The Healthcare Divide – Episode 5

Filipino migrants make up a critical portion of Canada’s healthcare workforce, as nurses and care aides. They also have one of the lowest average employment incomes among groups designated as visible minorities. 

Conditions such as low wages and precarious migrant status were exacerbated by the COVID-19 pandemic. We examine what that crisis revealed about labour in Canada’s healthcare system.

Dolie Anne Bulalakaw, assisted living worker

Valerie Damasco, assistant professor of sociology at Trent University.

Ethel Tungohan, associate professor of politics at York University

The Healthcare Divide

Episode 5 – Front and Centre: Filipino Healthcare Workers and COVID

Dolie Ann Bulalakaw Every day your life is at risk. Every day that time you keep on thinking about it. I don’t know if I can. Is this worth it?

Dr. Alika Lafontaine Canada’s healthcare system should provide equal access to everyone. But in reality, it’s a system of haves and have nots. I’m talking to the people who have experienced inequities firsthand, and those who are working to create change. 

Ethel Tungohan These are the workers who were ensuring the Canadian society kept going. And yet after we got sick of kind of banging on our pots, tooting our horns, and calling them heroes, there’s a segment of the population kind of blaming them and getting mad at them. And I think for some of the care workers, there’s still PTSD from what happened.

Dr. Alika Lafontaine Immigrants from the Philippines make up a significant part of the frontline workforce of nurses and care workers in Canada. So when the pandemic hit, these workers were disproportionately affected. In this episode, we’ll take a look at the burden Filipino nurses and care workers carried through the peaks of the pandemic.

I’m Dr. Alika Lafontaine, an Anesthesiologist and the first Indigenous physician to have led the Canadian Medical Association. From the Canadian Race Relations Foundation…this is The Healthcare Divide.

When Dolie Anne Bulalakaw was young, she dreamed of being a nurse. 

Dolie Ann Bulalakaw Yeah, that is one of my biggest dream. But unfortunately, my, my mother and father passed away when I was in my high school days, so nursing in Philippines is a little bit expensive.

Dr. Alika Lafontaine Since she couldn’t afford nursing school, she became a school teacher. But when Dolie immigrated to Canada in 2012 to be with her husband, she saw it as  a second chance to realize her dreams. 

Dolie Ann Bulalakaw What I heard to my in-laws that when you’re in healthcare, maybe this is the big opportunity that you can grow and continue your dreams to be a nurse. It’s so easy and fast that you can able to be hired because most of the facilities is always hiring. And you know, healthcare workers are always 24/7 need in the facilities and in the hospitals. So there is a lot of job opportunity that you’re able to be hired.

Dr. Alika Lafontaine She got a job at an assisted living facility. 

Dolie Ann Bulalakaw It’s just like my stepping stone to go to my real dreams, which is to be a nurse.

Dr. Alika Lafontaine As an assisted living worker, Dolie can do many different tasks. Residents still perform many of the usual activities of daily living. This means they have more independence than in long-term care homes. Dolie works the 3pm to 11pm shift. For most of that time, her job is to make sure residents take their medication properly. But at 8pm, many other staff members go off the clock, leaving Dolie and the residents to sort out problems until the next morning.

Dolie Ann Bulalakaw At 8pm, we don’t have the nurse, so we are dealing all the nurse that’s job. We don’t have also a janitor. So it looks like we are dealing everything. From the laundry. For instance, the residents have a problem in the washroom, we are the one dealing that one.

Dr. Alika Lafontaine Then there are the parts of the job that are less tangible, but also important. And taxing.

Dolie Ann Bulalakaw That is part of our job, dealing and taking care of the residents’ emotional support, too, because mostly the family are able to visit. But what I notice is like 10% of those residents’ family only are able to take care of their parents and visit it. So most of them are lonely or most of them there is no family coming up to take care of them. So that is part of our job, to support their emotion. I am really sensitive kind of person, sometimes I’m trying to have boundaries between me and the residents. But of course we’re just only a human being that we can feel and give them sympathy, right? So when it comes to emotionally, we are the first person that the residents can share their emotional frustration.

