A Review of Indigenous Health in Canada

The health and well-being of Canada’s first inhabitants, Indigenous Canadians, requires attention. Many factors, originating from the effects of colonialism, have resulted in a variety of health disparities and in turn, a greater incidence of chronic disease (Richmond, 2009). Specific frameworks, such as the extended chronic care model, have been created to address chronic disease in the Indigenous population while also keeping in mind the importance of cultural elements (Indigenous Services Canada, 2018). But is this enough? The following will examine health and contributing factors of health, while discussing steps required to improve indigenous well-being in the years to come.

The Indigenous (also referred to as Aboriginal) culture of Canada is comprised of three groups: First Nations, Métis, and Inuit (Government of Canada [GoC], n.d.-b). Together, they accounted for over 1.6 million people or 4.9% of the total population of Canada in 2016 (GoC, n.d.-a). Although Indigenous people account for less than 5% of the total population, this population is growing faster than the population of non-Indigenous people: from 2006-2011 the Indigenous population grew by 20.1% compared to 5.2% of non-Indigenous people (Richmond & Cook, 2016).

The term “First Nations” refers to Indigenous people in Canada who are not Métis or Inuit (First Nations Study Program, 2009). The term “Métis” refers to people with ancestry derived from a combination of First Nations and European bloodlines. The term “Inuit” refers to Indigenous people who live in the Arctic; primarily residing in the Northwest Territories, Yukon, Norther Quebec, Labrador, and Nunavut (GoC, n.d.-c). In 2016, there were 977,230 First Nations people in Canada including both status and non-status (Statistics Canada, 2017). In the same year, there were 587,545 people who identified as Métis and 65,025 people who identified as Inuit.

Figure 1

The Aboriginal Population in Canada

Note: From " The Aboriginal Population in Canada, 2016 Census of Population" by Statistics Canada, 2017 (https://www150.statcan.gc.ca/n1/pub/11-627-m/11-627-m2017027-eng.htm). Copyright 2017 Her Majesty the Queen in Right of Canada as represented by the Minister of Industry.

Health is impacted by a variety of external and internal forces. The determinants of health consist of a wide variety of factors including (but not limited to) finances, employment, education, life experience, environment, social support, behavior, culture, gender, race, genetics, and access to health care (GoC, n.d.-d). Within the determinants of health, specific socio-economic factors that affect health are deemed the social determinants of health. Health inequities can be understood through assessing the determinants of health.

Reading and Wein (2009) discuss the social determinants of health of Indigenous people through several lenses: this includes historical and political factors such as colonialism and racism; community factors such as resources and health care accessibility; as well individual factors such as health beliefs/behaviors, and direct environments. Of significance, both colonialism and the Indian Act of 1876 has impacted Indigenous health by excluding Indigenous people from self-determination, and furthermore resulted in detrimental affects of Indigenous culture (Reading & Wein, 2009; Richmond & Cook, 2016). Colonialism systematically created policies that created social inequities and poor access to health services (Richmond & Cook, 2016). The effects of the Residential school system (which stripped Indigenous people of their culture, language, and community ties) is still relevant today.

The rate of chronic disease in the indigenous population is disproportionately greater than that of non-Indigenous people (Richmond & Cook, 2016; Richmond, 2009). Chronic diseases of significance for this discussion will include cardiovascular disease, diabetes mellitus [diabetes], and mental illness.

The risk of cardiovascular disease (CVD) for the Indigenous population is substantially greater compared to non-Indigenous people: the rate of CVD in Indigenous people is nearly 50% greater than that of non-Indigenous Canadians (Leclerc, Basque, Miquelon, & Rivard, 2019). The mortality rate of CVD is also markedly higher: 30% higher for male First Nations people, and 76% higher for First Nations females (Leclerc et al., 2019). Diabetes is another chronic disease that tends to be more prevalent in the Indigenous culture: First Nations living off-reservation have a diabetes prevalence of 1.6% greater than non-Indigenous people, while Métis people have a diabetes prevalence greater that 1.5% (Leclerc et al., 2019). Lastly, mental illness in the form of suicide ideation and attempts is prevalent among the Indigenous population: data available from the 2011 Canadian census finds that the non-Indigenous death rate from suicide is 8 per 100,000 people, compared to 24.3 deaths per 100,000 First Nations, 14.7 deaths per 100,000 Metis, and 72.3 deaths per 100,000 Inuit (Kumar & Tjepkema, 2019).

