Health Status Backgrounder
Population and Demographics
Saskatchewan has one of the highest populations of First Nations people in Canada at 13% (141,379), and the combined population of the PAGC communities as of the 2014 PAGC Annual Report is 38,532, making up 27% of the provincial total. The PAGC population statistics are based on the Indian Registry numbers and would include those members living off reserve. Statistics relating to health service provision is more easily accessible for those First Nations living on reserve. Therefore, the population of First Nations living on reserve in the PAGC and Meadow Lake Tribal Council (MLTC), essentially the northern half of the province, decreases to 32,743; however, this represents 47.3% of the total Saskatchewan First Nations population living on reserve. Furthermore, this figure would not include those First Nations people that are living in communities in close proximity to their home reserve.
First Nations communities across Canada have a younger population compared to the general population… this is no different with respect to PAGC communities. In 2012, 54% of First Nations people living on reserve in Saskatchewan were under the age of 25, compared to 33% of the general population. Between 2004-2012, the First Nations on reserve population of PAGC and MLTC grew by 19%. There is a higher birth rate among First Nations women and non-First Nations, at nearly 5 times the rate of the national average and the highest age group population proportion is that of the 5-9 year age group. The proportion of those 50 years or older is lower among First Nations than those in the general population.
Health and Illness Trends
Mortality and morbity are two of the most common indicators of health and illness in a population. Mortality is death, morbidity is illness. Health status reports typically report vital statistics, which are the births and deaths of a population. Cause of death is also commonly reported, giving an indication of what is causing death in the population. And from the age of the person at time of death, values such as potential years of life lost (PYLL) provide an indication of the loss to the family, community and population. Morbidity is illness. It is often reported in terms of injuries or diseases, an indicator of what is causing illness within a population. Furthermore, chronic disease and illness cause by injury has an impact on an individual’s ability to look after oneself or be a contributing member to the community – another indicator of population health.
Infant mortality is when a baby dies within the first year of life and is an indicator of the health and wellbeing of a population, as well as the effectiveness of public health, education and prevention in the area of maternal and child health. During the years 2000 and 2007, the rate of a infant mortaility in the 3 northern health regions was 10.3/1000, while the provincial rate was 6.3. The top three causes of infant mortality in the north were congenital anomalies, unclassified including SIDS and perinatal. The infant mortality rates in PAPHRA has fluctuated from year to year but as of 2005, the rates were similar to the provincial levels (-8.2/1000). Congenital anomalies are birth defects, unclassified including SIDS means that there was no known cause, perinatal means that there were problems for the baby while in utero, and may be stillborn or die within the first week of life.
Other Causes of Mortality
The age-standardized rate of mortality in the 3 northern health regions between 2005-2007 was 837 deaths per 100,000 people. This is significantly higher than the provincial rate of 583/100,000. The top 7 cause of death were injuries, circulatory systems, cancer, respiratory, other, endocrine-nutrition-metabolic and digestive.
From 2003-2007, there were 34 deaths of children, aged 1-14 years, on reserves in Saskatchewan. This is an average of 3-9 deaths per year, and the leading cause of death was external causes at 62%. The most common external causes were land transportation accidents, fire exposure, intentional self-harm and assault. The next highest cause of death was nervous system diseases at 11%.
The 25-44 age group of on-reserve population had similar causes of death: external causes, cancer, digestive diseases, and circulatory diseases. There were 185 deaths in this age category. The numbers being high enough for a gender difference analysis – 61% were male and 39% were female.
The external causes of death decreases in the older age categories: 45-64, and 65 years or older. The leading causes of death are circulatory disease, cancer, metabolic disease and respiratory disease.
Morbidity is a measure of illness within a population. The illness can be caused by the same sources as causes of mortality already presented; such as injury or disease. Measuring morbidity can be challenging, as the severity of the illness is going to determine whether health care services are accessed, and therefor measurable. Causes of hospitalization is one measure of morbidity that is an accepted standard.
Causes of Hospitalization
According to the PAPRHRA, the top five causes of hospitalization by diangois are as follows: pregnancy and childbirth, digestive system disease, genitourinary disease, circulatory disease, and respiratory disease. In the three northern health regions, the top five causes for hospitalization were supplementary causes (including live born infants), pregnancy & childbirth, respiratory, injuries and poisons, and digestive diseases. It may be of interest to note at this point that the La Ronge Hospital in La Ronge and St. Joseph’s Hospital in Ile a la Crosse would typically be the first point of contact for hospital services for the three northern health regions. If those hospitals don’t have the capactity to handle the care required, then the Prince Albert Victoria Hospital and or one of the three Saskatoon hospitals would be the next stop. For the PAGC communities within the Kelsey Trail Health Region, Nipawin or Melfort Hospital would be the first point of contact, followed by either Prince Albert or Saskatoon. Some of the Peter Ballantyne Cree Nation communities that border the Saskatchewan/Manitoba border access hospital services in Flin Flon, Manitoba.
