Why do Canada’s Indigenous people face worse health outcomes than non-Indigenous people?

Medical student Paul Kim on the need for trauma-informed care, addressing the social determinants of health

Why do Canada’s Indigenous people face worse health outcomes than non-Indigenous people?

Content warning: this article contains mention of suicide.

For its fourth consecutive year, Canada has been ranked as number one in the world for quality of life, according to the U.S. News & World Report. A factor that drove the ranking was Canada’s advanced health care system.

But when it comes to access to health care and health outcomes, the glaring disparities that separate Canada’s Indigenous and non-Indigenous populations cast an ugly shadow on the ranking.

A June 2019 Statistics Canada report indicated that, between 2011–2016, First Nations people experienced a suicide rate that is three times higher than that of the non-Indigenous population. How can such a disparity exist in a country ranked at the top spot for quality of life?

How Indigenous people face worse health outcomes

Suicide rates among Inuit youth in particular are one of the highest in the world, and 11 times greater than the national average. In some First Nations communities, the suicide rate among youth under the age of 15 is almost 50 times greater than the rate among non-Indigenous youth.

Lower life expectancy and the prevalence of chronic conditions — such as hypertension, obesity, diabetes, and arthritis — also disproportionately burden the Indigenous population. Tuberculosis, a disease that is both curable and preventable, is reported at a rate that is more than 40 times higher among Indigenous people living on-reserve than among non-Indigenous people.

In 2016, a U of T-affiliated comparative study compared racial health inequalities between the US and Canada. Though Canada’s population fared relatively better in the margin of inequalities seen across racial minorities, according to the study’s findings, the health inequality between the Indigenous and white population in Canada was greater than in the US.

Furthermore, the observed health disparity held when adjusted for demographic, socioeconomic, and behavioural factors in Canada. In the US, some of the differences could be accounted for by socioeconomic factors.

So what’s the reason for this inequity, and why is it especially prevalent in Canada?

The factors that drive the disparity

Paul Kim, a U of T medical student, recently published a paper in Health Equity about the social determinants of health disparities that affect Indigenous people in Canada.

He discussed his findings with The Varsity, highlighting the need for Canadians, especially those in health care, to understand the historical context that underpins the health outcomes for Indigenous people seen today.

Kim’s research discussed how distal determinants of health, such as colonialism and racism, can worsen individualized factors, such as health behaviours and socio-economic status.

“The reason why we still see health inequity over time, even though the residential school system doesn’t exist anymore, is because of longitudinal policies that influenced parenting habits, influenced diet habits, [and] influenced lifestyle habits,” he noted.

“And [it’s] not just one generation of impact — [it’s a] multi-generational impact between parents and children, and their children’s children.”

A vicious cycle of health injustice among Indigenous people was set off by the cultural deprivation and systemic isolation of Indigenous people created by residential schools and colonial practices.

Forced assimilation following the Indian Act of 1876 — operationalized through the residential school system, the ‘60s Scoop, and legislation banning Indigenous languages from being spoken, as well as forbidding the practice of traditional ceremonies and rituals, created a deep rift between culture and personal identity within Canada’s Indigenous population.

In his paper, Kim elucidated how the trauma endured by children in the residential school system has continued to manifest in poorer mental health outcomes and cognitive dysfunction decades later.

He explained how these outcomes stemmed from the oppressive environment created by the residential schools, abusive teachers, the psychological stress of being taken from their families and communities, and the fact that this all happened during a critical period of cognitive development and identity formation: childhood.

“As a kid, in particular, emotional stress influences mental health as an adult because the brain is still developing,” he noted.

“And that’s important to remember,” he continued, “because the residential school system targeted children. It’s during this critical developmental stage that they learn to make rational judgements, form goals, and develop skills for later in life.”

Research has shown that enduring abuse in childhood leads to an increased number of hospitalizations, physical and mental illnesses, and poorer overall self-rated health later in life. Likewise, family separation in childhood is a significant long-term predictor of depression.

Kim also noted the significance of education as an influence on health status later in life. A good education fosters academic and social development, which is necessary to develop strong interpersonal relationships as well as health literacy.

Conversely, negative educational experiences, most notably the abuse experienced by Indigenous children in schools, not only fail to prepare children with the skills they need to thrive, but effectively turn them away from the prospect of academic success and ambition.

Bridging the gap

When asked how we can begin to resolve this issue, Kim expressed optimism, but highlighted the importance of being aware of the connection between Canada’s colonial past and the health inequities we see today.

“I think the way that we’re headed currently with trauma-informed practice, with the government recognizing what’s happened, is a step toward the right direction.”

Trauma-informed care is an approach that aims to provide health care services in a manner that is sensitive to the experiences and needs of people that have dealt with trauma. This is especially important given that people who have experienced trauma can be re-traumatized in health care and service settings, and therefore may be less likely to access these services.

