Rainbow Community Health Co-operative: A Case Study
The essence of the co-operative model of organisation is to serve the needs of its membership. Hundreds of millions of people around the world have chosen to build and join co-operatives because of the co-operative structure's ability to respond to people's needs in a meaningful way. In British Columbia, the creation and development of the Rainbow Community Health Co-operative represents a concerted effort to effectively and respectfully deliver health-related services to people living in the communities of Surrey and Delta.1 , Surrey-Delta is one of the fastest growing areas in Canada, and boasts a diverse population; according to 1991 census data, people of South-Asian descent2 comprise the largest non-English speaking group (Liotta, 1997). In addition to the South Asian group and the English linguistic group (the largest), there are a number of other ethnic groups living in the municipality, including people of Chinese, Filipino, East European, Spanish, and Vietnamese descent.
The Rainbow Community Health Co-operative (RCHC) focuses on providing health-care services for Canadians of South-Asian descent and new immigrants from South Asia, although the needs of people who are members of other ethnic communities are included in some of the co-op's programs, and no one is excluded from its services. People in these specific groups, especially new or relatively new immigrants, have "special linguistic and cultural needs and resources" (Liotta, 1997, p. 6). The co-op's research showed that "many residents experience barriers to accessing the health care system because of income, language and cultural differences" (Liotta, 1997, p. 6). As well, it found that "in several critical health areas, there are gaps in services, especially for the immigrant and visible minority population" (Liotta, 1997, p.6).
Currently (2001) RCHC is the only health co-operative which operates in British Columbia; in the rest of Canada there are approximately thirty co-operative health centres, most of which are found in Saskatchewan, Quebec and Manitoba.3 For this reason it is essential to document the origins of and impetus behind RCHC, and its subsequent growth and success.4 The following study outlines the health co-op's origins, its roots in the South Asian community that it serves, its daily operations, its external and internal structures, and its future plans.
The people interviewed for this case study were members of RCHC, or were actively involved in the Progressive Intercultural Cultural Society (PICS), which is the umbrella organisation5 for the co-op6. Among them are various community leaders, co-op members, and representatives of the RCHC board of directors. The initial study took place over a three-month period, June to August of 2000, with a follow-up visit and interview in June 2001 by two other BCICS researchers, Kristen Sinats and Cory Rushton.
BCICS researcher Upkar Singh Tatlay conducted interviews, both in-person and by telephone. All participants were asked to sign a Letter of Informed Consent, which outlines the goals and methods of the study, the obligations of the researcher (BCICS), the value of participating, and how the study will be of benefit to participants and in general. Interviews ranged in length from thirty minutes to three hours. Fifteen interviews were conducted; five of these provide the basis for the study, while the other ten supplemented the research data. In some instances a participant decided to not sign the consent form after the interview, and that information was not used directly in this study.
Interviewees of Indian origin helped clarify the contributions made by Indian culture to the success of the RCHC. These and other participants were helpful in highlighting the health experience of first, second, and third generation South Asians. Other informants, although not members of the South-Asian community, provided information that has enriched the study. Mr. Charan Gill (Executive Director of PICS and chair of the RCHC board of directors), along with Mr. Devinder Sekhon (President of PICS), both shared information about their past experiences in the Indian co-op movement as they discussed their involvement in Canadian co-operatives.
The RCHC program manager, Monika Laul Verma, provided information to Tatlay on several occasions; Laul Verma also helped facilitate guided tours and walk-throughs of the RCHC facility, which allowed the researcher to observe the daily life of the co-op. Laul Verma greatly facilitated the research process by taking the time to establish the relationship between RCHC and BCICS, and by helping with contacting and introducing various potential research participants. Her knowledge and understanding of the co-op provided a strong foundation for the research. In addition, BCICS received a variety of informative documents which were published by RCHC or PICS for the community at large, and which were available in English, Punjabi, and Hindi. These materials included brochures and leaflets, and offered information about initiatives, upcoming clinics, events, and other activities.
A member of the South Asian community, Tatlay developed a rapport with co-op members. His proficiency in English, Punjabi, and Hindi offered research opportunities that surpassed those available to a researcher who could only communicate in English. The participants had a variety of backgrounds; some had emigrated from India, others were first generation Indo-Canadians, and some were Caucasians born in Canada. As most of the participants were heavily involved in their communities as activists, professionals and leaders, finding enough time for interviews was difficult. BCICS is grateful to the participants for the time each contributed to the research.
