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8 steps toward addressing Indigenous health inequities


The health inequities between Indigenous and non-Indigenous Canadians have long been shamefully apparent – the various studies finding infant mortality rates in Indigenous populations to be 1.7 to four times that of non-Indigenous populations; the diabetes prevalence that’s nearly twice that of non-Indigenous people; the fact that Indigenous people are six times more likely to suffer alcohol-related deaths; and many more.

These disparities have become normalized and accepted, says Alika Lafontaine, president of the Indigenous Physicians Association of Canada and an anesthesiologist in Grande Prairie, Alberta. There are signs, however, of increasing recognition from all levels of government that a multitude of efforts and massive, structural changes are required to address the health crisis. “I think many Indigenous leaders have a glimmer of hope now,” says Darlene Kitty, a family physician who serves members of her Cree Nation of Chisasibi community in James Bay, Quebec. Prime Minister Justin Trudeau has promised major funding for Indigenous education and other areas, as well as to implement all 94 recommendations of the Truth and Reconciliation Commission of Canada. One of the recommendations calls for the federal government, in consultation with Aboriginal people, “to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities.”

Of course, calling for the health gap to be addressed is one thing. Addressing it is another. That’s why, in support of the TRC’s call, we reached out to 10 people who provide frontline health care to Indigenous people, researchers in Indigenous health and Indigenous leaders. We asked what health system-level changes – big or small – are necessary to begin to address the health crisis facing Indigenous peoples. What follows is meant to provoke a greater understanding and more conversation around the many barriers to health that Indigenous people face at the federal, provincial, local and clinic levels.

1) Better support for health workers in Indigenous communities

Many nurses who serve on-reserve populations are expected to do everything from obstetrics to immunizations to diabetes treatment to mental health counselling. “The turnover rate of registered nurses in Indigenous communities is extremely high,” says Shelly Gladue, director of community and public health for the Bigstone Health Commission, which provides home and community health programs for the Bigstone Cree Nation in Alberta. “It’s a really big learning curve. It overwhelms the individual.” She thinks that providing training and mentorship opportunities can go a long way to help federally funded nurses feel better supported. As Kitty points out, “I hear a lot of stories of nurses providing care on reserve communities but they don’t have the trauma training or the Advanced Cardiac Life Support training that they need.” But increased funding for nursing staff is necessary, too; the Canadian Association of Nurses recently pointed out that nurses are often unable to leave work to attend training sessions due to inadequate staffing levels.

Kitty adds that the health workers should also be provided time to interact with the culture and people they care for – time that isn’t always afforded in communities with staffing issues. “Health workers should be invited to events at youth centres, to go fishing or hiking, to learn some of the language or to have meals with families,” she says. “You need to engage with the community and culture to appreciate its challenges and its resilience, to build good relationships with patients, and to feel rewarded in the work you do.”

2) Address prejudice among health workers

Lafontaine says that, too often, health workers let media narratives prejudice their encounters with individual patients. “We’ve done tons and tons of health research but I think what we’ve got out of it is ‘Indigenous people are supposed to be a suicidal, they’re supposed to be addicted to drugs, they’re supposed to not care about their health,’” he says. “Many times, I’ve overheard other colleagues ask if the Indigenous patient is diabetic and they say no, and they ask the question eight more times, like they’re lying or they’re ignorant about their health.” Examples abound in Canadian health care of missed diagnoses resulting from the assumption that a person’s symptoms are related to addiction. Notoriously, Brian Sinclair died of a bladder infection after health professionals largely ignored him for 34 hours, assuming he was sleeping off drunkenness.

In his cross-country lectures, Lafontaine explains that “no health worker wakes up and thinks, ‘I’m going to do harm to Indigenous patients today,’” but, without recognizing it, health workers too often treat Indigenous patients based on previous patient encounters and media reports. Some, including Tailfeathers and Kitty, think mandatory cultural competency courses could help – and the TRC is calling for such courses to be required for medical students.

In addition, health workers should question their treatment of Indigenous patients, Lafontaine says, asking, “Am I diagnosing based on what the patient is telling me and test results, or is prejudice factoring in?” says Lafontaine. Janet Smylie, a Métis family physician and research scientist at the Centre for Research in Inner City Health, has also written an article suggesting ways those involved in health care delivery can advance reconciliation and respect.

