicated that health tends to decline over the duration of their stay in Canada. People of colour, and women in particular, consistently report barriers to accessing health care information and treatment. This is similarly true of immigrants to Canada, who experience racism, language barriers and cultural isolation. While Canada boasts the number one ranking among best countries in which to live, if the conditions of its Aboriginal population were isolated, it would rank 63rd.(2)

In the glaring absence of specific promises or plans in the report of the federal government of Canada, the following discussion utilizes recent Canadian research in outlining key health issues of particular relevance to racialized groups. It should make clear that racism affecting health care is an issue that mandates immediate and profound attention.

Health Issues and Racism

Lack of Race-Conscious Health Research

A thriving feminist health movement has made important gains in advancing gender as a crucial axis of analysis in health care research and treatment. However, women have often been treated as a homogeneous group within such analyses. A report from the Chinese Canadian National Council states, "Medical research communities as a whole are still not tuned into the changing demographics and the differences in the needs of racial minority communities due to different physiques."(3) Race, where it is considered at all, is often seen as merely an extra category to be 'added' when considering the needs of women of colour, rather than a fundamental organizing principal of a system which treats different women differently. Systemic racism and socioeconomic concerns also structure how people of colour gain access to health care and information, how comfortable they feel in seeking help, and their level of trust in 'outsiders' who assess and treat their families.

Various studies indicate that while immigrant and refugee women have many health needs that are similar to those of Canadian-born women, they possess far fewer resources, for example, in support networks, employment, and income. This indicates a need for culturally diverse services and programs that are tuned to immigrant women's issues. It also points to the need for accessible information about Canadian law, women's rights, and how to utilize the health care system. Further, the Canadian Centres for Excellence in Women's Health call for more research to clarify the areas where the needs of Canadian-born women and immigrant women diverge, as well as where they are similar. They identify key areas requiring more investigation, such as the influence of language ability on health, the impact of social determinants on immigrant women's health and the need for interpreter services. Their study reports that it remains unclear, for example, "whether immigrant and refugee women under-utilize preventive services due to differences in their concepts of health and health promotion, or systemic barriers, including those in the health system, and other socio-economic and linguistic factors."(4)

Immigrant men, too, may experience particular health problems related to gender identity and the transition to a new culture. A recent thesis examines the experiences of Guatemalan immigrant men in Canada, relating their common reluctance to report or seek help with health problems to particular understandings of masculinity. It calls for greater attention to how the meanings attached to gender, race and cultural identity positively and negatively influence health and help-seeking behavior.(5)

Access to Health Care

Racialized women in Canada tend to use healthcare services less and to receive diagnoses later than do women from other populations. This has been attributed to systemic linguistic, gender, race, cultural and class barriers. A report from the Ontario Health coalition notes that "discrimination places many people at a disadvantage, and is a barrier to accessing health care."(6) This has been found to be true of many racialized and immigrant populations. A recent study on the service seeking experiences of Chinese immigrants notes that barriers to communication and cuts to health and social services make it extremely difficult for these immigrants to find assistance, despite their overall high level of education.(7)

A study of Arab Canadians identifies important barriers to accessing health care. Namely, the study found very few Arabic speaking health care providers, a lack of interpreters, few Arab female physicians for women, and a much greater need for culturally sensitive mental health services.(8)

Cultural differences present particular issues for health-provision. For instance, in the drive to be 'culturally sensitive' many people rely on stereotypes and generalizations, or attribute particular problems to the 'backwardness' of other cultures, rather than to the complex forms of oppression immigrants may have experienced. Research with Somali women in the Lower Mainland of British Columbia found a troubling lack of appropriate, skilled and respectful reproductive care for women who had undergone female genital mutilation.(9)

The same report found that institutions, such as residences for seniors, often fail to understand and respond to the needs of immigrants because "their operating principles are drawn from dominant care models." Many societies place more emphasis on collective or community health than on individual well-being; thus racialized groups and immigrants seeking help may place their own needs after those of their families. Institutions are often insensitive to or judgmental of these values.(10)

 

Language barriers, social isolation, unfamiliar hospital environments and the need to rely on family members as interpreters can create discomfort in relating personal experiences. In the case of Aboriginal health care, traditional methods of recovery and treatment are being reinvoked or combined with mainstream medical and psychological models. It is important that such efforts be supported and that Aboriginal patients be encouraged to access them when desired.

