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Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology

Issue 16 - Evidence

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OTTAWA, Wednesday, May 30, 2001

The Standing Senate Committee on Social Affairs, Science and Technology met this day at 3:44 p.m. to examine the state of the health care system in Canada.

Senator Michael Kirby (Chairman) in the Chair.

[English]

The Chairman: Honourable senators, this is the one session of the committee on the subject of the federal government and the actual delivery of health care services. As you know, the health care policy from the federal government's standpoint is largely a policy issue, not a delivery issue. Today we will hear from the people who are responsible for delivering the services. They are essentially people from Health Canada and Indian and Northern Affairs Canada, followed by presentations from various Aboriginal groups who receive these health services. That is our agenda for the next three hours.

We have with us Ian Potter, the Assistant Deputy Minister for First Nations and Inuit Health Branch at Health Canada, with his officials, and we have Chantal Bernier, the Assistant Deputy Minister of Socio-economic Development Policy and Programs for Indian and Northern Affairs Canada.

Mr. Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada: I am joined today by Jerome Berthelette, the senior Aboriginal Health Adviser in Health Canada, and Dr. Peter Cooney, who is the Director General of the Non-Insured Health Benefits Program, which is an insurance program that provides supplementary health services for First Nations and Inuit.

I have left with the clerk of the committee a presentation that you may have before you, in French and English. It covers a few points. It describes what the First Nations and Inuit Health Branch is. It indicates who the people are that we serve, the programs and services that we provide, the challenges we face, and some discussion about future directions. I will go through these quickly. If you want to follow along, there is a presentation that might help.

First Nations Inuit Health Branch is a branch that actually provides health care services on reserves and provides both the curative interventions in certain situations. It also provides health promotion and environmental health services, public health services, and general promotional health and population health type initiatives.

Our objectives are to improve health outcomes for First Nations and Inuit; to assist First Nations and Inuit to access to quality health services; and to support greater control by First Nations and Inuit over programs and services in health.

I will give a little of our history. The federal government has been in a very concrete way involved in this area and has had an Indian health service since 1904. We started building hospitals in 1917. Our first nurses were hired as part of our programs and services in 1922. By 1924, all reserves had doctors on part-time and nurses involved in the system.

In the latter part of the 1980s and 1990s, we have been involved in devolution of the management, control and delivery of health services to First Nations themselves. Today approximately 80 per cent of the services in the community are managed and delivered by the First Nations themselves. They receive funding from our federal government program, but they are actually operating the services.

[Translation]

The people that we serve, a population of 790,000 members of the First Nations and the Inuit, have extra medical coverage for drugs, dental care and eye care. We serve 389,000 communities and reserves where we provide services directly. According to estimates, population growth among First Nations over the next ten years will be 135,000 people, an increase of 2 per cent per year.

The Aboriginal population is very young, with 40 per cent under the age of 20. Aboriginal people generally live in small villages, and 77 per cent of communities have fewer than 1,000 inhabitants.

[English]

If we compare what has happened in the past with what is happening now, we can see that we have made some significant gains. Since 1979, infant mortality has dropped by half, but it is still about twice the rate of the general population. The life expectancy of a First Nation Inuit has increased in that same time period by about 10 years. We still face significant problems. Heart disease is 1.3 times higher, arthritis is two times higher, and diabetes is four times higher among Aboriginal men.

There are some particularly difficult situations vis-à-vis mental health, and injury. Suicide rates are six times higher in Aboriginal communities; injury rates are three times higher, and TB remains a significant and difficult problem with rates that are eight or 10 times the general population.

The Royal Commission on Aboriginal People made the point that in spite of the significant improvements, a gap in health and well-being between Aboriginal and non-Aboriginal people remains stubbornly wide.

We spend approximately $1.3 billion a year on the programs and services that we deliver and we provide primary health care services in 198 communities. The communities that are isolated or semi-isolated are the communities to which the federal government delivers health services. We have nurses on site; we operate clinics and handle emergencies and the day-to-day nursing and health care of the people in the communities.

We provide public health service in about 435 communities. We provide prevention and promotion programs such as Aboriginal Head Start, programs to avoid chronic diseases or to avoid infectious diseases in more than 700 communities.

We also have an extensive addictions program where we fund 64 treatment centres and we fund addiction treatment workers in the Aboriginal communities.

The health insurance program that we operate is the largest health insurance program in the federal government. It is one of the largest health insurance programs in the country. This is a supplementary health insurance program. We cover 690,000 people for drugs, dental, vision and access to medical services.

I have given to the Clerk of the Committee a detailed map that shows the distribution of the communities that we serve. We operate in many communities across Canada; we do not operate directly in the Northwest Territories and Nunavut, but we have agreements with those two territorial governments to manage the services on our behalf. We transferred those responsibilities to the territorial governments as part of the general transfer of health care responsibilities. Outside of that, we essentially provide services from one end of the country to the other.

I have provided a chart that gives an idea of the kind of establishments that we have. We still operate four small hospitals and we are trying to move away from that. We have 77 nursing stations, 217 health centres, and a number of other facilities.

We have a budget of $1.3 billion, about half of which is spent on non-insured health benefits, which is the insurance program for drugs, vision, et cetera. The other half is spent on community health services, which includes the curative and promotional parts.

With regard to spending on public community services, the largest part is transfers where we have transferred responsibility to First Nations. The other is equally divided among primary care, public health and health promotions.

The largest insurance program expenditure is on pharmaceuticals at approximately $225 million a year. Next to that is transportation, which is becoming a larger part of our responsibility. Our objectives are to either provide the services or to see that First Nations living on reserves can have access to the services. As provinces have generally centralized services in larger centres, our transportation costs go up because we provide the transportation for people, say, in northern Manitoba to fly to Winnipeg for tertiary or secondary health care services.

Non-insured health benefits cover drugs, dental, medical transport, vision and care. It provides some information on the growth. We are facing significant growth in both the population that we cover and in the costs.

I would like to mention four initiatives that we have recently taken. One is the First Nation and Inuit Health Information System. The government has launched the development of an information system that provides access to much better information on the services that we are providing, the efficacy of those services and the state of health in the communities. That is a gradual program and there is still a large amount of work to do on that front.

The federal government has now introduced a Home and Community Care program to serve First Nations members living on reserves. Last year that budget was $45 and this year it has doubled to $90 million.

Another important initiative recently was the introduction of an Aboriginal diabetes initiative. We spend approximately $11 million a year on that initiative and it is a combination of both improving the services to people with diabetes and supporting primary prevention and promotion to avoid the growth of diabetes in that population.

The Aboriginal Head Start on Reserves is another program the government has recently introduced. This is a broad preventative program. If you can provide good support to children in their early lives, significant health and social benefits will be gained throughout their lives.

We work with the provinces and the territories. Our services have to fit with the provinces. They are the major providers of hospital services and physician services but we work in a variety of different ways. Our program is very decentralized, as you are aware, given the nature of the health service system in Canada.

The First Nations living on reserves are entitled to the insured services that the provinces provide. Therefore, the physicians that visit the centres that we operate are usually reimbursed for their services based on the provincial fee service program. We find that it is difficult to encourage doctors to visit those communities. In many cases, we have arrangements to cover their transportation, or to provide them with guaranteed funds to visit the communities and we just then offset the provincial insured part of their service.

We face the same challenges as the rest of the health care system: a shortage of doctors and nurses. Most of our communities are isolated. Maintaining and attracting physicians and nurses to work in them is a major challenge. Costs are going up significantly as drugs, medical technology and transportation costs increase. We are seeing difficult access to some specialized services. There has been an increase in the rate of diseases, such as diabetes, that require tertiary care and sometimes involve difficult access. We obviously need to work for better coordination with provinces.

Health is linked to the social and economic circumstances in the communities. Those are long-term conditions that we work to change, but they will not change immediately.

I will finish, Mr. Chairman, by saying that the first ministers last fall signed the health accord. It sets out three key goals: to preserve, protect and improve the health of Canadians; to ensure timely access to service; and to ensure the long-term sustainability of health care systems.

A number of underlying items and goals comprise that accord. The accord governs the services that the federal government offers to First Nations and Inuit. The accord really sets much of our future agenda.

The minister has indicated in meetings with provincial ministers of health and with leaders of First Nations and Inuit communities that we are in the process of renewal. We have put in place structures to promote discussion on how the health accord provisions can be implemented in our business and in a manner that respects the kind of collective and collegial way in which we must work with provinces, territories, First Nations and Inuit.

[Translation]

Ms Chantal Bernier, First Nations and Inuit Branch: I am accompanied by Ms Terry Harrison, who is on my right. Ms Harrison is Director of the Social Policy and Program Branch in the sector that I am responsible for, the Socio-economic Development Policy and Programs Sector of Indian and Northern Affairs.

Under its enabling statute, the Department of Indian and Northern Affairs is responsible for all matters involving Indians and Inuit, in the Canadian North, except for areas specifically assigned to another department.

Health is one of those areas. However, although my department is not directly responsible for the health of First Nations and Inuit people, we are responsible for other issues that affect the health of Aboriginal people, including water quality, housing, income security, child and family services, education and economic development.

I would like to describe for you our activities in each of these areas. First of all, with respect to water quality, recent events have reminded us of how important water quality is for health. The department is responsible for infrastructure and for training operators of water treatment plants. For a number of years now, we have increased our efforts through internal budget reallocation to improve facilities. We have recently gone a step further by increasing resources for training programs to involve a larger number of operators and undertaking a detailed assessment of the condition of water treatment plants to determine infrastructure needs accurately. We are about to carry out an information campaign in the communities to ensure the best possible management of water treatment activities by communities and individuals.

[English]

The quality of housing, particularly in relation to mold and overcrowding, clearly impacts on health. The housing program provides needed support to First Nations and individuals residing on reserves in accessing safe, affordable housing. We recognize that work is required to renovate the number of substandard houses, to build new homes, to reduce overcrowding and to accommodate new family formations, while at the same time addressing health and safety-related issues such as mold contamination.

In July 1996, the government announced a new federal on-reserve housing policy that represented a fundamental shift from the previous approach.

Under the 1996 policy framework, First Nations have increased flexibility in how the funds are to be used. This allows them to develop good governance structures around housing and to be more efficient in responding to community needs.

We are making some progress in improving housing conditions. In the past five years the total number of houses on reserves has increased by more than 13 per cent, rising from approximately 78,000 to approximately 88,000. Over the same period, the percentage of adequate housing has also improved, from about 50 per cent of the houses to 57 per cent of the houses.

[Translation]

The next area is income security. On average, reliance on social assistance in Aboriginal communities was 37.5 per cent in 1990-2000. As a result of the Income Security reforms, we are working in co-operation with the First Nations to develop a new strategic framework for social assistance, so that it becomes a tool to help people become independent and to make the transition from social assistance to the labour market, thus contributing to the well-being of individuals and communities.

Generally speaking, social services contribute to good health, and our department provides a range of social services on reserves. For example, our adult care services help the elderly and disabled adults living on reserves. These services include household help to support people in their day-to-day lives and services in nursing homes where limited care is provided. These services complement those of Health Canada and are part of the complete range of services that we are developing.

Other social services include child and family assistance, shelters of victims of family violence and a variety of programs for children, such as the Aboriginal component of the National Child Benefit.

[English]

With regard to education, the correlation between education and health is well established. On average, First Nations have less education than the non-Aboriginal population. The proportion of First Nations adults with less than a grade nine education is significantly higher than that of non-Aboriginal adults. DIAND provides funding for elementary, secondary and post-secondary education and supports a range of employment strategies for youth. This range of programming contributes to improving labour force attachment and labour market outcomes, which in turn alleviates poverty and improves the health status of communities.

[Translation]

Last year, as a result of the Auditor General's report on First Nations education, we intensified our efforts in this area. We worked with First Nations to identify priority areas such as the development of a special education program, which is particularly necessary for First Nations because of the high number of children born with physical or mental disabilities.

Another priority identified was the transfer of responsibility for education to the First Nations, with improvements to technological infrastructure also a key area to focus on.

[English]

The final area is economic development. Economic development and social development go hand in hand and both create the conditions for healthy people and healthy communities. Economic development is one of the keys to addressing the full range of conditions on reserve in a sustainable way and to give the hope that is essential to mental well being.

We need to build strong foundations that will ensure that we get the most from our economic development investments. Therefore, as economic development improves conditions for health, we need healthy people to increase economic activity.

Consequently, the government strategy is to be holistic and to seek to support First Nations in capitalizing on economic opportunities, putting priority on the following aspects.

[Translation]

First, human capital: In his report on education, the Auditor General pointed out that gaps in this area have a direct impact on employment, income, well-being and economic self-sufficiency. We need to continue to focus on early childhood development and good basic instruction and to provide targeted job training in order to achieve benefits.

With respect to the exercise of powers, research has shown that when First Nations actually exercise authority, it helps build solid communities and economies by creating a climate that encourages and supports investment and new businesses.

Our department is working to develop partnerships that will invest in the indispensable infrastructure such as access roads, energy sources, telecommunication links and housing. This will level the playing field and enable First Nations to access new opportunities more easily. This strategy provides Aboriginal people and their communities with the tools they need to take a more active part in the Canadian economy and to find solutions to the situations described in the Auditor General's report, that is, poor socio-economic conditions because of low educational levels.

Thank you for your attention, and I will be pleased to answer your questions. If you require any information that I do not have with me here, I will be pleased to send it to you later.

[English]

The Chairman: Before turning to my colleagues, I would like to ask a few factual questions.

Let me turn first to Mr. Potter. Your terminology confused me somewhat. On your overhead No. 18, you talk about supplementing provincial and third-party programs. If an Aboriginal is living on a reserve, the full cost of providing that service is paid by your part of the federal government, although the service itself may be delivered in the way it would be delivered to any other citizen of the province. That means you reimburse the province. Are those the mechanics?

Mr. Potter: The process is that services that are insured and that are recognized under the Canada Health Act as insured services, such as hospital and doctor services, are available and are paid by provincial governments.

The Chairman: What you call Canada Health Act services, I prefer to call hospitals and doctors, because people think Canada Health Act services are a lot more than they really are. However, under the Canada Health Act, Aboriginal residents of a province are the same as any other resident of the province, regardless of whether they are on or off reserve?

Mr. Potter: That is correct, in principle.

The Chairman: I always worry when someone says "in principle."

Mr. Potter: A First Nations resident of a reserve located in the southern part of the province near a city has access to what is essentially the provincial services - physician, clinical, hospital services.

It is different, however, for residents in a community that is located in the far north of the province, where there is no regular transportation.

The Chairman: I give Peace River country as an example.

Mr. Potter: In such a case, while in theory the services are insured and available, they are only really available in the community with the intervention and support of the federal government. In those isolated communities the federal government makes sure there are resident nurses. We pay for those nurses; they are nurse practitioners. They provide basic primary care and emergency care, funded by the federal government.

The Chairman: Those services are funded directly by the federal government?

Mr. Potter: Directly, yes. In those communities, we usually try to arrange for physician services. Usually a physician will arrive at a clinic maybe once or twice a week, or once every two weeks. Those physician services are on a fee-for-service basis. The provincial medicare plan is charged for those services. Usually there is not enough in it to assure that they are accessed.

We enter into contracts. In northern Ontario, we have a contract with McMaster University. McMaster University provides physician services in the communities. We pay McMaster a contract, and then we reclaim from the provincial government the fees for services that the physicians receive. It is usually only a smaller part of the overall cost.

The Chairman: I have another factual question, about the non-insured services you described. By non-insured, I mean not insured in the sense that they are not hospitals or doctors and they are not subject to the Canada Health Act.

On your Number 18 you refer to drugs, dental, medical transportation, vision care and so on. It is not in your overhead but in your comments you suggested that they are supplementary health programs. You used the word "premium" somewhere in your statement. Am I right that the people in those programs pay a premium?

Mr. Potter: No. I apologize if I misled you.

The Chairman: I may have misunderstood you.

Mr. Potter: That program does pay premiums for First Nations residents who are living in provinces where a premium is assessed in order to access medicare. That is in British Columbia and Alberta. We pay the premiums to the province.

The service is provided. It is a service that covers drugs, dental, medical care and vision. It is a similar service to what you would get from an employer.

The Chairman: When you say you provide it, what do you mean?

Mr. Potter: We insure it and enter into contracts with providers. We operate like an ordinary, private insurance company.

The Chairman: Why do you that? What do you not just farm it out?

Mr. Potter: Actually, the administration is by and large farmed out, but the government manages the rules and the policies. One of the reasons we manage them is that most private insurance providers do so on a basis of a percentage of the premiums or the expenditures that they provide, and in that circumstance there is not always the incentive to look carefully at the costs that you are incurring. In this situation, the individuals are not paying a premium. In other words, the federal government essentially pays the premium for First Nations and Inuit people. In that circumstance the individuals who are seeking the insurance do not have the same incentive a private insurer would have in terms of trying to keep their premiums down.

Given that we are one payer, and we pay for all the costs without premium or without additional co-payments by the user, we manage the cost and effectiveness of the program.

The Chairman: I will not be argumentative with you, but I have an observation. With respect to employees of the federal government, or anyone else who is a member of an employer-sponsored plan, your logic suggests that the fact that they pay part of the premium has an impact on their behaviour. In all the years I have been working, and I have been under many different plans, I do not know of any employees who, once under an employer plan, had a change in behaviour on the notion that abusing the system would likely to lead to an increase in rates. I want to make sure I understood the point you were trying to make.

