Content. How can Health Professionals Contribute to Improving Aboriginal Health? INTRODUCTION

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thanks to Dr Kent Saylor Mohawk Pediatrician, McGill University, Montreal Content Introduction/definitions History of Aboriginal

pediatrician from Kahnawake, Quebec developed slides on historical and social background to increase awareness for medical students,

1 How can Health Professionals Contribute to Improving Aboriginal Health? Ann C Macaulay CM MD FCFP Professor of Family Medicine, McGill University Director, Participatory Research at McGill With very many thanks to Dr Kent Saylor Mohawk Pediatrician, McGill University, Montreal Content Introduction/definitions History of Aboriginal peoples in Canada Outline of health issues Resilience of Aboriginal Peoples Suggestions for health professionals Dr Kent Saylor- Mohawk pediatrician from Kahnawake, Quebec developed slides on historical and social background to increase awareness for medical students, residents, pediatricians etc Dr Ann C. Macaulay, family physician in Kahnawake, community-based participatory researcher, coordinator for Indigenous Health Curriculum McGill University medical students INTRODUCTION

Health is a state of complete physical, mental and social well-being being,, not merely the absence of disease or infirmity (WHO 1978) Well-being is associated with high self-esteem, esteem, a

Rhea Joseph from the Royal Commission on Aboriginal Peoples 1996 The graduating student will demonstrate compassionate, culturally safe, relationship-centered care for First Nations, Inuit, and Métis

2 Health is a state of complete physical, mental and social well-being being,, not merely the absence of disease or infirmity (WHO 1978) Well-being is associated with high self-esteem, esteem, a feeling of being at peace and being happy. This includes education. It includes employment. It includes land claims. It includes resource management. All of these lead back to wellness and well being. Rhea Joseph from the Royal Commission on Aboriginal Peoples 1996 The graduating student will demonstrate compassionate, culturally safe, relationship-centered care for First Nations, Inuit, and Métis patients, their families and their communities. The term cultural safety includes the skill of self reflection, in addition to increased cultural awareness, cultural competence, and cultural humility. It is a continuation of the patient centered approach. First Nations, Inuit, and Métis Health Core Competencies Critical Reflection Tool IPAC AFMC Curriculum Implementation Toolkit for Undergraduate Medical Education April aboriginal health e.php New Indigenous Health Curriculum for all Canadian Medical schools 2005 Association Faculties of Medicine of Canada agreed that All medical schools should make a commitment to increase the content of undergraduate curriculum related to Aboriginal Health 2009 First Nations, Inuit, Métis Health Core Competencies - a Curriculum Framework for Undergraduate Medical Education - developed by Indigenous Physicians of Canada in partnership with Association of Faculties of Medicine Canada Indigenous Health Curriculum can help build relationships with Indigenous peoples, organisations and communities Avoiding Pan-Indianism, there is a need for health professionals to understand the diversity, commonalities, and differences of Indigenous cultures Health professionals who demonstrate non-colonising attitudes can help empower Indigenous patients to step outside of behaviors learned through colonization and gain trust in a culturally safe way.

DEFINITIONS AND HISTORY First Nations Descendants of the original peoples of Canada who are not Inuit or Métis. M Term used mainly in Canada. The term First Nations is preferred over Indian.

3 DEFINITIONS AND HISTORY First Nations Descendants of the original peoples of Canada who are not Inuit or Métis. M Term used mainly in Canada. The term First Nations is preferred over Indian. In Canada, a First Nations person is considered a Status Indian if they are registered under the Indian Act Considered non-status if not registered. Many First Nations people live on reserves (approx 50% live in cities) Account for 61% of Aboriginal population Definitions Aboriginal refers to people who are either: First Nations Inuit Métis

4 Inuit The indigenous people inhabiting Arctic regions of Canada, Russia, Alaska and Greenland. Live in 4 regions of Canada: Nunavik (northern Québec), Nunatsiavut (Labrador), the Inuvialuit Settlement Region (NWT) and Nunavut. Culturally and linguistically very different from First Nations and Métis. Historically referred to as Eskimo. Eskimo. Inuit means the people (and is the preferred term). One person of Inuit descent is an Inuk, singular for Inuit. Inuit are not Innu (First Nations from QC). Inuit live in communities, hamlets or villages (not reserves ) Account for 4.4% of Aboriginal population. Métis Poorly defined term refers to people of mixed heritage (First Nations and European) who self-identify as Métis Canadian government uses the term for anyone of mixed heritage. Métis National Council states that a Métis M person must have heritage that can be traced back to the Métis of the Red River region in west central North America. Distinct from First Nations and Inuit people Accounts for 34% of Aboriginal people

1492 Royal Commission (1996) est. 500,000 Aboriginal people lived in what is now known as Canada http://www.ainc-inac.gc.ca/ch/rcap/sg/sg3_e.

