Indige­nous Peo­ples’ Health: Our Big­gest Chal­lenge to Rec­on­cil­i­a­tion

Policy - - In This Issue - Robin V. Sears

In an­nounc­ing his gov­ern­ment’s plan for a new ap­proach to Indige­nous rights in Fe­bru­ary, Prime Min­is­ter Justin Trudeau told the House of Com­mons, “We need to get to a place where Indige­nous peo­ples in Canada are in con­trol of their own des­tiny, mak­ing their own de­ci­sions about their fu­ture.” Vet­eran pol­icy ad­viser Robin Sears writes that the gov­ern­ment’s ap­proach to Indige­nous health care should re­flect that same spirit.

Few would ar­gue that first con­tact be­tween Euro­peans and Indige­nous peo­ple around the world was usu­ally deadly for those com­mu­ni­ties. The mas­sive death tolls were less from mil­i­tary slaugh­ter than from epi­demics.

Sadly, few today would ac­knowl­edge that the legacy of disastrous health im­pacts con­tin­ues, which, demon­stra­bly, it does.

The list of pri­or­i­ties fac­ing those in gov­ern­ment at­tempt­ing to ac­cel­er­ate the pace and breadth of rec­on­cil­i­a­tion with Canada’s first peo­ples is long. It in­cludes ev­ery­thing from treaty im­ple­men­ta­tion to re­source rev­enue-shar­ing to the gran­u­lar de­tail of shared-gov­er­nance agree­ments.

But in its im­pact on the lives of Cana­dian Indige­nous fam­i­lies, noth­ing ranks higher than gen­uinely im­prov­ing health care and health out­comes.

Eco­nomic de­vel­op­ment suc­cesses will be un­der­mined if Indige­nous chil­dren con­tinue to suf­fer many times higher lev­els of di­a­betes, as they do today. Greater pros­per­ity—on and off re­serve—means lit­tle to the par­ent of a child with lost teeth and rot­ting gums, or asthma, tempted into sui­cide.

Even progress in im­prov­ing ele­men­tary school ed­u­ca­tion can­not be sus­tain­able if chil­dren are raised on bac­te­ria-laden wa­ter tanks car­ry­ing tu­ber­cu­lo­sis and other dis­eases.

The di­ets too many of us live on today—heavy on starches, sugar and un­sat­u­rated fats, highly pro­cessed and fi­bre-poor—are clearly not healthy for any­one. For Indige­nous chil­dren whose cul­ture does not in­clude cen­turies-long adap­ta­tion to our ap­petites, they can be fa­tal.

These in­her­ited and so­cial de­ter­mi­nants of health have enor­mous im­pact at both ends of the life cy­cle. A Man­i­toba study re­ported in­fant mor­tal­ity rates for abo­rig­i­nal chil­dren at twice those of other Cana­di­ans, sud­den death syn­drome in in­fants at seven times. In­fants in First Na­tions fam­i­lies are twice as likely to be hos­pi­tal­ized be­fore their first birth­day, ac­cord­ing to a Québec study.

Indige­nous peo­ple are more than twice as likely to die of avoid­able causes be­fore they are 75 than other Cana­di­ans. In the most at-risk groups, they are five times more likely to die younger. The range of health threats runs from di­a­betes to high blood pres­sure, to kid­ney dis­ease and tu­ber­cu­lo­sis.

This is the enor­mous chal­lenge fac­ing the fed­eral gov­ern­ment and Indige­nous lead­ers across Canada as they at­tempt to make the first real progress in im­prov­ing the sus­tain­able health of Canada’s most at-risk com­mu­ni­ties. Ot­tawa ap­par­ently un­der­stands that there is no one fix for the wide ar­ray of is­sues. For ex­am­ple, Inuit rates of TB are 300 times higher than non-Indige­nous Cana­di­ans, and trend­ing up­wards. In March, Ot­tawa an­nounced with Inuit Tapiriit Kanatami (ITK) pres­i­dent Natan Obed a tar­get date for the elim­i­na­tion of TB across all tra­di­tional Inuit ter­ri­tory, with more fund­ing to come.

Ot­tawa com­mit­ted $1.5 bil­lion over five years to Indige­nous health-care ser­vices in this year’s bud­get and an ad­di­tional $173 mil­lion to elim­i­nate toxic wa­ter on re­serves, on top of the $1.8 bil­lion promised last year. But the chal­lenge is far, far big­ger than that, and more money alone is not even a suf­fi­cient an­swer.

Among the stun­ningly grim health and child wel­fare statis­tics is this: al­though Indige­nous chil­dren make up only 7.7 per cent of all chil­dren, they rep­re­sent more than half of all the chil­dren in fos­ter and other forms of care, nearly eight times more likely to be in care than other Cana­dian chil­dren.

Com­par­isons to the tragic im­pact of the “six­ties scoop” or the res­i­den­tial schools scan­dal would be un­fair, but it is un­de­ni­able that chil­dren fos­tered out­side their fam­ily, com­mu­nity and cul­ture al­ways face far higher ob­sta­cles in life.

