(3) INDS 111 - Refugee Health & Canada's Refugee System

Regarding medical care, what organization do you bill for refugees? For asylum seekers?

- medicare for refugees - blue cross for asylum seekers

List some services provided by PRAIDA.

- Information regarding the immigration process - Assistance with emergency housing - Referral to organizations who can assist in search for more permanent housing - Aid with applications for social assistance - Assistance in obtaining a work permit - Contact information for immigration lawyers Information about registering children for school - Nursing triage and resources for medical evaluations

What are the top 5 birth countries of asylum seekers in Quebec?

- Nigeria - India - Mexico - USA - Haiti

What are some risk factors that affect the health status of refugees?

- Poor living conditions (ie - access to water and sanitation) - Trauma - Exposure to vectors of disease (ie - mosquitos) - Neglect from long periods in refugee camps - Social stratification (ie - race, gender, income, education, occupation) - Susceptibilities (related to migration stress, ethnicity) - Access to preventative care including immunization - Linguistic and cultural barriers to care

If a refugee claimant receives a positive decision, what other services do they have access to?

- Quebec Medicare (RAMQ) - child benefits - subsidized daycare - can also apply for permanent residence and to bring any immediate family members to Canada

What are some services provided by CDAR?

- Screening refugee health assessment - medium term care for the most vulnerable asylum seekers (i.e. those with unstable chronic medical conditions or severe mental health conditions) - Attestation letters describing scars and female genital mutilation - referral to specialists and to community support services - Registration on the provincial wait list for a family doctor

What is CDAR?

- a clinic dedicated exclusively to care of refugees and asylum seekers - receives referral from PRAIDA and lawyers

What is a person without legal status?

- a tourist/temporary resident who has not renewed their tourist visa/study permit, or whose work permit has expired and has not left Canada - a person whose asylum application has been refused, who has exhausted all possible recourse and who has not obeyed a removal order - a person who has illegally crossed the border and has not reported to the authorities

If an asylum claim is rejected by the Refugee Protection Division, what are the person's options?

- appeal to the Refugee Appeal Division - may request federal court to review decision - if a person would not normally be eligible, can apply on Humanitarian and Compassionate grounds - risk deportation

Where can an asylum claim be made in Canada?

- at a port of entry - inland with Immigration, Refugee and Citizenship Canada (IRCC) office

Where can a refugee claim be submitted in Canada?

- at a port of entry (POE) - at an office in Canada

What is covered under the Interim Federal Health Program (PFSI)?

- basic medical coverage (similar to provincial/territorial coverage) - in-patient and out-patient hospital services by physicians and allied healthcare professionals (clinical psychologists, psychotherapists, counselling, occupational therapists, speech language therapists, physiotherapists, etc.) - pre and post-natal care - laboratory, diagnostic and ambulance services - prescription drug coverage (similar to coverage given to social assistance recipients) - supplemental coverage - limited vision and urgent dental care - home care and long-term care - assistive devices, medical supplies and equipment (orthopedic and prosthetic equipment, mobility aids, hearing aids, diabetic supplies, incontinence supplies oxygen equipment)

Why is there no routine screening for PTSD?

- because it can be more harmful to force someone to open up about their traumatic story (and many refugees/immigrants have been exposed to war or significant social unrest)

Despite healthcare for refugee claimants being federally funded, why might they have difficulty accessing healthcare?

- because they do not have provincial healthcare coverage = no provincial healthcare card - many offices/healthcare practitioners do not recognize the federal healthcare document, or do not ask for this document

What are some benefits of the voluntary Refugee Health Assessment?

- covered by the Interim federal health program - includes a well-being assessment by a social workers as well as a health assessment by a nurse - this assessment is much broader than the screening tests done by the border agency - referral for further assessment or treatment as necessary - registration on waiting list for a family doctor

What makes a person ineligible to make a refugee claim?

