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Health and Refugees in Canada

Overview
Canadian Refugee Facts
What is a Refugee?  
Canadian Refugee System
Health of Refugees in Canada
Infectious Disease
Mental Health
Kosovar Refugees
South East Asian Refugees
Somalian Refugees
Bosnian Refugees
Refugee Children and Youth
Refugee Health Programs
References, Reports and Websites

Overview

According to the 2001 Canadian Census, a total of 27,894 refugees arrived to Canada in 2001, representing 12.5% of the total immigration for that year (Statistics Canada, 2002). Newcomers to Canada have basic settlement needs when they arrive to Canada. These include orientation on arrival, accessing employment, enrolling children in school, opening a bank account and language learning. In addition, refugees may have special health needs as many may have escaped torture and abuse and may have physical, psychological and emotional health needs relating to their experiences.

Refugees are a special type of immigrant, whereby they are forced to leave their country of origin due to the occurrence of political and economic unrest. However, much of the research to date has incorporated refugees into research on immigrants. Therefore, findings indicate that refugees experience healthy immigrant effect and immigrant overshoot much like immigrants who voluntarily resettled in Canada. However, the initial health state of refugees upon arrival to Canada may be significantly worse. It has been stated that the health status of refugees is poorer than that of immigrants in general because of their experiences prior to arrival and the less stringent selection process (Health Canada, 1999). Nevertheless, it is important separate immigrants and refugees when discussing health status.

Research shows that refugees are at high risk of arriving to Canada with a number of physical and mental health conditions (Dillman, Pablo, & Wilson, 1993; Redwood-Campbell, et al, 2003; Tribe, 2002). The possible stress and pre-migration trauma, coupled with separation from family, cultural conflict and communication barriers may contribute to the poor mental and physical health status reported among refugees entering Canada.

Research on specific groups of refugees in Canada is relatively limited. Again, many reports incorporate refugees into the “immigrant” category and therefore, many of their unique needs are overlooked. In order for Canada to develop realistic and effective social and health policies for refugees, information regarding to the health of this population is essential. Research in the area of health status of refugees in Canada is urgently needed. Some areas of Canada have recognized the need for specialized health services directed toward refugees and have begun addressing these needs in a comprehensive and culturally appropriate manner.

This document will provide an overview of the available research on the health of refugees in Canada. Other summaries of the literature to date are also provided at the following two web links:

Canadian Council for Refugees. State of Refugees in Canada.
http://www.web.ca/ccr/state.html (link not working)

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Canadian Refugee Facts

A 2006 article in on the CBC website cites some interesting Canadian Refugee facts outlined by the Government of Canada.

  • Between 1979 and 2003, an estimated 4,025,546 people emigrated to Canada of which 409,526 (15.4%) came as refugees.
  • pproximately 25,000 individuals made refugee claims in Canada between January 2003 and September 2003. 52% of claims were made inland, 36% at the border and 12% were made at the airports.
  • Around 40% of all refugee claims filed were accepted and refugees were given permission to stay in Canada
  • The United Nations estimates that there were approximately 10 million refugees in the world in 2002.

To review the CBC article, refer to the following web link
http://www.cbc.ca/humancargo/realstories/fact_and_fiction.html

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What is a Refugee?

According to the Canadian Council on Refugees (2006) a refugee is “ a person who is outside his or her home country and who has a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion” (Canadian Council on Refugees, 2006, P. 3). Given that definition of a refugee, an individual can be faced with a wide spectrum of circumstances that lead them to flee their country of origin to become a refugee. Some examples include 1) a homosexual individual who is beaten by gangs in a country that prohibits homosexual acts, 2) a member of a specific ethnic group that is be suppressed and maltreated by the government, 3) a women who is repeatedly beaten by her husband in a country where matrimonial violence is ignored and 4) presence of war and concerns about safety.

Several distinct characteristics differentiate between Canadian immigrants and refugees. Firstly, immigrants choose to come to Canada; either to join family or search for opportunity. They have the chance to return home at any time, provided the opportunity and the means to do so. Refugees on the other had, are forced to escape their country of origin because of political or economic unrest. They come to Canada in search of safety and stability. For the most part, refugees are not allowed back in their country of origin.

