Isaac Phan Nay, Local Journalism Initiative Reporter, The Tyee

Eloina Alberto remembers coming to Canada from Mexico about a decade ago. Although she had applied for a work permit, she was not yet covered by the BC Medical Services Plan.

“I was really stressed and I was pregnant,” she said. “I was thinking, ‘If I’m not getting MSP on time, how much will I have to pay for this?’”

Because she had worked as a nurse, Alberto said she knew she needed to get proper care to deliver her child. But without access to coverage, her birth could be costly.

Other mothers in Alberto’s community had been charged upwards of $10,000 for their pregnancies. And many were afraid that heading to the hospital could put their — or their child’s — status in this country in jeopardy.

So she took a chance, and reached out to a local community group: Sanctuary Health. The organization — which at the time was a grassroots network of advocates, community members and health-care workers — helped get her into the BC Women’s Hospital where she could deliver her baby without fear of having her immigration status questioned.

“I was afraid to go to the hospital, so I reached out to them,” Alberto said. “That’s the way that I got support. My little one will turn nine next year.”

Alberto is one of the hundreds of mothers, workers and refugees that have turned to Sanctuary Health for help accessing health care in B.C.

Over more than three decades, the group has transformed, growing from a philosophy held by health workers and advocates, to a network of health-care workers willing to take on patients off the record, to an organization migrants call on in their times of need.

The group became a vital lifeline for the refugees who have come from war-torn countries hoping to call Canada home, the construction workers who came to build the Canada Line and the farm workers who put food on B.C. tables every year.

Through the Harper government’s cuts to refugee health care and the Liberals’ tightening of immigration policies, Sanctuary Health’s mission has remained the same: to help people access health care regardless of their immigration status.

Now, as the federal government cuts immigration numbers and adopts stricter border security measures, Sanctuary Health is preparing for the worst. The organization is ramping up its outreach efforts, running information sessions and even preparing for a U.S.-style immigration crackdown.

“What is coming is going to be worse than when the Conservatives were in power,” said Byron Cruz, who — along with his partner Ingrid Mendez — helped found Sanctuary Health. “We want to be prepared. Health care should be in the hands of communities.”

Long recognized as the first point of contact for migrant workers in need of health care, Cruz is starting to pass on the torch.

Now a community outreach worker at several Vancouver-based migrant support organizations, Alberto has started picking up dozens of calls from people with precarious status, connecting them with health-care programs and accompanying them to appointments to act as an interpreter.

“Since I met Ingrid and Byron, I was really inspired by all the work that they were doing,” Alberto said. “I did anything that I could do, because I was part of this.”

She’s joined by Karina Villada, a longtime outreach co-ordinator and legal educator with the Migrant Workers’ Centre.

“We cannot say no and will try to help in any way that we can,” Villada said.

‘Help for refugees essentially did not exist’

Ask Cruz, and with a smile, he’ll say he is just a small part of the organization called Sanctuary Health.

But any other migrant outreach worker in the province will tell you Cruz and his partner, fellow health outreach powerhouse Mendez, have shepherded the organization through the shifting political tides and policy changes that affected migrants’ access to health care in Canada.

Cruz and Mendez grew up in Guatemala in the 1970s and 80s during a brutal civil war that pitted government forces against leftist insurgents and Indigenous peoples. During the conflict, the government-backed military of the small central American country was carrying out mass killings of Maya people in what would come to be named a genocide.

Mendez remembers leaving her home in a small town in the Quiché province to head to secondary school in 1984, then politics at Guatemala’s national university in 1987. It was during her time in university that she started to notice her classmates were disappearing.

“Our compañeros and compañeras were being kidnapped,” she said. “I would see them one day, and the next they were not there anymore.”

So, Mendez started leading rallies calling for their return. She said she was part of the students’ movement for eight months before she met Cruz.

“Byron came back from exile, because he was in exile for a bit, and we met because I was already involved in the organizing of things,” Mendez said. “We started organizing together and ended up being together.”

Then, Mendez said, things took a turn for the worse. The government continued taking action against demonstrators and classmates continued disappearing, she said. Some ended up dead.

Mendez and Cruz were forced to leave. The two emigrated to Canada in 1991.

