The night bus to Toronto’s North York General Hospital was nearly empty at two o’clock in the morning in September 2014, and Dan McLaughlin was nervous. He was on his way to receive an MRI so that doctors could diagnose a painful back injury, the result of years of hard labour, previous drug abuse, and sleeping on the streets. Procedures like this often happen before sunrise, and although the hour was early McLaughlin was relieved to finally be receiving medical attention for an ailment that was causing him increasing discomfort. The injury had gotten so bad that he was spending most of his time in bed.

“I could barely stand, barely walk,” he remembers. He spent one week using his computer chair to wheel himself around his rental house in Toronto’s east end so that he could do basic things like use the bathroom.

When McLaughlin arrived at the hospital he approached the receptionist in the waiting area, and she asked for his Ontario health card. McLaughlin had anticipated this, of course, and he knew his only option was to lie. He told the woman that he’d left his health card at home. “I need to do stuff like that to get by,” he explained.

In reality McLaughlin did not have a health card at all. He didn’t own a single valid piece of government identification.

For 15 years, McLaughlin had been trying tirelessly to prove to the Canadian government that he exists. He’d taken trips to Service Canada and ServiceOntario offices to get a social insurance document, a health card, a citizenship certificate. Even though he once owned those pieces of ID, nobody would give him any replacements. Each one of the receptionists, clerks, and officers McLaughlin spoke to told him he needed to show supplementary identification—a birth certificate, a social insurance card, a driver’s licence, a passport—before they could issue him new ID.

He went to his old elementary school to try to search for copies of his birth certificate, but the school no longer kept those records. He found two separate lawyers who agreed to advise him pro-bono on how to get identification, but neither of them were able to solve the problem. “The only thing they could get me were copies [of my documents], and copies aren’t good in Canada,” he says. One time, McLaughlin walked into police headquarters in downtown Toronto, where he knew his information was on file because he had a criminal record, and asked the officers to fingerprint him, take his photograph, and vouch for him as a Canadian citizen. “I’m in your system. You know who I am,” he pleaded. None of these tactics worked.

McLaughlin was stuck. He was living as a pseudo-citizen, a Canadian with no proof that he is one. He could not access welfare or health care without identification and most employers would not accept his social insurance number, or SIN, which he knew by heart, without the hard copy. He toyed with the idea of travelling to Scotland, his birthplace, to find a copy of his birth certificate—that is, until he realized he would be unable to leave Canada because he could not get a passport without identification.

His back problems were growing worse, and he was tired of relying on odd jobs for cash in lieu of a SIN card and a payroll position. He needed a piece of identification badly.

“Short of chaining myself to an embassy, I don’t know what else to do,” he says.

According to statistics from three Canadian advocacy projects—the Housing Help Centre, Partners for Access and Identification (PAID), and Street Health—McLaughlin is one of thousands of Canadians who are living without at least one piece of official identification. As a result, many live on the fringes, without access to doctors, employment, welfare, or other social security nets.

One woman is 84 years old and has not been able to get ID for more than 20 years. Another is pregnant and cannot access health care in Ontario because she does not have a provincial health card. In some cases parents do not register their children’s births in the first place, which makes identification especially difficult to obtain later in life.

Beyond the everyday frustrations that come from lacking the mobility, security, and autonomy that other Canadians enjoy, to live without any identification, any proof of belonging somewhere, is a form of citizenship that is unique in its invisibility. Not having ID can mean not feeling welcome in a place that is meant to be your own. “I’m a man without a country,” McLaughlin often mused.

Without the ID to get a job, travel, or get health care, McLaughlin felt trapped. “I can’t do any of the things most Canadians can do,” he said. “I want more out of life than this.”

***

McLaughlin is jovial, bearded, and missing the middle finger on his right hand from his days working as a handyman. Now 52, he has spent time as a landscaper, a carpenter, a plumber, and a mechanic. He came to Canada with his family when he was an infant; it quickly became his home.

McLaughlin’s youth was full of freedom and mischief. When he was 15 years old he travelled from Windsor to Detroit with a girl he loved using only his library card, which he says the border guard accepted as valid proof of identification.

In his early 20s, while hitchhiking northbound on the American west coast, a man offered him a drive and a job setting up fencing on a horse ranch in Oregon. It was there that he spent his days saddling up and riding horses along the perimeter of the property’s 4,000 acres, lying down and adjusting barbed wire as he rode the expansive boundaries of the ranch. After tiring from a full day’s work, he would tie up his horse to one of the fence posts and doze off on the grass underneath the bright stars of the Oregonian countryside until the sun came to wake him up in the morning.

But as he got older, McLaughlin found himself in some legal trouble. He keeps a nine-page list in his bedroom of his criminal convictions—including auto theft, robberies, and break-and-enters—that date back to the 1980s and finish in 2011.

He was first arrested when he was 16 years old, when he was managing the pinball machines at an arcade store in Richmond Hill, Ont. His family life was dysfunctional, and he was itching for change. His girlfriend at the time was from British Columbia, and she wanted to go back out west, so that is where the couple decided they would flee.

