December marks one year since the first wave of Syrian refugees arrived in Canada, with over half settling in cities across Ontario.
Now that the initial settlement stages are complete for many — finding schools, housing, language classes, and other such logistics — front-line health practitioners are bracing for the next stage in the process: helping refugees deal with traumatic events prior to their arrival, and from their continued adjustment to their new home.
Health-care providers worked quickly to be ready for the 15,000 refugees who arrived in Ontario this year (about half the annual total). Most settled in Toronto, Hamilton, Ottawa, London, Kitchener-Waterloo, and Windsor, where community health centres worked closely with family doctors and settlement agencies to address immediate health needs.
Providers are now preparing for a phenomenon called the newcomer health effect. Branka Agic, manager of health equity at Toronto’s Centre for Addiction and Mental Health (CAMH), says refugee mental and physical health typically improves upon arrival in Canada. But after that initial year, their health tends to decrease.
“People experience a honeymoon period,” says Agic. “They are really enthusiastic to start their new life in Canada, but the resettlement process is complex and refugees face many challenges: they do not speak English, there are worries of family left behind, financial problems — all of these factors impact the health of refugees.”
Reviewing evidence gathered by CAMH and from the Mental Health Commission of Canada, Agic says that anywhere from 10 to 40 per cent of refugees could develop mental health problems over their lifespan. In most cases, those problems will be expressed as depression and anxiety. Some will experience more serious illnesses, such as PTSD and psychosis.
Though it is not yet known exactly how many Syrian refugees are experiencing mental health problems, representatives from community health centres are seeing signs of pending problems.
Community health officials say they are working with refugee clients who are beginning to deal with the trauma of witnessing sexual violence in their home countries. They are also hearing from schools that refugee children are expressing behavioural problems.
“We assume all have experienced trauma of some kind,” says Denise Brooks, executive director of Hamilton Urban Core Community Health Centre.
The effects of xenophobia here in Canada create another set of concerns. Clients have reported incidents including racial slurs and physical attacks. Vandalism at local mosques with hate messages — “Go home” — is concerning to refugees and undermines their ability to feel like they are integrating into their new communities. “That is something that we are concerned about and I think more needs to be done,” says Nhlaloenhle Ndawana, a manager at Hamilton Urban Core.
This is compounded by a stigma against mental illness, which is strong among Syrian refugees, says Ndawana. Many will never approach a health-care provider for help.
For those ready to access care, landed refugees are eligible for up to 10 psychological counselling sessions as part of the Interim Federal Health Program. But that program only applies to refugees for a year after arrival, after which time they are transferred to the Ontario Health Insurance Plan (OHIP).
Once they are in the standard OHIP system, these former refugees join the rest of Ontarians in trying to access mental health services. That means long wait times and major service gaps. Siffan Rahman, manager of newcomer health at Ottawa’s Somerset West Community Health Centre says the situation is “really bad, especially for children.”
With waiting lists that were, until a few months ago, close to a year at the Children’s Hospital of Eastern Ontario, Rahman has been hesitant to ask refugees about mental health, to avoid promising services that may not be forthcoming. “Best practice guidelines say not to screen initially for mental health issues [in the refugee population]. You are not doing them a service by talking about it when you can’t refer them to anyone. So, we don’t screen.”
Refugees experience additional barriers to accessing mental health supports, beyond the ones Ontarians in general face. Psychotherapists and family physicians are generally neither trained nor set up to provide services that are linguistically and culturally appropriate.
Brooks says, “There is no set aside funding anywhere for cultural interpretation services in the province of Ontario (unless you are a victim of sexual assault). Most external providers don’t pay for cultural interpretation to make services accessible.”
She says at Hamilton Urban Core they “spent more on cultural interpretation in the first four months this past year than the entire previous year all together.”
Community health centres across the province are working to get ahead of the issue by hiring Arabic-speaking counsellors, helping to cover transportation costs for clients, and offering in-house supports to address mental health issues.
The Ministry of Health and Long-Term Care, according to a recent statement, “has committed $10 million (over 2.5 years) for 43 refugee targeted initiatives delivered by 33 organizations in Ontario to address refugee needs and Syrian-specific challenges.” Some of this funding will be directed toward facilitating local planning, service coordination, and partnerships to meet education, employment, and mental health needs.
Hamilton Urban Core just received a small amount of funding to offer some additional mental health services. Brooks says she has used it to carve out two new roles: one to focus on women and the other on youth.
As she readies for refugees to continue arriving in 2017, she and her small staff try, as best they can, to still help the ones who came before.
CORRECTION (Jan. 20, 2017): This article has been updated to reflect that wait times at the Childen's Hospital of Eastern Ontario improved mid-year, instead of persisting throughout 2016, as we originally wrote.
Rebecca Fortin is a public health practitioner and a 2016 fellow in global journalism at the Munk School of Global Affairs, University of Toronto
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