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Editorial staff of CMAJ recently boasted championing the health needs of “vulnerable populations” [1]. It has been more than a decade since the CMAJ championed better access to safe and appropriate pre-travel clinical prevention for vulnerable Canadians travelling overseas [2]. The most vulnerable group of travellers are children and their hard-working immigrant parents visiting friends and relatives (VFR) [3], who still live in economically poor countries across the globe. In Calgary, imported cases of malaria are mapped mostly to municipal wards with the highest proportion of immigrant travellers returning from African and South Asia [4]. Epidemiological studies among Canadians consistently identify VFR travellers as bearing the greatest burden of preventable travel-related diseases such as malaria, hepatitis A and typhoid fever [5]. Yet the federal and provincial governments continue to avoid addressing this ongoing problem, in part due to constitutional confusion over responsibility [6].
Across Canada, provincial governments have deinsured pre-travel clinical prevention while paying foreign physicians for unregulated care, when travellers seek medical attention for fully preventable or self-treatable diseases (for example, Ontario [7,8]). This financing paradox applied to travel medicine’s continuum-of-care perversely promotes cash-strapped high-risk travellers to avoid effective pre-travel clinical prevention for life-threatening conditions, such as malaria and vaccine preventable diseases. However, need for publicly-funded pre-travel services will grow. The federal government recently announced an ambitious plan to increase immigration to nearly 1 million people over the next three years, [9], with a majority coming from developing countries. With changing demographics, there will be increasing travel back to home countries in the tropics and subtopics, opening Canada up to increasing risks of imported infectious threats. We are likely less prepared now than during the SARS outbreak of 2003, especially as government policies toward pre-travel clinical prevention continue to undermine sustainable local public health and medical capacity building.
Yet provincial bureaucrats continue to moralize defunding pre-travel clinical prevention for vulnerable groups such as the VFR population as being medically unnecessary. The rationalization implies that working-class immigrants and their Canadian children have a “choice” not to leave this country, if unable to afford all out-of-pocket expenses associated with necessary prevention to safely visit the home country. However, travel is a mobility right under the Charter [10], and not simply a “choice”. Children of immigrants from other Western countries may travel freely to visit relatives, and there are few travel restrictions for overseas relatives to visit Canadians here at home. Grandparents and extended family members living in poorer nations in the regions of African, Asian and Latin America face very different prospects, often being prohibited from visiting Canada due to fears of economic migration. Thus, the only realistic way for VFR children to keep personally connected with relatives is to travel to destinations with significant health risks and very limited medical care. Various levels of government thus neglect to protect Canadian children travelling internationally.
The CMAJ states that it champions vulnerable groups. What about taking up the cause of vulnerable VFR children, whose only fault is to have hard-working parents being born in another part of this world?
Reference:
[1] Patrick K, Flegel K, Stanbrook MB. Vulnerable populations: an area CMAJ will continue to champion. CMAJ 2018;190:E307. doi: 10.1503/cmaj.180288. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5860889/pdf/190e307.pdf (accessed 2018 May 26). Archived: https://web.archive.org/web/20180526194439/https://www.ncbi.nlm.nih.gov/... (archived 2018 May 26).
[2] Keystone JS, Hébert PC, Stanbrook MB, et al. Protecting Canadian travellers: prevention is than cure. CMAJ 2008;178:373, 375. doi: 10.1503/cmaj.080027. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2228351/pdf/20080212s00003p... (accessed 2018 May 26). Archived: https://web.archive.org/web/20180526194540/https://www.ncbi.nlm.nih.gov/... (archived 2018 May 26).
[3] Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on international travellers who intend to visit friends and relatives. An Advisory Committee Statement (ACS). Ottawa: Her Majesty the Queen in Right of Canada, as represented by the Minister of Health; 2015. Available: https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/tmp-pmv/... (accessed 2018 Apr 28). Archived: https://web.archive.org/web/20180428201636/https://www.canada.ca/content... (archived 2018 Apr 28).
[4] Lee CS, Gregson DB, Church D, et al. Population-based laboratory surveillance of imported malaria in metropolitan Calgary, 2000-2011. PLoS One 2013;8:e60751. doi: 10.1371/journal.pone.0060751. Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3626683/pdf/pone.0060751.pdf (accessed 2018 Jun 16). Archived: https://web.archive.org/web/20180616200518/https://www.ncbi.nlm.nih.gov/... (archived 2018 Jun 16).
[5] Bui YG, Trépanier S, Milord F, et al. Cases of malaria, hepatitis A, and typhoid fever among VFRs, Quebec (Canada). J Travel Med 2011;18:373-8. doi: 10.1111/j.1708-8305.2011.00556.x. Available: https://academic.oup.com/jtm/article/18/6/373/1806353 (accessed 2018 Jun 16). Archived: https://web.archive.org/web/20180616200912/https://academic.oup.com/jtm/... (archived 2018 Jun 16).
[6] Zimmer R. Competing visions for travel health services in Canada. J Travel Med 2018;25. doi: 10.1093/jtm/tax096.
[7] Ontario Ministry of Health and Long-term Care. Fact sheet: travel medicine services. Toronto: Queen’s Printer for Ontario; 1998. Available: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/4317/bul4317b... (accessed 2018 Jun 17). Archived: https://web.archive.org/web/20180617074926/http://www.health.gov.on.ca/e... (archived 2018 Jun 17).
[8] Ontario Ministry of Health and Long-term Care. OHIP coverage while outside Canada: find out what OHIP covers when you’re temporarily outside Canada. Toronto: Queen’s Printer for Ontario; 2018. Available: https://www.ontario.ca/page/ohip-coverage-while-outside-canada (accessed 2018 Jun 17).
[9] Harris K, Hall C, Zimonjic P. Canada to admit nearly 1 million immigrants over next 3 years. Toronto: Canadian Broadcasting Corporation; 2017. Available: http://www.cbc.ca/news/politics/immigration-canada-2018-1.4371146 (accessed 2018 Apr 28). Archived: https://web.archive.org/web/20171101200208/http://www.cbc.ca/news/politi... (archived 2017 Nov 01).
[10] Canadian Charter of Rights and Freedoms, Part I of the Constitution Act, 1982, being Schedule B to the Canada Act 1982 (UK), 1982, c 11.Dec 7, 2017. Available: http://laws-lois.justice.gc.ca/eng/Const/page-15.html (accessed 2018 Apr 28). Archived: https://web.archive.org/web/20180428202722/http://laws-lois.justice.gc.c... (archived 2018 Apr 28).