- criminal record - if they had previously made a claim in Canada and were rejected - refugee status in another country - if they had previously made a refugee claim in the US (new) - if the person is deemed a security threat

When is the health screening of refugees and asylum seekers performed?

- done within 12 months prior to arrival in Canada, or within 60 days of asylum claim in Canada

Who provides assistance to refugees upon arrival in Canada?

- either receive assistance from the State, local NGO or a group/organization that has agreed to sponsor them

What is a better approach to help patients recover from PTSD?

- empathy, reassurance, and advocacy

What is included in the Refugee Health assessment?

- history and physical exam - CBC, Hb electrophoresis, Vit D level - Screening for HIV, syphilis, Shisto, varicella IgG, HBV, HCV, TB

What are the recommendations for mental health screening in immigrants and refugees?

- maintain a high index of suspicion for mental health disorders; many patients present with somatic complaints depression; screen using a validated health questionnaire if an integrated treatment program is available - PTSD; vigilance but no routine screening - child maltreatment; vigilance but no routine screening - intimate partner violence; vigilance but no routine screening

What is the difference between overseas selection of refugees versus an in-Canada refugee claim?

- overseas selection is via state support or private sponsorship by a group/organization; refugee status determination is made by an overseas immigration officer - an in-Canada refugee claim = asylum seeker; decision on refugee status is taken by the Immigration and Refugee Status Commission (IRB)

If an individual is eligible to make an asylum claim, where are they referred to?

- referred to the Refugee Protection Division of the Immigration and Refugee board of Canada for a hearing

What is the responsibility of PRAIDA? When does their mandate start?

- responds to the needs of individuals requesting refugee status in Quebec - their mandate starts when a person who requests refugee status receives an official document from the Quebec Immigration Service identifying him/her as an asylum seeker

What are some issues with the health screening process for refugees and asylum seekers?

- results are not necessarily linked with any follow up (i.e. if something doesn't look right, but it's not a public health risk) - patient may not be aware of need for follow up - results are difficult to access as they are property of the government

What are some health recommendations for the health of female immigants and refugees?

- screen for unmet contraceptive needs (culturally sensitive, patient-centered counselling) - if between ages of 9-26, vaccinate against HPV - screen for cervical abnormalities via PAP test

If an individual is eligible to make an asylum claim, what services do they have access to while awaiting evaluation of their claim?

- social assistance - education - emergency housing - support to find permanent accommodation - legal aid - healthcare - language classes - access to school for minors - access to a temporary work permit note: only while decision is pending

What are some consequences associated with pregnancy in the refugee population?

- social isolation, depression and PTSD, which affects growth of children and increases maternal morbidity - possibility of sexual abuse resulting in stress, STIS, social rejection, infant abandonment or mistreatment - infectious diseases - poor nutritional status - workplace hazards - female genital mutilation - incorrect or incomplete obstetrical histories - higher incidence of hypertensive disorders of pregnancy

What trend have we seen in Quebec and the rest of Canada regarding the number of asylum claims from 2016 to 2018?

- the overall number of asylum claims has risen significantly (from 5525 to 27 970 in Quebec, from 23 925 to 49 775 in Canada)

What type of medical services are available for persons without status?

- they cannot be refused emergency treatment, however, they have no medical coverage - Medecins du Monde offers a free medical clinic, offering primary healthcare for persons without status

What is the Canada-U.S. Safe Third Country Agreement (STCA)?

- this applies at official border crossings only - means that if a person has no relative in Canada, they can be found ineligible to claim asylum and are immediately returned to the U.S.

What is the purpose of health screening of refugees and asylum seekers?

- to assess a limited number of health risks; does NOT provide preventative screening - to protect the general public; claim will not be denied for health reasons

Refugee claimants get access to what level of education?

- up to highschool only, no post-secondary education

According to the Canadian clinical practice guideline for immigrant and refugee health (2011), what health services should be routinely offered?

