Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence - March 26, 2009
OTTAWA, Thursday, March 26, 2009
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 10:45 a.m. to examine and report on the impact of the factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health (topic: population health policy for Aboriginal Peoples).
Senator Wilbert J. Keon (Chair) in the chair.
[English]
The Chair: I call the meeting to order. I will not go around the table for introductions. Instead, I will introduce each person as we hear from them, in the interest of time, because we have a large number of witnesses. We are really anxious to hear from all of them.
I will make one exception. Jeff Reading is on the TV screen. He is coming in from Victoria.
We will begin with Kathy Langlois, Director General of the Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada. She is accompanied by Catherine Lyons, Director General, Business Planning Management Directorate, First Nations and Inuit Health Branch, Health Canada; and Shelagh Jane Woods, Director General, Primary and Public Health Directorate, First Nations and Inuit Health Branch, Health Canada.
Kathy Langlois, Director General, Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada: On behalf of Health Canada, we would like to thank you for inviting us here to speak with you today. I am pleased to attend with my two colleagues who have just been introduced.
[Translation]
We are pleased to be here to discuss the committee's work in linking the social determinants of health with better health policies and programs. My comments this morning will touch on two areas: first, Health Canada's national and international efforts to integrate the social determinants of health into policy development, and, second, the department's collaborative work to apply population health to national health programming.
[English]
My comments this morning will touch on two areas: Health Canada's national and international efforts to integrate the social determinants of health into policy development; and the department's collective work to apply population health to national health programming.
In both cases, my comments are in the context of First Nations and Inuit health, in particular the work of Health Canada's First Nations and Inuit Health Branch. I will be emphasizing the crucial role of partnerships in linking population health knowledge to effective policies and programs. As you well know, social determinants of health have wide-ranging and complex influences on the health of people, so good health policy and program development depends on solid relationships with key partners.
For example, Health Canada collaborates with other policy makers and practitioners around the world to exchange knowledge and share best practices regarding population health. This includes formal relationships with the United States and Mexico, and work with Brazil, Australia and New Zealand. Health Canada participated in the Adelaide Indigenous symposium in 2007 and in the 2008 meeting of the Pan American Health Organization, the theme of which was social determinants of health and the indigenous peoples of the Americas.
This work reinforces that a social determinants' lens is critical for policy makers. For example, our knowledge of water quality, sanitation and housing influences the development of a First Nations public health plan. We know that we need to consider education and income if we want to have effective health policies and programs. As well, we need to consider factors with more specific importance to First Nations and Inuit, such as their role in community governance or self-government and the strength of traditional culture.
Given that many of these determinants are formally outside of Health Canada's domain, we recognize that to build effective policies and programs, we must work with our partners, which include other federal departments, provincial- territorial governments, and most importantly, First Nations and Inuit communities. That is why Health Canada has built important relationships with these partners, some of which have been very long-standing.
This brings me to my second point: the department's work to best address the unique health needs of the population we serve. This includes specific programs and interventions targeted at distinct populations, including children, those with chronic and infectious disease including mental health, and those that are healthy. There is ongoing engagement with First Nations and Inuit, honouring their choices and advice; formalizing new partnership agreements between provincial governments and First Nation to integrate federal and provincial health systems and to optimize scarce resources; encouraging more flexible funding arrangements between Health Canada and First Nations that give communities more autonomy to match resources to their unique health needs. First Nations and Inuit communities interested in having more control over their health programs can decide among the different types of funding agreements because they vary in level of control, flexibility, authority, reporting requirements and accountability. My colleague Ms. Lyons can speak to that in more detail.
We work closely with other federal departments on key health-related initiatives, such as collaboration between Indian and Northern Affairs Canada, Environment Canada and First Nations to ensure safe drinking water on reserve.
Finally, because access to health care is a key determinant of health, we are focused in particular on improving access to quality primary care for First Nations and Inuit who live in remote and isolated communities. We are looking at innovations in health technology and the composition of our nurse-based care teams. Integrating population health knowledge into health policies and programs is key to improving the health of First Nations and Inuit. This integration needs partnerships to succeed. As I have said, these partnerships are with national and international groups, other levels of government, practitioners, researchers and, above all, with First Nations and Inuit.
[Translation]
Thank you for this opportunity to address the committee. If you have questions, we will gladly do our best to answer them.
[English]
The Chair: Ms. Quinn, please proceed.
Mary Quinn, Director General, Social Policy and Programs Branch, Indian and Northern Affairs Canada: Thank you for the opportunity to address subcommittee members today. The subcommittee continues to do important work leading to a better understanding of the social determinants of health and how they relate to Aboriginal and non- Aboriginal Canadians. It is a privilege for me to appear before you today, along with panel members who each have valuable perspectives on the issues before us today.
[Translation]
The department I represent, Indian and Northern Affairs Canada, has a broad mandate that touches on a number of the determinants of health for Aboriginal people in this country. Many other federal bodies also have responsibilities in this area.
[English]
We are continuing our efforts to improve coordination by working in partnership with other federal departments and agencies, First Nations, Inuit and Metis as well as provincial and territorial governments and other key partners.
I would like to describe a few recent initiatives that illustrate the interplay of health determinants for First Nations. As subcommittee members know, education, income, housing and health are all interrelated. The Government of Canada has been working with willing partners to identify and attack root causes of issues facing First Nations communities. Three years ago, for instance, 193 drinking water systems in First Nations communities were at high risk of failure. Today, the number is 58 and continues to decrease as a result of the partnerships that my colleague indicated among First Nations, Environment Canada, Indian and Northern Affairs Canada and Health Canada. Last week, Minister Strahl announced spending of $165 million to accelerate water and waste water infrastructure projects in 14 First Nations communities, which are essential to their health and safety. These investments will not only improve the quality of life on reserve, but also have the potential to stimulate economic growth.
[Translation]
Using a similar approach, the Government of Canada is putting particular emphasis on improving education for First Nations in partnership with provinces and First Nations.
[English]
An example of early efforts in education partnerships is the memorandum of understanding signed in April 2008 between the New Brunswick First Nations, the Province of New Brunswick and the Government of Canada, in which the parties agreed to work together to improve the educational outcomes of First Nations students in band-operated and public schools in New Brunswick. Under the agreement, the provincial government is committed to reinvesting 50 per cent of all future new tuition funds received from First Nations and the federal government to improve programs and services for First Nations students in the public education system. In addition to the $1.7 billion that the department invests in First Nations education, the federal government is investing $268 million over five years and ongoing funding of $75 million in subsequent years in two new education programs that are expected to set the foundation for long-term improvements in First Nations education. The programs are the First Nation Student Success Program and the Education Partnerships Program.
[Translation]
With new spending of $200 million over two years in Budget 2009, Minister Stahl has announced the construction of new schools in seven First Nation communities and three major school renovation projects.
[English]
A final example involves the problem of inadequate housing. The recent budget provides $400 million over the next two years to support on-reserve housing. To date, Minister Strahl has announced that approximately $50 million and $65 million will be made available to First Nations in British Columbia and in Ontario respectively, to address on- reserve housing needs in their communities. In this area we have Canada Mortgage and Housing Corporation as a key player as well.
The government has invested $300 million in a market housing fund to promote home ownership and to improve access to mortgages for First Nation families. Over the next 10 years, the money is expected to translate into some 25,000 houses on reserve. Each of these initiatives that has been undertaken or announced is characterized by a collaborative, comprehensive and long-term approach to a single issue.
In closing, I would like to note that the department is continuing to review the Food Mail Program to determine whether it is the most efficient and effective way of addressing the high cost of food in isolated northern communities. I know that both the department and the subcommittee are concerned about access to healthy food at affordable prices, given that it is a significant factor in improving the quality of life, nutrition and health in isolated northern communities.
Research conducted at the department has identified some progress in the living conditions and well-being of Aboriginal peoples of Canada over the past 20 years in key areas such as life expectancy, education, housing and income. For example, there have been improvements in educational attainment by First Nations, Inuit and Metis women. Such improvements are widely acknowledged to lead directly to improved population health outcomes. While there are many challenges in attempting to close the remaining gaps, the fact that well-being has been increasing in Aboriginal communities is promising.
