The Sorry Saga of Bhutan's North

The Sorry Saga of Bhutan's North
Click over the map to know the differences

Friday, March 16, 2012

Researchers try to unravel mystery of immigrants' health woes

Tika Devi Gurung, left, and her children Sudesh, Parash, Suk Bahadur and Phul Maya, spent years in a refugee camp in Nepal before they were finally resettled in Ottawa in December.

Tika Devi Gurung, left, and her children Sudesh, Parash, Suk Bahadur and Phul Maya, spent years in a refugee camp in Nepal before they were finally resettled in Ottawa in December.

Photograph by: Bruno Schlumberger, The Ottawa Citizen , Ottawa Citizen

DAMAK, Nepal — It's a late November afternoon in Beldangi II camp, one of half a dozen United Nations refugee camps clustered in the southeastern corner of Nepal. Sixteen-year-old Sudesh Gurung is sitting on a stool outside his bamboo hut, poised for flight.

Nearly 20 years after they escaped ethnic tension in the mountain kingdom of Bhutan, the Gurung family — and almost 5,000 other Bhutanese refugees — are moving to Canada for resettlement, at the invitation and expense of the Canadian government. Within a few weeks, Sudesh, his widowed mother and three siblings will fly to Ottawa, where they will become permanent residents and begin to build new lives.

Lean and eager, Sudesh works hard at school, and does his homework by camp light. He can hardly fathom what comes next, and health is not at the top of his mind. In limited English, he hesitantly asks a visitor: "What school will I go to? Can I play cricket and soccer in Ottawa?"

At the other end of the migration journey, almost 45 years after arriving in Canada, Harminder Magon putters in his white and black Ottawa kitchen. He weighs the health values of every dish he's making, and reminds himself to check his insulin level and take his cholesterol pills.

Magon is a storyteller and bon vivant by nature; a husband, father and immigrant by choice. The restless youngest son in a wealthy Sikh family in Kenya, he came to Canada in 1967, and built a happy, prosperous life. Sudesh Gurung, on the other hand, arrived just two months ago. He hopes Canada will be where he finally can have safety, education and a country to call his own.

They came here assuming that if they worked hard and did their best, they would thrive. If they thought about health at all, it was simply that our medical system would take care of them, just as it takes care of all Canadians.

But a growing number of doctors, nurses, researchers and policy-makers say that's a flawed assumption, and a potentially dangerous one. They argue that — much like employment — health care is emerging as one area of immigration where Canada is failing many of the people we have brought in, whether they are recent arrivals like Sudesh or longtime residents like Magon.

Since the 1990s a growing body of data has suggested that most newcomers arrive in Canada healthier than the native-born population, only to have that advantage erode over time. New immigrants tend to live longer than the Canadian-born population, but within a decade of resettlement, their mortality rates creep up, as do their rates of chronic disease. In looking at almost a decade of data in its biannual National Population Health Survey, Statistics Canada also found immigrants were almost twice as likely as native-born Canadians to report feeling unwell. Recent non-European immigrants — the largest proportion of newcomers we currently admit — were the most likely to report their health declining from good or excellent to fair or poor.

No one has been able to put a price on the "healthy immigrant effect" in terms of lost productivity or health-care costs, but some basic math hints at the potential. Immigration has been a cornerstone of Canada's labour policy for decades. In 2010, we admitted 280,000 permanent residents, including skilled workers, sponsored family members and United Nations refugees, on top of 250,000 temporary visitors, such as foreign workers, international students and asylum-seekers asking for refugee status. Almost 20 per cent of us were born outside the country and immigrants are now responsible for two-thirds of our population growth, yet in many parts of Canada, policy-makers now consider immigrants an under-served population, along with First Nations and seniors.

While researchers and medical professionals are struggling to understand the precise why's and how's of this unhealthy welcome, there's a consensus that Canada's health-care system has been too slow to adapt to our increasingly diverse population. From front-line doctors and nurses to policy-makers, all levels of the medical system have been reluctant to let go of the hidden assumption that we're all pretty much alike, when it's clear that we aren't. Fixing that perception, advocates say, means learning to ask the right questions at every stage of care, from the waiting room to the examining room to the operating table, and from the well-baby clinic to the rehabilitation centre and the cancer survivor's support group.

"We assumed people would come, hook themselves up with a doctor and everything would be fine — after all, we have universal health care," says Morton Beiser, professor of psychology at Ryerson University and an expert on immigrant mental health. "What we didn't realize, and I think we still haven't quite acknowledged, is if you bring large groups of people from all over the world, it enriches your society but it also calls for institutional change. We have institutions that have been very slow to respond to the call for change, including the health care system."


