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Health inequity in Parc Ex amplified by Quebec government policies and anti-immigrant rhetoric

“At best, the government has been ignoring Parc Ex, and at worst, it’s been demonizing it.”

It’s no secret that Quebec’s healthcare system has taken a beating during the pandemic. It’s stretched to the brink by staff shortages and overwhelmed hospitals while one third of Montreal residents remain without a family doctor. The challenges are huge across the board. 

But advocates and community workers assisting refugees and asylum seekers are sounding the alarm. They say some parts of Montreal, like Parc Extension, are much more vulnerable, and Quebec’s politics have only reinforced health inequities. They warn that Quebec policy makers are failing to provide linguistically and culturally tailored health and social services to the local population and are refusing to understand the value of building trustable partnerships. They also point to government rhetoric as only amplifying health inequities and increasing government distrust.

As part of McGill University’s research Advocating for Vaccine Confidence and Trust Project in Parc-Extension, funded by the Canadian Institute of Health Research, researchers spoke with Parc Ex residents to better understand how social determinants of health (SDOH) influenced their vaccine decision-making and their access to social and health services. It quickly became apparent that multiple barriers were at play.

A different linguistic and cultural reality 

Montreal’s Parc Ex has long been a landing pad for immigrants and refugees seeking a better life. It’s a lively, densely populated, working-class neighbourhood that is vibrantly diverse but faces unique challenges as new arrivals work hard to integrate. 

A majority (57%) of neighbourhood residents are immigrants or belong to visible minority groups and 69% of residents have a mother tongue other than French and English. These are factors that must be taken into consideration when healthcare policies are implemented as one-size-fits-all. Language barriers are a huge impediment to accessing healthcare, and government policies demanding that communication only take place in French six months after arrival in the province have exacerbated said barriers.

“Can you imagine telling someone who doesn’t even read or write their own language to learn a whole other language in six months?” asked a community organizer quoted in the study.

Even without added barriers, the challenges remain enormous. Parc Ex has one of the lowest registration rates for family doctors at 61%, forcing residents to go to emergency rooms or find walk-in clinics. A CBC article quoting the CEO of the CIUSSS du Center-Ouest-de-l’île-de-Montréal refers to Parc Ex as a “medical desert” and the situation as “truly catastrophic.” The shortage of doctors has huge impacts, as small health problems that aren’t immediately tended to can become big problems. 

Dr. Juan Carlos Chirgwin, a doctor at the Parc Extension CLSC, admits healthcare challenges are complex and attempting to solve them often doesn’t win many votes for aspiring premiers or prime ministers. 

“How we invest our time and money to protect publicly funded healthcare is very important,” he says. “On top of the one million Quebecers with Medicare cards who don’t have a family doctor, there are also thousands of refugee claimants and asylum seekers in Montreal who don’t have Medicare cards and are not accounted for in that total.” 

The inaccessibility of medical professionals and information tailored to the community doesn’t encourage inclusion and a horizontally collaborative approach that involves community organizations — which are far better equipped to recognize local needs. Mass vaccination campaigns on TV and online may be effective for a majority, but how do you get the word out to newly arrived immigrant communities who are often unilingual, unable to speak either official language or have little to no internet access? 

“This study was conceptualized because we saw a change in trend in terms of vaccination,” says Maryam Parvez, a McGill research coordinator. “Initially there was a lag in terms of doses, but then there was an increase, so we wanted to understand how community initiatives affected the change in the trend. Once we started conducting interviews, we saw that a lot more was going on. We were able to see the social determinants of health and how they all interact and influence behaviour in terms of accessibility, given that the population is immigrant and asylum-seeker dense.” 

One of the key findings was the importance of community organizations filling in for inadequate government support. “In our research,” Parvez says, “immigrants and asylum seekers would reach out more to community organizations because of a lack of government support, with respect to childcare, for example. We quickly realized community initiatives were already tapped in, and were much more successful in leveraging that relationship and bridging the gap.” 

Language a huge barrier

Quebec’s French language reform, Bill 96, which requires newcomers to receive information solely in French after a six-month period, has made accessing healthcare in Parc Ex harder. Not having access to people speaking your language to help you can lead to further health complications.

“Xenophobia is bad for public health, and it undermines trust in institutions,” says Sasha Dyck, a vaccination nurse at the CIUSSS du Centre-Ouest-de-l’Île-de-Montréal and a Parc Ex resident himself. 

“There’s a link here,” he continues. “If people don’t trust public health officials, and the government at large, then one part of the government is hurting the other. Bill 96, Bill 21, all that anti-immigrant posturing during the election, affected public health. We were doing well, we were engaging, we brought the rates of second doses above the Montreal average. But now when we look at the data on the ground, Parc Ex is lagging again.”

Dyck says people tend to think of the government as a monolith, but general distrust can be created by government statements, like when CAQ immigration minister Jean Boulet declared “immigrants don’t integrate, don’t work, don’t learn the language.” He says government policies like Bill 21 and Bill 96, which target minorities, also affect their trust in policy makers and what they communicate. 

“I do see that link in the general mistrust,” says Dyck, “because when they feel the government ‘doesn’t like us,’ ‘doesn’t really want us here,’ ‘it just wants our tax dollars,’ when the message is ‘Get vaccinated,’ and if it’s only in French because the budget for translations has been cut, or they’re no longer coming to your temple (a place you trust), then you’re less likely to comply with the advice.”