3) Provide benefits for Indigenous people not recognized by the Indian Act

Gloria Fraser, director of the Nunee Health Authority in Fort Chipewyan argues that many Indigenous peoples not recognized as “Status Indians” by the federal Indian Act should qualify for federal Non-Insured Health Benefits (NIHB). Currently, Métis are not eligible for these benefits, which cover drugs, as well as travel and accommodation to access needed care. “Métis people also went to residential schools and are dealing with the trauma from that in their community, but they don’t receive the same health benefits,” says Fraser. The discrepancy is especially becoming acute as more and more services, including breast cancer screening, are not available in Fort Chipewyan and require a $500 to $1,000 round-trip flight. “It’s a huge barrier for our clients,” says Fraser.

The coverage is also necessary for those in urban areas, where most Indigenous people in Canada reside, adds Smylie. Numerous studies show poverty is “a major barrier to accessing required prescription medications and dental care for Indigenous peoples in urban areas who do not qualify for NIHB,” says Smylie.

4) Put less addictive pharmaceutical options on the formulary

At the Blood Indian Reserve in northern Alberta, approximately half of the 70 people who have died in the past year died from an alcohol or opioid addiction – largely Fentanyl, says Esther Tailfeathers, a family and emergency physician who serves the community.

Various estimates suggest opioid-related causes account for upwards of 1,000 deaths of Canadians each year. The epidemic has especially hit Indigenous communities, with more than half of the inhabitants of some communities struggling with dependencies. In some cases, the drug may be prescribed; in many other cases, they come from the black market. Inevitably, however, when Tailfeathers asks her patients how they got addicted to Fentanyl, they explain it started with opioids prescribed by their doctor.

The federal government can curb this crisis by funding less-addictive options, several of which are more expensive and not on the formulary for Non-Insured Health Benefits, says Tailfeathers. For example, Gabapentin, a powder-containing capsule is currently being mixed with crushed Fentanyl in southern Alberta to create a drug known as “Oxy 80”. Its counterpart, Lyrica, which has less potential for abuse, is not on the formulary.

5) Collaborate more across service providers

Sol Mamakwa, health director of the Shibogama First Nations Council in Sioux Lookout in Ontario, recently heard at a regional roundtable discussion that probation officers or police officers made 12 referrals to health professionals for children to be tested for Fetal Alcohol Spectrum Disorder in a year. The children were around 15 and were being referred only after they had broken laws. “The health system and the education system totally missed the boat on that one,” says Mamakwa, who points out that early identification of FASD is the first step to accessing educational and social supports that can help prevent children entering the correctional system. Health providers need to work to build better collaboration across government departments, says Mamakwa. “The different service providers should sit down and start with the question, ‘How are we going to make an impact on that five-year-old in the community so in 15 years, she is a healthy, engaged productive member of society?’”

6) Make trauma-informed care the standard of care

The trauma of residential schools is not dissipating with generations, but snowballing, says Mamakwa. He explains the phenomenon this way: “People who went to residential schools were abused by strangers, but the youth now, they may be abused, but the abusers may be people they know.” As Tailfeathers puts it, “A lot of parents who went to residential schools often abandoned their children because they were dealing with their own trauma, or they ended up losing their children to the system because of their addictions.”

Health workers who treat victims of trauma in a way that’s perceived as authoritative or judgmental can trigger traumatic memories and lead Indigenous people to avoid health care settings. For this reason, The Klinic Community Health Centre in Winnipeg calls for health providers to provide care that is “trauma-informed.” Its Trauma Toolkit provides practical instructions to avoid acting in a way that could be interpreted as coercion or judgement – including making decisions “with” patients rather than “doing to.” Health workers should also make it clear to patients that they understand their addictions as necessary “survival mechanisms,” while helping them on alternative ways to cope with trauma.

Of course, trauma-informed care will not resolve the trauma that many Indigenous people have been exposed to. As Smylie notes, classic cognitive behavioral therapists typically don’t have comprehensive trauma training and can unintentionally re-traumatize clients. Smylie estimates that based on prevalence of severe trauma, 40,000 trauma therapists are necessary for Indigenous people in Canada. “Yet currently, there is not a single readily accessible trauma therapist I can refer to in Toronto,” she says.

7) Address smoking rates in Indigenous communities

Almost a third of First Nations and Métis people smoke, while the smoking rate among the Inuit is 39%, according to Statistics Canada. Smylie explains extremely high rates of PTSD and depression in many Indigenous communities – both highly correlated with smoking – provide context to the prevalence of smoking.

“We know that two thirds of smokers will die from tobacco related diseases,” says Raglan Maddox, a postdoctoral fellow at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital who has studied public health interventions for Indigenous people in Canada and Australia. But mainstream public health messages may not work in Indigenous communities. “There is a need to recognize the significance of tobacco among First Nations and to differentiate ceremonial tobacco and commercial tobacco,” says Usman Aslam, a manager with the Aboriginal Cancer Control Unit at Cancer Care Ontario (CCO).