Dr. Alika Lafontaine Despite the challenges, Dolie finds her work fulfilling.

Dolie Ann Bulalakaw I love my job. That’s why I am almost ten years working this kind of job. Every day there is a purpose in life. So I’m just thinking that maybe there is a way why I am in the healthcare industry and I am helping others.

Dr. Alika Lafontaine Dolie also serves as her local union’s chairperson, representing both her assisted living facility and a long-term care facility. She helps colleagues who are going through hard times. And the story she hears from those working at long-term care homes is entirely different from what she sees in assisted living.

Dolie Ann Bulalakaw They’re crying because there’s a lot of circumstances and difficulties. Long-term care facilities, you are totally burnt out, every day. Exhausted. Stressful. If the residents is like, you change their residents with the clothes, especially if you’re in dementia area. So most of the residents or the patients are hitting you, pulling your hair because they’re refusing. So when you are a healthcare workers, that is everyday routine. And when the residents hit you, pull your hair, swear at you, it looks like normal. They feel like no one’s going to help them, no one’s going to care for the care aides. To be honest, most of my members said, I think if there is another chance to redo it again, back ten years, 15 years, maybe they are not take this kind of job anymore.

Dr. Alika Lafontaine Many people in Dolie’s line of work are immigrants, around 90% are women, and a large percentage of them are Filipino. 

Dolie Ann Bulalakaw Mostly Filipino are loving and caring for the elderly. So it’s easy for us to work in this job because this is part of our culture.

Dr. Alika Lafontaine In 2016, Filipinos made up about 30% of immigrants working in nursing or health care support in Canada, adding up to nearly 45,000 workers. And according to the 2016 census, Filipino care workers had one of the lowest average employment incomes among population groups designated as visible minorities. They were also among the first healthcare workers to lose their lives when the COVID crisis struck long-term care homes across Canada. We’ll return to that, but first, I want to dig into why Filipinos became so highly represented as care aides, which are among the lowest paid jobs in Canada’s healthcare industry. I called Valerie Damasco to get the backstory.

Valerie Damasco So I am an assistant professor in the Department of Sociology at Trent University.

Dr. Alika Lafontaine Valerie studies how migration and labour impact Filipino communities in Canada. She became interested in this topic through her own family history.

Valerie Damasco I am a second generation Filipino Canadian, so my family had immigrated to the country beginning in the late 1960s, and that was as a result of my aunt. She was the one who was first here in the country and she sponsored the rest of her family, including my mother, who followed.

Dr. Alika Lafontaine Valerie only learned the details of her family’s immigration story as an adult. She was getting her Master’s degree at the University of Toronto when she came across a professor teaching a course about women in the Philippines.  

Valerie Damasco I was very curious because, you know, talks about the Philippines, talks about Filipino migration, weren’t really there yet in higher education.

Dr. Alika Lafontaine So she set out to learn more. Valerie joined the Filipino Life History Group, a collective that interviews people about how they ended up in Canada. Starting with her own family.

Valerie Damasco The first person who I talked to over lunch one summer was my aunt, my Auntie Lourdes. And I remember being at her home and asking her just this one question, you know, how did you get here? What made you come to Canada? And she said to me, well, you know, Valerie, I was a nurse who was recruited from the Philippines. And that word “recruited,” carried so much meaning. It carried so much questions. I thought that she was sponsored by my uncle. I thought that she had worked in Italy as a domestic worker or caregiver first before being able to land a job here as a nurse. She showed me this offer of employment letter, which to me was really shocking. She was basically telling me that, during that time, there were a ton of recruiters in the Philippines, recruiters from Canada and the United States, trying to hire Filipino nurses to come here.

Dr. Alika Lafontaine The first big wave of Filipino nurses immigrating to Canada began in the 1950s.