But first, the pair needed money to make the trip. McLaughlin broke into his family’s house in Toronto and stole a large aquarium that had a Plexiglas slot on top, which his parents put money into to save up for trips. He filled a pillowcase with cash, and on his way out the door he took his mother’s jewelry, including his grandma’s wedding ring, which had been given to his mom when she married his father. Altogether, McLaughlin and his girlfriend stole about $600, enough for three bus tickets to B.C.—one for him, one for his girlfriend, and one for her brother.

Shortly after McLaughlin arrived in B.C. he learned that his parents had a warrant issued for his arrest. A neighbour saw him and his girlfriend leaving the house with the loot. “The whole thing lasted about a week,” McLaughlin remembers. He returned to Ontario, turned himself in, and got probation.

Years after the robbery, in 1999 an explosion next door caused the family home to burn down. The only items saved from the flames were photo albums that had been wedged so tightly into bookshelves that the fire had no oxygen to destroy them. Original versions of McLaughlin’s birth certificate, citizenship card, and landing papers, which today would help him prove his identity, were incinerated.

After that, in a separate incident, McLaughlin’s wallet—which contained his driver’s licence, a photocopy of his birth certificate, and his health card— was stolen.

Even though McLaughlin filed taxes each year to the Canadian government and was audited by the Canada Revenue Agency last year, he had no luck getting any ID back.

“If you lose your driver’s licence, you still have a whole wallet full of ID. You can go into [the Ministry of Transportation] and say ‘I’ve got this this, this, and this,’” McLaughlin says. “But if you don’t have those starting pieces, you’re fucked. You’re me. You’re trapped in a country.”

Today, McLaughlin says he’s cleaned up his act, but he’s still stuck without ID. “They sent me to prison to reform, and to become a productive member of society, but I can’t do that without ID,” he says. “The only thing to my name is my criminal history.”

***

McLaughlin’s motivation to find identification came in months-long cycles, beginning with hope and ending in despondence. A fresh lead or a conversation with a friend would inspire him to find a way to get a health card or a citizenship card but inevitably, each time he tried, McLaughlin would hit a dead end, grow exasperated with the recurring rejection, and give up for months at a time—that is, until another friend, or another lead, picked up his hopes once again.

Many people in McLaughlin’s situation are even less lucky than he is. While little data on the matter is available, anecdotal evidence from social and ID workers suggests the issue is widespread. One ID clinic worker says he knows of at least 20 cases of people living in downtown Toronto who have no identification in their possession.

Many do not have the support systems or resources that McLaughlin enjoys, like a house that is rented to him by a local shelter for 30 percent of his monthly income, or a resumé with names on it like Ford and Texaco Express Lube and Car Wash, or a robust circle of friends and acquaintances. “I’m lucky that I have enough skills that I’ll be able to carry on and survive, but for someone who is not as confident as me, someone else could just get run right over,” McLaughlin says. “They’d be a nameless face.”

Without ID, McLaughlin got by with connections and luck. A friend of his, who is a nurse, was able to vouch for him so that he could access a doctor when his back acted up.

He often relied on his checkered past, too. He memorized his criminal barcode—491512B—the number that came up on the dashboard computer in police cars when cops stopped him and punched his information into their system—and recited much to the surprise of police officers, when they asked him to produce identification.

“How do you know your number?” they would ask.

“I’m just a barcode,” he responded.

By late 2015, McLaughlin had been living without formal ID for more than a decade—and that seemed unlikely to change any time soon.

***

The atmosphere in the dining area of a community centre on Toronto’s Queen Street East was chaotic late last December: music played from a small radio in the corner, while patrons sat at tables talking. Others appeared to be intoxicated, pacing around the room. Most were experiencing homelessness and using the day shelter as a refuge from the wintery outdoors.

Inside a small office sat Gaétan Héroux, a polite man with grey hair and a suitcase full of envelopes. By 1 p.m. he had already checked 17 people off on his list of appointments, and more still were trickling in to seek his help. This is one of his busiest stops on his daily route through Toronto.

As one of the city’s few identification workers, Héroux travels the city solving people’s identification-related problems—although he would tell you that ID is not the problem; rather, it’s the symptom. “The real problem,” he says, “is housing.”

Most people facing significant ID-related issues are homeless, or at least precariously housed, he says. In fact, when McLaughlin first lost his identification 16 years ago he was living on the streets too—he had been robbed of his wallet, which contained multiple ID cards, while he was taking a shower in a Toronto homeless shelter.

Many in Canada’s homeless population may have trouble holding onto their identification because they do not have a safe place to put their ID. To combat this, some homeless shelters and advocacy projects installed “ID safes”— cubbies or drawers for people to store their ID until they need it again. One man, for example, who deals with mental health challenges and lives on the street, visited Héroux’s office to replace a health card that he lost just one day after he took it out of an ID safe.

Even for low-income individuals who do have housing, renewing lost identification can be difficult and costly. Depending on the province, some identification cards can cost up to $75, while a five-year passport will cost upwards of $120.

“If you have the necessary financial means, it’s not really an issue,” says Mary Ann Proulx, who helped develop an ID clinic in York Region, Ont., to assist people living without identification.

One of Proulx’s toughest cases was a three-year-old girl whose birth was never registered by her parents. The girl’s mother later passed away, and her father had been in a severe accident when her stepmother approached Proulx for help.

“It was unclear whether the dad was going to live,” she said. The stepmother needed to get the girl’s birth registered so that the family could access tax credits and benefits that would help them during the crisis.