Kim believes that several aspects of trauma-informed care are especially important for care providers to keep in mind. Best practices include practising non-judgement when people discuss their trauma, as well as empathy with how one’s trauma may relate to an inability to seek help or heal.

He also emphasized using a patient’s knowledge of their trauma to facilitate strengths-based skill-building. “Trauma is a negative thing,” he said, “but people are resilient.”

At a systems-level, Kim believes overcoming Canada’s health inequities requires implementing policies that specifically address social determinants of health, particularly on reserves and rural areas. This includes access to clean water, fresh food, job opportunities, and mental health support systems.

“The next time you’re on a reserve, think about where the closest hospital is, or where the closest tertiary hospital is, as well as where the closest grocery store is where you can get fresh food.”

The Truth and Reconciliation Commission of Canada’s Final Report is a good start, said Kim, but policy recommendations need to be “granular and specific” in order to be effective.

“I wouldn’t say it’s redemption,” reflected Kim. “I would say it’s the right thing to do. I would say it’s a moral obligation.”

If you or someone you know is in distress, you can call:

  • Canada Suicide Prevention Service phone available 24/7 at 1-833-456-4566
  • Good 2 Talk Student Helpline at 1-866-925-5454
  • Ontario Mental Health Helpline at 1-866-531-2600
  • Gerstein Centre Crisis Line at 416-929-5200
  • U of T Health & Wellness Centre at 416-978-8030.

Warning signs of suicide include:

  • Talking about wanting to die
  • Looking for a way to kill oneself
  • Talking about feeling hopeless or having no purpose
  • Talking about feeling trapped or being in unbearable pain
  • Talking about being a burden to others
  • Increasing use of alcohol or drugs
  • Acting anxious, agitated, or recklessly
  • Sleeping too little or too much
  • Withdrawing or feeling isolated
  • Showing rage or talking about seeking revenge
  • Displaying extreme mood swings

The more of these signs a person shows, the greater the risk. If you suspect someone you know may be contemplating suicide, you should talk to them, according to the Canadian Association for Suicide Prevention.

A look at the Master of Public Health in Indigenous Health

The program aims to educate students on Indigenous health with focuses on traditional knowledge and medicine

A look at the Master of Public Health in Indigenous Health

This is the inaugural year for the two-year Master of Public Health: Indigenous Health program at the Dalla Lana School of Public Health through the Waakebiness-Bryce Institute for Indigenous Health.

Dr. Suzanne Stewart, Associate Professor at the Ontario Institute for Studies in Education and Director of the Waakebiness-Bryce Institute, designed the program alongside Dr. Angela Mashford-Pringle, Assistant Professor at Dalla Lana and Associate Director of the institute. The program was created with the objective of “[offering] a program based in Indigenous knowledges that’s guided by our traditional knowledge keepers, our elders, our healers, our teachers.”

The involvement of knowledge keepers, she says, reinforces the importance of traditional knowledge, which “is at the core of Indigenous health.”

Stewart explains that increasing the number of researchers and professionals in Indigenous health was one reason for the creation of the program. Another was to increase the number of Indigenous people who can, thanks to programs like these, access education in fields like health care while feeling culturally safe.

“I think the objective of the program, overall, is to create a training program that ensures that everyone who’s a part of that program is a part of the solution,” says Stewart.

The Indigenous population is the fastest growing demographic in Canada. An improvement in this community’s health can lead to higher levels of youth employment and education and increase the overall life expectancy of Canadians, says Stewart.

Due to the poor state of Indigenous health care, Stewart says that “we need to have people who are trained and capable of actually addressing these problems.”

The program includes courses on general public health, quantitative research, and social determinants of health, as well as specific courses such as Indigenous Health, Indigenous Health and Social Policy, and Indigenous Food Systems, Environment & Health.

At the end of their first year, students must complete a practicum over the summer. The practicums are in collaboration with Indigenous communities and all levels of government nationwide, in areas such as policy, program development, and research.

Stewart says the practicum “gives students an opportunity to actually spend time in Indigenous communities, working with Indigenous people, and being able to learn what it’s like to be there and do this work from a cultural perspective.”

Traditional knowledge is localized, explains Stewart, as is healing and its interpretation, which can vary depending on the communities from which elders and teachers originate.

“Indigenous healing and spirituality and pedagogy are not objective,” says Stewart. By learning about traditional Indigenous knowledge, there is a departure from linear thinking. Through this, students learn about the interconnectedness of mental, physical, spiritual, and emotional health.

Stewart notes that the spiritual aspect is important, but usually not incorporated in Western health care programs, including policy.

Stewart hopes that students learn “how to be the person that they’re supposed to be and that they continue to contribute to the solutions and stop being part of the problems.”