It was the newspaper ads that ignited his curiosity. Harminder Magon vividly remembers seeing large notices in Kenyan newspapers in 1967, declaring that Canada needed hard-working immigrants. He knew nothing of this place beyond the cliches of igloos and wheat fields, but it didn't matter.

"I wanted to see the world," Magon says. "I figured if Canada wanted me, they'd find something for me to do."

The visa officer in Nairobi liked what he saw in Magon, a burly, six-foot-two, 21-year-old with an advanced secondary school education, charming and eager to work. But first he had to pass a medical examination to make sure he wasn't bringing tuberculosis or other communicable diseases into the country.

The image of the newcomer as a threat to public health is as old as Canada. The first Europeans to arrive in North America brought with them "white man's diseases," including measles and smallpox, which decimated the Huron, or Wyandot, nation. In New France, doctors boarded newly arrived ships to conduct medical examinations to keep the plague at bay. In 1832, colonial officials rushed to set up a quarantine station at Grosse Ile, Que., to contain the cholera pandemic sweeping Europe. In its early years, the hastily-erected station was an early sign of the unhealthy welcome, as it proved to be an unhygienic death-trap where thousands of previously healthy migrants — primarily Irish — died of cholera or typhus.

In 1928, the Canadian government made pre-departure medical examinations mandatory for all prospective immigrants. The landmark 1976 Immigration Act, which laid the basis for current policy, went further with the introduction of "excessive demand" on Canada's health-care system as grounds for inadmissibility. The act defines excessive demand as anything more than the average annual cost of social services per Canadian. That figure is updated annually and currently stands at $6,141.

Today, if an immigration medical officer believes an economic class immigrant or a sponsored parent or grandparent would put an undue burden on Canada's social services — by needing dialysis to treat kidney failure, for example, or special care for a severely disabled child — the application would most likely be rejected unless the applicant can prove otherwise.

The exceptions are the 25 per cent of permanent residents who are refugees (like Sudesh and his family) or spouses and children sponsored by permanent residents. They are screened and steered toward treatment if needed, but the excessive burden test is not applied to them. When they had their immigration medical in Nepal, Sudesh's 24-year-old sister Phul Maya tested positive for latent tuberculosis. Their departure was delayed nine months so she could receive treatment, and as soon as the family arrived in Canada, Ottawa Public Health began regular monitoring to make sure they are TB-free.

The immigration medical system is designed to catch and treat communicable diseases before they cross our borders, and screen out costly conditions. For the most part, only the healthiest get approved. That may explain, in part, why the emerging data on the healthy immigrant effect turned heads in the 1990s.

At first the effect was thought to suggest that all newcomers faced worsening health after migration to Canada. More recent findings suggest that it matters whether someone is from Warsaw or Kinshasa, whether they arrived 30 years ago or three, and whether they came to Canada as refugees traumatized by war or software developers searching for greener pastures.

With a few exceptions, the healthy immigrant effect appears to apply less to immigrants from Europe and the United States, while it hits other groups hard. Clarifying why, for example, people from the Philippines, China and India — the three biggest source countries for immigration to Canada — are over-represented in prevalence of chronic disease is crucial to finding a solution.

Similar patterns have been found among immigrant populations in other western countries, and researchers believe the problem lies in a combination of factors, starting with the complex interplay between genetics, diet and lifestyle.

"Fundamentally, we are all a product of our experience, our culture, our religious background, where we've lived," says Dr. David Butler-Jones, head of the Public Health Agency of Canada. "Then there's our parents and grandparents, our genetics. How that manifests itself depends on our environment. What we've been exposed to can shape how healthy we are."

Every Canadian carries his or her own risk factors, and ethnicity-specific diseases are nothing new. Canadian practitioners have long known to be alert for sickle cell anemia in patients of African descent, or to screen Jewish patients for Tay-Sachs disease. What's new is that as immigration Canada began to select a broader range of immigrants in the late 1960s, the ethnic composition of our population began to change, from heavily European to increasingly Asian, African, Latin American and Caribbean, while most of our medical research and guidelines for practitioners continued to be based on the risk factors and behaviour of Caucasian populations.

That's slowly changing. Researchers such as Dr. Sonia Anand, professor of medicine and population health expert at McMaster University in Hamilton, Ont., have started mining existing databases and conducting primary studies to explore the link between ethnicity and health. Thus far, the most studied communities have been the two biggest non-European ethnic groups in Canada: people from South Asia (India, Pakistan, Nepal, and others) and, to a lesser extent, from China.

An early database study suggested that Chinese Canadians had higher rates of cancer and lower rates of cardiovascular disease than the general population. Anand later led a team looking at risk factors across four ethnic groups — Caucasian, South Asian, Chinese and Aboriginal.