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The Canadian Refugee System

The Canadian Immigration and Refugee Protection Act (2002) identify two ways in which refugees can obtain protection in Canada, 1) the Resettlement Program and 2) the Refugee Claim Process. Individuals protected under the resettlement program are brought to Canada and assisted by the government or sponsored groups. They usually become permanent residents as soon as they arrive to Canada. Individuals protected under the Refugee Claim Process are inside Canada or at the border and claim for refugee protection. The Citizen and Immigration Canada decide whether these individuals are eligible. Refugees under the Refugee Claim Process must apply separately for permanent residency. Individuals protected under either of these two methods, become protected persons and certain rights such are given to them; such as the right to work or study. For more information on the Canadian Refugee System visit the following website http://www.cic.gc.ca/english/refugees/index.html.

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Health of Refugees in Canada

Refugees represent a diverse group of individuals in Canada. They come from many different countries and backgrounds, each experiencing their own history in their country of origin. Refugees are forced to leave their country due to political or economic unrest. Consequently, many refugees may have experienced trauma and unhealthy living conditions prior to migration. Therefore, refugees are at increased risk of various diseases and health conditions. However, Canadian research on the health of refugees specifically is scarce.

Dillmann, Pablo & Willson (1993) investigated the health of 1,104 refugees who came to Calgary between January 1989 and October 1990. A total of 34% of the refugees required a referral to a health care professional. Health problems common among this group included vision and hearing impairment, oral health problems, ear infections, women’s sexual health problems and respiratory infections. This study suggests that refugees have special health needs that require attention during the early stage of resettlement.

Immigrant Health Assessment: Profiling Health Diversity in Canada. http://www.europaforum.or.at/site/HomepageMetropolis2003/en/WS9.1DesMeules.pdf

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 Infectious Disease

Refugees come from countries from around the world, including those countries where serious infectious diseases such as tuberculosis and malaria are rampant. Screening is conducted by the government when the refugee enters Canada, however, a number of conditions are not tested for and tend to show up in an active state months after arrival.

Tuberculosis

The rate of TB among foreign born individuals in Canada is significantly higher than the general population. This suggests migration patterns from high TB endemic countries.

A study by Marras, Wilson, Wang, Avendano, & Yang (2003) investigated the rates of active TB and drug-resistant TB in 181 Tibetan refugees in Toronto, Ontario. A group of Tibetan refugees entered Canada between 1998 and 2000. Of the approximately 525 Tibetan people who crossed the border during that time, 181 individuals were referred TB assessment. 58% of individuals reported having a previous case of TB. 97% of the 181 patients tested positive for the tuberculin skin test. Further, 17% had active TB and many individuals had high rates of drug resistant TB. This indicates a high prevalence of active and drug resistant tuberculosis among this group. Many of these individuals reported coming from northern India, which has an extremely high rate of TB. In addition, many of these individuals lived in refugee camps before coming to Canada; thereby they lived in crowded living conditions, which may have contributed to an increased susceptibility.  

Malaria

Malaria is a serious concern for morbidity and death among refugees and host country populations. Refugees infected with the disease relocate to an area where the disease is practically non-existent, which leads to the potential to spark malaria epidemics. A total of 6,670 cases of malaria were identified in Canada between 1985 and 1997 (Canadian Communicable disease Report, 2000). Malaria is becoming a growing health problem in Canada and screening among refugees from countries where malaria is an epidemic is essential.

A study by Ndao, Bandyayera, Kokoskin, Gyorkos, MacLean, & Ward (2004) investigated the prevalence of malaria among Tanzanian refugees after an outbreak of Malaria in Quebec. Shortly after 224 refugees landed near Montreal, Quebec from Tanzanian refugee camps, McGill University centre for Tropical Disease reported an increase in malaria confirmatory testing and assistance in treatment. An outbreak of malaria appeared across the province of Quebec. A total of 535 Tanzanian refugees who arrived to Quebec between August 2000 and March 2001 were screened for Malaria. Findings indicated that malaria infection was present in 18.8% of the sample population. Further, Malaria parasites were found in 24 or 210 (11.4%) of smears. Many of these individuals were asymptomatic at the time of testing. This study indicates a population whereby the malaria prevalence is significant. Health risks apply to the refugees themselves as well as the host population. Regular screening and surveillance is required to ensure control over the outbreak of malaria in Canada.

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Mental Health of Refugees

Refugees are fleeing their countries often because of fear for their lives. Typically, they leave on at short notice to an unknown destination. Consequently, refugees face many losses that in turn impact their mental health status. They leave a country that is home, a culture, family, possessions, employment, language and friends. They leave their life in their country of origin for a life involving multiple changes, significant adjustment and an uncertain future. Several predisposing factors have been identified to negatively impact a refugee’s mental health status. These include separation from family and community, severe and long-term trauma before migration, being elderly or an adolescent, not fluent in the host country’s dominant language and loss of socioeconomic status (Tribe, 2002). Refugees are a vulnerable group and because of their past experiences prior to migration and adjustment in a new country, they may be at risk of mental health conditions.