A framework created by Indigenous Services Canada (2018), provides guidance for the disease prevention and management for Indigenous people. Unique to this framework is the emphasis and role of culture. The Indigenous Wellness Framework includes physical, spiritual, emotional, and mental components (see figure 2). It also includes the use of the Expanded Chronic Care Model which has been viewed to be more appropriate for Indigenous health as it considers the role of social, environmental, and culture factors on health (Indigenous Services Canada, 2018).

Figure 2

Indigenous Wellness Framework

Note: From "Preventing and Managing Chronic Disease in First Nations Communities: A Guidance Framework" by Indigenous Services Canada 2018, p. 9 (https://publications.gc.ca/collections/collection_2018/aanc-inac/H34-313-1-2017-eng.pdf). Copyright 2018 Her Majesty the Queen in Right of Canada and represented by the Ministry of Indigenous Services Canada.

Health promotion models applicable for the use in Indigenous populations include social-ecological models (SEMs). SEMs are beneficial as they include a multilevel approach to diseases (National Cancer Institute, 2005). The different levels used to approach disease include the following considerations: individual, interpersonal, organizational, community, and public policy factors. SEMs examine how each level affects health.

A specific SEM of health that is used in Indigenous health promotion is the Expanded Chronic Care Model (ECCM) (Figure 3). The ECCM is a collaboration of both community and clinical health care services (Indigenous Services Canada, 2018). Furthermore, it also recognizes the role that the social determinants have on health. The ECCM is especially beneficial for use in Indigenous populations as it utilizes community engagement for the creation and revision of health services (Indigenous Services Canada, 2018). This collaboration with community members is important to ensure that cultural elements are included when creating services for Indigenous people. Several provinces in Canada currently use the ECCM (Indigenous Services Canada, 2018).

Figure 3

The Expanded Chronic Care Model

Note: From "Preventing and Managing Chronic Disease in First Nations Communities: A Guidance Framework" by Indigenous Services Canada 2018 p. 18 (https://publications.gc.ca/site/eng/9.840823/publication.html). Copyright 2018 her Majesty the Queen in Right of Canada and represented by the Minister of Indigenous Services Canada.

A key step in advancing the health care of Indigenous people in Canada is to first ensure that the right to health care is made a statutory right (Wilmot 2018). The Canadian Health Care Policy objective is to “protect, promote and restore the physical and mental well-being” of Canadian residents (Canadian Health Act, 1985, p. 5). Neither the Canada Health Act, nor the Canadian Charter of Rights and Freedoms identify the right to health care as statutory. The World Health Organization (2018) believes that people have the right to health and healthcare. Amending Canadian legislation to ensure that health care is seen as a statutory right will help ensure the well-being of Indigenous people (and non-Indigenous for that matter).

Secondly it is important that Canada continues to follow and act on existing documents that aim at improving the lives of Indigenous people. Two important documents that pertain to health equity of Indigenous people in Canada include the United Nations Declaration on the Rights of Indigenous People (UNDRIP) and the Truth and Reconciliation Commission of Canada Calls to Action (TRC). Both UNDRIP and TRC identify the gaps that exist in the current Canadian health care system that contribute to the poor health outcomes of Indigenous people (United Nations, 2007 &Truth and Reconciliation Commission of Canada, 2015). These documents also emphasize the importance of providing health care that is culturally appropriate. Providing culturally appropriate health care is vital as First Nations view health differently than non-Indigenous people with a greater emphasis on community and spirituality (Wilmot, 2018). On of June 21, 2021, Bill C-15 (the United Nations Declaration on the Rights of Indigenous Peoples Act) became law (Department of Justice, 2021, June 21). This should prove to be monumental in creating health equity for Indigenous people while adhering to TRC.