"What we observed and has been observed in other studies is that, for South Asians who live in Canada, the longer they live here, the more risk factors they accumulate for heart disease and diabetes, and at higher rates than Chinese or Caucasian," says Anand, adding that those risk factors include abdominal obesity, elevated blood sugar and higher amounts of so-called bad cholesterol.

South Asians have significantly more body fat than Caucasians with the same body mass index, so "a South Asian person might not look grossly overweight, but their percentage of body fat is too high," says Anand, putting them at risk of chronic illness at weights lower than people of other ethnic groups.

According to the Heart and Stroke Foundation, all Canadians have a one in three chance of having a heart attack or stroke. But Canadians of South Asian descent have three to five times higher risk than the average simply because of their genetic heritage. And that's for those who watch their weight and exercise — if you are of South Asian descent, overweight and largely sedentary, your risk of heart attack jumps to eight times the average.

Researchers around the world now recognize that South Asians, whether they live in New Delhi, Manchester or Ottawa, have a significantly higher risk of heart disease and diabetes than other ethnic groups. The Diabetes Foundation of India estimates there are 40 million people in India with Type 2 diabetes, and expects that figure to double by 2025. Indian public health authorities are grappling with malnutrition among the poor and obesity among the growing middle and upper classes — another signal that the healthy immigrant effect is about much more than what genes a newcomer brings to Canada.

"The analogy I use is that it's like taking a seed from a certain soil and transplanting it to a different soil, with the seed being genetics," says Anand, herself the Canadian-born daughter of immigrants from India. "If the normal environment or soil for a South Asian seed is rural India, that's where it will flourish. If you move that seed into an urban environment — whether in India or elsewhere — where we don't expend much energy but we consume a lot of energy, the seed grows in a different way. If we all just stayed in places like rural India, doing jobs where we sweat a lot, South Asians would not have an epidemic of Type 2 diabetes and heart disease."

Harminder Magon's grandfather emigrated from India to Kenya, and made a fortune in business. He was also a diabetic who died following complications from a leg injury. Magon's father and three of his uncles all died relatively young, all from heart disease or diabetes.

When he transplanted to Saskatoon almost 45 years ago, Magon quickly got a job as an architectural technician and embraced the Canadian diet with gusto.

"Breakfast would start with Coca-Cola and leftovers from the night before, which I would eat while I was cooking bacon and eggs with cheese, beans and sausages," Magon says of the years he now calls his "indulge and bulge" period. "For my morning break I'd have coffee with a cream-filled doughnut. Lunch would be mostly either pizza or Chinese buffets, or veal cutlet sandwiches with gravy and fries."

Supper with his wife, Surinder Kaur Magon, was usually a nod to their Indian heritage: a rich curry, some chapatis loaded with butter, some rice and a few vegetables, cooked to exhaustion. Dessert would be a store-bought cheesecake or ice cream, often followed by a late-night snack of double-deep-fried egg rolls.

By the time his son Harpreet was born in 1976, Magon weighed more than 300 pounds. "I was a big, fat jolly guy, and it didn't bother me," he says.

What did bother him was getting out of breath after five minutes of playing on the floor once his son started to crawl. He cut back drastically on sugar and fat, started swimming and cycling, and lost 100 pounds in eight months. It wasn't enough. First came back trouble, then his gall bladder. After he moved to Ottawa in 1990 to work for the Canadian Union of Public Employees, Magon began to travel a lot, eating irregular meals, sitting on planes and getting less exercise. Soon he developed circulation problems in his legs and later was diagnosed diabetic. It was the first time a doctor had explained his hereditary risk factors to him, and tied it to family, not ethnicity.

Then, last fall, Magon couldn't make it up the stairs at home without feeling winded. After excellent care at the Montfort Hospital and the University of Ottawa Heart Institute, he was diagnosed with unstable angina, caused by small blockages in his arteries. It was a warning Magon has taken seriously, dropping another 45 pounds, exercising regularly and taking medications for cholesterol, blood pressure and diabetes. He's also an evangelist for healthy eating, spreading the word about healthy international and South Asian food through cooking classes in his home and on his Facebook page, Desi Guys Should Learn How to Cook.

"I indulged and abused my body," he says with a sigh.

Surinder smiles. "You were too stubborn to listen to your body."

"I'm listening now dear, trust me," Magon replies.


Sudesh Gurung's father died suddenly while doing manual labour on the black market in Nepal several years ago. "It was blood pressure, maybe," Sudesh shrugs. What does that have to do with him, young, fit and full of the future?

