SHE Pod Season 2 Episode 1: Diego Silva and Ruth Lavergne on Ethical treatment of non-refugee migrants with tuberculosis in Canada

4:49AM Feb 28, 2021

Speakers:

Kathryn MacKay

Ruth Lavergne

Diego Silva

Keywords:

migrants

ruth

people

canada

paper

question

health

permanent residency

context

laughs

tb

diego

labour

tuberculosis

occur

precarious

migration

pathway

recognising

immigration

Hello, everyone, and welcome to the first episode of Season Two of the SHE research podcast. I'm your host, Kate MacKay. And I'm extremely delighted to be joined today by Ruth Lavergne from Simon Fraser University, and our own Diego Silva from Sydney Health Ethics. And we'll be discussing Diego's paper today, which was co-authored with Victoria Cook, James Johnston and Jennifer Gardy, entitled, 'Ethical Challenges in the Treatment of Non-Refugee Migrants with Tuberculosis in Canada'. And this was published in the Journal of Public Health. Hi, Ruth. Hi, Diego.

Hello.

How's it going?

Good. How are you both doing?

Well, happy to be here with you.

Thank you. Thank you. Thanks for joining us, Ruth, all the way from Burnaby.

Yeah, beautiful. Burnaby, British Columbia. And yeah, I'm at Simon Fraser University on... so I both live and work on unceded traditional territories of the Musqueam, Squamish and Tsleil-Waututh ah Nations. And I think it's relevant to this conversation for their work to uphold jurisdiction and sovereignty on these lands and our conversation about health and immigration systems that bear on these sort of broader questions of how we understand jurisdiction and nationhood. So, happy to be here and happy to join you there.

Absolutely. And we're joining from unceded lands of the Gadigal nation, where Diego and I both work and live in central Sydney. So thanks for that. Thanks for joining. Um, Diego, I guess the first thing to do here is to give the listeners a bit of an overview of what the paper is about.

Sure thing. So the idea behind the paper was that there's currently a lot been written, or not a lot, but some things been written for a general medical and public health audience related to what are our obligations to migrants in the context of health care. A lot of those, you know, pieces of writing that have been published tend to focus on refugees and more difficult cases, which is naturally important, you know, they deserve our attention. Our goal was to look at what are the ethical issues in quotidian migration as it were, or the non difficult cases, because ethical issues still arise there. And so we looked at non-refugee migrants in the context of Tuberculosis in Canada. So what we did was, we run through in the paper, some of the ethical arguments in favour of why we have an obligation towards migrants with regards to health.Critically for the listeners, I would say that it's overdetermined, conceptually, meaning that regardless of what theory you adopt, you're going to have some moral obligation to be concerned for the health of migrants. And so then we move into the actual issues with Tuberculosis, and migrants within Canada. And I guess, before that, it's kind of important to note that TB in Canada, is... it's actually low rates of TB in Canada. So usually, it's about five per 100,000 people, which is usually the case in many high income countries. But what is critical about the infection rate is the distribution of. So much of the infections occur in migrant population. So probably just under three quarters occur in people born outside of Canada, while the remaining actually - speaking of indigenous populations and land - occur in indigenous populations. Both those numbers, in terms of the percentage of TB, far outstrip the actual representation within the Canadian population. So, for example, migrants don't account for three quarters of the Canadian population say... probably, I actually don't know the number, what 30% 40%, I guess, are born outside. So. So that's a bit of the context of the two issues that we identified. One, were jurisdictional issues. So, you know, how do you navigate what you ought to do as a healthcare worker, between jurisdictions within Canada but also outside of Canada? So I think one salient example that comes up often, for my... two of my co authors who are physicians, public health physicians in Vancouver, our migrant populations have travelled back and forth frequently between their country of origin and Canada. So one question is, what do you do if somebody has TB? Do you alert the other jurisdiction if they're travelling, and the conclusion was is that no, you still want to maintain their privacy and confidentiality. And so the goal there is to, if they're adhering to treatment, is to not give that information away. If there are issues with adherence then you might actually reach out to your colleagues. And then the other sort of big issue was that of power imbalances. So we recognise that by being in public health, you know, the physicians, the nurses, the healthcare workers are clearly in a position of power over the migrants. Migrants will often - incorrectly but not, but it makes sense - think that within Canada and many other... many other high income countries that health care and immigration are tied together, when in fact they're not, or they ought not to be. And I intentionally using that normative language of the 'ought not to be'. So I think in practice, and Ruth can speak to this much more than I can, this delineation between what ought to happen, which is the cleaving of immigration and health care, doesn't actually occur. But we don't address that in the paper. So, so that... yeah, so that's it. So the the paper was for a general audience, general public health TV audience. So that's, that's, that's it in a nutshell.