- vaccinations for measles, mumps, rubella, diptheria, tetanus, pertussis, polio, varicella, hep B and HPV - screening for hep B and C, TB, HIV, intestinal parasites, iron deficiency, dental pain, loss of vision, cervical cancer

What is the current wait time for a hearing with the Immigration and Refugee Board (IRB)?

12 months.

What proportion of immigrants and refugees who experience traumatic events are able to heal upon reaching safety?

80%

Define refugee.

A person who receives protection from Canada because of risk/fear of persecution in their own country for reasons of race, religion, nationality or political opinion. OR someone who faces a risk of torture, risk to life or cruel and unusual treatment.

Define asylum seeker.

A person who requests protection from Canada upon arrival in the country or during a temporary stay; refugee claimants.

Why do so many people choose to cross "irregularly" at unofficial crossings such as Roxham Road?

Because the STCA does not apply (i.e. do not need to have a relative in Canada to cross).

Who decides whether asylum seekers will be granted refugee status?

Canada's Immigration and Refugee Board. Note: 45% of patients will be refused.

What does CDAR stand for?

Clinique pour Demandeurs D'asile et Refugiés

Who covers the cost of medical services for asylum seekers?

Coverage by the Interim Federal Health program via the Blue Cross-Medavie insurance company

True or false: rich countries like Canada take in way more refugees than poorer countries.

False; in many cases, refugees stay in poorer countries like Pakistan, Bangladesh, Ethiopia, etc. Germany is the only rich country that cracks the top 10 list of refugee hostage.

True or false: like asylum seekers, refugees run the risk of being forced to return to their home country.

False; they have already been selected.

True or false: if a refugee claimant receives a negative decision, they lose access to all the services they had before.

False; they retain their right to all services until their deportation date.

Who determines whether an individual is eligible to make a claim?

IRCC

Which services are persons without status eligible to?

Only the following two: - legal aid (which can help them regularize their immigration status, though it can cover other services such as family law) - public school for children under 18 (as of 2017)

Which organization does the Refugee Health Assessment on the Island of Montreal?

PRAIDA note: it is offered in 14 other cities across Quebec.

If a decision of a refugee claim is positive, what can the person now apply for?

Permanent residency.

What is PRAIDA stand for?

Programme Regionale d'Acceuil et d'Integration des Demandeurs d'Asile

True or false: an asylum seeker has access to health and social services, free of charge.

TRUE

True or false: it is illegal to refuse patients with the FIH document.

True (though not according to the refugee lawyer lecturer)

True or false: part of PRAIDA's mandate is to help all claimants.

True; as a result, their resources are often stretched to the limit.

True or false: many immigrants and refugees actually become less healthy when they get to Canada.

True; because of all the barriers they face.

As of 2017, which country was host to the greatest number of refugees?

Turkey.

the health screening of refugees and asylum seekers is performed by who?

The Canada Border Services Agency

What organization provides healthcare services to asylum claimants?

The Interim Federal Health Program (PFSI)

What accounts for the rise in refugee claimants in Canada in the last 2 years?

This is the "Trump Bump" --> people are coming from the States

Until when does a refugee claimant have legal status?

Until/if their application gets denied.

How can child maltreatment in immigrant and refugee families be avoided?

Via a home visitation program for migrant families living in high risk conditions (i.e. Teenage motherhood, single parent, social isolation, low socioeconomic status, mental health disorder, substance use)

What does it mean to say that clinical preventative care of refugees should be informed by the person's region or country of origin and migration history?

You would not do the same preventative care to everyone; rather this would be based on where they came from and their migratory path (i.e. what immunizations they should get).

How are refugees recognized in Canada?

by the Immigration and Refugee Board after submitting an asylum application upon arrival in Canada.

According to the Canadian clinical practice guideline for immigrant and refugee health (2011), what health services should be individualized to improve detection, adherence and treatment outcomes?

malaria, depression, PTSD, child maltreatment, intimate partner violence, diabetes mellitus, contraceptive needs, pregnancy