5 1492 Royal Commission (1996) est. 500,000 Aboriginal people lived in what is now known as Canada inac.gc.ca/ch/rcap/sg/sg3_e.html#10 Some estimates (Dobyns) that Aboriginal population in North America was between million people (~1 million in Canada). Important Acts Royal Proclamation 1763 British North America (BNA) Act 1867 Treaty 6 Medicine chest clause Indian Act 1876 After European contact the population fell dramatically In 1871, ~ 102,000 Aboriginal peoples in Canada 80%-90% decline (diseases, wars) Population Royal Proclamation 1763 Issued in October 1763 by King George III following Britain s s triumph over France in the French and Indian War/Seven Years War. The proclamation forms the basis of land claims for Aboriginal people in Canada. Some believe it is the first documented recognition of Aboriginal rights by the British Crown.

British North America Act 1867 Treaties Created the self governing Dominion of Canada. Established that Indians were under federal authority.

org/wiki/british_north_america_act Treaties are agreements between nations that have a unique status in international and domestic law.

6 British North America Act 1867 Treaties Created the self governing Dominion of Canada. Established that Indians were under federal authority. Allowed Canada to begin negotiations for the land. Treaties are agreements between nations that have a unique status in international and domestic law. There is ongoing disagreement about many treaties including many of the Numbered Treaties. Most First Nations people believe the treaties are about mutual respect and peaceful co-existence between peoples. Land transfer seems to be the main focus for the federal government. Prior to treaties After the treaties Royal Commission of Aboriginal Peoples 1996

7 Indian Act 1876 A Canadian statute that defines who is an Indian and outlines the rights inherent to registered Indians. Indians. A person is considered Indian if they are registered under the Indian Act. These people are considered status Indians. Many people, especially women, lost status by unjust practices (i.e. marrying a non-status person). Amended Start of the reservation system - lands ( often poor in quality) designated for Indians. Indians. Often did not relate to traditional hunting areas etc Inuit History Inuit have fought for their rights including their land and are now in the post land claim era. In Canada, each Inuit region has comprehensive land claims: Inuvialuit Final Agreement (1984) Nunavut Final Agreement (1993) Labrador Inuit Land Claims Agreement (2005) Nunavik James Bay and Northern Québec Agreement (1975) and the Nunavik Inuit Land Claims Agreement (2006). Adapted by Tracy Sarazin (ITK) from Inuit History and Heritage, Our 5000 Year Heritage Inuit History Not included in the Indian Act. Treaties had little to no impact on the Inuit. First contact with Europeans was in late 1500 s. Whaling and fur trade brought more contact and, with it, rapid changes including the presence of missionaries, RCMP posts and many diseases. Inuit land became mapped and given English names and claimed by outsiders. Métis History Métis people emerged out of relations between Indigenous women and European men. Initially they were considered people of mixed origin but with establishment of distinct communities, a new Métis M culture was born. Recognized as Aboriginal peoples in the Constitution Act 1982, but rights were not fully recognized until 2003 with the Powley decision by the Supreme Court. Provided formal hunting rights as Aboriginal peoples Do not have the same rights as First Nations or Inuit and not included in the Indian Act.

RESIDENTIAL SCHOOLS 1882-1996 Residential schools System established in 1892 to civilize Aboriginal peoples.

Children were forbidden to speak their native language. Considered to be places of physical and emotional deprivation.

Canadian Institute Health Information 2004 Residential school experience Residential schools legacy Many Aboriginal people still haunted by these

8 RESIDENTIAL SCHOOLS Residential schools System established in 1892 to civilize Aboriginal peoples. Children were removed from their homes and sent to boarding schools subsidized by Federal government and operated by the churches. Children were forbidden to speak their native language. Considered to be places of physical and emotional deprivation. Many children were physically and sexually abused. The last federally run residential school closed in Canadian Institute Health Information 2004 Residential school experience Residential schools legacy Many Aboriginal people still haunted by these experiences to this day: Post traumatic stress disorder Depression/suicide Alcohol/substance abuse etc. Multi-generational trauma Left a legacy of Aboriginal children where language and traditional ways were lost, parenting skills were not established and very many families were destroyed.

