National Immigration Health Policy: Existing Policy, Changing Needs, and Future Directions
Gushulak, Brian D., Williams, Linda S., Canadian Journal of Public Health
Canada has a long history of welcoming immigrants and a longstanding immigration policy framework. The historic principles that govern immigration selection and processing also include regulatory policies in the area of health.
Based on historical principles that pre-date Confederation, Canadian immigration health policy has remained relatively constant. Policies are based on the identification of specific individuals and the exclusion, if appropriate, of the affected individuals - an approach that continues today. During the past three decades, however, evolutionary changes in the patterns, volume and demography of immigration have created situations that may necessitate changes to existing policy frameworks. This paper reviews current immigration health policies and practices in Canada, describes the nature and impact of existing challenges, and proposes some alternatives for future consideration.
Immigration is a fundamental pillar on which Canada has been built. Beginning with European colonization, the medical assessment of migrants is one of the nation's oldest migration-related activities. Despite this long history, Canada's immigration health activities continue to reflect traditional approaches initially designed in an era when most immigrants and a small number of refugees came from Europe. Later, they were revised to prevent the arrival of migrants with chronic, costly health conditions. In recent decades, however, most immigrants and refugees have come from Asia, Africa, the Middle East, the Caribbean and South America, and have different health backgrounds and diseases. There is also a growing recognition that migration and population mobility are major factors underlying the processes of globalization. Changes in immigration health policy are needed to reflect these new realities.1
Countries have long recognized that travellers can import disease and have taken steps to protect their own populations. In Biblical times, lepers were isolated and their movements controlled to limit their contact with others. By the 14th century, the spread of plague in Europe due to mercantile expansion triggered the development of quarantine. Inspecting arrivals, denying admission, and either holding or treating them due to the real or suspected presence of disease became standard maritime practices.2 Quarantine practices came to the Americas in the 1700s, as European exploration and settlement brought cholera, plague, and "ship fever" (typhus) to the colonies.
Focus later shifted to other transmissible diseases, such as tuberculosis and syphilis. In the 19th century, concerns grew to include chronic and non-infectious diseases that were likely to make new arrivals dependent on publicly funded social and health services, such as chronic psychiatric disorders, developmental impairment, alcoholism, seizure disorders, and chronic tuberculosis. The masters of vessels bringing passengers to Canada were subject to a fine or bond for landing individuals who later became "public charges" because of disease or infirmity.
Assessing new arrivals for the presence of serious infectious disease, or the presence of illnesses that would impose a drain on public services, has remained the fundamental principle underlying the Canadian approach to immigration health. Similar approaches are observed in other developed nations with longstanding immigration programs, such as Australia, New Zealand, and the United States.3
AREAS OF POLICY
Current immigration health practices
Current immigration health practices and policies are defined in the Immigration and Refugee Protection Act rather than national health legislation.4 Until recently, Canadian immigration health practices have been solely designed to select and render inadmissible certain individuals on the basis of risk to public health or public safety, or on an excessive demand on health services. That process involves a medical examination for persons applying for, or already selected for (i. …