Proceedings of the Subcommittee on Population Health
Issue 3 - Evidence, May 2, 2007
OTTAWA, Wednesday, May 2, 2007
The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:04 p.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.
Senator Wilbert J. Keon (Chairman) in the chair.
[English]
The Chairman: Good afternoon, everyone. Thank you for coming, many of you from right across our land, to be with us.
This study on population health fundamentally looks at all of the factors that influence health, including the health care system, but there are at least 13 major determinants that we have now identified in Canada and the rest of the world. We hope to analyze these determinants in detail and make recommendations about the health of segments of our population that are not as healthy as they should be at this point in time. We hope their health status can be improved through our recommendations.
Without further ado, we shall begin. Our first witness is Professor Sylvia Abonji, the Canada Research Chair in Aboriginal Health of the Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan.
Sylvia Abonyi, Canada Research Chair in Aboriginal Health, Research Faculty, Saskatchewan Population Health and Evaluation Research Unit: Thank you very much for this invitation. I am extremely honoured to be invited here today to share my experiences with this committee.
As I have given you my notes, I thought it might be useful to tell you about myself, in order for you to know the context I am coming from with my comments.
I have been lucky for the past seven years to be working with the Saskatchewan Population Health and Evaluation Research Unit — SPHERU — working with northern Saskatchewan communities to look at their perspectives on the determinants of health. I will share today some of that experience from there.
At the beginning, it is important to say that I myself am not Aboriginal. I come from immigrant and refugee parentage. I am a first-generation Canadian, to put it in context. The views I am sharing are the perspective of a researcher who has worked with some of these communities. I have a Ph.D. in anthropology from McMaster University. We have a fairly diverse background on the panel here, so it might be useful to know what our disciplinary roots are.
As I said, for the past seven years, I have been with SPHERU and am also with the Department of Community Health and Epidemiology at the University of Saskatchewan. My comments today stem from the research experiences and community relationships I have developed as part of SPHERU. Our unit is made up of an 11-member interdisciplinary research team with a mission to promote health equity by understanding and addressing health disparities through policy-relevant research. We have identified three major theme areas in Saskatchewan that we focus on: northern and Aboriginal health, healthy children, and rural health. We have different people who take a lead on those areas.
I know one of the things the Senate committee is interested in involves interventions. We recognize that there are multiple levels of interventions around the determinants of population health targeted from individuals at risk up to communities and more broadly. Just to add to that, we try to think of the research approach that we take also as a kind of intervention, the approach we take being capacity-building, shared control, and cultural relevance of the work we do as a unit.
When I inquired about some of the questions the committee might have for us today, one of them was around the determinants of health in the Aboriginal populations of Canada. Your interest might be how those determinants differ from the 13 identified for Canadians in general. How do these health determinants interconnect? What is the capacity of government to engage with the determinants of health, and what are the priority areas for action?
Again, the entree to that conversation in Saskatchewan has been through some of the health issues with which people identify when we begin a conversation about why. Some of the things people talk about that lead to poor health status are mental health and addictions issues, high suicide rates, chronic health conditions such as diabetes and heart disease, and high rates of injury and death from preventable injuries, and high rates of violence.
People also talk about having limited involvement in the delivery of health services at the local level and not feeling empowered to take responsibility for their own health, on an individual level and with families and communities.
At the same time, people say that there are significant strengths in northern Saskatchewan that create a fertile ground for innovative partnerships, a couple of which I will talk about later.
In the main, there is a strong tradition of partnership in the province as a whole, a strong sense of unity in a very diverse group, a very strong sense of community in the North and a very strong desire to change some of the health issues that I briefly alluded to.
In terms of our research role and how we became involved in northern Saskatchewan, it began with doing a health transfer evaluation for one of the organizations in the province, and that is simply having the services for which they have control and funding — they need an evaluation of that every five years. Hence, we began there. At the same time, we were also working with the Inuit Tapiriit Kanatami, who had asked us to look at some of the indicators of health in a framework that would make sense.
In working with these diverse groups, we learned that both were highlighting common concerns about understanding and addressing the key determinants of health from within frameworks driven by culturally relevant notions of health and well-being developed at the local community level. As we tackled both of the contracts we were doing, communities were asking larger-level questions that could not be answered with the kinds of indicators around aggregations of individual data. They were interested in knowing how all of their programs and services — not just, for example, the health programs, social services and justice — intersect to create a healthier community. How do these things fit into their view of a healthy community? At the same time, they are arguing how we measure progress in these areas with the kinds of indicators we use. The development of those indicators also needs to be defined at the community level and should reflect local definitions of health and well-being.
That led to a research project that we have just been wrapping up with the northern Saskatchewan communities. We worked with them to define broad domain areas, which looked very much like the health determinants that you might see, and to identify some indicators. There is a framework diagram in the papers that I circulated, and the northern communities collectively agreed that that framework is the one for how they see the health of their communities.
We also looked at the fact that there is that common framework, but recognizing the diversity, we came up with a suite of measures that communities could apply in each of these health determining areas, with the communities saying that some of those made sense for them but others did not. To measure progress in culture and identity, one community might use three or four measures, while another community might use two of the same measures but two other measures as well. There is some variability in how they assess how they are doing in a particular area.
In suggesting some of measures people might use, we also wanted to look at what is already being collected in national-level surveys and what can be comparable there. We identified some of those and areas where data already exists for people.
We wanted to be able to compare how communities are doing across and not just within, the idea of a core set of indicators that could be common, with variability built in with indicators that might be community-specific, so that communities also can get a sense of how they are doing in their place.
In some domain areas, there are some good indicators that people are already measuring in surveys elsewhere. In other areas, such as culture and identity, there are not good measures yet, so there needs to be some development.
I also wanted to say that this idea about measures and indicators is just information. With respect to what that information means and how it is interpreted, it is important to have that kind of discussion happen at multi-levels, including the community, so that you get a sense from community members as to what it means if we are saying ``X percentage of people are speaking our language,'' ``Y percentage of people have access to a certain physical activity.''
The framework I have suggested identifies some of the health determining areas and maybe some of the measures that one might use. What is not yet clear is how those health determinants might interact with each other, and work still needs to be done in this area. There is this whole notion of why we want to measure that as opposed to this. How does that tell us what is happening? How do some of the things we are measuring under identity and culture intersect with what we are seeing in our services and infrastructure?
Part of the concern about understanding that dynamic at the local level is the larger-level work being done around developing indices, in which a whole bunch of measures are grouped and weighed in a particular way to come up with a sense of a collective well-being — which is very important work, the concern being that in aggregating up to those levels, some of the nuances might be lost by looking at some of those individual indicators. It is important to highlight that the indicator and indices happening at a national level is important, but the community side of things also must be taken into account. This is much in agreement with the Canadian Institute for Health Information in terms of what they are thinking as well.
Another question was about the capacity of government to encourage a population health approach in Aboriginal communities. My involvement there is not direct, but I wish to point to two directions where there are some successful multi-jurisdictional population health partnerships taking place in northern Saskatchewan that might be good models to look at. The other direction is to look at what is happening in the realm of research and role of the federal government.
The first is the Northern Health Strategy in northern Saskatchewan, which was recognized by the Romanow commission on the future of health care as a successful health partnership. The Northern Health Strategy working group that handles that strategy includes partners from six federal and First Nation jurisdictions, six provincial jurisdictions and one multi-jurisdictional health organization, which is the other health partnership that is a good model to look at.
