A Guide for Health Professionals Working with Aboriginal Peoples (Parts 2 – The Sociocultural Context of Aboriginal Peoples in Canada)
Society of Obstetricians and Gynaecologists of Canada, 2000 See article at www.sogc.org
D:\wwwroot\tripdatabaseplus_live\control\reindex\html\80123D8B-F633-4928-9251547CCEB9BC12 S O G C P O L I C Y S T A T E M E N T No. 100, December 2000 A Guide for Health Professionals Working with Aboriginal Peoples THE SOCIOCULTURAL CONTEXT OF ABORIGINAL PEOPLES IN CANADA This Policy Statement has been reviewed by the Aboriginal Health Issues Committee and approved by Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. PRINCIPAL AUTHOR Janet Smylie, BA, MD, CCFP, Ottawa, ON ABORIGINAL HEALTH ISSUES COMMITTEE Janet Smylie (Chair), BA, MD, CCFP, Ottawa, ON Pierre Lessard (Past Chair), MD, FRCSC, Yellowknife, NT Karen Bailey, MD, FRCSC, FACOG, Wetaskiwin, AB Carole Couchie, BHSc, RM (registered midwife), Toronto, ON Mary Driedger, RN, BScN, MN, CPM, Winnipeg, MB Erica Lise Eason, SM, MDCM, FRCSC, Ottawa, ON William J. Goldsmith, MD, FRCSC, Montreal, QC Roda Grey, RNA, SSW, Ottawa, ON Tracy O'Hearn, Ottawa ON Kenneth Seethram, MD, FRCSC, Yellowknife, NT SPECIAL CONTRIBUTORS Avis Archambault, MA, Phoenix, AZ Howard Cohen, MD, Ottawa, ON Margaret Moyston Cummings, BSc, PHN, RN, MSW, Ottawa, ON Pascale Desautels, MD, Val d'Or, QC Bernice Downey, RN, Ottawa, ON Claudette Dumont-Smith, RN, BScN, MPA, Ottawa, ON Jessie Fiddler, Sioux Lookout, ON Margaret Horn, MA, Kahnawake, QC Elaine Johnston, BScN, Cutler, ON Mae Katt, RN, BScN, MEd, Thunder Bay, ON Lorraine Kenny, BA, Sioux Lookout, ON Dorothy LaPlante, RN (EC), BScN, Ottawa ON Susan Maskill, BSc, Ottawa, ON Melanie Morningstar, Ottawa, ON Patricia Morris, MD, Ottawa ON Ann Roberts, MD, Iqaluit, NU Elizabeth Roberts, MD, Ottawa, ON Marie Ross, BA, RN, CGPA(Dip.), Truro, NS Carol Terry, BA, Sioux Lookout, ON Vincent F. Tookenay, MD, Russell, ON Alan Waxman, MD, MPH, Gallup, NM Cornelia Wieman, MD, FRCPC, Hamilton, ON SUPPORTING ORGANIZATIONS Assembly of First Nations Canadian Institute of Child Health Canadian Paediatric Society College of Family Physicians of Canada Congress of Aboriginal Peoples Federation of Medical Women of Canada Inuit Tapirisat of Canada Metis National Council National Indian and Inuit Community Health Representatives Organization Pauktuutit Inuit Women's Association These guidelines reflect emerging clinical and scientific advances as of the date issued and are subject to change.The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions.They should be well doc- umented if modified at the local level. None of the contents may be reproduced in any form without prior written permission of SOGC. JOURNAL SOGC DECEMBER 2000 1 "Of all the teachings we receive this one is the most important: Nothing of what is now Canada, and are part of a larger circumpolar Inuit belongs to you of what there is; of what you take, you must share." population that includes Greenland, Alaska, and Russia. "Inuk" _ Chief Dan George1 refers to an individual Inuit person. The previous term "Eski- mo" is actually Algonkian in origin, translating as "eaters of RECOMMENDATION A1 raw meat," and is now generally considered a misnomer. There are now four Inuit regions in Canada: Nunavut, Inuvialuit (west- Health professionals should have a basic understanding of ern Arctic), Nunavik (northern Quebec), and Nunatsiavut the appropriate names with which to refer to the various (northern Labrador). Historically, Inuit have registered with the groups of Aboriginal peoples in Canada. Department of Indian Affairs and Northern Development in order to obtain certain benefits, including health benefits. The Constitution Act defines "Aboriginal" as an inclusive term, Excluded from the Indian Act when it was revised in 1951, the referring to First Nations, Inuit, and Metis.2 Aboriginal peoples Inuit have now settled land claims in three Inuit regions after refer to themselves by their specific tribal affiliation (such as Mi'k- more than 30 years of negotiation, and an agreement in princi- maq, Cree, Innu, Ojibwa) or First Nations, Inuit or Metis. First ple has been reached in Nunatsiavut. Nations peoples may also be referred to as Native or "Indian," In the United States, Aboriginal peoples are commonly although the latter term, a misnomer based on an assumption referred to as "Native Americans," with other regionally specif- by early European explorers that they had travelled to Asia, can ic American terms including "Native Hawaiian" and "Alaska be offensive to some First Nations people, and so its use in this Native" referring to all Aboriginal peoples indigenous to what is article will be restricted to references from government statistics now Hawaii and Alaska respectively. The common term "Amer- and documents using this term. ican Indian" refers to those Native Americans living in what is The government classifies First Nations people according now the mainland United States, not including Alaska. Several to whether or not they are registered under the federal Indian American organizations, both Aboriginal and non-Aboriginal, Act. "Status Indians" are registered under the Act and numbered continue to use the term "Indian," including the Association of 610,874 in 1996. First Nations people who are not registered American Indian Physicians and the Indian Health Service. under the Act are referred to as "non-status Indians."3 First Nations people may also be classified as "treaty" or "non-treaty," RECOMMENDATION A2 with a "treaty" Indian's ancestry being traceable to First Nations people who signed treaties in Canada. "Treaty" lists or "band" Health professionals should have a basic understanding of lists are maintained by First Nations communities. The terms the current sociodemographics of Aboriginal peoples in "treaty" and "status" are not interchangeable. A person might Canada. be registered at the Department of Indian Affairs and Northern Development as having "status" FIGURE 1 per the Indian Act, but might be excluded from the band list at the community level. They STATUS INDIAN POPULATION (593,050) BY AGE AND SEX, 1995* would therefore be entitled to some rights Age according to their "Indian status" but exempt from "treaty" rights administered at the com- 85+ 80-84 munity level. 