Indigenous-centred resources for smoking cessation, are available online. In partnership with the CCO’s Aboriginal Tobacco Program, CAMH offers a course to help health practitioners support smoking cessation efforts to First Nations, Inuit and Métis populations.

Maddox warns, however, that a single approach isn’t adequate for Canada’s diverse Indigenous population. “There are massive differences among Indigenous communities in Canada – north and south, east coast and west coast, and the cultural tapestry of First nations, Métis and Inuit people,” says Maddox. “This complicates the public health messaging to some regard.” With research indicating that positive messaging showing to be especially effective, Maddox suggests health workers team up with local Indigenous people to find the positive messages that will resonate most in their community.

8) Implement basic standards for supplies in nursing stations in remote, Indigenous communities

In Canada, the federal government is responsible for health care for Indigenous people defined as “Status Indians,” while provincial governments are responsible for non-“Status Indian” Indigenous people and all other Canadians. The result is a two-tier system, says Lafontaine, with fewer health care resources available for Indigenous people. “Often, federal medical clinics in the north lack basic antibiotics or basic core emergency drugs like Ventolin,” says Lafontaine. “The clinic in Fort Vermillion [in Northern Alberta] is run by Alberta Health Services, and if they run out of these basic supplies, AHS pulls out all the stops to ensure they have continuity of care,” Lafontaine explains. “But when a nearby clinic that serves the Indigenous population under federal jurisdiction runs out of these supplies, they have to phone into Ottawa and wait days for approval.” (The Auditor General’s report from 2015 noted that the federal government does not routinely assess whether its nursing stations are able to provide essential services.)

According to Lafontaine, the disparities will only be addressed by more advocacy from health providers and the exposure of two-tier standards as unacceptable, says Lafontaine. “Health care professionals need to be more open about sharing these stories, about how ridiculously difficult it can be to access certain kinds of medication and to get approval for transport for Aboriginal patients – things that rarely happen when patients fall under provincial care.” 

 

The sources we spoke to provided many recommendations we couldn’t fit into this article. This list of recommendations is by no means complete. For one, there are many efforts that fall outside the health system – from water infrastructure improvements to reforms in children’s services policies – that are necessary to address the myriad ways in which social determinants affect health outcomes. We hope, however, that this article sparks more conversations – including in our comments section – about how the health system should respond to the ongoing health repercussions of long-standing racism and marginalization of Indigenous people in Canada.

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12 comments

  1. Debra Lefebvre, RN, MPA

    I am a nurse professional who has lived and worked in remote, isolated indigenous communities. While I agree with some points made in this article, the assumptions made in Points 1, 2 and 6 cause me concern. I note that nurses, who are largely primary caregivers in remote and isolated indigenous communities, were not consulted nor quoted in this article. Had they been, a more true picture of indigenous health care may have emerged. Moreover, rather than place blame for health inequities between indigenous and non-indigenous Canadians on health workers (RNs), focus should be on the political structure in these communities, with a call for greater accountability to their constituents.

    With respect to Point No. 1, the remote and isolated location of many communities is the real challenge in recruitment and retention of health workers. This is not only an indigenous issue but one faced by many small and rural communities. Increased funding is not necessarily the answer. Creative and innovative strategies are needed, and perhaps a review of what other rural communities are doing to attract staff and/or residents could help. In addition, nurse professionals are responsible to inform their practice and should not take on a position that they are not qualified for. Employers should not hire a nurse who does not meet the basic requirements. At the very least, the qualifications for any remote nursing position should include at least one-two years medical nursing or emergency nursing, as well as advanced cardiac life support certification. Mentorship could help, along with an adequate orientation schedule for newly hired nurses, but they should have these basis requirements.

    Kitty suggests that nurses should be provided time to interact and engage with the culture and people they care for, inferring additional funding is needed. Not so. My colleagues and I attended various activities and did not necessarily need time off work to do so. We engaged with the community by attending feasts, youth activities, and funerals not only during usual work hours, but in the evenings and weekends. We also went to peoples’ homes and broke bread together. We shared happiness and grief with the community on many occasions. I/we did not need additional funding or relief staff to build good relationships with patients and the community, to feel rewarded in the work that I/we did.

    Lafontaine’s claim that “too often, health workers let media narratives prejudice their encounters with individual patients,” in Point No. 2 is interesting. It is comments like this that only fuel the health worker shortage and create a barrier to effective recruitment strategies for remote and isolated communities. I recall heroic patient care and advocacy efforts on the part of my nurse colleagues and myself in caring for our patients. Not once did I witness a missed diagnosis resulting from “the assumption that a person’s symptoms are related to addiction”. The case Lafontaine referred to is an isolated one and should not be used with such broad strokes. I find Lafontaine’s comments to be offensive and politically motivated.