Depression and Post Traumatic Stress Disorder are common disorders among refugees (Walker, 1999). A study by Redwood-Campbell et al (2003) investigated the health and settlement of 157 Kosovar refugees in Hamilton, Ontario. The findings indicated that 21.7% of individuals had PTSD symptoms. In addition, 26.8% of Kosovar refugees reported fair or poor health status, which may be a result of the post traumatic stress disorder.

Post Traumatic Stress Disorder: The lived Experience. Prairie Women’s Health Center. Available at http://www.pwhce.ca/pdf/ptsd/PTSDReport.pdf

Tribe, R. (2002). Mental Health of Refugees and Asylum-Seekers. Available at http://apt.rcpsych.org/cgi/reprint/8/4/240

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Kosovar Refugees

A report by the Centre of Refugee Studies and the Joint Centre of Excellence for Research on Immigration and Settlement illustrates the findings from a study that investigated how well Kosovar refugees are settling in Ontario. 706 Kosovar refugees participated in the study. A survey questionnaire was completed and the results were as follows. Very few refugees had found employment at the time of the interview. Language was a major barrier in finding employment. However, a large majority of refugees were currently attending language classes at the time of the interview. Refugees stated that they are in good health, however, they face barriers to accessing health services such as dental and prescription drugs. Over 90% of Kosovar Refugees stated that they would like to remain in Canada than return to Kosovo. Therefore, the results of this study indicate that increased support in the area of income support, language classes, employment and health are required. For more detailed information on this study, refer to the following web link - A report on the Settlement Experience of Kosovar Refugees in Ontario. (2001).http://www.yorku.ca/crs/Publications/OCEP%20PDFs/Lawrence%20Lam%20-%20kos-Report%20exe%20sum%20ont.pdf

A study by Redwood-Campbell, Fowler, Kaczorowski, Molinaro, Robinson, Howard, & Jafarour investigated whether organized settlement efforts had a positive effect on adaptation and perceived health for Kosovar refugees in Hamilton, Ontario. Kosovar refugees were compared to a Czech Roma refugee population who arrived to Hamilton in 1997 without a pre-migration plan; this population was used as a control. A total of 50 Kosvars and 50 Czech Roma individuals participated in the study and completed a questionnaire on socioeconomics, health, well-being, and perceived adaptation to Canada. Findings indicated that a greater proportion of Kosovar refugees reported their health as poor (11.5%) compared to Czech Roma (1.3%). The prevalence of Post Traumatic Stress Disorder (PTSD) was higher among the Kosovar refugees (21.7%) compared to the Czech Roma (0%). Kosovar individuals were more likely to report poor adaptation to Canada. These results did not support the initial hypothesis that the Kosovar refugees would have better improved self-perceived health and settlement experience compared to the Czech Roma refugees as a result of the extra services received due to the pre-migration plan. It is suggested that the high prevalence of PTSD may have contributed to the poor health status.

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South East Asian Refugees

A study by Beiser and Hou (2001) investigated the effects of unemployment and language facility on the mental health of Southeast Asian refugees in Canada. Data was gathered on 1348 refugees at three different time points during the first ten years of the refugees stay in Canada. Findings from the study indicated that language proficiency improved as time spent in Canada increased. In addition, employment rates improved among the refugees over the 10 year period. The prevalence of major depressive disorder declined during the 10 year period, from 6.48% when the refugees arrived to 2.27% ten years later.   Unemployment rates were found to be high during the early years of resettlement. In addition unemployment was found to be significantly related to depression at the last two time points. Further, language fluency was associated with increased probability of employment at the later two time points. Of concern however, were the 8% of refugees who reported speaking no English 10 years after arriving to Canada. This study suggests a relationship between mental health and language proficiency and depression among refugees. By the end of the first decade, this study found language proficiency to be a substantial predictor of depression and/ or employment.

A study by Noh, Beiser, Kaspar, Hou and Rummens (1999) investigated the relationship between refugees’ experience of racial discrimination and their level of depression. In addition, they examined the experience of refugees that confront discrimination, and how individual ethnic identity affects the relationship between depression and racial discrimination. A total of 647 South Asian refugees participated in this study and completed personal interviews. Findings indicated that refugees who reported experiencing racial discrimination had increased levels of depression compared to those individuals reporting no racial discrimination. In addition, those individuals who reported confronting the racial discrimination were not significantly associated with depression. This study concluded in suggesting that strong ethnic identification may increase the likelihood of depression in the face of racial discrimination.