75-79 The Metis are a group of Aboriginal peoples 70-74 65-69 whose ancestry can be traced to the intermarriage 60-64 of European (mainly French but also Scottish) 55-59 50-54 men and First Nations women in the western 45-49 provinces during the 17th century.3 Over the next 40-44 two centuries, the Metis became a sizeable nation 35-39 30-34 with a distinct language (Michif), culture, and eco- 25-29 nomic role in the buffalo hunt and fur trade. Indi- 20-24 15-19 viduals of mixed Native and non-Native ancestry 10-14 who are not directly connected to the Metis of the 5-09 0-04 historic northwest may also identify themselves as 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 Metis. Metis have historically been excluded from Percent of Population treaty negotiations and the Indian Act. * Based on Health Canada data. The Inuit traditionally lived above the tree line JOURNAL SOGC DECEMBER 2000 2 TABLE 1 and members of a First Nation, 19,220 did not report identity.4 LINGUISTIC GROUPINGS AND LANGUAGES OF In addition, some would not reveal Aboriginal ancestry or iden- ABORIGINAL PEOPLES IN CANADA tity to a non-Aboriginal enumerator. Aboriginal peoples tend to ALGONKIAN Abenaki KUTENAIAN Kutenal move more often and make up a significant proportion of home- Blackfoot less people, making chronic undercounting more likely. Finally, Cree SALISHAN Bella Coola some individuals of Aboriginal ancestry may have chosen the cat- Delaware Comox Malecite Halkomeiem egory "Canadian" rather than specifying Aboriginal ancestry. Mi'kmaq Lilooet Although there is little information on the health status of Montagnaia Oakanagan Ojibwa Sechelt individuals who report Aboriginal ancestry versus those who Potawatomi Shuswap report Aboriginal identity, it could be postulated that the risk Squamish for some health problems with a genetic component, such as ATHAPASKAN Beaver Straits Carrier Thompson diabetes, might be increased in those with Aboriginal ancestry, Chilcotin whether or not self-identified as Aboriginal. The limited health Dogrib SIOUAN Dakota statistics on Metis people suggest that disease prevalence does Han Hare TLINGIT Inland Tlingit not necessarily decrease for persons of mixed Aboriginal and Kaska European heritage compared to the total Aboriginal popula- Kutchin TSIMSHIAN Coast Tsimshian tion.5 However, as a result of historic, systemic, and attitudi- Sarcee Nass-Gitksan Sekani nal inequities, many individuals with significant Aboriginal Slave WAKASHAN Haista ancestry may not openly self-identify as Aboriginal. Hence, Tagish Heiltshuk Tahitan Kwakiuti despite the recent shift of census statistics to identity-based Tuchone Nootka questions, ancestry questions may be the most relevant for the health professional while being less threatening for some clients. HAIDAN Haida INUIT Inuktitut The Aboriginal population of Canada identified by the IROQUOIAN Cayuga 1996 Census is much younger than the general Canadian pop- Mohawk ulation, with an average age of 25.5 years compared to 35.4 in Oneida Onendaga the general population. Children under 15 account for 38 per- Seneca cent of all Aboriginal peoples, compared with 20 percent of Tuscarora the general population.4 Half of all Aboriginal peoples in Cana- * Adapted from a chart obtained from Dr. Vincent Tookenay, former da are under the age of 24 years.6 President of Native Physicians in Canada. In the 1996 Census, 1,101,960 people reported FIGURE 2 Aboriginal ancestry (3.9% of total Canadian pop- INUIT POPULATION (36,215) BY AGE AND SEX, 1991* ulation), with 799,010 (2.8%) identifying them- Age selves as Aboriginal persons.4 Of these, 867,225 individuals reported "North American Indian" 65+ ancestry, 220,740 individuals reported Metis 60-64 55-59 ancestry, and 49,845 individuals reported Inuit 50-54 ancestry. By identity, the numbers were 210,055 45-49 for Metis, 41,085 for Inuit, and 535,075 for 40-44 North American Indian. A follow-up survey of 35-39 the 1991 census4 indicated that approximately 30-34 25-29 two thirds of individuals reporting Aboriginal 20-24 ancestry will identify themselves as Aboriginal.* 15-19 Census data is likely to underestimate the 10-14 numbers of Aboriginal peoples for several reasons. 5-09 0-04 In the 1996 Census, 77 reserves with an estimat- 10 8 6 4 2 0 2 4 6 8 10 ed total population of 44,000 people were incom- Percent of Population pletely enumerated, and therefore not included in * Based on Health Canada data. any census counts.4 Among "registered" Indians * Ancestry questions pertain to the cultural or ethnic group(s) of a person's ancestors, while identity refers to whether or not that person considers him- or herself a part of that group. JOURNAL SOGC DECEMBER 2000 3 FIGURE 3 TRADITIONAL LAND BASE OF ABORIGINAL PEOPLES IN CANADA ACCORDING TO LANGUAGE GROUP T In lin A ui g t t i h t ap H a a s id c a a n shian n Tsim an h S s a ak li a s K h u W t a e n nai A Algonkian a lgo n nkian Siouan Athapaskan Inuit Haidan Salishan Iroquoian Siouan Tsimshian Iroquoian Kutenaian Tlingit Wakashan Aboriginal children under the age of 15 are more likely than British Columbia, and the Northwest Territories. Sixty-five percent non-Aboriginal children to live in single parent families (32% vs. of Metis live in urban areas, compared to 77 percent of the general 16%). In urban areas, over half of Aboriginal children under 15 Canadian population. Even in those largest urban centres with the live in single parent families.4 highest numbers (Winnipeg, Edmonton, and Saskatoon), the Metis There is also a trend towards increasing urbanization of Abo- represent a small percentage of the total urban population (2.5-3.7%). riginal peoples in Canada, with 70.9 percent of all Aboriginal peo- Approximately half of the Metis population lives in villages, hamlets, ples identified by the 1996 Census living off-reserve.6 One out of and rural communities concentrated in a band just above the "fertile five Aboriginal peoples live in seven of Canada's 25 metropolitan belt" in the Canadian prairies, as well as in areas of Northern Ontario, census areas (Winnipeg, Edmonton, Vancouver, Saskatoon, the interior of British Columbia, and the Northwest Territories south Toronto, Calgary, and Regina).4 of Great Slave Lake. In these areas, the Metis may make up a very sig- The majority of Inuit identified by the 1996 Census live in nificant part of the total population, and in some instances define the and around 55 communities in the Arctic and sub-Arctic regions community as Metis. In keeping with the age profiles of other Abo- of Canada, most of which are remote and isolated. A small but riginal groups, the Metis also have a young population: 37.8 percent increasing number of Inuit live in urban centres in southern Cana- of those of Metis identity were 14 years of age or under.8 da. Like the First Nations, the Inuit population is also a very young population compared to the general Canadian population (Fig- RECOMMENDATION A3 ure 2). The birth rate of Inuit women (3.4) is the highest of all Aboriginal populations and is twice as high as the Canadian aver- Health professionals should familiarize themselves with the age (1.7). In some northern regions, the proportion of persons traditional geographic territories and language groups of under 30 years is as high as 60 percent.7 Aboriginal peoples. Most Metis identified by the 1991 Census live in the prairie provinces, although there are also significant populations in Ontario, The Aboriginal peoples in Canada embody approximately 50 JOURNAL SOGC DECEMBER 2000 4 culturally diverse groups, the roots of which are found in dis- _ It has had a major, ongoing