The Northern Health Strategy partnership developed the Shared Paths for Northern Health project, which was funded through Canada's Primary Health Care Transition Fund, the Aboriginal envelope, and that funding allowed them to develop technical advisory committees that were organized around some of these major health issues identified earlier. Those committees were comprised of people delivering services and community members receiving those services. They worked together to develop plans to deal with those across the North and across the Aboriginal communities, First Nations, Metis and the provincial communities.
The technical advisories committees around specific issues were supported by other committees that focused on areas of human resources, information technology and health information systems as well as other committees and components that looked at cross-jurisdictional issues. As they were raising questions around how these things were supposed to work and how their plan was to be implemented, they could go to these committees with some of the barriers they were running into. The other health partnership was the Athabasca Health Authority.
In terms of priority areas, one priority is to look at how some of those health partnerships are working in northern Saskatchewan as innovative models. A second one is to continue funding initiatives such as Canada's Primary Health Care Transition Fund, which helped the Northern Health Strategy in its planning activities. Another one that is unfolding is the Aboriginal Health Transition Fund. It has been around for three years, but no money is flowing yet to the communities. That is just starting. Three years down the road, the proposals that have come from communities are in the assessment stage now, so it is a fairly slow rollout.
Another priority is more research in the community health frameworks and indicators area, in particular, around the intersections of the health determining conditions. The approach to that needs to be a community-based partnership approach. I will leave it there.
The Chairman: Thank you. I have some questions I would like to ask you, but I will hold them until the other presenters have spoken.
Dr. Kue Young, Professor, Department of Public Health Services, Toronto University: I, too, am honoured to be invited to be here. I have never been a witness in any situation, so this is a first for me.
I previously submitted a book chapter on health determinants. I am also here to flog the rest of the book, which I will deposit with the committee so you can order it for everyone else.
I shall only make a few general remarks about health determinants in the Aboriginal population of Canada. It is heartening that the Senate subcommittee has taken an interest in the topic of health determinants of Aboriginal people in Canada. It does not need repeating that Aboriginal people suffer substantial disparities in health status compared to the rest of Canadians. Much research has documented these disparities and the evidence pointing to their origins in broad socio-economic and behavioural determinants that exist.
As a little bit of a background, I speak as an academic researcher who has devoted some 30 years of his professional life in the field of Aboriginal health. I started out as a young general practitioner, when there was no grey hair, in Sioux Lookout in northwestern Ontario, working in a small, rural hospital serving First Nations people and flying out to remote communities, working alongside nurses and community health representatives to provide primary health care. It was an exhilarating experience, introducing me, who came from the Far East, with its teeming millions of people, to a different kind of medical practice and, more important, to Aboriginal people and their culture. Since that time, I have engaged in public health administration, teaching and research in both Northern Canada and developing countries. I have done quite a bit of research on Aboriginal health, and my current research interests focus on the prevention of diabetes.
Now I will be more provocative. Thirty years ago, I thought I knew the solution to the problem of health disparities between Aboriginal people and other Canadians. Today, I am not too sure that there are ready solutions. We all know what the problems are, and we are quite sure of their causes, but despite a massive amount of human financial resources these disparities have not been erased. There are communities in northwestern Ontario that I have visited repeatedly over the years, and I am sad to conclude that not only has health and well-being not improved but that in many cases the situation has become worse. A few weeks ago, The Globe and Mail carried a full-page article about a community in northwestern Ontario. This is a community I know very well. This article, published in 2007, could easily have been published in 1977, with not a single word changed, and even the name of the community would remain the same.
I would be happy to engage with you a discussion about some of the issues and some ideas that could help redress this disparity.
The Chairman: Thank you very much, Dr. Young. We will now hear from the National Aboriginal Health Organization.
Carole L. Lafontaine, Acting Chief Executive Officer, National Aboriginal Health Organization (NAHO): Good afternoon. It is an honour to be here once again. NAHO welcomes this opportunity to appear before the committee today.
NAHO is an Aboriginal-designed-and-controlled body that strives to influence and advance the health and well- being of Aboriginal peoples through knowledge-based activities and strategies. First Nations, Metis and Inuit concepts of health incorporate the mental, physical, spiritual, emotional and social aspects of health. Furthermore, the health and well-being of individuals and communities are interdependent and equally important.
Over one million people in Canada identify as Aboriginal, representing 3.3 per cent of the overall population. Sixty- two per cent are First Nations, 30 per cent are Metis, and 5 per cent are Inuit. Each group is significantly distinct from the other and has a unique history. Within each group, there is also considerable diversity. Compared to the general Canadian population, the Aboriginal population is young, with 50 per cent under the age of 25, rapidly increasing in size, with the highest birth rate in Canada, and mobile, with large segments increasingly concentrated in urban and inner-city areas.
Understanding the interactive nature of the social determinants of health requires a holistic response to the complex dilemmas faced by First Nations, Inuit and Metis communities. Woven together, the meagre social indicators corresponding to First Nations, Inuit and Metis affect quality of life and health status of Aboriginal peoples.
Additionally, the health of First Nations, Metis and Inuit is further affected by such factors as geography and access to health services. For example, the health profile of an Inuit community in Northern Quebec versus a First Nations community located within 20 kilometres of an urban area is distinct and shaped by access to health services, mental and physical, access to affordable healthy food, access to post-secondary education and to employment opportunities. Geographical considerations render pan-Aboriginal approaches inappropriate.
While the social and broader determinants of health offer a comprehensive analysis of understanding the pathways leading to the disparities in the health status of Aboriginal peoples in general, First Nations, Inuit and Metis require a specific lens and appropriate solutions accounting for their historic and contemporary realities.
Specifically, here are some examples of how the social determinants of health interact to affect specific populations. For Inuit, the high cost of food combined with low incomes of Inuit families facilitate food insecurity in Canada's North. I will give you an extreme example: One litre of McCain orange juice in Pond Inlet costs $21.69, versus approximately $3 elsewhere in Canada in 2006. A nutrition and food security pilot project in Nunavut found that five out of six Inuit households were classified as food insecure.
The low education attainment by Inuit youth can affect life choices. High-level literacy makes it possible for people to have the knowledge and the understanding they need for education, employment and coping skills and provides the best foundation in making healthy life choices.
Overcrowded households affect mental health and illnesses such as respiratory, skin and intestinal illnesses. Investments in housing can augment the mental health of Inuit families, but complementary investments in education and community infrastructure can lead to improvements in the overall health of the community.
For Metis, the limited comprehensive data on Metis in general makes it difficult to precisely gauge the social determinants of health for Metis. The best sources include census data and the Aboriginal Peoples Survey where there is a Metis supplement.
Data from the 2001 Aboriginal Peoples Survey reveal that Metis experience disadvantage from childhood. Low income and single parenting jeopardize access to nutritious food and quality housing, two fundamental determinants of health with specific impacts on healthy child development.
Compounding this, employment and income shape overall quality of life in both rural and urban settings.
For First Nations, incomplete education levels and inadequate income translate into high dependency on social assistance. Overcrowded and substandard housing can stress the mental health of First Nations by facilitating social tension and depression. When accessing health services, many First Nations face linguistic and cultural barriers in dealing with mainstream service providers. Developing culturally competent health care provisions can enhance the quality of health care and services for First Nations people.