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Somalian Refugees

Industry Canada has provided a brief overview of the Somalian settlement experience in Canada. This document describes the physical and mental health of Somalians in Canada, in addition to problems with health services access. The majority of Somalians who arrived to Canada as refugees escaped the trauma and hardships of their home country and arrived with very few resources. As a result, the physical health profile of this population tends to be poor. Highly prevalence physical health conditions include dental problems, intestinal parasites, tuberculosis, gastrointestinal disorders, gynecological problems among women, post traumatic stress syndrome, asthma, and allergies. Because of the persecution and trauma experienced in their homeland, many Somalis experienced poor mental health. Post traumatic stress syndrome, depression and anxiety were all common. Somalians also faced a number of barriers to their health including the presence of a language barrier causing difficulties communicating with health professionals, poor housing conditions and high unemployment rates. More extensive research is required on the health of Somalians in Canada.

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Bosnian Refugees

A study by Kopinak (1999) investigated the link between trauma, resettlement and health among Bosnian refugees in Canada. Ten Bosnian refugees were interviewed three times over a three month period to gather information about their resettlement experience and their health. The ten refugees in this study came to Canada to escape the war characterized by genocide and ethnic cleansing in their country of origin. These individuals were forced to leave their countries quickly, thereby leaving behind possessions and family to seek safety. The average age of the refugees was 39 years. The findings from the interviews indicated that the individuals who were able to escape the war during the first few months did not experience significant weight loss. However, those who were surrounded by war for months lost up to 30kg of weight. As a result of the poor nutrition and daily threats to safety among these individuals during the war, these individuals reported experiencing loss of teeth and hair, sleeplessness, stress, tiredness and irregular menstrual periods. This study indicated that the trauma and forced resettlement of the Bosnian refugees in this study negatively influenced health. Characteristics such as age, pre-war good health, higher education, exposure to tourists, and professional work experience contributed to the development of self-esteem, flexibility and confidence and in turn few negative health conditions.

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Refugee Children and Youth

The refugees arriving to Canada include children and youth. These refugee children and youth can arrive with family members as well as on their own. A 2002 CBC article outlines the increase in unaccompanied refugee children and youth claiming refugee status in Canada over the past few years. The article can be viewed at cbc.ca website.  

Regardless if a refugee child or youth is accompanied or not, they are at high risk of psychological stress due to the possible trauma experienced in their country of origin as well as in their migration process.

In 1997, Goldstein, Wampler and Wise published a study that investigated the impact of modern warfare on the psychological state of Bosnian refugee children. A survey was conducted on 364 Bosnian children aged 6-12 years and their parents in Bosnia during the war. The survey directed at the parents was intended to collect information on the children’s warfare experiences. The survey completed by the children attempted to evaluate war related distress symptoms. Findings indicated that the war-related experiences by the children were vast and included separation from family, close contact with war and combat, witnessing of death, injury and torture, bereavement, and extreme deprivation. Approximately 94% of children met the DSM-4 criteria for Post Traumatic Stress Disorder. Further, sadness and anxiety were reported in 90.6% and 95.5% of children respectively. This study illustrated the impact of war-related experiences and the impact on a child’s state of mental health. Children and youth arriving to Canada from war-torn countries may have experienced trauma and therefore, the vulnerability and mental health needs must be addressed.

The following are articles and/or resources on the health of refugee Children and youth:

Halcon, L., et al (2004). Trauma and Coping in Somali and Oromo Refugee Youth. Journal of Adolescent health, 35, 17-25. Available at http://www.utoronto.ca/ethiopia/Ethiopia%20articles%20for%20web%20page/Halcon.J%20Adolesc%20Health.2004.35(1).17.pdf.pdf

Canadian Pediatric Society. (1999). Children and Youth New to Canada: A health care Guide. Available at http://www.cps.ca/english/publications/Bookstore/ChildrenNewToCanada.htm

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Refugee Health Programs

A number of programs have been set up across Canada to provide primary health care specifically to immigrant and refugees. The programs tend to respond to local needs by addressing language, cultural and information services barriers. These programs work to provide accessible, comprehensive primary health care to immigrants and refugees, while attending to the social, cultural and settlement issues that are common. Services include language services, health services, settlement and integration services and peer support and counselling.