Dr. Jeff Reading, Professor and Director, Centre for Aboriginal Health Research, University of Victoria: Thank you for the opportunity today. It is a long time coming, and I hope that your deliberations result in addressing Aboriginal issues, which are really in a crisis. That is the way I have to characterize it.
The crisis in Aboriginal people's health today is complicated by issues that are deeply rooted in long-term, historical, social disparities, which is why there is a concern that no amount of risk assessment or health recommendations will reduce the burden of disease without a parallel understanding of the importance of social change. We can either address this now or we can wait 10 years, and I think without addressing those fundamental determinants, nothing will really change.
That population level factors that determine the health and well-being for any collectivity have their origins in upstream historic, cultural, social, economic and political forces affecting the lives of indigenous people in Canada, has been articulated for more than two decades. As was noted by Ms. Langlois, many of the determinants of health for Aboriginal people are really beyond the scope of the health care delivery system. Such determinants include, changing diets from traditional to non-traditional foods, the issue of food insecurity, stress due to economic factors, pollution and environmental degradation, global capitalism, et cetera. These are all forces that are upstream of the health care system.
It is important to understand that words and their interpretation are very important in a discourse on determinants of health, especially if the aim is to better understand the causes. I will talk a bit of causes of causes of causes, and that gets a little redundant, but it is important.
Aboriginal peoples historically and to the present day have really not been full participants in the nation state called Canada. As the political economy of Canada evolved, it became necessary to dislocate Aboriginal peoples from their traditional lands and their way of life in order to make way for settler societies. That is not my opinion; it is a matter of fact. The process of dislocation as a result of colonization meant many Aboriginal people and communities were socially excluded from Canada. This led to marginalization in education and employment, housing, health care and many other services. This, in turn, effectively created a two-tiered society in Canada — one standard for Canadians as a whole and another standard for Aboriginal peoples.
This is difficult for many Canadians to accept, but, a plethora of evidence proves the Aboriginal experience in Canada is unequal. I recently submitted a report to the committee and Sen. Keon which had over 500 references and 155 pages of single-spaced text documenting this unequal experience. Essentially, Aboriginal peoples experience greater health risk in almost every category that we measure, which in turns leads to profound disparity for Aboriginal peoples, especially the most vulnerable, namely children and the elderly.
The social determinants are often referred to as causes of causes. This is coined by Sir Michael Marmot, who is the grandfather of social determinants. This means that disease, disability and death are influenced by individual risk factors such as smoking, obesity, substance abuse, et cetera. These risk factors have been criticized as blaming the victim, as it is really now fully understood that risk factors are socially embedded in the collective lives of individuals, families, communities, regions and even in this case, nation states.
Disparities in social determinants require social remedies, and that is a take-home message. One social remedy is the Assembly of First Nations' campaign to end poverty now. Poverty eradication is the most important determinant of health, in my view, because it is through income that other determinants are purchased, such as adequate housing, access to health care services and even education, potable water, nutritious foods, et cetera.
A recent report from the Public Health Agency of Canada said Aboriginal peoples experienced disparities that are not simply explained or understood using mainstream templates for what determines Aboriginal health. For example, when Aboriginal peoples living off reserve in urban settings were compared to non-Aboriginal people, both groups in urban settings and at comparable levels of income, the Aboriginal group experienced significantly more depressive episodes, 21 per cent versus 13 per cent for their non-Aboriginal counterparts. There is something more than income and geography at play in this scenario. Interestingly, as the income comparisons went from low to high for both groups, so too did the gradient in depressive symptoms, which was reduced to statistical insignificance at the highest income level.
To explore the origins of health for Aboriginal people, the unique context includes an examination of social political factors, a holistic perspective on health with optimization at each stage of life from preconception to death. This life course perspective is extremely important.
I want to talk about causes of causes of causes, which I have segmented into proximal, intermediate and distal. The proximal factors in terms of determinants include health behaviours, physical environment, employment and income, education and food insecurity. The upstream intermediate determinants, described as upstream to the proximal, include health care, education again, community infrastructure, resources and capacities, environmental stewardship and cultural continuity. The most distal determinants include the experience of colonization, racism, social exclusion and the need to pursue self-determination as a step towards Aboriginal population recovery.
The goal is to optimize the developmental trajectory over the entire life course, and the object is to address the complex interaction of health determinants and exposures in particular Aboriginal contexts, whether First Nations, Inuit or Metis, urban, rural or remote, over the entire life course. That is the challenge.
The discussion needs to include community level or broad reaching risk factors that influence health and well-being across the life course for collective health. These cross-cutting risk factors help to set the stage and highlight the underlying risk factors, including health and well-being for Aboriginal population.
We need to begin to look at life stages. I cannot emphasize this enough. Naturally, this could begin with a discussion of prenatal risk factors, including in-depth discussions of birth and the connection to early childhood, childhood and adolescences, and adult risk factors. This is a natural and logical ordering that follows the life trajectory and the temporal course of risk exposure and disease development. These factors and influences are connected to one another across the life course. While this separation of the different life stages is important, it is also important to remember that many risk factors are present at several life stages.
My proposal is for a community-based population health model that would address health determinants, facilitate and complement a whole-of-government approach to Aboriginal population health at the federal level, with partnership at the regional level, of course. The model would need to create a strategic alliance that connects the health determinants.
According to the third report of the Senate committee, over 30 federal departments and agencies are delivering over 360 programs and services to Aboriginal people, with more than half, about 190, available to all groups, and the remainder available to particular groups. That was the 2008 report. The six core areas of the proposed strategic alliance here, I would propose, are education, which is extremely important, community prevention and intervention, a special focus on mental health, housing issues, community development and capacity investments, and finally the need to build a cadre of health professionals at all levels in the development of a comprehensive aboriginal health workforce.
Given that some 50 per cent of Aboriginal population is under the age of 25, it is logical to invest heavily in the health of future generations while not ignoring the needs of the present. During early life, from pre-conception to the prenatal and postnatal periods, life is almost totally dependent on the health of the mother. Although malleability is greatest in the earliest stages in life, spending on health, education and general well-being is the inverse of that, with the least amount spent in early life and the greatest investments made at the end of life. There has to be balancing there to optimize the developmental trajectory.
The regional health survey found that the social support and well-being undertaken by the First Nations there of children is directly affected by the socio-economic status and educational attainment of the parents. Thus, education of children is one of the most obvious solutions. Longitudinal follow-up studies of the Head Start Program in the United States and other places shows that early childhood education programs increase educational attainment, lower rates of social assistance, crime and teenage pregnancy.
In closing, I believe it is important to reflect on the pursuit of a whole-of-government approach, which is being done in Australia with the support of the Prime Minister, and support Aboriginal peoples' legitimate desire to achieve self- determination. In health services this means a development of Aboriginal-led regional health authorities, funded and supported by federal and provincial funds. We need to seek commitment among Aboriginal political organizations, political, territorial and federal government to a multi-year dialogue to explore common issues and agendas for action to improve Aboriginal health and well-being. This will not be a quick fix. It needs dialogue and discussion.
Another idea is to facilitate and accelerate the dissemination and translation of knowledge into potential applications and benefits through policies, interventions, services and products. Finally, there is a need to encourage multilateral collaborative ventures among communities, between communities and institutions concerned with improving the health and well-being of Aboriginal people. We need to promote multi-disciplinary, multi-institutional, multi-sector collaborations, and build upon existing frameworks of policy-makers and researchers to further develop capacities on Aboriginal people's health in areas of mutual shared priorities.
I would like to leave the last word to the Senate Committee on Population Health from its fourth report, where they state and in fact the subcommittee believes that it is unacceptable for a privileged country like Canada to continue to tolerate such disparities in health.
Debbie Dedam-Montour, Executive Director, National Indian and Inuit Community Health Organization: Our organization works on behalf of CHRs, community health representatives. The CHRs are front-line, paraprofessional health care providers serving First Nation and Inuit communities for 47 years. Many of these communities are remote or isolated. We provide an annual national training session promoting holistic health and build capacity on various issues ranging from abuse prevention, tobacco misuse, abuse, injury prevention and diabetes, to developing resources on HIV/AIDS, to keeping older Aboriginal elders active. To look at closing the gap, we need to address health inequities. This presentation will focus on how CHRs can facilitate that objective.
