On Bill 96 and Quebec health-care

As a group of multilingual Quebec residents and first-, second- and third-generation immigrants passionately studying and/or actively involved in the health-care field, we are concerned by the potential impacts of Bill 96, An act respecting French, the official and common language of Québec, on health-care delivery to all Quebecers and, in particular, vulnerable immigrant and indigenous populations.

The COVID-19 pandemic has exposed systemic flaws in our health-care system that require fundamental changes. Bill 96 will further stress and complicate health-care delivery by introducing language barriers.

Bill 96 was adopted in May to halt the steady decline of French. However, according to political journalist Michel C. Auger’s book, Debunking 25 Political Myths in Quebec, this fear is based on the relative decline of French as a maternal language from 79.7 per cent (2011) to 79.1 per cent (2016), though the absolute number during this time grew. However, a record 94.5 per cent (2016) of Quebecers were able to speak/sustain a conversation in French and the rate of using French at home is increasing. Auger attributes these changes to immigration, which decreases the maternal French rate since most immigrants’ first language is not French, but increases the overall percentage of individuals who speak French due to obligations from Bill 101/Charter of the French Language.

Immigration has impacted English in the same way, decreasing its relative share of non-French/English mother tongues. As put by the journalist Francine Pelletier at the end of her Canadian Broadcasting Corporation (CBC) French documentary Fight for the soul of Quebec: “Little by little, Quebec is opening up to the world again. Change is in the air. Diversity, too. The soul of Quebec is far from disappearing, it’s expanding.”

Multilingualism is an asset. Martin Braun, who holds a doctorate in languages, states: “Numerous studies have shown that speaking multiple languages provides many advantages that go far beyond the knowledge of the languages themselves. Multilingual speakers can concentrate better, resolve conflicts easier and empathize better with others.” 99.1 per cent of Quebec parents agree, believing that it is either very or fairly important for their child to learn English as a second language.

Putting aside the question of whether French is truly in decline, we wholeheartedly take pride in being French speakers and believe it is an important aspect of Quebec identity. At the same time, Bill 96 has wide-ranging implications on the economy, business, judicial system, education and other public and private sectors, services and domains. As a result, this would impact Quebecers’ social determinants of health (“the non-medical factors that influence health outcomes”), including education, working life conditions and social inclusion and non-discrimination.

Legal experts contend that the bill itself does not explicitly exclude health services.

Premier Francois Legault has stated that Bill 96 will not impact health-care delivery in languages outside of French, but legal experts contend that the bill itself does not explicitly exclude health services. The bill states: “An agency of the civil administration may depart from [the French requirement] by using another language in addition to French in its written documents … where health, public safety or the principles of natural justice so require.” This clause is ambiguous and up to interpretation. Therefore, this bill warrants further discussion given that there have been accusations of language discrimination in health-care pre-Bill 96. We believe multilingualism is crucial in the context of delivering health care to the general population during an emotional, stressful and painful moment of their lives.

Bill 96 is an update to Bill 101 with the Quebec government preemptively using the Canadian constitution’s notwithstanding clause to prevent legal challenges. Bill 96 mandates that businesses and public-sector workers communicate with their clients exclusively in French, with the following exceptions:

1. Recognized bilingual institutions and municipalities, which retain the right to provide services in English but cannot provide services in languages other than English or French (apart from situations outlined below).
2. Interactions with individuals who are:

a) Historical anglophones and attended elementary school in English in Canada or previously communicated with this institution solely in English.

b) Indigenous peoples.

c) Tourists.

d) An immigrant who arrived in Quebec less than six months ago.

The application of these exceptions may prove difficult, as 2a) would likely require an official letter from the school board as proof; for 2d), arrival dates aren’t always present on immigration documentation.