Mm hmm. And so could you maybe say something for folks who aren't familiar about the way that the migration system or immigration system and the healthcare systems in Canada are set up?

Yeah, sure. So the immigration system - and Ruth, please jump in, because you probably know this better than I do - so the immigration system is run by the federal government, whereas healthcare is run by the provinces. So it's similar to what you have in Australia, where the Commonwealth is in charge of immigration in health care is the purview of the states. So when it comes to migrants coming in and being screened for TB, for example, the screening will occur at the federal level. But the treatment for LTVI, so Latent Tuberculosis Infection, and the surveillance say, will occur at the provincial level. So there is a lot of discussion between doctors working within the immigration system, and those in public health.

At the provincial -

At the provincial level, yes. Yeah. And usually there's good working relationships between between those groups.

And Ruth Do you want to add to that?

Sure. Yeah, I can jump in. So it's absolutely the case that we have the separation with the federal government only having limited roles in health insurance for refugees in Canada, whereas most classes of migrants would be interacting with their provincial health system. So there is this high level separation. But one of the things I was thinking through and reading this paper is what does that actually mean practically? So we're in the practical space, not the OT space here. But that, especially when we're talking about migrants who who may be in Canada temporarily, on work permits, study permits, may have precarious status, where they came to Canada with a permit and that... have lost that over time. Migration and their status, and access to health insurance are closely tied. And then there's an additional tie, again, at the at the level of sort of... work in that many, if you're a temporary worker in Canada, your status is connected to a specific employer. And so at that level, health concerns accessing care, leaving work to access care, may feel quite directly tied to your immigration status. This could also occur in the context of individual health care interactions, where inappropriately but commonly, health care providers deputise themselves to enforce immigration, sometimes that's sort of framed around concerns about whether they'll be paid and concerns about whether people have insurance. So as soon as we move into this space, where status may be precarious, and where actors sort of within provinces have become sort of part of the immigration enforcement system, then a sort of new set of arguments may be needed. So I think I was - in in responding to Diego's paper - it was those sort of muddier cases that I was curious which arguments apply and which might not... in that it's absolutely the case that there is this federal and provincial distinction. But practically the nature of the firewall discuss and the interaction of those systems at the experience of individual migrants may feel quite intertwined.

Yeah, that's really interesting. And I think... so now, I want to ask, Diego, you said a couple of minutes ago that theoretically - or you may have said conceptually - the motivation to care for migrants is overdetermined. So I wonder if you could explain why, hopefully in relation to Ruth's question (laughs).