HEALTH ISSUES Census 2006 1,172,790 people identified themselves as Aboriginal in 2006 (3.

Average age of Aboriginal people 27. Average age in Canada 40. Life expectancy much shorter.

There is very little data on the health status of Aboriginal peoples in general and almost none focusing on

9 HEALTH ISSUES Census ,172,790 people identified themselves as Aboriginal in 2006 (3.8% of the Canadian population). A very young and fast growing population. Average age of Aboriginal people 27. Average age in Canada 40. Life expectancy much shorter. Inuit life expectancy 64 yrs, Canadian rate 80 yrs. Two key points! Aboriginal population is young! 1. There is very little data on the health status of Aboriginal peoples in general and almost none focusing on children. 2. In general, on virtually every measure of health status, Aboriginal peoples fare much worse than the average Canadian Census First Nations Regional Health Survey 2007

Health conditions Obesity First Nations children 0-110 years: 22% overweight 36% obese First Nations youth 12-17 17 years: 28% overweight 14.

10 Health conditions Obesity First Nations children years: 22% overweight 36% obese First Nations youth years: 28% overweight 14.1% obese CIHI 2004 RHS 2003 Prevalence of Chronic Diseases Rh Arthritis Hypertension Allergies Type 2 diabetes Asthma Cardiac disease Cataracts Thyroid Chronic bronchitis Cancer (age adjusted) Suicide in First Nations First Nations males (15-24 years) suicide rate 126/100,000 (Canadian rate 24/100,000) First Nations females (15-24 years) suicide rate 35/100,000 (Canadian rate 5/100,000) Canadian Institute of Child Health 2003http:// iginal.pdf Suicides in British Columbia lower or absent in communities with high levels of cultural continuity ( includes settled land claims) Chandler MJ, Lalonde CE. Cultural continuity as a moderator of suicide risk among Canada s First Nations In: Kirmayer LJ, Valaskakis G. editors. The mental health of Canadian Aboriginal peoples: transformations, identity, and community. Vancouver, BC. University of British Columbia Press 2008

Residential school experience Colonization - past Loss of land (food, clothing, shelter, culture) Loss of language

11 SOCIAL DETERMINANTS OF HEALTH Colonization: The heart of the social determinants Social determinants of health Colonization loss of traditions: religion, culture, holistic view of life racism, stereotypes, discrimination Residential school experience Colonization - past Loss of land (food, clothing, shelter, culture) Loss of language (many languages have been lost) Loss of the right to self government Reserve system Poverty Food insecurity and poor housing

12 Land Ongoing colonization Many land claims ongoing- 272 claims settled since 1973 Currently takes years to settle one claim Language Many Aboriginal people feel a strong knowledge of their traditional language is vital to maintaining health. To succeed in today s s society you must be proficient in either English or French. Health Ongoing colonization The traditional holistic view of health has been separated into many silos. silos. Health, housing, education, land, language, culture, religion, family etc. all have a role to play in the overall health The role of traditional medicine has been all but ignored. Many Aboriginal people consult traditional healers. Traditional healers have lost their role. Ongoing colonization Broken Promises Royal Commission on Aboriginal Peoples 1996 Few recommendations followed through Kelowna Accord 2005 Fully ignored after 2006 federal election Poverty Some Aboriginal people are doing well. "The social and economic status of Aboriginal people is lower than that of non-aboriginal Canadians on virtually every measure. CIHI - Improving the Health of Canadians 2004

Housing According to the 2006 census, 11% of

(>1( person per room). Improved from 17% in 2001.

insecurity Housing In 2002, two-thirds thirds of

13 Housing According to the 2006 census, 11% of Aboriginal people live in overcrowded conditions (>1( person per room). Improved from 17% in This is still 4 times higher than the general population. CIHI - Improving the Health of Canadians 2004 Food insecurity Housing In 2002, two-thirds thirds of First Nations adults reported their home was in need of repairs. One-third stated the repairs were major. 18.3% no telephone 70.7% no internet connection. Regional Health Survey 2007 Montreal Nain, Labrador

their illness experience and respond to treatment regimens, and to respect the logic and rationale of another system of thought.