Bill 96’s impact on health-care professionals

Despite each health-care profession having its own licensing guidelines, they are all bound and guided by the same four fundamental pillars of ethical medicine: (1) autonomy; (2) beneficence; (3) non-maleficence; (4) justice. Bill 96 places health-care professionals in conflict with these tenets, and therefore with their certifying bodies. The following examples are just a few, among many, of how the bill will obstruct patient care and prevent health-care professionals from achieving the ethical standards necessary to maintain a professional license:

• Autonomy means that “every human being of adult years and of sound mind has the right to determine what shall be done with [their] own body.” Patients must provide informed consent, meaning they are given “an adequate explanation about the nature of the proposed investigation or treatment and its anticipated outcome as well as the significant risks involved and alternatives available.” Since Bill 96 prevents health-care practitioners from communicating with patients in their primary language, it is likely that information will not be provided “in a manner that [they] understand and can apply.” This would breach health-care directives, leading to negligence or assault charges against the health-care worker.
• Beneficence and non-maleficence mean that medical practitioners must provide the best available care by acting in the patient’s best interest and allowing no harm through neglect. Bill 96 would prevent medical professionals from using a professional translator/interpreter; transferring patients to a multilingual facility; and/or transferring to a colleague fluent in a patient’s native language. This would also include transferring a native French patient from an employee with elementary French to a colleague who is more fluent. Here are specific conflicts that different health-care professionals would have between Bill 96 and their professional associations:

a)         Physicians: Not being able to transfer patients due to a language barrier conflicts with the Canadian Medical Association (CMA) Code of Ethics, which states that physicians must be “cautious not to overstep the limits of their knowledge and skills … [and] seek advice and support from colleagues in challenging circumstances.”

b)         Critical Care Nurses: Bill 96 would violate the communication standards set by the Canadian Association of Critical Care Nurses (CACCN) by handicapping nurses’ ability to “gather data concerning patients’/families’ needs and responses to the critical care experience” and “advocate[s] with patients/families to address their expectations and needs.” Any misinformation due to miscommunication would be passed on to the multidisciplinary team and negatively impact the treatment plan prescribed.

c)         Psychologists: Psychologists are responsible for assessing and helping patients overcome problems in thinking, feeling and behaviour and must operate in accordance with scientific principles. However, studies on mental health assessment in a second language demonstrate that providing care in a non-primary language “interfere[s] with clinician and patient knowledge and rapport, leading to qualitative as well as quantitative differences in… treatment.” As such, language barriers impair a psychologist’s ability to diagnose and treat, while placing undue stress on patients.

• Justice requires that medical professionals uphold existing legislation and the equitable treatment of persons. Bill 96 would force health-care practitioners into making an impossible choice: Abide by Bill 96, but provide substandard care due to miscommunications issues introduced by a language barrier and suffer professional consequences from their governing body, including a potential loss of license; or violate Bill 96 to communicate effectively with patients in their native language but be subject to punitive government fines.

Quebec’s Institute of Public Health states “Every code of ethics that health and social service workers abide by stipulates they must do everything in their power to provide service of the highest possible quality. This means that they must ensure that the level of mutual understanding they have with users does not interfere with the quality of service. Health professionals should therefore not only make every possible effort to speak the language of users, but – and most importantly – use every means available to ensure mutual understanding in cases where they are not proficient in the users’ language.” As such, Bill 96 severely compromises the quality of medical care for all Québec residents regardless of language or origin while putting health-care workers in a compromising position both professionally and financially. As put by the editor of The Suburban newspaper, Beryl Wajsman, “Compassion should be the only language of health.” We couldn’t agree more.

Bill 96’s impact on patient care

Quebec’s Act respecting health services and social services states that health care must be adapted to support all patients regardless of language or culture. According to Quebec’s Institute of Public Health, patients who are provided care in their non-mother tongue are more likely to:

1)     Be prescribed medication, receive an inappropriate prescription or not understand or know how to take their medication.

2)     Not understand their diagnosis.

3)     Spend additional time in the emergency department and receive more medical tests.

4)     Be exposed to undesirable events, such as hospitalization, unintentional injuries or complications.

5)     Be discharged from hospital without a follow-up appointment.

And are less likely to:

1)             Use mental health services.

2)             Be satisfied with their care.

3)             Show up to future appointments.

All of these consequences increase the cost of care and medical burden on patients.

Even under seemingly ideal circumstances where a health-care professional speaks the patient’s language, mistakes are commonplace.

