In the December 6th issue of The Lancet (Improving the health of older Indigenous Canadians), editors begin by saying: “Refreshingly, 2013 has been a year in which the health inequities between Indigenous and non-Indigenous peoples have gained greater attention.” They give generous mention to the Health Council’s report Canada’s Most Vulnerable: Improving Health Care for First Nations, Inuit and Métis Seniors released November 28, 2013 which is all well and good. And they (The Lancet) also sneak in a line from this report that tells a bigger story: ‘little attention has been paid to the healthcare needs of Aboriginal seniors in either research or public policy.’  We should ask a much larger question: how can we address the healthcare needs of all First Nations, Inuit and Métis seniors in Canada?

For the past five years, the Health Council has held discussions across the country to hear, first hand, about some of the issues which contribute to maintaining the gap between the health status of First Nations, Inuit and Métis and the larger Canadian population. We reported on maternal and child health (2011); healthcare delivery and access to care in selected urban centres (2012) and most recently on the care (or lack thereof) for Indigenous seniors. And while the focus of work changed, some of the same systemic issues called out for attention.

First, we need to look at funding and the ‘stop start’ solutions that result. Second, there is the inherent lack of trust among many Aboriginals about the cultural safety and appropriateness of ‘western’ medical practices. Third, healthcare must be included in the continuing drive by First Nations, Inuit and Métis for self-determination in all aspects of their lives. Fourth, policies need to change that have not kept pace with the needs of First Nations, Inuit and Métis populations, regardless of whether they are living in rural and remote regions or urban settings.  

During the 2011 sessions to develop Understanding and Improving Maternal and Child Health in Canada, we heard from participants that ‘governments initiate many great programs that are responsive to the needs of Aboriginal people and incorporate all the attributes of promising practices — but then funding ends and many of the gains that have been achieved are lost.  They thought that regular data collection and evaluations, together with common goals, partnerships, and trusting relationships, would encourage governments to commit to long-term sustainable funding and support, but this has not happened.’

In the 2012 work leading up to the report, Empathy, Dignity and Respect, participants commented on some of the work that began with the Aboriginal Health Transition Fund, but also said that governments should provide adequate and sustained funding and other resources to support the development, maintenance, and enhancement of activities that support cultural competency and cultural safety.

The issue of building trust was ever present in our sessions when developing the report, Empathy, Dignity and Respect which focused on urban healthcare delivery. We found that racism and loss of self-identity were primary barriers for Aboriginal peoples seeking healthcare.  Even healthcare providers, some those of Aboriginal descent, commented on how peers would discriminate in often very subtle ways. The impact of racism on health status and health outcomes can be profound often resulting in lack of follow up for medically necessary treatment or postponing an initial visit because of historical experiences of family members or fear of approaching ‘the institution’ of western medicine partly because of the long standing memories from residential school experiences. There must be trust in order to establish an effective relationship between provider and patient. Fortunately, there are two prominent strategies we learned of that lead to building a relationship of trust.  First, there is the awareness and subsequent behaviour shift that comes from cultural competency training; the second is the practice of having patient navigators in hospitals that allow patients, in their own language, to interact confidently with their healthcare providers.

The week of December 11, 2013 marked the one year anniversary of Attawapiskat First Nation Chief Theresa Spence's 44-day hunger strike to spark a meeting with the Prime Minister, the Queen, the Governor General and First Nations leaders to address Treaty violations. This and the Idle No More movement focused world attention on First Nations continuing drive for self-determination. In healthcare, we are seeing a similar trend as provincial First Nations organizations begin to negotiate with governments to repatriate healthcare as First Nations responsibility. Of course, all eyes are on BC where the patient-focused mantra of ‘nothing about me, without me’ is actually a reality. There, the First Nations Health Authority is working towards providing culturally sensitive and effective care for the province’s First Nations population. This is a solution five years in the making, resulting from a tri-lateral agreement between Health Canada, the BC Ministry of Health and the First Nations Health Council. 

Finally, I turn to policies that have not kept pace. As we consulted with healthcare professionals, community and government representatives in preparing our most recent report, Canada’s Most Vulnerable: Improving Health Care for First Nations, Inuit and Métis Seniors, there was considerable discussion about jurisdictional wrangling, lack of coordination in care and how the best leaders ( federal, provincial, territorial, community, and Aboriginal) separate politics from service delivery. They focus on building equal partnerships to resolve problems and provide First Nations, Inuit, and Métis seniors with access to the services they need. Indeed, we do not need to be reminded that it was the politics of ‘who is responsible for what’ (federal versus provincial government) that lead to the death of a young Aboriginal boy in a Manitoba hospital in 2005.  In Canada’s Most Vulnerable: Improving Health Care for First Nations, Inuit and Métis Seniors, we do acknowledge that some policies are being re-examined as to their relevancy. In Nova Scotia, for example, action has been taken between Health Canada’s First Nation and Inuit Health Branch (Atlantic Region) and the Atlantic First Nations Chiefs, resulting in a shared decision- making committee that has made the needs of elder care, a priority.  Through this committee, an Elder Care Assessment Tool was created to determine just how much flexibility the FNIHB Atlantic region had in ‘adapting’ the Non-Insured Benefits Program to the population needs.  The result: an adjustment to the medical transportation guidelines that are often cited as preventing adequate access to care. The Atlantic region is now looking at what other national policies could be adjusted to meet the needs of seniors in that region. 

In all of the Health Council’s reports, we’ve focused on the positive solutions created in pockets across the country. This essay is not to diminish the great work of many in communities across the country, rather we urge governments and communities to do more of it, with greater connectivity, so that all First Nations, Inuit and Métis populations benefit, and the health gap between them and the larger Canadian population closes. 

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