Abortion

Access to safe and legal abortion for all women has long been a stated goal under the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) and the Canada Health Act. CEDAW requires that women be able to decide freely on the number and spacing of their children, and that all women have access to family planning information and services. The Canada Health Act recognizes abortion as a decision to be made by a woman in consultation with her doctor. This Act also states that all medically required procedures be covered by medicare in both hospitals and private clinics. However, abortion is the only procedure in Canada that is not mandated under this category.

Since the Act, hospitals have been allowed to determine their policies on abortion on an individual basis, and abortion performed in private clinics is not covered in several provinces. Abortion services are also limited in many cases to large urban centres. This has important consequences for Northern women, many of whom are Aboriginal, who lack access to urban facilities, and also for low income women who do not have the ability to pay. In most reciprocal billing agreements among provinces, abortion is excluded from coverage. Therefore women who travel to another province to access the service are forced to pay for their own care.(11)

Gender Violence

Aboriginal women, immigrant women and other women of colour experience disproportionate rates of domestic violence in Canada, where rates of violence against the general population of women are already severe. Among Aboriginal women, the rate of domestic abuse may be as high as 80%. In some communities, all women have a history of abuse.(12) Poverty, too, can increase a woman's risk of violence in her home. One study found that women with a household income under $15,000 were twice as likely to be battered as were women in general.(13)

Immigrant women, women of colour, refugee women, live-in domestic workers, and women from linguistic minorities more often encounter barriers in accessing appropriate services, and therefore bear a greater burden from violence than other women.(14)

The Centres for Excellence in Women's health report that health care delivery services to immigrant and refugee women are insufficiently equipped to deal with the impact of violence on health. There is consistent evidence that many refugee women suffer mental health problems attributable to multiple traumas such as rape and torture experienced prior to emigration.(15) One study examined both pre-migratory and post-migratory experiences of violence against refugee women from Peru and Chile. It found that "exposure to violence in the pre-migratory context, lack of familiarity with their new environment, and the isolation that Latin American refugee women experience upon their arrival in Canada increase their vulnerability to domestic violence, single parenthood and mental distress."(16)

Black women, in particular, face significant barriers in reporting incidents of domestic violence in Canada. Due to the overwhelming discrimination faced by Black men in the justice system, Black women are justifiably fearful of reporting the men who abuse them. They face a double-edged sword, as they must choose to either risk perpetuating the violence against Black men at the hands of police and other justice officials, or remain in violent relationships and risk injury or death.

Life Expectancy, Mortality and Disease

Statistics Canada identifies 12 regions as having well below the average life expectancy of the general population.(17)

Aboriginal people make up almost half of the population in nine of these regions, where average life expectancy is equivalent to that of the general Canadian population 25 years ago. The three regions of low life expectancy that do not have large numbers of Aboriginals are characterized by higher levels of poverty and lower levels of employment than the national average.

Rates of death due to most causes are higher in Aboriginal regions than in non-Aboriginal areas of Canada; many are even higher among Inuit populations. Most Aboriginal communities, including Inuit communities, experience higher than the national average of death rates from circulatory disease and cancer, among both men and women. Mortality due to respiratory and circulatory disease is even higher among Aboriginal women than men. Further, the rates are generally higher among Inuit populations than other Aboriginal communities. A Statistics Canada report calls the rates of lung cancer and respiratory disease among Inuit women "particularly alarming."(18) The death rate from respiratory illness in Region du Nunavik and Nunavut is over 3.5 times the national rate. This correlates with the fact that two thirds of Aboriginal residents in the north smoke, as compared with one third of non-Aboriginals and 29 per cent of the populations of the provinces. Aboriginal people also become smokers at younger ages. Diabetes rates for Native peoples are three times the national average.(19)

Aboriginal women suffer from much higher rates of reproductive and breast cancers than non-Aboriginal women in Canada, and the number of Native people living with HIV/AIDS is much higher than the national average.(20) A study of racialized women in Canada found that written information about AIDS-related health concerns is not sufficiently accessible to African-Canadian women, who are at high risk.(21) It states that HIV/AIDS is quickly becoming a crucial issue for Black Canadians.

Infant mortality rates in Aboriginal communities are up to 2.8% higher than in the general Canadian population. In Region du Nunavik and Nunavut, which have very large percentages of Aboriginals, they are over 3.1% higher. For Aboriginal infants and preschoolers, the rate of death due to injury is four to five times higher than the Canadian rate.(22)

Aboriginal peoples, along with the elderly, immigrants from countries with high rates, and those who live in poverty, are much more susceptible to tuberculosis than are other Canadians. Tuberculosis is closely associated with low socioeconomic status and poor living conditions. Although the disease has generally been on the decline for the last fifty years, among Aboriginal peoples the decline has been slower and unsteady, and they maintain some of the highest rates of infection, particularly in the northern regions.(23)

A report on the health of Northern residents(24) found an overall substantial difference in Aboriginal and Non-Aboriginal health, although the differences were not consistently in one direction. For example, fewer Aboriginal people drank alcohol, while fewer non-Aboriginal people smoked. This indicates the need for more specific and detailed information in order to meet health provision needs in these regions. The study also suggests than the lower rate of some chronic conditions reported in Aboriginal people may be due to underreporting and lack of diagnoses, as they also demonstrated lower rates of contact with physicians.