After weeks tracking down and getting a hold of the appropriate documents, Proulx went to the hospital where the girl’s father was staying so he could sign her birth certificate.

But that’s a best-case scenario for those in this predicament. “There were some cases where I could not get ID for them at all,” Proulx says.

Meanwhile, in December 2016, Proulx’s clinic closed its doors when York Region chose not to renew its annual funding.

The government, it seems, can do little to help. In an email statement, Citizenship and Immigration Canada, the government body that replaces citizenship cards in Canada, wrote: “If an individual would like to replace their citizenship certificate, they must fill out the application form and provide necessary documentation to prove their identity. If their previous card or certificate was lost, stolen or destroyed, the applicant must provide details such as when, where and how this occurred.” (The department declined a phone interview for further questioning.)

In the United States, the situation is not much different. On a cold Philadelphia morning last November, 74-yearold Chip Delany found himself standing in a line of about 50 people waiting to sort out identification-related issues— similar to the ones McLaughlin faces here in Canada.

“It’s blowy, and my nose is running,” Delany said on the phone as he waited outside the ID office. He was hoping to get identification for his partner, Dennis Rickett, who had been without it for 27 years. Rickett himself had grown so frustrated searching for proof of his own citizenship that he left the task entirely to Delany, who worried that, if he were ever to die, he would be leaving his partner to fend for himself without identification, and without a way to provide himself with shelter, care, or basic income.

“You can’t do anything, you can’t have a bank account or insurance if you don’t have ID,” Delany says. “I’m dealing with this practically every day and it’s very depressing. Nothing seems to work,” he says.

“The whole thing is just a nightmare of a catch-22.”

***

On November 9, 2015, McLaughlin waited in a crowded room at a ServiceOntario office in Toronto’s east end, holding a signed letter vouching for him from the ID clinic and the certified copy of his landed immigrant document—a piece of identification a parole officer was able to dig up for him years ago upon his release from prison, but that proved to be useless before.

“I really don’t think this is going to work,” McLaughlin says, beginning to feel hopeless. “Maybe we should just get out of here.”

His friend, who drove him to the offices in a Zipcar, urged him to stay, and then McLaughlin’s number was called.

McLaughlin walked up to the counter to begin to plead his case. He knew this part well: He would go up, tell them that he does not have supporting documents other than a copy of his landed immigrant document, try to negotiate, and then the person behind the counter would deny him.

“I’m not sure you’re going to be able to help me,” he told them, already growing weary.

The man behind the counter looked at McLaughlin, looked at the small piece of paper, furrowed his brow, and began punching information into his computer.

Then, moments later, much to McLaughlin’s surprise, he walked out with a health card. It was a specific date, inked in fine print on the copy of his landed immigrant document, that did the trick, falling within a range that was deemed acceptable to prove identity.

“Often it just depends on the bureaucrat you get,” explains Héroux. “This is the world of ID. You’ve got to negotiate.”

McLaughlin was thrilled, phoning and texting friends, and setting up appointments to get his back checked out by a medical professional. This small piece of recognition of his existence gave him not only access to health care but also, perhaps just as importantly, validation that he belongs here. In our current system, a piece of paper can dictate how we feel about our place in society.

McLaughlin was able to get his back pain diagnosed—a herniated disc—and is now deciding on treatment options. An Ontario health card is just a small step on McLaughlin’s journey. He learned quickly that it could not act as supporting ID for a social insurance card and he still needs a steady job, so the journey is not yet over.

“It’s just a start,” he said. “If I hadn’t gotten that health card that day, I would have given up.”

When the new study guide for immigrants applying for Canadian citizenship was published last November, a reporter asked Citizenship and Immigration Minister Jason Kenney why there was no mention of Canada’s world-leading (but still-in-progress!) record on equal rights for gay and lesbian people. Here’s what Kenney said:

“We can’t mention every legal decision, every policy of the government of Canada.” […] “We try to be inclusive and include a summary. I can tell you that if you were to read the old book, you wouldn’t even know that there are gay and lesbian Canadians.”

You understand, of course: in a 63-page guide that explains why there’s a beaver on the nickel and the origins of the Grey Cup, it was simply too crowded to work in any mention of a landmark Canadian freedom that almost no other country on earth has implemented.

But the truth will, uh, out, and in this case, the Canadan Press reported yesterday that the original draft of the guide included three references Canada’s gay-rights record: the 1969 “out of the bedroom” law; the Charter barring discrimination based on sexual orientation; and the legalization of same-sex marriage in 2005. All three  found themselves at the business end of Minister Kenney’s red pen.

But Mr. Kenney, who fought same-sex marriage when it was debated in Parliament, ordered those key sections removed when his office sent its comments to the department last June.

Senior department officials duly cut out the material — but made a last-ditch plea with Mr. Kenney in early August to have it reinstated.

The compromised second draft strikes again. Adding insult to injury — or maybe coverup to crime — it also appears that after national LGBT lobbyist Egale inquired about the no-homo study guide last fall, Kenney told them their concerns were simply “overlooked.” Surprise! Not the case.

So, welcome to Canada, where we have one constitutional monarch, two official languages, and you only get three downs. But just in the interest of truth in advertising: if you want an all-hetero paradise, you’ve got other options.

