By Reuel S. Amdur
Just about the time that the swine flu epidemic made its major assault on First Nations communities, the Senate’s Subcommittee on Population Health released its report, “A Healthy, Productive Canada: A Determinant of Health Approach.” Much of that report focuses on Aboriginal populations.
Why has the epidemic caused such havoc in places like the Indian community of St. Theresa Point, Manitoba? Severe overcrowding, lack of indoor plumbing in many homes, poverty. The report reminds us that health is not just medical. Far more, it is determined by other factors, such as housing, education, employment, income, and the gap in income between those at the top and those at the bottom. In order to address health, including Aboriginal health, the subcommittee argues that Canada must address these matters.
One table outlines the differences in some of the pertinent factors for Aboriginals and other Canadians. Life expectancy for non-Aboriginal women in 2004 was 82 years, for Indians 77 years, and for Inuit 70. Sixteen per cent of non-Aboriginals in 2000 were of low income, compared to 38% of Indians, 37 % of Métis, and 61% of Inuit. Twenty-two per cent of non-Aboriginals smoked daily in 2004, compared to 38% of Indians, 37% of Métis, and 61% of Inuit. Incidentally, the Tories killed a program to decrease tobacco use among Aboriginals.
A useful appendix to the report by Jeff Reading provides great detail about health problems of Aboriginals. He makes one point that is frequently overlooked: Aboriginal communities differ, both in terms of health conditions and in terms of culture. Thus, while there are over-all solutions that apply, there are also differences that need to be considered. And of course there are differences between those living on reserves or in other remote communities and those living in cities, where most now reside.
The report makes five recommendations that relate specifically to Aboriginals:
–Aboriginal peoples need to be involved in the design, development, and delivery of federal programs that address health determinants in their communities.
–The Prime Minister should work with the Premiers and Aboriginal leaders to close the gaps in health conditions through comprehensive, holistic, and coordinated programs and services.
–Priority needs to be given to clean water, food security, parenting and early childhood learning, education, housing, economic development, health care, and violence against women, children, and the elderly.
–Where there is disagreement on who pays, health determinant issues are to be settled by payment by the first government contacted. The final determination of who is left with the bill is to be resolved later.
–The Canadian government in consultation with the various stakeholders should support and finance the strategies and mechanisms to address the disparities in determinants of health affecting Aboriginal communities.
There are some confusions in these goals. For example, it is unclear what, other than narrowly defined health care, can be understood in the principle of payment by first government contacted for health determinant issues. More seriously, there is a lack of specifics. How much decline in smoking over what period of time? How much of an increase in post-secondary education by what date? And how much money needs to be spent? How is it to be allocated? The Tories found the $5 billion over five years in the Kelowna Accord to be too rich, as the money could apparently be better spent on attack helicopters, drones, and expansion of the prison system.
On-reserve improvements in health indicators will be dependent among other things on governance. The report does not address these. Two main governance issues arise: responsible and responsive councils and consensus on who is legitimately in control. The Assembly of First Nations (AFN), under Grand Chief Phil Fontaine’s leadership, recommended establishment of an ombudsman and auditor-general for reserves. The Tories have not accepted this proposal.
The issue of legitimacy is, on some reserves, more difficult, involving elected band councils versus hereditary leadership, as well as other players in some instances. Sometimes elected chiefs have reached out to hereditary leaders to try to make things work. For progress to occur in such communities there is need for skilled negotiations and dispute resolution.
The report speaks favourably of such programs as Quebec’s local health and social service centres, Ontario’s less extensive community health centres, and Cuba’s polyclinics. These offer a range of services such as nutritional and social work counselling, addictions and mental health support, immigrant integration, etc. Unfortunately, the Quebec centres have become more and more medical in their orientation, tending to move away from the broader concept of social determinants.
One problem is the report’s failure to address the special problems of small communities in remote areas, communities with just a few hundred residents. These locations are not able to sustain a health and social service centre. Instead, it may have to rely on a single facility housing an elementary school, nursing station, and band council, with perhaps some minimal staffing. In some cases, the appropriate focus will be on joint services of some nature with non-Aboriginal neighbors.
Another issue is that of poverty in cities. While some specifically Aboriginal services, such as friendship centres and health centres, are appropriate, the low level of social assistance payments affect non-Aboriginal people as well. The problem exists because poor people tend to be a low priority for government. The Canada Assistance Plan (CAP) matched provincial welfare programs with federal dollars, but governments, both Liberal and Conservative, chose to cut funding for health and social programs. The Liberal Party gave birth to CAP under Lester Pearson and buried it under Jean Chrétien.
While the Senate subcommittee report has many valuable features, especially the long and detailed appendix on Aboriginal health, the recommendations are weak. Perhaps that is the best that can be expected from a report requiring the kind of political support needed to get it approved.