Lastly, it is paramount that Canada evaluates the need for First Nations governance in health care (Wilmot, 2018). The Province of British Columbia has explored this concept through the creation of the First Nations Health Authority (FNHA) in 2013 (Wilmot, 2018). The FNHA helps to ensure that culturally appropriate health care is provided to the Indigenous people of British Columbia. While exploring First Nations governance for health care it may be beneficial to implement strategies for multi-level governance (Wilmot, 2018). This is evident in British Columbia through collaboration of the FNHA, the First Nations Health Council, the First Nations Health Directors Association, and the Tripartite Committee on First Nations Health (First Nations Health Council, 2021). This is important as Wilmot (2018) states that multi-level governments distribute power to enable collaboration and utilize negotiation.

Through examining the health status of the Indigenous people in Canada, it is clear that intervention is required to address health inequities. However, it is important that governments engage in collaborative efforts and heed to the voices of Indigenous people. This can occur with guidance from the UNDRIP and TRC to ensure culturally appropriate public policy is created. Additionally, enabling Frist Nations governance will help to give back power to Indigenous people (Wilmot, 2018). This year has already brought promise with the passing of Bill C-15 into statute, and hopefully that momentum will continue.

References

Canada Health Act, Revised Statutes of Canada § c. C-6 (1985). https://laws-lois.justice.gc.ca/PDF/C-6.pdf

Department of Justice. (2021, June 22). Legislation to implement the United Nations Declaration on the Rights of Indigenous Peoples becomes law. https://www.canada.ca/en/department-justice/news/2021/06/legislation-to-implement-the-united-nations-declaration-on-the-rights-of-indigenous-peoples-becomes-law.html

First Nations Health Council. (2021). Our approach. https://fnhc.ca/our-approach/

First Nations Study Program. (2009). Terminology. The University of British Columbia First Nations and Indigenous Studies. https://indigenousfoundations.arts.ubc.ca/terminology/

Government of Canada. (n.d.-a). First Nations. https://www.rcaanc-cirnac.gc.ca/eng/1100100013791/1535470872302

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https://www.canada.ca/en/services/culture/canadian-identity-society/indigenous-peoples-cultures.html

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Indigenous Services Canada. (2018). Preventing and managing chronic disease in first nations communities: A guidance framework. https://publications.gc.ca/site/eng/9.840823/publication.html

Kumar, M. B., & Tjepkema, M. (2019). Suicide among First Nations people, Me’ties and Inuit (2011-2016): Finding from the 2011 Canadian census health and environment cohort (CanCHEC). Statistics Canada. https://www150.statcan.gc.ca/n1/pub/99-011-x/99-011-x2019001-eng.htm

Leclerc, A.-M., Basque, A., Miquelon, P., & Rivard M.-C. (2019). Cardiovascular disease prevention: A scoping review of healthy eating and physical activity among Indigenous peoples in Canada. Canadian Journal of Cardiovascular Nursing, 29(2), 26-37.

Reading, C., Wien, F. (2009). Health inequalities and social determinants of Aboriginal people’s health. National Collaborating Centre for Aboriginal Health. https://www.ccnsa-nccah.ca/docs/determinants/RPT-HealthInequalities-Reading-Wien-EN.pdf

Reading, J. (2009). The crisis of chronic disease among Aboriginal Peoples: A challenge for public health, population health, and social policy. Centre for Aboriginal Health Research, University of Victoria. https://eds.b.ebscohost.com/eds/detail/detail?vid=1&sid=572ec596-2de5-40e8-8df1-e094b28754ab%40sessionmgr103&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=edscel.227198&db=edscel

Richmond, C. A. M., & Cook, C. (2016). Creating conditions for Canadian aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(1), 1-16. https://doi.org/10.1186/s40985-016-0016-5

Statistics Canada. (2017). Focus on Geography Series, 2016 Census. Statistics Canada Catalogue. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/fogs-spg/Facts-CAN-eng.cfm?Lang=Eng&GK=CAN&GC=01&TOPIC=9

Truth and Reconciliation Commission of Canada. (2015). Truth and reconciliation commission of Canada: Calls to action. http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf

United Nations. (2007). United Nations declaration on the rights of Indigenous Peoples. https://www.un.org/development/desa/indigenouspeoples/wp-content/uploads/sites/19/2018/11/UNDRIP_E_web.pdf

Wilmot, S. (2018). Cultural rights and First Nations health care in Canada. Health and Human Rights Journal (20)1. 283-293.

World Health Organization [WHO]. (2018, December 10). Right to health. https://www.who.int/news-room/facts-in-pictures/detail/right-to-health