When we look at population health, any change we want to see is going to happen at the community level. The CHR's approach is to look at health from a wellness model, using health promotion, health education and disease prevention initiatives. The CHRs play a vital role as key individuals in community health, who know and monitor the pulse of their community's well-being. As front-line health care workers, they are the first line of defence in identifying a problem and to facilitate intervention in collaboration with other members of their health team. That is the level where CHRs work. They are key in delivering services in a local context, a lifeline in community health, yet supports for many CHRs are lacking.
The Royal Commission on Aboriginal Peoples stated that the CHR program is one of the most successful programs involving Aboriginal people in promoting their health. It further states that in particular, CHRs can help Aboriginal individuals and communities learn to exercise personal and collective responsibility with regard to health matters.
Our hope arising from the report of the Royal Commission on Aboriginal People was that such statements would set the stage for greater support and capacity development of CHRs. Sadly, instead of greater support for this program and these important stable and trusted frontline paraprofessional health care providers in First Nation and Inuit communities, the CHR program was removed from the compendium of programs at the federal level, and operational funding to the CHRs national organization was cut off. I believe that was in 1999 or 2000.
CHRs work with all community members within all stages of life, from promoting good preconception health, right up to providing comfort to those in the last stages of their life. In looking at closing the gap, one must look at the fact that on average First Nation and Inuit peoples' life expectancy is 5 to 10 years less than Canadians as a whole.
We need a well-trained community health provider who knows their community and has the trust of the population to help people work together on the modifiable factors to extend life expectancy; namely lifestyle, diet, exercise, driving safely, reducing misuse and abuse of tobacco and facilitating access to health care.
All these are within the scope of CHR duties. They can generate a positive impact but they need training, ongoing continuing education opportunities, sufficient culturally appropriate resources and wage parity.
It has been frequently stated that we need more health care professionals, yet there is an important workforce within First Nation and Inuit communities that is not being supported to build their skills capacity. The National Indian and Inuit Community Health Representatives Organization has developed a capacity development roadmap called Road to Competency, but that initiative has not moved forward since March 2007.
Some who have stated that the role of CHRs has diminished or communities are not hiring CHRs. What NIICHRO has noted is that the CHRs are being re-titled. Instead of building capacity and increasing the numbers of these paraprofessional health providers, a variety of new program positions are created. These new program workers are doing what CHRs have done for almost 50 years. This re-titling of CHRs has undermined the CHR program and CHRs ability to work across lifespans. New mothers are now under the responsibility of the newly created CPNP — the Canadian Pre-natal Nutrition Program, and elders deal with the newly created Aboriginal Diabetes Initiative worker. These programs are important but lead to program silos which have caused voids in health care delivery.
Work to increase the number of CHRs and their skills capacity is needed now more than ever, as we consider the lack of health professionals in this country. For isolated and remote First Nation and Inuit communities this is especially important as they suffer from periods when there is no nurse and only have access to fly-in doctors. The amount of time these workers spend is limited and does not provide continuity and opportunity to build trust relationships, both which enable better health outcomes.
In conclusion, the means NIICHRO sees of advancing the agenda of closing the gap is two-fold: Reinstate the CHR program in such a manner that it can evolve to respond to community needs now and in the future; and a policy that supports program delivery through CHRs, as they are the stable and trusted health care provider with expert knowledge of the local context.
The chair of this subcommittee, Senator Keon, in a recent presentation at the Aboriginal Child Rearing Showcase Conference stated that building human capital will lead to health capital. NIICHRO is in agreement with that statement as it relates to CHRs. Increasing the number and skills capacity of CHRs will bring better health outcomes at the local level.
Peter Dinsdale, Executive Director, National Association of Friendship Centres: Let me start by saying it is an honour to appear before the committee. I would like to acknowledge the other presenters. It is a great honour for us to be sharing this time with you. I also would like to acknowledge the clerk and all the work she had done chasing me around the country to make sure my stuff was in on time.
None of these things happen in isolation. I would like to acknowledge the great work of the National Collaborating Centre for Aboriginal Health, which has done a lot of excellent work on the social determinants of Aboriginal health.
We also had an opportunity to work with the Canadian Reference Group to the World Health Organization on social determinants of health, and had a great opportunity to provide feedback specifically on some Aboriginal issues. None of this happens in a vacuum. In our presentation today, we are trying to build upon the shoulders of all these leaders we have been talking with.
In case some of you are not aware, the National Association of Friendship Centres is a national Aboriginal organization. Sometimes we only talk about five; there are many others and we are one of them. We represent the concerns and interests of 120 Friendship Centres across Canada, from coast to coast to coast. They are not on reserve, but they are urban, rural and remote. Our mission is to improve the quality of life of Aboriginal peoples in these areas.
We provide about $114 million in programming on the ground through a variety of partnerships. About one third is other provincial and territorial governments investing; one third is other federal departments, including Health Canada, through some of the children's programs that were discussed today; and the other third is a variety of sources, including municipal, own-source revenue generation and other foundations.
We have included a more robust presentation. I will not go through it slide by slide, but there is a map showing where the Friendship Centres are located across Canada.
The thrust of my presentation is to highlight the challenges facing urban areas specifically. It is not to minimize the challenges experienced elsewhere, but it is a policy thrust that often gets ignored in program and service development which occurs after these issues are addressed. We have heard about some of that isolation today.
The 2000 census showed 54 per cent of all Aboriginal people live in cities. I will ask you in your deliberations, have you found that 54 per cent of the policy and program responses are geared toward addressing this population? I will tell you they are not.
One in 10 of the residents in Winnipeg are Aboriginal. We are seeing huge growth in areas like Edmonton and Halifax; in fact, all over the country, the urban population is growing. Just about half, 48 per cent of the population in the 2006 census, is under the age of 25.
As a service delivery provider, we are dealing with a very urban, young and impoverished population for all those reasons that the social determinants of health will talk about. This is the policy challenge we face every day, yet this is not the kind of program focus provided on the ground. That is the real problem for us.
You know the social determinants of health broadly. You know there are specific Aboriginal social determinants of health that have been articulated by the National Collaborating Centre for Aboriginal Health, the AFN and others, who have done great work in addressing some of these issues.
As a national body, we are in the process of articulating some urban Aboriginal social determinants of health. In my short time with you, I would like to focus on poverty. I am glad Mr. Reading said he thought it was one of the more significant issues.
I will provide an example of how poverty has a different focus in urban areas, and how the policy response will be different but we never get to this level of conversation in the Aboriginal community.
I will focus first on participation rate in the Canadian economy. The 2006 census showed that 66.9 per cent of all Canadians participate in the Canadian economy. The total Aboriginal rate is 63.1 per cent, significantly less. For rural Aboriginal people, it is 64.2 per cent, more than total Aboriginal but still less than Canada.
Urban Aboriginal people participate at 67.5 per cent, more than the Canadian average; yet our average income is much lower. The average income for Canada is $35,000 total family income and the total urban Aboriginal income is $26,000 and change.
There is a variety of reasons for that disparity, including education achievement. It is easy to get low-paying jobs in cities. We believe, because of racism and discrimination in cities, we are less likely to be promoted in jobs. We are in some of these locales where average income is artificially suppressed as a result.
As Mr. Reading said, this has a tremendous impact. Part of our issue with Kelowna — and we are one of the few Aboriginal organizations that did not agree with Kelowna in the final analysis — was that it did not help a mythical Aboriginal woman living in downtown Winnipeg.
She needs to work, to finish her schooling; she needs to access training and child care. If we are to impact the Aboriginal community broadly, we have to address the needs of that mythical woman and her child. If she finishes school, gets a better job and lives in better neighbourhood, her child will go to a better school and live in a better neighbourhood. Her life and her child's life will be better for generations.
These are the kinds of strategic investments and policy focuses that are required. Yet these are not the kinds of things we are seeing in the general discourse of federal Aboriginal employment training programming, provincial responses or in that murky jurisdictional area that exists, where neither the federal government wants to show leadership nor the provincial government wants to respond.
If you think about poverty, or maybe more specifically about employment and training, what are the responses that will be required nationally, regionally and locally in order to make a difference?
Nationally, we need a federal partner that understands these challenges and is willing to act. Currently, in federal Aboriginal training employment programs, most of the focus is on a First Nation, Metis or Inuit basis. That is a great policy basis, but if 54 per cent of all Aboriginal people live in urban areas, there is a huge gap. That three-group focus does not reach non-status Indians or people across Canada. There is a huge grey area that does not get addressed with that kind of programmatic response.