Speaking of the first year’s cohort, Stewart says that she is delighted. The students, she explains, are dedicated, open to learning, and committed to the work. Furthermore, she notes that specialized programs are unique because there is something that drives the students to be passionate about the issue. 

The existence of this program, and others like it, can aid in the process of decolonization.

Stewart explains that “all healing for us as Indigenous people begins with the spiritual, and all healing is spiritual. And for us to want to heal the system, we need to do that in a basis of traditional knowledge and spirituality, and that’s really what this program is about.”

A glance at the state of Indigenous health

Professors of public health shed light on generational barriers Indigenous people face in accessing health care

A glance at the state of Indigenous health

Though the number of studies are scarce, there emerges a consistent and worrying pattern on the status of Indigenous health.

A Statistics Canada study spanning 2011–2014 found that whereas around 60 per cent of the non-Indigenous population perceived their health as good or excellent, only 48.5, 51.3, and 44.9 per cent of First Nations, Métis, and Inuit people respectively reported their health as such.

Life expectancy is also lower for members of Canada’s Indigenous population, with an average life expectancy of 68.9 for Indigenous men and 76.6 for Indigenous women, compared to 78 among non-Indigenous men and 81 for non-Indigenous women. The cause of this can be attributed to a number of compounding issues, some of which are not immediately related to health care. 

Racism and discrimination against Indigenous people in the medical system are a big factor in preventing them from accessing and returning for continual services, explains Dr. Suzanne Stewart, Director of the Waakebiness-Bryce Institute for Indigenous Health.

Stewart says that the issue regarding Indigenous access to health services is “about actually being able to go into a health care environment and feel like it’s safe to be there mentally, emotionally and spiritually.”

This is made more difficult by the legacy of the residential school system, funded by the government, which forcibly removed Indigenous children from their communities to undergo aggressive assimilation. From the nineteenth century to 1996, an estimated 6,000 children died in the system out of the 150,000 forced to attend.

Children were underfed and malnourished. One residential school experimented with feeding children just a flour mixture. This systemic malnutrition caused by residential schools has been linked to health issues such as diabetes.

Even today, biases remain in the system, says Dr. Anna Banerji, Associate Professor at the Dalla Lana School of Public Health. “I’ve witnessed it first hand,” she said.

Banerji has been researching Indigenous health for 25 years, travelling to the Arctic over 30 times to study respiratory infections in Inuit people.

Banerji discovered that Inuit babies are more frequently infected by respiratory syncytial virus than the wider Canadian population. But, Banerji says, “there’s an antibody that’s cheaper than the cost of admission [to a hospital] and no one is implementing that [in Inuit communities].”

South of the Arctic, Cat Lake First Nation recently made headlines due to a housing crisis that developed into a health crisis. Almost 100 houses in the fly-in community contained black mould, which caused rashes and bacterial infections, including lung infections.

Stewart explains that current health issues in Indigenous communities were “created by the systemic factors of all colonization,” which in turn “created a group of people who are highly traumatized and who have no resources to cope within that very system that created the trauma,” leading to crisis.

Furthermore, Stewart says that resources tend to assist in the immediate aftermath of crises, but not to sustainable preventions of them, such as research and programs so that issues like addiction do not escalate into crises.

Traditional medicine and knowledge are ways by which Indigenous people can heal.

Dr. Angela Mashford-Pringle, Assistant Professor at the Dalla Lana School of Public Health and Associate Director of the Waakebiness-Bryce Institute for Indigenous Health, also stressed the barriers to the Cree notion of “pimatisiwin,” which is a traditional conception of “a good way of life.”

“We can’t live that way because we have too many systems pushing down on us,” says Mashford-Pringle.

Stewart says that traditional healing and medicines are rather inaccessible and it is up to individuals to seek them out, despite the fact that Indigenous health is included in treaty rights.

Mashford-Pringle works with Cancer Care Ontario, which offers courses in cultural competency to inform health care providers about Indigenous history and knowledge.

Stewart echoes the need for courses, saying, “We haven’t done anything that’s more meaningful such as [to] require our staff and our health care workers to undergo cultural safety training, to collaborate with Indigenous communities, to provide culturally-based services, provide access to traditional medicines and traditional healing.” She says that this “would bring meaningful change to health equity and health access for Indigenous people.”

“Why is it okay for them and not for me?” asks Banerji. She notes a disparity in acceptance and that “what is accepted for Indigenous children would not be accepted for non-Indigenous children.”

Stewart says that it is essential for non-Indigenous people to understand the ways they have benefitted from the harm done to Indigenous people, including through health care accessibility.

“Spend five minutes and learn about Indigenous people,” says Mashford-Pringle, adding, “Don’t stand in our way, even if the only thing you ever do is stand aside so that we can push for our right, that’s better than standing in our way and making it [worse].”