This year’s bud­get also pledges to pump an ad­di­tional $1.4 bil­lion into Indige­nous child wel­fare over the next six years with a fo­cus on pre­ven­tion. Sev­eral prov­inces have ramped up their com­mit­ments to abo­rig­i­nal child health ser­vices. Many bands and re­gional First Na­tions or­ga­ni­za­tions have been in­creas­ing their com­mit­ments to child­care, lo­cal clin­ics and train­ing as well.

Sadly, each of these ef­forts faces a range of bar­ri­ers to suc­cess. On re­serve, es­pe­cially in re­mote com­mu­ni­ties, it is im­pos­si­ble to serve a com­mu­nity mem­ber with a chronic health con­di­tion—tu­ber­cu­lo­sis, re­cur­rent pneu­mo­nia, late stage kid­ney or liver dis­ease—lo­cally. So, care must be of­fered, of­ten re­quir­ing long dis­tance, high-cost air travel, over long pe­ri­ods of treat­ment in a dis­tant city.

Guar­an­teed ac­cess to safe drink­ing wa­ter be­gins with heavy cap­i­tal ex­pen­di­ture on chem­i­cal and bac­te­rial fil­ters, pumps, stor­age and plumb­ing, but it is sus­tain­able only with ex­pert op­er­a­tion and su­per­vi­sion by a trained team. As Walk­er­ton and other ex­am­ples trag­i­cally re­vealed, that guar­an­tee col­lapses if even one per­son makes a late or wrong de­ci­sion.

Huge sums have been wasted in re­cent decades on abo­rig­i­nal health pro­grams: fool­ishly ex­pen­sive, re­motely de­liv­ered so­lu­tions to is­sues that could have been man­aged lo­cally, du­bi­ous busi­ness part­ners cho­sen to host adult and child pa­tients in big ci­ties more in­ter­ested in higher prof­its than bet­ter ser­vice. These are stop­gap so­lu­tions to re­cur­ring crises rather than in­vest­ment in pre­ven­tion, train­ing and sus­tain­able so­lu­tions.

These fail­ures have en­gen­dered deep cyn­i­cism on the part of many of­fi­cials and politi­cians about the in­tractabil­ity of the prob­lem, and de­spair on the part of par­ents whose chil­dren are the vic­tims of these re­peated fail­ures. The lev­els of health and child wel­fare ser­vices pro­vided to Indige­nous fam­i­lies have been justly con­demned by the Cana­dian Hu­man Rights Tri­bunal. More money is re­quired. But real re­form is also es­sen­tial. Fund­ing must go

These in­her­ited and so­cial de­ter­mi­nants of health have enor­mous im­pact at both ends of the life cy­cle. A Man­i­toba study re­ported in­fant mor­tal­ity rates for abo­rig­i­nal chil­dren at twice those of other Cana­di­ans, sud­den death syn­drome in in­fants at seven times.

to chil­dren, fam­i­lies and com­mu­ni­ties and not to lawyers and agencies to ap­pre­hend chil­dren and move them to non-Indige­nous fos­ter fam­i­lies.

More train­ing and ca­pac­ity-build­ing in com­mu­ni­ties is as es­sen­tial here as it is in any part of an over-bur­dened health care sys­tem. But as provin­cial gov­ern­ments have dis­cov­ered in re­cent years, merely in­creas­ing spend­ing at twice the rate of in­fla­tion, al­low­ing health care spend­ing to rise to more than dou­ble that of ed­u­ca­tion fund­ing, does not by it­self change health care out­comes—and it does be­gin to crowd out other es­sen­tial pro­grams.

Cana­dian hos­pi­tals are not world-beat­ers on the gov­er­nance and ac­count­abil­ity scale. They are heav­ily stove-piped in­ter­nally, of­ten ad­min­is­tered by med­i­cal rather than man­age­ment pro­fes­sion­als, with lead­ers hes­i­tant to dis­ci­pline their for­mer med­i­cal col­leagues. They are gov­erned by cit­i­zen boards whose ac­cess to the re­al­ity of “life on the ward” is de­lib­er­ately kept lim­ited; big city hos­pi­tals strug­gle to mea­sure let alone im­prove out­comes pre­dictably.

Some pi­o­neer­ing Cana­dian med­i­cal pro­fes­sion­als have fought to cre­ate multi-pur­pose clin­ics as the first line of health care de­liv­ery. They choose the makeup of their teams in­clud­ing psy­chol­o­gists, nurses, doc­tors and aides. They re­ceive fund­ing on a per-pa­tient ba­sis an­nu­ally, and they are deeply com­mit­ted to putting pa­tients and their health out­comes first.

There are sim­i­lar coura­geous pioneers in Indige­nous health, such as the Wa­bano Cen­tre in Ot­tawa and their peers in sev­eral ci­ties across Canada. Pioneers like Carol Hop­kins, founder of the Thun­der­bird Part­ner­ship Foun­da­tion, who has de­voted two decades to cul­tur­ally sen­si­tive ap­proaches to men­tal well­be­ing and al­ter­na­tive ap­proaches to sub­stance abuse treat­ment. Bri­tish Columbia has been a leader, with its First Na­tions Health Au­thor­ity and Health Coun­cil. These are all sources of in­valu­able coun­sel on how to do Indige­nous health bet­ter.