The RCHC held a signing ceremony for its bylaws on November 3, 1997 and registered under the Cooperative Association Act of British Columbia on December 12, 1997. The co-op celebrated its official launch at the Surrey-Delta Indo-Canadian Senior Centre on February 18, 1998 (Indo-Canadian Voice, 7 March 1998). Founding members included Rosh Bharaj, Ron Bonner, Gulzar Cheema, Charan Gill, Cheryl Hewitt, Safron Kanzeon, Preetam
S. Mukkar, and Sandra McElroy (see Liotta, 1997; The Province, 22 November 1997). Bharaj, Bonner, Cheema, Gill, and McElroy became members of the Board of Directors, along with Girmaye Gabre, Christine Liotta, Devinder Sekhon, and Bikker Singh Lalli. Initially, the co-op signed on 148 members.
According to the RCHC Statement of the Incorporators, the intention of RCHC Association is to "provide a wide range of medical services to people so they will be encouraged and enabled to follow healthy habits through culturally sensitive education and promotion of preventative practices." The Association proposed to operate a nonprofit community health centre according to the principles of co-operation established by the International Co-operative Alliance (ICA):
- Voluntary and open membership;
- Democratic membership control;
- Full economic participation by members;
- Autonomy and independence;
- A commitment to education, training and information;
- Co-operation among co-operatives; and
- Concern for the community as a whole.
The initial funding for the co-op came from three main sources: the sale of shares, available debt financing, and startup funding granted by the British Columbia Ministry of Community Development, Cooperatives and Volunteers.
A core group of people worked earnestly to develop the Rainbow Community Health Co-op, and together they achieved the co-op's initial success. Christine Liotta, who was initially involved as a consultant to develop the co-op's business plan and who later served as a member of the board, remembers that it "was a group process. We had a steering committee of people, many of whom ended up being the first directors. I can't single anyone out ... it was the way people interacted with each other that made the co-op a success" (Liotta, 2000).
The steering committee Liotta refers to was formed 18 months before the co-op opened its doors. Other people who were involved in the early stages of the co-op's development attest to the instrumental role that Charan Gill played in the process. His leadership role was highlighted in the media (see, for example, the Indo-Canadian Voice, 7 March 1998). Gill's central role is not surprising. His activism in the South-Asian community is well known. He is a founding member of both the Canadian Farmworker's Union and the B.C. Organization to Fight Racism. Gill was named to the Order of British Columbia in 1999 for his long and distinguished career of community service.
Choosing the co-op model
Devinder Sekhon believes that the decision to choose the co-operative model was largely influenced by Charan Gill, who he says was the lead proponent. Sekhon also remembers that Gill and a few other people essentially determined that the co-op model should prevail, although they also discussed the pros and cons of forming a society. The funding available through the provincial government boosted the co-op option, but according to Sekhon, the ease with which different people could relate to being involved in a co-op clinched the decision (Sekhon, 2000). Liotta's recollection of the group adopting the co-op model is similar: "We were committed to [the co-op idea], partly because of the community that was identified, [partly because of] the needs, and [partly because of] where the initial funding came from."
The South-Asian Co-op Heritage
Many South Asians living in the Surrey-Delta area are familiar with the co-operative model, either through their own experience with it in India or through their knowledge of the history of India's co-operative movement. Because of this awareness, residents of the Surrey-Delta area often readily accept the model and its potential role in society. Laul Verma commented:
South Asians are very familiar with the co-ops - it is rooted in them. We have credit unions; agricultural co-ops are very famous in India, so they grew up with that idea and are very familiar with it. It's nothing different. We never have to sell it to them or even describe it because they are familiar with it (Monika Laul Verma, 2000).
A founding member of the RCHC, Dr. Gulzar Cheema,7 recalled that his own interest in co-ops is connected to his great-great-grandfather, who was active in founding various co-ops in Lahore (The Province, 22 November, 1997). In India, co-operatives can be traced to the nineteenth century, when credit and consumer co-operatives first began to flourish in the province of Madras.
The Progressive Intercultural Community Services Society
In the period that Charan Gill was promoting and working to develop the co-op, he was also the executive director of Progressive Intercultural Community Services Society. Indeed this organisation has played a critical role in the development and sustainability of RCHC. The Progressive Intercultural Community Services Society (PICS) is the umbrella organisation under which RCHC operates. The co-op is supported both fiscally and administratively by PICS. Today, RCHC is an integral component in the PICS platform of services and programs.
PICS has been dedicated to supporting British Columbia's immigrant populations since 1987; the Society now offers many services, including English as a Second Language (ESL), assistance to farm workers, anti-racism programs, and a variety of health initiatives, including the RCHC (Asian Express, 29 July 2000). Since its inception, PICS has gained a good reputation for its many social initiatives including a multicultural housing project, agricultural workers employment, a homebound women's project, a sewing program, immigration consulting, and RCHC. PICS is currently developing plans for a value-added resource co-operative in the Lower Mainland, and is exploring an initiative around youth and co-ops. The reputation of PICS could not help but enhance the status of the young RCHC. When the Rainbow Community Health Co-operative was in its infancy PICS provided an instant array of community links to a new an untried co-op. Christine Liotta said of PICS:
The credibility of the sponsoring organisation, PICS, was huge in creating community involvement. People were used to coming to PICS for various services ... people were coming to an organisation that is connected to PICS; they weren't really aware of the co-op as an exciting new principle, but instead it was a familiar concept (Christine Liotta, 2000).