Mr. Potter: I was not trying to make the point that it has to do with abuse.

The point is about the kinds of services that you are providing and the policies that you would build into the system. In the public service plan, people accept that there is a limit on certain dental services. They recognize the connection between that limit and the premium they pay, and that part does not exist within the program we operate in that we pay for the whole service.

The Chairman: Ms Bernier, with respect to education, in contrast to health, the federal government runs the schools and pays for the post-secondary education. Is that right?

Ms Bernier: We do not run all the schools. There are only a few federally run schools left. The bands run the schools. However, we do pay for the students on reserve.

The Chairman: To that extent, it is different from the health care situation in that you treat the residents of a reserve in the same way they would be treated as residents of a municipality. What do you do for a status person who is not living on a reserve with respect to education?

Senator Morin: And health. That was my question.

Ms Bernier: Our education program is strictly on reserve, the exception being post-secondary education because the post-secondary institutions are off reserve. Therefore, the student who comes from a reserve will still enjoy support.

The Chairman: What happens if the person has Aboriginal status, does not live on a reserve and wants post-secondary education?

Ms Bernier: Our post-secondary education is not available to all Aboriginal students. In fact, we are struggling with that issue. It is a finite pot of money, and it cannot be given to all.

We have a certain amount of money that we distribute per community; in turn, the community distributes it to the students who want to pursue post-secondary education, and those students are from the reserve.

As to First Nations primary and secondary education, the education is given either on the reserve because there is a band school. If the children are next to a school that is off reserve and is run by the province, the children attend that school and then we reimburse the province.

The Chairman: You reimburse the municipality.

Ms Bernier: We reimburse the school.

The Chairman: Whoever is paying. That is the background I was seeking.

Senator Morin: My question is about federal responsibility with respect to First Nations people living off reserve.

Mr. Potter: In the program, about one-half of our budget is spent on community services, and the other half on the insurance program. The community services are community based and include the health promotions, care treatment, public health services and environmental health services. Those are community based for reserves. It is like a municipal service, a public health centre on reserve.

The other half of the program, the insured program - not the non-insured health benefits program - covers all status Indians and Inuit.

Senator Morin: Whether they are urbanized or on reserve?

Mr. Potter: That is right.

Senator Morin: What proportion would be on reserves, and what proportion urbanized?

Mr. Potter: About half each.

Senator Morin: Those urbanized Indians would have their drugs paid for whether they are in a city or somewhere else?

Mr. Potter: The insurance program is a second payer. The non-insured health benefits program is set up so that one accesses other services first and then this service. A First Nation status Indian who is employed in the city and whose employer provides health insurance would go there first.

Senator Morin: What about an unemployed person?

Mr. Potter: Unless a provincial welfare program provided coverage, we would pay.

The Chairman: You are the payer of "last resort."

Mr. Potter: Yes.

The Chairman: With respect to the Inuit, which you touched on only to say that you fund the two territorial governments directly and they in turn provide the service, does that apply to education as well as health?

Ms Bernier: No, it is devolved. We do not do education for Inuit. We do some programs for Inuit, but most are devolved.

The Chairman: Do you pay the territorial government that will in turn provide the service? Or are you out of it entirely?

Ms Bernier: It does not go through our department. The Inuit youth can avail themselves of some of our programs, but the education program is south of 60.

The Chairman: North of 60, you are not in education but you are in health. Is your role any different than the transfer of funds to a province that, in turn, runs a health program? You transfer it to the territorial government in this case.

Mr. Potter: It is slightly complicated. In the Yukon, we are providing the direct services of a health nature to communities.

We recently signed an agreement with the Northwest Territories and Nunavut to transfer funds to them, and they run most of the community-based services. We have added some services since that agreement, such as children's services, where we are involved in some direct programs, and services in the North.

We have entered an agreement recently with the three territorial governments to endorse what we call the "Northern Wellness Agenda," which tries to integrate our activities so we work collectively in an integrated fashion.

With respect to the Inuit, it is not as easy or clear-cut given that there is not a reserve-based system. The communities are not reserves and therefore not federal lands. We enter into agreements with them directly or with the territorial government.

The Chairman: Based on head count?

Mr. Potter: Based on numbers. There is a formula system more or less per capita.

Senator Callbeck: Ms Bernier, I wanted to ask you about a section on page 4. The other day I was talking to a Métis, someone I thought was quite well informed, who told me that the federal government did not have any health programs for Aboriginal seniors or on or off reserves.

At the top of page 4, you mention services through the Adult Care Program provide assistance to elderly and infirm First Nations individuals resident on reserve. Has this program just started or has it been there for a long while?

Ms Bernier: The distinction resides in what we call a health program and a social assistance program. What DIAND provides is social assistance, not a health program. Sometimes the distinction is rather tenuous: When does the care become medical in nature or when is it just social in nature? That is the distinction. What we provide is assistance but not medical care.

The example I gave you in my notes is in relation to home care, where we do not provide medicare at home. We provide homemaker assistance.

Senator Callbeck: Has that assistance been there for a while or are those services new?

Ms Bernier: I would be happy to send you a date as to when that program started.

Senator Callbeck: I would like to have statistics on the services that come under this Adult Care Program.

Mr. Potter, would you care to comment on what I said?

Mr. Potter: The person you were talking with probably identified an issue with respect to nursing care services on reserves. In general, this is an area where we do not have a policy that speaks to that service. There was some development without a policy and without a budget a number of years ago. The ministers of health and Inuit affairs put a moratorium on some developments in that area and we are working to try to develop a policy.

We are striving to come to grips with this issue. How do you address the need for residential care for seniors when you have very small communities? As I said, 77 per cent of the communities have fewer than 1,000. Currently, we encourage arrangements with the adjacent municipalities or the provinces to find care facilities in the nursing homes off reserve. However, in many communities, there is a pressure to create nursing homes or extended health care facilities on reserves, and the issue becomes one of size, how to maintain them and how to manage and link into a policy such as that. The person to whom you were talking probably identified an area of which we are aware and in which the two departments are trying to clarify how to deal with that need and build a service program.

Senator Callbeck: With respect to the shortage of health care workers in some areas, I notice here that a December 1999 report indicated that 45 per cent - 233 nursing stations in northern isolated communities - were vacant or filled temporarily. Is that situation getting worse or better? Where does it stand?

Mr. Potter: We have introduced some policies to try to retain the nurses we have and attract new nurses to those communities. The situation has remained about the same. We have put in programs to support nurses in training; we pay for their final year living expenses and tuition in exchange for services in our communities.

The report is correct. About 45 per cent of the Northern communities lack a permanent nurse. However, these stations are not without services. We contract services on a temporary basis. We deal with private agencies that provide nursing services. We found ways to do that, but it is a continuing battle.

As the situation with nurses in general becomes more difficult, both by age and by number of retirements, it is obviously difficult for us to attract nurses to isolated communities. We are aware of this and have identified this area as requiring more attention. I am currently in the process of staffing a senior nursing officer for the branch to try to bring much greater attention to this area and take some leadership for the kind of programs we would need to attract and keep nurses in those communities.

Senator Callbeck: What about recruiting Aboriginal health care workers? Are there special measures in that direction?

Mr. Potter: There are a variety of different measures across the country. This is an area where we provide some minor assistance and work but it is essentially training and education, which falls within the responsibility of provincial governments. There are special programs in some university medical schools where they hold positions for Aboriginal people and in nursing programs.

I am told that one of the big problems is the nature of those programs and the success of those programs. I met with a dean of nursing the other week who explained that they had a program, and they brought in about 40 people. Within a year of a two-year program, all of them had left. There are real problems.

I am told that the number of Aboriginal nurses is only in the 1,000-2,000 range across Canada out of a population of 260,000. I believe we only have 100 Aboriginal physicians out of a population of 50,000 to 60,000 physicians in Canada. It is something we have identified as a need. It obviously requires more attention and cooperation from those provinces running the training programs.

Senator Roche: Mr. Chairman, I am a little afraid to put my question lest the witnesses interpret it as an accusatory question to them.

Senator Morin: We will defend you.

Senator Roche: I am perplexed. We are here this afternoon, as I understand it, to discuss the health of Aboriginal peoples. What is the health of Aboriginal peoples?

The Chairman: We are here to discuss the role of the federal government vis-à-vis the provision of Aboriginal health services.

Senator Roche: I am going to come to that. I will take one second for a preamble.

Tuberculosis is almost seven times higher among Aboriginals than among the general population. Heart problems are three times worse. Infant mortality is twice as high in First Nations than in the rest of the country. The suicide rate is two to three times that of the population, and among youth, it is five to six times higher. Alcohol and solvent abuse are common among First Nations and Inuit. AIDS is increasing. Smoking is more prevalent by far than in the general population. The life expectancy is some seven years lower.

Now, these are outrageous reflections on a segment of the Canadian population. I would have expected our witnesses to come storming into this committee to wake up the politicians around this table and, by extension, the system, about what is going on.

What I have recounted here is not particularly new. Those with any sensitivity at all to First Nations problems and with any reference to the royal commission's report of two or three years ago are familiar with these things.

The witnesses have given us material that says that the First Nation and Inuit health systems face significant challenges, including a shortage of doctors, increasing costs of drugs, aging infrastructure and more need for specialized services. That is bland stuff compared with the depth and gravity of the problem.

I recognize that our witnesses are from government departments. Perhaps my comments should be more particularly directed to the political establishment that made the policies they are following. However, I am very concerned about why they are not telling us the real facts and reminding us of how serious this problem is.

If senators on this committee are to do a report on Canada's health care system, I would have thought they would have been telling us these things to remind us to get them into the report. Will we let all this stuff I have been recounting slide off the table and deal only with transfers between systems and shuffling of paperwork?

Mr. Chairman, shuffling paperwork will not address the root of the problems of Aboriginal health.

The first ministers' health accord established three key principles. One is to preserve, protect and improve the health of Canadians. I do not think the federal government is doing much of a job in preserving, protecting and improving the health of Aboriginal Canadians and something must be done about that.

I hope the witnesses will not interpret what I have said as a reflection on them personally. It is not at all. I recognize that they are doing their job. However, I strongly protest. If this committee is going to deal with Aboriginal health seriously, we have to get down to the basics rather than this paperwork.

The Chairman: I do not disagree with anything you said. Simply for clarification, some of the facts you listed, Senator Roche, the witnesses gave us. However, there is no question that your list was better and more thorough.

Mr. Potter, would you like to comment?

Mr. Potter: I would, Mr. Chairman. First, if the committee would like more information with respect to the health of First Nations and Inuit with regard to epidemiological conditions, we would be happy to provide that. As it can be voluminous, we did not deal with it today.

Second, I hope that our approach did not leave the impression with senators that we are passionless about the subject. The people who work in this area are absolutely passionate. They are dedicated. They work, at enormous expense to their own personal circumstances, in very difficult situations. They care very much about the health of First Nations and Inuit people. If I have let them down by not conveying that passion, I apologize.

On a day-to-day basis, on an individual patient basis, and on a system basis the people who work here cry out for improvements in the system and for better outcomes for First Nations and Inuit health.

Finally, improvement to health is not accomplished only through health care services. As my colleague mentioned, education is key issue to improving health outcomes. Employment and the social environment in which people live are other key issues.

All of these facets need to be worked on in conjunction with the health service delivery system to improve health outcomes. We are working together on that. The challenge is enormous. If I did not convey that, I apologize. Passionate and committed people are working for the federal government and they want to see much greater improvement to the statistics that you cited, senator.

The Chairman: To echo Senator Roche's point, the issue of the health status of the Aboriginal community has been touched on periodically by various witnesses or through the tabling of health data on various segments of the Canadian population. Some of us on the committee were stunned by the data that Senator Roche raised. We all understand that politics is frequently the art of shifting the wind. In fact, when one looks at federal-provincial relations, one often wonders whether that is not the underlying strategy of the game. I say that as one who has been involved in federal-provincial relations on both sides.

The feds cannot transfer blame to anyone in this area. This is why I asked whether it is true that the federal government is responsible for the delivery. Frankly, we are very troubled that there is a segment of the Canadian population living under those circumstances. Ms Bernier spoke about the increase in improved housing yet also said that only - although "only" is my word - 57 per cent of the housing is regarded as adequate. As a Canadian, I regard that as inadequate.

The committee will have to deal with that and we will want to have you back in the fall when we put out our issues and options paper. We may be able to exert some modest influence - perhaps even some provocative influence -on the federal government and wake up the conscience of the rest of the country on this issue.

Senator Robertson: I want to echo Senator Roche's comments with no reference to civil servants. Without being political at all, I become embarrassed when I refer back to statements, red books and Throne Speeches talking about what the government is going to do about the conditions in which our native people are living.

Matthew Coon Come may have identified it best when, on May 24, 2001, he talked about the human rights catastrophe that exists with our native people. We all know that Canada is not a shining example in the international community of human rights treatment for our native people. There has been much comment about that.

We must get to the bottom of some of these issues and find better answers. It is so discouraging and so embarrassing to have our Aboriginal people living in the circumstances that they do, to have them drinking water that is not safe. Of course, that happens in other communities these days too, but in those places the problem is easier to correct.

We know that housing has an impact on health. We know that in regard to social circumstances, if you live in poverty you have poor health, generally speaking - one follows the other. It is not a very scientific appraisal of circumstances.

We continue to hear these statements - that they are going to do something. Obviously, they are not giving you the tools to do what they say they want you to do. By "they" I mean government. I think that is wrong. For instance, who tests the safety of the water consumed by your native people? Who is responsible for your public health? I believe all good health starts with public health.

Mr. Potter: In the branch that I manage, we have environmental health officers who test the safety of the water in those communities. We have systems whereby they test on a regular basis. If there are problems with the water, they give advice to the band to boil the water or use alternative sources.

Senator Robertson: If you give advice to boil the water, what does your public health do to correct the problem that causes the requirement to boil the water?

Mr. Potter: That is a division of responsibilities. On the health side, we test and determine whether there is a threat to health. Then we advise the operating authorities, which is the band, supported by Indian Affairs and Northern Development. There is need to correct the situation. In some cases, it is a difficult thing to correct.

Maniwaki, a community not far from here, must have drinking water provided in bottles because they have a well system and the natural uranium in the rocks in that formation has resulted in a high concentration of radioactive isotopes in the water. Therefore, we must find a way of bringing water in from some distant place. Currently they are on a bottled water system. In many small or isolated communities, it is difficult to correct the situation.

Senator Robertson: If this occurred in a non-Aboriginal community, they would find a way of correcting it.

Senator Morin: I would like to deal with the health indicators. You may not have the answers immediately, but I think these health indicators are important. I share Senator Roche's indignation that they are totally unacceptable for a country such as Canada.

If 50 per cent of the status Indians are urbanized and 50 per cent are on reserve, is there any difference between the health indicators, whether they are life expectancy or other factors?

Senator Gill, from Quebec, has told me that the health indicators are better in Quebec than elsewhere. Is that a fact - that there are differences between provinces as far as the health indicators of the First Nations?

Finally, is there a difference between the health indicators of Aboriginal population and the health indicators of isolated communities? For example, a study was done in Quebec that showed the health indicators were very poor in northern, isolated communities, or in the Gaspé, or small communities where unemployment was high, and education was low.

There was a study in Montreal that shows that the difference between the West Island and the East Island is 12 years in life expectancy, which is more than you have between the First Nations and the Canadian population.

Are these health indicators explained solely on the basis of education, economic development and children's services, or is there an added cultural deprivation component to it? If these indicators are strictly similar to the isolated communities or the urban poor, then we should solve this like we solve problems in the rest of the Canadian population. If the health indications are worse than they would be strictly on that basis, then we must explore other areas that are more difficult. I am talking about cultural deprivation. I am sensitive to that element. It may not be as important as far as the health indicators.

Perhaps you do not have that information at the tip of your fingers, but you see why I am posing those questions.

Mr. Potter: I could provide the more specific details, but I know the general answers to those questions. You posed the question: Is there a difference between the health indicators in urban situations versus isolated and rural situations. Yes, there is. Generally, that exists for First Nations as well as other Canadians. People in urban centres tend to be healthier than those in rural areas. Education does seem to be a factor: there is a link between education and health status. Therefore, First Nations who are better educated usually have a higher health status.

You asked if there is a cultural aspect to these differences. That is a more difficult question to ascertain. I believe you have some witnesses coming later this evening who may be better able to deal with that question.

There does seem to be an issue with respect to health, in that health seems to be related to the sense of both power and control and your sense of belonging to organizations.

Senator Morin: Perhaps I am not making myself clear. I think we should compare the health indicators in small, isolated communities that are not Aboriginal with those of reserves. If they are grossly different, this means there is a cultural element. Most of the small Quebec communities are French Canadian and they are no different from those people who are urbanites.

I realize there is a difference. I realize that cultural deprivation is an important issue that must be addressed. I am trying to determine if there is a cultural component to the poor health indicators we find in the First Nations.

Mr. Potter: I do not know the answer to that question. We could look to see if there is evidence to that effect.

The Chairman: That would be helpful in terms of the broader study. I thank all of you for coming. You will be hearing from us again and we will be hearing from you again come the fall.

Senators, we have six witnesses in our next panel. I know there are a number of people who wanted to come to table. Because of time and space limitations, we can only hear one person per group.

