The Cultural Politics of Health for All: A Pragmatic and Uncertain Path to Access in Toronto, a Sanctuary-City

By Professor Patricia Landolt
 
Making the case for Health for All requires a powerful and irrefutable storyline. This is the work of cultural politics. In Canada, the cultural narratives mobilized to extend access to healthcare for precarious legal status migrants are ambiguous. They help secure short-term and strategic gains, but they fall back on liberal nationalism to make the case, obscuring the essential links between human rights, mobility rights, and healthcare access.

Globally, pathways and access to citizenship are increasingly restricted. The human rights of ‘people on the move and out of place’ have been eroded. In Canada, this takes the form of a two-track, two-step immigration system that prioritizes temporary migration. The immigration system also continually produces people out-of-status. All temporary migrants have precarious legal status. They are deportable and there are legal limits set on their access to work, healthcare, and education.
 
Mapping Cultural Narratives of Access
Access to healthcare for precarious legal status migrants is a battleground in the fight for human rights and mobility rights. I interviewed Health for All advocates in Toronto to understand the cultural narratives of healthcare access.

Frontline healthcare workers juggle three narratives of access:

• Legal status-blind narratives that portray precarious noncitizens as members of a ‘high-risk’ population with “equal vulnerability and need as the homeless;”
• Legal status seen as a formal obstacle to healthcare access; and,
• Immigration status interpreted as a social determinant of health that intersects with and compounds other vulnerabilities, including poverty and precarious work.

Healthcare managers prioritize risk management and fiscal efficiency. They emphasize preventive healthcare as a cornerstone of the medical system. Access ensures migrants will not wait till a health need turns into a costly medical emergency.

Policy-change advocates focus on legal and human rights. They make value-laden links between the International Covenant on Economic, Social and Cultural Rights, the Canada Health Act, and the 1982 Canadian Charter of Rights and Freedoms. Advocates deploy these narratives in variable combinations to advance their agenda.

Community health workers find procedural wiggle room in existing regulations, stretching eligibility criteria for specific groups. Resource limitations and partnerships with hospitals impose access restrictions based on categories of immigration status. This usually means no visitors or international students. Time in Canada and vague ideas about a migrant’s ‘intention to stay’ become the discretionary filters for health access.

Policy work tends to be strategic and opportunistic, focusing on winnable issues that align with other drivers of the health care system. It prioritizes the extension of health insurance to citizens-in-waiting and leaves other categories of temporary migrants out.

On the frontlines, in hospital and clinic management, and in policy-work, the cultural politics of healthcare access fall back on a normative attachment to Canadian citizenship—as likelihood or ideal. This sets limits on how migration is understood, migrants are imagined, and health deservingness is practiced, resulting in the erosion of the links between Health for All, human rights, and mobility rights.
 
Patricia Landolt
Professor of Sociology
University of Toronto