After the jump, a video from Current.com explaining the “no-homo” phenomenon.

Sure, the web is rife with nonsense. But real political dialogue thrives too

In my more idealistic moments, I always imagine I’ll stumble upon raging intellectual debate on the subway. But based on the conversations I’ve overheard lately, here’s what I can tell you about the public mood in Canada: saving GM is both the best and worst thing we’ve ever done; Lady Gaga “sucks”; and, at least according to that one guy, “this sandwich is delicious!”

Gauging the opinions and temper of a society has always been a rough enterprise at best: part statistics, part science — and part overhearing things on the train. But when we start to record our reactions in a public space that makes overhearing things easer — like the web — discovering what people are thinking becomes far easier. And with the rise of what you might call the “real-time web,” capturing and then becoming part of “the public conversation” is no longer metaphor so much as it is reality.

And yet, the real-time web has got itself a bad rap. You’ll hear it when people grumble about sites like Twitter and Facebook, which revolve around a constantly-updating stream of short-form musings from peers and complete strangers. The standard complaint about these new sites is that they’re full of details along the lines of “Going out to the store now!” The truth, however, is that people tend to post what they’re thinking as much as what they’re doing. Sure, taken individually, it’s just some person recording their thoughts. But when you put all of them together, instead of only inane chatter, you also have a living record of people’s ideas and conversations.

In fact, the real-time web is opening up possibilities for both documenting and understanding the public mind. With realtime search engines, such as the one now built into Twitter, one can also instantly wade through the torrents of chatter to find up-tothe minute takes on a specific topic. Some searches, like typing in the name of a nearby restaurant to see what people think of it, can be straightforward. Search by locale, and you might get a sense of what locals think of the weather, their latte or local politics — an experience web thinker Leisa Reichelt charmingly labelled “ambient intimacy”: a vague sense of others that hovers quietly in the background.

While these chirpings can at times be pleasantly mundane, at others they can be more serious thoughts on politics and ideas. And if one of the ideals of democracy is healthy public debate, the real-time web expands the reach of this conversation while it focuses it, providing quick feedback and a variety of perspectives you may not have gotten before. Technology can often be isolating and alienating, but this, it seems, is not one of those times. Sites like these do a great deal to connect, rather than separate us, from the ebb and flow of social conversation.

Yet, just like overhearing chatter on the subway, sometimes we hear things we’d rather not. The recent protests by Tamil-Canadians in Toronto produced a storm of opinion on Twitter, some of it ugly and xenophobic. The effect of reading so much collected, subtly racist bile was disturbing and unsettling. Ambient intimacy can quickly turn into a threatening sense of alienation when voices you wish you never heard sit side-by-side with your friends’ in the public register. For all the times sites like Twitter make us feel part of something, moments such as the Tamil protests highlight the limits of this new, immediate web.

The problem is, there is only so much depth one can fit into a couple of sentences. In order for a conversation to happen in realtime, it has to be composed of short, pithy statements that lend themselves to being read quickly. We might dream of a world in which lengthy, measured response is the norm, but it’s undeniably easier for someone to say “immigrants go home!” than “hey guys, we really need to think about whether we should reformulate our concept of national identity to deal with the reality of our shrunken, globalized world.” The downside to all this immediacy is that polemics frequently trump profundity.

But all media have their constraints: you wouldn’t read a novel in a newspaper just as you wouldn’t go to the cinema to watch a sitcom; the point is to have each form of communication do what it does best. Though the real-time web certainly encourages a sort of flippancy, it also gets people talking in a way they might not have before, making public conversation broader, more immediate, and ultimately more rewarding than merely nodding after reading a newspaper column or fuming after watching a spot on the news. And if an ideal democracy involves an engaged, excited populace, spouting opinions while they argue and debate, then maybe, for the sake of the living out our democratic ideals, we can occasionally put up with what that guy down the street thinks of his sandwich.

Nurse Jennifer D'Andrade and Dr. Paul Caulford consult with patients at the volunteer clinic in Scarborough. Photos by Arantxa Cedillo.

Dr. Paul Caulford will never forget what happened to Patricia. An 18-year-old girl from Grenada, she had an athletic build, black skin, and black hair cropped at her ears. She had come to Toronto at the age of 15 and her father had applied to sponsor her, but the family split up and Patricia’s father let the sponsorship drop. She had no immigration status, no health-care insurance, and peculiar blood. Patricia had sickle-cell anemia, a condition that’s particularly common among people of African descent. In places where malaria is prevalent, those with sickle-cell anemia were evolutionarily preferred because their blood was too hostile for malaria to survive. But it can also be deadly. When Patricia’s blood cells don’t get enough oxygen, they morph from their regular sphere shape into what look like crescent moons and clog up her smallest blood vessels.

Caulford explains how Patricia had gone to a clinic in extreme pain and the doctor had sent her to the emergency room. She was having a sickle-cell crisis. At the hospital, she was told she’d have to pay at least $350 before seeing a doctor because she didn’t have health insurance. But she didn’t have the money either. Patricia decided to stay anyway, and sat in the emergency room, writhing in pain, until she fell unconscious. Only then was she admitted and given an IV. She spent days in the hospital recovering and racked up a bill in the thousands.