Thus far, PICS has played a pivotal role in the life of RCHC and it seems unlikely the co-op would have survived without the society's support.
Co-op Activities and policy
Under the auspices of PICS, RCHC directly addresses a number of key issues confronting the South-Asian community including substance abuse, prenatal care, HIV/AIDS, diabetes, heart disease, cancer prevention, depressions, family violence, and dental care. The co-op adhered to a community-based process to draw out the issues people felt needed attention.
Several methods were employed to ascertain how the health co-op should focus its activities. These included focus groups, research, and interviews with both regional health officials and community leaders. Meetings with members of the Surrey-Delta community allowed the most pressing issues facing ethnic minorities (particularly South Asians) to be brought to the forefront. Christine Liotta describes the process:
We went to the community and did a needs assessment, [held] focus groups and [conducted] surveys. What we found was that there was a need for a one-stop health centre where all people can come if they have any kind of questions regarding health without having a clinical aspect to it. There were so many needs identified. We considered what were the programs this co-op could focus on effectively without scattering energies. Determining priorities and getting it down to a list of some eight to ten [programs]. There are still a lot of unmet needs in the community, yet now the co-op is working on dental and so on. It was all about envisioning the best for the community (Christine Liotta, 2000) .
One of the ways the health co-op felt it could help meet the primary health care needs of people requiring health services was to ensure that physicians working at the clinic would take the full amount of time with the patient at the RCHC opted to pay the physicians it hired a salary, rather than on a fee-for-service basis. The co-op felt it important to ensure that doctors would spend sufficient time with their patients. Laul Verma explains:
Our doctors are on salary. [...]. They can see one patient per day, and they would receive the same wage if they saw forty patients a day. In terms of the physician, she or he doesn't have that urge to get more people through the door; they won't make any more money. So each patient that comes in, the doctor spends more time with them because that [person] is the owner of the co-op, a member of the co-op - and that is the person with the empowerment of the co-op (Monika Laul Verma, 2000).
In essence, this means that physicians who work at RCHC are employed by their patients. In addition to the doctors, members of RCHC have access to nurses, dentists, and social workers; this team makes up the co-op's core of service providers.
Organisation and structure
The Board of Directors is made up of nine individuals. It has an executive committee consisting of four of the board members. The Rules of the co-op state that there are to be nine directors in total; "three of whom shall be elected from among candidates put forward from [PICS], three of whom shall be elected from among health service providers, and three of whom shall be elected from the general membership." 8
If not enough positions are filled in the first two categories, the vacant positions may be filled by electing someone from the general membership. Although meetings were held quite frequently in the first fiscal year of the co-op, some members claim that meetings are now somewhat rare. There are rumblings among members that meetings actually occur so infrequently that some board members are really not involved with the co-op at all. Rosh Bharaj admits that there has been a "general lack of meetings in the last three years, since the co-op first emerged" (2000)." The feeling that only a few members of the co-op are directing all policy has become a point of tension.
Some of the current directors emphasise the importance of the close relationship between PICS and RCHC, and say the relationship is essential to the co-op's survival. It could be that this relationship and the overlap of people involved in both organisations are resulting in a conflation of meetings and decision-making. From an outsider's perspective it can seem difficult to untangle the relationship between PICS and the co-op. In the final analysis both organisations are subject to regulations; perhaps more importantly, each organisation is accountable to its members, and it is up to the membership to determine the organisation's direction.
Membership and fees
Membership in RCHC is open to anyone over the age of 16 years. Persons wishing to become members must apply in writing to the directors, who either approve or reject it. Upon joining the co-op, a fee of $5 must be paid; this grants the member one share (and one vote). The fee was determined in the co-op development advisory committee's initial meetings, which had a mandate to keep services accessible to all while not compromising the quality of the services rendered to clients.
Membership termination occurs after a member writes a letter to the association, after which the association gives the individual a refund equaling the amount s/he owns up to the moment of termination.
We wanted the fee structure to be accessible and not exorbitant for anyone. We made projections based on the present, and projected outwards three years. They were optimistic projections. The basic fee structure was based on the principle of making it as low as possible and not being a burden to members (Christine Liotta, 2000).
Members may hold up to twenty shares, but the co-operative principle of 'one member, one vote' stands. Shares are non-transferable, and joint memberships are not permitted.
