It’s a catch-22 for healthcare providers. Because tuberculosis (TB) is a contagious disease and therefore a public health issue, an uninsured person with TB is entitled to medical care. Yet, under the current system the tests to diagnose TB are not covered. As Angela Robertson, Executive Director of the Central Toronto Community Health Centre (CTCHC) explained, “the diagnosis of TB doesn’t just walk in and present itself,” resulting in what Robertson called a “conundrum” for many providers.
This is just one example of the complexities of providing health care to marginalized populations in Ontario. Community Health Centres, including the CTCHC, are uniquely situated in their ability to serve clients who face barriers to care. For example, they are the only places in Ontario where the government provides funding to assist uninsured individuals.
The CTCHC shares a space with the IMAGINE clinic and both serve similar inner city communities in the Queen and Bathurst area. To learn more about the CTCHC, the IMAGINE advocacy team sat down with Angela Robertson, who has been leading the clinic for about two years.
A history of serving the community
The clinic has roots dating back to the late 1960s and the founding of a student health organization called SHOUT. It began as a collaborative between students in a number of health disciplines at the University of Toronto - a model similar to the IMAGINE clinic. The aim was for students to experience working within an interdisciplinary health team and to provide care to the residents of the Alexander Park Community.
Then in the 1980s, two community health centres - the Alexandra Park Community Health Centre and the nearby Niagara Community Health Centre - opened in the area. In 1982, they were amalgamated to create a larger community health centre - the West Central Community Health Centre. It was eventually renamed the Central Toronto Community Health Centre in 1997.
Although the clinic has evolved over the years, Robertson explained that it has always been targeted at low income, working poor and immigrant communities. The centre has also expanded to serve new priority populations to meet the needs of the local community.
Today, the CTCHC serves a significant number of individuals who are homeless or street involved, as well as those who are living with a mental health and/or substance abuse issue. Another priority population is the Aboriginal community.
In the earlier days of the clinic, the main newcomer groups served by the Centre were Italian and Portuguese. Nowadays, the local community includes newcomers - refugees and sponsored immigrants - from Mainland China, and Vietnam, as well as those from the African continent and Middle East.
Tailoring services to meet client needs
About 80% of people come to the clinic seeking access to primary care, and many face a language barrier in communicating with their provider. In order to address this, the clinic offers both in-person and over the phone interpretation services.
The CTCHC has a range of other services in addition to primary care. Harm reduction services include street outreach led by peers with lived experience of addictions, services offered in local shelters, safe use kit, and distraction and other programs for youth. Counselling services are also offered, including in Mandarin and Cantonese (the clinic does not currently use interpreters in mental health contexts).
Another component of the Centre’s services involves doing work related to population health. Health promoters work with different communities doing group work and community-building. For example, the clinic runs an Aboriginal diabetes program that is not simply focused on the disease but also on issues related to the trauma of residential schools, the trauma of long-term homelessness and poverty.
Health promotion work offers the clinic an opportunity to care for clients in a holistic way and “to respond to new and emerging issues,” explained Robertson. One of these issues is about workplace health and safety. A significant number of newcomer women, particularly from the Vietnamese and Chinese communities, are employed in nail salons. In order to understand the health risks and employment conditions associated with this type of employment, the CTCHC developed a collaborative program with the National Network for Environment and Women’s health. This is an example of how health promotion can be used to “identify trends, population disparities and/or challenges as a way to start small and scale up,” said Robertson.
Policy’s effect on clinical work
The CTCHC has seen the effects of changes to government policy on the way they serve clients. In 2012, changes were made to the Interim Federal Health Plan, which provides temporary health care to refugees, that reduced and eliminated elements of coverage for refugees and refugee claimants.
On the ground level this has meant that CTCHC clients who were once covered no longer are. “Resources that …we would use to cover other folks who were uninsured [now need] to be stretched to cover a new group of folks who were once insured,” explained Robertson.
Ontario has introduced a bridging plan to fill the gap between the cuts made by the federal government. However, gaps in coverage still exist because of the “complex bureaucracy” of determining which procedures are covered. Many providers are reluctant to provide care because of the complexity of the system, and thus these clients do not receive care. Some providers also question why their role should be to determine a person’s eligibility, when they have been trained to provide care, said Robertson.
Improving the quality of care for different client populations
The CTCHC recognizes that different client populations may face particular barriers to care. Recently the clinic has started to develop programming specific to trans clients. They are also improving access to primary care and have created testosterone kits (t-kits) for safe hormone injection.
Robertson explained that a huge barrier for trans clients is transphobia, both from the general public and the healthcare system. Providers may refuse to get a client’s pronouns correct, or may be uncertain how to ask. “Depending on how you respond…as a provider [that] could either be welcoming or it could be alienating and stigmatizing,” she said.
Another significant issue faced by this community is poverty. It can be difficult for trans individuals to find employment and good jobs, and thus they may not be able to afford all the medications they require. This is one of the reasons why the clinic provides free t-kits.
Improving care for trans clients is not simply about creating new programs or offering supplies, it is also about training providers and creating a welcoming atmosphere. The clinic has brought in trans access trainers to educate providers. They have also been raising awareness through the clinic’s different programs and services so that other clients understand that trans clients are welcome and that discrimination and stigma are not tolerated. The clinic uses visual clues like the rainbow flag and trans-friendly posters to create a safe(r) space for clients from the moment they walk in the door.
In terms of improving access to healthcare for trans clients, Robertson said that there is a “steady chipping away at the barriers.” Having institutions and organizations in place that serve trans clients such as the Sherbourne Health Centre, Rainbow Health Ontario and Trans Pulse are a “statement of change.” However, Robertson pointed out that organizations that are not specifically created for trans or LGBTQ clients must begin to make their services inclusive. Otherwise we will create “another kind of a ghettoization and/or a marginalization of trans clients to only areas or programs that are trans and/or LGBTQ specific,” she said.
Advocacy & the challenges associated with it
Robertson believes that advocacy is “embedded” in the work of service providers. “People who we serve in our organization come to us with needs and challenges that are the result of inequality either in income, in access to services [or] in discrimination… so therefore our work as providers is not just to respond to the symptom that clients present to us with but also respond to some of the root cause.”
The CTCHC is involved in advocacy efforts around a number of issues: cuts to the IFH, access to care for the uninsured, advancing harm reducing, income security and increasing funds for homelessness programs.
However, advocacy comes with challenges. In her 1999 book, Scratching the Surface:
Canadian Anti-Racist Feminist Thought, Robertson wrote about how anti-racist advocacy had been fragmented and bureaucratized by the state. Sixteen years later she said that it has become increasingly harder to do advocacy work, particularly in terms of public coalition building to protest government policies.
Robertson explained that the economy has put a strain on many of the people who are involved in advocacy, who simply do not have the time to mobilize. Another barrier is “advocacy chill,” a phenomenon that occurs when organizations that speak up about a certain issue have their funding threatened or cut.
However, Robertson was hopeful that today’s activists and movements are becoming more connected. “I think that the movements that are emerging and that are present today are really bringing an intersectional kind of perspective because there’s a recognition that globalization makes it so we cannot be single issue. I think there’s a great deal of promise there.”
Hopefully, this will translate to increasing health equity for clients at the CTCHC and beyond.