Patricia’s was one of the many stories shared over meals by a group that included Caulford, the chief of family medicine at the Scarborough Hospital at that time, Yasmin Vali, the hospital’s director of community and patient relations, and Jennifer D’Andrade and Cathy Tersigni, two public health nurses working in shelters and with the homeless. Their dinner meetings turned into planning sessions and resulted in Canada’s only volunteer clinic exclusively — and openly — serving the uninsured.

Citizenship and Immigration Canada plans to accept as many as 265,000 new immigrants in 2009, most of whom will settle in Toronto, Vancouver, and Montreal. Those immigrants will spend their first three months without public health care insurance. There are a further estimated 100,000 to 300,000 undocumented workers living in Canada without health-care insurance. Some come as temporary workers, or as visitors, and simply never leave. Others apply for refugee status and remain in the country even if they’re not accepted. Many have an “implied” right to be in the country because they’re applying for certain types of status, or they’re between permits. They are halfway legal, halfway not. They work, have families, buy food and clothing. They go to school, go on dates, fall in love, break up. But if they get sick, they can’t go to the hospital unless they pay up front. Or they can go without money — as long as it’s an emergency — and wait for the bill in the mail.

An accident, a sickness, or a pregnancy can leave an uninsured person with a debt they might never be able to pay off. Just one night in a hospital costs around $1,800. In intensive care it’s around $2,300 or more, depending on the treatment needed and on the hospital. For patients without much money, even a comparatively low cost — $350 up front in the emergency room, for example — can be too much. Vali remembers one man who was paying his debt to a Toronto hospital in installments of $5, every two weeks. It was all he could afford. There are a few clinics in Canada’s “big three” immigrant destination cities that see uninsured patients for free, but they are just stopgaps for a growing problem that needs a sustainable solution. The health-care community is beginning to realize it needs to make more room for these halfway people — halfway between the life they’ve left behind, yet not entirely accepted into the new one they’ve chosen.

Patients waiting for consultations in the Scarborough clinic. Photos by Arantxa Cedillo

“The problem was screaming at us,” says Caulford. In Canada, where everyone supposedly has a provincial health care card, the hospitals didn’t know what to do with people without one. Caulford had heard of many people not getting help, even in real emergencies such as broken bones, asthma, and appendicitis.

Caulford sits in a conference room at a large wooden table, donated by one of the clinic’s many supporters, with a pile of patient files in front of him. He’s volunteering here tonight and loves talking about the clinic that comes to life Tuesday and Thursday evenings, welcoming people living in Scarborough without health-care cards. The clinic opened in 2000, inspired by stories like Patricia’s. Patients arrive and sign in at the reception with Debby James, a social worker whose dark, rounded face beams with energy. When it’s their turn, the patients make their way down a narrow corridor, passing a small lounge, a washroom, three examining rooms, and a nurse’s room before arriving at the conference room, everything coated in pale-blue paint. They spend some time in the conference room speaking with D’Andrade before being guided into one of the examining rooms to wait for a doctor. A group of about 12 volunteer doctors rotate shifts to treat patients and train medical residents and foreign-trained doctors who are working to re-certify in Canada. But the clinic wasn’t always like it is today. It started with Caulford looking for doctors and Tersigni and D’Andrade for space. They recruited doctors willing to volunteer their time and found free space in a community centre and in a church basement, next to clothing boxes and decorations for the Christmas pageant. They brought medications, needles, and syringes to the sites in tackle boxes that Caulford bought at Canadian Tire. (He impressed a cashier who said, “Wow, you really like fishing! How much tackle do you have?”) At night, after seeing each patient and keeping the file for follow-up, they were often left with throat swabs, urine, and sometimes feces samples that had to be brought to the lab the next day. They would bring them home and keep them in their fridge overnight — much to the disgust of their families. Tersigni took to hiding the samples from her husband in a paper bag.

It would take Tersigni and D’Andrade about seven trips to transport all of the supplies from their cars to the MASH-type units. And because the two nurses alternated nights, they would meet sometime between Tuesday and Thursday evening to make “the switch”: they would park their cars at the side of the road and haul all of the tackle boxes and equipment from one car to the other.

They helped a lot of patients and put in long hours, but it still felt like second-rate care. “You don’t do pap smears very well in a church basement,” says Caulford. He has a friendly demeanour, and it’s easy to see how he could put even a nervous non-status immigrant at ease. He feels strongly that uninsured people should get the same level of care as everyone else, so although he was optimistic about the clinic they had put together, he worried that it wasn’t enough. “Why would it be second-rate or third-rate?”

Although the Scarborough clinic is the only clinic in Canada set up exclusively for the uninsured, there are other clinics that accept patients without coverage — but they try to keep that fact under wraps. Dr. Cécile Rousseau, a research and clinical psychiatrist at McGill University, collaborated with a team who surveyed healthcare professionals and community workers in Montreal, asking how they deal with uninsured patients. She says some clinics keep tightlipped about treating these patients because doing so is outside their mandates and they don’t want to be inundated with visits. Other clinics don’t want to draw attention for fear of their patients being targeted by immigration authorities.

Vancouver’s Bridge Clinic serves refugees and refugee claimants who get basic coverage under the Interim Federal Health Program and also has some prenatal programs for uninsured women. But it’s not enough to cover the large and growing needs of the uninsured population.