I know that some or all of the witnesses on the next panel have prepared some form of an opening statement. As we want to be able to ask as many questions as we probably have time for, I would ask the witnesses to be succinct, perhaps take five minutes to hit the high points and we will proceed from there.

Our next witness is Elaine Johnston from the Assembly of First Nations.

Ms Elaine Johnston, Director of Health Services, Assembly of First Nations: Honourable senators, I am a registered nurse by profession. I am a First Nations member of the Serpent River First Nation. I have worked in many communities in the North. The issue of health of the First Nations people is very important to me because I have worked in communities that have suffered high rates of suicide. I have had to deal first-hand with some cases where young people have successfully committed suicide. As a nurse, I have found it heart-rending to deal with the families of these young suicides. When I speak about health, I speak about it because I have a passion for it in my heart.

One of the first things that I wish to bring to your attention - and I appreciate that one of the senators had brought forward the national chief's concerns - is the overall poor health status of the First Nations. There has been a lack of programs and services in communities and a lack of response by the federal government to implement the Royal Commission on Aboriginal Peoples' recommendations to improve the status quo.

Honourable senators have in front of them some of the statistics that were mentioned earlier: In 1995, the life expectancy for First Nations males was 69 and for First Nations females was 76. The mortality rate is 1.5 times greater. The chief causes of death are injury, poisoning, motor vehicle accidents and suicides. There are some key hot spots across the country where there is a high rate of suicide. Diabetes is two to three times higher in the Aboriginal community. Tuberculosis is 18 times higher. AIDS in the Aboriginal population is 11 times the national average.

The "First Nations Inuit Regional Health Survey," published by the Assembly of First Nations, compiles these statistics. We worked with our communities to gather the type of data you mentioned earlier. Our challenge has been in securing of funding from the federal government, in recognition of this survey as one of the tools to be able to collect the necessary information. There has been no recognition of our ability to collect that information.

The question was raised earlier about whether we can compare data from the North and the urban population in the south. We have attempted to do that, but the problem is the lack of funding from the government to enable that kind of research activity to take place.

We are particularly concerned about the link between the conditions in the First Nations communities and poor social and economic conditions such as below-poverty income levels, substandard and overcrowded housing, exposure to unsafe and polluted water, inadequate sewer systems, and lack of professional care and other services. We must look at the broader determinants of health if we look at health in general.

It is interesting that the World Health Organization has recognized that individual good health can best be ensured through maintenance of healthy social, economic and cultural systems. Conversely, the exploitation and humiliation of societies will inevitably lead to both collective and individual ill health.

First Nations have struggled through years of oppression and the imposition of colonial government legislation; the impacts of which are evident in our communities in the forms of ill health, addictions and the struggle to assert our inherent right to be self-governing. If First Nations are to attain the level of health enjoyed by mainstream Canadians, it will be through the assertion of our inherent right to govern and the resurgence of our language and our cultural practices.

The First Nations' right to self-determination on governance and the application of governance is fundamental to building healthy communities and infrastructures. The imposition of colonial mentality and legislation still exists today. I say this because the Minister of Indian Affairs has announced his intention to develop and impose governance in legislation that will dictate further how First Nations will govern and be governed. It is a systematic application of oppression that will continue to undermine the inherent right of First Nations to self-government.

The current health and social environment has resulted in low numbers of First Nations individuals completing formal education. One-quarter of First Nations people have less than a grade 9 education and only 3 per cent have a university degree. Over half of the First Nations population is under the age of 25. Coinciding with the lack of completed education are high levels of unemployment and reliance on social assistance for income.

Forty-nine per cent of First Nations individuals 15 years and older have an annual income of less than $10,000, and the average annual income of Aboriginal people is $17,382.

This low level of income is a direct contributor to the poor health and social status and high incarceration rates of First Nations. Low self-esteem, perpetuated by lack of education, low income, inadequate and overcrowded housing, can be replaced by pride and hope as First Nations assert and implement their own governments systems. Poverty, ill health, educational failure, family violence and other problems reinforce one another.

To break this cycle, all determinants should be addressed together in a coordinated strategy - not a piecemeal approach. It is in the best interests of the Canadian nation for First Nations to determine the processes and frameworks that will result in viable governance models that will yield healthy communities. As First Nations governance emerges from First Nations-driven processes, valuable contributions to the Canadian economy and infrastructures will result.

The First Nations concept of wellness encompasses the four realms of human existence. Some First Nations refer to this concept as "the medicine wheel." It is believed that well-being and optimum health can only be achieved by addressing not only the physical aspects of health, but also the emotional, mental and spiritual needs of an individual. Those fundamentals make the First Nation view far more holistic than the biomedical model. I speak as a nurse having gone through a nursing program that was very much a biomedical model and does not look at all aspects of health.

The medicine wheel illustrates that First Nations people believe that a person is not only a body. If a person is to be healthy or achieve wellness then each of the four aspects of their life must be in balance. Appropriate attention must be given to each of the four aspects of a person. Not only must one be balanced, one must live in a balanced, harmonic community. Harmony must be addressed at all levels of existence and aspects of life. The prevention of illness and the promotion of good health and healthy lifestyles must be addressed through healthy communities and governments.

Issues of Health Canada's accountability to First Nations and Parliament should be addressed through evaluations of current health promotion and prevention activities and conducted jointly with First Nations. Comprehensive approaches and strategies need to be developed in partnership with First Nations that will embrace cultural practices and best practices while supporting the governance strategies of First Nations.

First Nations have a unique relationship with the Crown - the federal government. This relationship is based on historical documentation and the treaties developed between the two that were the basis for peaceful coexistence. First Nations were distinct and governing nations when these treaties and relationships were developed, and continue to assert the right to be distinct and governing nations today.

The treaties define a fiduciary responsibility of the federal government to First Nations. First Nations maintain that any discussions, policies or legislation that is developed by the federal government must be done in partnership with the First Nations.

A partnership process that respects the historical relationship between the First Nations and the Crown, and recognizes the inherent right of First Nations to be self-determining and governing will provide a basis from which to enhance capacity and result in healthier communities and economies.

Treaty implementation processes and land claims resolutions have been impeded by the lack of cooperation on the part of provincial governments in meeting Crown obligations to First Nations. First Nations maintain that they must be involved in all discussions or any policy and legislative developments that they feel impact First Nations. The provinces should only be involved if both the First Nations and the federal government agree that provincial involvement is necessary to the successful completion of the task.

The federal government has begun a devolution process, particularly in the area of health services. This process involves the transfer of health and social funding to the provincial governments to deliver health, social and educational services. Funding levels are determined by a formula based on the provincial population, including First Nations located within the geographic boundaries of the province.

This transfer process was developed without any First Nations involvement. The federal government engaged the provincial ministers in the development of the social union framework and excluded the First Nations leadership from participating. It is imperative that First Nations leadership is involved in all discussions on the Social Union Framework Agreement and Canada Health and Social Transfers. As First Nations emerge as self-governing nations - as is their inherent right enshrined in the Constitution of Canada - the Social Union Framework Agreement will have even greater implications and complications as First Nations are forced to negotiate with provincial governments for health services.

There is no impetus for the provinces to enter negotiations with First Nations; there are no treaties or fiduciary responsibilities with the provinces. That is why it is imperative for the federal government to include First Nations in the processes and policy developments that devolve the federal responsibility to First Nations to the provinces.

Further, the federal government, through the First Nation Inuit Health Branch of Health Canada, has been involved in the administrative transfer of health services to First Nations communities. This transfer initiative occurred under the guise of self-determination and self-government, but has resulted in little authority over the delivery of health service. This initiative was basically an administrative transfer attempting to devolve the federal government of the financial burden of delivering health services to a population that is growing at twice the rate of mainstream Canada and has a level of health status that is comparable to Third World countries. First Nations that have accepted health transfer are struggling to maintain the level of service prior to transfer and are running into deficit situations while services are decreasing.

The Non-Insured Health Benefit Program provides extended health services and prescription drugs for First Nations. This program was developed with the goal of raising the level of health in First Nation communities to that of the rest of Canada. While expenditures in this program have increased dramatically, the health status of First Nations has not. The level of funding for the delivery of health services has not met the needs of First Nations. The transfer of programs at the current funding levels and without opportunities to open the envelope to address actual needs is a recipe for failure of First Nations attempts to administer these programs. First Nations must be participants in the development of the federal plans to transfer and devolve health services.

First Nations governments and leaders have the capacity to involve their grassroots communities in the development of frameworks and strategies that will meet the health needs of the First Nations using responsible, transparent and appropriate resource management. Currently First Nations are involved in several joint initiatives with the federal government that are resulting in meaningful discussions and developments. The health renewal process of Health Canada is one example of such a partnership. This initiative is examining the current health delivery system of First Nations Inuit Health Branch and determining the most feasible deliverable strategy that would address the needs and issues of First Nations and optimizing the use of resources.

First Nations have maintained a willingness to enter meaningful partnerships with the federal government to develop strategies and frameworks that will address the needs of First Nations communities and promote the First Nations agenda of self-determination, governance and protecting all inherent and treaty rights. First Nations will embrace the opportunities to be included as equal partners in the study of Canada's health care system, as well as any discussions, other system analyses or legislative initiatives would impact on the delivery of services to their constituents.

I would like to conclude by saying that the message I wish to leave with the committee is that if we are to improve the health status of First Nations in our communities, the First Nations need to be involved in the development of those strategies. We have some valuable contributions to make in existing practices in which we have been involved. We do have the answers. As the Senate committee develops some options, we would like to present some possible strategies to help you.

I understand that the Senate committee is very interested in the health of Aboriginal people. I invite you to come to our communities to find out who we are. That is one way to find out the status of what is happening in our communities.

The Chairman: Thank you very much for your brief. We intend to talk to you again in the fall. Perhaps I could ask you to answer one question in relation to your opening comment when you stated that there were a number of research studies that you had hoped to get done and which were not being done. You said that the federal government was not funding the studies that would address some of the questions raise by Senator Morin earlier. Sometime over the next month, our researchers will contact you. It would be very helpful to know exactly what those studies should cover in your view.

Our next speaker is Mr. Morin from the Métis National Council:

Mr. Gerald Morin, President, Métis National Council: Good afternoon Mr. Chairman, senators, national Aboriginal leaders and fellow witnesses. The Métis National Council welcomes this opportunity to appear before the committee to address the issue of Aboriginal health. I wish to begin by thanking all the members of the committee for making the special arrangements to hear from the national Aboriginal leadership.

The Métis National Council is the national representative body of the Métis Nation in Canada. It was established in 1983, following the recognition of the Métis as a distinct people with Aboriginal rights in the Constitution of Canada. The Métis National Council has been recognized as a voice of the Métis Nation in constitutional negotiations and acts as an advocate and negotiator for the Métis with the Government of Canada at national conferences and forums. It also represents the interests of the Métis people on the international stage.

The Métis National Council is composed of local, regional and provincial organizations. The board of governors comprises presidents of each of the provincial member organizations and the president of the MNC. The five governing members within the MNC are: the Métis Nation of Ontario, the Manitoba Métis Federation, the Métis Nation of Saskatchewan, the Métis Nation of Alberta, and the Métis Provincial Council of British Columbia.

The regional or provincial presidents and their respective councils are elected through province-wide ballot-box elections in which all Métis have the right to vote. The MNC and our member organizations collectively represent the interests of the historic Métis Nation based in the Métis homeland in western Canada.

With respect to the capacity to deliver health programs, considerable capacity to deliver such programs exists within the member organizations of the MNC. In Manitoba, for example, the provincial government has begun to devolve family and social services to the Manitoba Métis Federation. In B.C., they recently signed a Métis Child and Family Services Agreement, which calls for devolution of those programs to the Métis Provincial Council of British Columbia.

Over many years, our member organizations - particularly in the Prairie Provinces - have developed many institutions to deal with a variety of issues including health, justice, family services, addictions, and economic development. Collectively the member organizations deliver millions of dollars of programs and services to combat certain issues in our communities and to deal with the needs of our people. We have a long way to go in terms of addressing those issues and there are certain problems which I will talk about later, but we have begun the process and we do have the capacity to deliver these programs to our people.

The MNC is encouraged by the relationship that has been developing with Minister Ralph Goodale, the federal Métis interlocutor. Since "Gathering Strength," there has been a sincere commitment to pursue a forward-looking Métis Nation agenda between the Métis National Council and the federal government. We are hopeful that by this fall, based on the minister's submission to cabinet, we will get approval to move forward with a framework agreement on a Métis Nation agenda, which will address Métis rights, jurisdiction and program service delivery issues for us. This holds out a great deal of promise to help us overcome many of the challenges that we currently face with the federal government.

Unfortunately, Health Canada is being exclusionary at a time when other federal departments are opening their doors to the Métis. The department is also undermining the relationship that we want to build with the federal government. Health Canada delivers Aboriginal health programming primarily through the First Nations and Inuit Health Branch. This results in the exclusion of Métis people from most federal government health initiatives.

Mr. Potter, an ADM from Health Canada, told this committee that the staff of Health Canada cares deeply and passionately about the health of First Nations and Inuit people. What does it tell us about the health care of Métis people in Canada when he openly admits that they do not care about the Métis people at all, or he excludes our people from his comments? Using the term "Aboriginal" interchangeably with "First Nations" and "Inuit" excludes our people completely.

This is a real problem. Institutional racism and discrimination against our people make it very difficult for us to access health-related resources to combat some of these urgent issues that are as great in our communities as they are in other Aboriginal communities.

The overall health status of Métis people is as poor or worse than it is for other Aboriginal people - equivalent to Third World conditions. Life expectancy is lower; infectious diseases are more common; the incident of life threatening conditions is rising; overall rates of injury, violence and self-destructive behaviours are high.

With respect to the national debate on health care, there is every sign that this debate will intensify as provincial and federal governments continue to struggle over the future of the health care system in Canada. Aboriginal people represent a small proportion of Canada's total overall population; yet as a group we are disproportionately affected by ill health.

The question for us is not a charitable one of gaining increased access to the Canadian health system. The Métis are recognized as an Aboriginal people; we are one of the three Aboriginal peoples recognized in the Constitution of Canada, which is the highest law of the land. We have inherent rights that are enshrined in the Constitution and those rights are also enshrined in international law and instruments. We must not allow the federal government to sidestep the central issue of the rights of Métis people and of our right to self-determination.

Despite the fact that the Canadian health care system has been praised as one of the best in the world, quality health care does not exist for many Métis people. Federal and provincial jurisdictional disputes, cultural barriers and geographic isolation that impede our access to the health care system. Métis communities are facing many of same health challenges as other Aboriginal communities but the difference is that Métis health issues receive limited and scant attention from the federal government. The fundamental issue at stake for the Métis is the unwillingness of Health Canada to deal equitably and fairly with the Métis people as one of the indigenous peoples in Canada.

Furthermore, one our major problems is that since Confederation, the federal government has held the position they do not have constitutional responsibility for Métis people as they do for First Nations and Inuit people. This amounts to institutional racism and discrimination in that our people are not able to pursue self-determination with the federal government, pursue rights-based issues such as access to land and resources to improve the well-being of our peoples. It also means that we have little or no access to all of the programs that are available through the federal government for Aboriginal people to address the same terrible conditions that exist in our communities.

In understanding Métis health issues it is important to remember that many of our communities lack basic health services; the health care system is not equally accessible to all. For those living in northern and isolated communities there is a lack of specialized services and the costs of health are prohibitive. The present system is fragmented and our communities would benefit from a health delivery model that integrates both social and health services.

The problems are holistic. To deal with these issues we must proceed in a holistic fashion in dealing with social, economic and health conditions in our communities in addition to getting to the root of the problem: Métis rights and self-determination on behalf of our people within Canada.

The MNC believes whatever improvements are made to the Canadian health system, they must include rules of access that give an equal opportunity for physical and social health to all Métis people.

I will not go into great detail with regard to issues of research, However, I would like to say that there is not enough information - research and data - relating to Aboriginal people and that is a problem for our people.

There are some statistics as part of the post-census survey done by Statistics Canada in 1996 and perhaps some by the Royal Commission on Aboriginal Peoples. There is a terrible lack of research, data and information with respect to the health conditions and the demographics of Métis people in this country.

As part of overcoming the jurisdictional issue and getting fair access and a fair deal with the federal government, we need a Métis Nation registry to enumerate our people to see how many Métis people there are where they live. This would provide us with demographic information, which would be helpful in determining how to best address the social and economic conditions that exist in our communities.

Our people face many barriers to good health. They live in substandard housing and many of them are poor. These issues must be addressed. I talked about the violence, alienation and the despair. There are also low literacy rates and lack of access to health services. All these must be considered in trying to achieve the overall good health of our people.

The Aboriginal diabetes initiative was recommended by "Gathering Strength." The diabetes rate among our people is very high. The federal government is spending $58 million over five years on the Aboriginal diabetes initiative, however, little of this funding will reach the hands of Métis people.

The Métis and off-reserve portion of this program has been restricted to prevention and education initiatives, whereas the on-reserve and Inuit program deals with care and treatment issues.

At the close of this last fiscal year 2001 Health Canada reported that the Métis off-reserve Aboriginal Urban and Inuit Prevention Program has lapsed 74 per cent of its funding; $1.85 million went back to the federal government because it had not been spent on what it was committed for. In spite of that fact, the Métis National Council submitted proposals, which were summarily rejected by Health Canada. So, we are not able to access monies that are allocated to us by the federal government and were lapsed. That is one of the problems. We also have some serious concerns about the diabetes initiatives and we need to address that issue.

