Ranjit Lehal

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In what capacity does your clinic provide health care for refugees?

I am a Family Nurse Practitioner (NP) at the Burnaby New Canadian Clinic. I see patients across their lifespan including children, pregnant women, adults, seniors, and families. Providing primary health care as an NP includes assessment, diagnosis and treatment of physical and mental health conditions, as well as additional elements of primary care that are equally important like health promotion, counselling, and education.

Although Burnaby New Canadian Clinic generally provides primary health care to government-assisted refugees; over the last couple of months our mandate has expanded to include privately sponsored refugees as well. In addition to my clinic in Burnaby, Fraser Health has two other clinics: Surrey New Canadian Clinic and Global Family Care Clinic. Both provide primary care to refugees.

As clinicians we contextualize care provision within the determinants of health. A critical component of this is assessing, monitoring, and supporting patients' health literacy needs. Burnaby New Canadian Clinic is a transition clinic. We assess the health literacy of patients when we admit them and throughout their time with us. Health literacy is complex and includes not only English language skills, but also help-seeking behaviors, appointment/ medication management, and self-management. As the health literacy of these individuals improves and medical conditions stabilize, they become more ready to transition to a permanent primary care provider in the community.

What is the average length of time that a patient will stay with the clinic?

There is a very small portion of patients who will always be with us - typically that would be someone with very low heath literacy, perhaps an elderly person who has multiple chronic healthcare conditions and a limited support system. However, this is a small group.

Generally, most patients will transition to a permanent primary care provider within two to four years. Some will transition sooner and some will take several more years - all depending on their health status, determinants of health, and health literacy level.

When patients are ready to transition, they may do this independently by finding a new provider on their own or they may need some support and direction.

What are your first steps when new refugees arrive and how does the health status of refugees compare with the rest of Canadians?

When refugees first arrive, if they have not had any screening done, we will run a number of tests based on their country of origin and country or countries of transit. This includes infectious disease screening such as syphilis, hepatitis A and B, tuberculosis, parasites, and HIV. In addition, we screen for conditions such as iron deficiency and thalassemia.

In general, the health status of refugees is poorer than that of other Canadians. Many have witnessed or been victims of war violence which can have significant impact on their mental health. They may have complications arising from chronic conditions that are either undiagnosed or untreated. Their health status may be further affected by pre-migration lack of access to clean drinking water, adequate nutrition, adequate housing and health promotion screening.

What has been the most significant challenges faced by refugee health programs within the last 5 years?

When refugees arrive, they definitely have medical concerns. Most come from war-torn countries and have experienced trauma. However, they continue to face challenges after they arrive, such as not speaking, reading or writing English, difficulty in getting employment, struggling to meet the costs of living and other significant financial stressors. Many refugees are only able to find positions at minimum wage.

Meanwhile, deductibles for programs such as Fair PharmaCare are high, and this discourages new Canadians from accessing medications. Access to rehabilitation services like community physiotherapy is also limited, and while some of these services are covered under MSP, many have user fees attached to them. We try to look at the issues as holistically as possible - many of these new Canadians are living in poverty, and most that we see have large families, which can make the financial stressors seem insurmountable.

All of these are significant challenges, and speak to how the determinants of health affect mental and physical well-being. For example if you have chronic low back pain, and there is not enough room to sleep, and you are sleeping on a mattress in the hallway, no matter how much medication is given for pain, it will be nearly impossible to improve your health outcomes without addressing the root causes.

What changes would you like to see?

I would like to see:

• Increased access to English classes
• Vocational counseling and support to help refugees secure sustainable, meaningful employment.
• Elimination of travel loans: when refugees arrive to Canada, they are required to pay back the cost of travel which is an enormous stress for many families.
• Reduced Pharmacare Deductible - for people who are working but living in poverty, the PharmaCare deductible can be a significant barrier to accessing the medications they need. Most people will choose to spend money on essentials such as housing, and food vs. medications.
• Increased access to community-based rehabilitation services. For patients who have chronic pain or an injury for which physiotherapy would be helpful to recover, access to community services is extremely challenging. While physiotherapy is covered by MSP the user fees make it cost prohibitive.
• Affordable housing, which is incredibly important. Refugees will typically apply for BC Housing but there simply are not enough appropriate housing units to meet the need. Therefore, many families remain under-housed and remain wait-listed for years which can impact their mental and physical wellbeing.

Has there been an increase in refugee health services during these past few years?

In this region there has been an increase in personnel for sure. Clinicians in the refugee health community try to work very closely with one another and our community partners. Community partners vary depending on geography but typically include settlement agencies, non-profit community agencies, public health, mental health and home health.

Global Family Care Clinic was established about three years ago as a partnership with the Burnaby Division of Family Practice to fill a gap for patients that were not seen by the New Canadian Clinics. This includes refugee claimants, migrant workers, undocumented people, people without MSP, and new immigrants. The New Canadian clinics are staffed by one full-time nurse practitioner and a physician one day per week. An additional NP position has recently been added between the two clinics to increase capacity.

The Surrey New Canadian Clinic has access to interdisciplinary team members. However, in Burnaby we rely more heavily on community agencies for support with counselling, parenting groups and post-partum support.

What other refugee health initiatives are you aware of within the B.C context?

Bridge clinic in Vancouver Coastal Health provides new arrival screening as well as primary care for refugees. Most of the referrals for the New Canadian clinics come from Bridge Clinic.

There are several other clinics such as New Beginnings at BC Women's Hospital that also see pregnant refugees as well as pregnant women who donot have MSP. So altogether there are the Canadian Clinics, the Global Family Care Clinic, and various community agencies such as MOSAIC, DiverseCity, Burnaby family life and Umbrella Co-op (pediatric outreach clinic, family practice, counselling) to name a few.

How can registered nurses and nurse practitioners in B.C become involved in order to support and advocate for improved refugee health?

Typically, BC receives up to 800-900 refugees annually. The large influx of Syrian refugees has put refugee health at the forefront of peoples' minds.

Registered nurses and nurse practitioners can become involved by first and foremost becoming aware. Refugees are a part of the communities we serve and therefore RNs and NPs who are not in specialty clinics may encounter refugees in acute care, community clinics and emergency room settings. Becoming familiar with trauma informed care, the impact of migration on health status, and the challenges faced by refugees will help to equip RNs and NPs with support and care for this population.

In addition, it would be helpful for RNs and NPs to gain a general understanding of the Interim Federal Health program which provides funding to allow for refugees to access health services and medications up to one year after their arrival in Canada.

What can ARNBC do to support nurses working with refugees?

ARNBC to can assist in raising awareness by providing continuing education, posting relevant information on their website, and providing links to resources.

Are there certain stories that have stayed with you throughout the years?

Many stories have stayed with me throughout the years. Some involve unimaginable grief and loss and others are related to enormous success. However, the overarching feeling my practice leaves me with is humility and respect for those we care for.

I am completely humbled by the resilience of these amazing individuals and their ability to escape terrible adversity in their homeland, face additional barriers in getting to Canada, and move forward to create a new life when they are finally settled.