Harminder Magon missed the red flags in his family tree and revelled in high-calorie traditional cuisine while adopting the worst his new environment had to offer. But when his health hit a crisis, Magon had the advantages of speaking fluent English, understanding the Canadian medical system and feeling confident dealing with his caregivers. He also recovered in a comfortable home with healthy food, a strong, supportive network of family and friends, and no worries about how to pay for extra costs or transportation.

Many recent arrivals are not so lucky. Problems in any one of those areas — housing, food security, social exclusion and income, known collectively as social determinants of health — can have a significant impact on their recovery and future health.

Toronto Public Health took a close look at the research on immigrant health in a study released last November, and one finding stood out, says Dr. David McKeown, the city's medical officer of health.

"We documented better than in the past that some of the challenges faced by everyone in maximizing their health potential — acquiring the social determinants of health, such as economic success and integration into the community — are real challenges for newcomers, have an impact on their health and cause them to gradually lose the health they brought with them," says McKeown.

In many ways, the healthy immigrant effect underscores the shortcomings of integration. Increasingly, immigrants who arrived in the last 10 years are underemployed compared to their skills and over-represented among Canada's poor. It's well-documented that poor people are less likely to have secure housing and good diets, and less likely to stay healthy.

The impact of migration on mental health is also key, and another reminder that one-size-fits-all approaches don't work for the newcomer population. How someone arrived here, and what path their settlement took, can make a crucial difference in how their mental health problems manifest themselves. Did they flee conflict only to live in limbo for decades, like the Gurungs, or did they simply trade one comfortable life for another? Did they struggle to find work, or did they slide right into an executive position?

Dr. Joel Ray, an obstetrician at St. Michael's Hospital in Toronto, sees many Filipina, Sri Lankan and Ethiopian women and their babies in his practice, which serves one of the country's most ethnically diverse neighbourhoods. He believes the gaps in health care for newcomers are partly the result of "unintentional, non-malicious insensitivity."

"As Canadians we're just understanding what our current, multi-ethnic generation of immigrants are really like and physicians and nurses are absolutely no better," says Ray. "They rarely understand the cultural health-related aspects of where someone comes from, and how that might have an impact on their health."

That can translate into newcomers having less of a chance of finding a family doctor than the average Canadian, says Dr. Kevin Pottie, a physician at the Bruyere Centre for Family Medicine in Ottawa.

"It's recognized that a big barrier to care is often integrating a newcomer family into community-based primary care," says Pottie, who is also a researcher at the University of Ottawa's Institute for Population Health. "Doctors are very busy and a newcomer family is often not at the top of their list" when it comes to choosing new patients.

And what if a practitioner and patient don't speak the same language, not just figuratively but literally? Sarah Bowen, a public health expert at the University of Alberta, has studied under-served populations and believes language is the single biggest obstacle to effective care for many new Canadians. Although the percentage of newcomers arriving with poor proficiency in either official language is on the decline as the government assigns more weight to language skills, there are still tens of thousands of Canadians who struggle. Bowen says patients who can't communicate with their doctors or nurses are less likely to absorb healthy living messages or seek preventive treatment, and more likely to go to an emergency room instead of a primary care physician.

"If you're not communicating properly, there's more chance you'll be misdiagnosed, more chance you won't understand the treatment or the medications and higher risk you'll take them incorrectly," says Bowen. "There's good evidence in the literature that providers, in the face of a language barrier, are more likely to rely on testing, which ups the costs. They say 'I'm not sure I'm getting the full story here, better to do an X-ray just in case.'"

This applies not just to recent immigrants, says Bowen, but to earlier waves of immigrants — for example, from Germany, Ukraine or Italy. As they reach old age and their cognitive abilities decline, some Canadians are losing their second language skills.

Part of the difficulty in forming a comprehensive policy is that the problem cuts across sectors and responsibilities: immigrants are federal, health is provincial. Immigrant health features prominently in settlement conferences and government policy papers these days, accompanied by calls for more data. Studies on the risk factors for South Asians have captured a lot of attention, but other large and growing ethnic communities await their close-up. In the meantime, practitioners on the front lines are starting to collaborate and compare notes.

"Immigrants today are like pioneers, and pioneers are the most productive, hard-working and often healthiest people," says Pottie. "Lots of different people are working together now, believing that we need better care for newly arriving immigrants and refugees, and we're building a foundation for that."

Sudesh Gurung is settling in at school, cheerfully unaware of risk factors and plenary sessions. As he updates his Facebook status, his friends — also from Bhutan — tease him about his new love for chicken burgers from McDonald's, and laugh at how Canadian clothes are much too big for them.

"Me, I'm very healthy and strong," Sudesh says with a broad grin. "No worries."

1 comment:

  1. Anonymous12:45 AM

    It's going to be ending of mine day, however before end I am reading this fantastic article to improve my knowledge.

    Here is my page - cellulite treatment