Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence, April 25, 2007
OTTAWA, Wednesday, April 25, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:22 p.m. to examine and report on the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chairman) in the chair.
[English]
The Chairman: Ladies and gentlemen, we can legally proceed because we have a senator from each side. There are more senators to come; the Senate rose at 4 o'clock.
I want to thank all of you for appearing. This is a truly outstanding panel of people. We are particularly anxious to hear from you early in our hearings so that we can proceed to get some of the early research documents ready. There is so much to be learned about population health from the Aboriginal health area.
It appears that, according to the 2001 census, about 1 million people or 3.3 per cent of Canada's population are Aboriginal: 62 per cent are First Nations; 30 per cent are Metis; 5 per cent are Inuit; and 3 per cent are people of more than one identity. This is a very large contingent of Canadians.
We have five outstanding witnesses today. We have Dr. Reading, Scientific Director, Institute of Aboriginal Peoples' Health for the Canadian Institutes of Health Research. I have known him for a number of years and he was good enough to meet with me earlier today to help us in planning our agenda.
We have Professor O'Neil, Director of the Centre for Aboriginal Health Research, University of Manitoba. It is interesting that the CAHR is a joint initiative of the Assembly of Manitoba Chiefs, the faculty of medicine at the University of Manitoba and the Foundations for Health. This centre can be of enormous help to us as we proceed.
We are also deeply grateful to have with us Mr. Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada; Mr. Ball, Director, Development and Partnerships Division, Strategic Policy Directorate, Public Health Agency of Canada; and Mr. Brooks, Director General, Community Development Branch, Socio- economic Policy and Regional Operations Sector, Indian and Northern Affairs Canada.
Dr. Jeff Reading, Scientific Director, Institute of Aboriginal Peoples' Health (IAPH) for the Canadian Institutes of Health Research (CIHR): Thank you for the invitation. I want to begin by acknowledging the traditional territory of the Algonquin people. It is our tradition to start the meeting that way in order to set the context of our discussion that is follow.
Where the health status of Aboriginal peoples in Canada is profoundly different than that of other Canadians, it is strikingly similar to the health disparities experienced by indigenous peoples around the world. To improve health in Canada and abroad for indigenous peoples requires an understanding of a complex array of social, cultural, economic, political and epidemiological issues combined with an appreciation for the interaction nested within a history of upstream dominant political forces that often determine the health of all populations.
Achieving optimal health is linked to political and economic policies of colonization throughout history, but also modern day forces of globalization that affect Canada and other countries with similar circumstances regarding minority indigenous populations. It is these upstream forces and social determinants that are key to our understanding of the root causes of Aboriginal health disparities and indeed indigenous health abroad.
Population health disparities are thus linked to upstream social determinants or the so-called causes of causes. This was first coined by Sir Michael Marmot and is relevant to contemporary Aboriginal peoples' struggles to achieve optimal health and well-being in Canada.
I suggest we need to extend that further. It is about causes of causes of causes. For example, we may have an epidemic of diabetes. The cause of that is upstream because people have limited choices for adequate food and limited choices for physical activity, which predisposes them towards obesity, which in turn predisposes them towards diabetes. The causes of those limited choices are upstream and have to do with social and economic marginalization.
That is linked to the political economy and the historic evolution of Canada as a nation state where the market economy and the trading of furs in the North, for example, was replaced by a welfare economy. There was a rapid transition in the way of life from that subsistence life to one heavily dependent on market goods and without the necessary resources to obtain nutritious foods and things of that nature. Therefore, causes of causes of causes is relevant in Aboriginal communities.
We must think of solutions in the same long-term fashion. There will not be overnight success.
Aboriginal peoples are still confronted with barriers to equal access to health services, which are legally mandated in provisions of the publicly funded health system as articulated in the Canada Health Act.
Canada has taken a bold step with the creation of a national institute for research on Aboriginal people's health. We have recently made policy where the governing council at CIHR agreed to support and make policy a set of guidelines for research ethics involving Aboriginal peoples. Essentially, this has created an ethical space within the agency to articulate and advance the knowledge agenda for Aboriginal health research nested within a dominant mainstream institution, the Canadian Institutes of Health Research.
The Institute of Aboriginal Peoples' Health has made progress in addressing urgent and emergent health concerns through an advanced knowledge agenda partnered with Aboriginal communities and eminent research scientists. We have made a lot of effort and progress in building health research capacity connected to institutions of higher learning, but also informed by Aboriginal peoples living in their communities.
We have articulated a process for translating health research into practice and have developed national guidelines, as I mentioned, for the ethical conduct of research. Altogether, this represents an opportunity for the academy and shows the way, in terms of implementing a vision, for Aboriginal health in Canada.
I wanted to keep my comments relatively short because I have produced an extensive review of social determinants that goes through early life, prenatal, maternal issues, child health, education, addictions, food security and health care access. I will not try to give you a sense of all of that in five or seven minutes. I would like to thank you for the opportunity and will be happy to answer any questions you may have.
John O'Neil, Professor and Director, Centre for Aboriginal Health Research, University of Manitoba: Thank you for inviting me to speak to you on one of the most important public health issues confronting the nation today.
The question before us is both a simple and a complex one. The evidence is clear that health inequities in the Aboriginal population are largely determined by inequities in the social, economic and cultural conditions that characterize Aboriginal communities. Poor housing, limited employment opportunities and inadequate community infrastructure and services are widely cited in the scientific literature as the key determinants of poor health outcomes.
Equally clear is the evidence indicating that these conditions will likely only change through Aboriginal self- government. Globally, in nations, societies and communities where citizens exercise more authority over the fundamental conditions of life in an equitable and culturally consistent way, health outcomes are generally better even when relative poverty is taken into account. In the Aboriginal context, increasing evidence is accumulating to support the premise that Aboriginal communities that are self-governing and have strong cultural continuity with traditions have lower rates of health problems.
As I have indicated, the answer to the question before us is a simple one. The primary social determinant of health in Aboriginal communities is self-government. The solution to improving health status in Aboriginal communities, I submit, is also simple, and that is to increase self-government. The complexity begins when we begin to examine the meaning of self-government and the mechanisms for achieving it.
Self-government has two dimensions. First, it is about an individual community or nation making autonomous decisions that determine the ways in which resources and opportunities are distributed and accessed. The literature is clear at all levels: Autonomous decision-making about resource and opportunity distribution is clearly linked to improved health status.
Second, self-government is meaningful only in the context of cultural continuity. All societies have structures and processes for making decisions that promote the collective good that are rooted in cultural decisions and that may differ significantly from one society to the next. Failure to recognize the significance of these differences and their importance to governance can be perilous. I ask you to reflect for a moment on the global conflict between Western democratic values and the desire in many Islamic countries for state-level governments that reflect sharia law as an example of these kinds of challenges. Clearly the difference between Aboriginal approaches to self-government and Canadian governance models are not as dramatic, particularly since Western parliamentary traditions borrowed significantly from Iroquois governance models.
The essential premise remains important. Aboriginal communities with clear mechanisms for maintaining continuity with their cultural traditions, however defined, revised or restructured, have better health outcomes. Governance mechanisms in these communities must reflect the core cultural values related to decision making or they risk undermining the fundamental idea of self-governance.