In the same study, 47% of Northern Aboriginals assessed their own health as "very good" or "excellent" while 69% of non-Aboriginals made such an assessment.

Physical Impairment

Aboriginal people are far more likely than other Canadians to face a physical disability. For adults the rate is 31% versus 13% for the national population. Among those aged 15-24 it is 22% versus 7%. These rates were similar across different Aboriginal groups and different geographic regions. In addition, Statistics Canada notes that Native peoples with disabilities face barriers through racism and lack of access to services. The severity of their disabilities and requirements for assistance have also been shown to increase after age 55, at which time a substantial proportion have unmet healthcare needs.(25)

A recent study also suggests that women of colour who live with physical disabilities face particularly acute barriers in the health care system. Women of colour with disabilities reported in a symposium that lack of sensitivity on the part of health care providers was a major problem in their experiences, along with a general lack of awareness of the interlocking effects of race, gender and disability.(26)

Oral Health

The Canadian Dental Hygienists Association states that a number of Aboriginal oral health issues remain unaddressed. In 1997, only 51 per cent of the Aboriginal population on reserves had visited a dentist during the previous year. Ninety-one per cent of children on reserves suffered from tooth decay, and 25 per cent of children regularly suffered from toothache or bleeding gums. Only half of the children on reserves had healthy gums.

In a plea for public coverage of dental services, the Association also cautions that oral health is poor among low income Canadians, who are the least likely to have insurance or to have visited an oral health care provider during the past year. A study of Toronto's West Central Community Health Centres revealed that 23 per cent of family benefits clients and 20 per cent of general welfare clients were refused treatment by a dentist.

A Toronto study on the oral health of street youth found that 41.4 per cent had dental decay and half reported dental and oral pain in the past month. The Dental Hygienists Association asserts, "To adequately address the oral health care needs of Canadians identified above, there is a need to provide more equitable access to oral health care by bringing a greater range of the continuum of health care under the umbrella of public funding." Indeed it is absurd that the treatment of dental illnesses, which can lead to life-threatening infections and heart conditions, remains outside the identified bounds of "medically necessary services."(27)

Cuts to Health Care

As mentioned above, cuts to provincially funded health care on the part of the federal government have been the locus of public policy debate in recent years. Many provinces have responded to these cuts by greatly reducing spending in the area of health care, and delisting important services from health care coverage. Women and racialized populations are naturally hard-hit by these reductions in spending. They are more likely to be poor and less likely to have access to health services and information in the first place. They are also less likely to incur supplementary healthcare benefits from their employers.

Recent reports on aging in Canada make clear that women, and particularly poor women, often compensate for decreased medical services by caring for family members at home. Further, home care workers are often women from racialized communities. They receive low pay and are required to perform more tasks to compensate for the increased burden of health care work, in positions with little opportunity for promotion. Such women are vulnerable to poverty and declining health.(28)

One study notes that health care reform in hospital obstetrics wards has created a great burden on the services delivered to racialized women, whose access to nursing care and information is limited. There is an increased need for community-based support systems for pregnant women from marginalized groups.(29)

A report on the effects of government cutbacks on immigrant and refugee populations states, "The downsizing of the health sector has weakened commitment to provision of services such as cultural interpretation, and practices of long term inclusiveness… There is an unraveling of inclusion and commitment to ethnoracial youth and children when major shifts occur in policy, programs, and services."(30) In addition, immigrants face barriers to health care when attempting to sponsor relatives who follow them. The sponsorship of elderly parents and disabled children often requires the signing of a waver guaranteeing the sponsor is liable for any medical costs.(31) Refugees are not eligible for provincial health care coverage, but can receive only limited insurance from the Interim Federal Health Program. Further, this program requires that they declare a need for financial assistance, it is unfamiliar to many health care providers, and has been analyzed as very difficult to use.(32)

The above report, along with other research presented here, outlines a growing gap between health services and the needs of immigrant and marginalized populations. The dramatic increase in uninsured services means that individuals and community organizations bear the burden of locating volunteers or providing cheap and accessible care. As newcomers to Canada already face gaps in services, their hopes of finding culturally and ethnically relevant means of support are rapidly fading.

