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Removing barriers to vaccination
For the past few months, vaccines against COVID-19 have been on everyone's lips in Quebec. Health authorities insist that mass vaccination is the only way to end the pandemic. But is it accessible to everyone?
It's 12:30 on Tuesday afternoon and Rose Ngo Ndjel is running all over the place. The line of people queuing up to distribute food extends in front of the William Hingston Center in Parc-Extension. “You have to wait because the truck has broken down! ” shouts Ms. Ngo Ndjel, director of the organization Africa for Women in Africa. Each week, she oversees food distribution in the neighborhood.
With a dynamic voice, she repeats everything in English. Speakers at the local neighborhood table spread the word in Hindi, Punjabi, and Greek. The crowd waits patiently; children play and elders check in on their neighbours while members of the neighborhood table hand out masks. The queue, which numbers around a hundred people, reflects the diversity of the neighborhood.
Some, who are asylum seekers, arrived in Montreal in the last few months; others were born in the city. In recent weeks, there have also been new arrivals. Two social workers from the local CLSC are promoting vaccination in several languages with the help of young interpreters from the neighborhood table. They answer the many questions residents have:
“Yes, anyone aged 18 and over is eligible now. There will be a nurse who can talk to you about the side effects,” said one of them. “No, you don't have to have a health insurance card. Vaccination is for everyone”, replies the other.
A “universal” care system
“At the beginning of the crisis, there were really a lot of barriers to accessing screening and care for undocumented people,” explains Jill Hanley, co-founder of the Center for Immigrant Workers (CTI), a Montreal organization that defends the rights of immigrant workers.
“I was pleasantly surprised to see how quickly we acted to make screening, COVID care, and vaccination free for all.”
She adds that the level of collaboration she observes between health authorities and the community sector is indeed unprecedented: “We did not work together as much in the past, because before the pandemic, there was not the same need! ”
Canada is often awarded for so-called universal health care. However, in practice, this care is only covered for people who hold a card from the Régie de l'assurance Maladie du Québec (RAMQ).
People without status, asylum seekers, people who arrived in the country less than three months ago, and international students as well as many temporary workers do not have this privilege. Across Canada, more than 1 million people are not entitled to a health insurance card or are at risk of losing it, according to the Migrant Rights Network, a pan-Canadian network of organizations defending the rights of migrant workers that seeks access to permanent resident status for all.
The pandemic, however, has improved access to health care for people with precarious status. In Ontario, health care has been free for all for one year. In Quebec, the expansion of access is more modest, but screening, health care related to COVID-19 and vaccination are indeed free for all.
“Vaccination is offered to everyone, at no cost and regardless of status, both for vaccines enrolled in the Quebec immunization program and for vaccines offered as part of special vaccination campaigns, as is the case for COVID-19,” indicates the Ministry of Health and Social Services.
No RAMQ, no vaccine? Wrong.
“A person who does not have a health insurance card can indeed be vaccinated, says Noémie Vanheuverzwijn, spokesperson for the Ministry of Health and Social Services. She indicates that you must provide your date of birth, but that there is no obligation to prove it with an identity document.
“The objective of the vaccination campaign is to vaccinate as many Quebecers as possible in order to reduce the incidence of COVID-19, says Ms. Vanheuverzwijn. This is, according to him, the reason why the vaccination campaign should not exclude people without a health insurance card. She adds that information provided at a vaccination center is in no way shared with the federal government.
“I've heard that you have to have proof of age, but I can surely show my passport or something,” says Mamadou, who doesn't have a health insurance card. The Guinean asylum seeker, who works in construction, wants to be vaccinated. It is thanks to the CTI stakeholders that he now knows the procedure to follow. He has not yet made an appointment.
Identification, an obstacle to vaccination
Although vaccination is available to everyone, there are several barriers for those who do not have a health insurance card. Out of 12 pharmacies in Greater Montreal that offer COVID-19 vaccination contacted at random, only 3 indicated that it was not necessary to present an ID. Three others requested some form of identification, and three said they did not know how to proceed. A pharmacy requested that a social insurance number be provided.
Finally, in two pharmacies, it was not possible to talk to someone directly. “The problem that remains is that people have to identify themselves,” notes Pénélope Boudreault, national director of Doctors of the World Canada (MDM) Canada (MDM) based in Montreal. She explains that, even if they have an ID, many fear identifying themselves because of their status.
“In mass vaccination centers, there are still breaches in the protocol — employees will ask for the RAMQ card or simply ask a lot of questions, which risks scaring people away.” She claims to have received calls from people who were refused access to vaccination, but specifies that these are rarer than cases of refusal to be tested at the beginning of the pandemic.