Although multiple challenges exist when addressing the disparities experienced by First Nations, Metis and Inuit, specific evidence can support appropriate solutions corresponding to the realities of each population. Public policies and fiscal allocations are better informed by specific data that show the scope of needs in First Nations, Inuit and Metis communities. Fractured jurisdictional responsibilities, lack of communication and duplication in research further complicates a needed comprehensive approach.
Due to the interactive nature of the social determinants, improving the health status of First Nations, Inuit and Metis requires short-, medium- and long-term goals that address the multiple priorities of each population.
Thank you for inviting NAHO to offer our insight to this Senate Subcommittee on Population Health. We appreciate and acknowledge your commitment to this work. If we can provide you with additional information, please contact our office. In the packages that we distributed, you will find supporting materials as well as background documents and suggestions for further research.
The Chairman: Thank you. We will hear from Dr. Michael J. Chandler, Professor at the University of British Columbia and distinguished health researcher with the Canadian Institutes for Health Research and with the Michael Smith Foundation for Health Research. I knew Michael Smith very well; he was a wonderful man.
Dr. Michael J. Chandler, University of British Columbia Professor and distinguished health researcher, Canadian Institutes for Health Research (CIHR), and Michael Smith Foundation for Health Research (MSFHR) Investigator, University of British Columbia — Department of Psychology: Thank you for honouring me by asking me to speak to the committee. I read with interest the committee's proceedings when some of my colleagues, all of whom are heads of something, appeared to give evidence. I am not the head of anything but am still what is quaintly called a ``curiosity- driven researcher'' — unemployed researcher, actually.
That aside, I will tell you about a project that has been going on for at least a dozen years in British Columbia. The project has to do with looking at the social determinants of the issue of Aboriginal youth suicide. I will use four quick talking points.
First, even though the research I will allude to was done in B.C., and even though it is about suicide, I shall try to make the case that those are perhaps not as narrowing as might be suggested and that there is some generalized ability from these findings to not only other provinces but also to other issues of the health of Aboriginal people. Second, I shall talk about what I will call the actuarial fiction of trying to paint in broad strokes claims about suicide in Aboriginal communities. Third, I shall unpack a notion, which I will refer to as cultural continuity, to persuade you that it is of critical importance that Aboriginal communities both achieve some sense of connectedness to their traditional past and gain some kind of control over their civic futures and that it is only by accomplishing those things that we can hold out hope of dealing with some of these health disparities. Fourth, I shall suggest a couple of action and policy implications that might flow from this work.
I will pick off those four points as quickly as I can, one at a time, and briefly comment on the fact that the data I want to describe to you from is B.C. is about suicide as opposed to some broader palette of questions about health disparity.
It is important to see youth suicide as a kind of coal miners' canary. I am the son of a Welsh coal miner — and as you know miners carried canaries into the coal mines. When the canaries fell off their perch and died, everyone knew it was time to take action because hazards were abounding. I want to suggest that suicide is like that. When communities fail to create a living environment in which young people feel that life is worth living, then we know that serious problems stretch throughout the whole of their health and well-being.
Relating to the issue of the fact that I will report on B.C. data, I know from the material that I read that the committee is very concerned with the units of analysis problem. You have intuited that it is probably not wise to talk about suicidality or any other health problem in terms of some generic reporting figure for the whole of Canada. You have asked questions about urban versus reserve Aboriginals and about Metis versus Inuit versus First Nations communities. There is a struggle not only in this committee but also in the scientific community at large to find a proper level of analysis. At one extreme there is the possibility of ending up with a conglomerate of anecdotes by looking at individual cases; at the other extreme, we are talking about the whole of the Canadian Aboriginal population with the intuition that that will not work. In my case, we tried to make and win the argument that the best level of analysis is probably the level that is most respectful of Aboriginal culture. Therefore, we have chosen band- level analysis of data to try to get at that question.
The bands happen to be in British Columbia, where there happen to be almost 200 of them. It is an enormously diverse population, with 14 different languages spoken and radically different living circumstances and histories. In a moment, I will tell you about our attempt to look at the restricted problem of youth suicide as it emerges across those 200 bands.
In terms of the broader implications of my research, I shall say a bit about this somewhat curious notion of the idea of generic claims about suicide in Canada as actuarial fictions. When people take all of the youth suicides in Canada and divide out by the number of young Aboriginal people and get a suicide rate that is between 5 and 20 times the national average, it is not uninteresting, and people did not get their sums wrong; at the same time, it is largely not only empty of real meaning but somehow equating the notion of suicidality and Aboriginalitily, which is often done in the press, and is a subtle form of racism. I will try to make that point. I believe two graphs were circulated to you. One is a spiky-looking thing called figure one. If you do not have it, I will describe it.
It plots on the vertical dimension suicide rates and along the bottom it lists out bands. If it turned out that what band you happened to be a member of had no bearing on the likelihood that youth in that community would commit suicide, that graph would be flat; it would be the same for every community. I draw your attention to the fact that it is not like that at all; in fact, it is just the opposite. That graph shows a radically saw-toothed pattern where, in many instances, the rate of suicide for a particular community essentially touches the ground, meaning there are no suicides. In others, the rate is hundreds of times the national average.
I want you to take away from that that, if you sum across all of that, it turns out that something like 90 per cent of the extravagant number of suicides in British Columbia are owed to only 10 per cent of the bands. Half the bands in the province have no suicides in what is now a 13-year reporting period.
That, if one can say so about our own data, is interesting and alarming. Any claim about the suicidal Aboriginal flies out the window in the face of such evidence. It is clear that we simply cannot talk about suicide as an Aboriginal problem; we have to talk about it as a problem that is characteristic of some communities and not others.
With that point, hopefully, made, let me go on to the third of my talking points. Here is where I promised to unpack the notion of cultural continuity. Once you look at a graph such as figure 1, the problem that inquiring minds want to solve is this: What is true of those bands that have no suicides? What distinguishes them from bands that have as many as 800 times the national average of suicides? If we could figure that out, then we would be off and running somehow. Much of the research that my colleagues and I have been doing is to try to answer that question.
I want to caution that, unfortunately, the ordinary way of addressing this problem is to go on a fishing expedition. You troll through 10,000 Statistics Canada variables hoping to snag something that correlates with the difference between bands that have high and low suicide rates. My caution would be that, if you do that, you will probably come up empty, and, if you do not, you will not know what to make of the results that you got in the first place. You have to have a theory-driven reason to look for what might account for the radical differences between these bands.
There is a long back story about how my own research group has tried to do this, and time will not permit me to go into that story, but it began with a decade of research — not into Aboriginal communities; in fact, not even Aboriginal people, just young people in general — asking what it was that characterized the difference between kids who were actively suicidal and kids who were not. The bottom line is that we ended up looking at an issue we call personal continuity of self; that is, young people who live in a rapidly changing world have to somehow understand themselves to be the same person they used to be and somehow have a commitment to the person they are en route to becoming. If you do not have that, you do not have any faith or hope about your own future.
The research I want to talk about is an attempt to project that notion of continuity onto the cultural level and ask what it means for a culture that too can only exist and is constituted by the fact that it has a history and a future. The question is this: What could we find that would be some expression of the effectiveness with which some communities but not others have achieved the sense of their cultural continuity connecting them to their traditional past and to their own, as yet unrealized, futures?