Article 7

Several areas of health care reveal that lack of sensitivity among healthcare providers, underscored by systemic racism, contributes to the difficulties racialized group members face in accessing healthcare treatment and information. It is clear that anti-racism education is essential in the training of medical personnel and other care providers, as well as more broadly in society.

Mental Health

Research has shown that immigrant women's mental health issues are often conceptualized by mental health experts as individual psychological problems, when in fact many such issues require understanding of the broader social and political contexts of women's lives. This is particularly true for women who come from countries in which they survived war or political persecution.(33) A failure on the part of health providers to understand political context, historical circumstances and different forms of oppression experienced by women makes it difficult for these women to seek treatment for mental distress.

Again a gender analysis is important in assessing risks for both women and men. As one study reports, "…the exceptional life contexts and personal experiences of immigrants and refugees often alter the pattern of social risks for mental health. For example… male subjects had more dangerous and traumatic experiences during exile."(34) This study also identifies common frustrations over underemployment among immigrants and refugees as risk factors for depression, particularly among men. It notes that lifetime rates for depression among Ethiopian immigrants to Canada are three times greater than depression rates in Ethiopia.

Mental health is also a crucial topic among Canadian-born people of colour. Most regions with large Aboriginal populations have suicide rates up to 2.9 times the general Canadian rate.(35) Health Canada states that registered Indian youth suicide rates are eight times higher than the national female average, and five times higher than the national male average.(36) The highest suicide rates among Canadian men are found in Region du Nunavik and Nunavut.

Post-Immigration Health Changes

Several studies suggest that new immigrants to Canada are, on the whole, healthier than resident Canadians.(37) This was found to be especially true of non-European immigrants. They exhibited higher life expectancies and lower incidences of disability and chronic disease. However, it has been noted that this is to be expected due to "healthy immigrant syndrome" which indicates that the healthiest people are the most likely to make major life changes and geographic moves, and also the most likely to be admitted to Canada.(38)

Importantly, the quality of immigrants' health has been found to decrease as their stay in Canada increases. As immigrants age, their formerly higher life expectancy tends to converge with that of Canadian-born residents, and their incidence of chronic diseases and disabilities comes to resemble those of the general Canadian population. While the reports from Statistics Canada do not speculate in detail as to the causes of this change, they suggest that the health-related behavior of Canadians negatively influences immigrants over time.

Other reports suggest that the failure to deliver healthcare based on anti-racist principles contributes to poorer health for women of colour in Canada. It is important that further research address the impact of such a failure on immigrants' health over time. A study by Vissandjée et al argues, "the critical question is not so much whether immigrant women are in better health than Canadian-born women, but rather what living conditions in Canada increase the incidence of various diseases among immigrants."(39) Such a decrease in health has been evident among immigrants in the United States and Australia as well. It remains unclear how much of the decline is due to the adoption of the new country's health habits, and how much to the failure of the health system to address the needs of immigrants, particularly those from non-European cultures.(40) Clearly, more research is needed to accurately assess and intervene in this trend.

Immigrants and Aging

The Québec-based Alliance des communautés culturelles pour l'égalité dans la santé et les services sociaux (ACCESSS) conducted a pathbreaking study on older immigrants and issues of aging in 1999. The research demonstrated that older immigrants face extra difficulties in accessing the health care system. Important factors cited were communication, increased vulnerability to poverty, social isolation, and a lack of family-focused strategies in mental health. Of particular concern is the increased role of older women caregivers in the context of their adaptation to immigration. Such women are more likely to face poverty, isolation and stress. Very little is known about the social issues around aging in immigrant and refugee populations.(41)

Clearly, Canada has ample cause for alarm over the health issues and needs of racialized and marginalized communities. For healthcare is about more than the emergency provision of help at times of crisis. An inclusive and comprehensive system demands strategies for prevention, education and support as well as recovery, so that the overwhelming crises in our midst might be averted in the future.

