Interim Federal Health Program Cuts and Bill C31 - U of T Psychiatry Position Statement
Position Statement from the Department of Psychiatry, University of TorontoAs mental health professionals, we are united in stating our grave concern and firm opposition to two recent announcements which will affect the mental health of refugees: the cuts to the Interim Federal Health Program (IFHP), which are scheduled to take effect on June 30th, 2012, and the proposed legislation of Bill C31. Both of these changes target the most vulnerable populations in Canada and will create undue human suffering. We join members of the wider medical community who have already voiced their concerns[1] about the proposed changes to the IFHP, including the Canadian Medical Association, the Royal College of Physicians and Surgeons of Canada and many other national healthcare groups[2].
Who we are
The Department of Psychiatry at the University of Toronto has a proud history in Canada since 1907 with over 700 active faculty members engaged in research, clinical care, and education. It is home to one of the largest training programs of psychiatry in the world. Our faculty members are dedicated to researching and providing frontline mental health care for all people living in Canada, including many marginalized populations such as immigrants and refugees.
Outline of Interim Federal Health Program changes and its impact
The Interim Federal Health Program (IFHP) provides temporary basic healthcare coverage, medications, and some supplemental benefits to accepted refugees and refugee claimants, many of whom have left everything they own to flee from persecution, rape, torture and violence in their home countries. Currently, IFHP benefits allow refugees to receive medications, outpatient psychiatric care, hospitalization and basic primary care. In addition, IFHP provides coverage for dental care and eye-glasses, both of which are necessities for people trying to find work and start a new life in Canada. This is similar to what other populations receive under provincial social welfare plans.
The new IFHP changes divide refugees into groups who will receive different healthcare coverage. At the Minister of Citizenship and Immigration’s discretion, certain countries (Designated Countries of Origin, or DCOs) will be deemed “safe.” This process cannot take into account the complexity of individual refugee’s experiences, their reasons for migration, or their need for clinical care.
The three categories of refugees under the new policy will be:
- protected persons
- refugee claimants from non-DCOs
- rejected refugee claimants and refugee claimants from DCOs i.e. “safe countries”
As of June 30th 2012, all refugees will see their medication coverage eliminated. This will include vital medications such as insulin, anti-epileptics, and psychiatric medications. The only exception will be medication for conditions posing a threat to public health or safety. All refugees will also see their vision, dental and supplementary benefits cut. Protected persons and refugee claimants from non-DCO countries, will only receive medical care if the condition is urgent or essential. People from so-called “safe” countries and rejected refugee claimants will no longer receive any medical assessment and treatment at all except for conditions deemed to threaten public health or safety. It is not only disturbing that the Minister of Citizenship and Immigration has the discretion to impose designations on refugee claimants based not on the validity of their claim, but on their country of origin, but to then further use this designation as a reason for allocating health care is unjust, and creates a two-tiered health care system amongst refugee claimants.
In terms of mental health care for refugees from so-called “safe” countries, it appears that coverage would only be provided if a person were deemed to be a threat to others, such as in an acute psychotic state[3]΄[4]. This restriction serves to further stigmatize our already marginalized patient population, since it deems people worthy of care only if they are dangerous. It appears likely that refugees from “safe” countries may not even be covered for emergency assessment or treatment if they are at imminent risk of suicide.
Further, the IFHP changes will cut coverage for assessment and treatment of physical health problems[5], which jeopardizes both refugees’ physical and mental well-being as the two are inextricably linked. For example, along with cuts to medication coverage, refugees from DCO countries will no longer be covered for conditions such as heart attack, trauma or pregnancy. These changes will put further stress on an already burdened population, and will leave many refugees with less access to care than what they may have received in refugee camps, putting them at risk of developing new onset mental health problems.
In summary, the IFHP changes will deprive refugees of basic physical and mental health care. They will take away hope from refugees when they need it most in order to make meaning of their experiences, move forward with their lives, and integrate into communities. In addition to facing well-documented challenges such as poverty, lack of housing, discrimination, and language barriers, refugees who have suffered inhumane treatment and trauma in their own countries and are seeking sanctuary will now also encounter systemic barriers to care. Not having access to timely intervention means that many health conditions, from physical conditions such as diabetes and cardiac diseases to mental health conditions such as schizophrenia, depression, and post-traumatic stress disorder may escalate to crisis levels, requiring more costly emergency or inpatient care. This legislation is therefore not only ethically flawed, it is fiscally unjustified and will lead to more costs for Canadian taxpayers.