RCHC and PICS' head office are currently operating from the same site in Surrey.They share space in a common administrative centre and waiting area in a building that is one block east of a major South Asian shopping district and only a ten-minute bus ride from a local temple. Although it is not an ideal location because of the number of warehouses and industrial operations in the area - the two organisations will be moving into new premises in the near future - it was nevertheless a strategic choice, given what was available and affordable at the time.
The RCHC waiting room has informative brochures regarding health, announcements pertinent to the South-Asian community, and upcoming events and clinics. This literature is a valuable link between the organisation and its members. This is a high traffic area, entertaining a variety of people awaiting service delivery and information, including access to HRDC computers and employment databases. Directly adjacent to the waiting area is the office of Monika Laul Verma. Beyond the waiting area are rooms specifically allocated for the use of RCHC, including two adjacent rooms containing dental equipment. Everything is as centralized as possible, given funding and space limitations; this centrality has been essential to the success of RCHC. As Laul Verma points out, RCHC "uses a holistic view of health and a multi-disciplinary approach to encourage individual and community health, and collaboration within the system" (2000). Unfortunately, a variety of funding issues and the nature of the collaboration has also had a substantial and frequently negative impact on the RCHS and the community it serves.
Financial and organisational support through partnerships
With a membership base of approximately seventeen hundred and fifty in July 2000, membership fees alone are hardly sufficient to cover the operating costs, staffing expenses, and numerous one-time costs assumed by the RCHC. In the three years since the co-op's incorporation in 1997 it is estimated that salary and operating expenses were $945,583 whereas revenue from fund-raising in that same period was about $23,000. Liotta says the board had decided to "[partner] with governments and other agencies for funding" quite early in the development of the co-op. Charan Gill agrees:
Even though we were very innovative, we thought we could only survive by collaborating with other resources. So we did, we collaborated with UBC [University of British Columbia] and many other people, pulling resources from other places, using it here for research or development whereby we could provide needed services to people (Charan Gill, 2000).
In order to ensure co-ordination and maximization of service delivery, RCHC has developed partnerships with the following community organisations: Surrey Memorial Hospital, the Boundary Health Unit, various private practitioners, alcohol and drug services, and mental health services. RCHC also has valuable relationships with the British Columbia Branch of the Canadian Alliance of Community Health Centre Associations, the Delta Credit Union, Guru Nanak Sikh Temple, the Heart and Stroke Foundation, Kwantlen College, and the UBC Faculty of Dentistry.
Of course, thus far the most important partnership for RCHC is the one with PICS. The next substantial partnership RCHC developed was with the University of British Columbia (UBC). In this collaboration the two groups are engaged in a five-year research project that is providing free dental care to co-op members who are seniors.9 The goal of the research is to determine if "preventive dental care makes for longer-lasting and stronger teeth for seniors (Vancouver Sun, March, 1998). In addition to its primary benefits, the existence of the dental program has meant the fledgling co-op has received a great deal of publicity, which has increased the co-op's profile in Surrey-Delta. Laul Verma says that knowledge of Rainbow's collaboration with such a credible institute as UBC has lead to helping the coop establish a level of legitimacy in research funding circles (Monika Laul Verma, 2000). Rainbow is now also partnering with the University of Washington, UBC, and the Boundary Health Unit in a research study called the Rainbow Smiles-Early Childhood Caries project. The five-year study, which began in 1999, aims "to evaluate the effectiveness of motivational interviewing in preventing early childhood caries in children between the ages of 6 and 18 months in South-Asian families." The children involved not only receive free dental check-ups but also gifts such as dental supplies.
Some attempts to collaborate have been as successful. Whereas RCHC was able to offer research opportunities to UBC, other prospective partners have not seen the potential benefits from such an alliance. Gill expressed his disappointment with government, credit unions, and other co-ops. He believes that the "credit unions are not keen to help out [because] everyone has their own agenda" (Gill, 2000) and he was dismayed over the lengthy proposal process demanded by government and co-operative organisations. His experience is that "[the] government has not helped us, the co-operatives say they'll give us money, [but] there are so many things attached, so many proposals," and adds, "[there are] too many problems and red tape, and we never get any money." From an outsider's vantage it seems that unless RCHC can make a strong case for the benefits of alliances, likely partners will not be interested in joining forces; at the same time, RCHC is determined to not compromise its own goals for the sake of increased funding.
Despite achieving some success with partnerships and with building links to various community groups such as schools, temples, other health organisations, RCHC still hopes to increase its connections to the broader community. The health co-op also wants to foster meaningful relationships with other co-operatives for moral support and perhaps for financial support.