    Health inequities are not largely caused by residential school syndrome or trauma as suggested by Tailfeather and Smylie in Point No. 6. If that was the case, Holocaust victims and their families should also experience health inequities due to a Holocaust syndrome or trauma. They suggest that health workers should acknowledge indigenous addictions as “survival mechanisms” due to the residential school system. They suggest that health workers are coercive and judgmental in caring for indigenous people with addictions. My experience has been quite different, where patient care has been compassionate and understanding. Moreover, while some indigenous people may suffer from this trauma, that is not the case for the majority who experience health inequities.

    I believe the social determinants of health are the underpinnings to this, including housing, infrastructure, and education. The situation in many of these communities is desolate and bleak. Many individuals leave their communities to seek their future elsewhere because little future exists within their own communities. This is the reality of many small, rural communities in Canada. Do we build mini-cities in these communities, or bring them to the urban centres? This has been the burning question for politicians and advocates for decades. Regardless, it is unfair to pin health inequities of indigenous people on health workers. It is a much larger problem.

    It seems that the remedy echoed throughout this article falls upon more health funding. Funding has increased over the years, and the health inequity gaps persist. The authors suggest that long-standing racism and marginalization of Indigenous people in Canada’s health system is the reason for the health inequity. Based on my experience, that is not the case and it is not as simple as that.

    • John Martial Merasty

      I am a student (2nd year) at the University of Saskatchewan in Saskatoon, Saskatchewan Canada.
      Absolute truth in these first hand knowledge reports. When Indian leaders request funding to address critical health care services that provide additional support the taxpaying public howls foul. The Fed gov’t bureaucrats get scared, get cold feet, and refuse to fund First Nations people. The education that is offered in post-secondary institutions is finally being flooded by young aboriginal students who live in their reserve communities before and after they complete their degrees. These young professionals are essential in spreading the gospel of healthy living and lifestyles. One cannot live in a class of modern society where knowledge of health, sanitation, comfortable and modern housing is taught without expecting that same comfort zone and standard of living toward their reserve communities. Live in the city for four years in a comfortable accommodation while eating good healthy foods to going back to overcrowded hungry homes. Not tolerable by educated first nation groups. That’s not to say that people living on reserve haven’t noticed deplorable living conditions already but mature students aged 25-30 have always been the vanguard of change. Change is coming and its coming fast. Non aboriginal folks better to get used to it and can help speed up the process by advocating for improvements to aboriginal lives instead of shouting down the leaders of change. They say that change is good. Don’t fix what’s not broken. But if you see a broken people and refuse to help them, then let your name be anathema.

    • John Martial Merasty

      Dear Debra: I will say that your comments are well taken and expressed as a health care practice as opposed to a politician or an educated angry first nation person. The truth always lies in the middle. We are taught this observation in university. So if the truth lies between the accused and the accuser then we should also ask the people who are being served. The health statistics on births, deaths, crimes, and causes are reported by professional people working in the indigenous communities of Northern Canada. The first nation politicians attend the funerals and hear from their people first hand on the needs of the community. The health care workers try their best to serve people who live in third world conditions. Its not their fault if people don’t eat right or sleep the right amount of hours or receive a healthy salary while living in a comfortable home. Adequate accommodations are provided to health care workers who choose to live and work in these northern communities. They provide reports and health statistics to Ottawa and the provincial health departments. Money runs all the expenses of providing health care. Less cost is better for everyone. More cost is unnecessary unless its for salary adjustments to meet provincial standards or higher airfare costs for aviation companies that provide essential transportation for everyone travelling in or out of any community not accessible by road or highway. I believe RN Debra Lefebvre is telling the truth. She tried her best but her best was not fully appreciated by first nation politicians and other annoyed and loud educated bums like….you know. The opinion polls fluctuate on every issue in politics including first nation health care costs. The first nation people usually lose the battle for funds as they are not taxpayers first and second they don’t count in the polls. The third strike is somewhere in the grey (gray) area of being the wrong color and being a minority. This is where the truth lies and where the truth hurts. Tell me about it. I’ve lived racism from the day I was born and will exist till the day I die. If only our people and our servants who serve us recognize the signs of racism. Racism is ugly, its out there, we haven’t dealt with it yet, we are dealing with it, we will defeat it but not yet. When we do we will see a more satisfied community. Utopia. Sounds familiar. Deja vu. We been there, done that, seen it, lived it, still there.