Valerie Damasco These nurses who arrived here in the ‘50s and ‘60s, they were trained in private nursing schools in the Philippines, and those were the first schools that were established in the Philippines. Some of them were established by the American colonial government during the early 1900s. The Philippines was rampant with infectious diseases, and so through the process of colonization, the Philippines became the Western medical lab of the United States, where they were doing all these testing pertaining to infectious diseases like tuberculosis, beriberi, etc. And so at that time, they had developed these hospitals, and the first nurses who were at these institutions were white American nurses. And these are people who trained folks like my aunt and subsequent generations of nurses from the Philippines. This training that they have received, the fact that it’s Americanized, I think really set them apart. When they had arrived here, they were basically ready to work the next day.

Dr. Alika Lafontaine This training also coincided with amendments to Canada’s immigration laws. 

Valerie Damasco That was a time also when there were different changes happening within the Canadian immigration system. So the liberalization of Canadian immigration policies, which were enacted in 1962 and then moving toward the late 1960s, which was the Canadian points system, when that was enforced.

Dr. Alika Lafontaine The root of a lot of discrimination and racism in health care against internationally educated health providers is sometimes rooted in the belief that they’re trained at a lower level or in a different way. Could you tell us a little bit more about how Filipino nurses were trained at the time?

Valerie Damasco There is this assumption also that these are people who have not been in leadership positions, right? Whenever I share this story, I think a lot of people are in shock when they hear that these nurses were running the floors or these nurses were in more senior leadership positions or even teaching at that time, right? Because today, the common story or the common issue is that nurses come here and are channeled into the front lines of healthcare. And I think the problem with being channeled into the front lines of healthcare is where there is, as we have seen on the news, a lot of burnout happening. And so the question is, if that’s the case, then why aren’t we allowing them to move into other positions within the nursing profession, which I’m sure they are qualified for.

Dr. Alika Lafontaine Valerie says there was a moment, towards the end of the 1960s, when this shift started.

Valerie Damasco During that time, immigration officials were becoming more strict in terms of the criteria that they were looking for. So initially, while, for example, English language scoring requirement, while that was not a specific criteria that they looked for in the past—these nurses, like my aunt, their first language was English. I mean, they were taught in English speaking schools in the Philippines. So in the late 1960s, that that really changed. They were looking for this set of criteria that they never used to. I would also say that toward the late 1960s, early 1970s, we saw a lot of nursing schools pulling out of the hospitals and moving into universities and colleges. And of course, the more you train domestic nurses, that is, those who are Canadian, right? Or who are accessing education here, chances are once those people have completed their education and training within these schools, those are the ones who will be provided with an opportunity to work in the profession. Now, what was going on at the same time in the late 1960s was that, again, they had all these nurses who wanted to come into the country and to work here as nurses. But because of the restructuring that was happening in the context of immigration policy with respect to these people taking on work as nannies and caregivers, their skills and qualifications were also useful in that type of profession, right? Even though, right now, I think the issue is that we have a lot of Filipino women who are trained as nurses back home, but are only able to come here as domestic workers and nannies.

Dr. Alika Lafontaine A major reason for this change was the Live-in Caregiver Program, introduced by the Canadian government in 1992. This program created a path to permanent residency for at-home care workers, including nannies. It led to another major wave of immigration from the Philippines. In many cases, qualified nurses took these jobs for a chance at a permanent life in Canada. There have been changes to that program over the years. The biggest change was in 2014, when the government removed the live-in requirement, and reclassified these jobs as part of the Temporary Foreign Worker Program. There have been concerns with the uncertainty of residency under the new program, but it remains popular. A recent report from Statistics Canada found that 2 in 5 skilled nurses who immigrate from the Philippines don’t do the job they’re qualified for.

Ethel Tungohan Certainly, we’ve heard stories of a folks coming here with a certain level of skills and they find that, when they get here, the job market isn’t registering that they are qualified to work these jobs because they only count Canadian work experience, right? Or they are required to amass more education. And that’s expensive. My name is Dr. Ethel Tungohan. I am an associate professor of politics at York University, and my research looks at immigration policy, social movements, and activism. And I wrote a book that is now released called Care Activism. So I think when you have, specifically, a look at Filipino health care workers, we have to factor in the costs it takes to be accredited, right? We also have to factor in how, especially for folks transitioning out of the caregiver program into Canadian permanent residency, spending a lot of money on retraining and trying to re-accredit and going back to school doesn’t make sense in light of the fact that they also have to save money for their family members to join them in the country. And so, for a lot of immigrants, then you kind of assess, well, is it worth it to to spend time, money, and resources to go back to school, to try to to re-accredit myself, to get the credentials needed? Won’t it be better if I just kind of take on the jobs that are in front of me and perhaps just hope that my children and their children will be able to practice the professions that they desire, right? So it becomes less about just the individual. It becomes more about looking at what makes the most sense for your family members, specifically your children and your grandchildren, as well.