Even under seemingly ideal circumstances where a health-care professional speaks the patient’s language, mistakes are commonplace. One study demonstrated that nurses who interpreted for physicians made serious miscommunication mistakes 50 per cent of the time. These requests are made frequently. Between January 2018 and November 2020, the McGill University Health Centre (MUHC) made 1,349 overhead announcement requests for a volunteer interpreter. This does not include situations in which someone on the treating team or in the vicinity (accompanying family and/or friends) speaks the appropriate language.

Though it is indisputable that French is the majority language, there is precedent from other areas of the world to offer minority language services: Californian facilities are required by law to provide language assistance services 24 hours a day for language groups that represent a minimum of five per cent of the population it serves; Finnish municipalities are considered bilingual if at least eight per cent of its population speaks the minority language. For reference, the regions of Outaouais, Gaspesie–Iles-de-la-Madeleine and Monteregie all have at least eight per cent of their population whose mother tongue is English. Montreal and Laval have 32 per cent and 25 per cent of their population respectively where their mother tongue is neither English nor French.

For immigrants in their first six months in the province, Bill 96 will have a particularly profound impact. Though research is limited on the time needed to acquire a second language due to the numerous variables at play (age, educational level, motivation, language learning anxiety and the closeness of origins between the primary and the new language), this six-month requirement to learn and be able to communicate in French does not seem to be based in science or consider the numerous challenges and time-constraints this population experiences. Based on 70+ years of teaching foreign languages to English-speaking diplomats, the United States Department of State Foreign Service Institute estimates that learning French takes 600-750 hours. This estimate is for a highly educated population (diplomats) that speaks English, which is 27 per cent lexically similar to French. Based on this estimate, all newcomers would require 25-31 hours/week of instruction to become proficient in French in six months.

Though these 25-31 hours may include exposure to French in day-to-day life, there must be intersectional efforts by the Quebec government, employers and society to foster a positive and uncoerced learning environment. The first step would be to set realistic goals that respect different backgrounds and circumstances that impact their ability to acquire a new language. The Quebec government’s own report confirmed that this six-month period was not realistic and recommends giving immigrants time to settle before beginning French courses. Unfortunately, this report was kept hidden and disregarded. This report is backed by psychologist, University de Montreal professor and scientific director of the interdisciplinary research team on refugee- and asylum-seeking families (ERIFARDA) Garine Papazian-Zohrabian, who stated that her research indicates that immigrants do wish to learn French and that instituting a six-month period to learn French is detrimental to the learning process. The aforementioned Braun agrees: “I’m absolutely convinced French is important and I love the French language. But when … everybody is more or less forced to learn French, it will not be a solution for French-speaking people in Quebec.”

Given all this, we do not understand why a proposed amendment to bring this timeline from six to 24 months was rejected. This bill discourages immigration at a time when we require additional immigrants to support the second fastest aging population in the world. Already, Quebec struggles with retaining immigrants – 38 per cent of the 53,000 immigrants welcomed to Quebec in 2016 have left for other provinces or countries. Thus, Bill 96 will not only make it difficult to support our aging population through reduced immigration, but also will complicate the recruitment of top research talent, ultimately impacting patient care and Quebec’s international scientific standing.

Even without the complications that Bill 96 poses, linguistic barriers have long been viewed as a reason for immigrants’ suboptimal health and dissatisfaction with health-care services. Compared to the general Canadian resident, immigrants and refugees are less likely to seek and use mental health services due to cultural and linguistic barriers. COVID-19 has made this case clearer with low-income refugees developing more severe infections and having difficulties accessing the virtual care system. The pandemic also has shown the importance of adapting public health messaging to cater to multiple languages and cultures.

Our health-care system already is on the brink of collapse with numerous interconnected problems, including primary care shortages (1.5 million Quebecers don’t have a doctor, a nearly four-fold increase in four years) that increase visits to emergency departments, which lack employees and hospital beds. Quebec has one of the lowest population-based hospital capacities amongst G7 countries; as of this past June, 12.3 per cent of hospitalized patients requiring long-term care could not be transferred to those facilities since they already were at full capacity and had unsafe staff to resident ratios. Ultimately, this delays Quebec’s surgery backlog (which neared 150,000 in 2021) since it doesn’t have the needed hospital beds or staff to perform the surgeries and has experienced a nursing and respiratory therapist exodus and shortage.