impact on the physical, mental, tinct languages and land bases. Table I outlines the 11 major emotional, and spiritual health and well-being of Aboriginal linguistic groups and the 50 distinct languages, while Figure 3 peoples in Canada shows the traditional land bases of the First Nations and Inuit _ It impacts on current relationships of Aboriginal peoples peoples according to linguistic group. The traditional home- with their health care providers and with the mainstream land of the Metis was the western prairie. health care system (which grew out of the colonial system) It is important to appreciate the significance of traditional _ Policies and attitudes which perpetuate this history still exist lands to Aboriginal individuals and communities. The Abo- today riginal concept of land and the relationship of humans to the The reality of Aboriginal existence for many First Nations and land is very different from the western European perspective. Metis has been described as the "Circle of Life" or the "Sacred Traditionally, most Aboriginal peoples did not have a sense of Hoop." This concept could be loosely described as a continuum "land ownership" in the western European sense, but rather of age-related roles and physical, mental, emotional, and spiri- perceived a responsibility to "take care of" or maintain certain tual well-being: which is congruent with the cycles of nature (see tracts of land that may have been inhabited for thousands of section B1). Prior to colonization, Aboriginal communities in years by their ancestors. Since these tracts of land and the plants the Americas were diverse and thriving. Shaped by the envi- and animals found there were the basis for survival, the geog- ronment and available technologies, they ranged from the large raphy of these traditional lands determined daily behaviours, cities of the Cherokee confederacy, Maya, and Inca peoples to linking traditional Aboriginal customs and cultures to these the smaller mobile groups of plains and northern peoples. traditional lands: Figure 4 illustrates how colonization completely disrupted Native people have a reverence for and attachment to their this "Circle of Life." Early European colonization of the Amer- land, even to the few acres left after the pillage of the forests icas brought epidemics of disease and included massacres, war, and plains by the dominant culture. Natives are products and and slavery. extensions of this land and the vestiges of Native ethics and The "Sacred Hoop" and "Circle of Life" concepts are not rules of behaviour, which continue to promote group unity and applicable to the Inuit, who have their own rich and unique cul- survival on Native lands, will not easily or soon be relinquished, tural heritage. Although Inuit did suffer from many of the oppres- even if the consequence of persistence in the old forms of sions listed in Figure 4, a more appropriate metaphor might be the behaviour is to be removed from competitiveness and success impact of these events on traditional Inuit community events such in the dominant non Native culture.9 as the sharing and eating together of traditional or "country" foods. The Inuit also have a strong connection to the land, and also to According to some historians, the first years of contact in what the sea: Our people are by tradition a people of the land. Our culture FIGURE 4 is strongly tied to the land and so are our people and our com- IMPACT OF COLONIZATION ON THE CIRCLE OF LIFE munities. Inuit have always recognized the fragility of the world they inhabited and the traditional Inuit way has been Sacred Hoop (Native World) Broken By: to live in harmony with the land that feeds and sustains us.7 These linkages remain strong in many Inuit communities: Inuit continue to keep a close relationship with the land and sea. Domination (by other races and societies) Virtually every family depends upon our land and sea mammal _ Government policies _ Theft of Homeland resources for vital needs such as food and clothing. Many fam- _ Imposition of "Unnatural" Social Order ilies look forward to the time when they can go out on the land _ Suppression of: Language, Ceremonies, for extended periods and live much like our ancestors.10 Culture, and "Spiritual way of life" _ Residential Schools RECOMMENDATION A4 _ Destruction of Native Family Systems _ Slavery by Churches and Society Health professionals should have a basic understanding of _ Denial of Native Historical Importance _ Fear _ Ignorance _ Stereotyping the disruptive impact of colonization on the health and _ Prejudice _ Oppression _ Racism well-being of Aboriginal peoples. _ Multi-Generational Trauma _ Pollution of "Mother Earth" While a detailed summary of the history of Aboriginal and _ Genocide European relations over the past 500 years is beyond the scope of this document, health professionals need to have some sense * Adapted from an illustration by Avis Archambault, a tradi- of this history for several reasons: tional healer and teacher of Lakota/Gros Ventre ancestry. JOURNAL SOGC DECEMBER 2000 5 is now Canada included fragile but relatively peaceful relations. opened. Seventeen regional "Indian" hospitals were built by The Royal Proclamation of 1763 called for negotiated settlement the federal government, initially in an attempt to control the of land transactions through treaty or purchase. Transactions epidemic of infectious diseases associated with colonization, included barter, trade, and military alliances.11 Unfortunately, such as smallpox, measles, tuberculosis, and poliomyelitis. Abo- governmental approach quickly shifted from negotiations to share riginal children and adults who screened positive for tubercu- land to a unilateral policy of assimilation intended to "remove losis were removed from their communities, often without Aboriginal people from their homelands ... suppress Aboriginal proper explanation or consent, and placed in these regional nations and their governments ... undermine Aboriginal cultures hospitals. By 1950 there were 33 nursing stations, 65 health ... and stifle Aboriginal identity."11 The Indian Acts of 1876, centres, and 18 small hospitals run by the federal government 1880, 1884, and later outlawed Aboriginal ceremonies such as to provide health care for Aboriginal peoples.12,13 the sundance and potlatch, gave the Indian agent authority over In 1962, the Medical Services Branch of Health and Wel- the food, goods, and travel available to on-reserve Aboriginal peo- fare Canada was created with the mandate to provide services ples, and supported the abduction of Aboriginal children to res- to treaty Indian and Inuit peoples. In the late 1960's, several idential schools where language and culture were actively universities became involved in the provision of direct prima- suppressed. Starvation, violence, infectious diseases, cultural sup- ry and consultant services to rural and remote Aboriginal com- pression and imposed religious practices, family and