Healthy Debate (Jan 7 2016): 8 steps toward addressing Indigenous health inequities

by Wendy Glauser, Joshua Tepper & Jill Konkin

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 Canadianseach 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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Health Canadacihr logo1This initiative has been generously funded by grants from Health Canada and the Canadian Institutes of Health Research. The views expressed here do not necessarily reflect those of the funders.