We were handicapped here because we had to find available data that somehow spoke to these questions. We proceeded in two steps. Wave one of this research operation covered a five-year period, 1987 to 1992, and we tried to pick out things that we believed were expressive of the efforts on the part of communities to hook up with their traditional pasts and to gain control over their own civic futures. We came up with half a dozen such measures. They include — and I know this is a topic of special interest to the committee — self-government, as well issues of whether the community had control over health delivery systems, educational and policing systems, and had created some vehicle for the preservation of culture, such as a community centre.
I want to turn your attention to what is now figure 2 in the handout. That figure means to demonstrate that, if you score every Aboriginal community in British Columbia, all 197 of them, in terms of how many of those six factors about cultural continuity they have, the answer could be all of them, none of them or everything in between. The graph shows that all those communities that have all of those factors have no suicides. Every community that has none of those factors has a suicide rate essentially 150 times the national average.
Again, if one can say so about one's own work, that too is startling. If you have this handful of things that can be said about you as a community, there will be no suicides in your community. If you have none of them, woe be upon you.
The second wave of data replicated that for the period 1997 to 2000, and in effect perfectly replicated it, but in addition it went on to add three new variables. One of those variables included whether the communities had control over child welfare services. Another was whether they had more than half of their tribal council made up of women. If you like, I could try to unpack why that is important, but it comes down to the fact that, in Aboriginal cultures and in other cultures, women are traditionally the cultural keepers and kin keepers. Finally, we most recently collected data about the success with which communities are hard at work preserving their indigenous languages. It turns out that all three of those factors — control over welfare, the number of women in Aboriginal government and efforts to preserve language — also strongly correlate with suicide rate, and if you throw them into the mix, again, every band that has all those factors has no suicides and every band that has none of these factors has an alarming suicide rate.
If time permits, I will say two quick things about what I believe to be policy and action implications. One of these, which is self-evident from the demonstration, is that there is a radical difference community by community in terms of suicide rate — and I would remind you that half of B.C.'s Aboriginal communities have no suicides. I take it to be obvious that any pan-intervention that tries to make the same remedy for every band is simply nonsensical. You are out there solving problems in communities where they do not exist or applying the same solutions to problems in communities in which these problems unfold differently. Somehow there is an important lesson about the specificity with which we need to pinpoint our intervention efforts.
A second and related implication has to do with a long topic, about indigenous knowledge. I am imagining producing a book on how to become a good colonizer. Chapter one would be entitled something like ``Epistemic Violence.'' You would go into any community you wanted to colonize and immediately define all of that community's indigenous knowledge as null and void. You would do that because, if they do nothing, you would be entitled to treat them as chattel and children who could be ordered about, hopefully, in their best interests. In many cases, that is exactly what happened in our context.
What is evident in the data that is presented in figure 1 — which shows that half the communities not only have no suicides, but have a lower rate of suicide than the general population — is that they obviously know something about how to run a community where young people think life is worth living. We could learn from them and they could learn from one another.
That is really my third point, which has to do with the overworked notion of knowledge transfer and the exchange of best practices. If you are in the business that I am in, writing grants and trying to live up to them, you know that you have to spend a lot of your time explaining how you are transferring knowledge. What that ordinarily means is that knowledge is a product of the academy — people like myself generating knowledge — and then it is handed over to people in government and elsewhere, who are brokers of that and who try to direct it to the users of that knowledge. That model is all top down, all trickle down.
There are two or three things — and Dr. Young said this in talking about how this community looked exactly like it looked 30 years ago. That is not working very well for a number of reasons. One is perhaps that it is not very well informed about on-the-ground conditions, and the other is that it is deeply resented. People do not like to have knowledge made in Ottawa or New York City somehow parachuted into their community, root and branch, and delivered to them. They resent this and often undermine it.
The top-down model does not work very well, or often does not. If it is true that half the communities, at least in B.C, have sufficient indigenous knowledge that they have no suicides — fewer than our general population has — then there is knowledge there. What about the lateral transfer of knowledge from community to community?
That is not without its problems. There is resentment and competition and every other kind of thing that is true of every community in the Aboriginal world. However, there is knowledge there, and my money is on the expectation that there would be less resistance to the sharing of indigenous knowledge than there would to be another round of trickle- down, top-down information being parachuted in from Ottawa.
The Chairman: Thank you very much, Dr. Chandler. That is absolutely fascinating testimony.
Before I go to the senators, I want to make a couple of comments. What we have been hearing so far is that we are not going to affect the problems very much of population health from 30,000 feet — in other words, with high-level bureaucracy. It will have to be done at the community level. We also heard previously, and heard again today, that governance is a big issue for Aboriginal people. When they get control of their governance, they seem to do well, and when they cannot get control of it, they have huge problems.
I will ask one specific question of you, Ms. Abonyi, before I ask the senators to go to questions, just to clarify our further hearings a bit. You mentioned that your structural framework is in keeping with the CIHI initiative — and we will be hearing about that in the next month. How close is it to the structural framework of CIHR, namely, the Institute Aboriginal Peoples' Health and the Institute of Population and Public Health? Is it in sync with them also?
Ms. Abonyi: I would say yes. One of the points I was going to come to was that the Institute for Aboriginal Peoples' Health, in particular, has recognized this kind of framework, and also the approach to developing these kinds of frameworks. That has played an important role in the capacity to do that.
Senator Callbeck: Ms. Abonyi, I wanted to clarify something about the Primary Health Care Transition Fund. It was my understanding that the Northern Health Strategy was funded through that fund. You go on to say that the fund is important but that it is cumbersome and hard to access and that there has not been any money flowing.
Ms. Abonyi: The second one I am referring to is from the Kelowna Accord out of 2004 — a new initiative. Regarding the Primary Health Care Transition Fund, Aboriginal envelope, I cannot speak to it too much. In working with some of these partners around the Northern Health Strategy, these are some of the challenges they talk about — writing the proposals to these, having them evaluated in a timely manner and having the funds released.
Senator Callbeck: That clears that up.
Dr. Young, you have certainly have had a lot of experience; you talk about working in the northwestern Ontario area. You said that you are sad to conclude that health and welfare of the First Nations, Metis and Inuit people have not improved and that, in many cases, the situation has become worse. You paint a very depressing and sad situation. Are there any health determinants that are being addressed properly here?
Dr. Young: First, I want to say that I did paint an unduly pessimistic picture. That was probably a momentary thing; most days, I am actually a much better person.
If you look at some clues, life expectancy is increasing. Even in the worst sub-Saharan country in the world, however, life expectancy is increasing, so it is not something we need to be particularly proud of. The infant mortality rate is going down but the disparity is still there.
There are some other determinants. The education level, in general, is increasing. For employment, not much has been changed. If you look at some of these crude sorts of measurements that are routinely collected, they paint a diverse picture, but that is not really where the action is. Mr. Chandler's research is really looking at different kinds of determinants. That is where the interesting things appear. Certain things are definitely much better. Some communities are still functional and coherent and cohesive. Yet, there are multiple cases in Canada where brand new communities are built from the ground up, where people are moved from one place to another; we build them new schools, new roads and buildings and within five years they are burned down. There are the kinds of cases that give one a sense of what else can we do.
We tend also not to bring up success stories. We are guilty of always looking at the bad side of things. There are communities that are doing well. Over the years, there are communities that have managed to sustain themselves despite all kinds of assaults from the outside.