Quest for funding support
Since its inception RCHC's financial shortfalls have largely been covered by the umbrella organisation, PICS. Devinder Sekhon tells it this way:
There was initial funding from the government [was $20,000.]10... Then after that there was no support to get it further. When it's a baby you really need to nurture it. We were able to sustain this co-op until now because of support from PICS. If the PICS board says no tomorrow then Rainbow won't be able to survive on its own,because PICS is a very established society and [has its] own accommodations and resources. PICS has been very generous to Rainbow (Devinder Sekhon, 2000).
PICS has been so essential to the success and continued existence of RCHC that some members are beginning to ponder an amalgamation of the co-op into the larger organisation.
The largest problem for the Rainbow Co-op, and indeed for many co-ops today, may be that governments and policy makers in Canada too often overlook the nature of co-operative organisations. As a result, policies often undermine the potential advantages and benefits of choosing to form a co-op. Co-operative associations are fundamentally different from non-co-operative organisations in their structure and, very often, in their purpose. It is a fact that co-ops take longer to organise and make into legal entities. However, it is also a fact that the survival rate of co-operative businesses is better than those of private or shareholder ownerships. Members of RCHC are frustrated with the obstacles the co-op has been encountering because of government regulations, policies, and attitudes. Charan Gill makes this clear:
The biggest problem is in a system, you must fit in. The system doesn't have to fit the people. It's such a bureaucratic mess, that's why things don't work. People out there are all different, from all over the place, and if [the co-op] wants to serve the needs of all these people you have to work differently with each group. The system needs to be much more flexible to accommodate this (Charan Gill, 2000).
Laul Verma agrees. She says, "[m]anaging a co-op is harder than managing a society because when you have a co-op, and your membership is open to the community, there are more people who will want to become members of the co-op, even if it's non-profit, than [join] a society"(2000). Laul Verma notes the RCHC's financial position makes it difficult to cover the costs associated with holding the annual general meeting, which are considerable considering the size of the membership. It is really a paradoxical situation, because the co-op wants its membership to be of a substantial size yet unless more financial support is forthcoming it is difficult to carry on the business of the co-op. Laul Verma points out that the Rainbow Community Health Co-op is non-profit organisation that is set up for the benefit of members, many of whom live below the poverty line. Therefore the co-op cannot expect its funding needs to be met by asking clients (that is, members) for more money. "One of the problems I think we are facing as a service co-op is we don't have revenue coming in," Gill says bluntly. "That's the biggest problem we have." And he adds that although the government seems to support the idea of co-ops, it is reluctant to provide much more than initial funding. "Many co-ops die due to lack of support," he says.
Laul Verma and Gill's experiences are evidence that not much has changed for co-ops in the past ten years. In 1990 Angus and Manga reported that one of the major reasons for limited growth in the health co-op and community health care sector was inadequate funding by governments, and the difficulty of acquiring non-governmental revenues (Angus and Manga, 1990).
There is some suspicion among members that the lack of government and sector funding is related to its reluctance to associate with 'troubles' in the Indo-Canadian community. Rosh Bharaj suggested that government's apparent disinterest in providing some financial support coincided with media reports of division and violence in the South Asian immigrant community. He says:
Rainbow arose around the same time that the South-Asian community was being portrayed in the media as highly segmented due to recent events in the temples and abroad. The government discontinued its funding of RCHC at this exact time, because perhaps it felt that it was wise not to invest in our community. These are ethno-specific barriers to funding, both from the government and the business sector, that [are] tainted when it sees all these things in the media. All of these socio-political divisions, self-perpetuated or not, real or untrue, have a major role in the financial woes of Rainbow (Rosh Bharaj, 2000) .
If these suspicions were somehow proven to be true it would be an unfortunate state of affairs. Canada's cultural 'mosaic' is viewed by many, including governments, as one of the country's strengths, as are Canada's democratic ideals; still there are enough examples of the apparent inequitable distribution of governments monies, either through taxation practices or revenue distribution, to suggest that something may be amiss.
The RCHC in the Community
Financial woes and frustration aside, RCHC has made a significant impact on the community it strives to serve:
Once a community gets involved ... you become their centre for everything. The other day we received a call from a woman who wanted assistance in soliciting the municipality to install a bus stop bench for her to sit on. Not just are we providing health services, but just as we are to her, we are a vital link for many South Asians to a world that is largely negligent of their needs (Monika Laul Verma).
RCHC has become more than a mere provider of community health-care. It is an outreach program, distributing information on a broad variety of subjects and taking on a life of its own within the community. As the manager of RCHC's programs, Monika Laul Verma experiences this first-hand:
People call us all the time to apply for Medicare cards, yet we don't advertise that we even have applications here. There are special government programs for people who are earning $30,000. per year and less. One of these programs is called "Healthiest Baby Program." It is premium assistance given by the government, and people in the South-Asian community simply do not know about it. Now out there, if they went to a doctor or elsewhere, that info would not be given to them. So it becomes more than a medical clinic, it literally becomes a people's community health centre, with a community that is very much connected to it (Monika Laul Verma, 2000).
