03/14/2013 04:59 EDT | Updated 05/14/2013 05:12 EDT

Taking Action on Health Inequities

Saskatchewan Premier Brad Wall has joined a slew of health providers in criticizing the Harper Conservatives legislation denying refugees health care. For the Premier -- it is "unbelievable that some of the decisions that have been taken federally are having this impact on people who are clearly the most vulnerable, refugees who are obviously fleeing something quite terrible -- that is why they're refugees."

Ritika Goel is a local Toronto family physician and one such health provider who has also eloquently criticized the decision. She reflects on why the decision was wrong from a first person experience as well as reflecting on her medical journey -- in the US and Canada -- so far.

You have been a medical doctor for close to five years. Tell us about that as well as yourself?

I work as a family physician in downtown Toronto with the Inner City Health Associates. My training and clinical work has always been focused on working with individuals who are marginalized by our society in one way or another. I've worked predominantly with people experiencing or at-risk of homelessness as well as with immigrants, refugees and people without immigration status. Through this work, I regularly meet people who have had tremendously difficult lives.

I meet people who have ended up homeless as a result of sudden job loss, people who have fled war and persecution or left their home to provide a better future for their children, people who have turned to substances as a result of childhood trauma, people who cannot access healthcare due to their immigration status and people suffering from mental illness as a result of life circumstances. I see people who are struggling to survive and others doing an incredible job surviving despite their hardships, and I see them all faced by a system that puts barriers in place to health and wellness. I don't, however, see people abusing the system as we're often led to believe people living in poverty are.

You have been very vocal in your criticism of cuts to refugee health care in Canada and broader changes to immigration policy. Why are these issues important to you and Canada as a whole?

The cuts to refugee health care have come to the fore because they highlight the inhumane nature of a slew of current immigration changes, but are by no means the only regressive policy change of late. As of Canada Day in 2012, people coming to Canada fleeing war, domestic violence, persecution based on their sexual orientation and various other concerns are no longer able to access essential medicines through the federal healthcare provided to them. This means diabetics no longer have this coverage for their insulin treatment and people with high blood pressure don't have coverage for their pills. The most affected are those from a group of so-called 'safe countries' - a list of 35 countries, from which claimants have even lost coverage for emergency treatment for a heart attack, pregnancy care for women and check-ups for children. This group has effectively lost all access to doctors, hospitals and medicines!

The Minister of Citizenship and Immigration implies that individuals from these countries are "bogus claimants" even though the list includes Hungary, which has a documented history of persecuting the Roma people, who originated from India in the 11th Century. Individuals from these countries are being denied access to healthcare, fast-tracked through the system and denied the right to appeal that other claimants have, with the goal of deporting them as soon as possible. Having served many individuals from this and other countries that have been designated as safe, I have heard the stories of women fleeing sexual violence and men fleeing physical violence, making these policies completely nonsensical. This policy is essentially adding to the already half million uninsured in Canada and Bill C-31, another recent policy change, will create more undocumented people due to its impossible refugee claims timelines.

Tell me about the organization you work with, the Inner City Health Associates?

Inner City Health Associates is a group of physicians, primarily family doctors and psychiatrists that work with people experiencing or at-risk of homelessness in Toronto. It has a really unique model where the physicians mostly run their clinics in shelters and other community agencies where people are already accessing services and have already built trust. This is very helpful for a population that may have been poorly treated by the medical system or are unable to access regular services due to challenges such as mental illness or immigration status.

We try to think beyond what is standardly considered medical care with recognition of the social determinants of health knowing the link between income, housing and health. We work closely with social workers, case managers and other such professionals to help our patients address these basic needs knowing that often this is what will most greatly improve their health. I work with this group both as one of the family doctors and also as the Population Health Lead. This means I have the opportunity to take a bird's eye view and think about what can be done to provide better care overall. I focus a lot on ensuring we are collecting data to be able to engage in continuous quality improvement.

You did your Master of Public Health at Johns Hopkins School of Public Health in the United States. What is your perspective of Canada's health care to that of the United States?

It has always amazed me that Canada and the US sit next to one another with such drastically different healthcare systems. The US spends substantially more per capita on health care than any other country in the world (17.4%, with the distant second being the Netherlands at 12%, Canada spends 11.4%) and has much poorer outcomes in most arenas. This is due to a for-profit health insurance based model which treats healthcare as a market good.

This means that health care services are allocated based on ability to pay instead of need, and people are often denied care when they have pre-existing conditions. The US has an estimated 50 million people without any health insurance and many others who are under insured as the insurance companies regularly deny claims after people have sought out medical care. This is why 62.1% of personal bankruptcies in the US are due to medical bills!