Jasjit Goraya

On March 10, 2016 images of First Nations children from the Nishnawbe Aski Nation who were covered in rashes and skin lesions surfaced on the internet. A total of 16 children with acute cases of skin infection were identified as in need of immediate medical help. Health Canada immediately issued a statement claiming that medical health professionals were on their way to the community to conduct door-to-door investigations to determine if other children had developed similar bacterial infections or symptoms. Following the news release, a debate ensued about the potential causes of the skin infections, with some citing poor water conditions and others stating that it was a case of a bacterial infection caused by unsanitary living conditions.

In another part of the country, the Cross Lake Cree community of 8,300 people, located 500 kilometres north of Winnipeg, appealed for federal aid in the beginning of March after six suicides took place in two months and 140 suicide attempts were reported over the course of a few weeks. Further investigations into the community found that living conditions were unsanitary,  with as many as  27 people living in a home that would only be fit for a small family The community leaders stated that, despite utilizing all frontline medical workers, they did not have enough access to mental health facilities, nor the resources to deal with high-risk cases or emergencies. Locals connect high unemployment rates and housing issues to the recent outbreak of suicides, claiming that living situations have added a lot of stress to an already desperate situation.

The cases of the Nishnawbe Aski and Cross Lake Cree nations illustrate a dire shortage of mental health and medical resources on remote and isolated Aboriginal reserves. University of Victoria Centre for Indigenous Research Director, Charlotte Loppie Reading and Dalhousie University Social Work Professor, Fred Wein state that inefficient health care resources on reserve are the result of historical policies of assimilation have left Aboriginal communities marginalized in all aspects of life.

Since Indigenous peoples were viewed as “wild and childlike”, their presence in urban centres was considered incongruous to 19^th century policymakers’ goals for urban development. For indigenous communities, the state’s goal of Indian assimilation was understood to be attainable through economic assimilation. A pivotal marker for identifying whether an Indigenous individual had assimilated or not was whether the individual had entered into the waged or industrialized workforce. It was vital for the Crown to categorize Indigenous peoples into groups based on assimilation because of the need to know which peoples the Crown owed particular legal duties to—or who had particular rights.

As a result of this forced assimilation, the First Nations community, today, has a unique relationship with the Canadian government, as illustrated by the provisions made under the Indian Act of 1867, which include health care. For the First Nations, Inuit, and to a degree, the Metis peoples, the colonial process had severely weakened self-determination, which meant a lack of influence on policies that directly impacted Aboriginal work, health, culture, and social-wellbeing. All Aboriginal groups lost socio-cultural resources, land, and language. This meant that holistic approaches to medicine were not recognized as legitimate and access to health care was severely limited for those in remote locations. Generally speaking, remote communities, whether they are Inuit, Metis, or First Nations , have higher rates of illness and disease than non-Aboriginal communities. Unsurprisingly, poor physical environments—like crowded housing—lead to high rates of stress and anxiety.

Additionally, because local health clinics are further away, many families have resorted to treating illness’ and infections only with Tylenol or Advil.

Today, approximately 50 per cent of the Aboriginal population in Canada resides in remote and rural communities, where life expectancy is five to seven years shorter than in most of Canada. The cases of Cross Lake Cree and the Nishnawbe Aski Nation bring into question that amount and quality of health care services that Aboriginal populations are receiving on reserves. After the Economic Action Plan 2013 pledged $48 million over two years to improve health care delivery to remote Aboriginal communities, there was an expectation that conditions and facilities would be updated with new equipment and appropriately skilled professionals, in addition to improved transportation to local health clinics. But according to an investigation conducted by the Auditor General of Canada (2015), access to health services for remote First Nations communities remains an underdeveloped area. Barriers to health care include, but are not limited to: low population density, a lack of transportation infrastructure, long wait times, high rates of staff turnover, harsh weather climates, and inadequate human resources.

First Nations communities’ physical remoteness translates into low retention rates of health professionals. Recently graduated nurses who accept employment in a remote location will often stay for the short-term before moving onto a placement in a more urban setting. Additionally, nursing graduates within the Aboriginal communities consider their degree as a “way out” of the isolated reserves and into a setting where more competitive salaries are offered in exchange for their skills.