Problems with Bill C31
The health of refugees is further threatened by Bill C-31[6], the “Protecting Canada’s Immigration System Act,” which was introduced in Parliament in February 2012. This bill will create a two-tier system of refugee protection in Canada, dividing those who are deemed to arrive through an “irregular arrival” from others, thereby discriminating against certain refugees based on their method of arrival. This bill includes a number of provisions[7] deeply concerning from a mental health perspective, including:
- Giving the Minister of Citizenship and Immigration the power to designate a country as “safe” without external review. As outlined above, refugees from so-called “safe” countries would not receive access to any medical or psychiatric care except when their condition is deemed to be a risk to public health or safety. These refugees may also face additional restrictions, such as not having work permit for 180 days or until their claim is accepted[8],[9], effectively limiting their ability to afford any kind of care.
- Allowing refugees only 15 days to file a written claim on arrival and 15 days to appeal an initial refusal. This provides insufficient time for a population that is often traumatized to seek assistance in organizing their narrative into a coherent account. These unreasonably short timelines also disregard the reality that refugees have a multitude of needs that need to be met simply to survive upon their arrival to Canada, and filing a written claim within 15 days may not be possible.
- Providing the Minister with the power to designate groups of refugees as “irregular arrivals” based on mode of arrival. These refugees will be held in mandatory detention for up to a year, with reviews only at two weeks and 6 months[10]. Children over age 16 would also be detained and imprisoned as if they were adults, while children under age 16 would be either separated from their parents or detained with them in prison-like conditions. For this group of refugees, they will also be denied permanent residency and family reunification for at least 5 years.
These measures serve to punish people who have already been victimized and endured extreme hardship in search of hope and a new beginning. The mental health effects of detention are well known. Evidence shows that detention of children affects both their mental and physical health, and studies show the development of mutism, sleep disturbances, nocturnal enuresis, nightmares, impaired cognitive development and suicidality even in young children who are detained[11]. Many families are forcibly separated during migration, and the delay in permanent residency for 5 years will further delay family reunification, negatively affecting children as well as their parents. Recent evidence from Canada and internationally shows the harmful effects of immigration detention on adults, including high rates of psychological distress, depression and PTSD[12].
The proposed legislation of Bill C-31, if adopted, will offer a dangerous welcome to refugees seeking asylum in Canada. Many more refugees will face fast-tracked deportation if their country is deemed to be “safe,” regardless of whether the individual has experienced persecution, especially with the additional changes barring refugees from having a Pre-Removal Risk Assessment or application for Permanent Residence on Humanitarian and Compassionate grounds for one year. We know that it takes time for those who have suffered severe trauma to collect themselves, establish trust, and get connected with the most basic resources, and the 15-day limit on submitting documents will hinder refugees from filing accurate claims. For some refugees, resettlement stress will be further augmented by the delay in citizenship and family reunification, with potentially dire consequences in their ability to integrate into our community.
Why should you care?
The stated aim of the IFHP changes and the proposed Bill C31 is cost saving[13]. Bill C31 was also introduced to decrease the processing time of so-called “bogus” refugees. In actuality, these policies will neither save us money nor “deter” refugees, but instead, will create additional human suffering and further marginalize and victimize already vulnerable refugees.
While the IFHP cuts are projected to save the government about $20 million per year[14], this is at an untold cost to refugees. Untreated physical and mental health conditions not only worsen health outcomes for refugees, but also further disadvantage them in their journey to restart their lives and integrate fully into communities in Canada. The detention and other measures proposed in Bill C31 will have a devastating negative impact on the health of refugees. Any short-term savings from IFHP changes will be at the cost of much higher expenses in acute emergency care, hospital treatment for severe conditions, long-term medical costs for chronic conditions, and overall lost productivity. From a fiscal perspective, these changes will not only fail to save taxpayers’ money, but rather, they will increase health care costs as care is diverted form primary care preventive settings to emergency rooms and inpatient hospitalizations.