On the national Aboriginal health organization, we were very happy that the federal government announced that it would move with the Aboriginal Health Institute as part of "Gathering Strength." We agree with this in principle, however we do have some serious concerns. First, it is being implemented in a pan-Aboriginal model where Métis are marginalized. We have two members on a 15-member board. Second, it is being implemented in such a manner as to bypass the legitimate representative organizations of the Métis Nation.

I wish state clearly that the MNC has the jurisdiction and the mandate to represent the Métis Nation on all matters, including those related to health. The National Aboriginal Health Organization or any other organization cannot usurp our jurisdiction to represent our people and we will continue to represent the interests of our people in all matters - certainly in the area of health related matters.

Thank you for listening to me. We need leadership in this particular area and we are prepared to work with you in achieving solutions and better health for our people and for all Canadians.

The Chairman: The Scientific Director, Institute of Aboriginal People's Health will be on the panel immediately following so you may well wish to on and listen.

Our third speaker is Larry Gordon from the Inuit Tapirisat of Canada.

Mr. Larry Gordon, Inuit Tapirisat of Canada: On behalf of the Inuit Tapirisat of Canada, I am pleased to make this presentation to you. It is our hope that the information we are about to share will assist us in providing direction as we work towards changing the face or the direction of Inuit health.

I am an executive director with the Community Development Division of the Inuvialuit Regional Corporation in Inuvik. I am a member of the Inuit Tapirisat Health Committee. Other staff members of the health committee have joined me for this presentation.

As you have copies of our brief, I will not summarize it here. I would like to give the committee some food for thought on some of the key issues faced by the Inuit in Canada's north.

I would like to start by telling you who the Inuit are. There are thousands of Inuit living in the south, but the majority of Inuit live in 53 remote communities across Canada's North, in Northern Labrador, Inuvik, and Northern Quebec, in Nunavut and the Northwest Territories. Most of our communities are only accessible by air, therefore, the cost of living, including transportation, food, and housing expenses are probably the highest in Canada and as such adequate health is a challenge for us.

The health services and programs available to the Inuit do not begin to approach what is taken for granted by southern Canadians. We know that achieving parity will take some time. We are also aware of the constraints imposed by the isolation of our communities. We are committed to working together towards achieving our goal so we can have health services at the level that we need.

For example, patients with serious health problems are treated in major northern centres or are flown down south. This results in separation for families and the community and it impacts on the individual's physical well-being and their recovery time. This also has an emotional effect on patients, their families and their communities. There are also additional financial costs, including transportation and living expenses for those who do come south as translators or as escorts.

The range, quality and delivery of services in the north vary among regions, but there is one common feature in the provision of health care: the small health centres, which have a limited range of service. Life-saving medical equipment - such as defibrillators - considered essential in southern Canada, are not available in most northern small communities.

The Inuit are addressing some of their basic health services and needs in partnership with the federal, territorial and provincial government. Some examples include the successful establishment of midwifery centres in Rankin Inlet, Pangnirtung and Povungnituk. There is also an elders group in Pangnirtung that is addressing mental health issues faced by the youth in that community.

In Labrador, there is a flexible, innovative community-based approach to the delivery of a range of health programs, which are delivered by the Labrador Inuit Health Commission. The community health committees provide input into their commission on local needs and have considerable latitude in determining how services will be designed and delivered in such areas as mental health and home community care and diabetes.

These projects I have mentioned offer solid examples of how cooperation between the Inuit and the federal, territorial and provincial governments can provide for needs locally. These needs are met through appropriate cultural context.

It is important to keep in mind the perspective that our culture, our way of life, and the natural resources form the foundation of our nutrition and our health. However, in recent years this foundation has come under attack with the increased contamination of the Arctic food chain by pollutants from both national and international sources. The link between environmental change such as global warming and the influx of environmental contaminants must be established. The effects of these changes on health include, but may not be limited to, increased cancer rates, neurological effects, nutritional effects, and rising incidence of chronic diseases such as heart disease and diabetes.

On average, Inuit women's breast milk has PCB levels five times higher than that of women in southern Canada. It is not reasonable or practical to ask the Inuit to stop eating country foods. Not only is it central to our culture, but it is essential to our proper nutrition.

It has been demonstrated that taking someone off a country food diet, given the alternatives - such as low nutritional foods from the local store, many of which are costly - can lead to serious, even fatal, health problems including diabetes, obesity, tooth decay and iron deficiencies. It would be impossible to replace a country food diet with store-bought foods in an economy where only a few have access to money. One estimate that was made on the replacement value of country food for an Inuit family - if money were the only factor, which it certainly is not - was over $20,000 per year. That equals over $6 million per community, adding up to an approximate cost of $318 million worth of good nutritional food. We know the fiscal resources to replace traditional food simply do not exist.

Our work at the Inuit Tapirisat over the years have helped us to understand that many concerns about nutrition and Inuit health include complex associations between the environment, the social economy and culture. Housing issues are causing overcrowding, which has been shown to impact family violence, mental illness and suicide rates. Therefore, health issues must be looked at in a holistic manner.

Partnerships with Inuit must be continued and further developed. This will ensure that the fundamental rights of Inuit to access health programs and services that are at par to those afforded to all Canadians will become a reality.

The Chairman: Thank you very much. You have raised a number of questions and have brought some perspective from the Inuit. The earlier presentation from government officials focussed more on the issue of Indians living on reserves in southern Canada.

Our next witness is Mr. Clark.

Scott Clark, President, United Native Nations: Honourable senators, I am the president of the United Native Nations and the representative for the Congress of Aboriginal Peoples, or CAP. Our organization was formed in 1970 and it represents the interests of Aboriginal people not living on reserves. Close to 80 per cent of Aboriginal people do not live on reserves - a growing population. This includes our Métis people, our First Nations, our Inuit and of course the non-status people who are lost in the entire fold.

Things are getting worse as far as that particular population is concerned because the federal government refuses to recognize its fiduciary responsibility for that population; like the provincial governments they off load to the municipal governments that do not know what to do.

The largest reservations of Indians in Canada are in Vancouver, Saskatchewan, Regina, Montreal, Toronto, Winnipeg - the list goes on. When governments refuse to recognize those very real and pressing issues, it is no wonder things are getting worse.

I will not dwell on that because we are at a crossroads where we will find ourselves in either a situation of crisis or of opportunity. I choose to look at the opportunities that we have and aim to work together for a better future for our people, our communities and for Canadians as whole. There has not been a lot of discussion on that and I hope questions will arise after my five minutes.

It has been an ongoing struggle. CAP has a slogan that calls us the "forgotten people." We have been forgotten by the federal government and by others. Elijah Harper has stated that we are the untouchable peoples; no one wants to go near that population which will double in 25 to 30 years and will double again in another 35 to 40 years. Paralleling that, the Canadian mainstream population is not coming close to its own replacement level. This is a huge issue. We are very young and we have unique needs. We are dynamic. We are certainly diverse, as you can hear from the different presentations, and significantly different from the mainstream population with different needs.

Housing is a prime example. Since 1993, the federal government has opted out of the housing arena. Housing needs for mainstream Canadians are significantly different than they are for Aboriginal people. The federal government only funds First Nations housing units on-reserve and at that, there is not a sufficient number.

Aboriginal people are disproportionately represented in the growing homelessness crisis in the country. What is even more troubling is that Aboriginal single mothers are finding themselves out on the street. When people need services and when health conditions of those people deteriorate where do they go? They go to the hospitals; and the hospitals spend a significant amount of money trying to get their health back and then they go back out on the street.

The new national Aboriginal housing strategy of the federal government is through the criminal justice system. We spend anywhere from $60,000 to $120,000 to house an Aboriginal person within the prison system. If progressive thinking prevailed, those resources could be channelled to housing in the urban, rural and remote communities. Our people would then have an equitable opportunity to compete with Canadians for jobs, for education, for training, and to address the employment equity issues that the federal, provincial, and municipal governments claim they want to do.

I applaud the committee members for this component of the research, it is great work; it is monumental work. The federal government spent $58 million on the most expensive report in Canadian history on the Royal Commission on Aboriginal People. Unfortunately, well over 90 per cent of that report has nothing to do with urban Aboriginal peoples who make up almost 80 per cent of the population.

The issues for us in the urban, rural and remote communities is attempting to get the federal government, provincial government and municipal governments to start saying that this crisis is all over the place. Health is not based upon hospitals and patients. The health of the individual is based upon ensuring people have equality of conditions so that they can compete for jobs, so they can have economic self-sustainable development and small business.

The only way to move forward on that particular agenda is when Canada recognizes that this is a crisis situation, it is an embarrassment to Canada that we actually live in not Third World conditions but fourth world conditions and that we are paying for it one way or another. We can either be preventative and start doing those initiatives, or continue the old way and house people in prisons, house them in hospitals, house them wherever they may find themselves, which often has negative social characteristics that you have heard of today. It is a choice.

I hope that this report will involve us from today onward. I hope that this process you are including will recognize and respect the diversity of the different indigenous peoples who live in Canada and find ways to ensure that everyone is involved in an equitable manner so that we can make progress.

The Government of Canada is looking at a $15 billion surplus. Meanwhile, the poverty rate has increased, homelessness has increased and health conditions have worsened for our people. It is time that the federal and provincial governments and everyone else finds a way to creatively work with those communities and bring the appropriate partners to the table and find proactive visionary strategies that address the dire needs in the communities.

The Chairman: Our next witness is Michelle Audette from the Native Women's Association of Canada.

[Translation]

Ms Michelle Audette, Acting President and President of the Native Women Association of Quebec: I think that everyone realizes, because the evidence is clear, that there are substantial gaps between the health of Aboriginal people and that of the rest of the Canadian public. I hope that over the next few minutes, I will be able to bring to your attention the realities of Aboriginal women living in this great country of Canada.

Health issues for Aboriginal people are extremely complex and go far beyond the absence of disease. The health status of First Nations' people is intimately linked to underlying problems and factors such as poverty, family violence, low educational levels, substance abuse and so on. All this has been laid out for you by my colleagues.

But it is crucial to look into the dynamics of the various socio-economic factors that affect health. There is rarely only one cause for illness or a single aspect involved in physical, mental, emotional and spiritual health.

The health determinants approach is very much in keeping with the holistic vision that First Nations' people have regarding health. First of all, an individual's health is bound up with family health and community health, and vice versa. So we can see that it is a cyclical process. The health of First Nations's people and, in particular, Aboriginal women, is also affected by administrative and legal factors because these factors determine the services and health care provided.

Similarly, the law must also be considered to be a health determinant. The women that I am speaking on behalf of include those with status, those without status and also those in certain provinces that are involved in jurisdictional matters, even though responsibility for this issue lies with Indian Affairs. Women have been refused victim-assistance services in one province, because they were Aboriginal.

The division of powers and fragmentation among the various services, service providers and authorities create confusion regarding the services to which Aboriginal people are entitled. It is not just the recipients that suffer, but also the people providing the services and community managers. Social problems are both a cause and a consequence of the problems encountered by families and individuals in their communities, and we feel that they should be the focus for health interventions concerning First Nations' people. Governments are increasingly taking into account the special situation of women, which put women at a disadvantage. Women live in greater poverty, they are more subject to sexual discrimination, they are less well represented at decision-making levels, they have a double workload, they are more often single parents with more than one child to raise and they are likely to be young parents. They are both users of the health system and care providers, whether on a paid or unpaid basis.

It is important to keep in mind that the health of Aboriginal women is a much broader issue than just physical health and therefore requires an examination of power issues and social iniquities experienced by women.

One of the concerns regarding the health of Aboriginal women is the lack of prevention programs and activities in areas such as sexuality, social and health education, substance abuse, fetal alcohol syndrome and violence. It is also important to invest more money to promote health. The key is to realize that good health is based on overall well-being, and that health and quality of life are one and the same. Healing and well-being are contingent on the self-esteem of the individual, but also of the nation.

I would like to point out that research is vital. Aboriginal women in Canada have no infrastructure for talking about women's health. They need to do lobbying. We need eventually to have national policies on Aboriginal women. We need to take into account regional and other types of disparity. What is happening in the South may be different from what is happening in the North, and there are isolated, semi-isolated and suburban communities. There is currently a time bomb ticking in our communities, with the Aboriginal population growing, and funding constantly shrinking. Women at the national, regional and local levels need infrastructure for doing gender-based research, since there is a tendency to take a blanket approach to Aboriginal people, whereas it is important to take into consideration regional, gender and age differences. All those things are important.

I hope that I have sparked your interest so that women's issues become a priority.

[English]

The Chairman: Our final witness is Ms Dewar from the Pauktuutit Inuit Women's Association.

Ms Veronica Dewar, President, Pauktuutit Inuit Women's Association:

[Ms Dewar spoke in her native language]

English is my second language. The message that our people would give to you would be in their own language. It is sometimes difficult for me to speak in English.

Senator Morin: You speak better English than I do.

Ms Dewar: No, I do not. It is with practice. With these issues we want to bring to you today I will speak in English in form of a written presentation.

I was very impressed when Ms Johnston said that she has compassion for the health issues pertaining to her people. I feel the same way with our Inuit women, with our people in the communities in the Arctic. The Arctic is a harsh environment in which our people, our children live.

I wish to thank senators and fellow presenters and guests. I would like to express my gratitude to the standing committee for its invitation to the Pauktuutit Inuit Women's Association to present this brief. Pauktuutit is a national non-profit association, which represents all Inuit women in Canada. Its mandate is to foster a greater awareness of all the needs of Inuit women and to encourage their participation in community, regional and national concerns in relation to social, cultural and economic development.

Pauktuutit is committed to the principle of equality for Inuit women - both in our communities and in the broader Canadian society. We are equally committed to holding Canada accountable for implementing its commitments to ensuring women's equality generally, and specifically with regard to health policy. We believe this will benefit all Inuit. Pauktuutit has become widely recognized and highly respected for its expertise in a broad range of health promotion and prevention issues nationally and internationally and, most importantly, among Inuit throughout Canada.

The Chairman: Ms Dewar, I wish to ensure there is time for questions. It will take a very long time to read nine pages. I have read your brief and there are some very good recommendations on page 9. I wonder if you could go to your recommendations and since most of us have read the brief we can then turn to a discussion of some of the issues with you because I am concerned that we have time to ask you questions. Do you mind doing that, please?

Ms Dewar: This will really throw off my presentation.

The Chairman: You were starting out to read the whole document.

Ms Dewar: It is seven pages.

The Chairman: Seven pages this closely written will take about 25 minutes to read. Everyone else was kind enough to stick within a reasonable time limit, so it would help if you would go to the recommendations on page 9 and then I can turn to my colleagues beginning with Senator Roche and then Senator Morin to ask you some questions.

Ms Dewar: I do not have the recommendations with me because we narrowed it down this afternoon.

The Chairman: We will give you the list that was in your brief. They may have been reduced somewhat but even the longer list is fine.

Ms Dewar: I wish I had an interpreter.

The Chairman: Your comment is interesting. The one thing we do not have here are interpreters. We have English and French translation but unfortunately we do not have Inuktitut.

Ms Dewar: I will highlight briefly some recommendations that we would like to give to the committee.

Inuit women have not been involved in policy and decision-making on health issues pertaining to Inuit women. One important point we would like to make is that, in discussions about Aboriginal health issues, we Inuit are included under the term "Aboriginal" along with First Nations people. We have nothing against the people personally.

It is how the system was formed that we must address. Inuit are put in the pot with the other Aboriginal people and we frequently do not see the funding that we could have used for the people in the Arctic and for the Inuit women's health.

Inuit women are sent to hospitals in the south to give birth rather than stay in the community. The connection with the family is broken. The first time family does not see the child being born. Many times the Inuit who are sent down are unilingual and do not speak English; they do not understand the system, they do not understand the health terms in the southern institutions.

There are no facilities for performing mammograms on women in our communities. We are sent down south. We have to cry out for medical attention in our communities. We are sent out for specific cancer treatment. It has been our cry for many years to see these types of things implemented in our communities. The health system needs to be looked at very carefully in the North. Our people in the Arctic have been neglected far too long with respect to health facilities in the communities.

There are no doctors in the small communities - only in the larger communities such as Rankin Inlet and Iqaliut. There is one doctor for seven communities in our region in Keewatin. There is no mammogram equipment in Iqaliut. Women have to travel to Yellowknife, Winnipeg or Ottawa for tests. Often Inuit women neglect their health and say nothing because they do not want to leave their families or their communities for better health.

These factors are real. I hope this committee will be an avenue for some of our cries from the people in the Arctic and other Aboriginal peoples.

The additional details that the committee wishes to hear are the fundamental recommendations that would greatly enhance our ability to participate in the development of meaningful improvements in the health of the Inuit women in Canada. We strongly encourage the federal government to consult directly with Inuit women on health issues. As women and as members of families and communities, we have a great wisdom and expertise to share.

To facilitate effective consultations government must also provide the necessary financial and human resources for Inuit women to build their capacity to participate in health policy discussions and planning.

Our time is short and I do not know if I will have time to go through the other recommendations, however the committee has them in the brief. I would greatly appreciate answering some questions.

The Chairman: I assure you there will be questions.

Senator Roche: I would like to say to all the witnesses that it has been an outstanding presentation. It is a devastating recounting of the situation. I have been very moved by the testimony and I wish to thank the witnesses for their frankness.