Why would we want to squeeze Indige­nous health care into a sys­tem al­ready strug­gling to serve its chang­ing de­mo­graph­ics, one fo­cused on hos­pi­tal care, and re­mote from the lives of most Indige­nous fam­i­lies to be­gin with? It is hard to ar­gue that Indige­nous health out­comes wouldn’t be im­proved sig­nif­i­cantly if health care were more of­ten de­liv­ered by com­mu­nity man­dated and op­er­ated clin­ics, as the en­try point to the sys­tem in ci­ties and on re­serve.

If First Na­tions, Inuit and Métis gov­er­nance bod­ies, con­tracted with health agencies and hos­pi­tals, had the power to de­ter­mine bud­get pri­or­i­ties, cul­tur­ally ap­pro­pri­ate ap­proaches to treat­ment and a com­mit­ment to de­liver pro­grams of ed­u­ca­tion and pre­ven­tion, it is hard to imag­ine that this would not pro­vide a bet­ter long-term foun­da­tion for Indige­nous health care de­liv­ery and bet­ter health out­comes.

Cana­di­ans have in­vented a new model for a uni­fied wel­fare and so­cial ser­vice de­liv­ery known as the “Com­mu­nity Well­be­ing and Safety Hub”. In­vented by some in­no­va­tive po­lice and so­cial ser­vice lead­ers in Saskatchewan, it has spread across Canada. These coura­geous pioneers’ epiphany was that sud­den rises in risk lev­els – drop­ping out of school, fam­ily mem­ber sent to or re­turn­ing from prison, ev­i­dence of do­mes­tic dis­rup­tion and vi­o­lence— are of­ten pre­dic­tors of tragedies on the hori­zon. Shar­ing the in­for­ma­tion with the agencies who can in­ter­vene in ad­vance of dis­as­ter has saved hun­dreds of lives.

To make these hubs work re­quired break­ing down pri­vacy si­los, and grant­ing ac­cess to in­for­ma­tion about shared clients. This meant cre­at­ing the pro­tec­tions and per­mis­sions that would al­low such a process to op­er­ate with­out putting pri­vate data at risk. The orig­i­na­tors cre­ated a four-level sys­tem of proofs and pro­tec­tions, to de­liver such a guar­an­tee. In its lat­est it­er­a­tion, the Hub pioneers have be­gun us­ing tech­nol­ogy to be­gin to de­liver ser­vice re­motely, over long dis­tances. Em­ploy­ing se­cure broad­band links and iPad-like de­vices, clients and ser­vice de­liv­er­ers can com­mu­ni­cate se­curely in live real-time video con­ver­sa­tions. It is not hard to imag­ine how an ur­ban-based Indige­nous health agency could serve both their lo­cal clients and iso­lated com­mu­ni­ties many kilo­me­tres away with both emer­gency re­sponses and reg­u­lar check­ups.

Five years from now, af­ter a gen­er­ous in­crease in fund­ing, in­cu­bat­ing new pre­ven­tion and de­liv­ery mod­els for Indige­nous com­mu­ni­ties, and fo­cus­ing on out­comes not in­puts, we may be able to look back on 2018 as the year when we started to slow the rise of the ap­palling health trend­lines for the first peo­ples in Canada.

Look­ing back to the days of first con­tact, an­other tragedy was the de­struc­tion and dis­ap­pear­ance of tra­di­tional cul­ture and learn­ing, in­clud­ing tra­di­tional health care and medicines. Today tra­di­tional Chi­nese medicine is boom­ing, be­ing de­vel­oped along sci­en­tific phar­ma­ceu­ti­cal lines, as are the South Asian ayurvedic natur­o­pathic teach­ings and ther­a­pies.

Would it not be a gra­cious con­tri­bu­tion to rec­on­cil­i­a­tion if ef­forts were made to re­cover and re­store some of the Cana­dian Indige­nous health teach­ings as part of a re­formed health care de­liv­ery sys­tem?

It could rep­re­sent a highly sym­bolic bend­ing of the arc of our so-of­ten tragic re­la­tion­ship, to­ward gen­uine rec­on­cil­i­a­tion. It could serve as an em­pow­er­ing gift to a new gen­er­a­tion of Indige­nous chil­dren. It could cap an en­dur­ing legacy for the part­ners and gov­ern­ments that helped to achieve a new level in bet­ter health, for the next gen­er­a­tion of the first peo­ples of Canada.

Matt Ush­er­wood, iPol­i­tics photo

Na­tional Chief of the Assem­bly of First Na­tions Perry Bel­le­garde, Min­is­ter of Crown-Indige­nous Re­la­tions and North­ern Af­fairs Carolyn Ben­nett and Min­is­ter of Indige­nous Ser­vices Jane Philpott take part in a press con­fer­ence dur­ing a two-day emer­gency...

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