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Selena, a middle-aged woman from Ethiopia, has found a small lump in her breast. She doesn't speak English or French and so she when goes to a doctor to find out what it is, she brings her 12-year old daughter to act as her interpreter. The doctor suspects breast cancer, but isn't sure whether Selena wants her daughter to know this.

The language barrier between Selena and the doctor is just one example of many challenges newcomers face when it comes to taking care of their health in their new country. Yet the barriers extend far beyond language - the health care system, health care providers and, often unwittingly, the patients themselves each play a part in impeding newcomers' access to professional health care.

Clinics across the country are trying to make a difference for immigrant health needs

Among others, family physician Kevin Pottie is determined to make inroads when it comes to improving both primary and preventive care delivery for newcomers to Canada. At the Elisabeth Bruyère Family Medicine Centre in downtown Ottawa, Dr. Pottie and a team of interdisciplinary health professionals specialize in new immigrant, refugee and cross-cultural health care. "Access to quality health care should be available for all Canadians" says Dr. Pottie. "And primary health care in particular should be delivered in the context of a patient's life. This means we need to thoughtfully acknowledge a person's background—geographically, culturally and individually."

The health care team consists of two family physicians, a nurse practitioner, and a receptionist, as well as a pharmacist, an infectious disease specialist, and a children's infectious disease specialist who are available for consultations when necessary. Patricia Topp, the nurse practitioner, says, "We all have specialized skills that complement one another and because patients see the appropriate provider, we increase the access to health care for this population."

In any given week, professionals at the specialized clinic work with patients who embody the range of common challenges newcomers face. As in the example above, many newcomers have limited skills in English or French and this means they must rely on others to communicate their situations. When family and friends get involved in interpretation, it can often lead to issues involving confidentiality, misconstrued facts or symptoms, and conflicts of interest; for example, a husband is not an ideal person to interpret questions relating to a woman's sexual history. As well, it's difficult to build trust when there is a language barrier, and according to Dr. Pottie, "Being appreciated and understood goes a long way in forming trust and navigating cultural and linguistic nuances." Furthermore, newcomers often face long physician waiting lists, racial discrimination, stigmatization, and lack of access to continuous care.

Teaching is vital

Helping newcomers learn about our health care system is an important part of helping them overcome barriers to health care services. For example, teaching them about common practices like making doctor's appointments, ordering prescriptions and the importance of regular physical examinations is vital to their understanding of the system. As part of its practice, the clinic offers patient orientation to the Canadian health system as well as to health promotion practices. "Continuous teaching at every medical visit is essential to the process of smooth integration in the health care system," says Patricia Topp.

In addition to routine preventive care services, the clinic provides travel health consultations for immigrants who are travelling home to visit friends and relatives. Immigrants who make these journeys may face a higher risk than Canadian born individuals for travel-related diseases such as malaria, typhoid, hepatitis and other vaccine preventable diseases because of an increased likelihood to be exposed to local conditions and a decreased likelihood of seeking preventive services prior to travel. These illnesses can result in significantly higher death rate for immigrants. Yet, many of these diseases can be treatable or even preventable with appropriate measures such as vaccination and health counselling.ⁱ

As well as providing opportunities to teach immigrants about our health care system, the specialized clinic also offers a unique learning environment for medical students, residents and nurse practitioner students where they can observe both the challenges and victories experienced daily by immigrants and health professionals.

Sustaining health by preventing disease and injury

In addition to his work as director of the specialized clinic for newcomers, Dr. Pottie also leads a national network of health professionals and immigrant multicultural health brokers committed to improving prevention services for immigrants. For many of Canada's immigrants, Western ideas of disease prevention and health promotion are unfamiliar. But, says Dr. Pottie, this doesn't mean they aren't interested in these ideas. "Healthy living is relative to where a person comes from," he says, adding that, "many immigrants are, in fact, very conscious and interested in their health-it's just that their way of approaching it may differ from ours. We need to respect this and work cooperatively, offering them additional options as they assimilate into the Canadian health landscape. Diet and exercise are classic examples. Many immigrants come from warmer climates where they were more physically active and where locally available fresh foods are part of cultural traditions; it's not easy to adapt to our Canadian climate and new foods."

In order to assist primary health care practitioners and the immigrant communities they serve, Dr. Pottie and his research team are developing a comprehensive preventive care guide. The guide highlights specific health concerns relating to immigrants including displacement history, exposure to torture and violence, and preventable infectious diseases such as tuberculosis, hepatitis and malaria. By assessing newcomers' health early and providing preventive vaccinations and counselling on healthy living, health care practitioners can help new Canadians ease into their new life

Hope for the future

Dr. Pottie has a vision for the future: "In twenty years, I would love to see a culturally and linguistically diverse base of health care professionals, policy makers and communities," he says, noting that, "integrating into a new country will always be stressful, but we can alleviate some of this stress by breaking down certain barriers, particularly in terms of health services."

"The vast majority of our immigrant population has a genuine desire to contribute to the growth of Canada," Dr. Pottie observes. "Ensuring that they have the same level of quality and access to health care as other Canadians is not an unreasonable goal".

New Canadians are generally very keen to adapt to their new country and it helps a lot if their fellow citizens support them on their journey. Supporting their right to health is a great start. As Dr. Pottie puts it, "Health is gold, it doesn't matter where you are from or what language you speak."

ⁱ Preparing for Diversity: Improving Preventative Health Care for Immigrants. By Kevin Pottie, Institute of Population Health, University of Ottawa, Lucenia Ortiz, Edmonton Multicultural Brokers' Cooperative, and Aleida ter Kuile, Centre for Global health, Institute of Population Health, University of Ottawa.