Because of time I will ask one question and I will direct it to Ms Johnston, although I certainly would invite Mr. Morin or Mr. Clark to join in the answer if they wish.

Ms Johnston's testimony should be required reading for every senator. I hope good chunks of it find their way into the report because Ms Johnston told it like it is and we need to hear that. She provoked me to ask the following question. My question comes out of a little experience I have had in working with First Nations peoples on abuse questions. I have found that it is difficult to isolate the specific points; everything is related.

In this case, almost everything gets related back to what Ms Johnston said in her own brief this afternoon. She used the words "systemic oppression." I will have to read exactly what she said, but what I heard her say was that she thought that even the present government minister in advocating new programs was perpetuating systemic oppression. That is strong language, but it does reflect the underlying concern that all of our witnesses have expressed here today. The problems of health, poverty, economic and social deprivation stem back from this colonialist mentality that governments of Canada have perpetrated decade after decade. That has led to their own feeling that, as Ms Johnston said, health questions are related to everything else. She even said that while expenditures have been increasing the health status has not.

How are we going to get at this, Mr. Chairman, as a committee here looking at this? Much of what has been said here today is also found in the pages of the royal commission's report. It seems to be occupying library space instead of the active file in the government. I do not know exactly what to do.

Mr. Clark says this is monumental. His criticism is devastating that we are solving the housing problem of native people through the prison system. I will take Ms Johnston up on her words when she said, "First Nations people need to be involved in the solution of this long list of things that are wrong."

I will take two out of that long list: alcohol and substance abuse and the extraordinarily high suicide rate. Those are two manifestations of the depth of the problem. What are we to do? What can we recommend that is of a practical nature that will not get caught up in this network that persists of one problem being related to another all the way back to the colonialist mentality?

I put it to Ms Johnston very respectfully, what would you have us do? What would you have us recommend for immediate impact, not something way down the line. Of course, we all want long-range gains but we need something that would be discernible in the life of the young people today.

What would you suggest we recommend for inclusion in our report to cut down on alcohol and substance abuse and to lower the suicide rate?

Ms Johnston: That is a very thought-provoking question. I believe that the First Nations and the Aboriginal people need to be involved in the strategies of what we need to do. I have heard the leaders and I have been a leader in my community. I have sat on council. I have been a nurse in my community and in the communities up north where people have successfully killed themselves.

This has been a strong standing issue for me. Why is this happening? These are my people I see suffering. When I look back at some of the suffering that we have gone through it has been through many years; there has been the residential schools, the reserves - the Indian Act has been a strong part of that. We are the ones to decide how to get back from that.

My grandmother was my greatest teacher. She was a healer and a midwife in my community. She told me it is getting back to our traditional ways, getting back to our culture and our language, to who we are as First Nations people because we were a very strong nation before the Europeans came to this country. We had a strong system of governance, we had a strong system of health and healing and we knew how to do that. We lost our way because of the different things that have happened over the years. There is a lot of healing that needs to occur in our communities.

We can never go back to the original way we were 100 years ago. We can take the best of our past, of our culture and history and our language and move it forward. We have to be involved and there has to be recognition of that right that we have as the indigenous people of this land.

As long as that happens and as long as government puts in legislation like the governance act and does it without us and says that it will decide what is best for us, then we will continue to perpetuate that oppression. That is my personal opinion. We need to be involved in whatever strategies move forward.

Senator Roche: Others may wish to augment that answer, but I would still like to focus for a moment on alcohol and substance abuse and suicide. Are there specific things that we need to recommend to get those figures down?

[Translation]

Ms Audette: It is clear that substance abuse, whether we are talking about alcohol or drugs, is a behaviourial issue. Why are people using these substances? Because there is a social problem in the community, a major problem. We need to deal with the social problems in our communities and reduce their impact. We have seen what happened in Davis Inlet, where they do not have access to drugs as easily as in communities that are close to urban centres. So what do they use? Gasoline.

Regardless of the substance, social problems are what lead people to take these drugs. If we now want to deal with this problem, it is important to set up an ongoing prevention program for women, children and the community in general. There is no follow-up for these people.

I will give you an example: the Department of Indian Affairs conducted a study which demonstrates that 80 per cent of women from these communities have experienced or are continuing to experience violence at this time. In our communities, there are no programs to assist victims of violence and no programs to assist victims of sexual assault. And yet, we have the highest figures. There is an alarming lack of infrastructure. It is important, and I will repeat this, to establish an ongoing prevention program.

Government policies and measures are ephemeral: they are established for only one year, or maybe at most for five years. That is the crux of the problem. None of them last. You cannot change 130 years of history in 5 years, or change the Indian Acts that oppressed us and changed our lives.

In the past we had our ways. Today, we must bridge traditional life and contemporary life, our history and our present. Oftentimes, we meet women and men who want to heal themselves in the traditional way, but they do not have access to Health Canada funds because they say: "You do not fit our criteria." Health Canada can offer them pills or therapy recognized by Health Canada, but not the salt or steam baths and other methods typical of our own ways of healing. This is another obstacle. If there were some flexibility to respect our diversity, that would be a starting point.

[English]

The Chairman: Mr. Clark, I believe you want to make a comment.

Mr. Clark: The question is: Do we address the symptom or the cause? Pragmatically, why can we not have a federal interministerial council looks at cooperative strategies among those federal ministries in equitable partnerships with our respective national political organizations. We could get the provincial partners and other partners from the private sector and universities and look at long-term solutions that are more preventative in nature. At the same time we can not lose sight of the dire need right here, right now.

Any of the strategies have to involve the players. That interministerial council has to set it up, formalize it and look for solutions.

The treaty process, the title and rights issues, the self- government agreements - we do not know when it will happen but we know right now we have a crisis and we are all paying for it one way or another. Why do we not roll up our sleeves and get to work and do it?

Senator Roche: The last sentence probably said it. We have a crisis right now. I do not know whether the committee can go deeper in getting solutions to the crisis. Even for us to be able to articulate and project it to wake up the consciousness of the political establishment -

The Chairman: Is a major step forward.

Mr. Morin: When we talk about some of the initiatives Health Canada has to offer, we are talking about dealing with the short-term urgent immediate health- related issues that exist in our communities. Many of the measures are Band-Aid solutions or stop-gap measures but they are nonetheless important and we have to deal with them.

I think you cannot simply concentrate on the symptoms because if you do that all you are doing is stopping the leakage and meanwhile the leakage continues and eventually you sink. The root causes of the problems and challenges that exist in our communities have to be addressed. Many people talked about statistics around this table, poverty and alcoholism. Those are all the symptoms of a root problem that exists in our communities.

I wish to remind people of the $60 million exercise of the Royal Commission on Aboriginal Peoples and the 440 recommendations. At the core of the report and the recommendations was that the history between Canada and Aboriginal peoples has been deplorable and a miserable failure. It is a relationship based on colonialism, racism - a negative history. That has to stop. The status quo is not acceptable, it will simply perpetuate the problem and the problem is getting greater every day.

The core of their recommendation is that we have to change and bring about a new chapter in history between Canada and Aboriginal relations. As well, there needs to be political will on the part of the governments of Canada to enter into a new relationship with Aboriginal people based on mutual respect, recognition and sharing.

That new relationship has to be premised on a nation-to-nation, government-to-government, people-to-people basis. If you are going to deal with the root causes you must deal with the holistic picture and get to the fundamental issues. I think you have to deal with the core of the report of ARCAP and start moving on Aboriginal rights, self-determination and government has to have the political will to do it. That is the only way to have long-term solutions.

Finally, we, as Métis, have unique challenges within the federal system: the systemic discrimination, the lack of recognition of our peoples, the lack of recognition of our rights. That deserves specific mention and highlighted in your report because if you simply talk about us in an Aboriginal perspective without recognizing the distinctness of our people and our unique challenges, you will be doing us a disservice again.

You must deal with the real issues and the fundamental messages that Aboriginal leaders have been giving to Canadian governments for many years now.

Senator Morin: I want to thank the witnesses, merci beaucoup Ms Audette, and I want to thank my distant cousin Mr. Morin. What you have expressed and Senator Roche said earlier should certainly be the priority of the health care system from a federal perspective and I hope our report expresses that. The other point you raised is that the responsibility for health care should be in your hands. Here we are promoting regionalization at the provincial level and there is no reason that we should not do that for your own health care.

I would like to pose a question to all of you and then I have one question for Mr. Gordon, Ms Dewar and then Mr. Clark.

The federal government is now spending $1.3 billion a year on health care delivery to First Nations and our programs have increased more than provincial programs by 10 per cent a year and there seems to be no end to that every year. If we add what the provinces are spending on First Nations health care, then the First Nations are the group in Canada that receives the most government money per capita for health services. It may not be enough.

Maybe we should be spending more; or maybe we are not spending it correctly. I would like to hear your opinion on that. From an outsider's perspective it is not that we are not putting in money, we are. There is a 10 per cent increase a year. This does not include research money, this is all health services. Maybe we should double it but I would like to have your opinion on that.

My question to Mr. Gordon and Mrs. Dewar is: From the material we have received, it appears that the majority of Inuit people are outside Canada, in Alaska, Greenland and Russia. Is the health status of the Inuit people in these other countries better than it is in Canada? Are there models in those countries? I suppose we tend to see what is going on in Greenland and in Alaska that could be adapted to our country.

Earlier Mr. Potter told us that off-reserve Indians - status Indians - were under federal responsibility and that these off-reserve Indians received what we called "non-insurable services" such as drugs and so forth, with the exception of community services. Is that a fact? You seemed to say that we are not under federal responsibility.

Mr. Clark: With regard to the $1.3 billion and the 10 per cent, if Health Canada were to recognize its fiduciary responsibility to all Aboriginal people - including non-status, Métis, First Nations and Inuit living in the cities - that funding should go up exponentially. I would even suggest significantly higher and so the answer to that question is yes.

The other part of the answer is that is not only a matter of turning over money. There is another serious envelope that has to be developed. We have a dynamic population ready to take on that envelope and that is the employment and training initiatives, the educational aspirations our people have; they want to get involved. We also have to start setting up a "readiness criteria" so that when we take on further programs and services, whether it be through the friendship centres, First Nations, or other organizations that we have the appropriate Aboriginal trained people to do it and that takes a plan. That visioning and planning should have taken place long before.

However, until the government recognizes its fiduciary responsibility to all Aboriginal people it will continue to be a piecemeal approach.

Ms Johnston: In relation to the $1. 3 billion the issue is how it is sent out to the First Nations because the concern is that the First Nations are not in the decision points in regards to how that money gets out to the communities. The issue is whether it is based on need or on the crisis of the moment. What are the criteria that this money goes out to First Nations?

One of the concerns raised by one of my colleagues was the whole issue of dealing with the root cause of some of our health problems. I have heard from the First Nations that the money that does come into the communities is very stove-pipe; it does not provide for the needs in the community. It is very specific as to how it is allocated. There are concerns in regard to that.

We as First Nations say that we need more money, but the problem is that Health Canada's priorities and allocations of funds are not necessarily in line with how the First Nations see it and how we feel funds should be allocated. We must work together on this if we are to resolve the health status.

The other concern I have with Health Canada is they are responding to public perception - the media. They are responding to concerns about sustainability of the system, they are talking about accountability and all of these issue. We as First Nations are concerned about the fact that we have high rates of suicide in our communities, high rates of tuberculosis and diabetes in our communities. These are our concerns. Yet, Health Canada is saying that they have concerns about accountability. Our issues and our priorities are different.

The other thing that I wanted to put forward is the issue of language. We saw this here in regards to the Senate committee. In working in the First Nations communities, language is key and critical to health in our communities. How you view health or the word health will be very different in the language.

Language is critical to what we are talking about if we are going to look at strategies in health, health promotion and prevention and what we are doing in the communities. We as Aboriginal people need to be involved in the strategies put forward.

In regards to your question about non-insured health benefits, the intent of the non-insured health benefits is to provide services to First Nations status on- and off-reserve. The challenge is that off-reserve people are not living in the communities and have not been involved in some of the discussions about non-insured health benefits, but the same thing can also be true for the First Nations living on reserve.

Health Canada makes the decisions. I will raise the Corbière decision, which allows those off-reserve to vote. What has happened is Health Canada and Indian Affairs does not provide money to the First Nations for services for those people living off-reserve. They only provide funds for people living on reserve. It is a challenge.

Senator Morin: Does that include pharmaceuticals?

Ms Johnston: For some pharmaceuticals, yes.

Senator Morin: There is a difference as far as pharmaceuticals are concerned between on- and off-reserve.

Ms Johnston: That is correct.

Mr. Morin: I understood the opposite. We have to check on that because Mr. Potter told me exactly the opposite when I questioned him on that.

Ms Johnston: It is a concern because there are concerns in regard to some pharmaceuticals. It depends on access, that is the other issue. Maybe that is where the misinformation is because it is access to the non-insured health benefits. I hope I have answered your question.

[Translation]

Ms Audette: For people living in urban areas, it is essential to offer them improved access to information on programs offered by the Medical Services Branch, for example, and to produce a guide which provides a list or access to services. In some places, the card for non-status Indians is not accepted. This guide could help people, given that they may not have a close relationship with their community or the required information. Also, I think it is important to create some sort of 1-800 number that would provide quick access to information, suggestions, or to lodge complaints or have access to information on their rights, et cetera. This is something that we should be thinking about for people in urban areas.

[English]

The Chairman: Mr. Gordon I believe you also had a comment.

Mr. Gordon: With respect to Senator Morin's question about the Inuit living outside of Canada, at present the conditions are similar to what we are going through; in some instances they are better and in some they are worse. I can provide the information.

Senator Morin: The reason I asked is if you had come across models or experiences that could be helpful to you. For example, does Alaska or Greenland have models that might be useful for Canada?

Mr. Gordon: I can get the information for you on those. I do not have it available right now. On the $1.3 billion you are talking about spending, partnerships would provide assistance to Aboriginal people in the communities. Such partnerships would have to be meaningful in both directions; they would be transparent from both sides and decisions would not come from the top down because the needs, issues and priorities in the communities are different than what is seen in Ottawa.

It is like the community I come from in Inuvik. In 1954, Aklavik was the centre of our region at the time and we had spring floods every year. The bureaucrats in Ottawa decided to build a town, model it after a southern community and drop it where my community is now. My community was conceived and born down here in Ottawa.

Senator Kirby: I do not dare ask you how it works.

Senator DeWare: I am very pleased to be here today. I am not a member of the committee but I have been active in the health and education systems. It is hard for us to realize the reality of the health problems that you have when we live in areas where all aspects of health care are accessible.

You have talked about alcohol and substance abuse and suicide. If we are looking for a way to eliminate these problems we have to look at what Ms Johnston was talking about where 40 per cent of the population are youth and a quarter of that youth of that population do not go past Grade 9. Education often seems to be the answer to many problems.

A busy young person, a happy productive young person is a healthy young person. How do we educate young people and keep them in the system? What incentive is needed to stay there? Do we have to develop a different strategy for your particular communities? How do we motivate them? Maybe the education system we are trying to teach them is not what they need. Maybe they need different types of skills. Maybe they want learn how to use a computer. Maybe we need a modified community college program for them.

Let us ask what they want to learn and offer it to them to get them started. Ms Johnston is a perfect example that once educated, learning is a lifelong process. We are all learning. Today we are learning from you something that may change our lives and make us think differently about the Aboriginal communities.

How do we teach young people motor skills? If young people are busy people then they are not interested in substance abuse or suicide. The Royal Commission on Aboriginal Peoples recommended a cash program over the next 10 years to educate and train Aboriginal people to staff and manage health, social services, and mainstream institutions.

I feel that our young people are part of the answer. I know there is a problem that must be addressed now, but we also have to find a way to alleviate the problem in the future for young people. I put that to you.

Ms Johnston: I appreciate what you are saying about young people. I have heard the elders say exactly what you are saying in our communities: that the young people are the future of the nation.

Our programs must focus on self-esteem, the identity of who they are as people. You referred to me as an example of learning. What was valuable to me was my relationship with my grandparents, who taught me about my culture, my identity and who I was as a First Nations member. That is very key and very important. There has to be recognition of who we are as First Nations people in this country.

The young people are questioning who they are. They are questioning because of what has happened in the past, because of the residential schools, because some of the parents have been affected by what has happened in the past. The strategies that we focus on will be taking what is good from our past and our present and moving it into the future.

We as First Nations and as Aboriginal people in this country will have that dialogue and will have it with our elders and our youth to decide what it is that we need to put forward. We need to be given the opportunity to do that, and we need to be acknowledged that we are given the resources. With regard to funding, if it is to meet the needs in our community, allow us to take that funding and use it for what is best in our communities. That is what I see needs to happen.

Senator DeWare: Why are the young people dropping out? Health Canada talked about their training program for nurses, and how at the end of one year they had all dropped out. Is there any follow-up as to why they dropped out? Is there a reason for that?

Ms Johnston: I can address from my own experience of having studied nursing and gone through the college and university systems. The educational system does not allow you to invest some time to look at health in a holistic manner. That is the one criticism that I have of the college and university system.

When I took my nursing training my grandmother taught me a great deal about the mental, physical, spiritual and the emotional aspects of health. I had a hard time when going through the college and university system, particularly university, because it was very much based on nursing theory. What I found interesting was that the nursing theory did not focus on the spiritual and emotional elements; it emphasized the biophysical aspect, which was contrary to what my grandmother taught me.