The next question that must be asked is why most Aboriginal communities are not self-governing and why it is so difficult to restore self-governance where it is weak or absent. Unfortunately, the answer is rooted in the colonial history of Aboriginal people's relationship with the Canadian state. I say ``unfortunately'' because it has, to some extent, become unfashionable to blame colonization and history for the problems that afflict Aboriginal communities today. Although current governments may acknowledge the historical mistakes that have created much of the misery in Aboriginal communities — witness the residential school legacy — contemporary thinking and policy development favours a more forward-looking approach.
However, colonization is about much more than historical mistakes that cannot be changed. Aboriginal communities once exercised complete authority over lands and resources. These self-governing nations were not utopias. Conflict occurred in and among diverse communities. Some members benefited from traditional political structures more than others but, in general, governance structures had evolved to provide the maximum benefits to the majority of community members, and the evidence suggests that the health status of pre-colonial Aboriginal nations in Canada was enviable by today's standards.
Colonization as an historical process works on two levels. On the most obvious level, it works to remove the levers of decision-making and ownership of resources from the hands of the people and puts these decisions and resources in the hands of a foreign or occupying nation. On a less obvious level, colonization captures the soul of a people, undermining a sense of self-efficacy and being able to determine a future at the individual, community and societal levels. Again, the evidence is clear that this loss of self-efficacy or personal and community autonomy can have a profound effect on health outcomes at all levels.
Canadian governments over the past 50 years have made some effort at decolonization, establishing community governments and resolving land claims, but the impact of colonization remains as a primary barrier to achieving self- determination in Aboriginal communities and, as a consequence, I would submit, the primary barrier to reducing health inequities.
There have been many attempts over the past decade to develop solutions to the colonial legacy and to achieve self- government in Aboriginal communities. In particular, the Royal Commission on Aboriginal Peoples a decade ago addressed the same question that we are addressing today, and it reviewed similar evidence and drew similar conclusions, as you will hear in the other presentations before you. Here we are again engaged in a similar discussion with potentially similar outcomes: agreement on the roots of the problem but unwillingness to tackle the fundamental determinant of health inequities in Aboriginal communities.
You will hear in other presentations before you descriptions of important efforts by different government departments to tackle this issue. Health programs are being transferred to community control. Programs are in place to foster self-esteem and cultural pride in children, but I submit that however well-intentioned these programs are, they do not address the root causes of the problems, the causes of the causes of the causes. I fear that if we continue in this tradition of tinkering with the policy and program levers of the bureaucracy to address a fundamental structural issue in Canadian statecraft, we, or at least our children, will be gathered around tables like these in 10 years addressing the same questions and bemoaning the lack of progress.
Although I have argued that the processes for achieving a simple solution of self-government as the social determinant of health equity in Aboriginal communities are complex, I would like to propose some simple but not necessarily original solutions.
First, Aboriginal communities must have more flexible authority over the resources available to them to strengthen local social, economic and cultural conditions in ways that relate to health outcomes. I believe that one way to achieve this is to reconsider the current state separation of administering social determinant resources separate from health resources. Before you today are representatives from several federal departments, and these departments are committed to progressive policies that reflect population health models that we are discussing, but coordination across these departments in the context of a population health model remains an illusion. At the community level, dependence and accountability for resources to address social determinants is structurally separate from accountability for improving health outcomes. This seems to me to be fundamentally contradictory to all of the evidence before you on this issue.
Second, a restructuring of the federal responsibility for improving coordination of resources across multiple agencies and jurisdictions must occur subject to Aboriginal authority. Aboriginal self-government must be supported to function at the community, regional and national levels, and federal programs and resource allocation must be accountable to Aboriginal authorities at all of these levels.
Third, the resource base that should be historically available to Aboriginal social development must be honoured and equitably accessible. It is a myth that Aboriginal communities are poor. Although there are exceptions, most Aboriginal nations occupy territory that produces most of the wealth of this country. Resolving land claims, recognizing treaty rights and developing agreements that equitably distribute this wealth should be the first priority in order to strengthen the social determinant infrastructure of Aboriginal communities.
If I have time, and I think I do, I would mention two global examples of situations where indigenous peoples have achieved a higher degree of self-government than we have in Canada and, as a result, have better health outcomes. The first example is the Maori of New Zealand. Maori self-government is recognized constitutionally in New Zealand, and Maori institutional development across all sectors is significantly ahead of virtually all other indigenous nations. Maori health outcomes are certainly not ideal, but they are better in comparison to similar indigenous indicators in Australia, Canada and the U.S.
The second example is more complex. Two years ago I visited indigenous villages in a region of Colombia controlled by anti-government, paramilitary forces. The Colombia government no longer exercises authority in this region, and indigenous communities who once were part of governance systems much like Canada's are now essentially completely autonomous. They have done two things in response. One is to re-establish traditional trading systems across villages to ensure agricultural and renewable resources are equitably distributed. The second is to establish an organization outside their territory that contracts with the central government to provide health and social services on a per capita basis. The federal government simply provides the funding and does not expect accountability because the villages are beyond their jurisdiction in a practical sense. This organization has established primary health care services that integrate traditional medicine across the region and they serve nearly three times the population that is recognized in their government contract. Although we are still in the process of documenting the health impacts of these systems, early evidence suggests that these villages are among the healthiest in Colombia.
To conclude, the Royal Commission on Aboriginal Peoples made similar arguments to what I have proposed here and 10 years later we have made some progress at the community levels. We are beginning to address this issue at the regional or provincial level, but at the national level Aboriginal authorities remain largely advisory and their authority waxes and wanes, dependent on the political interests of the federal government. Equitable resource distribution remains contentious. Some land claims have been settled but most remain unsolved, and conflict continues over access to traditional lands. Aboriginal health inequities continue to be the number one public health problem in the country.
Thank you for the opportunity to speak to you today. I sincerely hope these discussions contribute to new approaches to restoring Aboriginal self-government as the primary determinant of improved health outcomes in Aboriginal communities and nations.
Ian Potter, Assistant Deputy Minister, First Nations and Inuit Health Branch, Health Canada: Thank you for inviting me today. Thank you for choosing to discuss Aboriginal issues in the context of your work. A discussion of social determinants in Canada needs to include the stories of First Nations and Inuit people. While I cannot relate their stories, I can tell you about how we in Health Canada have been working in partnership with First Nations and Inuit and what we have learned from those partnerships, as well as what we have learned and applied from the evidence base on social determinants of health.
[Translation]
Our mandate at the First Nations and Inuit Health Branch is to improve health outcomes for Aboriginal people, to ensure access to health care services, and also to support greater control for First Nations and Inuit over the health system. A major focus for us is health care services, which are included among the determinants of health.
However, as you know and have heard from other presentations, there are a number of other factors that have a major impact on health status.
[English]
You have heard about Michael Marmot's research in relation to health and social ranking. He demonstrated that people rank according to their social position and this is linked to their health status and life expectancy. There is a gradient from top to bottom which applies in Canada as well. The extent of social marginalization of Aboriginal people is reflected in health disparities in Canada.
Although there have been significant improvements in the health status of Aboriginal people in Canada, their health status continues to fall well below that of the general population. This is related to many of the same determinants that affect people in all societies: income, education, employment and housing.
The social and economic status of Aboriginal peoples is lower than that of non-Aboriginal people in general. Educational attainment is lower, fewer people are employed and average incomes are lower. These data are from the Canadian Population Health Initiative, CPHI, and Statistics Canada. There are also gaps in social and economic supports for early childhood development, which is another important determinant of health.
