Ukraine crisis highlights inequities in refugee care

Canada mobilized quickly to bring Ukrainian refugees to Toronto for cancer treatment — but questions remain about how to ensure such efforts are equitable and sustained.

Millions of people have fled Ukraine since Russia invaded the country in February. Most sought refuge in neighbouring European nations. Canada and other countries made emergency provisions early in the crisis to take in Ukrainians requiring specialized health care.

Toronto’s Hospital for Sick Children (SickKids) received five pediatric cancer patients who travelled to Canada with their families via a privately sponsored jet. The hospital has the capacity to provide cancer care for 10–15 children from Ukraine. Other pediatric hospitals in Canada expressed interest to do the same.

“While the priority at SickKids is meeting the needs of children in Ontario and Canada, we acknowledge that there is a responsibility to provide care to critically ill children from abroad when we have unutilized capacity,” the hospital told CMAJ.

Canadian officials have since expedited immigration processes and waived waiting periods for health care coverage for Ukrainians in an outpouring of goodwill that some have contrasted with Canada’s treatment of other refugees.

“Refugee health providers are seeing the attention and compassion that our world is giving to the Ukraine crisis and we’re very happy, but there’s frustration that so many other crises have gone ignored,” says Tim Holland, medical director of the Newcomer Health Clinic in Halifax.

Take Canada’s promised resettlement of 40 000 Afghan refugees — only 13 050 have made it here since August 2021. Meanwhile, Canada has welcomed 28 000 Ukrainians within a few months and the Immigration Minister said the government is prepared to accept an “unlimited number” more for the foreseeable future.

The federal government attributed these differences to logistical difficulties getting people out of Afghanistan

However, Canada’s Standing Committee on Citizenship and Immigration urged the government to extend special immigration measures that allow Ukrainians to fly to Canada without a passport or visa to refugees from other regions, including Afghanistan, Yemen, and Hong Kong.

Apparent double standards in immigration policies are also reflected in refugee health care.

Some provinces, including British Columbia and Ontario, are providing Ukrainians immediate access to provincial health insurance when they arrive in Canada. In Alberta, the government instructed health care providers not to bill Ukrainians while it sorts out coverage behind the scenes.

However, refugees from other countries may wait several months to access provincial health insurance, relying on the Interim Federal Health Program to cover them in the meantime.

The program suffered severe cuts under a former Conservative government, and although the Liberals have since restored coverage, confusion about the program and barriers to care and reimbursement persist. Some health providers still refuse to see patients covered under the federal program or bill them out of pocket.

One study of 400 Syrian refugees who resettled in Toronto found nearly half had unmet health care needs, even though more than 90% had seen a doctor within their first year in Canada. Long wait times and the cost of services were among the top barriers they reported. And many continued to report unmet health care needs up to two years later.

The situation is even more precarious for people without documentation or public health insurance who may be turned away if they can’t pay upfront.

Holland and others hope that efforts to clear red tape for Ukrainians will set new precedents for immigration policy and refugee care in Canada.

“I want to remain optimistic that this is going to be the cultural turn we’ve needed,” he said.

James Rutka, a pediatric neurosurgeon at SickKids, is involved in a fellowship program training doctors from Ukraine. He said Canada has a responsibility to help when other countries are in crisis and the situation in Ukraine could be a “threshold event” for a change in the response to mass migration events.

Russia’s nuclear threats put the global spotlight on the plight of Ukrainians, Rutka said. While the world is watching, “We should formulate strategies to look after children from other countries where there’s a real need like this.”

At a minimum, Holland said, “For someone coming to Canada as a refugee to become a part of our society, we have an immediate obligation for their health care.”

However, Holland is concerned that the federal government doesn’t “realize the incredible amount of investment they need to back up their promises to the Ukrainian people.”

Refugee health providers were already “stretched so thin” with the Afghan resettlement, Holland explained. Without “serious investment” to keep up with the expected influxes of newcomers, he worries about reduced health care access for refugees who are already here and “struggling to get what they need.”

“If someone is coming over temporarily for health care, it gets a bit more complicated,” Holland said. “We have to find a balance between what we require for our own citizens and how we can support beyond our borders.”

Such initiatives often depend on existing ties between countries, health institutions, or even individual providers — making it tougher to ensure equal access.

According to SickKids, “our long-standing partnerships with Ukrainian children’s hospitals and previously established oncology networks have enabled us to support urgent children’s health care needs.”

The hospital also has a fund that provides financial support to bring children from around the globe to Canada for procedures that aren’t available where they live.

Meb Rashid, medical director of the Crossroads Clinic, a refugee health clinic in Toronto, said a smart long-term strategy may involve strengthening health care systems around the world.

“Even if countries are not in conflict, sometimes the quality and availability of health care are so limited,” Rashid says. “What do we do when a child with cancer leaves South Sudan and goes to Uganda? Or an Afghan child goes to Pakistan? How do we, as one country, support that? It’s by building up health infrastructure, so people get good health care where they’re at.”