It didn’t take long before they each started doing outreach work for clinics on Vancouver’s Downtown Eastside. Mendez remembers supporting members of the growing Spanish-speaking diaspora arriving in B.C., many of them fleeing war or violent oppression in their home countries, including El Salvador, Chile, Nicaragua and Guatemala.

Through the outreach work, Cruz said he started to realize many refugees were struggling to access health care. Although migrant workers have been insured under the Interim Federal Health Program since 1957, many claims were being rejected or not reimbursed.

Cruz said some clinics would ask for proof that refugees had the proper documentation, making them jump through bureaucratic hoops before they could see a doctor. Many refugees and migrants were simply unable to get the health care they needed.

“Help for refugees essentially did not exist,” Cruz said.

Some of the refugees coming to Canada were doctors. Cruz remembers meeting a doctor from Guatemala, a doctor from Ethiopia and a doctor from Ukraine.

“When they came here as refugee claimants, they went through that process, and they realized that they needed to create a better model of health care,” Cruz said.

A small group of Canadian and refugee doctors approached Mount St. Joseph Hospital with a proposal that would let them deliver health care to refugees and other migrants. In September 1994, they opened the Bridge Health Clinic on the hospital’s third floor.

“The clinic was perfect,” Cruz said. “We could see anyone regardless of immigration status, and that was a good community model.”

At the time, provincial health authorities did not have explicit policies against calling immigration and border services on patients. Cruz said the Bridge Clinic had started filling an important gap in the health-care system by serving people without legal status in Canada.

The clinic also served as an important networking space for recently landed migrants, according to a Nov. 9, 1997, edition of the Province. Burmese physician Wyn Myint Than was a patient at the clinic when she emigrated to Canada in 1994, according to the newspaper. Contacts she met at the clinic later helped her land a job with the BC Centre for Disease Control.

‘We had the best health care project in the world… But we made a mistake.’

With the clinic up and running, Mendez and Cruz focused on working with vulnerable residents of Vancouver. Shortly after arriving in B.C., Cruz fell into a depression, missing his old life of political advocacy in Guatemala.

“The first months I was in Canada, I was depressed because I couldn’t spend the same energy organizing people,” he told the Province in a 1999 article.

Cruz threw himself into supporting recent migrants to the city who had fallen on hard times. He worked both as an outreach worker at the Main Street Clinic on the Downtown Eastside and as a spokesperson for the Latino Support Group.

In those days, Cruz could be found handing out condoms and checking in on people at Oppenheimer Park, or leading rallies outside the Carnegie Community Centre calling for safe injection sites or decrying police brutality.

In 1996, Mendez started working as an outreach worker with Watari Counselling and Support Services, which still serves Downtown Eastside residents today. She did outreach and counselling work at Watari for decades, eventually becoming the community health clinic’s executive director in 2018.

Cruz and some of the health-care workers involved with the Bridge Clinic also formed another organization — the B.C. Multicultural Health Services Society — dedicated to expanding newcomers’ access to health care.

The group’s advocacy would prove critical for migrants and refugees through the turn of the century, Cruz said.

“We were happy. We had the best health-care project in the world, we were able to provide services regardless of immigration status and people were happy to come,” Cruz said. “It was beautiful. But we made a mistake.”

Thirty years later, Byron Cruz is still fighting for better access to health care for migrants in British Columbia.

The Bridge Clinic was overseen by the Vancouver Health Board. In 1997, the Vancouver Health Board became the Vancouver/Richmond Health Board. The new authority started taking a closer look at the clinic.

Cruz said with the attention came funding, new doctors and better equipment. The clinic became a more robust centre for refugee health care. The health board took over operation of the clinic from the community workers — and also implemented stricter criteria for accepting patients.

“We started to lose control and started to lose power on decision-making,” Cruz said. “People without [immigration] status lost access. Their families lost access. And we didn’t have the power to stop that.”

The Bridge Clinic is still around today (last year, it moved to Victoria Drive and is operating in partnership with Immigrant Services Society of BC). The health authority kept the clinic running as the Vancouver/Richmond Health Board turned into Vancouver Coastal Health in 2001, and through the decades that followed.

But Vancouver Coastal Health did not implement a policy against calling the Canada Border Services Agency on patients without status.

For migrants, that meant accessing health care came with a risk of deportation. And for Cruz, that meant going underground.