It is a mixed picture, but the real important issue is that there is not a single solution. There is no magic bullet that will say, ``Do this and everyone will be fine.''
Senator Callbeck: Dr. Chandler, on your graph on the second page, how many communities are represented here?
Mr. Chandler: One hundred ninety-seven.
Senator Callbeck: In that, where we see the number ``6,'' I understand that means that when the six qualities you talked about are in the community there are no suicides. How many communities would be in that group?
Mr. Chandler: Almost half of the 197. That is a part of the story you do not hear and that Dr. Young was alluding to. Our trouble in understanding that comes with painting the statistics about these things with too broad a brush. We learn about an Aboriginal suicide rate — and we are looking at many things beyond Aboriginal suicide rate. We are looking at school dropout rate, accident rates and other things, and the picture is always the same. There is enormous variability from community to community in all of these negative outcomes. Talk about suicide makes it into the press, and it creates this illusion of despair.
What is remarkable is that pilloried and savaged as many of these communities have been, they have survived remarkably well. Somehow, if we are trying to ferret around for a solution, our attention needs to be riveted upon those communities that are behaving so successfully against odds. One important thing about this is that many of the things that these communities do that seemingly relate to the good health outcome status were not undertaken for the purposes of improving health. No one, to my knowledge, tried to achieve self-government while saying to him or herself, ``and this will reduce youth suicide.'' They may have had some generic assumption that it would improve life in general. A lot of energy and money has been directed towards things like suicide prevention, whereas much of the evidence suggests that the things that are most somehow protective against problems like youth suicide were undertaken for a broader purpose. There is a lesson to be learned in that as we try to figure it out. Certainly, it is not a lesson lost on Aboriginal people. They talk about holistic approaches. Perhaps we are being invited to share an Aboriginal perspective on this.
Senator Callbeck: You say half are in that group as compared to the other end — the ``0'' — of the chart. How many are in that?
Mr. Chandler: In the most extravagantly high group, there are probably only two or three communities. One of the problems, and this is a researcher's problem, is that in small communities, and some of these bands have 200 or 500 people in them, one suicide can jack the incidence rate for that community way up. We have tried to address that question by looking not only at bands but at band councils. Band councils, at least in British Columbia, are typically aggregates of 12 to 15 individual bands. All of the evidence that I have reported to you holds with reference to band councils as well as bands, although by the time you get to the band council level I think it is something like 15 per cent of the band councils have no suicides. All it takes is one person in one band somewhere to change that picture.
Senator Callbeck: That is certainly interesting. Ms. Lafontaine, you talked about the First Nations, Inuit and Metis. Are there health determinants that are more specific or relevant to one group than another, or are they basically all same?
Mark Buell, Manager, Policy and Communication Unit, National Aboriginal Health Organization (NAHO): In your package, we provided some background information, including a deck entitled ``Broader Determinants of Health in an Aboriginal Context. That is taken from some work NAHO did back in 2001. The determinants of health that Health Canada recognizes all apply to First Nations, Inuit and Metis; however, there is a context with First Nations, Inuit and Metis that you do not see with the general Canadian population. We put forth that there are additional broader determinants that need to be looked at. They include such things as colonization, globalization, migration, because clearly Aboriginal people are becoming increasingly urban, cultural continuity — which Dr. Chandler has spoken to at length. Another determinant is territory. Land, as a connection to indigenous knowledge, traditional knowledge, is linked to all other determinants, including self-determination, economic development and poverty. Other determinants of health include access to health services and access to education services — determinants of health that have a lot to do with geography — poverty, and we know Aboriginal peoples in general experience high levels of poverty, and self- determination. Each of these applies to First Nations, Inuit and Metis. How they apply, I would say, and Dr. Chandler has raised it, depends on the community less than the population.
Senator Johnson: You said they apply to Inuit and Metis.
Mr. Buell: And First Nations, yes.
Senator Eggleton: Let me try to get in three quick questions, starting with Dr. Young.
You said that we all know what the problems are and that we are also quite sure of their causes but that, despite massive amounts of resources, both human and financial, these disparities are not been erased. You said there was no magic bullet. That would indicate then that the solution is not necessarily more human or financial resources. What is the cause of human and financial resources not working? Is it an organizational matter? What is the solution?
Dr. Young: I have to be careful in responding to that, because I do not want to give the impression that no resources will improve health. I am not trying to say that. I am saying that merely increasing the quantity of resources will not help. How those resources are used and how they are distributed and how they are targeted, what group is receiving it, is as important.
In a more philosophic level, in a kind of academic environment, how you improve health — at one level, health is an individual responsibility. You educate people and make them do the right things, and health will improve. At the other extreme, you have the societal or macro view. Change society, and health will get better. There are these two extremes between which we tend to swing back and forth.
I have been in this game long enough to realize that neither one of them holds the true answer, because, clearly to improve health, certain preconditions must be met. At the societal level, things must happen, but the individual must also do certain things, so there is a role for the health care system to do certain things well. I am not sure that the health care system as it exists now is doing what it is supposed to do well.
If you look at the economic analysis, and unfortunately there are not that many studies being done on the economics of First Nations health care, the per capita expenditure is really a lot higher than in the rest of the Canadian population. There are transportation costs. If you are looking at purely a cost-benefit angle, we are not getting the bang for the buck. Despite what we are spending, we are not getting enough in health outcomes.
The solution is not to pour more money but to spend the money wisely in areas that have the most effect. This is where this whole issue of evidence-based health and medicine comes into play. We are doing a lot of things just because we have always done them before, and we are not looking at the effects. Do suicide prevention crisis phone lines really work? We have to test those types of interventions and see whether they really work.
This is at a very micro-level, but on the other extreme we also need certain changes in society that allow those things to happen.
Senator Eggleton: When you talk about the health care system in this case, are you referring to just the province of Ontario where your experience has been or are you saying all across Canada?
Dr. Young: I would hesitate to paint a broad stroke to the whole country. Let us talk about remote areas, which apply to the territories and the northern parts of provinces. Right now, Canada does some things very well. We are the world leader in putting nurse practitioners in isolated areas, where they function as physicians, and yet that is not very well advertised. We are shying away from that.
Clearly, technology can help in terms of using telehealth technology. Those are technological fixes that may or may not be applicable in all areas.
Senator Eggleton: My second question goes to Ms. Lafontaine. At the last meeting we had, Professor John O'Neil made a presentation in which he said that the primary social determinant of health in Aboriginal communities is self- government. Do you agree with that, and if self-government is a key factor for those who are on reservations, in terms of social determinants of health solutions, what about those who live in the urban areas, where you would have lots of bands? How would that work as per Mr. O'Neil's comments?
Ms. Lafontaine: I do not think that it is something that I or NAHO can comment on. It is more in the political environment. It is more appropriate for the political Aboriginal organizations to deal with these types of issues. I do not know. Do you want to add something, Mr. Buell?
Mr. Buell: The key point we would like to get across is not that one determinant is more important than any other. What is important is how those determinants interact within an Aboriginal context. Any interventions that are based on single determinants — it would probably be best focus on interventions that would address how the determinants interact. Finding the place where they interact and tethering your interventions to those areas would gain our support.