The RCHC has become a combination of medical clinic, information centre, and advocacy group for the Surrey-Delta region, all while providing numerous services and programs specifically oriented towards health-care provision and maintenance.
The health-care concerns outlined by the steering committee during the development of the RCHC - substance abuse, prenatal care, HIV/AIDS, diabetes, heart disease, cancer prevention, depression, family violence, and dental care - continue to be of special concern to the South-Asian community, but the weight of each of these concerns has fluctuated over time so that RCHC is able to better respond to the needs o the community it serves. Dental service has proven exceptionally popular and necessary, with 400 people on the wait list in the summer of 2000 (Laul Verma, 2000).
RCHC offers programs on anger and addiction counseling, anger management, drug and alcohol management, health and wellness, parenting and family classes, and various support groups. One of these services is assistance to seniors who are looking after grandchildren. The co-op also provides emergency dental care, sponsors an Alzheimer's outreach program, engages in fundraising activities and participates in an annual health fair held in conjunction with Kwantlen College.11 Services not directly related to health include translation, resource materials, general information and referrals (usually through PICS). Programs and services are available in English, Hindi, Punjabi, Urdu, and Gujrati. In essence, RCHC is far more than a health-care co-op to its community and clients.
Culturally sensitive services
Issues surrounding sexuality, STDs and birth control are difficult for any society to manage effectively. While all societies share this reticence, some members of visible minority and immigrant populations may feel this discomfort more acutely. For example, "AIDS is an issue that no community, regardless of its cultural make-up, is immune from. This is why the RCHC fills a great void by addressing it head-on" (Laul Verma, 2000). The Surrey Needle Exchange Program is used by an unusually high percentage of South Asians. Education that is aimed specifically at the South-Asian community is needed to help counter the growing use of drugs, including alcohol. The health co-op addresses issues that many in the South-Asian community would prefer not to acknowledge.
In addition to culture, language plays a large role in the mission of the RCHC. A less familiar concern in Canadian society than drugs or AIDS is the great sensitivity towards issues of propriety. According to Assanand et al (1990) the relationship between patients and physicians is typically much more formal in South Asia than it is in Canada. Many Canadian medical institutions, for example, do not take into account the stress South-Asian women often feel in anticipation of a visit to a doctor's office, let alone the prospects of a breast examination at a doctor's office, regardless of the health benefits that may accrue. As well, "South Asian women tend to be hesitant and shy about being examined and treated by male physicians and both they and their husbands believe that women should have a female doctor"(Assanand et al, 1990, p. 163). One of the goals of the Rainbow Health Co-op is to acknowledge linguistic and cultural barriers and put in place information and culturally-sensitive programs that respond to the particular needs of South Asians and others. One example has been to create culturally sensitive education programs that teach women to perform breast self-examinations. When the co-op circulated information regarding a free prostate cancer clinic it was conducting, line-ups occurred around the block; hundreds of men attended the clinic. Many of these participants had been unaware of both the cancer and the potential life-saving treatments available. RCHC had identified the gap and put in place a program understood by members of its community. RCHC not only brought these issues before the South-Asian community but also, by default, to the attention of the Canadian medical establishment. These are the kinds of insightful and responsive activities that take place at the RHCH.
Impact on the community
Evidence for the profound impact of the RCHC is easy to find. Handling all of these vital community needs, many of which were simply never addressed before the creation of the co-op, has made a strong impression. Informative clinics on diet and nutrition, general well-being, and various medical procedures are well attended and help to impart important information to the community. In one case, a recent initiative to address the growing rate of heart disease proved very successful, and the Canadian Cancer Society has been working closely with Rosh Bharaj on a series of seminars and clinics. Most important, perhaps, is the effect on the community's mental well-being as PICS and RCHC combine employment, health care and education initiatives in an over-all program of social care. As Laul Verma says, "... we are not only developing employment but we are actually creating healthier communities, which have a lasting impact. We have planted a seed, given them self-esteem, [and] empowered them because they are the part-owners of the co-op." The RCHC has made great strides despite the difficulties it has experienced, but it is becoming clear that some changes may be needed.
One of RCHC's key challenges is to obtain funding that will sustain the delivery of its various programs and services. Monika Laul Verma knows that obtaining sufficient financial support for the non-profit co-op is of paramount importance. "I think, being a non-profit co-op, I would like to see the business sector and the public sector help the co-op financially if they could," says Laul Verma. She remains committed to the co-op model, declaring it the "best model for the betterment of the community."