The North Hamilton Community Health Centre (NHCHC) has been providing immigrants and refugees with a comprehensive array of services through its Immigrant and Refugee Health Program since 1989. For more information on the types of services offered, refer to the following web link http://www.cmaj.ca/cgi/reprint/159/4/388

In Calgary, the Margaret Chisholm Resettlement Centre provides temporary accommodation and services to newcomers as they go through the resettlement process in Calgary. The centre works to help newcomers overcome obstacles to resettling in a new country. For more information on this centre, email Margaret Styczynska at mstyczynska@ccis.calgary.ab.ca

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References, Reports and Websites

1.  Council of Refugees
http://www.web.ca/ccr/fronteng.htm

2. Centre for Addiction and Mental Health. (2003). Alone in Canada. 21 ways to make it better. A self-help guide for single newcomers. Available at
http://www.camh.net/About_Addiction_Mental_Health/Mental_Health_Information/
Alone_in_Canada/index_introduction_aic.html

3. Canadian Council for Refugees. (1998). Refugees in Canada. Available at
http://www.web.net/~ccr/survey98.pdf

4. Kopinak, J. (1999). The Health of Bosnian Refugees in Canada. Ethnicity and Health, 4, 65-82.

5. Weir, E. (2002). Caring for Refugees. Canadian Medical Association Journal, 166(11), 1441. Available at http://www.cmaj.ca/cgi/content/full/166/11/1441

6. Redwood-Campbell, L., Fowler, N., Kaczorowski, J., Molinaro, E., Robinson, S., Howard, M., & Jafarpour, M. (2003). How are new refugees doing in Canada? Canadian Journal of Public Health, 94(5), 381-385.

7. Dillmann, E., Pablo, R., & Wilson, A. 1993. Patterns of health problems observed among newly arrived refugees to Canada.

8. Beiser, M., & Hou, F. (2001). Language acquisition, unemployment and depressive disorder among Southeast Asian refugees: a 10 year study. Social Science and Medicine, 53, 1321-1334.

9. Marras, T., Wilson, J., Wang, E., Avendano, M., Yang, J. (2003). Tuberculosis among Tibetan refugees Claimants in Toronto: 1998 to 2000. Chest: the Cardiopulmonary and critical care journal. 124, 915-921.

10. Centre for Refugee Studies & Joint Centre of Excellence for Research on Immigration and Settlement. (2001). A report on the settlement experiences of Kosovar Refugees in Ontario. Available at http://www.yorku.ca/crs/Publications/OCEP%20PDFs/Lawrence%20Lam%20-%20kos-Report%20exe%20sum%20ont.pdf

11. Canadian Council for Refugees. (2004). Immigration to Canada – 1979-2004. Available at http://www.web.ca/ccr/immstats.html

12. Canadian Communicable Disease Report. (2000). Canadian recommendations for the prevention and treatment of malaria among international travelers. Canadian Communicable Disease report, 26(supp 2), 1-42.

13. Ndao, M., Bandyayera, E., Kokoskin, E., Gyorkos, T., MacLean, D., & Ward, B. (2004). Comparison of blood smear, antigen detection and nested-PCR methods for screening refugees from regions where malaria is endemic after a malaria outbreak in Quebec, Canada. Journal of Clinical Microbiology, 42(6), 2694-2700.

14. Industry Canada. (2006). Somali Settlement Experiences in Canada.

15. Redwood- Campbell, L., Fowler, N., Kaczorowski, J., Molinaro, E., Robinson, S., Howard, M., Jafapour, M. (2003). How are refugees doing in Canada? Canadian Journal of Public Health, 94(5), 381-385.

16. CBC Article. Refugees in Canada: Fact and Fiction. (2002). Available at
http://www.cbc.ca/humancargo/realstories/fact_and_fiction.html

17. Goldstein, R., Wampler, N., & Wise, P. (1997). War Experiences and distress symptoms of Bosnian Children. Pediatrics. 100(5), 873-878.

18. Noh, S., Beiser, M., Kaspar, V., Hou, F., Rummens, J. (1999). Perceived Racial Discrimination, Depression, and Coping: A Study of Southeast Asian Refugees in Canada. Journal of Health and Social Behavior 40(3): 193-207.

19. Health Canada. (1999). Canadian Research on Immigration and Health. Available at http://dsp-psd.pwgsc.gc.ca/Collection/H21-149-1999E.pdf

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