Dr. Yvonne Blonde is a family care physician who works with other providers at REACH (Refugee Engagement and Community Health) Clinic in Saskatoon. The REACH clinic, in operation since 2017, provides medical care to all refugees welcomed into the city of Saskatoon, for up to one year upon arrival. This clinic operates at the Saskatoon Community Clinic, in collaboration with several local organizations including GGP.
With experience as a physician and educator, Dr. Blonde shares her insights on the landscape of refugee health in Saskatoon, what patient advocacy can look like, and the culture change that is underway.
For those who aren’t familiar, can you give an overview of the refugee health landscape in Canada?
Newcomers welcomed into Canada are often subject to the “healthy immigrant effect”: they present in better health than average Canadians, however they experience a decline in health and self-reported health in the preceding years after arrival. Refugees, people who have experienced forced migration and are fleeing persecution, are a particularly vulnerable group of newcomers largely due to the living conditions they have been forced to experience and endure.
Refugees have experienced hardship and trauma on multiple levels: the inciting event in their home country, then the migration stage, which comes with unstable housing and often refugee camps. During migration, people might not have access to acute or preventative healthcare, and there is lots of what you would expect in terms of health risks— for example food insecurity, poor living conditions, violence, sexual violence, inequities in terms of gender—that aren’t addressed.
The final trauma occurs in the host country, and this is the piece that as a nation we sometimes forget about. The first year or two years at least are quite traumatizing for newcomers. It’s an entirely different system, there are language barriers as well as health literacy barriers. Not only do refugees not speak English or French but they’re not aware of how the systems operate.
What I have come to learn as a primary care practitioner and family doctor is that while the healthcare system in Canada has many strengths, it’s in fact not as accessible as one might think to key populations or people living with marginalizing conditions. This contributes to health inequities. There are many barriers that prevent refugees especially, but all newcomers from having access to not just biomedical healthcare, but to all social determinants of health. As a result, refugees are susceptible to poorer health outcomes, even after arrival in Canada.
Sometimes we, as Canadians, think our response to newcomers, refugees and immigrants is adequate because we provide some healthcare coverage, and access to some social services. What we forget is that we need to support integration actively, not passively, and for the long term. We tend to ensure that ‘they’ are okay, rather than determining if we as a society are adapting and acting responsively as well. Without this consideration, it can lead to newcomer populations becoming more insulated and less integrated in society, leading to more inequity and ultimately a less healthy and safe society.
Other challenges are housing and income; people literally do not have enough money. Then there’s the discrimination/racism newcomers tend to experience, which is something I hear about and witness as a barrier constantly with the refugee population in Saskatoon, unfortunately, and across Canada.
Canada intentionally, by policy, tries to accept the refugees who have the most urgent need for a host country and the severity or existence of their health conditions is not a barrier. It is for all these reasons that we need supportive, responsive and trusted organizations like GGP. It’s why we need Cultural Health Navigators, and people to advocate for patients. It’s why a clinic like REACH can be indispensable and invaluable, particularly during those first few years after arrival.
What does advocating for refugee patients look like in your world?
We tend to think of advocacy as media related or large protests to bring attention to an issue or to large inequities, which it is certainly. The work of local and national advocacy organizations continually acts to protect and advocate for the well-being of newcomers. But as healthcare providers, we also have to advocate for the individual patient. Advocacy can often require extreme handholding to move patients through healthcare and other systems.
For example, I will often send a note for the healthcare provider that’s seeing them—specialists or other providers—explaining how to use interpreter services, or I select the services that have access to these services if possible. Very often, almost always, if patients don’t speak English it takes several tries before an appointment can be coordinated. We often have to call the specialist and make the appointment ourselves, then call the patient back.
We write notes to support anything that’s needed, be it housing or to please help this person access a particular type of income. We have constant communication, whether in office or not, between all the members in the care circles of the patient to ensure coordination of care. So, there’s medical advocacy but our role expands beyond what you might imagine happens at the office.
What are some challenges you see in Saskatoon?
It was only a few years ago that the REACH clinic was established, which is, in my view, a huge collaborative success, allowing us to pursue good evidence-based clinical care as well as teaching and research opportunities. This is allowing us to continue to push for more local awareness and recognition, which is definitely improving but still really, really needed, about the unique health needs of this population within health and social systems. Funding for this clinic however, is an ongoing and huge challenge; not only just to maintain the current clinical care, but also to offer expanded services that would so benefit this population, including more development for the kinds of services provided by GGP and other settlement agencies.
And, we so need to operate for more than 1 year….in many cases, a year is not long enough to ensure stability of health needs and a comfortable transition into the community. There is an ongoing need in the city for timely, accessible interpreter-based services and formally trained interpreters to alleviate one of the biggest barriers to good health experienced by this population—language.
Additional barriers include health literacy for newcomers, employment opportunities, transportation, mental health services, and more. And certainly, there needs to be recognition that it is imperative to implement ongoing training/courses, policies, and self-reflection within the healthcare system, and further develop cultural responsiveness or safety in care provided to newcomers, and frankly all people.
Do you think things are improving?
It is impossible for me to see the passionate, engaged and committed community organizations, colleagues and affiliated groups, including GGP, all operating for years before I arrived in Saskatoon, and not feel some optimism for the local landscape. But certainly there is a lot of work and activism needed to improve the health inequities in this key population.
One change is that we are providing evidence-based clinical care, screening and comprehensive adult and pediatric care that seemed to be inconsistently offered previously, e.g. in the case of latent tuberculosis diagnosis and management.
I see heartwarming changes from a teaching standpoint. Beyond responding to significant health needs for refugees, a clinic like REACH is important to educating medical residents. I hear from residents calling me saying, “Can you send me some information about the phone-interpreter services available at hospitals and Saskatchewan Health Authority (SHA) sites? I’m going to help them out [with accessing interpreter services].” I appreciate that the SHA funds a phone interpreter service here, especially when across the country a lot of major centres don’t get this particular access. We do still really need more local in-person trained interpreters!
As we make strides, and especially in a COVID crisis where resources are seemingly stretched, we have to remember the specific health needs of these key populations. This will benefit all of us. Selfishly, this is inspiring work. I learn so much! I meet so many interesting people. I have patients who have been in Canada for many years now and it’s amazing to have been present as they’ve moved through these aforementioned challenges. It keeps me in awe of human resilience.