Senator Eggleton: Dr. Chandler, I have to ask you — and you can respond to that question as well — this is astounding information. We have an abundance of information that paints a very gloomy picture — life expectancy being less for First Nations, infant mortality rates higher, chronic disease rates higher for Aboriginals. With respect to the suicide rate, we are told that overall, First Nations, five to six times higher and Inuit 11 times higher. Your chart says that almost 40 per cent of communities have no recorded deaths by suicide. There are two things I should like to know. One, while your study is based on B.C., do you suspect that it also would apply in other parts of the country, to about the same extent, more or less? Can you go over the formula these communities have found to come up with that, please. As well, if you can take the suicide rate figures that I just gave you a moment ago and bring them down to nothing, as you have done in 40 per cent of the Aboriginal communities, what about these other things — life expectancy, unemployment, chronic diseases — are they also much less in these communities as well?
Mr. Chandler: The data is from B.C. We have recently scored a federal grant to try to move this model to Manitoba. With luck, we will be able to answer with authority whether it also works in Manitoba. Manitoba was chosen for a reason. It has many Aboriginal people and problems in their Aboriginal communities. In good time, I will be able to answer with authority about that.
If you ask me to speculate, I believe the B.C. data is ``generalizable'' to other provinces and territories. First, across Canada, the overall suicide rate, and name any other health problem that occurs to you, is disproportionately high in Aboriginal communities, but that is again painting with an extremely broad brush. I believe, but do not know for a fact, if you looked at suicide, or name another health-related issue, anywhere in Canada you would find variability across communities. Whether you would find 40 to 50 per cent with no problems, maybe it is only 20 per cent with no problems, but they would be there.
If you then are in search of a solution to this problem, studying the difference between the communities with and without this problem is not again a simple and sovereign solution, but it is a smart way to spend your energies. Look at the difference between the communities that do and do not have obesity or diabetes. Maybe there is no community that does not have elevated diabetes rates, but I bet there are.
As a general strategy, this is an effective strategy. Not only does it position you in a way that alerts you to what the possible solutions are, but also it begins to lift the burden of despair felt by the community and the sense on the part of the country at large that this is an insolvable problem.
If I could speak to the question about whether John O'Neil is right, that self-government is somehow the pinion question here, I certainly appreciate his reasons for saying that, but I would argue slightly differently. I believe there are two sets of forces at work in the Aboriginal communities with which I have personal experience. One of these sets of hopes or expectations is pinned on retrieving a lost traditional past. Another set of expectations is the opposite, which says forget the traditional past, let us try to gain some kind of civic control over our future. In fact, there are often internal wars going on within communities about which of these is the better way to proceed, and there is often disrespect between the groups.
When I try to promote the idea of continuity of culture as somehow a better alternative than the notion of self- government, it is really because the notion of continuity is Janus-faced. It is looking back to the past and to the future at the same time. It somehow helps to heal a rift between these two kinds of community groups.
We have really strong data that suggest that attempting to rehabilitate your Aboriginal language is strongly associated with reduced suicide. There is no money to be made in rehabilitating an indigenous language. If the WHO is right, no matter how hard you work at it, three generations later it will be gone anyway. It is not an economic enterprise but it is an attempt to recoup some sense of meaningful connection to one's past.
I would argue that self-government is a manifestation of a community's attempt to situation themselves in time. It has these two features, both connecting to one's past and gaining some control over the future.
The Chairman: That is tremendously interesting, Dr. Chandler. I must say that the information coming out is tremendously interesting to the committee.
Fundamentally, looking at this from the top, we wonder why it is in this huge rich land with a small population that Canada ranks fourteenth in the world in population health. If we can study this properly, we are not truly fourteenth in the world. In some places, we are two-hundredth in the world; in other places, we are well above the rest of the world. It is good to know that the science is unfolding to begin to provide some answers.
[Translation]
My question is about Aboriginal youth. It is important to take care of the very young, but also of Aboriginal youth from 8 to 16 years old. A number of them lack schooling and end up unemployed. They often live in poverty and suffer discrimination.
What would you say are the main health determinants for the Aboriginal youth population? What form do you think a youth strategy would take? Should we have the same approach for Aboriginal youth living in cities? How could all that be coordinated? I think that looking after Aboriginal youth is very important.
[English]
Mr. Chandler: I missed the first part of your comment so I do not know to whom the question was directed.
[Translation]
Senator Pépin: No problem, you can answer.
[English]
Mr. Chandler: My group has recently completed a study in which we looked at the same set of factors that predicts youth suicide rates by community — self-government, control of health and education, welfare, et cetera — to see whether they also predict school dropout rates. In B.C., approximately 30 per cent of Aboriginal youth complete a high school diploma. Actually, among the general population, it is only 70 per cent, which is astounding. However embarrassed you are that only 70 per cent of the general population earns a high school diploma, it is more tragic still that only 30 per cent of the Aboriginal community achieves that. If you unpack that data and ask, ``What about community by community?'' you will find that many Aboriginal communities in British Columbia have never graduated a high school student — not one — whereas the rate in other communities, although not quite the same as the rate in the general population, is very close to it.
Senator Pépin: I never heard anything like this before.
Mr. Chandler: Again, if we had a graph that showed high school completion rates, it would be extremely saw- toothed. We already know that a set of community level factors predict which communities are doing a better job. That is not the complete answer to your question, but it is a step. It suggests that if these social-cultural resources are in place, then children will complete school.
The deeper question is why some of these communities are doing better. Although we cannot answer that question entirely, we can stave off some hypotheses. It is not a question of poverty — although I have to be careful in saying that because the entire Aboriginal community is deeply depressed socio-economically in comparison to the rest of the community. Forget for the moment about the rest of the community and look within the Aboriginal world itself. Their various predictors of socio-economic status do not predict either suicide or school dropout rate, and I can try to unpack that with you. The first intuition is that it is a matter of money, but it does not seem to be within the community-by-community differences in school completion rate or in the suicide rate. You might also guess that it is the people who are extremely rural versus the people who are more urban — but that does not work either.
While I do not want to pretend that we have all the answers to all of these questions, we have a solution strategy, that is, a way of looking that produces some results and a way that discounts some possible expectations that do not bear up to scrutiny.
Part of your question, as I understood it, was on the importance of emphasizing the youthful sector of Aboriginal communities. Certainly, that is exactly right on, but we do not have to do that by working out little programs for individual children. Rather, we have to work, I believe, at the level of community restructuring.
Senator Pépin: I am stunned because we hear so much about suicide in young Aboriginals and how they cannot cope and live like other young people. You tell us that in B.C only 30 per cent of them have a high school education. We need to know and understand your strategy.
[Translation]
Now, turning to Aboriginal women, their situation is quite different from that of other Canadian women. A number of them have significant health problems.
What are the main health determinants for Aboriginal women? Where are the gaps in our understanding of the main determinants? Then, what are the indicators and the steps that we must take to fill those gaps?
[English]
Dr. Young: On women's health, the same health determinants apply to men as apply to women, such as socio- economic conditions, smoking and physical activity. In women's health, relating to reproduction is in addition and family violence is very important. In reproductive health, for example, the Aboriginal population has a much higher fertility rate and a higher rate of teen pregnancy. That introduces a whole dimension of health issues, both for herself and her children. Family violence is, of course, a major problem, but, unfortunately, that is one area where we do not have good information as to how common it is.
If you want to highlight two or three things that are of particular importance to women, I would say family violence and reproductive health.
