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.

When epidemiology PhD student Jean-Paul Soucy checked his email while munching on lunch with his fellow graduate students on a Monday afternoon, he fell silent.

It was the first day of what was supposed to be a usual workweek, and an email with the words “Letter of Offer’’ could have applied to a mundane range of things. He passed his laptop to a colleague. “See if it says what I think it says,” he remarked.

It said just that. He had become part of the newest selection of Canadian doctoral students to be named Vanier Scholars. The Vanier scholarship is a highly prestigious award for doctoral students that is granted by the Government of Canada.

The award will provide Soucy with $50,000 per year for three years while he works with his colleagues at the Dalla Lana School of Public Health to conduct research and develop community-based solutions to rein in the excessive prescription of antibiotics in Canada.

In particular, Soucy’s research focuses on developing “antimicrobial stewardship” programs to facilitate best practices in antibiotic prescription by family physicians. 

Why Soucy’s research field is critically important to global health

A 2014 World Health Organization (WHO) report warns that the world may be entering a “post-antibiotic era, in which common infections and minor injuries can once again kill.”

While harmful bacteria have a natural ability to develop resistance to antimicrobial drugs, the way that healthcare providers across the globe have prescribed these drugs has accelerated drug resistance.

Misuse and overuse of antibiotics facilitates the exposure of bacteria to drugs for longer than necessary to treat infection. This exposure allows microbes the conditions that foster the evolution of drug resistance.

Soucy illustrated an example of misuse with the prescription of antibiotics for the treatment of respiratory tract infections — such as the common cold and flu.

“Respiratory tract infections… are commonly caused by viruses,” said Soucy. “[But] antibiotics can’t do anything against [viruses].”

“Unfortunately, in a lot of cases, we have respiratory tract infections being treated by antibiotics.”

The consequences of the misuse and overuse of antibiotics

Such misuses of antibiotics have led to a weakened effectiveness of treatments against potentially lethal diseases.

Research reported by the WHO identifies conditions such as pneumonia and urinary tract infections as being in urgent need of new treatments, due to the advent of antibacterial resistance.

Forms of tuberculosis resistant to at least four drugs have been identified in 105 countries, while strains of gonorrhea resistant to last-resort antibiotics have been identified in 10 countries, including Canada.

In addition to accelerating the resistance of microbes to drugs, inappropriate antibiotic prescriptions can also increase the vulnerability of patients to particular infections.

“In the hospital setting, we have this nasty Clostridium difficile [bacterium],” said Soucy. “When your microbial ecosystem is disrupted by taking antibiotics, especially these broad-spectrum antibiotics that target a lot of [bacteria] at once, it creates a hole in that ecosystem that C. difficile may then enter,” he explained.

Antibiotic stewardship as a solution to excess prescription of antibiotics

Soucy’s project will revolve around antibiotic stewardship. “Antibiotic stewardship is basically the idea of making sure that we use antibiotics in a judicious way, that we’re preserving our [antibiotics’] efficacy by not giving unnecessary prescriptions, and making sure we give the right prescriptions [for microbial infections] as soon as possible,” he said.

Stewardship programs have found a footing in hospitals, but not in the community where there is a lack of comparable infrastructure. More importantly, an overwhelming majority of Canadian antibiotics — a whopping 92 per cent — is prescribed by family physicians and dentists.

The project will develop an online tool to provide “feedback to family physicians about their prescription practices,” helping them compare their own prescription practice with local guidelines and with other physicians in the area.

Soucy emphasized the importance of community-based solutions for tackling antibacterial resistance. By facilitating stewardship programs without requiring the infrastructure of a hospital, the tool will be adaptable to a wider range of less resource-intensive healthcare systems.

The path that led Soucy to epidemiology research

Soucy’s multiple interests led him to conduct research in infectious disease epidemiology. His undergraduate degree trained him in ecology, evolutionary biology, and mathematics, fostering his expertise in the mathematical modelling of infectious diseases.

Add to this his interest in the social factors that cause disease to spread, and the field of infectious disease epidemiology formed the right fit. 