Dr. Alika Lafontaine After meeting the requirements for permanent residency, many pivot to jobs in long-term care or assisted living.

Ethel Tungohan When you look at how difficult it is to get a job in Canada in healthcare, especially if, for example, you’re a registered nurse in your home country, you come here and then you look at the requirements that you have to face. You look at the requirements presented by accreditation bodies. Then perhaps you kind of make do and say, okay, well, I’ll just work in long-term care because that’s close enough to what I used to do in my home country, right? So there’s also these structural reasons as well.

Dr. Alika Lafontaine All of these factors set the stage for people from the Philippines—Filipina women in particular—to find themselves on the frontlines during COVID. Ethel worked on a research project about the experiences of Filipina nurses, live-in caregivers, and personal support workers during the pandemic.

Ethel Tungohan During COVID, one of our key findings in our project is just how stressful care work is, especially personal support work. This was during COVID, mind you. The provision of PPEs or making sure that there are enough people on shift in a given workday. I was just surprised that things that I thought would be given without question, some workplaces were reluctant to provide.

Dr. Alika Lafontaine Dolie remembers the strain of those days.

Dolie Ann Bulalakaw There’s a lot of tasks, either additional tasks and services that added to your job, but you cannot be able to say no because that is for the safety for you and for everybody. So you need to do a swab just to make sure you don’t have COVID before you go to work. And you need to wear your PPE for 7.5 during your day, right? And also for emotional for the resident that they cannot able to communicate personally and in their family. So you need to double your job, double your emotion, double your effort during the pandemic and also during that time, I have my small children that I need to protect, too. It’s so hard because you’re just like, think, do I need to go back to work for the money that we can have for us? Or do I need to stop working because I need to take care of myself and my small children? So I’m just thinking if I have COVID at that time and if I die, who’s going to take care of my small little children?

Ethel Tungohan I think, you know, what we saw happening in COVID was basically a magnified version of what care workers face every day. Like, it’s exceptional, but it’s not. Some of the stories we heard would involve care workers knowing that someone’s parent was dying, but because of lockdown provisions, family members couldn’t come in. They would take it upon themselves to actually connect the children and have them FaceTime with their parents. You would also hear stories of care workers trying really hard to provide emotional support for the seniors living in long-term care homes and acknowledging the loneliness that they face and also trying to provide company and comfort, right? Some of the care workers, because of lockdown provisions, were actually asked by care homes to live in the care homes. Right? To prevent COVID spread. So they created like bunk beds at the bottom of the home and they would just be asked to sleep there. How can you even begin to recover emotionally from that?

Dolie Ann Bulalakaw One day I’m just sitting down and I’m crying. I said, I don’t like to go back to work anymore. Yeah, I know this is my profession. This is what I want. This is the way that I can help my family financially. But every day your life is at risk. Every day that time you keep on thinking about it. I don’t know if I can. Is this worth it?

Dr. Alika Lafontaine A 2021 survey by Statistics Canada found that 83% of personal support workers and care aides felt increased stress during the pandemic. The number was even higher among nurses. Between 2019 and 2021, job vacancies increased by more than 115% in nursing and residential care facilities. 

Ethel Tungohan I think a lot of the people who I spoke to are still healing from the trauma of being part of a workforce where, on the one hand, at the beginning of the pandemic, we were all banging pots. Do you remember that? We were like…

Dr. Alika Lafontaine Yeah. I remember!

