Professional Documents
Culture Documents
Refugees in Canada
Morton Beiser, MD, FRCP, CM
ABSTRACT
Canada admits between more than 200,000 immigrants every year. National policy
emphasizes rigorous selection to ensure that Canada admits healthy immigrants. However,
remarkably little policy is directed to ensuring that they stay healthy. This neglect is
wrong-headed: keeping new settlers healthy is just, humane, and consistent with national
self-interest.
By identifying personal vulnerabilities, salient resettlement stressors that act alone or
interact with predisposition in order to create health risk, and the personal and social
resources that reduce risk and promote well-being, health research can enlighten policy
and practice. However, the paradigms that have dominated immigrant health research
over the past 100 years the sick and healthy immigrant, respectively have been
inadequate. Part of the problem is that socio-political controversy has influenced the
questions asked about immigrant health, and the manner of their investigation.
Beginning with a review of studies that point out the shortcomings of the sick immigrant
and healthy immigrant paradigms, this article argues that an interaction model that takes
into account both predisposition and socio-environmental factors, provides the best
explanatory framework for extant findings, and the best guide for future research. Finally,
the article argues that forging stronger links between research, policy and the delivery of
services will not only help make resettlement a more humane process, it will help ensure
that Canada benefits from the human capital that its newest settlers bring with them.
MeSH terms: Canada; immigrants; settlement and resettlement; migration policy
dentifying a category of people as vulnerable implies that they suffer a disproportionate burden of illness, lower
than average life expectancy or compromised quality of life. As a group, immigrants fulfil none of these criteria.
Immigrants are, on average, in better
health than native-born Canadians, and
have lower mortality rates. However,
shortcomings in immigration and resettlement policy jeopardize immigrants health
advantage.
Canada selects immigrants on the basis
of attributes such as education, job skills
and youth, all of which are grouped under
the rubric of human capital. Screening
helps ensure that they are healthy as well.1
After immigrants enter the country,
responsibility for assuring they stay healthy
devolves to the provinces. However, aside
from defining a mandatory waiting period
before becoming eligible for health-care
coverage, and arranging surveillance for
immigrants with a history of tuberculosis,
provincial health policies have little to say
about immigrants. Refugees, a sub-category
of immigrants, have, by definition, suffered unusual stresses and assaults on their
health prior to coming to Canada. In some
ways, refugees are like other immigrants.
For example, like immigrants in general,
refugees have lower death rates than
native-born Canadians. However, refugees
are in less robust health than their immigrant counterparts, and they have a particular vulnerability to infectious and parasitic diseases.2
Expending a great deal of effort to select
people to become part of Canada, and
then more or less ignoring them is shortsighted. Resettlement experiences exert
enormous influence on the eventual health
of immigrants and refugees, and on the
likelihood that their human capital will
fulfil its promise.3 A century or more of
research concerning the health of immigrants and refugees has produced potentially useful findings that are, however,
diverse, scattered and sometimes contradictory. This article advances an integrative framework to help make sense of an
unwieldy literature. It proposes that the
two paradigms that dominated 20th century research and practice the sick and the
healthy immigrant, respectively were, at
least in part, products of the socio-political
context of the times, and that they fail to
do justice to a complex issue. It further
in this area derived from critical mass theory, whose premise is that immigrants who
settle in areas in which there is an established like-ethnic community have a mental health advantage over immigrants
deprived of such community.16,165,166 Both
hospital- 16,17 and community-based
studies112,114 of the risk of mental disorder
in immigrant and minority communities
support the concept that a like-ethnic
community of significant size confers mental health advantage.
Theoreticians have suggested that receiving countries offer different levels of hospitality to newcomers. 167 Although the
proposition that the more hospitable the
reception, the better the chances of maintaining good mental health168 makes intuitive sense, testing the proposition is difficult because it is hard to know how to
measure hospitality. One study compared
the mental health and adaptation of government and privately sponsored refugees.