[Translation]
To add to the complexity of the situation, there are some historical factors that are particular to Aboriginal people and that are quite distinct from factors that affect other marginalized groups in Canada. The health status of Aboriginal people in Canada is affected by unique determinants related to the history of colonization, and their efforts to regain some level of self-determination and community control.
[English]
Professor Marmot found that what determines different rates of disease has much more to do with how much control you have over your life circumstances and the degree to which you are able to participate fully in society; that is called capabilities.
Canadian researchers Chandler and Lalonde did some work in this area and demonstrated that ``the risk of suicide in First Nations youth is strongly associated with the ways in which these young persons undertake to construct and defend a sense of identity that allows them to survive . . . despite often dramatic individual and cultural change.''
Chandler and Lalonde identified six markers: self-government, participation in land claims, education, health, cultural activities, and the management of police and fire. They demonstrate that the variability in suicide rates across native communities is associated with the efforts of these communities to regain control of their cultural life and to regain a sense of cultural continuity. Communities that have taken active steps to preserve and rehabilitate their own cultures are also those communities in which youth suicide rates are dramatically lower or nonexistent; they just do not have them.
[Translation]
In a similar vein, through the Harvard Project in the U.S., professors Cornell and Kalt have found that among American Indian communities, sovereignty is positively associated with stronger economic and social development, which encompasses a number of important health determinants.
The programs of the First Nations and Inuit Health Branch reflect the evidence base on health determinants in four key areas: health services, healthy childhood development, aboriginal control and cultural continuity.
[English]
We have been working with First Nations and Inuit partners and provinces and territories to improve the access and quality of services for promoting and protecting health as well as health care. This means better integration of services between the various players that deliver services, as well as increasing First Nations and Inuit capacity to participate in the design, delivery and governance of services. We have increased the number of and access to nursing services in many of our communities. We are currently working with the B.C. government and B.C. First Nations to develop a tripartite agreement that we believe will improve health services and, ultimately, the health status of B.C. First Nations.
Experiences in the early years lay the foundation for a child's development, affecting lifelong health, well-being and learning outcomes. During this period, critical neurological developments related to functions such as vision, emotional control and language take place. While conditions are improving, the general health status of Aboriginal children in Canada ranks below the national average.
We are working with mothers and infants, as well as young children, through a couple of programs I will mention. One is Maternal and Child Health, a program that has a long-term goal of supporting pregnant First Nations women and families with infants and young children who live on reserve to reach their fullest developmental and lifetime potential. The Maternal and Child Health Program realizes this goal through providing home visits by nurses during pregnancy, post-partum and early childhood; service coordination for families with special needs; and increased access to health promotion activities. We have allocated $110 million over five years to this program improvement.
The second area of focus is Aboriginal Head Start On Reserve, AHSOR. That program provides early childhood intervention that targets the needs of young First Nations children up to six years of age. The primary goal of the program is to demonstrate that locally controlled and designed intervention strategies can provide First Nations preschool children with a positive sense of themselves, a desire for learning, and opportunities to develop fully and successfully as young people. We are expanding this program and are now spending $57.3 million per year, providing services to 9,400 children in over 330 communities. This preschool intervention supports the development of the physical, intellectual, social, spiritual and well-being of First Nations children.
To date, some additional observed benefits of the program include a positive change in children's attitudes as they learn to socialize and utilize the basic skills they require in school; First Nation language development and use; the provision of nutritious foods for children and the education of their parents and staff about the relationship between nutrition and a child's capacity to learn and develop. Promoting physical activity is a key curriculum component at all sites, often in response to the growing concern regarding the early onset of type 2 diabetes.
We continue to work with Indian and Northern Affairs Canada on self-government agreements and to ensure that issues related to health are addressed. Within our mandate in Health Canada, we support the transfer of health services to First Nations and Inuit communities, which involves gradually removing control of resources and responsibilities for community health services and programs into the hands of First Nations communities. Health Canada has been transferring the responsibility of health services since 1988, and to date more than 80 per cent of First Nations communities are involved in this continuum of control. Most of them have taken over the day-to-day delivery of health services on reserve.
[Translation]
Greater control is phased in over time through a capacity-building approach. This includes a comprehensive assessment of community readiness — experience, strengths and weaknesses in program and financial management — in order to take on more responsibility for planning and managing their health programs. Over time, recipients may wish to move to a higher or lower degree of control as their capacity and circumstances change. The First Nations and Inuit perspective on health is distinguishable by a strong holistic emphasis. This includes not only broad social and economic determinants of health, but also cultural distinctions that play an important role in maintaining health at the level of the individual, the family and the community. Integral to such an approach is enabling the First Nations and Inuit to have an effective role in the planning and delivery of their health services.
[English]
First Nations and Inuit Health Branch is working with partners and communities to explore innovative approaches to service to promote the integration of Western and indigenous knowledge. This will increase access to culturally appropriate services and blends traditional and Western approaches, enabling a holistic continuum of health services.
A primary goal of our Aboriginal Health Human Resources Initiative is to increase access to culturally appropriate services. The initiative aims to increase the number of First Nations, Inuit and Metis health professionals and paraprofessionals. We are exploring conditions conducive to the retention of First Nations, Inuit and Metis health care workers and to provide non-Aboriginal health care workers working in First Nations communities with the cultural competencies that can improve their health services.
The First Nations and Inuit Health Branch has been supporting research such as that related to the work of the World Health Organization Commission on Social Determinants of Health. Policy papers on First Nations, Inuit and Metis have been written and will ensure that any discussion of inequities includes Canadian Aboriginal perspectives as well as global perspectives on the determinants of indigenous health.
[Translation]
At the end of the month, we will be participating in a symposium being hosted by Australian Commissioner Fran Baum. We have supported the development of policy papers from the First Nations, Inuit, and Metis perspective that will form the basis of Canada's contribution to the discussion. A consolidated report from that symposium is expected to form the basis of a presentation on a global perspective on indigenous health.
[English]
This presentation will be given to the WHO commissioners when they meet in Vancouver in June.
These are some of the initiatives that the First Nations and Inuit Health Branch have in place within our own mandate, which build upon the evidence related to social determinants of health. At the interdepartmental level, our approach is to work closely with other departments and agencies to promote intersectoral action on the social determinants of Aboriginal health.
Jim Ball, Director, Development and Partnerships Division, Strategic Policy Directorate, Public Health Agency of Canada: Thank you. I am pleased to be here today on behalf of the Public Health Agency of Canada to speak to the social and other determinants of health affecting Canada's Aboriginal communities.
Since you have previously heard about the agency from Dr. Sylvie Stachenko, I will not review the agency's mission and mandate in detail. However, I will take a moment to outline our key roles and relate those to our work on the social determinants and in turn the health inequalities experienced by Canada's First Nations, Inuit and Metis peoples.
Our mission is to promote and protect the health of all Canadians, including Aboriginal peoples, through leadership, partnership, innovation and action in public health. The agency's primary role is to work in collaboration with its partners to mobilize pan-Canadian initiatives, including unique federal efforts, in preventing disease and injury as well as promoting and protecting national and international public health. This work includes facilitating multi- sectoral efforts to advance action on the social determinants of health.
The agency is firmly committed to addressing the health inequalities experienced by First Nations, Inuit and Metis peoples. We take the approach of working with partners from the health portfolio, national and regional Aboriginal organizations, provincial and territorial governments and the international arena.