‘Marijke, you speak Spanish, come quick!’

Midwife Marijke de Zwager met Mendez and Cruz on the job. She remembers being called to help a Spanish-speaking woman deliver her baby — “catching” the newborn, in midwife-speak.

“I was in my last year of school, and I was at the hospital one day, and the staff were like, ‘Marijke, you speak Spanish, come quick! We can’t understand the girl in room whatever!’” she said. “I ran in there and I caught a baby for somebody whose care provider hadn’t made it yet.”

That was in 2009, when de Zwager was finishing up a degree in midwifery at the University of British Columbia. The experience stuck with her.

“I remember thinking it’s so important that people can talk to their care providers, be listened to and get the attention they deserve,” she said.

So when de Zwager started practising midwifery in Vancouver in 2010, she made sure people knew she was happy to take on patients who did not speak English.

Marijke de Zwager met Mendez and Cruz on the job when she was called to help out during a birth.

That’s how she met Cruz. By then, the health outreach worker had already stepped into his role as the 9-1-1 for migrants.

Cruz was often the first person that both undocumented and documented migrants called when they were injured, and he would put them in touch with a group of about 30 doctors, nurses and midwives willing to offer off-the-books care — health care workers like de Zwager. (Off-the-books care means that health-care providers are operating outside of the health authority’s system.)

“Providing services to people without status was part of their mandate,” he said of the group of health-care providers. “It’s part of why they became a doctor, their Hippocratic Oaths.”

Cruz remembers one undocumented worker had an accident at a construction site and came to the organization with a nail impaled through his hand.

“I have the picture still on my phone,” Cruz said. “He was afraid of going to hospital, because at that time, the hospitals were calling immigration and border services.”

So Cruz and a nurse went to go see the worker.

“I just came up behind him, held him, and the nurse used some kind of scissors to pull it out,” Cruz said. “We just put some alcohol on his hand and we gave him an anti-tetanic shot.”

A large part of the group’s work included helping undocumented mothers deliver their babies.

On top of her work as a midwife through the provincial health-care system, de Zwager started accepting patients “off the side of her desk,” who might not have had legal status in the country or enough money to pay the health-care system for treatment.

“I was the only Spanish-speaking midwife in Vancouver doing that,” she said. “So it wasn’t hard for people to know who to go to, because there wasn’t anybody else.”

According to de Zwager, the cost of childbirth for uninsured residents could be more than $3,000 at the time. Outreach worker Villada said today, childbirth can cost non-residents anywhere from $10,000 to $15,000, depending on the complexity of the delivery.

De Zwager remembers many of her patients were the wives of workers who had stayed in Vancouver after helping build the Canada Line or the 2010 Olympics facilities. Others were undocumented migrants who had been injured on the job.

“They think it’s safer to deal with an infected cut or something like that on their own than it is to present to health care and have their status revealed,” she said. “You’re never sure if somebody’s going to call.”

Government cuts and sanctuary cities

Meanwhile, refugees’ access to health care started to erode. In 2012, former prime minister Stephen Harper’s Conservative government made major cuts to the Interim Federal Health Program, which covered refugees’ health care while they applied for status.

The cuts meant thousands of refugees struggled to pay for health care.

Migrants rights group No One Is Illegal and a local Latin American community group held community forums in Vancouver to discuss how to support migrants left behind by the cuts. Cruz said some of the doctors, nurses and outreach workers involved with the Bridge Clinic attended.

“Sanctuary Health was born from the forums,” Cruz said. “We decided to create a collective, and that collective quickly moved towards not just advocating, but also treating migrant workers without status.”

That’s how the informal network of health-care providers and advocates became a grassroots community group called Sanctuary Health.

At the same time, Cruz was also involved in a new initiative. The BC Multicultural Health Services Society started to organize pop-up care clinics for farm workers in the Fraser Valley and Abbotsford area. In the early 2010s, volunteer health-care workers would set up a clinic every week out of an RV in an Abbotsford Value Village parking lot.

Cruz said it was important for the society to build a clinic controlled by the community, instead of the health authorities. The mobile clinic turned into the Umbrella Multicultural Health Co-op, which opened in New Westminster in 2011.

“The idea was to create a co-operative model, so at least there will be some kind of barrier against the system taking over,” he said.