Devinder Sekhon realises that the co-op model works well in terms of having widespread community involvement and ownership, but is concerned because the co-op "doesn't have the financial resources [...] to survive on its own." Sekhon thinks that Rainbow is becoming too expensive for PICS to maintain in its current form. "Basically, it is heavily relying on PICS for administration, for other things, for accommodation. It's a drain with two administration structures," he says, "and without special funding for co-ops, we can do it more cheaply as an off-shoot of PICS." Whatever happens with RCHC, Sekhon insists the "service [it provides] will remain regardless" because the need remains.
Charan Gill accepts that something must change and admits there is a debate about amalgamating the coop into PICS under [the] Rainbow Health Project. The discussion is likely not an easy one. Like other people involved with the co-op, Gill feels strongly that there "has to be something in the legislation and in the government view as to how they can help co-ops, especially service co-ops that provide health and dental care to society's poorest people." They simply cannot survive on their own. He points out that circumstances for non-profit co-ops are different from those of other kinds of co-ops, and as such they require special consideration.
The Rainbow Community Health Co-operative continues to make ambitious plans in spite of the uncertainties it is facing. Greatly influenced by community response and appreciation, RCHC leaders are seeking new initiatives to serve the South-Asian community better, including daycare services and a pharmacy. Laul Verma believes that the pharmacy in particular will benefit both the community and the co-op. "With the addition of a pharmacy, we would be more solid [financially]," she says. "Since we are non-profit, all the resources from the pharmacy would go directly to the co-op." Laul Verma is interested in having all health-care related services at a single location; the possibility of an integrated, multi-faceted co-operative facility seems appealing. A community co-operative in Chile that has its own hospital, school, daycare, and community centre has come to her attention and she is following its next stages of growth and development closely.
Central to these plans is the new PICS/RCHC building, with a Seniors Multicultural Housing project to be the first section opened. The new building will be located nearby a major shopping district, surrounded by stores and other community services. Furthermore, the new building will be more visible to the public and easy to access as it is situated near Scott Road, a major roadway. The groundbreaking ceremony for the new building, which includes $350,000 in facilities for Rainbow, is scheduled for September 21, 2001.
The new building will include a 3700 square foot community health centre with in-house medical and dental offices, and will host educational seminars on pension and health issues for seniors, among other services.12
RCHC wishes to develop programs aimed at senior care. With the establishment of a Seniors Housing Facility by PICS, any initiatives undertaken by RCHC would be useful and fruitful. As it stands, the South Asian community does not have sufficient programs or initiatives that are directed at seniors13. RCHC is acutely aware that more and more seniors require health-related services which are culturally sensitive. In Surrey-Delta many seniors are falling between widening cracks in both health and social systems that seem to be turning their backs on our retired citizens. One of the factors contributing to the problem is the change in the way family members care for one another. For example, in many instances the grandparents in South Asian families are caregivers to their young grandchildren. However, their own children, who have very busy lives, too often are unable or unwilling to provide emotional and practical support to their parents. In their study, Assanand et al (1990) claim that that the health of many elderly South Asians, especially those who have recently arrived in Canada, is being compromised by the uneven consequences of cultural changes. The authors explain that the married children have taken over running the household and in doing so the elderly South Asians experience a "reversal of traditional patterns of dependence and authority [which] can cause conflicts and a loss of self-esteem and depression in the elderly"(p.156). Assanand et al explain: "Especially in situations where both parents are working, the elderly person may be given the responsibility of housework and babysitting. Family members who are preoccupied with becoming established may have little time to devote to ageing parent who lack linguistic skills and confidence to venture out on their own" (p. 156).
The conflicts and other negative repercussions of these circumstances are usually kept within the confines of the families but there is evidence that if services to help the elderly are available, they will be used. The other factor contributing to the unmet needs of elderly South Asians is the inability of the Canadian health system to recognise and properly address the ramifications of changing family practices, and, in this case, their impact on the health of South Asian seniors. Situations such as this are intensifying the need for services for seniors, and the necessity for the Rainbow Community Health Co-op to fill the widening gaps.
Expanding into other locations
RCHC (and PICS) are considering expanding their services into other regions in the Lower Mainland, notably the community of Abbotsford in the Fraser Valley. South of Surrey-Delta, Abbotsford is emulating the Surrey-Delta area. Devinder Sekhon believes that many South Asians are attracted to the Abbotsford area because its rural, agricultural character is much like India itself. Furthermore, as the population density increases in Surrey-Delta, many South Asians are becoming interested in Abbotsford. RCHC already sees many South Asians living in nearby communities in the Fraser Valley who make the trek to Surrey to use the co-op's services. These people are often agricultural workers and senior citizens who feel neglected by the current medical system: "We have a lot of members from Mission, Abbotsford, that whole area there," says Laul Verma. "And they come for the emergency dental clinic; there is no service like this anywhere [else]." She also notes the co-op receives clients from Vancouver, White Rock, and other Lower Mainland communities, which indicates that Abbotsford is not the only potential source for expansion. The similarities between Abbotsford and Surrey-Delta make it very likely that the Abbotsford area would benefit greatly from the kind of localized health-care service that Rainbow provides in Surrey-Delta.