Reasoning that refugees sponsored by private groups would receive more individualized attention than others left to the care of
government bureaucracies, the study predicted a mental health advantage for the
privately sponsored group. Results failed to
confirm the prediction. Further investigation revealed that undue pressure by sponsoring groups could have the reverse effect,
that is, the dependence of refugees on their
sponsors made them vulnerable to
exploitation and insensitivity. 113,114,169
However, according to the results of a
follow-up study, at the end of 10 years privately sponsored refugees were better integrated than their government-sponsored
counterparts.170
FUTURE DIRECTIONS
If it could be shown that whatever applies
to majority culture Canadians also applies
to new settlers, there might be no need to
develop an immigrant and refugee database
about health. This is not the case, as exemplified by research that demonstrates that,
although immigrant families are far more
likely than families of native-born
Canadians to be poor, immigrant children
tend to have better health.82 Unexpected
and paradoxical findings underline the
need to take account of heterogeneity in
future studies of immigration and resettlement. Immigrants differ by country of ori-
adhere to principles of non-biased observation and honest reporting. Health professionals should also be aware of the potential (mis)use of health metaphors in
debates about immigration, whether pro or
con.
The socio-politically influenced models
of the sick and healthy immigrant are
insufficient to account for the complexity
of the process of immigrating and resettling, and for the diversity of research findings. To do justice to the phenomenon,
researchers and providers must elaborate
more complex models, taking into account
predisposition, whether genetic and/or
developmental, pre-migration and postmigration stressors, psychological and
social sources of strength, selection
whether self-selection or selection resulting
from administrative process and local
conditions that can affect resettlement.
Most discussion about immigration
focusses on human capital, usually translated as education and job skills. Health, like
education, is an important component of
human capital. Although health receives
little attention in Canadas current view of
immigrants and refugees, policy decisions
have important and potentially far-reaching
repercussions on the health of new settlers.
For example, most provinces impose a
mandatory waiting period before persons
can qualify for health care. Researchers2
have demonstrated that this is not a period
of quiescence, but of pent-up demand.
When the waiting period is over, there is a
surge in immigrant and refugee health-care
visits. The consequences of mandatory
waiting periods and their effects on decisions regarding preventive health care
require careful study.
Just as policy has implications for
health, health should be taken into
account when formulating policy. For
example, in the years 2002 and 2003,
Canada seriously considered adopting a
program of regionalization, under the
terms of which entry could be facilitated
for people who promised to settle in areas of
low-population density and where there
were few other immigrants. None of the
debate that swirled around the issue
most of it rightfully centred on human
rights issues regarding freedom of movement took into account studies demonstrating the health advantage of like-ethnic
communities, particularly during the early
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RSUM
Le Canada accueille un peu plus de 200 000 immigrants chaque anne. La politique nationale
impose une slection rigoureuse de ces gens afin de sassurer quils sont en bonne sant, mais il
existe remarquablement peu de politiques pour sassurer quils le restent. Cette ngligence est
aberrante quand on considre que maintenir les immigrants en bonne sant cest faire preuve de
justice et dhumanit dans lintrt national.
En isolant les vulnrabilits de nature personnelle et les principaux facteurs de stress lis la
rinstallation qui agissent isolment ou en conjonction avec les prdispositions naturelles et se
traduisent par un risque pour la sant et, dautre part, les ressources personnelles et sociales qui
rduisent ce risque et favorisent le bien tre, la recherche sur la sant serait en mesure dapporter
une contribution la politique et aux pratiques. Cependant, les paradigmes sur lesquels la
recherche sur la sant des immigrants sest appuye au cours des cent dernires annes
limmigrant malade ou en bonne sant respectivement se sont rvls inadquats. Une
partie du problme vient du fait que la controverse sociopolitique a eu de linfluence sur la nature
des questions poses aux immigrants au sujet de leur sant et la faon de les examiner.
Aprs avoir fait une revue des tudes qui soulignent les carences des paradigmes de limmigrant
malade ou de limmigrant en bonne sant, lauteur de larticle affirme quun modle dinteraction
tenant compte tout la fois des facteurs de prdisposition et des facteurs socio environnementaux
offrirait le meilleur cadre explicatif des constatations qui se perptuent et serait la faon la plus sre
dorienter la recherche lavenir. Enfin, lauteur de larticle affirme quen renforant les liens entre
la recherche, la politique et la prestation des services, on pourrait rendre le processus de
rinstallation plus humain, et donner ainsi au Canada la possibilit de profiter du capital humain
que les nouveaux arrivants amnent avec eux.