communi- munities in collaboration with Medical Services Branch. Many ty disruption and relocation, and physical, emotional, and sexual of these programmes were based out of the same small "Indi- abuse were common realities for Aboriginal peoples in Canada an" hospitals which had previously been opened in response to during these chaotic times. The traditional healers in Aboriginal infectious diseases such as tuberculosis.12,13 communities had never seen diseases such as smallpox and Journalist Geoffrey York argues that oppressive policies and poliomyelitis, which wiped out many families and some com- attitudes toward Aboriginal peoples survived well into the munities. The population in the area of what is now Canada, esti- twentieth century, and in fact still exist today: mated at 500,000 people prior to European contact, was reduced Strangely, most Canadians are better acquainted with the his- to 102,000 by 1871.11 tory of native people in the eighteenth and nineteenth centu- Regrettably, there have been many opportunities to docu- ry than they are with the unsavoury realities of recent years. ment the devastating impacts of European colonization world- Canadians know that the early settlers and governments took wide. The result is a clear and long lasting pattern of illness and land from the Indians, but it is easy to feel detached from disease over time: those events of long ago. It is more difficult to deny responsi- All peoples of the world who undergo colonization tend to bility for the misguided policies of the twentieth century. And experience three stages of health and illness patterns as they so the ugly events of recent history are buried behind a wall become more urbanized and industrialized. The first stage is of illusion--the illusion that progressive thinking and marked by famine, high rates of infectious disease, and high improved attitudes have brought fair treatment to Canada's death rates, especially among infants and children. The sec- native people ... Hundreds of native communities are still ond is marked by declining rates of infectious disease and enduring the malignant effect of institutions that seem benign rapid population growth. The third stage is marked by the to non-native Canadians: the churches, religious boarding rise of chronic and degenerative diseases. Canadian Aborigi- schools, provincial and federal schools, child welfare agencies, nal people seem to be between the second and third stages, courts, government departments, hydro corporations, and as despite the extension of medical and social services in some resource developers. The social conditions on modern-day form to every Aboriginal community, Aboriginal people reserves are a legacy of the decisions and policies of the most still experience unacceptable rates of illness and distress.12 powerful institutions of the nineteenth and twentieth centu- The history of the current health care system for Aboriginal peo- ry. Many of those policies--and the attitudes that shaped ples has its roots in the colonial system. Traditional healing meth- them--still exist today.14 ods were banned as "witchcraft" and access to medicinal plants Examples of systemic oppression that continued into the twen- was denied as part of the legislation associated with the early Indi- tieth century are residential schools, relocation, and the "Six- an Acts. The first western health care came in the form of semi- ties Scoop." professionally trained Royal Canadian Mounted Police (RCMP) Approximately 100 residential schools operated in Cana- and missionaries: the same missionaries and RCMP that were da from 1849 to 1983. Indian Act legislation in 1920 made removing children to residential schools. school attendance compulsory for all First Nations children Some of the first physicians arrived with the Indian agents between the ages of seven and 15. The residential school expe- and offered medical assistance to First Nations communities rience is described in the following excerpt from the First conditionally upon the signing of treaties by those same com- Nations and Inuit Survey Report: munities. In 1930, the first on-reserve nursing station was In some areas as many as five separate generations of children JOURNAL SOGC DECEMBER 2000 6 were removed from their homes, families, culture, and language centralized settlements. Relocation sites were selected by gov- ... At the schools children's long hair was cut off and school uni- ernment officials and did not take into account the fact that per- forms issued ... many of the children endured long years of iso- manent villages were not part of the Inuit experience. lation and loneliness ... Children entered a strange new world Furthermore, the hunting conditions of the new sites were often in residential boarding schools ... Scores of children died from suboptimal, interfering with the traditional food supply:18 disease; others were emotionally and spiritually destroyed by the Although the intentions were to have Inuit gain better access harsh discipline and living conditions. Children were referred to government services this movement initiated a period of to as `inmates.' Survivors report being hungry all the time. In social, cultural, and economic upheaval for the Inuit. With- some cases, children were separated from their siblings, tortured in the space of a few years, many of us had left a life that was for speaking their mother tongue, forbidden to honour their based on an intimate reliance on the resources of the land and traditions. Grievous sexual abuse also occurred in some schools, sea and stepped into a different way of living.10 but other outstanding issues include physical abuse and poor In the 1950's, as the result of amendments to the Indian Act, quality of education.15 the provinces were guaranteed federal funding for each Abo- Inuit children were not spared the residential school experience. riginal child apprehended by child protection agencies: result- Mary Carpenter summarizes her experience of residential school: ing in a ballooning of the number of First Nations children who After a lifetime of beating, going hungry, standing in a corri- were taken into care and made legal wards. This accelerated dor on one leg, and walking in the snow with no shoes for removal of Aboriginal children from their homes is known as speaking Inuvialuktun, and having a heavy stinging paste the "Sixties Scoop." The percentage of apprehended children rubbed on my face, which they did to stop us from express- who were of Aboriginal ancestry jumped from one percent in ing our Eskimo custom of raising our eyebrows for `yes' and 1959 to between 30 and 40 percent in the 1960's. Aboriginal wrinkling our nose for `no,' I soon lost the ability to speak my children continue to make up a disproportionate percentage of mother tongue. When a language dies, the world it was gen- the children who are apprehended from their homes by social erated from is broken down too.16 service