Economic development strategies need to make sure they are reaching people where they live and providing access to capital and appropriate training. The focus of the Aboriginal economic development strategy in urban areas will be different than in rural and remote areas. This is not oil and gas; it is starting small businesses.
Until the provincial and federal thinking around Aboriginal programming changes, we will continue to only talk about oil and gas and resource extraction. We will not talk about small businesses in urban areas where our people are living.
Regionally, we need to make sure that labour market initiatives and agreements among provinces, the federal government and cities work for urban Aboriginal people. That is not always the case for a variety of reasons.
Locally, we need to make sure daycare funding is available. We need to ensure we do not have an artificial barrier that because you are an urban Aboriginal person, you are not able to access the federal employment training program — which exists sometimes right now.
This is the kind of policy approach and lens that needs to be used if we are going to take a serious run at addressing the issues in a systemic way across Canada.
You have asked a number of specific questions and we responded to them in our presentation. Because I have a limited amount of time, I will end with recommendations.
We have hinted at a bunch of them. I want to also mention that the Aboriginal Friendship Centre Program was cut by 25 per cent in the 1990s —1996 to be exact. Not one cent has been invested in it since. With inflation, that is nearly a 50 per cent reduction in purchasing power.
Imagine if your Senate offices were restricted to 1996 dollars in terms of how you could staff your offices and the work you were able to do. Image if this committee's dollars were in 1996 dollars. This is what is facing our front line community agencies across the country.
Some of our executive directors are being paid $40,000 a year. They are doing great work for that, but we are not attracting the best to serve this growing and emerging problem.
We served 1.3 million client contacts across the country last year through these agencies. We need to leverage significant provincial, federal and local support for the programs and services. This is a complex job. We need highly trained and educated people, but we also need to be competitive in this wage economy.
One thing this committee can do is recommend that the Department of Canadian Heritage respond appropriately and take safe stewardship of the program they have, which is called the Aboriginal Friendship Centre Program.
That is my presentation. There are other direct questions that you asked of us as presenters here today, and I will be pleased to answer them afterwards if you would like to explore them.
Rosella Kinoshameg, President, Aboriginal Nurses Association of Canada: Thank you for inviting me to this panel. I am the President of the Aboriginal Nurses Association of Canada and I am in my second term. However, I have been with the association since its beginning. We came together in 1974 and became formally established in 1975.
We are the only Aboriginal professional nursing organization in Canada. It recognizes that Aboriginal people's health needs can be best met and understood by health professionals of a similar cultural background.
We do have our vision as the wellness of Aboriginal people. That is in a broad sense. Therefore, our mission is to improve the health by supporting Aboriginal nurses and to promote the development of Aboriginal health nursing practices. Our nurses stretch across Canada. We have a representative from each province on our board but a few of those seats are vacant right now either because we do not have nurses in those communities or there is no one available to take on those seats.
The nurses that we have that belong to our association work in communities in various capacities. Quite often, our nurses are considered the experts in Aboriginal health and they should be because that is what they do. As a president, I do all of that, too.
Our present numbers cannot meet the demands of the health requests that are out there right now. Forty-one per cent of Canadian nurses are over the age of 45 and you all know that; that is a known fact now. Twenty-five per cent of the nurses of Aboriginal ancestry are over the age of 45. The baby-boomers are leaving the work force and are entering retirement. I, myself, will be doing that very soon. Less than 1 per cent of registered nurses in Canada are First Nations, Inuit and Metis. That is a very low number.
By the year 2011, there will be a nursing shortfall of 78,000 and that will increase to 113,000 by the year 2016. The numbers simply are not there.
As an association, we have developed partnerships with CASN — the Canadian Association of Schools of Nursing — and CAN — the Canadian Nurses Association. Hopefully, we will increase the number of nurses or nursing students. It is not a formal partnership but we are aligned with the Canadian Nurses Foundation to increase scholarships for Aboriginal nursing students in the baccalaureate, masters and nurse practitioner categories and for people doing research in the communities.
We also want to support nursing students through mentoring programs. Our association ran such a pilot project this past year. We will also be looking forward to doing a mentoring program for nurses when they finish their entry into their practice because they need it when they go into their communities.
I will not go into all the determinants of health that were discussed because they are all true. You all know that. However, I did look at all the possibilities and options that were put out for consideration and I can see the consideration of those three options to some extent.
There must be consultation. I have been in situations where one Aboriginal person speaks up and that is considered consultation. I am not referring to that kind of consultation. There must be consultation with Aboriginal people; there must be involvement and full participation of the Aboriginal leaders. That is a must.
All areas across Canada are different. We cannot generalize them or say a ``pan-Canadian approach'' because one size will not fit all. They all must be different.
Perhaps we have to focus on selected determinants; that may have to be the approach to go in some areas. We also may need to strengthen peer learning for greater sharing of experiences and approaches. Some areas have gone ahead and done great work where they were. They have successful programs and that needs to be shared with others so that others are aware that the wheel does not need to be reinvented.
Aboriginal leaders must be consulted or else it will not go anywhere; they must be involved. Also, I do not think it can come down from the top to the bottom. It has to go to the bottom leaders and then work with those people.
I would suggest maybe bringing one or two Aboriginal leaders from each area together to a training session or a strategic planning session to discuss what has been presented in terms of the population health and the determinants of health — or, maybe, we should say ``determinants of wellness'' — the health disparities and the statistics that have been presented.
These things do not filter down to the people at the bottom level and I think we should see a movement once they know all these things — the statistics and what population health is and what the social determinants of health are. I know there are people that are already familiar with those but there are others who are not familiar with those terms.
We need to engage Aboriginal leaders in capacity building, training in the terms we have discussed — population health — and even develop their capacity to participate in this whole process.
As far as coordinating and integrating activities of different departments and agency, they have to be coordinated and the policies need to be coordinated because I have experienced being passed from one department to another or from the federal to the provincial. Each says is it not their issue; it is a back-and-forth battle all the time.
There is a need to access current process of programs, services and funding areas. Population numbers are sometimes being used to determine the level of funding and I think simply using numbers and not looking at communities sets a system to fail.
I had suggested that this Subcommittee on Population Health take the lead in terms of bringing all these people together so it can all be discussed. Part of that is being done today but it is a small group. We need to broaden that to include other people so everyone is engaged.
Perhaps we need to have pilot projects that include the various levels of communities: Those communities that are isolated or small or those that are close to the urban or large centres because they are all different.
Capacity building is also very important. There needs to be authority over the resources. There must be flexibility to address what needs to be done in your own community.
In talking about closing the gap, we should bring together the First Nations Inuit Health Branch, INAC, Health Canada and the health integrated networks now in place. That will allow them to address those gaps so that they are not working in isolation. We need to work more closely together to ensure that there are no gaps.
Traditional teachings say we need to listen with our eyes, our ears and our hearts. At a session I was at this morning they talked about the need to listen and to love so that we can do the healing. That love will come from our hearts. When we do that, healing will take place among our people. Meegwetch.
The Chair: The senators have questions for all of you. I have a question for Ms. Dedam-Montour, Ms. Kinoshameg and Mr. Dinsdale to answer, as well as anyone else who wishes to respond.
We had a careful look at the Cuban health system so that we could study the polyclinics in the communities on the ground, where they offer primary health services, education, social services, promotion of productivity, et cetera. We came back convinced and prepared a report to say that this model could be most helpful in Canada, in particular to First Nations.
Ms. Kinoshameg, what impressed me about the polyclinics is that they do provide not only services but also the development of human capital in the broadest context. They were not afraid to step over the boundaries. For example, we have heard from some Canadian nurses that one problem with getting Aboriginal nurses is that there are not enough people in the Aboriginal communities qualified to get into nursing. Cubans do not worry about that. They train nurses to whatever level they can get them to in the local polyclinics. As well, they train other health professionals needed in local polyclinics. They meet their manpower needs locally with training on site in the polyclinics.
Since you are a nurse, what do you think of that? The same applies to the doctors. There are two big medical schools in Havana, but 16 small educational schools in the polyclinics. They train the doctors to whatever level they can and they have literally hundreds of doctors. They have the lowest doctor-patient ratio perhaps in the world.