“We can’t. It’s not our mandate,” says Shirley Alvarez, the clinic’s social worker, “The clinic would be closed if we don’t follow our mandate.” Although they make some exceptions, Alvarez admits that it just scratches the surface.

“There is a need, but right now we don’t have anything to support this need,” she says.

There’s no data available in Canada that exposes the health effects of living without insurance, but research from the United States shows that a lack of insurance leads to lower-quality medical care and a higher incidence of disease. As the number of uninsured people in Canada increases, it’s getting even harder for them to access care. “There has been some tightening of the rules,” says Rousseau. “When it’s just a few people, it’s very easy to take a social and human rights approach and say, ÔOh, we’ll do it anyway.’ But when it becomes a big load on the finances of the hospital, it becomes more difficult.” She says that the first reaction has been for hospitals and clinics to close their doors to the uninsured: there are posters up in some Montreal hospitals warning people who don’t have coverage that they will have to pay. But she thinks more and more people within the health-care community are trying to work together to find solutions and to give care to everyone who needs it.

“show me where the pain is,” says Caulford to his 29-year-old patient. Alberto is standing shyly in the pale blue examining room, wearing black jeans faded in the front, a brown sweatshirt and a Budweiser baseball cap.

“It’s in my lower back. And all the way down here.” He points to his knees. “I feel, like, tingly. My legs are tingly, numb sometimes,” he says softly, with a slight Latino accent. His thin moustache and trace of a beard frame his thick lips. Caulford looks at his chart and breathes out slowly. He knows this is not just muscular pain. It’s more serious and it’s going to take a while to heal.

Alberto’s from El Salvador, the small Central American country where over a decade of civil war between guerrilla fighters and paramilitaries left a generation that grew up knowing nothing but fighting and a place where unemployed youth are often drawn into crime and violence. Alberto fled to the United States and had been living in Maryland for the last two years, working as a forklift driver in a warehouse. When an agent told him he could get a job with the same company in Toronto, where his uncle lives, he paid the agent $500 to get him across the border. He didn’t get the job. He’s been working with his uncle, who is a carpenter, but now he’s in too much pain. He doesn’t have any legal status in Canada so he’s trying to live under the radar.

“Can you stand up?” Caulford stands behind Alberto. “Just bend forward for me.”

“What? Down?” says Alberto, giving a nervous laugh and appearing embarrassed with a female resident doctor in the room. He does as the doctor says, but he can barely bend down before the pain shoots through his back.

“I think you’ve injured your disc,” Caulford tells Alberto. He draws a picture of a spine with its discs and vertebrae on the white paper sheet that covers the examining bed. He explains that there’s no magical cure for this, only medicine to take away the pain. “Avoid bending over, avoid lifting anything heavy, at least for the next three or four weeks, to let this disc heal.” He steps out to get Alberto some pain medication.

In a room across the hall, Adeola, a Nigerian woman in her 40s, is sitting with one of her legs stretched out across the examining bed. She’s wearing a brown toque and a beige-and-white-striped sweater. Her denim pant leg is rolled up and a bandage hangs open, revealing an oozing ulcer on the side of her calf. She came to the clinic for the first time last week and has just been diagnosed with diabetes. In Nigeria, Adeola was a teacher and her husband a civil engineer. Their children were all in school. They applied to Canada as landed immigrants and were accepted. “I wasn’t keen on leaving,” she says in her calm and good-humoured manner. It was her husband’s idea to emigrate.

Adeola and her family, like all permanent residents who settle in Ontario, British Columbia, Quebec, or New Brunswick, have to wait three months before getting access to public health insurance. When her ulcer first started bothering her, Adeola saw a doctor at a walkin clinic. “I had to pay for the consultation,” she says, “but he didn’t treat the wound.” She paid $100 to open a file and $30 for the consultation. But she didn’t go back, nor did she find out about her diabetes. She’s worried. Both she and her husband are having trouble finding jobs — they have no Canadian experience — and her diabetes is out of control.

The clinic is a crossroads of migrants, all arriving in different ways, but all uninsured. Unlike Alberto, who snuck into the country, Adeola and her family came as permanent residents, papers in hand. |But they’re both without public health-care insurance and have found their way to the Scarborough volunteer clinic for the uninsured. The three-month wait period for new immigrants (and for Canadians returning to the country after long stints abroad) has been in place in British Columbia for decades. In the early 1990s, Ontario and New Brunswick adopted it, with Quebec following suit at the start of the millennium. It’s supposed to prevent people from abusing our universal health-care system, but critics argue that it winds up hurting one of Canada’s most vulnerable groups. Although new immigrants are encouraged to get private insurance, they’re often not told until they arrive in the country, and at that point, many are more worried about finding a place to live, buying winter coats, and going grocery shopping than paying for private insurance, something many people didn’t have in the countries they left. Plus, private insurance doesn’t cover pre-existing conditions, so if newcomers have heart problems or diabetes, they’ll often have to pay out of pocket. Most new immigrants will be fine and won’t need any medical care for those months. Others aren’t so lucky.

