How can the health community foster and promote the health of Aboriginal children and youth?

Abstract

Aboriginal people have poor health status, but there is also evidence that they access the health care system less effectively and find it more intimidating than other Canadians. The present paper reviews the evidence for this, details some of the history that has led to the continued disenfranchisement of Aboriginal people and makes some modest suggestions for ways that the health system can work toward better health and health care for Aboriginal people. Efforts should focus on making the entire system more patient-centred, improving cultural competence, increasing Aboriginal presence in the health workforce, and improving access through cultural and language interpreter services and outreach.

The comparatively poor health status of Aboriginal Canadians is well documented (1,2). In addition, Aboriginal people find the health system intimidating, inaccessible, unfriendly and not patient-centred. There are disparities in care, and we as a system do not do well when it comes to ‘cultural competency’ toward Aboriginal cultures. The present paper aims to document the historical policy and legislative context that partially explains the divide between the cultures of Aboriginal people and other Canadians, and to provide some modest suggestions for the health system to work toward improved health and health care for Aboriginal children.

THE HEALTH CARE SYSTEM

As individuals, health professionals are altruistic and caring. However, ‘patient-centredness’ is not a characteristic of the Canadian health care system, which is difficult to navigate (even for the dominant culture), inconsistently accessible and involves much waiting. Patients feel a lack of a ‘customer-service’ orientation. The system seems, to the public, to be more professional-oriented. The now-famous Institute of Medicine report entitled “Crossing the Quality Chasm: A New Health System for the 21st Century” (3) has documented the need for health care systems to become more patient-centred if quality of care is to improve.

Why do Aboriginal people find the system even more intimidating than other cultural groups (who also receive less adequate care)? To understand this phenomenon, some historical background is required.

THE HISTORY OF RELATIONS BETWEEN EUROPEANS AND ABORIGINAL PEOPLE

History has resulted in a series of legislative acts that ingrain racism. Systemic racism occurs when institutions such as government agencies, businesses and organizations responsible for developing and maintaining public policy, health care and social services function in such a way as to limit rights or opportunities on the basis of race. Determining eligibility for health services and benefits rests with the interpretation by individuals employed in these organizations. Jurisdictional ambiguity for Aboriginal people’s health care has limited or restricted access to services (4) and has been cited as the rationale for not providing a specific service.

In 1763, the Royal Proclamation established that “Indians” were under the protection of the crown. In 1867, the British North America Act reaffirmed that Aboriginal people were under federal authority, while health care became a provincial jurisdiction. The Indian Act (1876) established that the federal government had the right to make decisions regarding the health of Aboriginal people, but that Indian Bands also had the right to create bylaws respecting the health of on-reserve residents. The same year, the famous ‘medicine chest’ clause was enshrined into Treaty 6. This established a poorly defined duty of the federal government to provide basic medicines and medical aid equipment. Supreme Court challenges in 1935 and 1966 affirmed the First Nations interpretation that this clause established health care as the fiduciary responsibility of the federal government. A branch of the federal government (now the First Nations and Inuit Health Branch [FNIHB]) was established in 1962 to provide service to First Nations and Inuit. The Métis were never part of the agreement. Subsequent policies also created a large cadre of nonregistered First Nations people. For example, the Indian Act disenfranchised women who married non-Aboriginal men. Responsibility for these people, who often lived in the same communities, was provincial. The Canada Health Act in 1984 established the principles on which universal health care is guaranteed to Canadians. However, the federal government has never fully acknowledged its obligations in this regard and has steadily encouraged the provinces to take responsibility. Aboriginal people are frequently left in jurisdictional limbo. The following case study illustrates this issue:

An 11-month-old girl with a congenital heart defect, corrected surgically, remained on a respirator, had a tracheotomy and was fed through a gastrostomy tube. Her brain was normal. Unfortunately, the family lived in a northern reserve community. Because home ventilator support is not available in remote sites, she needed a medical foster home. The parents, who remained involved, agreed. Although a good home was found, placement was denied by the First Nations Child and Family Services Agency, on the strength of a directive indicating that Indian and Northern Affairs Canada and the FNIHB would not fund the costs. The Agency would have been left in deficit with unfunded costs. The parents were faced with the option of giving up their rights to the child so that she could become a ward of the province. Ultimately, this child stayed in hospital for 14 months before the issues were resolved. Resolution required several meetings bringing together key individuals from each of the jurisdictions and getting them each to agree, on humanitarian grounds, to bend their rules a little and accept some responsibility beyond the literal interpretation of their rules. The problem was solved for this child, but similar issues occur daily in paediatric institutions across Canada.

The racist nature of legislation and jurisdiction goes back as far as the legislation mentioned above. Once the territory that became Canada had been ‘won’, much jurisdiction passed federally reflecting then-current ideas that Aboriginal culture was somehow inferior to European culture, and that assimilation of Aboriginal people was the best policy. Table 1 summarizes some of these key policies and laws.

TABLE 1.