Most newcomers that the researchers spoke to recognize the importance of French-language acquisition for proper integration. But they were also vocal about a reality that does not make it possible for everyone to do so. Financial insecurity was one barrier frequently mentioned. Although Quebec provides financial assistance for some people to learn French, many, including those with undeclared status, do not receive compensation. On top of searching for jobs and childcare, learning French without adequate social support is nearly impossible.

“The research makes those links clear,” says Dyck. “Access to French-language classes is a major vector of integration, but accessing them is difficult. Not only are the wait lists for classes very long, but the criteria to access those subsidized classes are very high. If you’re a refugee claimant, you can’t access them.”

“We’ve heard from many asylum seekers who don’t have access to subsidized classes,” says Parvez, “so it’s either learning French or taking care of their children.”

Engaging with community organizations 

Because of language and cultural barriers, patients sought information from a source they could trust and understand. Throughout the pandemic, Parc Ex residents often had to rely on family, neighbours and community organizations to guide their decision-making, instead of the government. 

“The participants we spoke to said they were able to relate a lot more with those who were engaged in community tables,” says one of the co-authors of the study, Joyeuse Senga. “Because, again, the language barrier was addressed, but there was also that community representation, going back to that idea that they were able to relate to those individuals and really see concern for the community.” 

The Parc Ex Community Roundtable, a local social development collaborative mechanism working to improve the quality of life for residents, and the Bureau d’information de Parc-Extension (BIPE), a multilingual reference service about resources available to residents of Parc Ex are invaluable. Some BIPE counsellors speak up to seven languages and communicate with newcomers in a language they can understand and trust. BIPE group members were instrumental in helping ramp up the vaccination rate in the neighbourhood during the pandemic. 

“That roundtable project was a great project,” says Dyck. “They hired four to five people who spoke all the languages in the neighbourhood to go door-to-door with a phone in their hand and just book people their appointments. It was very successful, and it was funded by a private foundation, the Trottier Foundation, that ended up getting flack by other, more established groups who said, ‘Oh, let’s leave public health to take care of this’ — but public health wasn’t taking care of it. There was a gap. The foundation did the same thing in Montreal North and was incredibly successful, but it didn’t come from the government. They did it themselves,” says Dyck. 

The takeaway of both the project’s success and this study is the need for better and more frequent collaboration between government and community organizations.  “It needs to go beyond the pandemic,” says study co-author Nora Moidu. “Funding should be consistent, not only in getting people vaccinated but also in tackling social issues. A more horizontal working relationship between public health and community organizations can go a long way.”

That also means more money for community groups shouldering a big part of the overall burden. “Community organizations don’t have enough funding and staff,” says Senga, “so we need to apply pressure on the government because these organizations can’t take it all on.” 

Dyck says a ‘government-knows-best’ approach is to be avoided when it comes to healthcare. “Public health isn’t used to collaborating with the Montreal Tamil Health Initiative, for example. They don’t see it as a privileged partner. The last thing they would think of is to get them to translate posters, and yet that’s where the payoff is in terms of public health.”

Dyck says that government needs to not only provide these groups with more funding, but also to engage with them more and see them as part of the solution. “The government may be allergic to houses of worship but if you want to reach people to vaccinate, do it in a mosque. It took so much for them to finally do it, and when they did, it was huge. There was a lineup outside.” 

Ultimately, it’s about community trust. “We need that two-way interaction,” says Parvez, “where community groups are given a seat at the table, not tokenizing community participants, or using them only as translators, but also understanding that because of their relationship with residents, they’ll have a greater reach.”

Anti-immigration rhetoric affects us in insidious ways

“We need to make the links between election campaigns and how some of the CAQ’s grandstanding for votes outside of Montreal can have an impact on neighbourhoods like Parc Ex, and, ultimately, on public health,” says Dyck. “People in this neighbourhood are working public-facing jobs, they’re mixing with everybody, and so when Parc Ex is hit everybody gets hit. Xenophobia and anti-immigrant rhetoric weakens trust in vulnerable neighbourhoods.” 

Dyck doesn’t mince words when he describes how he feels public policy makers have treated the neighbourhood. “At best, the government has been ignoring Parc Ex, and at worst, it’s been demonizing it.”

The public health crisis has only added to a neighbourhood already facing a growing housing crisis, renovictions, poverty and environmental racism.

“If there’s anything the pandemic taught us,” says Dyck, “it’s that health equity is a lie, even in countries as rich and prosperous as Canada. We’re not all equal when it comes to the virus or access to healthcare and the people who were the most vulnerable and who continue to be the most vulnerable are immigrant communities with additional barriers to healthcare and limited means.”

Numerous studies across Canada have shown that immigrants, refugees and those in low-income neighbourhoods were disproportionately affected by COVID, with higher case rates and lower rates of COVID testing. But it’s far from being a problem limited to certain neighbourhoods. 

People who continued working during the pandemic in frontline jobs were often left exposed to the virus. And not only did some neighbourhoods have it far tougher, but added obstacles contributed to vulnerable residents not getting the care that they needed. Asylum seekers made up a large portion of the “guardian angels” Premier François Legault routinely praised in his daily briefings and conveniently forgot afterwards.

“Weak links then become the entry point for active outbreaks that spread far beyond the neighbourhood and impact entire cities and countries,” explains Dyck. 

“From a medical perspective, the virus doesn’t know your nationality or your (citizenship) status. It’s just looking to jump from one person to another. This study is ultimately a reminder that you can’t have public health policies for the majority. They need to be for everybody because some groups require specific outreach. We need to take those on the margins seriously, or else we’re all impacted.” ■

Read more weekly editorial columns by Toula Drimonis.