While we need to deepen our knowledge of the complexities of the issues, excellent work is currently being done to better understand the determinants of health for all Canadians. However, as you have heard, there are unique historical governance and cultural dimensions that converge to exacerbate these forces with respect to Aboriginal peoples, negatively affecting determinants such as access to health care and appropriate individual, family and community supports. Continued collaborative efforts are needed to better understand the interplay of those determinants so that we can more effectively address them, including those impacting urban and other off-reserve Aboriginal peoples.
The agency has supported work on the determinants of Aboriginal health in a number of ways. For example, we were instrumental in establishing and are continuing to support the creation and operation of the National Collaborating Centre for Aboriginal Health, which has the mandate to generate, synthesize and transfer public health knowledge.
This centre was specifically created to increase the capacity of Aboriginal people to address their determinants of health through facilitating the development and exchange of information to inform policies, practices and future public health interventions. The centre is guided by a national advisory committee that includes, importantly, public health experts from the Assembly of First Nations, the Inuit Tapiriit Kanatami, ITK, the Metis National Council and the Government of Nunavut.
The agency has also established and provides ongoing support to the Canadian Reference Group on Social Determinants of Health, which includes Aboriginal and First Nations and Inuit Health Branch representatives. One initiative currently underway, which Mr. Potter referred to, is exploring self-determination as a determinant of Aboriginal health both globally and in Canada. This important project will be reported on in June 2007 in Vancouver.
Within the broader federal health portfolio, Health Canada plays a key role in addressing health issues facing all Aboriginal peoples. This role is led and coordinated by the First Nations and Inuit Health Branch, and you have already heard much about this from Mr. Potter. I would like to emphasize that the agency and this branch have been building a collaborative and effect relationship at the program level working with Aboriginal organizations to address First Nations public health issues, such as pandemic planning and the prevention and control of HIV and AIDS, tuberculosis, diabetes and cancer.
In the context of our broader policy work, the agency has begun to engage bilaterally with the AFN and ITK and will be meeting with other national and regional Aboriginal organizations to discuss public health issues and to work more effectively together to address these.
Within the context of the federal-provincial-territorial collaboration required, the Public Health Network is in place and supported by the agency and represents the key mechanism for federal-provincial-territorial collaboration and coordination on public health issues while respecting jurisdictional responsibilities in public health. The network council, its senior and central governance body, has been working with national Aboriginal organizations on opportunities for appropriate inclusion of Aboriginal health expertise and advice in the work of the network and its expert group substructure.
The agency is also working with Health Canada, a number of provinces and territories and national Aboriginal organizations as a member of two advisory committees to the Aboriginal Health Transition Fund being managed by a secretariat within Mr. Potter's branch. This initiative is intended to address the gaps in health status between Aboriginal and non-Aboriginal Canadians through providing support to projects undertaken by provinces and territories.
As you have heard, it is widely understood that early childhood development is a key determinant of health and that early investments yield positive future outcomes for individuals and communities. The Public Health Agency of Canada has three community-based programs that seek to ensure that children have a healthy start in life. These include the Community Action Program for Children, the Canada Prenatal Nutrition Program and the Aboriginal Head Start program in urban and northern communities. It is important to note that we operate these programs collaboratively with partners, including provinces and territories, and in many cases with Aboriginal organizations and communities.
The agency also addresses the public health needs of the broader Aboriginal population through its work on key issues such as diabetes. For example, we lead the renewed Canadian Diabetes Strategy, focusing on preventing diabetes among those who are at higher risk for developing type 2 diabetes, including Aboriginal people, who are three to five times more likely to have this disease than non-Aboriginal Canadians.
Overall, our programs are designed to help strengthen public health capacity, including that of Aboriginal peoples and communities, and in so doing, address some of the most important determinants of their health.
On the issue of health information, as you are aware, there are significant limitations regarding data and information on the health of Aboriginal peoples and specific challenges before us with respect to privacy protection in the collection, use and dissemination of personal health information. Access to this data is crucial for our understanding of the impact of the social determinants of health on all Canadians, including Aboriginal peoples. The agency is currently working with the First Nations and Inuit Health Branch and others in the health portfolio on a number of fronts to address health information issues related to First Nations and Inuit, and it recognizes the need to collaborate with Aboriginal organizations more broadly to address these issues with respect to all Aboriginal peoples.
In closing, as we look to the future, the agency is enhancing its overall capacity to address the social determinants of health in general, continuing to build understanding and increased focus on Aboriginal public health issues and needs more specifically.
The agency views health holistically and looks at the health system broadly, including with an upstream public health lens. Our focus is clearly on a system for health. We recognize that in building this system, Aboriginal peoples must be engaged and empowered in the development of the design and delivery of their health and wellness strategies.
Recognizing the importance of provinces and territories in the delivery of public health services to all Canadians, including Aboriginal peoples, we are dedicated to strengthening the Public Health Network as a platform for broader collaboration.
I would like to refer to the words of Malcolm King, a principal investigator for the Alberta Aboriginal Capacity and Developmental Research Environments network, who stresses that governments need to respect Aboriginal peoples' health aspirations and work with Aboriginal leaders and communities to improve health. To this end, the agency will develop a framework to guide and enhance our future activities in this area through collaboration with national and regional Aboriginal organizations, the health portfolio and other partners.
Marc Brooks, Director General, Community Development Branch, Socio-economic Policy and Regional Operations Sector, Indian and Northern Affairs Canada: I would like to thank the chair and committee members for the opportunity to speak primarily on the subjects of housing and water as they relate to social determinants of health for First Nations people on reserve.
All Canadians need decent, affordable housing and safe drinking water, and it is well recognized that for many First Nations people on reserve, this is all too often not the situation.
[Translation]
Today, I will speak about the water and housing situation on reserve, as it relates to population health. This is because the federal government responsibility and involvement with these issues is primarily on-reserve.
[English]
Within Indian and Northern Affairs Canada, we have compiled a community well-being index based on data from the 2001 Census of Canada. This index, which includes education, labour force activity, income and housing, confirms that a substantial number of First Nations communities score lower than other Canadian communities in terms of community well-being.
Although First Nations communities made up approximately 13 per cent of all Canadian communities in 2001, 92 of the bottom 100 communities were First Nations. Only one First Nation ranked among the top 100 Canadian communities. Housing and income are identified as two of the more important factors in explaining this gap.
[Translation]
Water quality also shows deficits. The most often cited is the drinking water advisory which is in place in 89 First Nations communities. This number fluctuates somewhat by season, and by other variations at community level.
For housing, the Government of Canada makes significant contributions to support First Nations to deliver on- reserve housing. Expenditures total $261 million annually, including $138 million through Indian and Northern Affairs Canada and close to $123 million from Canada Mortgage and Housing Corporation.
[English]
The current Indian and Northern Affairs Canada policy framework for on-reserve housing gives First Nations the flexibility to determine how best they wish to use the housing funds. It encourages First Nations control, capacity, development and shared responsibility such as establishment of rental regimes and utility charges as well as ownership options and better access to private capital.
More and more First Nations have recognized that they will not be able to resolve their housing shortfall and needs by relying solely on government funding. Instead, they are tapping into the resources available amongst community members, in some cases to pay rent as well as to buy and maintain their own homes. By pooling the resources from government, the private sector, community members and the community itself, they are turning housing on reserve from a liability into a community asset. They recognize as well that houses built to code and maintained well by the band and the occupants last longer and provide a healthier living environment.