In parting, Soucy emphasized the role played by research mentors, friends, and the community he found through extracurriculars, which enabled him to pursue his passions. These people have helped him through “all sorts of research opportunities,” keeping him motivated and resolute throughout the challenging years of research.

When asked for advice for budding researchers, he recommended students to adamantly challenge their fears.

“The way that I get past that feeling that says, ‘You can’t do this, you can’t figure this out,’ is [that] I just commit myself to doing it,” he said. “Then I have to do it — I have to figure it out.”

The World Health Organization ranked vaccine hesitancy as one of the top 10 threats to worldwide public health in 2019. In an effort to combat this issue, U of T has recently opened its own research centre at the Dalla Lana School of Public Health, dedicated to maximizing the benefits of immunization through research and education. 

One may expect that a research centre would emphasize either the hard sciences — which includes the natural and applied sciences — or social sciences when conducting research. But U of T has decided to take a different approach. Dr. Natasha Crowcroft, the Director of the Centre for Vaccine Preventable Disease (CVPD), emphasized the need for a “wider group of experts” from both social and hard science disciplines to advance research, countering the traditional emphasis on biology and immunology in health research. 

Crowcroft believes that this multidisciplinary approach at the CVPD will help “turn the tide” in the battle against vaccine hesitancy. 

The CVPD’s emphasis on interdisciplinary research is commendable. Tools from the hard sciences, such as big data, artificial intelligence, and manipulations of the biological mechanisms of vaccines are important for countering vaccine hesitancy. But it is also imperative that the CVPD remain consistent and committed to equal research in social theory and strategy. Only through fulfilling its promise of conducting interdisciplinary research can the CVPD meaningfully address the issue at hand.

It can, however, be easy to assume a bias against the social sciences, as much of the wider scientific community has. This bias could lead policymakers at the CVPD to ignore insightful results from the social sciences, which would seriously undermine their research decisions. 

For example, Dr. Elisa Sobo, an anthropology professor at San Diego State University, has found that scientific denialism does not play an important role in making someone hesitant about vaccines. A key role is instead the social pressure of fitting in with other parents within the community. This finding indicates that the CVPD must combine science education with additional efforts tasked at changing the culture surrounding vaccine hesitant communities. Thus, it is important for the CVPD to consider hard and social sciences with equal weight to avoid pursuing ineffective strategies.

Through such understanding, policymakers gain valuable insight into how vaccine hesitancy works while simultaneously deepening the scientific community’s knowledge of this problem. As a field that focuses its studies on human behaviour, the social sciences play an important role in making vaccine hesitancy understandable for policymakers and researchers in all fields. It enables them to come up with new strategies to address the many aspects of vaccine hesitancy. 

In addition, the research-intensive environment at U of T makes information sharing convenient between the hard and social sciences. Not only is collaborative research logistically easier because of the departments’ close physical proximity, but U of T’s hard and social science departments are among the best in the world, which ensures high quality work between the two to further our understanding of vaccine hesitancy.

As one of the top universities in the world, U of T’s social sciences departments rank among the best worldwide. Employing this knowledge pool when understanding a social problem is vital, especially when we consider its strength in research. 

As a global leader in academia, U of T has a lot of influence over other institutions across the world. Taking a serious stance on interdisciplinary research would send a clear message about the importance of social science in academia, potentially pushing other institutions to do the same. Interdisciplinary research at the CVPD reinforces the importance of social sciences to other academic and social institutions in the world.  

Vaccine hesitancy is a human problem: it does not operate under the constraints of scientific laws or logic, but is subject to the whims of human irrationality, and requires an emphasis on sociological research. 

Thus, ensuring that the social sciences continue to be heard at the CVPD is a necessary step for U of T to be truly inclusive of all scientific perspectives. It will also improve the quality of research on the issue, policy-making decisions, and foster a spirit of collaboration in the wider world.

Long Vuong is a fifth-year Human Biology and Statistics student at University College.

Cuts to public health funding by the Ontario government announced in April have taken the media by storm, leading a tripartisan group of previous Ontario Health Ministers to urge the government to reverse its decision.