In addition, nurses who work on reserve clinics are often mandated to perform duties outside of their legislated scope of practice. Such duties include: prescribing and dispensing specific drugs, such as intravenous medications for seizures or heart failure, broad spectrum antibiotics, intramuscular injection medication for treating vomiting and nausea, and performing x-ray imaging of the limbs and chest of patients over the age of two (all of these duties are typically performed by doctors). The Auditor General report found that only a small number of nurses working in the sample group of on-reserve nursing stations had completed all of the mandated government training courses.

In addition, the stations under investigation had numerous health and safety deficiencies in the form of: uncleansed tools, mold, drenched drywall, and improper placement of medical utensils.

As a possible solution to recruitment and retention concerns, Health Canada has stated that it will aim to make improvements in the workplace by ensuring that nurses have access to urban health care providers, such as physicians and nurse practitioners, who can provide advice in extreme and rare cases of illness; as well as, increasing loan forgiveness and tuition support for nurses who are transferring to remote locations. Health Canada’s Nurse Recruitment and Retention Strategy (2013) aims to augment and further stabilize the nursing workforce in efforts to address training gaps and high turnover rates.

In addition to low retention rates and unqualified personnel, on-reserve health care systems face transportation challenges, with some patients waiting for hours before a transportation bus can take them to the local clinics. Transportation vans are prone to breaking down, getting diverted by emergencies, and/or trip cancellations due to harsh weather conditions. Such unreliable transportation often leaves families at the mercy of calling the clinic for advice when a family member is sick. Such was the case of Brody Meekis, a youngster from Sandy Lake, who passed away from strep throat after a van was unavailable to transport him to the nearest medical centre for examination.

Brody’s father called the clinic for advice once he saw that his son’s condition was deteriorating. The clinic advised Mr. Meekis to give Brody Tylenol every four hours. Days later when a van was available Brody was taken to a local clinic where student nurses claimed that “he didn’t even look sick”. When Brody stopped breathing, the student nurse called in the head nurse who was able to revive Brody one time before he passed away the following morning. Brody’s case left Dr. Michael Wilson, regional supervising coroner for Thunder Bay and Northwestern Ontario, stunned, as he claimed, “Oh my God, people actually die from strep throat”.

When the medical clinic in Sandy Lake was first constructed, the community consisted of 500 people and although the clinic worked well at that time, the community has now grown to nearly 3,000 people. From that time until now, there has been no increase in the number of staff at the clinic and resources remained strapped.

Given the lack of resources at Sandy Lake and many other reserves, it is time that more was done to ensure that individuals are receiving the appropriate care they deserve from qualified medical practitioners.

Moving forward, considerations for improvement should encompass the following strategies:  

1. Provision of culturally-sensitive health care services;
2. A shift towards preventive health and health promotions services;
3. Emphasis on local power and authority over health care services and
4. Working with the Aboriginal communities, the provinces, and relevant municipalities to deliver targeted services.

Health Canada responded to the Auditor General’s report stating that they will work with First Nations communities to better integrate clinical care in a culturally appropriate manner.  In addition, Health Canada will continue working with nurse regulatory bodies and the provinces to explore possible strategies in aiding nurses who are placed in remote First Nations communities. While the Auditor General’s report did not reference the Economic Action Plan 2013, there was a recognition that training gaps were not addressed alongside funding gaps. Successful policies and initiatives could possibly include focusing on financial incentives when trying to attract more nurses to remote communities (i.e., subsided income, bonuses, community scholarships, etc.). Local community based networks for health care professionals is also something which would generate greater support for nurses who are often overwhelmed by their long hours in resource-strapped clinics.

Health care disparities in Aboriginal communities on reserve are more apparent now than ever before. The government should ensure that training gaps, staff retention, and infrastructure needs are regularly evaluated to ensure that health care delivery is consistent and dependable.

Jasjit Goraya is a 2016 Master of Public Policy candidate at the University of Toronto and a Compliance Analyst with the G20 Group at the Munk School of Global Affairs. She previously completed an Honours Bachelor of Arts Degree in Political Science and Criminology at the University of Toronto. Jasjit’s main areas of interest include Canadian youth justice policy, foreign affairs, and immigration policy.