So if we just take sort of a really broad stroke approach to ethical theories, right? And for everyone listening who does philosophy and ethics, please forgive me... but right you have your nonconsequentialist and your consequentialist accounts. Your consequentialist accounts, I mean, there's, you know, very little argument that can be made, that you're not maximising, or you're not contributing to the well-being or welfare of individuals, and that overall, it's a good thing, however, you define well being and however you count, so on and so forth. Deontological theories are often grounded in the moral worth of the individual and their autonomy or their flourishing. So they're in as well, there seems to be at least a prima facia obligation to migrants, regardless of whether they're in your hometown or not. So I would say that it might be that there are people, you know, philosophers, moral philosophers against providing support and healthcare in particular, for migrants, but it wouldn't be many, I'm kind of looking to you now, Ruth, Kate. So I mean, I don't think... I don't think there'd be that many scholars, who'd be against it. So then just briefly, to sort of come back to Ruth's point, I think, you know, where the rubber meets the road, things change a little bit. So I think that there's a difference between what we ought to do, obviously, and what is done. I think, it's really telling Ruth's example of physicians who take matters into their own hands, and appropriately. So there's a really clear example of that power imbalance that we were discussing in the paper. However, the paper, you know, we treat it as: you're either illegal or you're not, to use that probably outdated language. And I think what Ruth is getting at is a lot of the nuance and a lot of the grey in immigration status. And the other thing that we don't talk about in the paper, but I think is morally salient - so if I were to write a second paper or rewrite this paper - I think it's the... I think the other thing that we don't talk about, that Ruth is kind of implying is the context that we, we need to be really clear about the context in which we are actually, as you know, ethicists pontificating as to what ought to be done, and recognising the actual effects of of the power imbalance. I don't know if that answers your question. But...

Yeah, oh, yeah. Pulling like the complete reviewer to move why, like, why didn't that paper, the other paper that I wanted you to write that would directly answer my question (laughs).

But unlike most revered tos, I actually think you're right.

I think it's a really, it's a really interesting question, because it shouldn't just be moral philosophers that are convinced by moral reasoning and moral argumentation, it ought to also be the... everyone, including those physicians who sort of deputised themselves. So it's interesting to hear you kind of talking about this, it's such an interesting and tricky issue, because to my mind, the reasons behind caring for someone who has latent Tuberculosis, or perhaps active Tuberculosis, surely outweigh whatever payment worries you have, or etcetera. Especially given the fact that we are talking about legal migrants. I mean, it would be true even if we were talking about illegal migrants, but I think that's actually an important clarification for the scope of this paper, talking about people the government has purposely led in and perhaps even ideally wants to stay. So, yeah, Ruth.

That is absolutely the case. And to be very clear, again, I just keep saying 'but oh, but does this extend beyond does this extend beyond?' which is not what papers do (laughs). So, tuberculosis services are funded, they should be free at point of care, they should not affect people's status. But um, so that idea of people who have come here legally that the that the state has brought in and expects to support - absolutely true, except that we bring people to Canada with permits, again, that through caregiver programmes or agricultural labour programmes are tied to a place of work. And if any... if there are problems within that employer relationship, status is lost. So we're bringing people in through classes that are by definition precarious, and that connects to their access to health insurance. And again, health connects to that employment relationship. So it is definitely cleaner to say among people with current legal status, however, built into the immigration system are inherently precarious classes, where there is no intention for there to be a path to permanent residency or citizenship. And it is those classes of workers who are disproportionately affected by Tuberculosis and other... and other infectious diseases as well. And we're seeing that play out in the context of COVID-19. I think it has to be acknowledged, as well, both with higher prevalence, and then conversations about... in Quebec about people who've played frontline roles in providing care and long term... long term care, recognising that contribution through a legal pathway to permanent residency for people with previous precarious status. So it gets tied up so quickly, given the structure of immigration systems that... where precarity is built in and grassroots level connections to health care, risk and access to services are built in... Sorry to take it on the same rants again.

No, it's a great clarification. And I was also thinking, I mean, Canada had this experience with the agricultural labourers during COVID-19. Australia is also really heavily reliant on migrant agricultural workers to harvest, basically. But yeah, it's so interesting and problematic, that they're made so precarious, including for health reasons. I mean, that was a massive problem in Ontario, I think specifically,

Yeah, I mean...

