On Feb. 4, Maclean's is hosting "Health Care in Canada: Poor Health No More," a town hall discussion at the Winnipeg Art Gallery. The free, two-hour event--focusing on the social conditions that impact the health and longevity of Canada's Aboriginal people--is held in conjunction with the Canadian Medical Association, and will be broadcast by CPAC. The conversation on the effect of social disparities on health will continue in the coming months in the magazine, and at town halls in Hamilton, Calgary, and Charlottetown.
It was 3 p.m. on Sept. 19, 2008, when 45-year-old Brian Sinclair rolled his wheelchair into the emergency department of the Winnipeg Health Sciences Centre, referred by a clinic doctor because of a bladder infection caused by a blocked catheter. He was a Métis with a cascade of social and health issues, the product of a mother haunted by her residential school experience. He had neurological and speech problems, a past history of substance abuse. He'd lost both legs to frostbite in 2007 after spending a bitter February night outside. His landlord had locked him out.
To some who saw him on the streets he was a stereotype of dysfunction. But what killed him in this busy, inner-city hospital on a September weekend were equally insidious attitudes that rendered Sinclair invisible. He spoke to a staff member at the triage desk, then rolled into the waiting area ... and waited, vomiting and growing weaker. When he finally received medical attention--almost 34 hours later--it was to pronounce him dead. Fellow patients had found him dead in his wheelchair. The cause of death was "peritoneal infection." A change of catheter and antibiotics could have saved him. An inquest will finally be held this August. But as a headline succinctly said, Brian Sinclair was "ignored to death."
The manner of Sinclair's death was an extreme and aberrant example of failure in a highly regarded hospital. But it is also sadly accurate to say that there are many thousands of premature and preventable deaths in Canada every year. They are people whose lifespans and health outcomes are determined by the postal codes in which they are born and raised, by race or ethnicity, the function or dysfunction of their families, the quality of their housing, their levels of income and education, the jobs they hold, or don't, the foods they eat, even the degree to which they feel they control their destinies. These are the social determinants of health--an increasing area of focus and concern for researchers and health professionals. "We can't talk about the health care system without talking about this," says Anna Reid, an emergency room doctor in Yellowknife and president of the Canadian Medical Association (CMA).
Simply put, wealth equals health, a problem exacerbated by the growing disparity between the very rich and the very poor, and by social conditions taking a toll in Aboriginal and northern communities. The further you are down the socio-economic ladder, the sooner you are likely to die, a fact borne out in scores of Canadian and international studies. "We know that 50 per cent of patient's health outcomes are determined by their socio-economic factors, versus only 25 per cent by the actual health care system itself," says Reid. "The other 25 per cent of your health outcomes are determined by biological, genetic and environmental factors."
When physicians focus on income disparity in their clientele, it moves medicine uncomfortably close to the political realm. More than a few politicians have suggested the CMA should butt out of the issue, says Reid. "But, as I said, it's a big part of the health picture."
Drill down into the diffuse agenda of the Idle No More movement, and the foundational concerns are the same social needs that determine the health of all Canadians. "Poverty is killing our people," said Assembly of First Nations National Chief Shawn Atleo, before taking sick leave himself. "First and foremost the government has to make health a priority," says Chief Donavan Fontaine of Manitoba's Sagkeeng First Nation. "People sitting behind a desk sometimes don't take that seriously," he says. "Maybe if they felt what it was like living in those conditions one day they might change their perspective."
Poverty, of course, is not a uniquely Aboriginal problem. It takes minutes to travel by car or bus between the Winnipeg neighbourhoods of Fort Garry and Point Douglas. But those living in Fort Garry, a solidly middle-class enclave near the University of Manitoba, live on average more than eight years longer than those who alight from the bus in Point Douglas. There, income and education levels are lower, and a more transient population--29 per cent Aboriginal and with many new immigrants--endure poor housing stock and high crime rates. It's the difference between a man living to 80 in Fort Garry, and not seeing his 72nd birthday in Port Douglas, according to the Community Health Assessment of the Winnipeg Regional Health Authority.
But it is among indigenous Canadians that the health disparities are writ large. Last spring, the Health Council of Canada staged cross-country consultations to investigate Aboriginal health care delivery in urban Canada, where half of the country's 1.3 million indigenous people live. The council panel heard many Aboriginal people don't trust and don't use the mainstream health care system, until an illness reaches a crisis stage. "They don't feel safe from stereotyping and racism, and because the Western approach to health care can feel alienating and intimidating," it said in a report released in December.
The report cited examples of doctors who wouldn't prescribe painkillers on the assumption that an Aboriginal person would become addicted or was already abusing prescription drugs. There were cases in emergency departments where Aboriginal people were improperly assessed because they were assumed to be drunk when in fact they were injured or in a diabetic coma. One nurse refused to let a beaten, bloodied Aboriginal man have a bed because he'd only be discharged to resume his high-risk behaviour. In fact, he owned a home and was mugged on the way home from work.
No region has worse health than the predominantly Inuit territory of Nunavut. A 2011 territorial report comparing health indicators with the rest of Canada is a shocking read:
• Infant mortality is almost three times higher than the rest of Canada. Most infant deaths occur between 28 days and a year, the report said. "This means that social factors, rather than the medical care system, make a significant contribution to our infant mortality rate."