Even under the most ideal of circumstances, it would be difficult to address these and numerous other issues in our medical system. We do not believe the Quebec health-care system’s staff or patients can handle the additional and undue burden of Bill 96. Quebecers themselves believe health and social services should be exempted, with 57 per cent contending Bill 96 should be amended to allow for the best communication possible and 88 per cent expecting to be accommodated regardless of language.

All of this is not to say that there aren’t positive aspects to the bill, which would permit anyone in Canada to pursue a French university program in Quebec and pay in-province fees if they possess the requisite French knowledge and if that program is not offered in French in their province. We believe that this spirit of encouraging the French language should be the foundation of Bill 96 and would offer more opportunities to all Canadians.

Though we believe the bill’s intentions were to promote and preserve the French language, the way it is constructed will further deepen language divisions within Quebec and Canada.

Though we believe the bill’s intentions were to promote and preserve the French language, the way it is constructed will further deepen language divisions within Quebec and Canada. In the CBC French documentary, The Quebecers of Bill 101, many Quebec-born and bilingual children of immigrants say they are often treated like outsiders and non-Quebecers and are dissatisfied with the francophone educational system’s teachings on Quebec culture. The latter demonstrates that we need to reform our education system to better teach our youth about Quebec society. The former exemplifies how Quebecers, regardless of language, have faced language discrimination.

We recommend that Bill 96 promote French via positive reinforcement and community support. We believe we should re-examine the bill’s potential impacts in all domains, but more specifically in the health and social services sector. The government has a responsibility to ensure that all Quebecers receive equal services regardless of their language. We believe Bill 96 would further complicate health communication, exacerbate pre-existing health inequities, setback a fragile system, and expose Quebec’s health care, its workers, and citizens to increasing financial and human costs.

We encourage you to go through the thought experiment outlined by La Presse’s Rima Elkouri: Quebec is at war, you are forced to uproot your life and family to immigrate to Germany, and now must learn German in six months. Though you are willing to learn German, would you be able to master it in six months? Would you have the capacity to adapt to a new country while reaching a linguistic level where you would feel comfortable having complex and emotionally intense discussions regarding your health or that of a loved one? Or would you rather be accommodated and be provided a welcoming environment that gives you the appropriate time and resources to get you and your family settled before learning a foreign language?

Land acknowledgment: The authors would like to respectfully acknowledge that we are situated on the traditional, ancestral, and unceded territories of the Kanien’kehá:ka (Mohawk) and the Ho-de-no-sau-nee-ga (Haudenosaunee) people. As settlers, it is our responsibility to recognize the past, present, and future Indigenous communities that have made it possible for us to live here today. We encourage everyone to learn more about the lands we occupy by visiting https://native-land.ca/.

Translations of the petition:

(French)_Sur_la_loi_96_et_les_soins_de_santé_au_Québec

(Arabic)_مشروع_القانون_٩٦_و_الرعاية_الصحية_في_كيبك

(Simplified Chinese- PRC, South Pacific) 关于96号法案和魁

(Traditional Chinese- Taiwan, Hong Kong, Macao) 關於96號法案和魁省醫療

(Spanish) Sobre el proyecto de ley 96 y la atención médica de Quebec

(Italian) Sul disegno di Legge 96 e l ‘assistenza sanitaria in Québec

(Russian) O Законопроектe 96 ие Квебека

(Farsi) در لایحه ۹۶ و مراقبت های بهداشتی کبک

(Greek) Σχετικά με το Bill 96 και την υγειονομική περίθαλψη του Κεμπέκ

(Hindi) बिल 96 और क्यूबेक स्वास्थ्य देखभाल पर

(Mohawk) Bill 96 tánon Quebecnéha ata’karitéhtshera kaia’takehnháhtshera

(Punjabi) ਬਿੱਲ 96 ਅਤੇ ਕਵੀਬੈੱਕ ਦੀ ਸਿਹਤ-ਸੰਭਾਲ ‘ਤੇ

(Vietnamese) Bill 96 và sự chăm sóc sức khỏe ở Québec