On April 20, 2007, Ministers Prentice and Solberg affirmed the government's commitment to provide First Nations on reserve with the same housing opportunities and responsibilities as other Canadians by announcing the creation of a $300-million First Nations market housing fund. The fund represents a new and innovative market-based approach that will increase the housing supply on reserve and give many First Nations families the opportunity to own or rent their own homes. The fund will help to provide up to 25,000 new housing units over the course of the next 10 years.
[Translation]
In 1995, mould was first identified as an issue in First Nations communities. Remediation activities commenced the same year and have continued, funded under the department's annual First Nation Band Housing allocation. These activities are carried out by and at the discretion of individual bands. There is no federal funding allocated specifically to the remediation of mould in First Nations communities.
[English]
Nationally, Indian and Northern Affairs Canada, Health Canada, Canada Mortgage and Housing Corporation and the Assembly of First Nations formally presented a draft strategy on moulds that deals with specific actions and responsibilities, timelines, objectives and performance indicators to the Standing Committee on Public Accounts last November 30 to address and to eradicate the problems of mould in on-reserve housing. The next step will be the development of a communication strategy and, in collaboration with First Nations, the implementation of an awareness process to implement this strategy.
Turning now to water, all of us know the health concerns and risks associated with the treatment of drinking water, specifically on reserve. The Canadian government has been assisting First Nations in the provision of water by funding water and wastewater systems for several decades. Since 2003, the Government of Canada, specifically through INAC and Health Canada, has invested in excess of $1 billion in the capital construction, operation and maintenance of water and wastewater treatment plants on reserve. This funding has been used to train and certify water plant operators, develop standards and create a monitoring program to ensure that the plants are run effectively and maintained and that the water is properly treated.
[Translation]
Under its First Nations Water Management Strategy, Indian and Northern Affairs Canada uses what is known as a multi-barrier approach to ensure that water is safe for consumption. This means that there are multiple barriers protecting drinking water from possible contaminants or mistakes that could render water unsafe.
[English]
This approach helps to create a redundancy in protection so that should one barrier fail to stop the contamination of water, another barrier acts as a check against the system, thereby making certain that the drinking water is safe. The multi-barrier approach is the standard in water management and is a concept that is fully accepted by the Canadian Council of Ministers of the Environment.
Further, in March 2006 Minister Prentice outlined a five-point plan of action designed to address water issues in First Nations communities. This plan of action fits within the framework of the First Nations Water Management Strategy that was put into practice in 2003 and focused on the key points that will have the most impact on the provision of safe drinking water. Specifically, the plan of action called for the issuing of a clear protocol on drinking water standards; ensuring that mandatory training — operator certification — and oversight of water systems by certified operators were put into place; addressing the drinking water concerns for a determined set of high-risk communities; creating an expert panel to provide options for a regulatory regime for drinking water on reserve; and further reporting on the progress of the plan of action.
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These initiatives have yielded measurable improvements. In March 2006, there were some 193 water treatment plants categorized as high risk systems. Today that number stands at 97, and Indian and Northern Affairs Canada continues to work with First Nations to further reduce the number.
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You will be pleased to know that First Nations children and educators were also involved in the drive for safe and sustainable use of water. Working with Health Canada and Environment Canada and in collaboration with First Nations teachers, students and the Assembly of First Nations, Indian and Northern Affairs Canada recently developed the Water is a Treasure school kit for children. It is a bilingual, interactive resource that includes a poster, a variety of fun and educational activities and a list of Internet resources. Its key themes consist of the value of protecting water now and for future generations and the appreciation for the importance of clean, safe and reliable water from its source to the tap and back to the source.
It must be acknowledged that despite ongoing efforts and support, many First Nations continue to face significant challenges to establishing safe and effective water management regimes. Core challenges include the high costs of mobilization, construction and maintenance of facilities in remote and isolated locations; the lack of economies or independent resources to properly fund system operation and maintenance; and limited local capacity and ability to retain trained and qualified, certified operators.
In conclusion, our vision is that First Nations Canadians will have the same opportunities and responsibilities as other Canadians. We realize there is much left to be done, and through this statement I have shared what I believe is a concrete action plan or approach on water and housing that will serve to bring this vision closer to reality and will contribute to improved population health among First Nations people.
The Chairman: I thank all the witnesses for their excellent presentations. If it is agreed, we will begin with questions to Mr. O'Neil. I would bring you back, Mr. O'Neil, to the importance of self-government, which you mentioned.
All senators here today are in agreement that effective health services and so forth have to be organized at the community level. We accept that principle. The issue of self-government is much more complex than is organizing health services at the community level or organizing from the ground up. How effective will community health services be if they can be implemented prior to the changes that allow for self-government, which might take some doing?
Mr. O'Neil: The first question is complex. The intent of my remarks was to express the goal for improving the health status of Aboriginal communities, in particular First Nations communities, as well as Inuit, Metis and urban Aboriginal communities. That goal is to achieve a higher level of self-government as the ultimate social determinant that we are addressing. We are moving on that path. As my colleagues have outlined, efforts are being made in that direction. Certainly, representatives from the various Aboriginal communities are working on this issue as well. My remarks were meant not to suggest that it is not happening but rather to maintain momentum and to try to put in place policies and resources to speed up the process to achieve that goal more quickly.
It is an important question you have asked. In the absence of real self-government, local control or administration of services and local administration of health services, housing, education, or economic opportunities are at best half measures, but that does not mean we should not do them.
Our research centre was involved with First Nations and Inuit Health Branch in doing an evaluation of the transfer of health services over the last decade. We interviewed health directors in a large sample of First Nations across the country who had undertaken the health transfer. A significant majority of those health directors, almost all of them, said that this was a good thing, that they had achieved certain goals in terms of improving both the quality and the cultural sensitivity or acceptability of those services. At the same time, many of them felt that to some extent they were continuing, to use their phrase, to administer their own misery. They did not have the resources and the levers to change the fundamental conditions that were producing the problems that they were now responsible for trying to resolve.
We found in our work that, for the most part, if you saved money in your health budget at the community level, you were unable to put that money into housing. There are a few arrangements in the country where that kind of flexibility is possible with considerable effort, but most communities do not have that flexibility. If you are able to manage your resources at the community level and you want to put more money into the social determinant side to bring down your costs on the health service side, you do not have that flexibility. Provincial and municipal governments have that flexibility, but Aboriginal governments for the most part do not. That is one of the areas we need to work on.
Self-government in the area of health services is not a sufficient measure to address these broader conditions. Local and regional governments need to be supported in trying to integrate across the different kinds of programs and resources they have available to them and to try to realize savings in the service end in order to invest that money and those resources back into the determinant end.
Senator Eggleton: How will self-government work on a practical basis in dealing with these social determinants of health for the Aboriginal population in urban areas, off-reserve areas? How complex a situation does that bring you into? I can understand self-government on a reserve basis, but what about the urban areas in Toronto and other places? How would you see it being of assistance then in dealing with these issues?
Mr. O'Neil: It is complex, as you have indicated. There are ways of setting up institutional structures that provide more accountability for Aboriginal communities living in urban areas to Aboriginal authorities, not necessarily creating a fourth level of government, but having Aboriginal authorities responsible for housing, for providing services for the elderly in the community, for health services.
The pure concept of self-government that might be more easily developed on-reserve and in remote and northern communities clearly is not as easily implemented in the Aboriginal context, but it is a continuum. We all recognize it is not an absolute condition.