• Lung cancer deaths are four times higher.
• Potential years of life lost to suicide are more than nine times higher.
• Sexually transmitted chlamydia and gonorrhea are respectively 17 and 18 times higher.
• Tuberculosis rates are 30 times higher.
While Canadian life expectancy surpassed 80 years by 2005, it fell to 69.8 years in Nunavut, losing a half year from a decade earlier.
Reid, whose Yellowknife hospital treats many Inuit from the western part of Nunavut, says a high smoking rate--54 per cent of Nunavut residents 12 years and older smoke--has obvious health consequences. So too does the territory's grossly overcrowded housing, which increases stress, impacts education outcomes and employment prospects, and contributes to Third World levels of highly infectious tuberculosis (TB).
History also plays a role. Too often Reid sees cases of TB left untreated by elders who have painful memories of the hospital ships that traversed the North in the 1950s. Then, INUIT diagnosed with TB were kept aboard and sent to sanitoriums in the south for years at a time, often with no chance to notify family of their fate. Today, some elders suffering relapses of TB delay seeking treatment for fear they'll be sent away, like they were as children. By waiting until a crisis hits, they are indeed sent to Yellowknife, often to receive a terminal diagnosis, Reid says. They linger in Yellowknife until a bed and support nurse are shipped to the community. "These people are terrified," says Reid. "They just want to go home to die, which is why they never went to the nurse's station in the first place."
A lack of indigenous health care providers adds to the alienation. The Northwest Territories, for instance, has nine official Aboriginal languages, but not a single Aboriginal doctor. Winnipeg has the largest urban Aboriginal population in Canada, almost nine per cent of the city's citizens, yet just three per cent of health care staff are Aboriginal.
Dr. Catherine Cook, vice-president of population and Aboriginal health for the Winnipeg Regional Health Authority and a panel member on the Health Council of Canada report, says health care must reflect indigenous culture and values. Cook, a Metis, saw the "power imbalance" as a young doctor servicing fly-in communities in northern Manitoba in the early 1990s. A typical example was a nursing station that arbitrarily booked a pregnant woman on a flight south for delivery two weeks before her due date. When she didn't show for the flight, it was left to Cook to determine why. It turns out she needed to ready the home for her mother to babysit. "Nobody had asked if [the flight] was convenient for her."
The need to foster a sense of "cultural safety" is a priority for the health region, she says, "recognizing and acknowledging that racism exists in all our systems, our health care system, our education system, our judicial system. We need to get comfortable with the word and look at ways of addressing those actions that impact people, not only their physical health but their emotional health." A Winnipeg high school internship program that gives Aboriginal students credits for health care placements is yielding results. There are also incentives to consider medical school or nursing for the growing cohort of Aboriginal university students.
Aboriginal recruitment and mentorship has been a priority for 25 years for Barry Lavallee, a family doctor, director of the Centre for Aboriginal Health Education at the University of Manitoba. Lavallee, of Saulteaux and Metis descent, favours a separate Aboriginal health care system that values indigenous experience and traditional healing. He's medical adviser on one such successful program, the nurse-run Diabetes Integration Project, which serves 19 Manitoba communities, focusing on prevention, clinical assessment and intervention. Many of the staff are Aboriginal, all are non-judgmental and "incredibly literate" about First Nations culture, he says. The result is a significant drop in diabetes complications. Lavallee calls social determinants a "bulls-t" term that masks uglier words like racism, colonialism, classism, "all those -isms," he says.
It is from that frustration that the Idle No More movement has developed, he said. The demands for an equitable share of resources, safety for women, better housing and education are only part of the answer, he says. "If you don't address racism in the background, perpetuated by policy, then we're still not going to achieve true [health] equity."
On the Sagkeeng First Nation, 125 km northeast of Winnipeg, Chief Fontaine understands where the Idle No More springs from even if he doesn't like the slogan. "Patient no More" might be more appropriate. "If I want to put it bluntly," he says, "I haven't been idle." Nor does he like the victimization implicit in the word racism. "I've seen it, and I've probably experienced it myself many times," he says, "but I'm never going to play that racism card."
That said, as a member of the Assembly of First Nations committee on health, he sees the human cost of social policies. If the federal government sees education as the ticket to independence, jobs and health, why are Aboriginal students funded at rates 20 to 30 per cent lower than other students? Why this year did the band have to turn down 60 high school graduates with good grades seeking support for post-secondary education? Why is so little focus put on health prevention?
Fontaine hopes these are among the issues resolved in future talks with federal leaders. "We need to stand side-by-side, not toe-to- toe," he says. "Confrontation isn't going to work, we need the Canadian people on side."
The inquest this summer into Brian Sinclair's death is certain to open old wounds and confirm suspicions that the health care system fails Canada's indigenous people. Not long after he was found dead, protocols were established to prevent anyone lingering forgotten in Winnipeg's emergency departments. The hospital was equally quick to determine that, while the system for tracking ER patients was flawed, its staff were blameless.
That is the thing about a system failure: it has no face. Only its victims have names. In that regard, Brian Sinclair died a lonely and unnecessary death, but many thousands die with him--casualties of class or race or circumstance.
See also Aboriginal People, Economic Conditions.
Maclean's February 11, 2013