I know how concerned nurses' associations are about their standards, which is understandable, and the medical profession has the same concern. What do you think of the polyclinic model? I invite you to respond first, Ms. Kinoshameg, but I want to hear from Mr. Dinsdale and Ms. Dedam-Montour as well.
Mr. Dinsdale, I want you to explore this because the friendship centre that I visited could become the nucleus for community development in the cities in the form of polyclinics, educational facilities, social services and educational programs that lead to productivity and employment.
Ms. Kinoshameg: I would have to look into the model you are talking about. I have not studied it but I know that we are working with schools of nursing and with the Canadian Nurses Association to do something with our nursing schools across Canada so we can recruit more Aboriginal students and keep them. There is a need to ensure cultural sensitivity in the programs. Many nursing students do not stay in the programs because of things that happen, how they are treated or how they are spoken to. We need to make changes in the system so that they can stay and complete their nursing programs and ensure they understand that each nursing school will be doing the cultural training for their own area. In that way, the nurse will be able to go back. If they do not know their cultural teachings, they will learn them. The non-Aboriginal nurses will also learn those things so that when they go to a community, they will be able to work with the Aboriginal people in the community in a better way than they are doing now. We have a book called Twice as Good, because we have had to work twice as hard to get to where we are now. For me to be here today, I had to do that also.
Senator Pépin: You speak about nursing schools and about keeping those young women in nursing. Are you speaking about the nursing schools in general or about nursing schools for Aboriginal women? You say that they need to know more about their background and culture. Where do they train? Do they train in a special nursing school for your community?
Ms. Kinoshameg: I am talking about regular nursing schools across Canada, where they go to be trained. There is nothing specific for Aboriginal nurses in the communities. We take the normal stream.
Senator Pépin: Depending on where they come from, do they not have their cultural background?
Ms. Kinoshameg: Sometimes they do not have. This can happen as a result of colonization where we could not believe in or do the things that we did many years ago.
Senator Pépin: We were told also yesterday that the young women who are in the communities as nurses are leaders in their communities. There is a lack of nurses but we were told that they were leaders in their communities and that they could work well between different clinics. The big problem is the lack of nurses.
Ms. Kinoshameg: There are not enough to go around.
Ms. Dedam-Montour: I will comment on your reference to the Cuban model. As Ms. Kinoshameg said, we are not familiar with the polyclinics but I see the CHRs fitting in for the development of human capital at a local level. When we look at the CHRs and the road to competency and the kind of training required, currently many of them do not have a high level of education. Many of them have gone on to university or taken other kinds of nursing training but the majority are from the community. They have not had the opportunity to reach higher education levels.
We do an assessment to prepare them for training. We look at the skills they have. Some of these CHRs have been working in their communities for 10 years and they have had no formal training. They do it on the job. They are from the community; they are serving their communities; they know the needs. People will speak to them and tell them their problem. They help them through it to obtain access to health care.
We need to grandfather their skills, to recognize what they have gained through on the job work. We also need flexibility in the delivery of training. I think that is what they are doing in the Cuban model. They look at the need instead of looking at the system as a whole. They are looking at the individual and saying how we can improve their skills. No matter what the benchmark is for that country or region, we need to at least try to work towards that.
We see increasing skills through various models as possibilities to train CHRs. For example, we can use the technology of telehealth, which is being introduced into more and more communities. That is a means by which training can be provided.
Another issue we found is that there is a lot of stress and emphasis on the CHR because of the lack of health care professionals in the community. They are sometimes the only person to provide health care. The community does not want them to leave to get training. There is a problem where you need a trained workforce, but those who could possibly climb that career ladder and become a professional — whether it is to become a nurse or a doctor — are almost not allowed to undertake that because of the need in the community and the lack of health care providers.
Mr. Dinsdale: The general spirit of finding ways to get particular people into programs and overcoming artificial barriers is critical. It is important to keep in mind that there is a two per cent cap on post-secondary education funding on reserve, which artificially prevents many Aboriginal people from entering the school system. This notion that education funding is somehow discretionary is not helpful. The long-term viability of this being downloaded is a murky area.
In a previous life, I worked in Toronto at Native Child and Family Services. I was hired to develop an alternative school for Aboriginal street kids. We had a partnership with Jarvis Collegiate. The program is still operating and it is called the Native Learning Centre.
What is important about that is we did not start the program. We engaged with the University of Toronto First Nations House, which has a transition year program. In this transition year program, youth that got their high school education through Jarvis Collegiate ended up going to the University of Toronto three years later. They went from living on the street to going to school at the University of Toronto — a school that would not even look at my application when I applied coming out of high school. That is fabulous.
There are ways and models in Canada that could be emulated. We have a policy focus on Aboriginal lawyers — we have entry programs and summer programs. I think we need to have a similar priority for Aboriginal nurses or doctors. The Northern Ontario School of Medicine is supposed to have the training of Aboriginal doctors as part of its mandate. I have no idea where it is at. I was at the foundational meetings. Probably other colleagues are better positioned to respond to where other schools are positioned.
The spirit of the Cuban model is overcoming artificial barriers and boundaries that exist in Canada. It is necessary to have the policy focus and drive, the same as we have with lawyers, to say we require health care professionals as well.
You also mentioned specifically about friendship centres in the long term. We are community development leaders. We have been in this business since the 1950s. We have lacked a viable federal partner for some time in terms of employment, training, health programming and other areas. It is either not attractive or not the policy focus of the day to focus on people in urban areas. We will continue to position ourselves as effective, accountability professional partners. We are making a difference. We could do so much more if we had an engaging federal partner.
Shelagh Jane Woods, Director General, Primary and Public Health, First Nations and Inuit Health Branch, Health Canada: It is almost like I am practicing for another committee next week, which is where we will go to talk about the Aboriginal Health Human Resources Initiative. I wish I had done my homework in advance, but I can refer to some of the things.
We have a five-year initiative that winds down at the end of next year — the Aboriginal Health Human Resources Initiative. Money was granted in 2004 and we started up in 2005. There was $100 million over five years.
I do not have the things with me and I always forget the last of any list. There were three main objectives. First was to increase the number of Aboriginal health workers. We have toyed with the term ``professionals.'' There was a doctor focus at the beginning and then a nurse focus. We decided that it really needs to be the whole spectrum of Aboriginal health workers. Second was to do something about the curriculum. We started with medical schools. Third was to improve retention in Aboriginal communities of qualified workers, in particular, the Aboriginal ones.
We have talked about some of the initiatives here in an indirect way. I think what Ms. Kinoshameg is working on with the Canadian Association of Schools of Nursing is one thing we have been supporting. There was an initiative with the Association of Faculties of Medicine of Canada and with the Indigenous Physicians Association of Canada to develop content for medical schools that would add cultural safety and cultural competence. That will be announced today, actually. I am trying not to scoop my minister. It is considered bad for your career.
There are a number of initiatives. Mr. Dinsdale referred to the Northern Ontario School of Medicine. At least half dozen medical schools have already begun to develop cultural support programs for Aboriginal students. We are painfully aware of how difficult it is for Aboriginal students to find themselves in an unfriendly, foreign or unknown milieu and to have no one to turn to. Some of the early initiatives we funded have been the inclusion of elder services at some of the universities and colleges, for example.
The biggest part of our activities has been an enhancement of bursaries and scholarships made available to Aboriginal students, largely through the National Aboriginal Achievement Foundation. They have been managing scholarships and bursaries for us for a long time and we have added significant funds. That has enabled people across a broad spectrum of health careers to apply and receive funding support.
I thought it was important to mention those things. I think we are beginning to see some successes.
Senator Eggleton: I want to explore three areas. I will start with Ms. Langlois and her associates from Health Canada. Your presentation on the work you are doing is very good. As you point out, many of the determinants of health are outside the domain of Health Canada. It involves working with other people in other departments, and you say you are doing a lot of that.
However, there are many disparities and inequities that still exist, both within the Aboriginal community and between the general population and the Aboriginal community. In dealing with this at the federal level, not only is there your department, but there are approximately 30 federal departments involved in the concept of population health. Many are outside of your jurisdiction, such as anti-poverty measures, housing strategies or educational programs, et cetera. They are all still part of population health. How do we get these all coordinated to improve upon where we are now?