1. National Anti-Racism Council of Canada, o CultureLink, 00 - 160 Springhurst Avenue, Toronto, Ontario Canada M6K 1C2, Tel: (416) 588-6288; Fax: (16) 588-2435 email: kjacobs@culturelink.net or mkerr@culturelink.net; www.narc.freeservers.com

2. A. Saidullah. The Two Faces of Canada: A Community Report on Racism. (National Anti-Racism Council, 2001) [hereinafter Two Faces]

3. Chinese Canadian National Council. A Submission to the Romanow Commission. (June, 2002)

4. M.A. Mulvihill, L Mailloux, W. Atkin. Advancing Policy and Research Responses to Immigrant Women's Health in Canada. Report prepared for The Centres of Excellence in Women's Health. (Canadian Women's Health Network, 2001) [hereinafter Advancing Policy]

5. S. Dunn. "Keeping the Pain," Health, Belonging and Resilience Among Guatemalan Immigrant Men. (Unpublished Masters thesis, York University, Toronto, 2000)

6. Ontario Health Coalition. Our Health… Our Say! Word from the Street on Ontario's Healthcare System. (2002) http://www.web.net/ohc/ourhealth.htm

7. H. Leung. Settlement Service Policies and Settlement issues Among Chinese Canadian (sic) in Canada. (CIC-OASIS, 2000) http://ceris.metropolis.net/Virtual%20Library/community/hleung1.html

8. L. Yuan, I. Rootman, A. Tayeh. Health Status and Health Care Access for the Arab Community in Toronto: a Pilot Study to Assess Health Needs. [CERIS Research Report, No date]. www.ceris.metropolic.net

 

9. Advancing Policy

10. Ibid.

11. Canadian Abortion Rights Action League, Special Report to FAFIA (Toronto: CARAL, 2001)

12. Ontario Native Women's Association. Breaking Free: A Proposal for Change to Aboriginal Family Violence, (Thunder Bay, 1989).

13. Canadian Centre for Justice Statistics, Wife Assault: The Findings of a National Survey, 14 Juristat 9, (March 1994) at 13.

14. M. Shin. Violence Against Immigrant and Visible Minority Women: Speaking with our Voice, Organizing from Our Experience. (Ottawa: National Organization of Immigrant and Visible Minority Women of Canada, 1992)

15. Advancing Policy

16. Ibid.

17.

Life expectancy. Statistics Canada: 11 Health Reports 3, (Winter, 1999) [hereinafter Life]; Low life expectancy means at least three years below that of the general population.

18. Ibid.

19. Health Canada. The Health of Aboriginal Women, The Women's Health Bureau online

http://www.hc-sc.gc.ca/english/women/facts_issues/facts_aborig.htm

20. M.D. Stout. Aboriginal Canada: Women and Health

http://www.hc-sc.gc.ca/canusa/papers/canada/english/indig.htm

21. G. Simms. Aspects of Women's Health from a Minority/Diversity Perspective [hereinafter Diversity Perspective]

http://www.hc-sc.gc.ca/canusa/papers/canada/english/minority.htm

22. Life

23. K. Wilkins. Tuberculosis, 1994, Statistics Canada: 8 Health Reports 1 (Summer 1996)

24. B. Diverty & C. Perez. The health of Northern residents. Statistics Canada: 9 Health Reports 4 (Spring 1998)

25. E. Ng. Disability among Canada's Aboriginal Peoples in 1991, Statistics Canada: 8 Health Reports 1, (Summer 1996)

26. Diversity Perspective

27. Canadian Dental Hygienists Association. Brief to the Commission on the Future of Health Care

in Canada. (October 31, 2001)

28. Advancing Policy; The Bringing Care Home Campaign. In 20 Short Years: A Discussion Paper on Demographics and Aging. (Ontario Community Support Association, 2001) at 5 www.ocsa.on.ca

29. Advancing Policy

30. E. Kwan, Devolution of Social Programs and Spending Cuts: Impact on Immigrants and Refugees [Canadian Labour Congress, No date] at 19 [hereinafter Devolution] http://www.clc-ctc.ca/policy/social/rp9.rtf

31. Ibid.

32. Ibid.

33. Advancing Policy

34.

S. Noh, I. Hyman, H. Fenta. Pathways and Barriers to Mental Health Care for Ethiopians in Toronto. (Centre for Addiction and Mental Health & Department of Psychiatry, University of Toronto: April 2001) http://ceris.metropolis.net/Virtual%20library/health/hyman1.html at 17

35. Life

36. Two Faces

37. J. Chen, E. Ng, R. Wilkins. The Health of Canada's Immigrants in 1994-95, Statistics Canada: 7 Health Reports 4 (Spring 1996); J. Chen, E. Ng, R. Wilkins. Health Expectancy by Immigrant Status, 1986 and 1991, Statistics Canada: 8 Health Reports 3 (Winter 1996)

38. In fact, both the former Immigration Act and the new Immigration & Refugee Protection Act contain provisions which bar the entry of persons being determined as "medically inadmissible".

39. Advancing Policy at 10

40. Ibid.

41. Ibid.

 

 
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The University of Dayton School of Law
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