Ms. Abonyi: The other one that seems to be emerging is the difference in sexually transmitted diseases. The rates for HIV and so forth are higher in the female population than among men.
Senator Pépin: Do you have any specific recommendations for a way that we should handle that situation?
Ms. Abonyi: I would add to what I have been hearing some of the others say. It is about looking at some of the intersections of these determinants and understanding what is happening and looking at places where we are not seeing some of these issues, namely, how are some of these determinants intersecting there to produce healthy populations, rather than trying to look at the intersections around poor health.
Mr. Chandler: I do not have much to add, but I do have two things. First, two years passed in B.C. without a single young woman committing suicide. In general, their suicide rate is much lower than it is in males — and that is not only true for the Aboriginal world, it is true in general. It is perhaps too early to say, but there is a declining overall provincial rate of suicide, and it is due principally to the reduction among young women. If I were to speculate as to why that might be, it seems that when one's culture has been ripped from beneath one's feet, there continue to be meaningful roles for women, roles that reach back into history, and perhaps the issue of early teen pregnancy is related to this.
It seems to me that young Aboriginal men have no cultural place in the world. We are doing just the beginnings of a study where we are looking at bands in which there is a role for men that had status traditionally, like fishing, and there are other places where Aboriginal people pick fruit, which had nothing to do with their history. Some of the social determinants, like suicide and school dropout rates, are higher in those communities where there is no culturally respectable role for men.
The Chairman: I recall being in Iqaluit where a young man testifying before us said just that. He said: ``There is nothing left for us. We used to be the hunters and gatherers, but that is no longer necessary. The women have a place in society, but we do not have one.'' That is very depressing stuff.
Senator Cochrane: I have a supplementary to my colleague's first question. You said that only 30 per cent of Aboriginal graduate from high school. In speaking with several teachers who go to various isolated communities to teach the Aboriginal children, I am hearing that there is a certain time when they cannot teach because only one or two of the children will show up, all because their families take the children out hunting and things of that nature. Maybe we should be looking at having a different type of school system.
Mr. Chandler: Again, the school system that we have for the general population, where people get their summers off, was dictated by agricultural norms in the general population. We know how to do that. We have not bothered to or worked to figure out how to make the framing of the school system fit within the lives of different cultural groups. It is not rocket science; we could do it if we wanted to. If there were political will to do it, it could be done.
Ms. Abonyi: In one of the Northern Ontario schools where I worked, they worked the curriculum around goose breaks in spring and fall, so there was no school during those times. You are staying longer in the summer, but students were out for goose breaks. You do not have to choose between a dimension of cultural health and your educational health, for example.
Senator Cochrane: Did that work?
Ms. Abonyi: It was going very well there, yes.
Dr. Young: I want to caution that we should not assume that all Aboriginal communities want to have their traditional ways. They live in the globalized world of the twenty-first century. They need to know how to use a computer and the Internet. They will get jobs in the business world. You cannot say, ``Go and become a hunter.'' That will not work for them. They will have to decide what kind of education is best for them. Maybe the majority today would opt for, ``We want a computer in every classroom rather than let us go off and hunt.''
Senator Fairbairn: This is a very educational presentation that all of you have given to us.
Because I do a lot of work in literacy and education, I wish to dig a little deeper into this. I noticed, Mr. Chandler, in your comment, that in the case of British Columbia there are communities that have achieved a measure of self government, were quick off the mark to litigate for Aboriginal title to traditional lands, that promote women in positions of leadership and that have supported the construction of facilities for the preservation of culture. Much of that put together comes down to a level of education — or up, as the case may be. Ms. Lafontaine, you used a percentage of 90 per cent when you were doing your presentation on the issue of literacy and the difficulties.
In the larger picture, is the question of education or literacy a foundation issue in bringing on some of the negative parts of Aboriginal life, which, of course, would include suicide at any age level? Is that lack of learning or the desire to learn or the encouragement to learn a foundation issue to the problem?
Mr. Chandler: To have a well-reasoned answer to your question, I would have to have some information that I do not have. If you look at those communities, your intuition is that the communities that have struggled to achieve a measure of self-government and have litigated for Aboriginal title — that somehow that was driven by the fact that beneath all that there was a higher level of education. Maybe that is right; I do not know the answer to that. My intuition is that it is often very surprising how few people are required in a band to make some of these things work. Although I do not have the data in hand, if you could go back and discover what the educational level of this group was 30 years ago, it would not be that the groups that have succeeded were somehow at the top of the heap in terms of having better education. It is that somehow a group of community leaders has emerged, somehow almost beyond reason, out of a very bad situation and are driving progress in their communities.
I am certainly convinced that if we could raise the educational level of the whole Aboriginal world, it would not make a huge difference. We may not have to wait the 30 years for that to happen. It seems as if it is happening in pockets, not because people somehow have secretly become educated. I really do not know the answer to your question. If you ask why some communities produce these markers of success and others do not, the best answer is that some things that you would have guessed were the reasons they are not, such as more money at their disposal. I do not know whether they were better educated. I do not think so.
There is some interesting work by a man from Harvard, Stephen Cornell, who writes about an interesting intersect between traditional forms of government and the kind of government form that happened to be imposed by the federal or provincial government of the day. This is clearest in the U.S. where the forward march across the continent was fairly regular and federal policy kept changing as it intersected with bands further and further west. It was an almost accidental coming together of a certain kind of similarity between traditional forms of government and the kind that was being imposed. In all those cases where there was that kind of convenient mix, bands who seemed to have no resources have succeeded enormously well. Other bands that were sitting on a gold mine of resources have fallen into despair. It is a very complicated question. The work by Cornell and colleagues is a step in that direction, but no one can really answer the question you are asking right now.
Ms. Lafontaine: It is important to promote education within our youth. NAHO has a program, the National Aboriginal Role Model Program, where every year we pick 12 role models, four First Nations, four Inuit and four Metis. Those 12 role models yearly are tasked with going into communities and promoting education as well as their achievements. The last announcement of the role models was done by the Governor General here in Ottawa. It seems to be a successful program. When we started three years ago, we received maybe 50 or 60 nominations. We have just finished a call for submissions and we received over 150 nominations. That was really exciting. It generates a lot of positive attitude within the youth community. There is interest and they want to meet these role models and speak to them. We get several requests for them to attend community events and present themselves and their achievements. It is a very positive tool, one that allows youth to see that there is something out there for them, as well as promoting education in a large part.
Senator Cochrane: Are there boys and girls?
Ms. Lafontaine: Yes.
Mr. Buell: With regard to your comment on literacy, what Ms. Lafontaine was referring to in her presentation is that it depends on how you define literacy. There is a 2004 research paper from NAHO that looks at literacy in an Inuit-specific context. It looked at the idea of literacy as defined as a higher level analytical skill to make informed choices about one's life, not necessarily the ability to read or write.
Senator Cook: I am the last one on the list. Much has been said and much needs to be done.
I struggle for understanding here. I come from Newfoundland and Labrador. My first introduction to the problems of First Nations people was the issue of the residential schools. I am a member of the United Church of Canada. It was a big learning curve in trying to understand that phenomenon in places so far away from my remote island.
I am still preoccupied about the impact of that era. I am wondering how many children were involved. Was it an exodus of the population that ended up in residential schools? I still struggle with that one. How do you get your cultural continuity if it was taken from you?