Summary of key policies and laws

Year	Policy or law	Description of policy or law
1830	Sir Francis Bond-Head Policy	Assumption that ‘Indians were destined to die out completely’
		Took lands and relocated people
1842	Bagot Commission	Recommended establishment of residential schools to minimize family and community influences
1850	Lower Canada Act	Protected land base
		Defined entitlement as ‘Indians’
1857	Gradual Civilization Act	Defined how Indians could shed their status, become enfranchised and gain access to land as individuals
1869	Gradual Enfranchisement Act	Restricted self-government
		Allowed for disempowering Indian leaders
1876	Indian Act	Amendments that focused on removing cultural influences (eg, potlatch, sundance)
		Limited appeals of government decisions
		‘Pass’ system for leaving reserve
		Impossible for Indians to sell or mortage land
1969	White Paper	Continued assimilation
		Ignored Indians’ proposals for change
		Proposed shelving of treaties
		Transfer of responsibility to provinces

This legacy of legislation and policy has left Aboriginal people in a disempowered and disadvantaged position in Canadian society. Adelson (2) recently documented this history of disenfranchisement and the resulting disparities in health status. She rightly argued that the solutions lie well outside the health care system. Nevertheless, the present article is about what the health care system can do to make care more equitable and will concentrate on how health care workers can take small steps in that direction.

DIFFERENCES IN CARE

Spitzer (5) recently documented that nurses spend less time with Aboriginal patients than with mainstream women. In her study, nurses considered Aboriginal and other visible minority women as being too time-intensive. Nurses recognized this as an inequity, blaming the system and the demands placed on their time. Regardless of the explanation, this is evidence that the system treats these women differently. This scenario is likely common across the health care system. This could not possibly result in an equal level or safety of care. Recently, Martens et al (6) reported that, despite a disproportionate burden of premature mortality, First Nations people did not access specialists at a greater rate than did other Manitobans. Furthermore, people living in nonremote rural areas had the highest premature mortality and the lowest rates of specialist use. In such areas, primary care services are not directed at Aboriginal people, and referral to specialists is often unorganized and poorly coordinated. Mustard et al (7) showed that within the urban centre of Winnipeg, Manitoba, First Nations people are more likely to have discontinuous sources of care for their preschool children. Taken together, these results suggest that the system is not meeting the needs of Aboriginal people as well as it should.

HOW CAN THE HEALTH COMMUNITY BE MORE ADAPTABLE?

The health care system needs to become more patient-centred. The Institute of Medicine report (3) identified six characteristics of patient-centred care: respect for patients’ values, preferences and expressed needs; coordination and integration of care; information, communication and education; physical comfort; emotional support (relieving fear and anxiety); and involvement of family and friends. There is widespread agreement that this is needed to improve quality of care across the board. If we really took this to heart and did it, health care would become more sensitive to the needs of Aboriginal people.

More ‘cultural competence’ is also needed. This concept is gaining mainstream acceptance in health care (8). It is now recognized as a process rather than a fixed amount of knowledge or set of skills. Some consider it an essential skill for doctor-patient communication. It is about more than language (although language is intimately entwined with culture). It is about understanding the role that culture plays in shaping people’s views of the world, health and the values that they hold. Health care workers with this skill do not have to have a detailed and intimate knowledge of all the cultures they will ever encounter. They do have to be able to learn, question and accept that patients may have very different perspectives than the professionals themselves. They need to have the skill and experience to understand when there are cultural and communication issues interfering with a mutual understanding and agreement of the patient’s condition and the course of action to be taken.

Both of the above concepts require significant cultural shifts in health care. They need to be taught in the very beginning of undergraduate professional education, and major efforts need to be directed to changing the thinking of established professionals and managers.

A number of practical steps can be taken within individual institutions or professions. Some of the actions taken by the Winnipeg Regional Health Authority are described in Figure 1. Cultural awareness workshops and language and culture interpretation services can help. Health professionals are encouraged to read the policy statement produced a few years ago by the Society of Obstetricians and Gynaecologists of Canada (9). A challenge is to create a health workforce that is reflective of the proportion of Aboriginal people in Canada. Every professional should be advocating for greater efforts to attract and support young Aboriginal people entering health care professions. Because of historical and current barriers, this requires more than just waiting for competitive students to apply. A relatively successful program at the University of Manitoba has involved outreach, undergraduate support and tutoring, and cross-cultural brokering. A representative workforce is more than just about professionals. The health care system has a large number of well-paid jobs in paraprofessional and supportive roles. The challenge is enormous. In the Winnipeg Regional Health Authority, even with very large efforts over the past four years, our workforce contains only approximately 1% to 2% Aboriginal people.

Figure 1.

Aboriginal Strategy of the Winnipeg Regional Health Authority

We should all be aware of racism. Each of us has the responsibility to speak out when we see or hear racism within the system. We should gently remind our colleagues when it happens and try to create an environment where racist interactions become as uncommon as smoking. Health care providers should also try to improve access. Even when services cost no more to the individual, there are barriers to equal access for Aboriginal people. Northern, remote and some rural areas have suffered disproportionately from the shortages of professionals in the past decade. In some cases, services in home communities are at a lower level than they were in 1990. As health professionals, we all need to support (rather than undermine) services in Aboriginal communities and Aboriginal-directed services in urban areas. We should go out of our way to extend tele-health services, but they must tie in to the local primary care and secondary care systems. Outreach services are an effective way of improving access (10). There are some established Canadian outreach programs for remote areas. There is a need for more of these programs in areas that are not so remote. Even in urban areas, specialists should consider moving out of their tertiary care institutions and offering on-site (culturally appropriate) services in places where Aboriginal people live.

Aboriginal children born today face the potential of prejudice, worse health, a shorter lifespan, less affluence and less success in the workforce than other Canadians. The process of reducing inequalities within the health care system will be a long one. However, as long as these inequalities exist, there will be resentment, and one group of people who are the most disadvantaged in so many ways will continue to also fail to get the maximum benefit from the health care system.

By Lajah, Sooke, British Columbia

By Zoe, Sooke, British Columbia