As Cruz organized both formal and informal health-care projects, a “sanctuary city” movement was burgeoning across Canada. In 2013, Toronto city council moved to become the country’s first city to allow undocumented residents to access municipal services like police, libraries and care facilities, without fear of immigration status checks.

Three years later, the City of Vancouver adopted its own “access without fear” policy, meaning all residents could access city services without fear of deportation or detention, regardless of immigration status.

Some hospitals started to follow suit. After meeting with Sanctuary Health, Fraser Health adopted a policy in 2016 that stopped health providers from contacting CBSA without patient permission.

Vancouver Coastal Health cut down on contacting CBSA after meeting with Sanctuary Health, but never adopted a formal policy. BC Women’s Hospital started accepting pregnant patients who were undocumented or migrant workers.

The Provincial Health Services Authority (the health authority that runs BC Women’s Hospital) does not have a formal “access without fear” policy, but provides care while protecting patient confidentiality, a spokesperson said in an email to The Tyee.

“Our priority is to provide health-care services and supports to patients who come to us in need,” the health authority spokesperson said. “A person’s ability to pay or their immigration status is not a consideration in providing emergency or immediately life-saving care.”

Meanwhile, Vancouver Coastal Health said in an emailed statement that its facilities offer care to everyone regardless of immigration status, and that it protects patient information “in accordance with provincial privacy legislation.”

“People who seek care in our region will receive the health services they need,” the statement said. “Emergency or life-saving treatment is never dependent on a person’s ability to pay or their immigration status.”

Access without fear

Despite the growing Access Without Fear movement, some migrants still feared being reported by hospitals. Cruz said he started connecting clients to the REACH Community Health Clinic in Vancouver.

Melinda Markey, executive director of the REACH Clinic, said the board has long supported caring for people regardless of immigration status. She estimates about 30 per cent of patients that come through the clinic are not covered by the BC Medical Services Plan.

“We believe in health for all,” she said. “The board has always said that people need to be able to seek care here without fear of being reported, and that someone’s immigration status is actually not relevant to that provider-to-patient relationship.”

She added it took many years of delivering care for the clinic to build trust with Sanctuary Health and other migrant communities. But now, Markey said, patients have come from as far as Prince George and Victoria to get care at the REACH clinic because they know it will be safe.

“We would love to see an ‘access without fear’ policy at all health providers from the respective health authorities,” Markey said. “That’s way less of a burden on an individual center to try to figure this out by ourselves, and then people can receive care in the communities where they are.”

REACH Clinic opened an urgent and primary care centre in 2020, allowing health practitioners to treat a total of more than 37,000 additional patients each year.

“The REACH Clinic became like a permanent clinic for the undocumented,” Cruz said. “The community already knows that they are safe going there, and that they will be seen.”

The Watari clinic in Vancouver also started helping undocumented migrants get treatment and support services in the mid-2010s. It became an explicit part of their mission in 2018, when Mendez took over as executive director.

With clinics and hospitals extending care to undocumented and documented migrants, Sanctuary Health’s role started to change again. The push for “access without fear” policies shifted the burden of care for migrant workers, refugees and undocumented people from a WhatsApp group chat onto clinics and hospitals.

The group moved away from delivering care and now focuses on advocacy and connecting people with clinics like REACH.

While Cruz is proud of Sanctuary Health’s victories, he says his fight is nowhere near over.

“I would like to tell you, for media purposes, that we are bigger now. But that’s not true,” Cruz said. “We got these services going, and we slowed down. But right now we need to reactivate those networks again.”

Carney government changes likely to hike number of undocumented migrants

On a rainy Friday last March, four outreach workers gathered in the Migrant Workers’ Centre’s office in the Downtown Eastside. They sat around a large square table, sharing carnitas from Don Jose in the International Village mall (a favourite of Spanish-speaking migrant workers who visit the centre).

Three were outreach workers with Sanctuary Health: Cruz, Alberto and Villada. The fourth was Juan Treviño, a legal advocate with the centre. The next weekend, they were planning to host a pop-up clinic in the office space, offering vaccinations and minor care for migrants regardless of immigration status.

The initiative marked a return to form for Cruz. Besides pop-up vaccination clinics during the COVID-19 pandemic, it had been years since Sanctuary Health had tried directly bringing health care to migrant workers.