14 Sanitation and water 3.5% no flush toilet (2001) 3.7% no hot running water (2001) More than 116 First Nations communities must boil their water (April( 2010) Non-Aboriginal health-care professionals need to understand how Aboriginal people interpret their illness experience and respond to treatment regimens, and to respect the logic and rationale of another system of thought. They need to adapt their treatment plans and education programs to the cultural, social and economic circumstances of their Aboriginal patients and to recognize that many communities are geographically remote, with little access to specialty services The quest to improve Aboriginal health. Dr Jeff Reading. Scientific Director Institute of Aboriginal Peoples Health. Canadian Institute of Health Research. Canadian Medical Association Journal 2006;174(9):1233 (Eng), 1237 (Fr). DEVELOPING GOOD RELATIONSHIPS WITH ABORIGINAL PATIENTS General recommendations know that health encompasses physical, emotional, intellectual and spiritual well-being practice cultural safety includes self reflection, cultural awareness and cultural humility ask about local history and culture respect local traditions and do not impose your own values respect traditional beliefs and healing practices remember that English/French may be a second language

Cross Cultural Care less eye contact may be normal and a sign of respect patients may be very comfortable with long silences patients may not answer direct questions patients may not question someone

15 Cross Cultural Care less eye contact may be normal and a sign of respect patients may be very comfortable with long silences patients may not answer direct questions patients may not question someone who is perceived to have greater power and knowledge what happens to one individual will affect him/her, his or her entire family, and also the entire community Canadian Family Physician 2009;44: Macaulay AC. Improving aboriginal health. How can health care professionals contribute? Resilience of Aboriginal peoples! Anyone for Research? Research with and not research on or about Use participatory research to develop research projects in partnership with Aboriginal people, organisations and community Use the CIHR Guidelines for Research with Aboriginal People Macaulay AC, Commanda LE, Freeman WL, Gibson N, McCabe ML, Robbins CM, et al. Participatory research maximises community and lay involvement. BMJ 1999;319(7212): Respect Aboriginal Resilience Growing numbers of Aboriginal people are highly educated and well positioned to cause positive changes Many Aboriginal communities are taking control of their own healthcare delivery Enjoy the wonderful story telling, sense of humour and privilege of working in a cross cultural environment!