In the urban context, there are efforts in different parts of the country to develop Aboriginal-controlled authorities that have delegated responsibility for municipal governments to provide certain kinds of services and resources to their Aboriginal constituencies. It will vary from one city to another depending on the size and distribution of Aboriginal populations.
In Winnipeg, there is a significant investment in an Aboriginal centre that has a health clinic that provides other social services and that draws funding from government sources. It is envisioned as one-stop-shopping for Aboriginal populations in that sector of the city. Strengthening those kinds of institutions and authorities is the mechanism that is the way forward to improving health for urban Aboriginal populations.
The broader context of self-government is that many First Nations people in cities are still under the jurisdiction of their First Nations governments that are outside of the cities and communities. Strengthening their responsibility for delivering a range of services across a migrant, mobile population is another way of strengthening the concept of self- government for the Aboriginal population.
Senator Eggleton: Then you have the further complexity in some of the large urban areas where people come from different tribal backgrounds or origins and so have different roots into the self-government process back from where they originate. That would probably mean whole different structures of self-government.
Mr. O'Neil: There are certainly differences and people have different traditions, and there are different interests at stake, but in my experience, where the resources have been available and the opportunity is there, Aboriginal governments are cautious but quite willing to build collaborative institutions and structures in order to administer them. It is not easy, but it is possible.
Senator Pépin: You may not have time to elaborate, but in your presentation you mentioned that coordination across the different departments of the federal government in the context of a population health model remains an illusion. After that, you said that at the community level, dependence and accountability for resources to address social determinants is structurally separate from accountability for improving health outcomes. You said that that seems to you to be fundamentally contradictory to all the evidence before you on this issue.
I listened to all the other presentations. How do we organize or plan something that will work with respect to coordination?
Mr. O'Neil: In the presentations, you heard that there are efforts nationally and regionally to bring together different government departments, different jurisdictions, provincial and federal, around some of the recommendations that came out of the Kirby report about trying to resource communities to deal with social determinants as well as health services.
It comes back to the question asked earlier and the answer is similar. I will take a step back. One of the things I find most distressing in my work in meeting with chiefs and leaders in Aboriginal communities is that they do not see the relationship we are talking about here. They see health services as provided by the First Nations and Inuit Health Branch and the negotiation for them is about increasing the envelope of health services, increasing the money being put in. They see that as one political environment, and the other political environment is working with Indian and Northern Affairs Canada. They do not see them as connected. Some do and some do not.
From the community up to the federal government we need to build a broader understanding of the coordination of those resources so that if the community can realize savings in its health or social services budget, it can invest that money back into infrastructure. There are ways now. It is not as difficult to do now as it was five or 10 years ago, but there is quite a way to go in achieving those goals.
The Chairman: You stated that coordination remains an illusion. I have become convinced over the past number of years listening to testimony involved in previous reports that coordination can occur only at the community level. Is that correct or incorrect?
Mr. O'Neil: It must occur first at the community level. The communities must be the fundamental integrating institutional block in this. It must also occur at all other levels. One without the other does not work.
Within their cultural traditions communities understand this holistically, but then they have to go to different agencies with different unrelated proposals. We had a brief conversation before the meeting about water quality. There are different departments with different responsibilities and different individuals. If that is not coordinated outside the community, then the community is at a disadvantage to do that coordination.
The coordination is not as well developed as it should be. It is not that there are not processes in place and efforts to bring about more of that coordination, but I think we all agree there is a way to go and it could be much stronger.
The Chairman: Thank you very much indeed. Mr. Reading, the opportunity for cross-fertilization and collaboration is tremendous, as we were discussing earlier today. All the presentations here this afternoon show you have much in common.
How closely is your Institute of Aboriginal Peoples' Health aligned with the Institute of Population Health? I understand the organization of Canadian Institutes of Health Research. I know how the worker bees sit around the same table planning their projects. Is there cross-fertilization between the Institute of Population Health and your Institute of Aboriginal Peoples' Health?
Mr. Reading: Yes, there is, certainly at the institute level because we represent a population-based institute. We are not specific to a discipline, a disease, or a body part as some other institutes are. We have interests across all domains of the other institutes: cancer, heart and lung, gender, et cetera. We do collaborate quite a bit with all of the institutes.
Having said that, the Institute of Population and Public Health has a special relationship, as does the Institute of Neurosciences, Mental Health and Addiction, because of the issues that are contained within the mandates of those institutes. We are collaborating on a number of issues with Public Health Agency of Canada. It was mentioned that the National Collaborating Centres for Public Health has a centre dedicated to Aboriginals in the University of Northern British Columbia. I am on the advisory council of all the collaborating centres and that advisory council is chaired by John Frank, the scientific director of the Institute of Population and Public Health.
Last weekend, I opened a talk on community campus collaborations in health. That was an international conference with a group based in Washington State in the United States. The assistant director of the Institute of Population and Public Health, who was on the committee organizing that meeting, had put my name forward.
These are the kinds of things that happen on a daily basis that you do not read in reports. A strength of the Canadian Institutes of Health Research is that we meet every month with Alan Bernstein and the vice presidents to articulate national health research priorities. In that process we wind up having hallway conversations about what is happening in our various domains.
When it comes to social determinants, obviously we have a very strong joint vested interest in the processes. When we talk about Monique Bégin, Michael Marmot, the WHO Commission on Social Determinants of Health, the meetings taking place in Vancouver and other places in the world, we are participating with our colleagues on a formal and an informal basis. That is one of the strengths of what we have created in Canada.
Incidentally, it is the only institute at the national level, anywhere in the world, that focuses on indigenous peoples' health. It is a leadership role for Canada, but it is also quite innovative. It is a niche for Canada when we talk about advanced research.
The Chairman: I am a great believer in the CIHR organization. I think it was a dream come true for everyone in research.
Senator Eggleton: I have a question for Dr. Reading and one for anybody and everybody who might want to answer it.
Dr. Reading, your slide chart on health disparities shows the difference in life expectancy between registered Indians and the general population. Tuberculosis is 6 times higher, diabetes 2.7 times higher, suicide rates 4.3 times higher and for the Inuit, 11 times higher. These numbers depict the stark reality of a major problem we face in this country.
I assume that these statistics are for reserve and non-reserve together. Do you have any information as to what the statistics would look like if they were separated between reserve and non-reserve?
Mr. Reading: I am glad you asked that question. These are aggregate data. In some cases they are for Inuit, in some cases for First Nations, some for urban Aboriginals and some for community. When we produce national data and compare it to national data for other Canadians, it is on aggregate.
Interestingly, if you take a graph and you plot health versus wealth, you have a linear relationship: as your income improves so does your health. That is the social determinants and health paradigm. However, there is a scatter of health and wealth on that graph. In other words, for a given level of wealth, some communities are healthier than others. The ones that are healthier than others at the same level of wealth are the more resilient communities.
The area of resilience is an interesting question. What is it that makes some communities more resilient than others? In the context of Aboriginal communities, does it involve culture, the role of women as caregivers or the advice given by elders? We do not know the answers to some of those interesting questions.
The question is also relevant to mainstream social determinants. You do find very wealthy communities that are dysfunctional and where people's level of health is not comparable to other communities that have fewer resources.
It is often tempting to say, for example, that it is important to have income because income is the one determinant that purchases the other determinants. However, that is not the whole story. Many other factors are involved.