Last night's news carried a story about the government apologizing for that terrible time in our history. The chief still wanted something more. Parliament apologized, but the chief wished that the government had done that.
How realistic is it for that generation to be able to let go? That question preoccupies me. Does it manifest itself in those people?
My question is one of a wish. Given that 50 per cent of Aboriginal people are under the age of 25, and it is a fast- growing population, and the White population are older and have fewer babies, if each one of you had to take a first step and to use your wisdom to help that group of people, what would you do? How would you use your wisdom to help those people through this maze that we are trying to get through?
Dr. Young: Are you referring to the residential school survivors?
Senator Cook: You can speak from your knowledge, understanding and experience.
I went to a conference on poverty for my church about 20 years ago. There were circles, talks and dialogue. There was an elder from the Cypress Hills band who never spoke for three days. The last session was: Who will roll away the stone? We had to take our stone when we went there and put it back with a solution. When she put her stone in, she looked at us — we were predominantly Caucasian. She said: ``You White people talk too much.'' I fear we are trying to understand; you have all accumulated wisdom and experience. At some point, we have to put our foot in the water and implement something. That is what I am asking. How would you take your first step to address some of these issues?
Mr. Chandler: Everyone is looking down.
Dr. Young: I am too timid to tackle that.
Senator Cook: Someone has to. We have to.
Mr. Buell: It is a very difficult question. If I had the answer, I probably would not be sitting here right now.
It goes back to something Ms. Lafontaine mentioned, celebrating successes of Aboriginal youth through things like the role model program, but also research into those communities that are doing something right and finding out what is going right in that 50 per cent of communities in B.C. That is happening nationally. Lots of bad things happen to lots of people. Some people are more resilient than others. What is that resilience factor? That is my personal opinion.
Mr. Chandler: I will speak to what I think is your easier question first, which is how you reconnect to a cultural past that may have somehow evaporated before you were born.
There is a wonderful book called Harmony Ideology, written by a woman whose name is Nader. She happens to be the sister of Ralph Nader. In it, she talks about American Indian people of the southwest and northern Mexico. In her analysis, many of the things that are held as very important cultural aspects of southwest culture did not pre-date colonialization but were responses to colonialization. These things did not have a 10,000-year history; they had a 200- year history.
One thing I see in British Columbia is people reinventing culture — often self-reflectively inventing culture. I think of the pan-Indian movement. We have people running around B.C. practising Plains Indian procedures. They are making up a culture in the wake of residential schools. It is something we all do. There is nothing unique about Aboriginal people in this way. We all make up our culture. I do not see this as an impossible task. Historically, we have all made up our culture. For me, at least, that is not a real problem. You see people solving the problem effectively.
With decades of focusing and pathologizing about Aboriginal people, focusing on success is important. Certainly, this program of heralding the accomplishments of successful young Aboriginal people is something people talk about this all year long. It is important. It is a sub-species of a general strategy, which is to play the strengths.
My only caution here is that the word ``resiliency'' has a negative implication. There was — 30 or 40 years ago — a big wave of research in psychology about resilience, and it became a way of blaming the victim. There were people who were not resilient, so therefore they somehow did not measure up. That to me is a way of individualizing the notion of resiliency. We have to look at cultural resiliency or community-level resiliency. If we do that, it does not present answers to our problems but prevents a solution strategy for problems. It tells us where to look to get right answers.
Ms. Abonyi: I am thinking hard about how to answer that question. I am thinking about some of the processes that we engage in when we work with communities. These same questions we are asking here and the same approaches come from these Aboriginal communities as well. Following with them in partnership and developing capacities back and forth, a lot is coming to the table there instead of coming from the top down. Answering the questions and looking at an issue using measures developed in a local way might allow you to see the issue in a different light, because some of the local communities are coming up with measurement tools that are not in our standard set of indicators. We talked about education, and that is something that the community groups we are working with came up with, the sort of western education, but they are also developing indicators around traditional education and putting those things together. You want to look at the interconnections.
Basically, my main message is really the sort of partnership process to try to get at some of these questions instead of bringing them there and saying, ``We need to look at you.'' Those communities are asking those same questions. What is going on right here and how and why? Let us think about the way we see health. What pieces of our programs are contributing to that little piece, and can we then put more resources there or there?
Senator Cook: Isolation is a factor, as well. Senator Cochrane and I grew up in Newfoundland, where there were not many roads. Our roads were made of water. I can see in my own childhood the same types but not the stresses of communication.
We have to do something, because my sense is that collectively this particular population does not feel very good about itself. Until you feel good about yourself, you will not tackle the bigger issues and challenges out there. You will not make sure you have clean water or your child has a place to play. Yes, we live in a global village, and the things that are good need to be accessed.
I firmly believe that people have a right to live wherever they want to live, but that can only go so far. In the 1960s, in my province, the government of the day undertook a resettlement program. That was good and bad — but, looking back, for the most part it was good. It was simply smaller communities came to a larger community. We all want to be home. The challenge is to make a home that addresses the poverty issue and the other determinants? Dr. Young, do you have anything to add?
Dr. Young: You used the word ``wisdom,'' and that really scared me because I do not have much. I completely agree with what has been said. There is a lot of wisdom out there from the communities that we could tap into. I am very leery of offering expert advice. We look at things from an academic or scientific point of view, which is one way of approaching knowledge, but there are other ways of acquiring knowledge, and solutions should come from there.
Senator Cook: For the medical profession, you will always be the flying doctor, because of access to roads and better services. I think the women will probably fix it — the nurse practitioners.
The Chairman: Ms. Abonyi, you mentioned there are a number of successful models of population health partnerships in northern Saskatchewan, but I was not clear as to why you think they are successful.
Ms. Abonyi: One of the models I am referring to, the Athabasca Health Authority, is a fairly new model. The other one, the Northern Health Strategy, is a little older. Romonow looked at that and saw that the inter-sectoral and multi- jurisdictional groups of people were coming up with plans that were helping address population health issues across that diverse group across the North, which we know consists of the Metis, First Nations, people on reserve, people off reserve and non-Aboriginal folks. They were tasked with delivering health services to all of them. Because some of these are newer organizations, they are tracking the partnerships that have been successful, who we are working with and what agreements we have managed to negotiate. Those are some of the earlier successes. Those are in place. How that will play out down the road in actual health — that is the plan for five years or more down the road.
Some of the early process indicators are showing some right things are happening here, and the proof about what this means for health outcomes will come out in the end.
The Chairman: In other words, you do not know the outcomes yet but you are getting into position to measure them.
Our time is up. I thank you very much. This was a truly encouraging session. As we work our way through this over the next couple of years, if we are to make truly useful recommendations, they have to do the kind of dissection of the problem we have heard today and break it down. We have had too many generalities. I cannot prejudge, but I suppose we will always need to have very broad-based vaccination programs and public health programs, et cetera, but at the same time we have to really focus on community and small populations.
Senator Fairbairn: There is one thing we did not really ask about, which is, when you are talking about the suicide level, what is the degree to which alcohol or drugs is in the life of that reserve and whether that is at the foot of some of those very sad situations.
Mr. Chandler: I am confident without an evidence base that all communities that have high suicide rates have high drug and alcohol rates. Whether that is a cause or effect is the big question.
The Chairman: Thank you, again.
The committee continued in camera.