“A percentage of the community still don’t have access to health care and are afraid of these services,” Cruz said.

Despite Vancouver’s commitment to its “access without fear” policy, people with precarious status are still often uneasy accessing health care.

According to Hugo Velazquez, director of family and settlement programs at the immigrant support organization MOSAIC, migrant workers still take their work permits to the hospital. He said Sanctuary Health is still a critical lifeline for thousands of immigrants in B.C.

“They’re crucial because we are working together towards promoting sanctuary cities, and they have a whole history,” Velazquez said.

“They laid a lot of work to make this happen, and they have a whole network of sanctuary services that could be available for a population that, unfortunately, is growing.”

Last year, the federal government capped immigration numbers, resulting in a 35 per cent reduction in new study permits and 20,000 fewer temporary foreign workers across the country.

At the end of March, the Strengthening Canada’s Immigration System and Borders Act was passed by Canadian Parliament, changing the requirements for refugees asylum claims.

Velazquez’s organization expects those policies will mean up to 1.6 million migrants will have their work or study permits expire this year.

“They might become people without status or undocumented in this country,” Velazquez said. “They will not have access to services, but they will still be here.”

Cruz says he’s wary of the sea change in immigration policy. He says Prime Minister Mark Carney’s Harper-style public service cuts remind him of the cuts that inspired Sanctuary Health’s inception nearly 15 years prior.

Starting in May, the Interim Federal Health Program, which covers health care for some refugees and asylum seekers, will also require co-payments for medicines and other supplementary services.

“All these new [laws] will increase deportations and eliminate work permits,” he said. “When that comes, we will be here, already having a plan, already telling people in construction and farms, ‘We are here for you’.”

For the first time in years, Canada Border Services has started the deportation process for a construction worker who went to a Surrey hospital this January looking for treatment. The man, Francisco Barahona, is still facing high medical bills and the threat of deportation.

The incident has disoriented Cruz.

“There was truly some change,” Cruz said. “We are not sure right now, after what happened with Francisco. I just don’t know.”

It also comes amid a wave of public sentiment against immigration in Canada. Prime Minister Carney’s tougher refugee and asylum policies come after two years of Liberal party cuts to immigration, reversing the party’s previous embrace of immigration.

At the Conservative Party of Canada convention this year, the majority of delegates endorsed a policy to crack down on deporting non-citizens who have committed serious offences. And 97 per cent of delegates called for tighter immigration policies.

In January, hundreds gathered in Toronto’s Nathan Phillips Square to protest immigration to Canada.

This backlash is happening against the backdrop of the United States government’s brutal crackdown on immigrants in cities like Minneapolis, Chicago and Los Angeles — and the growing use of what experts call concentration camps to jail increasing numbers of detained immigrants.

Cruz says he’s now trying to reactivate the network of doctors, nurses, midwives, doulas and other health-care providers that once offered migrants care off the books. He’s also passing on his role as the first point of contact for migrants in B.C. seeking care.

Alberto said she sees the sea change in immigration policies take its toll on migrant workers in Vancouver. She said many are mothers of her child’s schoolmates, who are struggling to have work permits renewed and considering leaving the country.

“I see the stress in their parents,” she said. “Many people will lose their status, so the need for support will increase for sure.”

Over the past 12 months, Villada and Alberto have volunteered their time to help Sanctuary Health continue its mission. Each now fields up to eight calls from migrant workers asking for help accessing health care each week.

For example, four hours before lunch that Friday, Villada spoke with a woman whose 10-month-old child was born in Canada, but was denied coverage under B.C.’s Medical Services Plan. The family is one of the dozens that have turned to the longtime outreach worker and doula for help.

“They trust me,” Villada said. “They know that I’m careful, and that I’m not going to send them somewhere that they’re going to be at risk.”

Meanwhile, Alberto has high hopes for the pop-up clinics. She said Sanctuary Health will start hosting the clinics once a month, and has plans to offer testing for sexually transmitted illnesses, sports massages to help injured workers recover, tetanus shots and cervical cancer screening.

She added she’s excited to be able to help mothers, workers and families the same way Sanctuary Health helped her.

“We are taking care of each other, because as migrants, we do not have family here,” Alberto said. “When you’re building these relationships, when you’re building this community that means taking care of each other.”

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