It's time for action
Brian Postl, MD
CMAJ 1997;157:1655-6
Dr. Postl is Vice-President of Clinical Services with the Winnipeg Hospital Authority Inc.
© Canadian Medical Association
s 1997 draws to a close, concerns about health status remain high on the list of unresolved issues facing Canada's aboriginal peoples. Although significant improvements have occurred over the last 3 decades, a consistent and disturbing gap remains. In 1997 infant mortality within this group stood at 2 times the national average, and there was an 8-year gap in life expectancy at birth.
The list of documents outlining the ill health of Canada's aboriginal peoples is thick indeed. In 1994 the CMA issued a paper on native health that revealed the increasing incidence and prevalence of chronic illnesses -- diabetes, cardiovascular disease, cancer and end-stage renal disease -- that had been superimposed upon a first-order epidemic of infectious illnesses such as tuberculosis, otitis media, sexually transmitted disease and hepatitis.1 These problems are further superimposed over "social" illnesses relating to alcohol and drug abuse, violence, suicide and injury. Later that year, a profile prepared by the Canadian Institute of Child Health pointed out that aboriginal children are the most vulnerable of all.2
The results of these problems are disproportionate mortality and hospitalization rates and high overall use of the health care system. When these are coupled with a lack of education, low self-esteem and the pervasive burden of poverty, we have a population that is unique in Canada, with its young people carrying an especially terrible burden.
Because Canada's native population is growing, physicians are likely to become more aware of the problems these patients face. They represent the country's sickest patients, and the key feature of our interaction with them over health care issues will remain simple: remarkable inequity.
The connection between health status and socioeconomic issues may not be new, but it is constantly being rediscovered. Like the skin of an onion, these determinants of health are layered over historical determinants and antecedents that often contribute to the perpetuation of ill health. Jurisdictional uncertainties, residential schools and treaty-based health entitlements are all important examples.
Canada enjoys a history of insightful and provocative social policy initiatives focused on health care. The Lalonde Report of 1974 "made room" for health determinants, while later reports developed health-promotion concepts in which empowerment was identified as a key vehicle in the drive to improve the health status of Canadians.
Research has played a vital role in cataloguing and identifying ill health within Canada's First Nations. So many data have been produced that it could be argued further study is not needed: it is time to act. Fact-finding may already be serving as a substitute for action, delaying important interventions instead of encouraging them.
Two recent reports set the stage for what should happen in 1997 and beyond. The 1996 Report of the Royal Commission on Aboriginal Peoples provides a comprehensive and seminal review of the conditions and needs of Canada's aboriginal peoples.3
Although the commission did not focus specifically on health, it did serve as a forum to highlight serious health issues. One of its cardinal recommendations was a call for justice and fairness in a renewed relationship between aboriginal and nonaboriginal people in Canada. The commission noted that self-determination and its corollary of self-government are guaranteed to all aboriginal peoples. Reaching land-claim agreements across the country is important because having a land base is recognized as an important factor in achieving economic viability and cultural integrity, and job creation is a key signal that economic viability exists.
There is remarkable linkage between concepts of health promotion and the empowerment of aboriginal peoples through self-government. For example, the commission called for an effort to refocus on family support instead of placing the emphasis on alternative child care (the apprehension of children by child-welfare authorities).
In terms of health care, the commission said the focus should be on paying "attention to whole persons in their total environment." It also made recommendations concerning adequate housing and water and sewage systems, devolution of the educational system, a human-resource policy that would add 10 000 aboriginal health workers, and creation of a network of aboriginal health centres and healing lodges. All of these proposals are logical expressions of health promotion through the devolution of power.
The National Forum on Health also identified aboriginal health as a key issue and identified the inherent inequality of life facing aboriginal peoples.4 A key component of the forum's recommendations was the establishment of an Aboriginal Health Institute that would play an advocacy role and replace existing functions within Health Canada. It would also support the training and education of aboriginal peoples as health care professionals. This latter suggestion is a sign of the considerable overlap between the forum and royal commission, which called for creation of an Aboriginal Peoples International University.
One recent publication focused on the health care problems facing aboriginal children and served as a report card on their health status.5 The marks were not good.
Canada is a signatory to the United Nations Convention on the Rights of the Child, and this report looked at how well we are meeting this commitment. As Stephen Lewis stated, the principle of nondiscrimination is clearly compromised by the inequity apparent in the health status of First Nations' children.
The report also said that child poverty, most specifically the poverty aboriginal children must cope with, is an area where Canada must take much stronger measures. The emergence of street gangs and problems related to violence and physical safety are identified as specific concerns; Wayne Helgason of the National Association of Native Friendship Centres identified the "young female face of poverty" as a major issue.
As Canada approaches a new century, the way it treats its aboriginal peoples will be a test of its national character. The studies have been done, and it is time to act. In epidemiologic terms, we must focus on relative risk instead of attributable risk if we are to serve this population. To do otherwise is to risk the perpetuation of ill health in Canada's First Nations. Do we really want to show off our national character under such a dim light?
As another year draws to a close, it is distressing at best and unconscionable at worst that Canada's aboriginal peoples and their children continue to face the disadvantages and inequities that have defined their lives for decades.
References
- Canadian Medical Association. Bridging the gap. Promotion of health and healing for aboriginal peoples in Canada. Ottawa: The Association; 1994.
- Canadian Institute of Child Health. The health of Canada's children -- a CICH profile. 2nd ed. Ottawa: The Institute; 1994.
- Report of the Royal Commission on Aboriginal Peoples. vol 15. Ottawa: The Commission; 1996.
- National Health Forum on Health. Canada health action: building the legacy. Ottawa: The Forum; 1996.
- Canadian Council on Social Development. The progress of Canada's children. Ottawa: The Council; 1996.
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