We did an international request for applications in a partnership with Australia, New Zealand and Canada through the CIHR and the national funding agencies of those other countries. We asked the researchers and the community people in all three countries what would be the most important question. We all agreed that resilience was the important question.
We did an international review and we picked the best proposals. It was chaired by a Native American researcher funded by the U.S. National Institutes of Health who did not have a vested interest in any of the outcomes. It turned out that HIV ranked number one, mental health and addictions number two, and workforce development issues number three.
The questions that come out of this are very interesting. What makes some workers more resilient? Why are these workers capable of handling extremely heavy workloads while others burn out? What makes some communities better able to cope with the stresses and pressures related to HIV or mental health?
I am alluding to the whole characterization of native communities as being sick and dysfunctional. It is very insidious, quite pervasive and a form of racism. If you pick up The Toronto Star, The Globe and Mail or the National Post, you will undoubtedly find stories of native Canadians that have to do with dysfunction, such as sniffing gasoline, physical violence or being unable to manage financial affairs. The stories of wellness and resilience in the face of challenging health circumstances are not published in the newspaper, yet there are many of them out there. We can see that this generation has more people graduating with degrees, but there is this disparity. We must try to balance the negative message with a positive one.
In the context of your question and previous questions, when a community is characterized as dysfunctional, that undermines its legitimate aspiration to achieve a level of self-government. In other words, you will not spend millions of dollars on someone to manage a complex process if you think that they are dysfunctional, if the whole system of media and research characterizes that community as being unable to manage its own resources. That is a dilemma. It undermines the power relationships.
One of the most important factors is that we must focus on resiliency. What are the factors associated with strong and healthy communities in the context of very difficult circumstances that, frankly, I do not think many people in this room would be able to tolerate?
Senator Eggleton: I agree. In terms of the statistics, they can break out differently between the urban and reserve and between Inuit and First Nations or Metis. Perhaps when we come to the point of making recommendations, we might find it useful to know some of that. The solutions may not apply right across the board.
After Professor O'Neil put a lot of emphasis on self-government, I did not hear much about it. I suppose we all agree that self-government is a good thing, and we want to go in that direction. However, it comes down to the question of how much it plays into the issue, at this point in time, in dealing with social determinants of health.
I believe the chairman indicated that this is a long-term endeavour, and we need to find the shortest route to solutions. I wonder if any of the other panellists have any comments to make about self-government.
Mr. Potter: I could perhaps speak for a moment about Health Canada's approach, because we are trying to manage two things at the same time. The mandate of our branch is to improve health outcomes of First Nations and Inuit people and also to ensure that they have access to health services.
The long term is the improved outcomes, and self-government is definitely part of that. Therefore, we work with Indian and Northern Affairs Canada, which has the legal responsibility to represent the federal government in those negotiations that deal with governance and authorities. At the same time, we are trying to see more governance and more self-management by First Nations in the health care system that we operate. There is our support to the broader self-government effort where First Nations can take over broad government functions, but there is also the delivery and management of health services.
I have talked about how we have transferred in large part the day-to-day health care service delivery to First Nations and we work with them to do that. Similarly, we are trying to work with them to integrate the services we deliver with the provincial services because the federal government funds only a limited number of health services on reserve. The bulk of the health services that First Nations on reserve get, namely hospital services and physician services, is under provincial responsibility. We are working with them to see if they can have a larger role to play in the provincial government's delivery of services so that it can be a more integrated system with greater authority by self- government.
Another aspect of self-government is being able to have the people of your community deliver the services that you want. We are supporting First Nations and Inuit to get the education necessary to be doctors, nurses, dentists and other health managers and administrators so that they can populate the health services and self-government can take on the role of delivery. They are there and they understand the culture.
On the other side at Health Canada, we are trying to encourage that cultural aspect. We fund and we are very grateful that the Governor General has agreed to be a patron of the National Aboriginal Role Model Program, where a process selects about 17 young people who go out and show that they can succeed, that there is success in Aboriginal communities. It gives a sense of pride. We contribute to the National Aboriginal Achievement Awards process where they try to encourage Aboriginal people to have a sense of pride and culture.
We also work with Aboriginal people to ensure that their traditional medicine and healing are integrated with the services as best we can. There are all sorts of legal difficulties in trying to manage this, but we think our service should support a more holistic understanding of health; often our usual service does not give enough attention to the cultural and spiritual aspects. Therefore, we have within many of the centres that we fund healing lodges and traditional healers who can try to work with a more Western medicine specialist.
We see these as all part of the self-government perspective, not just the legal instrument of self-government but also self-government in its many manifestations.
Senator Cochrane: I believe you mentioned earlier during the first round of questions from Senator Eggleton that your main focus is on groups that are resilient. You referred to the resilience of communities to become self-sufficient and have fewer problems.
Mr. Reading: I was suggesting that there are important lessons to learn from communities that are healthier at a similar level of income and resources than communities that are not as healthy. In terms of research, we are not too sure about what constitutes resiliency in the context of some communities.
Aboriginal people do not have a monopoly on that question. It is a relevant question for all communities in Canada.
Senator Cochrane: I look at the adverse, whereby if we would concentrate on the opposite, on those individuals and communities who are truly deprived and who cannot cope, maybe by doing that, we could find even one solution.
Mr. Reading: I do not want to suggest for a moment that we would ever ignore a community that is experiencing extreme poverty, for example. We know enough that in those circumstances where the determinants of health are so severely lacking there are basic health measures we can implement. Part of the reason we are having this dialogue is that we know quite a bit about what constitutes healthy communities. There is a lack of political will to move on some of these basic fundamental aspects. We are talking about adequate water in a country that has a human development index that ranks among the top in the globe. Yet, First Nations are ranked somewhere around sixty-third, comparable to Thailand and Mexico and middle-income countries. Many communities within the province of Ontario, as recent reports in The Globe and Mail have shown, are at low-income country levels like sub-Saharan Africa and places like that. Yes, I could not agree with you more, and it is extremely frustrating.
My opinion differs from the conversation here around governance quite a bit. I think there has to be a radical rethinking of governance. It has to be based on a Jeffrey Sachs kind of model. He is a world economist who takes an approach of differential diagnosis to the problem of communities and even nation states. For example, to have sustainable economic development, you need to have a sharing of resources at the regional level. Canada is an economy based on natural resource extraction. We cannot get away from that. The irony is that the resources are extracted along with the wealth, and they flow south where people drive Mercedes and live in 6,000-square-foot houses, while people who live in the regions where the resources are extracted from have a depletion of the assets. It is more insidious than that, because before industry came to the region they were able to have a traditional way of life where they could gather food from the forest in the traditional ways, and in many cases environmental degradation left by multi-national firms extracting resources has reduced that asset and reduced the ability of those people to be able to extract a living, and consequently they rely on handouts from the government and have to go to a food store where they do not have adequate nutritional choices for their children.
Senator Cochrane: You do not have to go to the native community to find that.
Mr. Reading: No, but we are talking about native health. If you want to hear the truth, I will give it to you.
The Chairman: Senator Cochrane is from Newfoundland and is worried about her oil.
Mr. Reading: I am from Newfoundland as well.
Senator Fairbairn: I am glad we have this group. Mr. Potter and I have known each other for a long time. He is still in there and still working. That is a very helpful and comforting thought.
The question was raised about the importance of self-government. I would say it is at the very foundation of what we are talking about here today.