As a former President of the Treasury Board, I know that there are enormous challenges in trying to bring about horizontal links. This is a silo or stovepipe system where the allocation of money is in the purview of particular ministers. How you get this all to flow to get a whole-of-government approach is an enormous challenge.
What are your thoughts on how we can move this up, how we can go to a whole-of-government approach, how we can know whether we are succeeding or not? Do we need performance indicators? Do we need anti-poverty strategies and things like that as part of it? How do we move this up a notch to be able to improve upon where we are?
Ms. Langlois: I think it goes to the heart of what the committee is focused on. You are making this recommendation around a whole-of-government approach and how we will we get there.
From a health perspective, I would say our interest is to ensure there are the determinants of health. I can tell you that our medical officers of health are often concerned about what they will see in terms of their knowledge of the housing conditions.
They are anxious to engage with communities to begin to address housing. They are anxious to engage with INAC around housing. We see internally within the health system and our own staff the pressure to begin to look beyond our borders to deal with some of these causes of causes of causes, as Mr. Reading alluded to.
I can tell you that with our ADM — I can start there in terms of the senior management of the department — and certainly our deputy minister, there is engagement with INAC on a regular basis. There is discussion about how we work together, how we move forward on agendas. Ms. Quinn and I co-chair some different committees to begin to see how we can work better together to effect the kind of change you are looking for.
I would be remiss not to say it has to go beyond our level. It comes to fundamental accountabilities in the system for us as public servants in terms of our role of working horizontally. My experience and knowledge in working in the provincial system is you get people's attention on working horizontally when you put that in their performance objectives and their pay is tied to that.
You will see examples in the Alberta government. There have been examples in the Saskatchewan government. As your performance pay is tied to how well you achieved that horizontal initiative and worked with your colleagues, you begin to see attention being paid to that.
That is a personal perception about how you get people to change their behaviour. I would acknowledge, as well, the tremendous challenges there are in working horizontally, certainly in a federal system because it is so large.
Senator Eggleton: We need leadership from the top and then you need to put it into performance pay, requirements, contracts or whatever with employees. Those are good ideas.
Dr. Reading: I just came out of a meeting with Australia, New Zealand, Canada and the United States. It has been a year since the Prime Minister in Australia issued a statement on closing the gap.
In Australia, there is a national effort to close the gap between the health status for indigenous Australians versus the mainstream. On the first day of Parliament every working year, the Prime Minister reports to Parliament on the progress the entire government is making on closing the gap.
There is a 17-year gap there between indigenous and non-indigenous people. They are looking at closing the gap on life expectancy, on infant mortality and mortality in children up to five years old, the gap in literacy and the numeracy gap.
It is a big turnaround for Australia, but to be clear, it must come from the highest level. It has to be a priority of the Prime Minister.
Senator Eggleton: What do they have in terms of a structure to ensure this flows properly? Is there a cabinet committee or does the Prime Minister personally oversee this entire project?
Dr. Reading: I can tell you from my discussions with the people in the trenches there producing the data that there is a tremendous amount of work going on to address this issue. They have their marching orders and the parliamentary committees are reporting directly to the Prime Minister across all of government on this issue. As the Prime Minister says, it is a core priority of the government.
Senator Eggleton: That was actually my second question. I was going to ask Dr. Reading about Australia.
My third question is for Ms. Quinn, who mentioned the investment in the First Nations Market Housing Fund of $300 million over the next 10 years, which is expected to provide some 25,000 housing units on reserve. As Mr. Dinsdale pointed out, 54 per cent of the Aboriginal population do not live on reserves; they live in the general population in towns, cities and rural areas across the country.
They may well qualify for other housing programs that are available to the general population. However, given the disparities that we have talked about today and that we know about, what is being done that is specific for off-reserve Aboriginals in terms of housing?
Ms. Quinn: As you indicated, there are programs of general application for off reserve, but given the depth and scope of the issues off reserve, more needs to be done there. In terms of our department, we do provide for housing on reserve. Canada Mortgage and Housing has programs concerning renovation or other kinds of assistance that can help. The federal government more recently has been allocating funding to social housing in the North, and I think that has been of assistance.
Senator Eggleton: Unless anyone else wants to jump in on those questions, I am finished.
Ms. Dedam-Montour: You said 30 federal departments are involved in population health. I do not know if all those departments deal with Aboriginal issues. That is a question for me, because whenever I mention Aboriginal issues, INAC and FNIHB, First Nations and Inuit Health Branch, are really it. HRSDC has an Aboriginal component, in the other departments, I really do not know who is actually dealing with the Aboriginal population. As was stated, there are the on reserve programs and the mainstream. How half the population in the mainstream is dealing with these issues is not something I am really aware of.
It made me think of the Jordan's principle legislation that was passed — the child first principle. That whole Jordan's principle came about because of jurisdictional wrangling — who will pay for this? In the meantime, a child suffers.
It is not just for children. This same issue happens to all age groups. Perhaps we need to look at individual first and look at how some of these other departments can work with the Aboriginal population. I do not know if it requires policy changes within the government, or if it is on our end, where we learn more about those programs and what they can offer the communities and the people.
Senator Champagne: Let me bring you into the world of utopia for a minute. What if the government was to put together a central office? As you just said, we have programs in INAC, Health Canada, Heritage Canada, et cetera. What is there was to be one office, including people from all those different departments, where nothing would be done until it goes there and those people together can do it. Maybe it is possible; maybe it is utopia, as I said. It is at least hypothetical.
I wonder who would represent the Aboriginal population. You are here today with many fantastic ideas and you are expressing your needs and so on.
If we were to have a centre point in government, who would be best to represent Aboriginal needs? As you said, there are status and non-status Natives; there are various groups such as Inuit and Metis; some live on reserves or in isolated communities; and others live in the middle of cities.
Who would be the most apt person or group to deal with that dreamlike group in government that would be trying to share the wealth from all the different departments and what is the most needed thing for tomorrow morning?
Ms. Dedam-Montour: I do not think it is a utopia. I think it is a nightmare.
One central body becomes a giant monster. I am sure that many of the regions in Canada would have different views. I know from a First Nation perspective that each First Nation region would talk about their own self- governance issues and they would have difficulty looking at a national ``megabody.''
I would pose the question to you: Who do you see at that table or as that body? Are they political people or administrative people? That would define who would be on the other side of the table.
Senator Champagne: I really did not mean abolishing the different departments that are working to help our Aboriginal people. I was thinking that, if we to do something — let us say in health — it might be good to talk to someone who is maybe from Heritage Canada and see what we could do with the Friendship Centres. Is that where health could be? I did not mean to get everything out.
I was trying to find someone who or something that would coordinate whatever is being done to be more helpful. Certainly, I am not looking at abolishing anything and trying to make only one ministry to look after all that is Aboriginal in Canada. I realize that would be a real nightmare. You are right.
Mr. Dinsdale: I would like to jump back because I was trying to pick up on Senator Eggleton's question. It is very instructive. When there is an excellent policy approach to housing, but a large segment of the population does get dropped off. I do not think it is sufficient to say there are programs of general application. If that was sufficient, we would be having equity of outcomes right now but clearly we do not.
I think this is typically the response we receive when we talk about the need for off-reserve-specific programs. The other challenge is that $300 million was allocated to off-reserve housing a number of budgets ago. The federal government transferred that immediately to the provinces in the form of housing trusts and the provinces were the ones to define the programs. While defining the programs, some of that $300 million was hived off into administrative and other costs and some jurisdictions still have not spent any of it.
It boils down to a lack of leadership. I think INAC becomes caught up in legal responsibility versus a need to serving communities. The Canada Mortgage and Housing Corporation (CMHC) does not provide social housing to Aboriginal people off-reserve. The closest we get is HRSDC in shelters, where they have transition homes. Your finger is on that exact issue.
I would like to address the question raised here. Sometimes it is frustrating when Aboriginal people are asked who represents them because you also talk about the other side: on-reserve, off-reserve, Inuit, Metis, status and non-status. I often ask Canadians who represents them. Is it your councillor, mayor, school board trustee, your provincial MPP, the provincial or federal government or a coalition of NGOs? There is a variety of organizations that represent Canadians and we do not seem to have problems understanding when we should talk to whom when that occurs.