How the Rainbow Community Health Co-operative manifests in the future is uncertain. Within the organisation people are stating things must change, if only to deal with the ongoing financial problems the co-op experiences. A new provincial government dedicated to its own notions of "fiscal responsibility" will likely not make the financial picture any easier. However, if RCHC continues to be supported as strongly as it has been in the past by PICS the co-op is likely to survive and prosper. The Rainbow Community Health Co-operative will move into the new building later in 2002, gaining a renewed sense of purpose along with its new facilities.
1 Surrey is city near Vancouver, in British Columbia's sprawling Lower Mainland region (population 350,000, Municipal Stats 2000). Situated next to Surrey, Delta is a district comprised of three communities: Ladner (pop. 22,000), Tsawwassen (pop. 22,000), and North Delta (pop. 50,000). For the purposes of this study the city of Surrey and the Corporation of Delta will be referred to as Surrey-Delta.
2 For the purposes of this essay, the designation "South Asian" refers to any individuals who are either from the Asian sub-continent, or demonstrates descent from such an individual. This can include India, Pakistan, Bangladesh, Nepal and Sri Lanka, but can also refer to the larger diasporic community in Canada, England, Fiji, East Africa, and other places (Assanand et al, 1990).
3 In Canada's prairie provinces there are 15 health co-ops, Ontario and Prince Edward Island each have 3, Quebec and Nova Scotia each have 7.
4 Although the RCHC remains British Columbia's sole co-op, other notable co-ops in Canada include the Evangeline Community Health Centre Co-operative (located in Wellington, PEI), employing a dentist and two general practitioners in a health centre which focuses on prevention and maintenance. It has interdisciplinary programs designed to promote social health and well-being. The Evangeline area has the highest co-op density in Canada, and the health co-op serves Acadians, a distinct minority population. The Evangeline example, with its minority constituents and the economic success of the Acadian co-operative tradition, mirrors the experiences of the South Asian community in Vancouver most directly.
5 By "umbrella organisation" we mean that PICS started RHCH and continues to be deeply involved in the facilitation, administration and operation of the RHCH on many levels.
6 PICS is a United Way Member and Affiliate Agency with a broad community-based mandate. More information about PICS is provided further on in this study.
7 Dr. Cheema became the B.C. Minister of State for Mental Health in June 2001.
8 This information is available in the Appendix D of Liotta (1997).
9 Study participants must be seniors. This has attracted many volunteers, not all of whom are Indo-Canadian.
10 The funding received from government for start-up was $20000, according to Charan Gill (e-mail, September 11 2001).
11 Located in the Lower Mainland of British Columbia, Canada, Kwantlen University College serves over 25,000 students on four campuses. Two campuses are situated in Surrey, one in Langley, and one in the nearby municipality of Richmond.
12 For more information see PICS website: http://www.picssociety.com
13 The South Asian senior population in Canada, approximately 200,000 people in 1996, is expanding rapidly, and will increasingly have an impact on the Canadian health care system.
Angus, Douglas E., and Pran Manga. "Co-op/Consumer Sponsored Health Care Delivery Effectiveness." Ottawa: The Canadian Co-operative Association, 1990.
Assanand, Shashi, Maud Dias, Elizabeth Richardson and Nancy Waxler-Morrison. "The South Asians." In Cross-Cultural Caring:AHandbook for Health Professionals. Eds. Nancy Waxler-Morrison, Joan M. Anderson and Elizabeth Richardson. Vancouver: UBC Press, 1990.
BC Stats, (1997a, October 29), "1991 Census Profile - Abbotsford."
BC Stats, (1997b, October 29), "1991 Census Profile - Delta North."
BC Stats, (1997c, October 29), "1991 Census Profile - Surrey-Newton."
Bolan, Kim. "Health co-operative in Surrey offers free dental care." In The Vancouver Sun. March, 1998.
"Health co-op open to both Delta and Surrey residents." The Province. 22 November 1997: B2.
Liotta, Christine. Rainbow Community Health Co-operative (Health Care Centre for Surrey Delta): Three-Year
Business Plan. Unpublished report, 1997. "PICS launches Rainbow Community Health Co-op." In Indo-Canadian Voice. 7 March 1998