  2. Marjaleena Repo

    #9 Train Indigenous midwives to work in Indigenous and northern communities.
    #10 Cultivate and support non-psychiatric drug approaches to mental health and addiction issues, and track the health consequences of often prescribed psychiatric drugs on children, youth and adults.

  3. Northerner (yes I'm not listing my name because I am afraid of backlash from my health workers)

    Reality is that a lot of these concerns are real. I agree with the comments that not all health workers were consulted, but see they’re lumping everyone together (docs, RNs, LPNs, etc).

    Of course the community has some of the blame as does the system. But to say that the political structure is a bigger problem doesn’t make sense with the issues that well run communities have with the exact same issues.

    To also say that residential schools have no effect on health outcomes illustrates how deep your bias and ignorance go.

    • Debra Lefebvre, RN, MPA

      Northerner, it is unfortunate your experience is so different than mine. I wish to clarify that I did not suggest that blame be placed on internal political structures. Rather, I suggested that greater accountability is in order, with consultation with communities on priority spending in the areas of health and social issues. Blame is not the answer and rarely brings solution to any problem. Also, I suggested that while some indigenous people may suffer from residential school trauma, I believe that is not the case for the majority who experience health inequities. I believe the social determinants of health are largely the underpinnings to this, including housing, infrastructure, and education, to name a few. I agree in that it would be ignorant to suggest that the residential school has no effect on health outcomes.

  4. CPD - Faculty of Medicine - University of Toronto

    One possible response is to create a forum to discuss these issues and to develop solutions with Indigenous peoples.

    Health care providers have a critical role with Indigenous populations in advocating for the improved status of an individual, family, community. Through creating dialogue with Indigenous peoples, experts in the field and healthcare providers, there is an opportunity to develop better educated, more culturally competent health care providers for Indigenous peoples. This in turn will improve health care service, the understanding of healthcare needs, help formulate community-based research questions and improve advocacy for Indigenous peoples in Canada.

    %featured%The University of Toronto, Faculty of Medicine’s upcoming Indigenous Health Conference (IHC) 2016: Towards Health and Reconciliation will allow health care professionals and Indigenous community members to discuss solutions towards improved health for all Indigenous peoples.%featured%

    The conference objectives are to facilitate the translation and dissemination of knowledge and improve cultural sensitivity about Indigenous health in Canada through the voices of Indigenous peoples. The emphasis is on creating healthy environments and improving health equity.

    Details:

    May 26th – 27th 2016 at the Hilton Meadowvale, Mississauga ON

    http://www.cpd.utoronto.ca/indigenoushealth/

  5. Kate O'Connor

    I%featured% would argue there also needs to be move comprehensive coverage under the NIHB program that supports better access to interprofessional care. Physiotherapy is largely not covered on reserve, yet injury rates are much higher in First Nations communities. %featured%In addition to the need for rehabilitation post-injury to address mobility, pain management and quality of life, physiotherapy can play an important role in the management of complex chronic disease through movement/exercise and self care. Unfortunately, NIHB only recognizes “rehabilitation” as it relates to medical equipment and supplies, not hands on care.

    The Canadian Physiotherapy Association is taking the recommendations of the TRC seriously and will be launching a new bursary for Indigenous physiotherapy students with the hope that we can increase the number of indigenous practitioners, but also respond to the following recommendations from the final report:

    • Ensure the retention of Aboriginal health-care providers in Aboriginal communities;

    • Take action to ensure long-term Aboriginal athlete development and growth;

    • Ensure that policies to promote physical activity as a fundamental element of health and well-being, reduce barriers to sports participation, increase the pursuit of excellence in sport, and build capacity in the Canadian sport system;

    • An elite athlete development program for Aboriginal athletes; and,

    • Establish programs for coaches, trainers and sports officials that are culturally relevant for Aboriginal peoples.

  6. Marianne Cerilli Instructor CD/CED Red River College, Winnipeg MB

    Wow, this is a great prescription for moving away from the medical model which wastes money and we can no longer afford and doesn’t work for individual people or communities. It is beyond time to move to up stream approaches to health that create healthy, sustainable communities. Thanks for posting.

  7. G. Goudreau

    #1 Better support and training for Indigenous health care providers. We need to let Indigenous people figure out how to address the health inequities in their communities which is rooted in the colonial past and present. Yes they need allies and support but all health programs in Indigenous communities need to be Indigenous led . I’m hoping this article was written with an Indigenous person. If not we are still doing for them and not letting them work it out themselves.

    Miigwetch, “G”

  8. Audrey Caskanette

    What a Informative Site.

    Resources like this will be made available to participants at the “indigenous Knowledge and Health, small gathering we are hosting in Sept.
    Chimeegwetch

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