I think we need political discipline as a structure to identify who serves whom. The Assembly of First Nations represents on-reserve Indian chiefs. There is no question about that. They represent their citizen-status Indians and do it better in some ways than others but it is tough.
The Metis National Council (MNC) clearly serves Metis people. They have a definition of Metis people, though it does not necessarily address the people in the east. However, they address Metis people.
Inuit Tapiriit Kanatami (ITK) represents Inuit people no matter where they live. It is a small organization and it is a big country. It is tough for them.
The Congress of Aboriginal Peoples say they represent off-reserve Aboriginal peoples and I ask no questions as to their ability to do so but that is what they claim. The Native Women's Association of Canada say they represent Native women.
I do not think it is confusing but I think the challenge arises when we only talk to political players for service delivery questions.
I think it is a lack of clarity as to the answer we want and we sometimes bring in the wrong people.
Senator Champagne: While listening to everyone, my feeling was that, sometimes, the right hand does not know what the left hand is doing. It is not as helpful as it could be. While we are full of good intentions, we make the wrong move. I was trying to suggest that.
Mr. Dinsdale: There was a Ministerial Committee on Aboriginal Affairs until it was dissolved. It was housed in the Privy Council Office. I do not know if that was more effective than what we have today. You could ask your colleagues to look at that and find out whether that was the effective tool or not.
Senator Eaton: I wonder if I might pick up what you and Senator Eggleton were discussing.
I need education here. We will say ``wellness determinants'' to be positive. Are they not the same for the First Nations, Metis, Aboriginal communities in an urban centre as for the population at large?
Mr. Dinsdale: Are the social determinants of health —
Senator Eaton: In other words, are their issues not also housing, education, health, et cetera?
Mr. Dinsdale: Culture and language would be a big difference for Aboriginal people. There are notions of self- determination, which are expressions of colonial interactions that we have had in terms of the ability to have specific programs or governance. There are others we would add which may be different.
In addition, the responses of our typical social or wellness determinants would be different to an urban Aboriginal person than to a general Canadian. We know, through employment and training — and health experts can speak to health in a variety of domains — that general programs do not reach Aboriginals very well. I do not want to go too far down this road because that is not your question.
We are saying that, if they were, we would have employment parity because there is EI, training programs, et cetera, for everyone.
Aboriginal people require culture-based approaches.
Senator Eaton: You were talking about a transition program that worked very well, with the University of Toronto and your Native centre. For instance, St. Michael's Hospital is a large teaching hospital in downtown Toronto. Could we not have a wellness clinic or a walk-in clinic with a transition team there that would work with an Aboriginal doctor and nurse but you would also have access? I am using that as an example, Senator Keon. It could work in any large urban centre. Then they would have access to all the specialized care. Could you use that?
Mr. Dinsdale: We would not articulate in the Friendship Centre movement a parallel system for Aboriginal people in cities. If that was coming across, it was not our intention. Whether it is an education or health program, you want to find entry points and sometimes they are different. In education, we explain that our kids are just as smart. Sometimes we need a blanket of services wrapped around them to protect them from all those other things we have been discussing in order to help them achieve their education.
That is how we describe the Native Learning Centre; it was that blanket of support around that student. Sometimes it was increased funding to do those other programs. It was incredibly helpful when they mentioned their health transition program; that they had those interventions.
My purpose in bringing up the Transition Year Program was more of a government-wide approach to getting more Aboriginal health care professionals in terms of stepping over some of those artificial barriers that exist. I did not mean it as necessarily a front-line service delivery option. I think it would have merit.
Senator Eaton: We have facilities in health and housing. Could we not use them in Friendship Centres to provide transitions into those, using what we already have?
Mr. Dinsdale: In some cases, that would work. It would depend on the area and location. Regardless, we are not saying two systems. There are entry points and a variety of ways of getting there.
Senator Fairbairn: This has been a wonderful session today.
You have set before us a flag to try to bring action faster and deeper. It is clear that you have been doing tremendous work. I come from Lethbridge, Alberta. We are on Treaty 7 land and the Kainai Nation is just down the road.
Since the university started in the 1960s with a mindset to be very much engaged with Red Crow Community College on the reserve to try to keep it alive when it was falling down. There was the effort to bring as many young and older people into this new university. The result of that in so many ways, health included, has been a tremendous uplift on that reserve because of the connections made through this bridge to and from the community. People from the reserve are teaching now in the university and the college in town.
On the reserve, certainly there are difficulties in health. Things happen in southwestern Alberta where everyone gets into difficulties. It is fair to say that the connecting link that has opened over these years has changed the opportunities of working together. There is a group of people working on the reserve who have come from the university or college who are making a huge difference?
There are still many difficulties, as there are everywhere else. Have any of you been involved with that? The degree to which there have been successes because of the connections over a period of time has been interesting. As well, deep friendships have been forged and collaborations developed between the two levels. For the children in the last several years, the effort to reach them before they are too old has met with success. Have you heard of those connecting links from that part of Canada, where we have a great and wonderful group of Aboriginal people?
Ms. Dedam-Montour: I do not know about this institution and the relationship that has been built but I can relay my personal experience. I graduated in 1976 from high school. I went to an institution called Manitou College, affiliated with Dawson College in Montreal. It was a First Nation education institution. While I am Mi'kmaq and I lived on reserve, I did not know what it was to be a Mi'kmaq until I went to Manitou College, where there were Montagnais people, Huron, Cree, Mohawk and others. It was there that I came to understand better where I came from. Together, we learned in an educational institution. It was a very formative time in my life that shaped me into who I am today, sitting at this Senate table. I am privileged to be here.
I am only one example of the many students who went through such an educational institution. Another person I know is Ms. Ghislain Picard, Regional Chief of the Assembly of First Nations Quebec-Labrador. Even though I was there for only one semester, it had a great impact on me.
Those who have graduated from that institution work in various levels of government or work for political organizations or might be politicians. They work at the community, local, regional, national and even international levels.
Supporting First Nation education within a First Nation environment is an excellent experience. Unfortunately, I did not have the opportunity to graduate from the college because the government closed it. I remember not understanding why, because we were getting a great education. The government talked about budget restraints or said there was too much promiscuity or alcohol abuse. That happens in all educational institutions when university and college students become liberated from their home environments and enjoy life to a different extent that later on is not the same.
Whatever the government policy or justification was at that time, the end result is they closed that institution. Many great leaders came from that college. I am sure that it is the same in your region — many people who have gone through the institution have become leaders in their communities.
Senator Fairbairn: Some have become doctors.
Ms. Dedam-Montour: There are many benefits. Manitou College was in a very native environment and so it was enriching emotionally and culturally. However, because the government closed it, I had to go to Dawson College in Montreal, which was not the same. I was afraid to leave the train station and take a walk because I was afraid of getting lost. That was my experience. Students coming from smaller, more isolated communities, where there are no roads, no sidewalks and no running water are completely uprooted to get an education. They are in a foreign environment where the language and cultures are different.
The supportive environment mentioned earlier facilitates development.
Dr. Reading: This committee needs to reflect on what economists are calling the great recession as a global factor in all of this. Aboriginal people are the poorest of the poor and the consequences of this global recession are that investments will be withdrawn around factors that we know are supporting the determinants of health. Canada is out of step with its counterparts in other countries.
As we all know, Barack Obama has made a significant effort to stimulate the economy through strategic investments at a time when it is needed and he has reached out to Native Americans. He is put a lot more resources into the Indian Health Service and is committed to meeting with native leaders to address the determinants of health.
As I mentioned earlier, Australia is doing the same and New Zealand has a long history of engaging with the Maori. I think Canada is out of step internationally with what is happening.
The consequences will be enormous. More than 50 per cent of the Aboriginal population is under the age of 25. That cohort of young people needs to obtain necessary, practical training. I am not talking about people becoming university professors — although some will. However, skills and opportunities for employment through training will be important to addressing the determinants of health. Government has a role in a recession to invest in the capacities of the next generation.
We have to look at the realities instead of shrinking away from the responsibilities of the population. We need to invest more. Mr. Dinsdale's commented that he is being forced to operate within a funding envelope that has not increased since the 1990s. This is despite making enormous gains and being able to respond to government evaluations, et cetera. That is tragic. There is something horribly wrong about the priorities of the government. It is about equity, human rights and inclusion.