13. Banerji et al. Lower respiratory tract infections in Inuit infants on Baffin Island. CMAJ 2001;164(June 26):1847-50.

16 13. Banerji et al. Lower respiratory tract infections in Inuit infants on Baffin Island. CMAJ 2001;164(June 26): The vision of the Indigenous Physicians Association of Canada healthy and vibrant Indigenous nations, communities, families and individuals supported by an abundance of knowledgeable, welleducated, well-supported Indigenous physicians working together with others who share this vision. The President s Message Dr Marcia Anderson. Indigenous Physicians Association of Canada References 1. Henry F. Dobyns. Estimating Aboriginal American Population: An Appraisal of Techniques with a New Hemispheric Estimate. Current Anthropology, Vol. 7, No. 4 (Sep., 1966), pp Report of the Royal Commission on Aboriginal Peoples, British North America Act (The Constitution Act), Indian Act Martin DL, Goodman, AH. Health Conditions before Columbus: paleopathology pathology of native North Americans. WJM January 2002, vol Treaty 6. inac.gc.ca/al/hts/tgu/pubs/t6/tre6-eng.asp. 7. Statistics Canada 2006 Census release #5: Aboriginal Peoples Canadian Institute of Health Information. Improving the health of Canadians, chapter 4. Sept 2004, Aboriginal Peoples Health First Nations Regional Longitudinal Health Survey (RHS) 2002/03: The People s s Report. ers.ca/english/pdf/rhs reports/rhs the_peoples_report_afn.pdf 10. Aboriginal childen s s survey. bin/imdb/p2sv.pl?function=getsurvey&sdds=5108&lang=en&db=imdb&dbg=f&adm=8 g=f&adm=8 &dis=2#2 13. Willows et al. Prevalence of anemia among James Bay Cree Infants of northern Quebec. CMAJ 2000;162(Feb. 8): Ward et al. Vitamin D-deficiency D rickets among children in Canada. CMAJ 2007;177(2)(July 17): Schroth et al. Oral Health and the Aboriginal Child: A forum for community members, researchers and policy-makers. June 7&8, Forum Proceedings. acsdp.org/pdf/oh_conferenceproceedings_2007.pdf 17. Canadian Paediatric Society position statement. Risk reduction for f type 2 diabetes in Aboriginal children in Canada. Paediatr Child Health Jan 2005;10(1): Canadian Paediatric Society position statement. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatr Child Health Sept. 2007;12(7): Schroth et al. Oral Health and the Aboriginal Child: A forum for community members, researchers and policy-makers. June 7&8, Forum Proceedings. acsdp.org/pdf/oh_conferenceproceedings_2007.pdf 20. Canadian Paediatric Society position statement. Risk reduction for f type 2 diabetes in Aboriginal children in Canada. Paediatr Child Health Jan 2005;10(1): Canadian Paediatric Society position statement. Vitamin D supplementation: Recommendations for Canadian mothers and infants. Paediatr Child Health Sept. 2007;12(7): The Indian Act: Historical Overview. indian-act- historical-overview overview 23. Treaty Guides. Indian and Northern Affairs Canada. inac.gc.ca/al/hts/tgu/index-eng.asp eng.asp 22. Treaty Guides. Indian and Northern Affairs Canada. inac.gc.ca/al/hts/tgu/index-eng.asp eng.asp 23. The Constitution Act, Inuit in Canada: A statistical profile. Inuit Tapiriit Kanatami, Statistics Canada. Selected findings of the Aboriginal Children s s survey 2006: Family and Community. November 26, x/ /article/10729-eng.pdf eng.pdf 27. The Royal proclamation of =A1ARTA Métis Health Benefits, Northwest Territories Health and Social Services.. tis_benefits/default.htm 29. Campaign Report card on child and family poverty in Canada. C Canadian Institute of Health Information. Improving the health of Canadians, chapet 4. Sept 2004, Aboriginal Peoples Health First Nations Regional Longitudinal Health Survey (RHS) 2002/03: The People s s Report. ers.ca/english/pdf/rhs reports/rhs the_peoples_report_afn.pdf 32. Banerji et al. Lower respiratory tract infections in Inuit infants on Baffin Island. CMAJ 2001;164(June 26): Campaign Report card on child and family poverty in Canada. C Canadian Institute of Health Information. Improving the health of Canadians, chapet 4. Sept 2004, Aboriginal Peoples Health.

17 31. First Nations Regional Longitudinal Health Survey (RHS) 2002/03: The People s Report. ers.ca/english/pdf/rhs reports/rhs the_peoples_report_afn.pdf 32. Banerji et al. Lower respiratory tract infections in Inuit infants on Baffin Island. CMAJ 2001;164(June 26): Kovesi et al. Indoor air quality and the risk of lower respiratory ry tract infection in young Canadian Inuit children. CMAJ 2007;177(2): Royal Commission on Aboriginal Peoples at 10 years: A Report Card Blueprint on Aboriginal Health: A 10 year transformative plan. sc.gc.ca/hcs-sss/pubs/system sss/pubs/system-regime/2005-blueprint-plan-abor-auto/index_e.htmlauto/index_e.html 36. Assembly of First Nations. Backgrounder: First Nations and specific land claims Chandler, MJ and Lalonde, C Cultural Continuity as a Hedge against Suicide in Canada s s First Nations. Transcultural Psychiatry 35: Waldram, JB, Herring, DA, Young, TK. Aboriginal Health in Canada: historical, cultural and epidemiological perspectives. University of Toronto press, 2 nd ed Métis National Council website Statistics Canada 2006 Census release #5: Aboriginal Peoples. recensement/2006/rt-td/ap-pa-eng.cfm 42. What First Nations People Think About Their Health and Health Care, Summary of Findings. First Nations Centre, NAHO. July ummaryofnah OPoll.pdf

The Safety and Health Divides: Concerns of Canadian's First Nations' Women and Children. Michael W. Young Ph. D. April 10, 2015

The Safety and Health Divides: Concerns of Canadian's First Nations' Women and Children Michael W. Young Ph. D. April 10, 2015 Background on Canadian native Issues In Canada, there are three major Aboriginal