In the promotion of these policies, there is often an attempt to portray refugees in a negative light, creating an “us” vs “them” mindset so that our natural human response to empathize is muted by distrust and indifference. Refugees are fleeing from danger and persecution, not shopping for healthcare benefits. From an ethical and humanitarian point of view, these policies create undue human suffering. They target the most vulnerable, disadvantaged, and voiceless segment of the population, and run counter to Canada’s national identity and values as a country that promotes human rights and equity. Health is a fundamental human right that we believe in. Equity is about fairness, and this includes the recognition that some of us are at a disadvantage not of our own accord or choosing.
Therefore, as mental health professionals, we strongly urge the government to rescind the IFHP changes and withdraw Bill C31. It is time for all levels of government to work with health professional organizations towards a more efficient, economical, evidence-based, and inclusive way of delivering equitable healthcare to all people living in Canada, irrespective of immigration status or country of origin.
What can you do?
1. Participate in a National Day of Action against the IFHP cuts occurring in multiple cities on Monday, June 18th, 2012 at 1 pm
Toronto location: The CIC building at 25 St. Clair St. East
Organizers have asked all health care workers to wear a lab coat or greens, and RSVP at Docs4refugeeHC@gmail.com
2. If you are a member of another student or professional organization, consider putting together a position letter with your colleagues, and using your organization to raise awareness about the IFPH cuts and Bill C31 to other members, the public, and the government.
3. Call or write to the following MPs:
Hon. Jason Kenney – Minister of Citizenship, Immigration and Multiculturalism – at 613-992-2235 / jason.kenney@parl.gc.ca
Hon. Leona Aglukkaq – Minister of Health at 613-992-2848 / leona.aglukkaq@parl.gc.ca
NDP immigration critic – Jinny Jogindera Sims - 613-992-0666 / Jinny.Sims@parl.gc.ca
NDP health critic – Libby Davies – 613-992-6030 / libby.davies@parl.gc.ca
Liberal Party immigration critic – Kevin Lamoureux - 613-996-6417/kevin.lamoureux@parl.gc.ca
Liberal Party health critic – Hedy Fry - 613-992-3213 / hedy.fry@parl.gc.ca
4. Call or write your local MP
(Contact info can be found at: http://www.parl.gc.ca/MembersOfParliament/MainMPsCompleteList.aspx?TimePeriod=Current&Language=E)
Letters tend to be particularly persuasive, especially if they are clearly not a “stock” letter (i.e. they are hand-written).
5. Sign a petition about the cuts to the IFHP.
http://www.change.org/petitions/stop-the-cuts-to-healthcare-for-refugees-in-canada
For more information, please see http://www.doctorsforrefugeecare.ca/index.html or email Docs4refugeeHC@gmail.com
http://www.canadiandoctorsformedicare.ca/may-2012-letter-to-the-minister.html
[3] http://www.cic.gc.ca/english/refugees/outside/coverage.asp
[4] http://www.cic.gc.ca/english/department/laws-policy/ifhp.asp
[5] http://www.cfpc.ca/uploadedFiles/Publications/News_Releases/News_Items/Summary%20of%20Changes%20to%20the%20Interim%20Federal%20Health%20Program.pdf
http://www.cic.gc.ca/english/refugees/outside/summary-ifhp.asp
[6] http://www.parl.gc.ca/LegisInfo/BillDetails.aspx?Mode=1&billId=5383493&Language=E
[7] http://ccrweb.ca/en/protect-refugees-c31-statement
[8] http://www.cic.gc.ca/english/department/media/backgrounders/2012/2012-02-16i.asp
[9] http://www.parl.gc.ca/Content/LOP/LegislativeSummaries/41/1/c31-e.pdf
[10] http://ccrweb.ca/en/comments-amendments-bill-c-31
[11] Kronick, R et al, Mandatory detention of refugee children in Canada: A public health issue?, Paediatrics and Child Health, October 2011
[12] http://oppenheimer.mcgill.ca/Bill-C-4-The-impact-of-detention
[13] http://www.themarknews.com/articles/8526-failing-canada-s-most-vulnerable
[14] http://www.theglobeandmail.com/life/health/new-health/andre-picard/why-cutting-health-care-for-asylum-seekers-makes-no-sense/article2432183/
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