agencies. Many of the parents of these children are them- The traumatic impact of residential schools on the individual selves survivors of residential schools.17 is described in the same article: Corporations involved in hydroelectric power and resource Former students have expressed the pain and confusion of development are also cited by York as modern examples of not fitting in either world, of being caught between two cul- modern institutions which have a disruptive impact on Abo- tures--the white culture of the residential schools and their riginal communities.14 Reviewing the health status of native Inuit culture. This chasm within has caused various illnesses peoples in the Hudson Bay/James Bay region in relation to of the soul, leading to depression, hopelessness and destruc- hydroelectric and other forms of development in the region, tive behaviours such as alcoholism, drug addictions, sexual Stieb and Davies conclude that the increased prevalence of for- promiscuity or violence, all with their own tragic conse- merly infrequent chronic diseases, injuries, poisoning, and vio- quences.16 lence appear to be linked to these environmental changes and Unfortunately, the impact of residential schools goes far beyond the accompanying social, economic, and cultural changes.19 the impact on individual survivors. Cornelia Wieman highlights the enduring aftermath of the residential schools, asserting that: RECOMMENDATION A5 In addition to the damage caused to the individual survivors who endured emotional, physical, and sexual abuse, we must Health professionals should recognize that the current consider the long-term, cumulative intergenerational effects sociodemographic challenges facing many Aboriginal indi- on First Nations Communities ... including dislocation from viduals and communities have a significant impact on health one's community, loss of pride and self-respect, loss of iden- status. tity, language, spirituality, culture, and ability to parent. The roots of this damage and these losses are reflected in the The dramatic improvements in health outcomes (such as life abysmal statistics which reflect levels of family violence, sui- expectancy, maternal and child morbidity and mortality) experi- cide, alcohol and other substance abuse in Aboriginal com- enced by the general Canadian population over the past 200 years munities today.17 have been achieved mostly by the increase in economic prosper- Governmental attempts to relocate Inuit communities began in ity brought about by the industrial revolution, which in turn 1934 when 22 Inuit from Kinngait (Cape Dorset), 18 from Mit- resulted in improved food supply, safe housing, clean water sup- timatalik/Tununiq (Pond Inlet), and 12 from Pangnirtuuq ply, adequate systems for waste disposal, and decreased birth rates. (Pangnirtung) were transported to Dundas Harbour. During the Modern health care systems have had a small impact compared 1950's and 60's, many more Inuit families were moved from to these changes.20 Other social factors that have been accepted their traditional living areas and relocated to permanent and as determinants of health outcomes include employment, JOURNAL SOGC DECEMBER 2000 7 education level, and certain environmental exposures. _ Education: in 1991, 49 percent of the Aboriginal popula- In contrast, many Aboriginal individuals and communi- tion in Canada had at least high school education, compared ties continue to experience social conditions that impact to 62 percent of the non-Aboriginal population. In the same adversely upon health status, including: poverty, inadequate year, 31 percent of First Nations persons living on-reserve and housing, unsanitary water supply and waste disposal, low edu- 45 percent of Metis had at least high school education. In cational achievement, unemployment, family violence, alco- 1996, 41 percent of Inuit women and 35 percent of Inuit hol and substance abuse, dependence on social assistance, men had at least high school education, while 35 percent of discrimination within the justice system, and environmental Inuit women and 32 percent of Inuit men had less than grade exposures.11,13 The prevalence and trends of some of these nine education.7 Levels of post secondary education and problems are outlined below. retention rates for on-reserve schools have improved for the past 20 years. In 1968, approximately 800 Aboriginal per- _ Income: according to the 1996 Census, 43.6 percent of sons were known to have post secondary education, increas- Aboriginal peoples were identified as being in a "low- ing to over 150,000 Aboriginal persons in 1991. Retention income" household compared to 19.2 percent of the non- rates for on-reserve schools improved from 13 percent in Aboriginal population.4 According to the 1991 Census, the 1969 to 75 percent in 1995-96.23 The First Nations and Inuit average annual income for Aboriginal peoples in Canada in Regional Health Survey found that education level was 1990 was 70 percent of the annual income for non-Abo- inversely related to self-reported history of chronic disease.15 riginal Canadians. On-reserve, the average annual income was 43 percent that of non-Aboriginal Canadians.21 Aver- _ Housing: Sixty-five percent of on-reserve housing was age annual income for Metis was 67 percent of the annual judged to be substandard by the Canadian Mortgage and income for the general Canadian population in 1991.8 In Housing Corportion in 1996. Although the prevalence of Nunavut, in 1996, the average annual income for Inuit was water delivery systems and sewage disposal had increased 44 percent of the average annual income for non-Inuit.7 dramatically over the past ten years, 25 percent of on-reserve houses lacked an operational bathroom in 1996. Thirty-one _ Food security: according to the Aboriginal People's Survey percent of First Nations people living on-reserve in 1996 in 1991, 8.3 percent of all Aboriginal respondents over 15 lived in crowded homes: housing densities ranged from 3.7 years of age reported food availability as a problem during to six persons per home, with the highest densities in Que- the year before the survey. Breakdown rates were: 12.7 per- bec, Manitoba, Saskatchewan, and Alberta.21,24 Poor hous- cent for Inuit, 8.5 percent for off-reserve "Indian" people, ing had also been found to be a factor in ill health among 7.7 percent for on-reserve "Indian" people, and 7.5 percent the Metis.26 Overcrowded and substandard housing is also for Metis people.22 In many isolated and northern Aborig- a major problem for the Inuit living in the North. As the inal communities, nutritious food is difficult and costly to result of increased building and fuel costs, 90 percent of attain: a nutritious food basket for a family of four that costs Inuit families in the North rely on social housing. In some $125 in Ottawa, costs $209 in Salluit, Nunavik and $260 communities, the waiting period for housing is several years, in Arctic Bay, Nunavut.7 and