Written by our Robin Sears for Policy Magazine. Click here to read the original.
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 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 well-being 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 Well-being 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.