But is this political treatment of public health a new phenomenon, or is this appended to a long history of budgetary cuts and perceived underfunding of its practice and research?

Another event in a long-lasting pattern

Dr. Steven J. Hoffman — the Scientific Director of the Canadian Institutes of Health Research’s Institute of Population & Public Health — and his colleagues would agree with the latter. In a timely paper published in May, the authors argue that public health in Canada is underfunded.

They assert that the 5.5 per cent of total Canadian health spending allocated to public health practice fails to sufficiently fund the range of work that public health practitioners are expected to undertake — from food and drug safety, to occupational health, to health inspection, and more.

More importantly, Hoffman and his colleagues point out that the current rise in the frequency of chronic disease, mood disorders, and anxiety disorders in Canada has failed to garner a “significant” increase in budget allocation to the appropriate venues of public health.

They say that this results from the public health community lacking an appreciation for the process of policymaking, which causes them to fail to account for the reasons why public health isn’t a clear win from a political perspective.

As a solution, the authors propose developing knowledge of political tools and processes among public health officials.

Public health saves lives

Public health efforts are focused on long-term goals, such as preventing, rather than curing, illnesses, or on analyses of statistical trends within the field. Often, its work seems intangible to the public, and is not exploitable by politicians.

Attempts to pull down the 28.1 per cent Canadian adult obesity rate, for example, would require public health officials to target multiple industries. They may need to advocate for businesses to change food labelling, health care providers to provide more expansive training programs, or ask municipalities to adjust local regulations, according to the 2011 Obesity in Canada federal report.

Such efforts aim to change individual behaviour on a large scale through multiple forms of societal intervention. However, it is difficult for non-experts to trace their effects back to conscious public health efforts.

The more these efforts are hidden from voters, the less clout they gather on the political agenda of politicians, who are already wary of being unable to reap rewards from these efforts within the timeframe of the election cycle.

Solutions to the lack of political will for public health funding

To solve this problem, the authors ask for members of the public health community to better appreciate the policy-making process and the actors involved in it, so that public health agencies can adapt strategies to the kind of policy-making network relevant to specific healthcare issues.

They similarly argued for improved understanding of policy instruments — regulation, communication, taxing, and spending — so that the regulatory tools used for public health can be better used. Increased efforts to spread awareness of public health efforts may counter its lack of priority in the voter base.

In the wake of the opioid overdose crisis, mental health crisis, and spread of preventable chronic diseases forming the leading causes of death in the province, public health cannot be more vital in addressing our most urgent needs. Whether the output of a work is deemed tangible or not by some individuals should not make the verdict over the survival of that field of work.

Nonetheless, concerted effort to engage with the political system in the push for improved funding and policy can ultimately win over politicians and policymakers.

A Globe and Mail article published late January revealed the difficulties of obtaining data in fields such as public health and energy economics.

‘Data gaps’ are the “areas at the national level in which data [is] not collected or readily accessible.” This includes inconsistent data collection, which makes it difficult to compare data, and data that is not updated on a regular basis.

For example, the article reports that data gaps have impeded research in a study on whether the American rise in “deaths of despair” — deaths of the white, middle-aged working class — can be observed in Canada as well.

One reason for data deficits lies in the appropriate collection of data. And even if data has been collected appropriately, barriers to accessing the data may remain.

Associate Professor Arjumand Siddiqi from the Dalla Lana School of Public Health explained in an email to The Varsity that, in her experience, data gaps occur in “groups for which we do not make a concerted effort to sample or identify.”

A summary on the evaluation of the Health Statistics Program between 2011 and 2015 highlighted that one of the recommendations made in the evaluation was regarding management.

The summary explained that for health statistics, which includes births, deaths, stillbirths, divorces, and marriages, the information would now be published 10–11 months after the reference period ended.

A recent blog post by Statistics Canada said that more, specific information on the population was needed to resolve the issue of data gaps.