I was lucky to have had the opportunity to talk about these things with my grandparents. Sometimes what we are taught at home is very different from what we learn in an institutional setting. The other aspect is the way of learning. I learned at home that it is based on experience and I find that the college and university system is not based on that.

Ms Dewar: I wish to give the members of the committee an idea of how difficult the assimilation and colonization of the Aboriginal people has been. It is has only been 50 years since the federal government came to our Arctic communities and began making demands that we run our communities in the so-called western world in English. Everything was forced upon us and it has not been easy. People still find themselves adjusting to the system that is foreign to our people.

This is not to say that we dislike everything that was brought to us; it is only that we have not been involved from the beginning. Our elders were drastically excluded from giving ideas to any system that was brought to the communities in the Arctic. I will give you an example.

I was in Rankin Inlet this past weekend where I met a young woman who is doing something for her people with the funding that we have been helping her to get. She has a women's sewing group called "Bringing Back our Sinew." The members of the group are provided with materials - everything, including skins - to sew and make caribou clothing, sealskin boots and everything that our ancestors made in the past. Inuit men are hunting again to catch the fur.

This brings back the self-esteem that was missing. This brings back the participation that they have not gone through in 30 years. Everything stopped because everything was brought to us. They were going through transition, they were going through hardship, they were going through confusion.

What do we do with this foreign system, justice system, courts, English schooling and everything else that was brought to us? How would you feel if we brought our culture to you in Ottawa: Here, do it.

It was sent to us in that manner. These things are hard. But include us in the process - include the women as well. We have the expertise in the health system. We have been excluded from sitting down with the other five organizations. Pauktuutit is not recognized by the federal government to participate in decision-making and policy-making. Inuit women want to be included. We want to work together. Many times we look at what the government is doing and say that this is wrong, but also we have to look at ourselves as leaders who have been assigned to do the work and organizations, include everybody.

The people who work in the offices in Ottawa with the health system have no clue about the Inuit in the Arctic. We need to educate each other. We need to be included.

[Translation]

Ms Audette: I would like to answer the question from the senator. For women, health is the cornerstone to ensure proper self-government down the line. It is important for us that people be in good health, but it begins with the individual: men, women, the young and not-so-young. Finally, the family and the nation. We take a holistic approach, you have seen, it is quite clear, and in this holistic approach, education is an important part, a key part for the welfare of our nations.

What do we do when young people know full well that they have no natural resources, no territory, nowhere to invest in terms of business within their community? The message that we are hearing from many young people is the following: "Why should I go to school when there is no future here?"

We need to change this mentality and make people accountable, not only women's groups, but at all levels, be it governments, existing entities, band councils, and everyone involved. It is difficult for them and it is just as difficult to begin sustainable development at this time within our communities, given the lack of territory, the non-recognition of our fundamental rights, the right to self-government, and so on. This leads to social problems in our communities. You know this, it is alarming, and I mentioned it earlier, it is a ticking time bomb.

Social problems also lead to juvenile delinquence. It has been proven that most of these young people suffer from fetal alcohol syndrome or related effects. Who gave them this syndrome? It is women. And why are these women drinking? Because society, social problems, et cetera. have led them to it.

I would like to say, that, yes, we must deal with youth, but we seem to forget the physical and mental health of Aboriginal women. It is very important to have specific groups, organizations and programs designed for women. You cannot destroy a people and then say: "well, there is a problem with our youth". You need to go to the heart of the problem, and it is women who give birth to children, unless that has changed. No. We are still the ones who bring children into the world. We are the ones transmitting HIV, fetal alcohol syndrom, and so on. We also need to think about women.

[English]

Mr. Clark: I have a quick comment on the issue of young people dropping out of school. Sixty per cent of our people are under the age of 25, and 80 per cent of those people live off reserve. That is the fastest growing ethnic group in the country and it will double. Back in 1962, there were four Aboriginal university graduates that we knew of. Ten years later, the National Indian Brotherhood - now the Assembly of First Nations - fought long and hard for Indian control over Indian education. Today there are approximately 20,000 to 30,000 people holding university degrees.

How do we address it? I say we extend the same principles of Indian control to Aboriginal control over Aboriginal education where the numbers warrant it in the urban centres. Why not? It has proven successful there.

I would be remiss if I did not share the following with you. I want to address in the most respectful manner possible the concept of dropping out. If it was randomly dispersed in society that people were dropping out then it is not a problem as an Aboriginal person. But in society we see certain patterns of people who are dropping out. Often those patterns of people in this particular case are Aboriginal, or they are poor, or they are people of colour. That suggests something that is not individualistic, that is, "I am making a choice to drop out."

Rather, it suggest that there is probably something there historical, something that is more systemic and something that leads more to pushing out people. When looking at the educational system, we have to recognize that there are young people who are bombarded with racism. I talk to these young people on a regular basis; they have that experience on a daily basis. We have a lot of work to do, but we cannot deal with education in isolation of housing, in isolation of child care, the whole list: employment, training and jobs.

That is why I keep returning to the one fundamental issue: It is a crisis. Let us recognize it, roll up our sleeves, bring together the appropriate partners and find a comprehensive approach to addressing the whole for the betterment of everyone in Canadian society. In the end, it would be far more cost-effective than the status quo seen today.

Mr. Morin: I want to come back to one issue. I would ask the committee to consider making a recommendation with respect to the Métis. In view of the fact that the federal government denies any responsibility or jurisdiction with regard to people in our communities, many programs and resources are not available to our people. Senator Morin mentioned the figure of $1.3 billion. Métis people in Canada have not been able to access that funding.

Many of the respect to programs are not extended to our people. The pharmaceuticals, for example: Many of our people are extremely poor. I have seen children of single mothers who have been diagnosed and are in a lot of pain, but they do not have the money to pay for their prescriptions. In some situations, I have paid for it out of my own pocket. Those examples exist everywhere and it is creating considerable pain and misery for our people.

The federal government needs to consider our unique circumstances and challenges. We will certainly offer any information that we have from our office in putting together your report and your recommendations, but there needs to be a specific recommendation that it is time that the federal government accept its constitutional responsibility for addressing Métis people in Canada.

Senator Robertson: It is most certainly learning process. All the witnesses appear to recognize that there are many root causes for the problems and that health does not stand alone. There seems to be a common consensus that the colonial system in which we have been living does not work.

One of more difficult things for this committee will be to address how to close to the truth and how to look at proper recommendations. Among all of today's witnesses, I see a commonality of concern as well as the individual differences depending on which group is represented.

If we put all the witnesses together in a room for X number of days, could there be agreement on references, recommendations to us? While there is a commonality, there is also a diversification. I do not know if that is possible but I think it might be quite interesting if we could get a response from all of you and see how we make out with that process. Right now, the process is scary because I do not know how we get around all these diversifications.

Mr. Morin: If you put a bunch of us in the same room to try to come up with solutions we might reflect the House of Commons.

There are certain common issues that we can work on together. What is important and what we are urging certainly from the perspective of the Métis Nation is the diversity of the Aboriginal peoples of Canada. There are three Aboriginal peoples in Canada recognized in the Constitution of Canada, the highest law of our land: the Indian people, the Inuit people, and the Métis peoples and we represent the historic nation.

As a starting point, you must recognize the fundamental distinctiveness of the three Aboriginal peoples in Canada and importance of how you deal with them. In our case, the Métis Nation dealing with the Government of Canada, on a bilateral basis to deal with the unique circumstances and challenges of the Métis Nation and the issues that we have in our community. That is important.

I would like to make one final point. Returning to my earlier comments about dealing with the fundamental issues, the rights-based issues, the self-determination and so on, I think that parliamentarians and governments across Canada know the solutions. We have been telling them for a long time. All it takes is good faith and political will and then simply do it. I suggest that that political will and that good faith is not there.

It is time that we begin the chapter that the Royal Commission talked about and form a new affiliation based on a nation-to- nation, government-to-government relationship. Somehow, we must figure out ways and means to create that good will and good faith to ensure that we achieve those solutions on behalf of our people and on behalf of our country.

Mr. Gordon: I agree with what Mr. Morin has stated. If you put us into a room we would agree on a majority of issues. The federal government must recognize that each one of our groups is unique. I have relatives who were brought up and live on the coast. When driving inland in the wintertime, they have become claustrophobic because of trees. Each group of people and each community is unique in itself and that has to be taken into consideration. To resolve many of the existing problems, we have to start at the community level. Funds must be made available for the communities to start working.

Ms Johnston: It is a very interesting question about putting us together. I would agree with my colleagues that we would probably agree on some key issues. We might have different strategies based on some of our jurisdictional questions and issues. I agree with my colleagues in saying that the government must recognize that we are distinct groups as indigenous people within this country.

If any message has to emerge, it is that we, as Aboriginal people, need to be involved in the decisions that move forward. I will use the social union framework. Jurisdictional problems occur because of the federal and provincial relationship. We are not included in those discussions when the provinces come together to talk about health care and that is what we are here to talk about. If we are going to be involved in the solutions of this country's problems relating to provision of health care to the indigenous people of this country, then we need to be at those tables.

We need to be part of the solution in putting forward the strategies. If you look at the status of health as First Nations and as Aboriginal people in this country, the statistics show that we are not the same as Canadians. We need to be part of the solution. As my grandmother said, if you are not part of the solution you are part of the problem. We have to be part of that and I would strongly recommend that if there are to be any social union framework discussions, we should be there.

Senator Robertson: This is my point. You want to be involved. If we ask you to be involved and we take recommendations individually from each group, then Group A may not agree with Group C and there is a conundrum there. If broad issues and recommendations that affect everyone in good measure could be brought forward, it would be a starting point for us.

Some of us have been told before, Mr. Chairman, that one of the reasons we do not make progress is because of the disagreement among the participants. I do not know about that, but I would like to see some agreement and we cannot move forward unless we have your advice, unless we consult with you. I believe a consultation is absolutely essential to how we get there. That is something I would like to return to.

The Chairman: Mr. Clark, I will give you last word.

Mr. Clark: Our young people and our elders have been saying that out of the royal commission it is obvious that we have more in common than we have in difference and therefore, yes, is the answer to that one.

A more important question in my mind is, could we get all the premiers and the Prime Minister together in the same room and get them to agree that we are facing a national crisis and let us get our work done?

Senator Robertson: We could recommend that.

The Chairman: Some of around this table have been involved in trying to do that on other issues.

Ms Audette: I feel the same way. We all need to sit down and to share expertise as long as the diversity is respected at the end.

I wish to thank you for the invitation. I hope within our five minutes - or for those who took more, lucky them - we each showed you a piece of the real picture that we face on a daily basis. It is difficult for us. We are here on behalf of our members, our people, our friends, but everywhere everybody will need to be involved.

We will also need some support because it is so difficult. As a woman I am lucky; look at this, First Nation, off-reserve and Métis and I believe in those organizations even if I work for Native Women's Association of Canada. I am so proud of the National Aboriginal Health Organization.

The Chairman: They are coming next.

Ms Audette: You will see that we are all sitting at the same table. There is hope, and many possibilities.

The Chairman: May I say to all of you on behalf of the committee, that all of your comments were really helpful to us and as Ms Audette said, you gave us more than a slice of reality. That is something those of us based in Ottawa could do with a lot more often.

Thank you for coming. We have Dr. Judith Bartlett and Richard Jock on behalf of the National Aboriginal Health Organization.

We have your presentation in front of us. You may take us through it, after which I will turn to Dr. Reading, appearing on behalf of the Institute of Aboriginal People's Health.

Dr. Judith Bartlett, Chair, National Aboriginal Health Organization: Thank you for inviting the National Aboriginal Health Organization to be present here today. I have five areas I would like to talk about.

First, I will tell you a little bit about the National Aboriginal Health Organization. Then I will look at Aboriginal health in 2001, including some of the indicators that were included in your interim report, and looking at Aboriginal people relative to those indicators. We will look at the current federal policy environment and the impacts of such policy. Finally, we will speak briefly on some recommendations for consideration by the committee.

NAHO is an independent Aboriginal health knowledge organization. It is focussed on improving the physical, social, mental and spiritual health of Aboriginal peoples. We have a number of priority areas that came about as a result of national consultations. Before our board was formed, an implementation committee and a joint steering committee went across the country to find out what the priorities were. Several priority areas were noted, as well as the issue of the distinctness or uniqueness of each Aboriginal constituency, whether First Nations, Inuit or Métis.

The first of the three major priority areas involves health research and health information, gathering information, and disseminating it to people in usable form. The second area looks at influencing policy development and building capacity in the health area, particularly in health careers. The third area looks at the traditional health and healing situation in Canada; we want to look at how we provide information and how we help to bring the traditional knowledge and perspectives to the Canadian health care system as we have it today.

We are developing three centres. As I said, it was very important throughout the consultations that the specific needs of First Nations, Métis and Inuit be addressed. Each constituency has different needs that are specific to them. As well, we will look at the central functions, and consider what issues are global, what issues are better looked at on a national basis, and then how we provide support to those centres.

With regard to Aboriginal health in 2001, I want to preface this with the comment that the data and information we have is primarily based on First Nations data. You will find there is a particular reason for that, in that there is very little information on the Métis and other Aboriginal peoples.

You have heard in your discussions that there is a persistent disparity in health between Aboriginal peoples and other Canadians. There is an increasing incidence of diabetes, tuberculosis and arthritis among Aboriginal peoples. These statistics have come through clearly in the Inuit and First Nations regional health surveys and in other places as well.

There is an increasing involvement of Aboriginal people in service-planning, delivery and administration of health services. That is in the First Nations communities as well as, increasingly, urban communities where urban Aboriginal groups are getting together and saying that they need a service specific for their Aboriginal constituency. That is happening variably across the country.

There is also a trend to community-controlled health research, as in the example of the First Nations and Inuit regional health survey and the longitudinal survey. Part of that trend for community control is because of historical experience in data collection, analysis and interpretation. Communities have had bad experiences where individuals have come in to do the research, but the participation at the community level to interpret the resulting data and make it usable for that community was not necessarily there. As well, the whole process of self-government is a reason why this trend is occurring.

We took the three indicators - the life expectancy at birth in Canada, the age-standardized mortality rates for all causes for Canada, and the infant mortality rates in Canada - and looked at the information that we have on First Nations. You will see that the gap for First Nations women is about 4.8 years. For men it is 6.9 years.

We superimposed upon the graph where these figures would have occurred in the Canadian population. You can see that the First Nations life expectancy falls somewhere around the 1970 level of all Canadians. I thought that was interesting.

To put this in a broader perspective, the life expectancy of First Nations is lower than in all of the 25 countries with the longest life expectancy that has been listed in the document that I received.

Looking at the age-standardized mortality rates, for First Nations men the rate is 1.4 times higher; for First Nations women it is 1.9 times higher. You can see that the age-standardized mortality rate for women actually falls somewhere around 1958 levels, when you look at the level for all Canadians. We have provided you that information to give a bit of perspective on what this actually means in terms of this type of data.

Infant mortality is still two times higher for First Nations relative to all others. Again, you can see that we are looking at First Nations women with an infant mortality rate of 11.5, as against the Canadian average of 6. Again, the rates are similar to years in the mid-1970s.

With regard to the federal policy environment, there has been a tendency toward an Aboriginal-wide approach from the federal government in new health initiatives, these being diabetes, HIV and AIDS. There have been new health initiatives such as our organization, the Canadian Institutes of Health Research and so on. That has been the trend over the last few years.

The federal First Nations and Inuit policy direction to health transfer has had implications as well in terms of the overall environment. There are no primary care services specifically targeted to Métis and non-status populations. I heard that earlier in this room. It is an extremely important point. It is federal policy that the federal government does not provide those services.

There is uneven urban focus regarding health services. Even in urban areas there are no specific services, for the most part, directed to the Aboriginal population.

Federal initiatives are underway to ensure sustainability of First Nations and Inuit health programs. The federal government recognizes self-government as an inherent right.

All of the provinces are at different levels with their involvement in providing health programming to Aboriginal people. One important area is the federal approach to direct program service to Aboriginal people in the provinces. That is an important piece of policy in that it allows Aboriginal people in urban centres to have a place to begin if the province is not ready to do anything on a more global basis. It allows a foot in the door to begin developing capacity in program development and delivery.

Regarding the non-aboriginal policy environment, we have extensive development in health research and health information. We have the CIHR and the CIHI. There is $500 million available for the Canadian information highway, which will be extremely important, and there is an $800 million primary care transition fund. As well, in the non-aboriginal policy environment, health reform has certainly painted a particular type of picture, as we move from hospital care to community care. That has significant effects on Aboriginal people.

What are the impacts of these policies? One impact is in the area of jurisdiction. Health services in First Nation and Inuit communities are fragmented and poorly linked as a result of these jurisdictional divisions between the federal and provincial governments. I heard that earlier today as well. Who is responsible for what? That seems to be a difficulty that has gone on for many years.

The Métis and non-status are in a jurisdictional void. They, in fact, are excluded from legislation, and this impacts on the eligibility for programs, so that piece of legislation is important.

There is significant stove-piping by federal and provincial governments. This often prevents efficient rationalization of programs. When you are trying to develop local programs that are holistic, and there are six or seven different funding bodies who all require different reporting systems, it is difficult to contend with that. There is variable provincial continuing care support in First Nations or rural communities.