families are overcrowded in small houses lacking ade- quate insulation, heating, plumbing, and sewers.7 _ Unemployment: participation in the labour force is lower and the unemployment rate is higher for Aboriginal peo- Health professionals need to be aware that health status is ples compared to non-Aboriginal Canadians. In 1991, the unlikely to improve significantly unless the roots of these unemployment rate for Aboriginal peoples was 19.4 per- sociodemographic issues are addressed. cent compared to ten percent for non-Aboriginal Canadi- ans. The unemployment rate for on-reserve First Nations RECOMMENDATION A6 people was 31 percent.23 Inuit and Metis communities suf- fer from similar lack of employment. The overall unem- Health professionals should recognize the need to provide health ployment rate in Nunavut in 1999 was 21 percent, services for Aboriginal peoples as close to home as possible. compared to less than nine percent for Canada. Unem- ployment rates for Inuit only are generally much higher. A significant proportion of Aboriginal communities are in remote Many Inuit are still dependent on a mixed economy, com- regions, many accessible only by air. According to First Nation bining both wage income and traditional harvesting pur- and Inuit Health statistics, approximately 20 percent of First suits for food and clothing.7 In 1991, the unemployment Nations communities currently do not have year round road rate for Metis averaged 21.7 percent.8 access.25 Almost all northern Inuit communities are remote and do not have year round road access. Post et al. 25 estimated that JOURNAL SOGC DECEMBER 2000 8 nationally, 30 to 50 percent of Aboriginal communities could be Health care providers involved in the decision making described as remote, noting that there is wide regional variation. regarding location of medical care for individuals and com- With the disruption of traditional systems of health care munity programs need to carefully balance the cultural and and the encroachment of federal medical systems, large num- biomedical impact of location of service. bers of individuals began to be evacuated from their commu- nities for medical services, often including birthing services. RECOMMENDATION A7 Given the attachment to and synonymity of geographic land base and culture described in section A3, the non-Aboriginal Health professionals should have a basic understanding of can begin to understand the disruptive impact of having to governmental obligations and policies regarding the health remove individuals from rural and remote communities to pro- of Aboriginal peoples in Canada. vide medical services as described by Roda Grey, Health Coor- dinator at the Inuit Tapirisat of Canada: Section A4 provided a brief overview of the context of relations Traditional midwives ... had special status within Inuit com- between Europeans and Aboriginal peoples in what is now munities and were respected and acknowledged for their skills Canada over the past 500 years. Current governmental obliga- ... Although they travelled far to obtain the services of the tra- tions towards Aboriginal peoples regarding land and other ben- ditional midwife, they were accompanied by family members, efits, including health care, can be traced back to the treaties and remained within their own culture ... Traditional mid- negotiated during this time period. Treaties, which are negoti- wives provided prenatal care, counselling on nutrition, physi- ated agreements between the Canadian (previously British) gov- cal exercise, and care of the newborn ...Once nursing stations ernment and Aboriginal communities regarding government were permanently established in Inuit lands, the practice of compensation of Aboriginal peoples in return for land title, have Inuit traditional midwifery was no longer permitted ... Preg- been employed as a tool for the negotiation of peace and shared nant women near delivery were sent to larger communities ... land use for several hundred years. Treaty making started as early Women were separated from their families and culture during as the 1600's, when the Two Row Wampum was negotiated an important life event. The health services dealt with emer- between the Mohawk and the Dutch in 1613,11 and continued gency cases and treatment rather than prevention and educa- well into the twentieth century (Treaty #9 adhesions 1929-30). tion. Elders within Inuit communities say that Inuit pregnant There are still living witnesses to the signing of some treaties. women no longer follow traditional health teachings.27 Unfortunately, many treaty agreements were not fully hon- Geographic location and culture are used almost synonymous- oured by the Europeans. In addition, the underlying meaning ly in Grey's description, reflecting the close connection between of the verbally negotiated treaties was often very different from the two. In further discussion, Grey described how Inuit elders the final written documents according to the perspective of the see pregnant women lacking physical exercise and a balanced Aboriginal leaders involved. Aboriginal leaders had been nego- diet, instead relying on "junk food" and spending large amounts tiating treaties among their own nations for hundreds of years of time watching television since the southern nurses took over prior to European contact. These "nation to nation" treaties their health. were based on verbal oaths, ceremonies, and symbolic visual Many Aboriginal individuals are still forced to leave their com- records such as wampum belts. The treaties with the Europeans munities for medical care as the result of geographic isolation. The were negotiated by Aboriginal leaders from this "nation to majority of Inuit still live in remote and isolated communities with nation" perspective. British expectations that the First Nations the nearest hospital usually hundreds of kilometres away, while would also acknowledge the authority of a distant monarch major referral centres may be thousands of kilometres away. For and cede large tracts of land to British control were not explic- example, the distance from Iqaluit to Ottawa, the major tertiary it in the verbal treaty agreements. Indeed, as noted in section care referral site for Iqualuit, is 2,055 km. In most remote Inuit A3, the notion of land ownership was a European concept. and First Nations communities there is only a nursing station, Negotiated agreements regarding land use and compen- staffed by a nurse or community health representative. Physicians sation continue to be settled between the federal government and other specialists fly into the community periodically. Many and Aboriginal communities, with hundreds of outstanding services, including rehabilitation, physiotherapy, chiropractic, and land claims yet to be negotiated. Some Aboriginal communi- mammography are not commonly available. ties never officially ceded their traditional lands through the Several rural and remote Aboriginal communities are