We all get it. I guess I am preaching to the converted. However, my main issue is that Canada is out of step with other developed countries.
The Chair: Thank you, Dr. Reading. We are a little overtime, but we will go further.
Senator Callbeck: In 2005, the Blueprint on Aboriginal Health was developed. I understand it was a guide on how we would move ahead in health. It was agreed by the federal government, the provinces, the Metis, Inuit and First Nations. It does not appear that it has gone anywhere. Is that a good guideline? Is that a starting point for population health?
Mr. Dinsdale: I cannot comment on the blueprint specifically because we were not engaged or part of the follow-up.
Although I disagreed with the outcome, I think Kelowna was the right process. It could have been more inclusive and focused its attention more on urban issues. Urban issues were a lens and that lens became a blindfold in our read of it. However, it was the right process.
It would be great if we had the three major national Aboriginal organizations here because they could speak to what they are doing. There are activities and perhaps our government colleagues can comment. It is an example wherein urban areas we were not engaged whatsoever in the development of the blueprint or its implementation.
Ms. Dedam-Montour: I agree that it is a good start. I have a seat on the Chief's Committee on Health at the Assembly of First Nations. I am not a voting member and I am not one of their technical supports, but I bring the community perspective.
The blueprint supports what leadership wants to do. It was a direction to pursue because it reflected a lot of collaboration. Simply to get a number of groups to agree on one document is an achievement in itself.
Although it was undertaken in 2005, there may have been a shift in some of the priorities. If it was brought back to the table, it would be a good step to have that opportunity to re-examine some issues and to update it to meet present needs.
Ms. Kinoshameg: I also was not part of that. Participation probably focused on the political leadership at that point to develop that blueprint. However, if it has not gone anywhere, maybe it should be reviewed. It could be a starting point along with everything else that has been discussed.
Senator Callbeck: Both you and Ms. Dedam-Montour mentioned the Chief's Committees on Health. Can you talk about those?
Ms. Kinoshameg: Ms. Dedam-Montour can speak to it.
Ms. Dedam-Montour: The Assembly of First Nations is made up of political leadership from each of ten regions across the country. Each region selects a chief to hold the health portfolio. This chief comes to the national level where they have meetings four times a year. To support the Chiefs' Committee on Health, each region will have a health technician. This person will look at policy, what is coming down, and assist developing strategies to guide what leadership can do in the next steps.
As leaders, you are sitting here today, but there are many people sitting behind you that have informed you, are guiding you and feeding you as much information as possible so you can make informed decisions. The Chiefs' Committee on Health has health technicians who do that. I have sat on that committee since 2005.
Senator Callbeck: Ms. Langlois mentioned that Health Canada talks a lot with other policy makers and practitioners in other countries of the world.
Are there initiatives or best practices that you have learned from other countries that you have initiated here or would like to initiate here in terms of population health?
Ms. Langlois: Maybe I can speak to one initiative with which I am familiar. There is a northern dimension partnership on health and social matters. It involves all of the Nordic countries — Iceland, Finland, Norway, Russia, Lithuania, et cetera. It is pertinent to the Inuit, but also to northern First Nation in terms of the issues addressed.
Last November, we hosted a meeting where representatives from those countries came. We encouraged them to bring indigenous people from their countries as well. Our approach in working with other countries is that we always want to ensure a one-for-one match between a government official and an indigenous representative to model the partnership to ensure it is not only governments talking at indigenous people, but governments working side by side.
We had the meeting in November. It was a brainstorming around issues of importance to indigenous people across these countries. It was an opportunity to discuss HIV/AIDS, nutrition and mental health and addictions. I went there to speak about mental health and addictions since that is my lens, but there was other work happening on HIV/AIDS and nutrition.
I will speak specifically on mental health and addictions. We had the opportunity to talk about what we are doing in Canada with the other countries. It became clear that the countries were excited to learn from the things we are doing in Canada. In much of the work we are doing, there are three constellations of programs recently put in place. There was the National Aboriginal Youth Suicide Prevention Strategy put in place as a result of the First Ministers meetings in 2004, but confirmed in Budget 2005 and Budget 2006 under the new government. We also have the Indian Residential Schools Settlement Agreement that has brought funding into Health Canada to support former students of residential schools as they go through the processes of the settlement agreement — the apology and the coming truth and reconciliation commission.
We also have funding under the new National Anti-Drug Strategy that will see us modernizing our addictions program. One key element is putting in place these multi-disciplinary mental wellness teams.
There is a lot of activity happening in this area. We had the opportunity to share that and there was some real excitement amongst the other countries. We were invited back; one of my staff went back to Sweden last week. There will now be work moving forward where Canada actually has best practices to share with other countries.
I know your question was whether we have learned about best practices in other countries. However, that is where the sharing comes from. We have opened the door; we are sharing our mental health and addictions programming and we are actively looking at the Maori suicide prevention strategy. That has been put in place in New Zealand and we work with that, understand it and we see how it informs our work.
Therefore, yes, we are doing that work in our programs and I think it would be the same in any of Ms. Wood's programs. Tuberculosis would be an important thing to speak about in terms of a recent national forum.
Senator Pépin: Some witnesses told the subcommittee that a population health policy should be established separately from a poverty reduction strategy. What do you think of that?
Mr. Dinsdale: A poverty reduction strategy has a particular connotation around education and skills development and training. It clearly has outcomes in health. However, the prevalence of diseases and illness and particular specific health outcomes require immediate interventions.
I think the social determinants of health and that approach, with poverty in particular, is a long-term approach. You need to deal with the immediate needs while trying to take that broader vision.
Dr. Reading: A poverty reduction approach is extremely important because the cognitive ability of an infant is most malleable, from a biological point of view. However, we do not invest very much in that stage of life. We do the inverse: We put a lot of resources into seniors through the tax system. Refocusing investment and support on the early stages of life — for children — through a poverty reduction strategy is an important way to try to optimize the potential for healthy growth and development.
I will talk about the issue of different governments and what they are doing. In the United States, there are Native American centres for epidemiology, which are funded by the Center for Disease Control and also the Indian Health Service. There are 11 of them across the country in the U.S., including Alaska. While some are under tribal control and some are urban based, they are governed by Aboriginal people themselves. They provide evidence tracking the health status of people within their regions. Then it is actually translated into programs and services. That is an important thing.
In Canada, we have the signatories of a tripartite agreement. First Nations, the federal government and the provinces have agreed to this with the leadership council to refocus on health. Many of us hope that will lead to regional health authorities under Aboriginal control. That is one of the big issues that needs to be addressed. We need to be supporting self-determination in the area of health and having Aboriginal people at the table as CEOs of regional health authorities.
To come full circle, Senator Keon's idea of the polyclinics in Cuba is a very good idea. However, I think it needs to be discussed and analyzed at the regional level through regional health authorities where Aboriginal people sit with other regional health authority leaders and discuss these issues.
Many of the regional health authorities in Canada have multi-billion dollar budgets and the Aboriginal piece is a very small piece; it is sort of on the side and not really a priority. However, if there was an Aboriginal seat at that table in each of the regions of Canada, then there would be a lot of good interaction among those authorities.
My experience as the Scientific Director of the Canadian Institutes of Health Research, as one of 13 institutes, was that there was a tremendous amount of synergy because the expertise was contained in our area. Like Ms. Dedam- Montour says, because you have many people behind you, supporting your decisions, we are able to add value to the CIHR.
In the area of health services, having an Aboriginal seat at the regional health authorities table would add value to the entire enterprise.
The Chair: Tomorrow we are meeting with the information gurus. It will comprise just about everyone in the country. What stage were you at in your institute when you completed your tenure there?
Dr. Reading: I had been there for almost eight years and we had funded over $100 million of Aboriginal research that probably would not have happened. A great deal of that funding was through partnerships with other institutes.
I want to emphasize that the CIHR does not compromise on its pursuit of scientific excellence; it is done through a very rigorous peer review system. Therefore, we were meeting international standards of research excellence while at the same time addressing community priorities and funding research that was relevant to Aboriginal communities.
I think the CIHR was a good model that would demonstrate how we could integrate across this in an inclusive way. To someone at this meeting I said, ``If you are not at the table, you are on the menu.'' I think it is time Aboriginal people had a seat at the table.
The Chair: We cannot beat that quote so we have to close the meeting.
(The committee adjourned.)