Another impact on the policies is in the area of First Nation and Inuit health transfer. The transfer policy is fairly restrictive. Not all programs are eligible, and no framework exists for integration of federal and provincial services under the policy transfer process.

There is a lack of flexibility in facilitating unique approaches for mental health areas in the transfer area that recommends community strengths. Thus, there is one package, and people have to try to work with that package.

There is also no research. To me this is an important area. There is no research that has been done to date, although it may come up in the future, but on the relationship of self-determination and health status. There certainly is international research on the area of locus of control and how that affects the health status of people over the long term, in terms of morbidity and mortality. That is an area that is affected by current policies that do not have that research available.

There are policy gaps. Federal policies may not exist in the critical areas - for example, mental health and other areas where certain health insurance coverage is not available. Mandates of health and social agencies may be unclear because of jurisdictional issues. In some provinces, we have new child and family services legislation that will change the whole scope of the environment in these areas.

In respect of program funding, eligibility of health organizations for funding may be counterproductive to the delivery of holistic care. Again, that is trying to manage several governments and multiple departments within governments. For example, for HIV and AIDS, it is policy that funding can be used for education pieces, but not necessarily for direct delivery of the pieces. Again, that is one of the barriers.

A lack of program funding increases can also result in the loss of capacity. There are examples of development of unique capacities in holistic approaches, but the lack of increase in federal funds, such as Head Start and the children's programs over six or seven years, really forces program cuts or loss of staff. Staff who have been trained and have become experts in development and delivery of culturally appropriate programs, tend to have little choice but to go to provincial or federal programs that pay higher salaries. There are restrictions in that.

Another effect is created by health reform. Early hospital discharge creates significant stress on limited continuing care resources in communities. There is poor urban access to health services. There might be a tendency to think that there would be good access, but, in fact, there is not. Much of that reduced access to health services is because of poverty. People require money to buy a bus ticket so that they can go to the health service. Also, there is a cultural inappropriateness of many of the services. Insufficient resources for capacity development exist in urban, rural and First Nation centres.

What needs to be done? We have four points to which we want to speak. First, we need permissive policies and investment in capacity guidelines to develop an integrated health system model, encompassing federal and provincial services. This is for First Nation, urban and rural communities.

Second, we need to develop mechanisms to collect and analyze Métis, off-reserve and urban Aboriginal health status baseline information. It is difficult to try to develop, rationalize and make a case for services when there really are no data. Canada-wide surveys often do not have sufficient Aboriginal population samples to prepare meaningful analyses. We have seen that happen a number of times. One survey - the First Nation Longitudinal Health Survey - may help this out to some extent.

The third recommendation is a need for a removal of barriers that prevent Aboriginal organizations from fully accessing information collected by Statistics Canada. One of the primary requirements for self-determination is the capacity to collect, analyze and use information. When there is less-than-adequate access to information, it makes it extremely difficult for First Nation, Métis or Inuit specific needs to be addressed.

The fourth point is that we need federal government leadership in dealing collaboratively with provincial and territorial governments to overcome the jurisdictional barriers that exist. You have probably heard that over and over again, but it is an important issue.

That is the summation of our presentation, unless Mr. Jock would like to add several comments.

The Chairman: In consideration of the time, I would like to proceed with our next witness, Dr. Jeff Reading.

Dr. Jeff Reading, Scientific Director, Institute of Aboriginal People's Health, Canadian Institutes of Health Research: I will talk about a few areas and then conclude with an update from the CIHR on Aboriginal people's health to impart a message about how strategically important this is in terms of improving the health of Aboriginal peoples and the influence on the health of other Canadians.

First, I would like to talk about the determinants of health. In listening to the various speakers today, it was quite evident that poverty and lack of opportunity were significant factors in poor health status. That fact is widely recognized in mainstream society, as well as in native communities. It is clear that healthy public policy in a broad spectrum needs to be implemented to improve the health and well-being. The provision of health services is only one determinant of health. There are many others.

We also talked about the regional health survey, in which I helped to develop. Surveys themselves are not that interesting, they are only questionnaires that collect data about people. However, this one was interesting in that it was the first time that nine political organizations in Aboriginal communities representing a national picture of health got together and undertook a survey in 183 communities involving some 10,000 participants. That level of cooperation in indigenous peoples has never been seen in a national research survey.

Undertaking research can be a significant determinant of health in its own right. It is a determinant of health because people are able to take control over factors affecting their lives. The context of native communities has been one where people outside the community have managed control for a great period of time. Now people have the opportunity to seize control and to start interpreting data about themselves.

When people participate in the creation and understanding of knowledge about themselves, they take greater ownership of their health problems and, in so doing, become active in terms of solving those problems. Research is the first step in terms of the drive toward self-determination and improved health status.

Listening to the other people in the panel talking about how important it was for First Nations and other Aboriginal groups to undertake their own survey research is a positive indication that they feel strongly about this. They want to take control over how the outside world views them through the results that they publish, not only in media reports but also in research journals.

Another advantage to that research is the capacity building upon which I will touch later.

I would like to move on to another important area, which is primary care. I know other speakers have been articulate in their promotion of primary care as an important community-based intervention that would improve health care of Canadians in general.

I circulated to you a recent study that was published in the New England Journal of Medicine on May 3, 2001. It is volume 344, number 18. It reports on the Finnish diabetes prevention study. In this study, they found patients with impaired glucose tolerance, which is a pre-diabetic condition where people have higher blood circulating levels of sugar. In this study, they divided a group of 500 patients into a control and an intervention group. The intervention group received individualized counselling aimed at reducing weight, total intake of saturated fat and fibre, and increased physical activity. Some astounding results were shown.

The results of the study showed that the cumulative incidence of diabetes after four years was 11 per cent in the intervention group, but more than double - 23 per cent - in the control group. That is a significant difference. The risk of diabetes was reduced by 58 per cent in the intervention group.

A disease such as Type II diabetes has high rates of morbidity and mortality, associated with it. It is a strong predictor of lower limb amputation, blindness, renal failure, and heart disease. If you take the high-risk group and do an intervention at the community level, you could solve significant problems for the patients and also for the health care system. There is some good evidence that I think is pointing in the right direction.

More than half the population in many native communities - people over age 50 years - suffer from Type II diabetes. As well, it is poorly controlled. This is major epidemic and a major problem. The question, from a research perspective, is whether this type of intervention could be implemented in a native community. Could primary prevention be implemented at the high-risk level before it turns into Type II diabetes?

I cite this example for two reasons. First, primary care is extremely important working at the community level in terms of making it more sensitive to community needs. Second, relevant research to patient groups can be used to track the health care systems and problems affecting all Canadians, including native people. This is extremely important.

Another area is one that is close to my heart. It is the Institute for Aboriginal People's Health, of which I am the scientific director of the Canadian Institutes for Health Research. We will soon have our sixth meeting of the scientific directors and we are starting to gel as a good group of scientists. We are looking at strategic plans and strategic initiatives. We will be focussing in the native community on building capacity in research intensive environments.

We want to have native-friendly environments within research centres of excellence - most probably at universities - when we build the next cadre of Aboriginal students to undertake research in this area. It is important because there are context issues around indigenous health world-wide where Canada can play an important role.

We will be publishing shortly a number of strategic initiatives where we will be doing requests for proposals. We will be asking the research community to partner with the native community to co-sponsor and work in partnership to develop a research enterprise and help to inform on improvements in health care.

The University of British Columbia published a book by Bob Evans entitled: Why are some Communities Healthy and Others Not? I pose the question from a research perspective in native communities: Why are some Aboriginal communities healthy and others not?

There is a lot of diversity in native communities. Some have some very significant challenges, but there are many that are very healthy. We must find out what differentiates one community from another. We must find a way to look at best practices in various communities, to share that with the native community and then, in turn, to share that with the indigenous community world-wide.

We have many challenges in the health research area and the development of a health care system but we are encouraged by some of the positive changes. We have a strong partnership with NAHO. Both Mr. Jock and Dr. Bartlett are on the advisory board for the Institute for Aboriginal People's Health. We have good integration, and we well be working together to harmonize our approach to research and policy development as it affects the evolving health care system.

The Chairman: Thank you for your last comment, which was going to be my first question.

Let me ask Dr. Reading and Dr. Bartlett a question, and then I will turn to Senator Morin.

Dr. Reading, your institute is almost the newest of the research institutes under CIHR, is that right?

Dr. Reading: As you know, the last time I came before this committee I was talking about integrating Aboriginal health research into the CIHR, Bill C-13. We were all created at the same time. CIHR has come up to its one year anniversary.

The Chairman: Do you have a list of the major research projects that either are now underway or, in your best forecast, are likely to be underway? I would like to get some feel for the topic.

Dr. Reading: We could send that to you. I am happy to report that of the 13 institutes, we have been quite proactive. We have a very detailed strategic plan with strategic research initiatives that has gone through its third level of review. We will be moving forward quickly. We are hoping in the month of June.

Our plan will include a flagship initiative that we are calling the "ACADRE" program - Aboriginal Capacity and Developmental Research Environments. It is the area to which I spoke earlier of creating this native-friendly environment in research intensive institutions. It is important to build the next cadre of scientists and researchers; it is also important for the research institution to have an opportunity to have an entry point to native communities.

For example, someone working in molecular genetics, who may be interested in studying diabetes in the native community, could approach a unit that works with the native community on an ongoing basis. It would make it a lot easier for them to develop their work with that community.

You heard earlier today that people say native people are tired of being researched; they have been researched to death. We need to make that relationship between the native community and the research community more transparent, more seamless and easier for each to work with each other because they have mutual interests in improving health. That is very important.

We will have six or seven strategic initiatives that look at important emergent areas of health care research. My institute advisory board has helped advise me on these areas.

The Chairman: Dr. Bartlett, in your four recommendations of what needs to be done, I wonder if you could send me some more details.

For instance, you say that barriers should be removed that prevent Aboriginal organizations from fully accessing information collected by Statistics Canada. I do not know what those barriers are, therefore, it would be difficult for us to make a recommendation to deal with the problem unless you define it for us more precisely.

Your second recommendation, development of mechanisms to collect and analyze Métis off-reserve and urban Aboriginal health status information. It would help if you could put a bit of flesh on that. Remember that we do not have the data. The data is in large measure owned by individuals, or alternatively provincial health departments or health organizations own it. What, specifically, could the federal government do to help?

I do not need it tonight, but I would like it in the next several weeks.

I have another question for both of you in light of the discussion we had earlier with Mr. Clark. Are there data that compare the health status of urban off-reserve Aboriginals with the urban poor? It would be interesting to see whether the urban Aboriginal problem is in fact different from the urban poor program, or whether it is merely part of the urban poor problem.

Senator Morin: How does a reserve compare to a small isolated community of the same economic development? There are health problems in both; we know that. You may not have the answer yet, but you are comparing healthy communities with sick communities. That is very good.

I do not know if you were present when I brought this up with Mr. Potter. How important is the cultural element here? Is it strictly economic and educational, or is there an additional determinative for health, which may well exist? It could cultural a cultural deprivation, which exists. There is no doubt about that.

I am addressing this to Dr. Reading because I know that he was talking about comparison in communities in your research projects.

Dr. Reading: It is a complex problem. I could not stand here and answer the question with a yes or no answer. Health occurs in a context, and the context involves socio-economic status. It involves historical relationships. It involves a number of other factors that we call culture. In Canada, we have looked at native communities through a lens from the outside. We have not looked from the inside of the community. Therefore, we know almost nothing about those cultural factors that might improve health for native people.

The question you are asking is whether this is a general issue about poverty, or is there something specific to native culture that makes them unhealthy?

I would say that -

Senator Morin: I am referring to cultural deprivation. Perhaps they would lack certain aspects of the Aboriginal culture that would have been taken away from them through colonization and so forth?

Dr. Reading: People have been writing on this topic. Rapid social and cultural change is associated with the economic and epidemiological transition. This transition is characterized by a number of the things that we see in native communities. We are really in a transition into an epidemic of chronic diseases. One must look at the rapid changes within the culture.

People have shown that the only way for people's health to improve at this stage is to return to aspects of culture that make them healthy, things that allow them to be healthy. That is something again that we know very little about.

I will take an example, because I think it is hard to talk around a topic. Look at the rate of tobacco use in native communities. We see a rate of tobacco use among those aged 20 to 24 years of about 72 per cent according that survey we undertook. That is higher than any rate that was ever reported in any community in Canada, ever.

The Chairman: By several multiples.

Dr. Reading: In the 1950s, we had a rate of about 52 per cent. That was before smoking was acknowledged to be a health problem. That rate is currently down to about 27 per cent.

There may be something about the non-traditional use of tobacco versus the traditional use. Tobacco is seen culturally as a gift from the creator, something that is used to allow direct communication between the person and the spirit world. One does not know really whether these aspects of culture are informing on the epidemic of recreational use tobacco among native people. We do not know the answers to those questions.

One could start to ask all kinds of questions about different aspects of native health. One could look at the impact of the transition from traditional foods to store-bought foods, moving towards a welfare-based economy, and not having access to the kinds of nutritious foods that one needs to sustain a healthy diet.

The Finnish study shows us the results that can be achieved. Food is an important part of culture. We always associate pasta with Italians and Chinese food with Chinese. Native people also have their traditions around food. Many times, those traditions and foods have been taken away because of the way in which the government has put native people into circumstances where the traditional foods could not be harvested, or they do not have the resources to undertake the lifestyle that they once had.

Such changes have an impact on a person's lifestyle and health. We currently have a major epidemic in diabetes in northern native communities, primarily because of the rapid transition from a food hunter-gatherer society into a society where one buys store-bought foods without enough selection or resources to get the kinds of foods that are needed. With a lack of physical activity, obesity and diabetes develop.

You could review all the indicators and make a strong case that there is a cultural basis for many of the health status concerns in native communities. The urban environment is a bit more complicated. Perhaps Dr. Bartlett might wish to speak to that.

Dr. Bartlett: I have wanted to address that particular question on comparisons against the urban environment. I am only aware of one study that was done in Winnipeg a number of years ago. I do not have the details of that study, but they could be made available. I believe that the study report is on a Web site.

The Chairman: Can you tell us what it said?

Dr. Bartlett: Certainly there were differences between First Nation and other groups in Winnipeg. There was a difference between the health status of First Nations, who lived in the suburbs as well, compared to other Winnipeg residents. There are differences, but it was only one small study. That is the point we are trying to make - there is not any information to determine the health status of urban Aboriginal people.

The Chairman: When you say "differences," I understand you to mean "worse."

Dr. Bartlett: Yes that is correct.

Senator Morin: Even though all other conditions are equal - economic development, medications, et cetera - they have worse health indicators, while other conditions remain constant. Is that right?

Dr. Bartlett: I do not think that information is available. There is very little information available on Métis or urban populations. Often, people take First Nations data, extrapolate the information and make assumptions that that information is valid for all groups. Certainly, in a study that was done recently in Winnipeg where they looked at the needs of Aboriginal elders, it was clear from some of the analyzed data that, for instance, the Métis health status showed much more chronic disease than the First Nation study showed. Again, that is one small study. We need more extensive work to determine exactly the health status and the differences.

The Chairman: I would like to ask both of you a question that you may want to think about and send us your responses. We recognize that our objectives and yours are somewhat different: You are interested in research and we are interested in giving the government advice on specific public policy objectives. Are there specific pieces of information that could be obtained through research that would be most helpful to government when it is deciding about returning to the $1.3 billion, or eventually to the $2 billion that is being spent on Aboriginal health care?

Are there two, three or four key areas that your organizations, assuming they were properly funded, could research to provide the answers that could help to ensure that those dollars are better spent? The one thing that absolutely strikes me is that it is not at all clear to me that we are spending the money in the right place. It is difficult to imagine that we could not get better results for the $1.3 billion we are spending. That is not based on any evidence.

As researchers, what advice could you give to the government in respect of policy terms? What pieces of information could you give to them that you think would drive a better allocation of resources in the future? I would like both of you to think about that, please. We would be willing to try to find ways to secure the funding. Mr. Jock, do you want to say something?

Mr. Jock: I would certainly support the need for additional ways of collecting information. However, the other part of the answer is in looking at some of the models for primary health care that may be more effective. Mr. Reading has alluded to that.

Some of the constructs for these models already exist in some of the work that has been done on health services integration. Many of the elements exist. We need to invest in the idea of capacity building to enable communities - urban, Aboriginal communities within the larger community, or First Nations communities - to develop these comprehensive primary care models which then can look more holistically. They would look at incorporating the necessary traditional elements within the models in ways that are currently prohibited by the means of regulating health services. One by one the services are well-intentioned, but collectively they are as much a barrier as anything else.

Investment in developing best practices is also required, because there are groups who are capable of developing these models in a way that makes sense. Certainly, the costing elements are also well defined in international literature. It makes sense that, where you have populations that are more sick, you need to invest more. That fact is in the international literature. In fact, most health reform actually follows the other direction. It skims off in the direction of ways to deal with the healthier populations.

We actually have a reverse circumstance, which affects Aboriginal people as a result of some of these regionalization and other kinds of efforts.

Senator Morin: Do we have the professional human resources to implement these models. We continue to hear that we do not have the adequate human resources to do that.

Mr. Jock: I would say that in terms of staffing it with Aboriginal people, there would need to be a transitional approach. However, developing the models that are directed by communities is important. Ultimately, having these models staffed 100 per cent by Aboriginal people may be an objective, but it does not have to be the first step.