signing of treaties. Others are contesting the historic federal investigating the use of advanced telecommunications equipment, interpretation of treaty agreements. In the area of health care, including video linkages between patients and off-location health there has been considerable controversy regarding the extent care specialists. Development of such telehealth resources may of governmental obligations towards Aboriginal peoples. Pro- assist in the promotion of better health care for Aboriginal peo- vision of health care services for Aboriginal communities was ples in isolated communities. part of at least some treaty negotiations, as demonstrated by JOURNAL SOGC DECEMBER 2000 9 the "medicine chest clause" of Treaty #6 signed in 1876 The Metis have been historically dismissed by the British between Canada and the Cree of Alberta and Saskatchewan: and Canadian governments. When European settlers arrived and In the event hereafter the Indians ... being overtaken by any made claim to their historic lands, the Metis were treated as pestilence, or by a general famine, the Queen ... will grant to squatters and pushed off the land. Instead of treaty compensa- the Indians assistance ... sufficient to relieve them from the tion with land and other benefits, as was being negotiated with calamity that shall have befallen them. A medicine chest shall the First Nations, Metis received "half-breed script" in compen- be kept at the house of each Indian agent for the use and ben- sation for relinquishment of Aboriginal title. Metis claims for a efit of the Indians at the direction of such agent.28 secure land base and political recognition have been continuing The "medicine chest clause" has been interpreted by many as for over a century. The Metis are currently excluded from health evidence that provision of health care services by the federal gov- benefits and programmes available to "status Indians" and "reg- ernment is a negotiated treaty right. istered Inuit" by First Nations and Inuit Health. As described in section A4, the historic basis of federal health Medical services and special health benefits for "status Indi- care services for Aboriginal peoples was based more on an ans" and "registered" Inuit have been provided through three assumed authority over Aboriginal nations than a negotiated governmental structures: the provincial governments (which are obligation. This policy of appropriation was formalized by the reimbursed by the federal government for services provided to 1897 Constitution Act, by which the federal government gave "status Indians" and "registered" Inuit); the former Medical Ser- itself legislative authority over "Indians and lands reserved for vices Branch of Health Canada; and the Department of Indi- Indians." The Indian Acts of 1876, 1880, and 1884 legislated a an Affairs and Northern Development. This heterogeneous federal policy of domination and assimilation, with health ser- structure has led to a fairly complicated service delivery system vices initially lumped together with other "services" for Aborig- with jurisdictional gaps and overlaps: for example, it is not clear inal peoples. Between 1867 and 1966, the responsibility for which agency is mandated with the provision of mental health "Indian affairs" migrated between several different federal depart- services for Aboriginal peoples. ments, including the Office of the Secretary of State, Citizen- Some services, such as chiropody, are only available on- ship and Immigration, Mines and Resources, and Northern reserve. Metis and "non-status Indians" are excluded from these Affairs and National Resources; until the Department of Indi- services, and receive no funding for non-insured health bene- an and Northern Affairs was finally created in 1966. In the inter- fits such as prescriptions and dental care. Although "registered" im, the responsibility for health services for "registered" Inuit and Inuit in remote communities may in theory be eligible for addi- "status Indians" had been transferred to Health and Welfare tional health services, in practice they are denied access to these Canada in 1945; until in 1962 the Indian Health Service was entitlements due to the lack of availability of these health care merged with six other federal health programmes to form the services in their communities. Medical Services Branch of Health Canada, renamed First Presently, First Nations and Inuit Health is divided into two Nations and Inuit Health in July 2000. principal components: the Non-Insured Health Benefits Pro- Since the early Indian Acts, only those Aboriginal peoples gramme (NIHB) and the First Nations and Inuit Health Pro- registered at the Department of Indian Affairs and Northern grammes (FNIHP). The majority of health programmes Development under the Indian Act and those recognized in formerly at the Department of Indian Affairs and Northern treaties have been entitled to certain benefits, including specific Development have been transferred to First Nations and Inuit health services. These benefits and services thus exclude a sig- Health. NIHB is a nationally-based programme providing nificant proportion of the Aboriginal peoples living in Canada. health benefits to "status Indians" and "registered" Inuit. Ben- According to the 1996 Census results, "status Indians" and "reg- efits included under the programme are pharmaceuticals, med- istered" Inuit account for less than 60 percent of the Aboriginal ical supplies and equipment, dental services, vision care, medical peoples in Canada: with the remaining Aboriginal population transportation, and individual mental health counselling. composed of those First Nations individuals who were exclud- FNIHP are community-based and include community health ed from treaties or lost their status, Metis, and "unregistered" nursing and the community health representatives. In addition, Inuit. Prior to 1985, "status" First Nations women who married primary care is provided in northern and isolated communities, "non-status" men lost their Indian status and the associated ben- often by a nurse or community health representative with physi- efits. Bill C-31 allowed some of these women and their descen- cian back-up by telephone or radio. These latter programmes dants to be registered or re-registered under the Indian Act, with are delivered either by regional offices or by First Nations them- certain limitations. Thousands of Aboriginal men also lost their selves and include such initiatives as: the National Native Alco- status as a condition of their military enrollment. In 1969, the hol and Drug Abuse Programme (NNADAP), the Brighter "White Paper" attempted to dismantle the Indian Act altogeth- Futures programme, solvent abuse programmes, the First er, including discontinuation of the special health services for Nations Health Information System, the HIV/AIDS pro- "status Indians" and "registered" Inuit. gramme, the Canada Prenatal Nutrition Programme (CPNP), JOURNAL SOGC DECEMBER 2000 10 and the Aboriginal Headstart on-reserve. 