Ethel Tungohan And we would like toot our horns, we were like, “Yay health care workers. Thank you so much!” Right? So there is kind of these discourses of heroism, on the one hand that they’ve observe, but on the other hand, this pervasive sense of being abandoned by policymakers, especially as death toll started rising. I mean, the pandemic, it spanned multiple years, there were multiple waves. After we started banging pots, maybe a year later, then you started hearing reports, some of which were corroborated in our research, where care workers started facing social stigma, right? Like, I’ve spoken to care workers, personal support workers who would be finishing their shifts, would be going home, and then they’d get dirty looks from people. And in some cases, they would experience, like, physical violence, right? And I just I just, I don’t I don’t understand that. So these contradictions are really hard…they’re really hard to understand. And I think for some of the care workers, there’s still PTSD from what happened.

Dr. Alika Lafontaine During the first year of the pandemic, police in Vancouver saw anti-Asian hate crimes rise more than 700%. A report from the Chinese Canadian National Council’s Toronto chapter blames this on the fact that the pandemic was quickly racialized, with then-US President Donald Trump calling COVID-19 “The China virus,” with some media following suit. The official stats on hate crimes have since declined, though cases are still being reported at a higher level than in 2019, and surveys suggest people continue to be targeted at high rates. Sociology professor Valerie Damasco is concerned about the mental health toll all of this takes on racialized nurses.

Valerie Damasco These are nurses who cannot afford to leave their job or move into another work sector because there are issues with accessing employment, right? If you’re a racialized person, chances are looking for another job is very difficult. And of course, sometimes in these cases, these are nurses who are providing for their entire family. I’m not so sure if they’re the only breadwinner in the family, but some of the times, that is a case, too, in addition to having to provide for their families back home in the Philippines. And so, there’s no way out. Meaning, if you are facing issues of burnout, chances are you still need to be there. These are people who are not readily able to access sometimes mental health supports, because mental health supports in our community are driven in a very different way. It’s driven in more so a community-oriented manner. And so especially when it comes to discussions of retention and trying to support those who are experiencing burnout on the front lines, how do we think about that in terms of ensuring that their skills and qualifications factor into that issue as well, where if they are burning out on the front lines, why are we not providing them with opportunities to move into nurse educator positions, nurse leadership positions where they’re more than qualified to do that, as in the case in the past?

Dr. Alika Lafontaine One thing that became clear to Ethel during the pandemic was a lack of standards to protect workers across the industry.

Ethel Tungohan I had a fantastic student, Leah Nicholson, who worked with me and tried to track all provinces’ policies in support of care workers during COVID, right? So she looked at, you know, the labour codes. She looked at occupational health and safety policies. She looked at the provision of emergency pay for direct care workers. What we found was that there’s simply no consensus across Canada when it comes to the types of entitlements that care workers receive. That surprised me as well. I thought, you know, during COVID, a health emergency, a pandemic, that there would be a universal desire to make sure that care workers who we’ve all called heroes, are protected in their jobs. And I think even the provision of paid sick leave, right? That’s not something all care workers have. And I think that was one of the most common source of distress that the care workers who we interviewed during the pandemic voice. So, you know, policies like why is there no universal paid sick leave across the country? These are the things that we need to talk about. So we also have to look at policies, not just kind of individual and workplace circumstances.

Dr. Alika Lafontaine We know that the Caregiver Work Experience Program, where you needed 24 months to be able to apply to permanent residence under the Home Childcare Provider and the Home Support Worker Pilots, they’re going to expire and be replaced by something in the near future. What do you hope that looks like, looking back at what we’ve learned over the last few years?