Siddiqi suggested that statistics may be difficult to obtain as the “infrastructure or the mechanisms” regarding availability and accessibility of the information have not been facilitated by statistical agencies like Statistics Canada. For example, Statistics Canada’s Research Data Centres inhibit collaboration between researchers who are not near the centres in which the data they require is stored.

Data in the field of Siddiqi’s research, which is centred on the relationship between social and economic factors and health, are difficult to obtain.

Other areas in which researchers experience difficulty in studying health are racial inequalities.

“Existing surveys don’t have sufficient sample sizes of non-whites, nor are these samples representative of those populations,” said Siddiqi.

While one tool, like the census, would provide information on Canadians, there lacks a relationship between other sources for the collected data to be useful.

It is important for Canadians to know our statistics as “we need to know what’s happening in our society, who is benefitting, and whom we are failing,” said Siddiqi.

We often turn up our noses at employees who come to work sick, wondering why they are not at home recovering, and sparing their coworkers a chance to contract their illness. Yet, many of us  often face barriers to taking days off from work. Fearing financial loss or even dismissal from employment, we soldier through our sneezes and force ourselves to take on work that, in reality, compromises our ability to get well.

As public health students, and members of the Decent Work and Health Network, we know that being forced to work while sick is not healthy. No one should have to choose between getting better and getting paid. Our health should not be a commodity valued at an hourly wage.

No one in the province of Ontario currently has a right to paid sick days; instead, it all depends on the generosity of your employer. Over 1.6 million workers are employed in businesses with fewer than 50 employees, which are exempted from legislation that protects their jobs if they take unpaid sick days. In other words, these workers could be fired for calling in sick.

What we need are paid sick days, so that no worker has to choose between going to work while sick and losing income, or even risking their job. We are part of a campaign demanding that everyone in Ontario gets one hour of paid sick time for every 35 hours worked, meaning seven paid sick days per year for a full-time worker. There are over 145 countries in the world, as well as 23 jurisdictions in the U.S, that give their workers some form of paid sick days. Ontario is rapidly falling behind.

The lack of paid sick days is just a symptom of the broader phenomenon of increasing precarity in the workplace – one that impacts students and young people especially. Whether it is by cycling through unpaid internships and practicum placements for course credit, through casual work in the retail and service industry, or as recent alumni jumping from one contract to the next, students and recent alumni are familiar with the world of precarious work.

Students are more likely to engage in part-time, casual, temporary, or contract work, and often we are not entitled to benefits like paid sick days. Precarious workers are also more likely to be women, newcomers, racialized and Indigenous peoples, and members of the LGBTQ+ community, adding another element of marginalization to the problem.

Ensuring access to paid sick days is one important way the government can improve our workplaces, and work is being done to ensure that these days are secured for employees. In one such action, on April 15, thousands took to the streets in front of the Ontario Ministry of Labour to protest unfair working conditions and labour laws. A diverse group of advocates, from union representatives to students to healthcare professionals, stood together united under the banner of the $15 and Fairness campaign. Along with paid sick days, the campaign is calling for fair scheduling, decent hours for decent incomes, ‘respect at work rules’ that protect everyone, and a 15 dollar minimum wage.

This campaign is especially relevant right now, as Ontario conducts the Changing Workplaces Review, a consultation process aimed at adjusting Ontario’s Employment Standards Act and Labour Relations Act. This historic review is taking place within a new era of changing workplaces, and we need to demand that the recommendations support decent working conditions for all. Paid sick days are a vital demand that must be enacted, but they are just a few of the policies to be implemented in a larger set of comprehensive reforms to our labour and employment laws. 

These reforms can lead to fairer workplaces, which lead to a happier, healthier and more productive workforce. As the next generation of workers and young professionals, we will inherit these outdated and troubling workplace policies unless we start to take active steps to fight for fairness to address these challenges head on.

Anjum Sultana and Antu Hossain are Masters of Public Health students and members of the Decent Work and Health Network. Anjum is the Executive Co-Director of IMAGINE, a student-run clinic affiliated with the University of Toronto. Antu is the health sector organizer with the Worker’s Action Centre.