Senator Morin: We heard repeatedly about the problem of retaining nurses in certain areas and attracting MDs to those communities as well. Whatever model you have, if the professionals - whether Aboriginal or non-aboriginal - do not go, what are we to do? If we have trouble keeping physicians in areas that are only 20 kilometres from cities, how can we keep them in distant communities?

Mr. Jock: At the risk of debating this too much, we may need a new model that would be useful to others. For example if physicians and other appropriate professionals were employed on a salary, they might be more satisfied to work in an situation where they may have a more comprehensive range of people involved in providing services, from health promotion right through rehabilitation interests. To me, it may be a potential contribution that Aboriginal interests could actually bring to the greater Canadian health care system.

Senator Morin: May I pose a question? Obviously, you have studied this much more than I have studied it. Your conviction is that there are models that could attract health professionals in outlying communities. The outcome would be far more satisfactory than what we are doing now, without saying what the models are, but that is your conviction. Is that it?

Mr. Jock: Yes that is my belief.

Senator Morin: That is a good point.

Dr. Bartlett: Regarding some of the work that NAHO wants to undertake, we hear about models, but they are not well-known. We need to look at what best practices exist. Once those are documented, then we need to determine how to transfer that knowledge in a way that makes it usable for other communities. That is part of the work that we will undertake over the next several years - the whole area of being a knowledge organization that looks at best practices, best practice programs and those kinds of matters. In that way we can ensure that the models that have been created and are stabilizing across the country, can be shared among the different groups.

Senator Morin: We heard earlier that, in consideration of Aboriginal health services, we should move out of the provinces and remain strictly federal and Aboriginal. That was suggested. Do you agree with that statement? Right now, the provinces are responsible for the health services. Should we move out of the provincial health care system? That was suggested this afternoon.

Dr. Reading: That is simply not feasible. Unless the federal government will be in the business of building tertiary care hospitals that offer -

Senator Morin: We could contract out.

Mr. Jock: Part of the issue is the locus of control issue. As you have pointed out, that is where the interest in various models is. It would be a mistake to have a cookie-cutter approach even to a primary care model. We need a series of variations that could then be used by groups as they choose.

It would be more a way of trying to be permissive, as we have stated. It would also allow for federal leadership in cutting through some of these things that have become sacred cows or inviolable over time.

We are saying that there is not any one particular model that will be the answer to all questions.

Dr. Reading: I could respond to your comment about a list of things that would be useful in helping to inform on this process. One item would be focussing on prevention and early intervention. This would require some strategic investment but would very likely pay off quite well.

There would be an epidemic of cardiovascular disease right now if there were not an epidemic of diabetes. Once we solve the problem of diabetes, we will have the same problem with heart disease unless we reduce the factors that predispose people to have these diseases. We have known for 30 or 40 years about the risk factors that predispose people to these kinds of chronic diseases. Thus, we know what to do. It is a question of implementing those in primary and preventive care models. A significant amount of investment into that area would have a profound impact.

A second strategy would be to adopt the harm reduction model in the area of addictions. Take for example, the transmission of HIV through needle-sharing and various drug use. Adoption of the harm reduction model would help to prevent the problem from spreading to people who would be victims of the circumstance. Acceptance of the fact that these things occur would reduce the amount of harm caused to other people. That is an important aspect.

Third, we should continue to have Aboriginal people involved in the research. It is clear that through the genetic, genomic and proteonic frontiers of knowledge we will learn all kind of things of which we could not even dream. It will change the health care system significantly in the next 20 to 25 years. We will not be able to recognize it.

Aboriginal people must be at the table and sharing in the kind of advantages of which we will learn as the health care system radically changes over the next while. We are glad to be participating in the research enterprise. We hope we can work with our colleagues in research and then help to inform indigenous communities world-wide of the things that we are doing in Canada.

The Chairman: Are you doing any international comparative studies? We had a question with respect to the Inuit. Can you learn anything from Greenland, for example? Is any work in that direction being done?

Dr. Reading: We are very interested in putting forward a letter of intent to the Canadian Foundation for Innovation. They recently received a $200 million pot of money. They are looking at funding some important health initiatives. Basically, we want to have an international global priority-setting consortium in indigenous health world-wide in partnership with NAHO, other aboriginal groups and the research community across Canada, as well as with indigenous research communities in Australia and New Zealand, Central and South America, and the northern circumpolar countries.

We share many health concerns with other communities. In the past we have worked with the international community and have helped to inform other countries in terms of the health problems in their indigenous populations.

We are talking about developed countries with minority indigenous populations. These populations are often marginalized and share similar circumstances. We could play a leading role. We will be working towards a letter of intent being prepared for a July 3, 2001 meeting. If we could have support, it would be very much appreciated.

The Chairman: May I thank all of you for coming. We appreciate it. We will undoubtedly be talking to you as we go down the road. I presume that in the coming weeks you will send the information I have requested - particularly with respect to fleshing out some of the statements in Dr. Bartlett's brief.

The Chairman: Senators we have two last witnesses and we will try to be reasonably efficient in that regard. We have Margaret Horn from the National Indian and Inuit Community Health Representatives Organization and Ron Wakegijig from Wikwemikong, which is a reserve on Manitoulin Island.

Given the lateness of the hour, we would like you to focus on what your major conclusions and recommendations are to us particularly from a public policy standpoint.

Ms Margaret Horn, National Indian & Inuit Community Health Representatives Organization: I will give a very short comment on the background of our organization because it is important to take note of the evolution of the community health representatives. They began in 1962 as a program initiated by Health Canada, which was then Health and Welfare Canada. The goal was to strengthen and enhance existing health education programs.

I listened to many of the presentations, and I want to concentrate my presentation on developing the skills capacity within the communities.

Our organization works on all the issues in the areas of promotion, prevention and education, and the health issues that were described earlier, including providing information on health promotion and prevention of diabetes. We have done some work on active living and aging. We have done a number of educational promotion projects on the aging population.

Community health representatives (CHRs) make a major contribution towards improving the health of First Nations and Inuit communities, and I speak only of the Inuit communities in Labrador. CHRs have increased accessibility to health care by bridging the cultural gap between health care professionals and their clients in the communities. The National Indian & Inuit Community Health Representatives Organization, NIICHRO, represents the CHRs as a worker group. We are a non-profit organization: We are not a professional organization where members pay dues. We do advocacy work, and we attempt to work with this body of workers. We have done many national training sessions, and we have developed training tools, which we do well, for that body of workers to use.

However, there are unresolved issues, relating to the working conditions of these CHR workers. Those issues have been identified in a number of studies that were done by the former MSB.

NIICHRO has gathered a lot of information from the body of workers. These studies discuss lack of funding for training, for community programs, a misunderstanding by health professionals of the CHR's role, and a lack of career opportunities. That is because most of the CHRs are not accredited and that is what I am leading into.

We need a body of health workers who are accredited. They are not accredited right now. They have diverse training, from one end of the country to the other. Some workers have good training in some areas. In other cases, they might be someone who has responded to an offer for a position as a CHR and has been put into the community to perform a variety of tasks in health promotion.

The other issue that CHRs are concerned about is that they have no liability coverage. They have an unrealistic workload, fluctuating salary scales and benefits, and, of course, there is job insecurity.

In 1992, NIICHRO, on behalf of the CHRs, filed a human rights complaint surrounding the issue of pay equity. Their work was compared with general services, - GS. Finally, on June 30, 2000, there was a mediated settlement between Health Canada, Treasury Board and NIICHRO, which was for $45.7 million that was to compensate for the lower salary scales of CHR workers from 1980 to 2000. There were about 1500 beneficiaries during those 20 years. The settlement lacked further protection for the CHRs. It did not protect the workers from further discrimination in their salary scales.

The less-than-desirable working conditions of many CHRs are, in part, related to their para-professional status. They reflect labour market inequities based on gender and racial discrimination. CHRs are overwhelmingly female and Aboriginal. That was the basis of the complaint to the Human Rights Commission: This body of workers, generally, was largely females who were underpaid, as seen when the salary figures were compared to those of GS-3 to GS-5 levels. That in itself was discriminatory, but we will not discuss that issue.

My point is that the health status of First Nations and Inuit people remains disadvantaged in comparison to most other Canadians. There continues to be a critical need for improved access to and delivery of a wide range of health care services. CHRs play a central role in health promotion, education and prevention. It is necessary to ensure that all those who work in these crucial areas have a solid foundation of knowledge and skills that can enable them to effectively and competently carry out these activities.

The Chairman: Are CHRs federal employees?

Ms Horn: No, they are now on contribution agreements. That evolved over 20 years.

The Chairman: They started out as federal employees.

Ms Horn: That is correct.

The Chairman: Now, they are effectively on contract.

Ms Horn: They are on contribution agreements with the bands. Health Canada has contribution agreements with the bands that employ the CHRs.

The Chairman: Essentially, federal funding is now provided to the bands, instead of directly to the CHRs. Thank you for the clarification.

Our last witness is Mr. Ron Wakegijig from the Wikwemikong Health Centre on Manitoulin Island.

I have read your brief. Could you focus on the section entitled, "My Thoughts," pages five, six and seven and then provide us with your recommendations and conclusions. I thought that they were wonderfully unique and different from some of the comments that we have heard.

Mr. Ron Wakegijig, Healer, Wikwemikong Health Centre: Previous speakers have raised most of my concerns. I do not feel that I can add much more.

Some speakers earlier mentioned the problem of alcohol and drug abuse. I would like to address that specific issue, if I may.

The Chairman: Could you also tell us what is the exact role of a healer within the community. That information would be helpful to us.

Mr. Wakegijig: We will begin with that. Healers used to be called "medicine men." That term had adverse implications because of the history with the churches. Now, they call us "healers," but I am not comfortable with either term. I would rather be known as a traditional health care provider. That is more appropriate.

I am not a healer. I use herbal medicines to help with the healing and most of the healing comes from within the people with whom we work. That is the nature of the work.

I was interested in the senator's question about alcohol and drug abuse and how he addressed the issue. Back in 1976, I established an alcohol and drug rehabilitation centre on my reserve. It was called "Rainbow Lodge." It was designed from a purely cultural standpoint. If a person applied for admittance for help to overcome his addictive problems, he was allowed to stay as long as he or she felt necessary - six weeks or 12 weeks - it was entirely up to the individual.

We gradually re-introduced the person to the culture. Many of those people had lost the culture through residential schools. Even the day-school system took away much of our culture when they prevented us from using our language on school property. We had to re-educate many of these people on their own culture. Our enrolment was quite high during those first few months.

Government interference incenses me. The government laid down special regulations that prevented us from carrying on that program in the way that we saw fit. They made a 28-day program compulsory in order to release funding for the project. We lost many of our local clientele as a result.

The evolutionary process that took place is that we get a lot of people from different native communities coming to Wikwemikong. Our people go elsewhere to similar institutions like Blind River, Thunder Bay, and places elsewhere.

The Chairman: Outside the reserve?

Mr. Wakegijig: That is right. That was our problem. Every time we tried to do something cultural, the government stepped in and told us we could not do it.

In 1993, when they took over transfer of health services, within that capacity we were able to develop certain programs as we saw fit, one of which was a traditional medicine program. We developed our own program with what was allocated to us in the way of finances. They wanted to curtail it, but we would not allow them that.

We are the only clinic in North America, as far as I know that has a traditional medicine lodge in the same building as a western style clinic. When you walk through the front doors of our clinic, you have an option. You can turn to the left, and you are on the western medicine side. Turn to the right, you are on the traditional medicine side. There is nothing that says you cannot use both, which is what many people do.

I have no aversion to working with physicians. By working closely with physicians, western-trained physicians, we are able to prove clinically that our methods work. We share the same medical histories as the clients that come to both us and to the doctor.

We see much success in treating diabetes. Over the past 15 years, out of necessity I needed to develop a remedy that works hand in hand with either insulin or oral hypoglycaemic to control blood sugars. It is effective, and we have proven it clinically. I am able to say that here. I never claimed that there is a cure for diabetes because there is not, yet - either from western or traditional medicine standpoint.

What we have started from our own community has national implications. Most health centres now being built across Canada have a traditional medicine component built into their structures. Many more of our traditional healers are starting to work with non-native or western-trained medicine people, doctors.

The other issue I would like to point out is something that is close to me. I am involved right now in negotiations with the Province of Ontario trying to establish a northern medical school for Northern Ontario.

My daughter graduated from medical school in Alberta four years ago under a special Aboriginal initiative. She was always complaining about the treatment that she got from the non-native component at the university. Because of the special program, the non-native students felt that our native people are stealing seats away from them or occupying seats that should have been for non-native students. That is a heck of a thing to go through when you are pursuing a career with the intention of helping your own people.

I support the northern medical school initiative because, I hope that more of our people would enter that very honourable field of medicine. Hopefully, that will improve health conditions on our reserves. We can have our own people coming back to the community to help keep us well.

My daughter is fluent in the language. Sometimes she does locum work on Manitoulan Island, in West Bay or Little Current. Many of the elders that still use the language make a point to see her because of she speaks it. People who would normally shy away from seeing a physician, go to her because of the language. The language is a healing process in itself. It is a very expressive language; it comes right from the heart. It has a special meaning to these old people, these elders. They enjoy seeing a physician that is going to be able to help them while speaking their own language. That is what it is all about.

We would like to see more of that returning to our communities. We would have our own people graduate as medical doctors come back and help us on our reserve in our own communities. That is one of reasons that I am a strong proponent of this northern medical school, which we hope will come to fruition within the next two years, three years or four years.

I have no complaints about our clinic. I am about 70 per cent satisfied with the medical care that we get.

Back in 1950, our doctors were still travelling by horse and buggy and horse and sleigh in winter. It was only in 1950 when our road system started to improve under the Wikwemikong reserves that we could actually have cars come on to the reserve and provide us with transportation.

It was interesting to hear Dr. Reading in his comments about possible reasons why the incidence of diabetes is rampant. It is an epidemic. It is well-known across Canada and the United States. There are some reserves where it is as high as 30 per cent, 50 per cent. On my reserve, with a population of 2,860, we have 286 diabetics, 10 per cent of the population. That is unacceptable.

It all points to lifestyle. We have a diabetes program. I have been after the federal government about this problem of diabetes for the past 20 years. Nobody would listen.

In 1993, the Ministry of Health for the Province of Ontario came up with a diabetes program in our area, known as the "Northern Diabetes Health Network." We are able to tap into that government agency for funding. For a population of our size, we only get about $42,000 per year. We cannot even afford a full-time worker. If we did not have our traditional program going, we would not be able to have a diabetes program on the reserve, because the criteria that the province set down is: one-quarter year for a coordinator and one-half a year for a diabetes educator, which is absolutely nothing.

We have every reason to be optimistic when we heard this announcement about several million dollars being put forward by the federal government for a national diabetes initiative. The same thing happened again. The bureaucracy takes its cut, then the provincial and territorial organizations take their cut. By the time that money trickles down to the reserve, there is nothing left that is worthwhile to anybody.

I believe the estimated allocation for our reserve of 2,800 is about $20,000 per year. That is what they calculated.

It is frustration after frustration when we are dealing with health at the reserve level. We are not allowed to exercise our own initiative. We are not allowed to run our own programs as we see fit, as they should be run: according to our cultural, traditional and spiritual beliefs.

In our practice of medicine, we treat the three components of the psyche plus one. First, there is the human side, the mind, body and spirit. When we are dealing with a headache, we want to know what is causing that headache. We are not only concerned with making that headache go away. We want to know why it occurred in the first place. Is it a brain tumour? Is it stress-related or what?

The fourth component is your environment, which many people shrug to the side as if it is unimportant. One of the most important things in the environment that affects people's health is the housing situation. When you double up in houses, three and four families living in one house, it is not a healthy atmosphere. Although we have tried to address the housing issue much to the detriment of the future of our band, putting our band into jeopardy. The CMHC, which is a mortgage outfit, could foreclose at some point in the future. It might be improbably, but it is a possibility. If CMHC foreclosed on the mortgages that we had on our reserve we would be bankrupt.

I do not know what else I could tell you at this time.

The Chairman: I must ask you, does your daughter practice western medicine, Aboriginal medicine or both?

Mr. Wakegjig: Both.

The Chairman: With the same patient on the same visit?

Mr. Wakegjig: Yes.

The Chairman: I had better ask this question rather than Dr. Morin. What has been the reaction of the western doctors in the clinic that is adjacent to the other one?

Mr. Wakegjig: Fortunately we had a cohort in the person of Dr. Jack Bailey who is a long-time physician in our area. He has been there since 1949. He believes in what we were doing. He added credibility to what we were doing. He was voted family physician of the year five years ago. It did not hurt matters.

Senator Morin: I really have nothing to add. I think that it is certainly the way to go. There is no doubt about that, and I am a western doctor.

I do not know if you were present when I went over several times the issue of the cultural component to health, in which I am a strong believer. There is no doubt that is what you are practising. Definitely Health Canada is not doing the right thing in not supporting you in the type of work you are doing.

It is not a question, but mention of support to what you have said.

The Chairman: I thank both of you for coming. Thank you to the various staff that have been with us for five and one-half hours. We are adjourned until eleven o'clock tomorrow morning. We will adjourn at 12:30 because there is a government caucus at 12:30.

The committee adjourned.

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