Maybe also...

you. But

This is a tangent, but we've been relying on migrant agricultural labour for decades, after the Second World War, displaced people were brought to Canada to work on farms, migrants from northern and eastern Europe came, and you had to work on a farm for a year or two. And then that was a pathway to... it was an open work permit, you could work in a factory, and then eventually apply for PR. Into the 60s that changed to bringing workers from the Caribbean and from Mexico. And as the streams of workers became racialized, the pathway changed and it became temporary worker programmes where there was no... there was no expectation of permanent residency at the end, it doesn't factor into our point system that would qualify you for permanent residency, it's simply a different a different pathway. And that corresponds to a shift to increasingly racialized people being recruited for this labour. Anyway...

I guess to bring it back to the paper for just a sec. Or probably actually, to getting close to wrapping up, Diego.

Kate (laughs)

Is there any kind of takeaway message that you want people to glean from the paper or even from the conversation or from from kind of both?

Yeah, I think there's kind of two takeaway messages. So one is that I think we need to do more work thinking about... thinking about cases that are not the extremes... when it comes to migrant health. So we we have a tendency to think about exceptional cases. And rightfully so, they're often the most morally problematic, or probably in... and require our attention. But I think, if we're seeing anything with COVID, it's, and I think this goes to my second point, and so I think what Ruth is saying is, is that we need to think through carefully the myriad of ways that people immigrate and the passage of people. And, you know, this is in the context of TV, which is relatively simple and straightforward. But we're seeing it with COVID. And we're seeing it... we're gonna see it more with climate change, the climate emergency and people being migrants for for climate reasons as well. There is a, you know, there's this perpetual struggle in global health, that we have a global health system that is based on the Treaty of Westphalia, which is, you know, it was just staunchly state centric. And this is I think, one of the, the wicked problems to sort of borrow that term that I think we ought to try to work with individuals who work in health systems like Ruth, to think clearly about, you know, how we can mix our labour and actually make a difference.

Ruth, is there anything that you wanted to add?

Well, you just said the mix our labour piece. Again, I'm not an ethicist. I work in health systems. So I come to you asking questions, but I think that makes a lot of sense to focus sort of on those... they're not extreme cases, but they represent substantial parts of migration flows and drivers of movements between places. And that point about sort of mixing labour where I am really interested in, is arguments that take out that state piece and think about... or connect the drivers of migration to responsibilities related to health directly, rather than through the role of the state, if that makes any sense. So again, thinking about these cases where even if someone doesn't have legal status having been brought to Canada to provide labour, agricultural labour, surely that must shape the context and the the nature and extent of obligations independent of legal status. And so I'm curious about about those directions. And I think similar questions would apply when migration is driven by by climate change, and other factors where the wealthy countries we're talking about here in a position to provide or deny care are also drivers of the causes of migration.

And also really white. (laughs) To bring...

See. Yeah.

So there is the raised the issue of racism as well playing through this. There's the the economic and, yeah, and the race issue, which makes us all feel uncomfortable, and rightfully so.

Yeah, yeah. And that's really, it's really interesting to think about those groups, they have such completely different experiences. And I come from a family of migrants. And I am myself a migrant, as a Canadian in Australia. That's, you know, obviously, completely different in every way from the experience of precarity that you were talking about Ruth, people who have been brought for a specific term and have no pathway to gaining permanence if they wanted it. I mean, it's just, yeah, I don't think we can even separate issues of race and privilege from those questions.

No,

no, no.

On that note, (laughs). Thanks for joining me. What a great conversation.

Thanks for having me.

Yeah. Thanks for joining us Ruth.

This has been so much fun. Thanks for that paper Diego. And thanks for all of the additional papers you're gonna write... (laughs) with my additional questions?

You know, you're not getting out of it, right Ruth?

I sense a co-authorship.

Yeah (laughs)

Well, thanks so much for listening everyone. You can find the paper we've discussed linked in this episode's notes, along with the transcript. SHE pod is hosted by me Kathryn MacKay and produced by Madeline Goldberger. You can find our other episodes on Spotify, Radio Public, Anchor or wherever else you get your podcasts of quality. Thanks again for listening. Bye.