3. Isaac T.An introduction to Aboriginal issues. J Soc Obstet Gynecol Can 1995;17:583-5. Current federal policies encourage transferring the man- 4. Statistics Canada. 1996:Aboriginal Census Data.The Daily. Statistics agement of special health programmes to Aboriginal commu- Canada, 1998. nities.12 As of March 1999, 41 percent or 244 eligible First 5. Statistics Canada. Language,Tradition, Health, Lifestyle and Social Issues: 1991 Aboriginal Peoples Survey (Catalogue 89-533). Ottawa, 1993. Nations and Inuit communities had signed Health Services Cited by Kinnon D, Health is the whole person: a background paper on Transfer Agreements. An additional 37 percent of eligible health and the Metis people. Submission to the Royal Commission on First Nations and Inuit communities were involved in transfer Aboriginal Peoples, 1993. 6. Statistics Canada data. Obtained by personal correspondence with via planning or contribution agreements.29 Doug Norris, Statistics Canada. 7. Pauktuutit. Inuit women's health: overview and policy issues. Pauktuutit RECOMMENDATION A8 _ Inuit Women's Association of Canada. March 2000. 8. Boisvert DA.A human resources development plan for the Metis nation. Metis National Council, Ottawa, June 1995. Health professionals should recognize the need to support 9. Brant C. Native ethics and rules of behaviour. Can J Psychiatr Aboriginal individuals and communities in the process of 1990;35:534-9. self-determination. 10. Inuit Tapirisat of Canada.We are the Inuit (brochure). Inuit Tapirisat of Canada 2000. 11. Royal Commission on Aboriginal Peoples. Highlights from the Report This recommendation is in keeping with the recognition by the of the Royal Commission on Aboriginal Peoples. Ottawa: Ministry of Royal Commission on Aboriginal Peoples that the inherent Supply and Services Canada, 1996. 12. Locust CS. Overview of Health Programs for Canadian Aboriginal Peo- rights of Aboriginal self-government are recognized and affirmed ples. In: Galloway JM, Goldberg BW,Alpert JS (eds). Primary Care of in section 35(1) of the Constitution Act.2 The Commission Native American Patients.Woburn USA: Butterworth, 1999:17-21. advocated the rebuilding and development of self-governed 13. Bridging the gap: promoting health and healing for Aboriginal peoples in Aboriginal nations.11 Canada. Ottawa: Canadian Medical Association, 1994. 14. York G The dispossessed: life and death in native Canada.Toronto: Lit- While the Royal Commission based its arguments on the tle, Brown & Co, 1992. inherent right to self-government, Gray cites Australian and 15. First Nations and Inuit Regional Health Survey, National Report, 1999. Canadian literature on self-determination and indigenous-gov- St. Regis QC: First Nations and Inuit Regional Health Survey National Steering Committee,Akwesasane Mohawk Territory, 1999. ernment relations as containing "an implicit view that from 16. Royal Commission on Aboriginal Peoples. Report of the Royal self-determination will flow the development and implemen- Commission on Aboriginal Peoples. 1996;6(10):372. tation of effective policy and programmes."30 He further states 17. Wieman, CA. Return to Native Roots.Aboriginal Health Building Informed Partnerships. Presented at the Society of Obstetricians and that a comprehensive United States review found that "real Gynaecologists of Canada 55th Annual Clinical Meeting, Montreal, 1999. improvements in the socioeconomic status of indigenous 18. Dickason OP. Canada's First Nations:A History of Founding Peoples Americans are directly attributable to political changes of the from the Earliest Times.Toronto: McClelland & Stewart, 1992,pp.396-7. 1970's, leading to increased Indian control over, and partici- 19. Steib D, Davies K. Health and development in the Hudson Bay/James Bay Region.Arctic Med Res 1995;54:170-83T. pation in, the formulation of Indian policy."30 20. Torrance GM. Socio-Historical Overview:The Development of the The Canadian Medical Association also supported the self- Canadian Health System. In: Coburn D, D'Arcy C,Torrance G (eds). determination of Aboriginal peoples in social, political, and eco- New P Health and Canadian Society. Markham: Fitzhenry & Whiteside, 1987,pp.6-32. nomic life, recognizing that this improves the health of 21. Department of Indian and Northern Affairs. Basic Departmental Data Aboriginal peoples and their communities. The CMA submis- 1996. Departmental Statistics Section, Information Quality and sion to the Royal Commission on Aboriginal Peoples states that: Research Directorate, January 1997. 22. Canadian Institute on Child Health.Aboriginal Children. In:The Health The failure of past and present western institutions to meet the of Canada's Children:A CICH Profile. 2nd ed. Ottawa:The Institute, fundamental need of Aboriginal peoples, not least in the area 1994,pp.131-48. of health, supports the view that Aboriginal peoples can best 23. Department of Indian and Northern Development. Highlights of Abo- riginal Conditions 1991, 1996. Ottawa: Departmental Statistics Section, determine their requirements and solutions to their problems.13 Information Quality and Research Directorate, 1995. The control of health services by Aboriginal peoples will be fur- 24. Canadian Mortgage and Housing Corporation, Social Directorate. ther explored in Section D. Housing Conditions of Aboriginal peoples in Canada. Summary Report. Ottawa: Government of Canada, 1996. 25. Postl B, Irvine J, MacDonald S, Moffatt M. Background Paper on the J Soc Obstet Gynaecol Can 2000;22(12):1070-81 Health of Aboriginal Peoples in Canada. Cited in: Bridging the Gap: Pro- moting Health and Healing for Aboriginal Peoples in Canada. Ottawa: Canadian Medical Association, 1994. 26. Kinnon D."Health is the whole person": a background paper on health REFERENCES and the Metis people. Submission to the Royal Commission on Aborigi- nal Peoples, 1993. 1. George D. My Heart Soars. Clarwin House,Toronto, 1974. Cited in: 27. Ross M.Aboriginal women's health: cultural values, beliefs, and practices. Lessard P. Aboriginal health care: how to understand and communicate J Soc Obstet Gynecol Can 1997;17:987-91. better. J Soc Obstet Gynaecol Can 1994;16:1571-9. 2. Constitution Act. Section 35(2). 1982. JOURNAL SOGC DECEMBER 2000 11 28. Young TK. Indian Health Services in Canada: a socio-historical perspective. Social Sciences Medicine 1984; 18:257-264. Cited in: Bridging the Gap: Promoting Health and Healing for Aboriginal peoples in Canada. Ottawa: Canadian Medical Association, 1994. 29. Health Canada.Ten Years of Health Transfer First Nation and Inuit Con- trol. Ottawa: Ministry of Public Works and Government Services, 1999. Cat. No.: H34-104/2000. 30. Gray D, Saggers S, Drandich M,Wallam D, Plowright P. Evaluating government health and substance abuse programs for indigenous peo- ples: a comparative review.Australian J Pub Health. 1995;19(6):567-72. JOURNAL SOGC DECEMBER 2000 12