I live surrounded in the southwest corner of Alberta with Treaty No. 7, and right across the river is the Blood Tribe. They are the largest and wealthiest community in Canada, but when you are on reserve, you see just what we are talking about here. There are great difficulties. With the best will in the world, somehow we do not get it right very often in the way in which we are dealing with our friends. This is truly a problem, because we have much to answer for. There was a time when our Aboriginal community, wherever it was in Canada, did get along pretty well. We came along with all sorts of changes and rules and laws and whatever. The Aboriginal people have the will, I think, but they need the tools to get where they want to go and we want them to go, and that is a very difficult part of this equation.
Today I was flying back from Saskatchewan and reading in the newspaper that we have gone through so many issues where health care has not been available, either at the beginning or in between or even at the end. Historically, we have watched communities virtually pass away from smallpox. We read in the paper about a whole new door that has opened on the question of what happened with children in schools with respect to tuberculosis. We have to be partners with our native people when we talk about self-government and wanting to help. It is not because we have to; it is because we want to. That is a message that does not get through all the time.
We have talked about diabetes and about tuberculosis, but one thing did not come up today, and I wonder if some of you could raise it because it is an issue with the health of our Aboriginal people from their earliest moments. Something that is very troubling is fetal alcohol syndrome. We did have a wonderful senator here in our midst from the Yukon, and that was going to be her whole cause as a senator. How can we help? I am really looking at you, Mr. Reading. How can we hold out a hand and try to work with the native people? It is so simple, of all the health issues. It is a question of if you do not drink, then you can have healthy babies and healthy lives. We ought to be able to help with that, and maybe this is something in our work as a committee that we could help with.
Mr. Reading: I addressed this in the background paper I wrote for this, and it is part of the official submission. In studies that look at women who engage in smoking and consumption of drugs and alcohol during pregnancy, there is certainly an overrepresentation of First Nations and Aboriginal women, but when you actually include non-Aboriginal women and you control for the effects of Aboriginal versus non-Aboriginal, the factors that come out are poverty. It is all linked to poverty, so the main policy lever is the eradication of poverty. Like so many issues, poverty is driving ill health, not only in Canada but around the world. As we heard, the Blood Tribe have perhaps high income, but there could be within that community nested pockets of extreme poverty. This whole dialogue is about addressing the social determinants and looking at those.
One of the best ways to resolve poverty is through education. You obtain an education, you obtain employment, and from employment you get the resources and purchase the services you need. You also gain not just the financial aspect but also an appreciation of things. All the studies have shown that these are associated factors.
Fetal alcohol syndrome is a perfect example of what I was talking about before, where the native community gets branded with an issue that essentially characterizes them as being totally dysfunctional. The fact is that fetal alcohol syndrome is starting to show up in women who are working as executives, do not know they are pregnant in the first trimester and are drinking socially to keep up with their male counterparts in the business world because it is expected. We do not see executive women characterized as being totally dysfunctional, but they are starting to have babies with fetal alcohol syndrome or fetal alcohol effects.
The Chairman: I am afraid we have to vacate the room because someone else is coming in here.
We did not get to ask questions of Mr. Ball and Mr. Brooks, but unfortunately, that is the name of the game. We have limited time. We could have gone on for another two hours.
Since we are not being evicted just at the moment, there was one very important issue raised by you, Mr. Ball, and that is the flow of information. Are you connecting with Canada Health Infoway with their new initiatives and new funding? I know the Public Health Agency of Canada is connecting with Canada Health Infoway, but I mean specifically in this area, is there a connection that will allow you to wire the system, so to speak?
Mr. Ball: Canada Health Infoway is certainly creating a foundation for better information collection management and, ultimately, its application. There are some fundamental issues that we need to resolve, as I mentioned, concerning privacy protection and use of information related to Aboriginal peoples. Those issues need to be addressed. We are working together within the health portfolio and with Aboriginal organizations in order to do that.
Clearly, Canada Health Infoway is one of the sources of support that will build a better foundation overall for information on population health of all Canadians and, hopefully, Aboriginal people.
Senator Cook: Thank you. First I should apologize for coming in late, but conflict with meetings does that to us around here.
I listened to all the expertise, the wisdom and all those components that are there, designed to care for those people and to bring them up to the norm. I wonder when all this will manifest itself in a community setting.
I am from Newfoundland and Labrador. I preoccupy my head, as I am sure Senator Cochrane does, with a model community in Conne River that is just wonderful. I try to see what elements are missing that makes Davis Inlet so different from Conne River and I see a lack of opportunity. Where do the people in Davis Inlet work? What do they do? What is there for their children? They still live in isolation, whereas the people in Conne River are connected.
At what point can we do something across the spectrum? Last week, I heard that a dozen eggs in Davis Inlet costs $8. When we look at nutrition, is there some way we can use subsidies so that those people do not feel they are getting handouts, that they are on a level playing field when it comes to the purchase of food? Surely that is one of the policies?
Why can we not move? We can build wells in Angola. I have helped as a member of the Girl Guide Movement. Why can those simple community projects not happen in our First Nations communities? Because, for sure, we destroyed them. I preoccupied myself for years with residential schools and our First Nation people and I woke up yesterday and no, it will never end. Now it is tuberculosis and the things we did not know that happened to those people.
I have thrown a lot of questions that I would like a few simple answers to, thank you.
Mr. Brooks: I will try to respond to a few of them. I have actually done quite a bit of work with Conne River in the past. There are always determinants for what makes a community successful and what does not. We do appreciate the problems with Davis Inlet. A fundamental determinant with Conne River is leadership. When you have a leader and council that has a vision and a community plan to put the vision together that encompasses socioeconomic components, where the community is today, where they hope to be in 10 or 15 years down the road and how they will get there, including all components like health, education, economic development, maintenance, caring for infrastructure and developing partnerships with other communities, that goes a long way.
I realize there are many issues with Davis Inlet and I cannot say too much on that.
One issue you did bring up, senator, was subsidization. Our department has a program referred to as food mail. I do not run that program, but it does provide partial subsidization, recognizing, to be honest, that food in remote communities is extremely expensive. I have heard cases of a litre of milk costing $12 in some communities. We are looking at some determinants of health right there. Getting fresh produce in many communities is virtually impossible because of the excessive cost to get it there.
Senator Cook: Are you saying that with the subsidies those are prices to the consumer?
Mr. Brooks: I do not know enough about the program to give you precision, but I would be willing to come back and provide that information.
Senator Cook: It is a dignified way of approaching a problem. People have a right to decent food and a right to live wherever they want.
Mr. Reading: In Ontario, and across Canada, the liquor control board makes sure that a bottle of alcohol, like rum or whisky, is set at a standard price for a province; if you buy it in Northwestern Ontario it will be the same price as it is in Ottawa. However the price of food varies quite a bit.
If we can afford to subsidize and democratize the purchase of alcohol across the province, even in remote areas, why can we not democratize and equalize the price of food for children? It seems to be backwards. I would not mind having to pay a higher price for alcohol to have a guaranteed basket of food that had all the nutritional components for healthy development. To me, that is a doable thing we can recommend.
The Chairman: We will see that that is in the report for sure.
Thank you very much. We really do have to run. We are in somebody else's territory right now.
To the committee, could we have a five minute in camera meeting in the room next door? We had a meeting of the steering committee yesterday on which we would like to report.
The committee continued in camera.