Rachel Heap-Lalonde, a member of the Health Care for All Coalition in Montreal and a community worker at Project Genesis, a social justice organization, has met some of the unlucky ones. She tells of a Mexican immigrant who was hit with a debt of more than $18,000 when his 13-year-old daughter was hospitalized for appendicitis in 2003. Another couple, whose three-year-old daughter started feeling sick just days after they had arrived from Morocco, waited over a week before taking her to the hospital. The young girl ended up in intensive care with a ruptured appendix and the family was billed for over $29,000 (although the bill was later reduced to just over $18,000). In 2007, a seven-year-old boy, whose family had recently arrived from Algeria, took a nasty fall in the playground that landed him in an intensive care unit with a ruptured liver. He recovered, but his family received a $63,000 bill in the mail. Heap-Lalonde argues that huge debts can make integrating that much harder: “It might only be three months when you come, but those three months can follow you forever.”

Even the Scarborough clinic isn’t able to do much when it comes to those types of bills. Although patients referred through the clinic get a discounted price at the Scarborough Hospital, they still need to cover the cost of their hospital care. The clinic can only cover things like blood tests, throat swabs and some diagnostic tests, but if a patient needs surgery, that’s another story.

Coalitions such as Health Care for All in Montreal and Right to Health Care in Toronto are pressuring their provincial governments to do away with the three-month wait period. The governments’ response has been that the measure is necessary to avoid abuse of the system and to harmonize rules among provinces. There are some exceptions to the rules, like the decision by the Quebec government to cover care for victims of domestic abuse, sexual assault, prenatal care and deliveries, and some infectious diseases during the three-month wait period (services that are not covered automatically in the other provinces). But the ministries of health in all four provinces with the wait period say there are no plans to eliminate it any time soon.

Besides new immigrants, many temporary workers also have to wait three months for coverage. In addition, workers such as livein caregivers often go through several stints without health insurance. Because their permits are tied to the employer, if they are laid off or an elderly client passes away, they lose their work permit and have to reapply, leaving them uncovered until they get a new job and a new permit. Workers given temporary permits for less than six months — which sometimes happens in the case of live-in caregivers — are generally not eligible for public health insurance. As the number of temporary workers accepted into the country increases, the number of people with precarious insurance coverage will likely grow as well.

Refugees and refugee claimants are covered under the Interim Federal Health Program, which gives them a basic level of care. But when some claimants are denied, they stay in the country anyway, trying to keep out of sight and not get sick. Or they’ll apply to stay on “humanitarian and compassionate grounds”: that is, after the time they spent working here, they consider Canada their home and want to stay permanently. In the meantime, they’re uninsured. Others come to the country on a visitor visa and apply to be sponsored by a family member. While awaiting an answer, which can take over a year, they fall into legal limbo, in which the government knows they’re here but because they’re not really allowed, they don’t get health-care coverage. Then there are those who haven’t applied for anything; they’re just trying to get by and not make too much noise.

The fear of mammoth hospital bills, or of getting caught by immigration authorities, can dissuade people from getting help when they need it. Rousseau has heard of kids staying home with appendicitis, and of pregnant women trying to deliver their babies at home without medical help. Dr. Jacques Ramsay, a coroner in Montreal, thinks migration status has been a contributing factor in several deaths over the past few years. One Korean man, who died of a preventable heart condition, had lived in the country with his two children for less than a year. He had a visitor’s visa and had been in pain for weeks prior to his death. “He didn’t have insurance, so he didn’t go get help,” says Ramsay. When people are afraid of going to the hospital, or seeing a doctor, small problems can suddenly become fatal.

A stout, round man in a black baseball cap, red golf shirt, and jeans walks down the hall carrying a container wrapped in paper towel that’s a little wet. D’Andrade tries to introduce him to me; the man goes to put out his hand, then changes his mind and gives a nervous smile. “Steve’s got his urine with him, so go ahead, Steve!” says D’Andrade, laughing playfully.

Steve sits down in the conference room. He has a slight moustache and tanned skin. His hands are rough and weathered from years of manual labour. For eight months of every year since 1988, Steve has worked on farms in Ontario through the government’s Seasonal Agricultural Worker Program. He planted and harvested onions, carrots, celery, potatoes, lettuce, and more. “I can work from nursery to harvest,” he tells me proudly. He’s even worked on a flower farm. “I can’t remember all the names of the flowers, though,” he says with a laugh.

Back in Trinidad, Steve worked on sugar cane and rice paddies, but it wasn’t the same as working here. “Here it’s extensive mechanization. You have plots of 100 or 200 acres,” he says. “I can work all farm equipment, combines, tractors — I know it very well.” He describes working on farms with enthusiasm and says he loves Canada and has learned a lot here. So much so that in 2003 he decided to stay. His wife and sons came to meet him, but soon after, the family broke up. His wife’s sister, who lives in Toronto, helped his wife and their children apply for permanent residence status while Steve was away working on a farm. He still doesn’t have legal status here.

Steve works on the farms in the summer and in construction the rest of the year. Often he’s paid in cash, but says he uses his social insurance number whenever employers ask. “I didn’t get enough money to start an application,” he says. To apply to be a permanent resident costs more than $1,000. It also requires a lot of paperwork — not Steve’s forté.

Two years ago, he started to feel pain in his stomach and had blood in his urine. He stands up and shows me a scar down the left side of his ample belly. He had surgery last spring to take out the stones that were lodged in his kidney, blocking the urine from flowing through to the bladder. “They were rock hard,” says D’Andrade, making a fist to demonstrate. He spent five days in hospital and racked up a $4,000 bill that he’s been paying off monthly.