To help address the problem, Médecins du Monde and CoVivre, an emergency response program, are producing proof of identity documents specifically for vaccination. “Despite our efforts, I cannot 100% guarantee that these documents will work,” regrets Pénélope Boudreault.
Proximity vaccination
A potential solution is the establishment of pop-up walk-in clinics, organized by local CLSCs and community organizations. People can get vaccinated in a safe and accessible environment. According to several stakeholders, these clinics are more attractive than mass vaccination centers for vulnerable clients.
“At the beginning of the vaccination, I was invited to visit a mass vaccination center on the MIL campus of the University of Montreal. The community of Parc-Extension was not there,” laments Rose Ngo Ndjel. “They're people who walk, and when it's too far, they don't go,” explains the intervener. “But when the CLSC organized a pop-up clinic here, all the doses flew away,” she says. “But when the CLSC organized a pop-up clinic here, all the doses flew away,” she says, so much so that, in the queue in front of the William-Center As of Tuesday morning, around three-quarters of adults had already been vaccinated.
Ousseynou Ndiaye is director of the organization An Itinerary for All, in Montréal-Nord. He emphasized the need for local vaccination centers, with the participation of community stakeholders. He believes that the establishment of accessible pop-up clinics, combined with the efforts of community employees who communicate with citizens and welcome them to vaccination sites, should be “profitable” in the long term. “Pop-up clinics are effective because you take the time to talk to everyone,” he continues.
It's demanding, but it works. We call everyone, we send WhatsApp messages; we reassure them, we even have volunteers who can take people to the centers.” Once there, the participants are supervised by speakers who know them and who speak their language. Mr. Ndiaye reiterates that there is no police presence near these clinics.
“We inform the authorities when we organize an event but on site, there are only us, the people of the district and the vaccinators, he says. Nobody is going to ask for your papers.”
Trust versus resistance
Mr. Ndiaye and his collaborators spent long hours on the phone to persuade neighborhood residents to come to a pop-up clinic. A recent survey conducted by the organization shows that only 37% of respondents indicated that they would get vaccinated as soon as possible. The majority of those who were hesitant wanted to see what effects vaccination had on others before getting a vaccine. “There is not much enthusiasm for vaccination. A lot of people don't trust vaccines,” acknowledges Mr. Ndiaye.
Out of 63 calls made, barely 5 people confirmed to him that they would be getting vaccinated. According to him, the distrust is partly due to the pharmaceutical companies themselves, which have carried out sometimes dubious clinical trials in several African and Caribbean countries. In the spring of 2020, the mess around a COVID-19 testing site in Montréal-Nord, dismantled only a few days later under the pretext that it was a study, did not help correct this feeling. The revelations about the rare cases of thrombosis linked to the AstraZeneca vaccine were also a blow. “People say they don't want to be guinea pigs,” summarizes Mr. Ndiaye.
He calls on the authorities to raise awareness among the churches and mosques in the neighborhood, and to understand that gaining the trust of anyone takes time. However, some migrant workers are hesitant to get vaccinated for other reasons. Jill Hanley of CTI almost no longer gets calls from people who are wary of the vaccine. “Now people are afraid to get vaccinated because they don't want to miss a day of work due to side effects. It's not pleasant to carry boxes all day in a warehouse if you're tired and your arm hurts,” she says. The price to pay can be catastrophic in case of absence.
“If you work for an agency and you miss a day of work, we will replace you.” The CTI is currently in talks with employers and public health to set up pop-up vaccination clinics in some workplaces that will be open on Friday evening to allow workers to recover over the weekend.
Preparing for the future
For many newcomers and people with precarious status, the idea of getting vaccinated to protect their loved ones from COVID-19 prevails. “We are told: 'Love each other, 'and getting vaccinated to protect each other is in this spirit,” says Marie Mbodji, a newly arrived Congolese refugee who lives in Parc-Extension. She has already been vaccinated.
“It's the only way to get back to normal life,” adds Mamadou, who intends to get vaccinated as soon as possible. He can't wait to see his friends again. Jill Hanley and Pénélope Boudreault hope that the pandemic will bring Quebec closer to a real universal health care system. “In the last year, we have seen a great deal of openness to expand the right to health care in Quebec,” notes Jill Hanley, who believes that the trend should become widespread.
If we give everyone access to care, without barriers and without fear, we won't have to do all this work. Trust will already be there in the next crisis.”