Ethel Tungohan All of the things that are being proposed by the government with respect to care worker programs, we need to also take into account care workers’ own demands as well. And one thing that’s incredibly frustrating post-2013, since the abolition of the Live-In Caregiver Program, is Canada has started establishing a whole bunch of pilot programs that expire every four years, right? And so what that does is, for care workers, they now feel that their lives are in limbo. Who knows what tomorrow’s policies will bring, right? And so I think that’s a huge source of frustration, especially since care worker activist demands have remained constant through the years. Right? One of the demands that care workers have sought is getting landed status upon arrival. Care workers provide valuable work for Canadian society. We’ve witnessed this, especially in COVID. So why is it that we’re asking people to go through this like, you know, temporary period where they don’t have status, where they don’t know whether they’ll get status, when we know for a fact that Canada needs care workers. Another thing with respect to potential changes with the care worker program, one thing that’s been overwhelmingly clear are how some of these policies, especially pertaining to meeting language requirements, are a huge barrier for care workers. Care workers are already working in Canada. So why are we then imposing language tests? That seems peculiar, too. So I think, you know, moving forward, this is something care workers have sought. This is something they’ve told me about. Why can’t we just remove policies that are designed to put in more barriers that prevent care workers from getting permanent residency?

Dr. Alika Lafontaine Since the pandemic, the healthcare industry has experienced major staffing shortages. In the first quarter of this year, there were more than 28,000 job vacancies across the country for registered nurses and registered psychiatric nurses, up nearly a quarter from the beginning of 2022. Provinces across the country are struggling to address the issue. In Ontario, for example, the fiscal accountability officer released a report saying that the province is on track to be short 33,000 nurses and personal support workers by the year 2027-28.

Valerie Damasco One of the issues is that not only do we have this problem of accreditation, foreign credentials not being recognized. But we have the problem of, again, not willing to recognize the kind of skills and training that these people bring into the country and therefore not allowing them to move across different roles within the profession where a lot of them are trained in. I think also a big problem today is that we are admitting a lot of health workers from the Philippines who have all this training, but we are only willing to provide them with opportunities below what they are qualified to do. And I think, with this whole issue about burnout, I mean, I think it’s really important that we take a look at that because there are times when errors can happen in healthcare institutions, right? If the workload is too high. Nurse-to-patient ratios are through the roof. And I don’t think that that’s ideally best for both nurse and the patients whom they care for.

Dr. Alika Lafontaine Dolie also wants to see changes to the system. She’s involved in a campaign called Care Can’t Wait.

Dolie Ann Bulalakaw Like, for instance, we are asking the government to standardize, because I am working in the private facility. Private facility is different than the public or government facility. They have good benefits compared to us. Their salary, their holidays, their weekend differentials is different, compare it to the private. I want the government to look after the healthcare workers who are working in the private sector to give more attention to be standardize our living and wages and the benefits and any other benefits that public have. So we are looking forward that the government will look after us.

Dr. Alika Lafontaine She worries if changes like these aren’t made, no one will want to work in these jobs. And many Canadians, especially vulnerable ones, will be left without the care they need.

Dolie Ann Bulalakaw Hopefully the government will look after us because if they are not able to fix this problem, maybe one day there is no healthcare. Ten years from now, no one’s gonna look after us, this kind of generation, right? Because no one’s going to take this job anymore. Dr. Alika Lafontaine Like many folks working in healthcare, I started down this path because of a deep desire to help people. The health system gave me a value proposition: in exchange for my time and effort, I would be rewarded with that opportunity. But there are hidden costs to working in healthcare I did not realize until later. Costs paid in lost relationships, financial instability, heavy physical strain, and an ongoing emotional toll on my mental health. For personal support workers like Dolie, and the many qualified health workers who come to Canada each year, this same value proposition, along with its hidden costs, is still being offered. Increasingly, folks are realizing that the value exchange may no longer be worth it. For decades, Canada’s healthcare system has been obsessed with getting more out of the resources we put into it. At the beginning of this obsession, we found cost savings through eliminating redundancy and improving interoperability. But it’s a truism that you can’t cut a system into sustainability. There is a point where there’s no more efficiency to give. Push beyond this point and efficiency can only be found through extracting it from the lives of health workers and patients who receive care—asking both to do more with less. Take enough resources away and people, programs, and health services break. Ask too much from people and they’ll look for other places to work, regardless of their deep desire to help people. I was once told by a mentor, an internationally respected surgeon who gave most of their life to the practice of medicine, not to repeat the mistake of sacrificing my self on the altar of medicine. Maybe the question we should be asking now is how can we rebalance that value exchange to make that sacrifice worth it?