The wound became infected. It swelled and had to be drained of all the pus and blood that had built up. Although the clinic only ran twice a week, D’Andrade and Tersigni made sure he had it looked at every single day, often going to his apartment on the weekend to change his dressing. It finally healed in August and Steve went to work on the farm until November. He’s not eligible for disability insurance even though he’s been working here for the better part of 20 years. Now the pain on the other side of his belly is becoming unbearable and he’s scared. He doesn’t know how he’s going to survive another summer without working.

Caulford has seen a lot over the years: tuberculosis, cancer, a host of terminal diseases, and even a seven-year-old boy whose ribs had fused to his hip following a Pakistani schoolyard fight involving grenades and Molotov cocktails. You never know what you’re going to see next. But the clinic’s not a depressing place. It’s full of life, of camaraderie and selflessness. And people from all over want to share their stories, or talk about the children they’ve left in their home countries, or the ones they’ve brought to the clinic. There are colouring books and crayons. Nobody looks dangerous. No one looks “illegal.”

Among the certificates, awards, and family pictures in Caulford’s office is a painting of a boat docked in a picturesque harbour. It’s a gift, given to him by the artist, a father who immigrated to Canada a few years ago with his pregnant wife and two kids. The family had come to the uninsured clinic while under the three-month waiting period. Now he works as an accountant and his family has adapted well to life in Canada.

“You pick up the paper and you read, ÔImmigrants cause TB,'” says Caulford, annoyed at a newspaper headline. “These people enrich our lives so much — they’re not just bringing TB!” Adeola comes in for her checkup. She stops outside the reception area where James, the social worker, is sorting through the canned food on a shelf that’s available for anyone who might need it. Chunky New England Clam Chowder, Campbell’s tomato soup, and Ocean’s sockeye salmon wait in stacked cans.

“I found a job,” says Adeola quietly. She’ll be taking care of autistic children. It’s through an agency. Her husband hasn’t found anything yet, but it’s a start.

The following week, the results of Steve’s blood test came in. On top of his kidney stones ordeal, he’s just been diagnosed with diabetes.

“What’ve you been doing? Eating sugar all week?” jokes Caulford as he passes Steve and one of the nurses who are sitting in the conference room looking through a pile of flyers on diabetes. Steve smiles nervously.

In Montreal, Heap-Lalonde of the Health Care for All Coalition has gotten word that the Algerian family would no longer have to pay the $63,000 debt. It was a sigh of relief for the family after more than a year with the bill hanging over their heads — and a wave of hope for the health-care and community workers who oppose the three-month wait period. And there have been other pardons such as this one, where ministers have erased hospital debts, realizing the hardship they cause and the inability of people to pay. But just like the ad-hoc clinics across the country that help uninsured patients, the pardons are unpredictable and irregular. Meanwhile, hundreds of thousands of people living in Canada spend time without healthcare insurance, and if they get sick or have a serious accident, they could be left destitute, or worse.

If we want to keep calling our health-care system “universal,” we need to make a place for these “halfway people” and not keep giving them only half the care they need. Although he’s passionate about the clinic for the uninsured, Caulford would like to see a fundamental change. He’d like to see health-care insurance for everyone living in the country, no matter who they are or how long they’ve been here. As for the clinic, he says, “We’d love a sunset clause. We’d like to put ourselves out of business.”

Names of patients have been changed

On April 17, thousands of “Lost Canadians” will finally have the opportunity to claim their longdenied Canadian citizenship, thanks to Bill C-37. Intended to restore citizenship to those stripped of their nationality without their consent or often even their knowledge, Bill C-37 will also rectify what some see as a violation of their human rights.

A Lost Canadian is an individual who was born in this country between 1947 and 1977, but automatically lost Canuck status when his or her father became a citizen of another country. Others who will benefit from Bill C-37 include certain war brides and babies, those born to Canadian parents outside the country, and those who had an illegitimate grandparent or even great-grandparent. In all, Bill C37 should enable nine categories of people to reclaim their status.

These problems stem from the Canadian Citizenship Act of 1947. By today’s standards, many of its provisions seem blatantly discriminatory. Ottawa modernized the act in 1977, but the changes were not made retroactive, as they were in many other countries that had updated these laws.

No wonder Don Chapman, the man who spearheaded the drive for change, thinks the latest amendments are long overdue. “For a country that espouses human rights around the world, Canada has been all too ready to disenfranchise its own citizens,” he says.

Chapman, who coined the term Lost Canadians, knows this first-hand. Born in Vancouver in 1954, he moved with his parents as a child to the U.S. where they became naturalized Americans in 1961. He remained proud of his ancestral roots and as an adult applied for a Canadian passport, a request that was denied.

Soon Chapman was buttonholing anyone he thought could help him. Media coverage and his website led to other Lost Canadians contacting him, and what began as a personal quest soon morphed into a full-fledged campaign to rewrite the law. The lobbying paid off when Bill C-37 received royal assent on April 16, 2008.

Now Chapman is anxiously waiting to see whether Parliament’s act has the desired results. Repeating a prevalent concern among Lost Canadians, he explains, “Just because a bill becomes law doesn’t mean they have to process our applications.”