On average, there were 7,000 hospitalizations per year for northern Saskatchewan residents. This includes all hospitalizations, regardless of location. The rates of hospitalization for the northern health regions is higher than the provincial rate. Age groups of less than 1 year and 15-30 have the highest hospitalization rates.
Pregnancy and Childbirth
On average there were 760 births per year in the three northern health regions from between 1998 and 2007. PAPHR reports an average crude birth rate of 14.2 per 1,000 population since 1996. The FNIHB-SK Health Status Reports statee that the Saskatchewan First Nations crude birth rate for the years 1999-20007 is 22.1 per 1,000 population. Regardless of the how the statistics are reported, what is clear is that the First nations population is experiencing growth at a higher rate than the rest of the province, whose crude birth rate is between 11.7 and 12.3 per 1,000, depending on the documentation source. And when it comes to hospital based services, giving birth has been medicalized to the extent that for all intents and purposes all babies are born in hospitals.
Very few PAGC communities are in close enough proximity to a hospital for a pregnant woman to get to the hospital at the time of labour. Mot women
Racism among Health Care Providers
Treaty Right to Health Care
The Treaties are sacred and enduring, and both parties agreed that they were to last “so long as the sun shines and the rivers flow and the grass grows.” In the summer of 1876, Treaty 6 was signed with the Cree at Fort Carlton and Fort Pitt. The use of traditional ceremonies and spiritual symbols made it clear that their authority and jurisdiction over health would continue to be exercised. However, eventually, through provisions of the Indian Act, the practice of traditional medicine was prohibited in favour of Western practices.
In the early days, the creation of Treaties was the mechanism by which both the French and British Crown sanctioned relationships for peaceful coexistence and non-interference with the sole occupants of the land, the First Nations. Pre-Confederation Treaties were entered into with First Nations on a nation-to-nation basis. The French and British Crowns recognized and respected First Nations as self-governing entities with a distinct system of law and governance. Treaties continue to be the mechanism preferred by most First Nations today.
The recognition of First Nations nationhood became unbalance when alliance with First Nations were no longer needed. As the non-First Nation population grew in numbers, non-First Nation governments abandoned the cardinal principles of non-interference and respectful co-existence in favour of policies of confinement and assimiliation. In short, the relationship between First Nation and non-First Nation people was based on colonialism. The mutual relationship between the Crown and First Nations that was created solely to maintain the livelihood of both parties was the Treaty. The 1763 Royal Proclamation indicates that
all Our [George III’s] loving Subjects, as well of our Kingdom as of our Colonies in America, may avail themselves with all convenient Speed, of the great Benefits and Advantages which must accrue therefrom to their Commerce, Manufacturers, and Navigation. We have thought fit, with the Advice of our Privy Council to issue this our Royal Proclamation….
meaning that there was a need to begin Treaty negotiations with First Nations. The intent of the Treaties, from the Crown’s perspective, was to obtain from First Nations “the surrender of large tracts of land, to establish friendly relations with the Indians in return for promises of aid with respect to education, farming, hunting, medicine, annual cash payments and other matters.”
Prior to contact, First Nations peoples were well adapted to their environment because of their subsistence lifestyles and traditional spiritual practices. There were First Nations health systems prior to contact which helped maintain good health and treat illnesses in traditional ways based on distinct spiritual traditions, beliefs, teaching sand knowledge of medicinal plants. In general Aborianal peoples, although prey to various bodily wills, were relatively healthy, free from substance abuse and were overall mentally, physically, emotionally and spiritually balanced. Indeed, the special relationship with the land, the traditional way of life, which included hunting, trapping, gathering and fishing, served to keep First Nations people healthy as they learned survival skills and preserved their knowledge of the land.
First nations people had their own forms of government, complete with full rights as governing nations, recognized and supported by their respective tribes. Because of this they were able to practise their own helath customs for they had traditional medicine people who were respected as healers. Knowledge about land-based medicines were attained through family, medicine people and by following closely the spiritual practice in the relationship to the Creator and His gifts, including the land and all its resources, families and all the people. Traditional protocol was practiced through the offering of gifts (tobacco) to the land in exchange for plant medicines, gifts to medicine people when asking for help with an illness or difficult times. One could say First Nations were in relatively good health prior to contact. Of course, these traditional medicines were also used to assist the newly arrived European neighbours.
Treaty 6 Medicine Chest
When First Nations finally agreed to the Treaty, the Commissioner took the promise in his hand and raised them to the skies, placing the Treaties in the hands of the Great Spirit.
In August 1876, Alexander Morris, representing the British Crown, was sent to negotiate with the Cree at Fort Carlton. The negotiations came about due to epidemics that plagued the First nations people which traditional medicines could not combat or cure. At the same time, First Nations people were worried about famine because the buffalo were no longer available as the main source of food.
Treaty 6 was negotiated at Fort Carlton and Fort Pitt in 1876 between the Plains Cree, Willow Cree and other bands. The devastation of European diseases that were ravaging First Nations people resulted in a request to “make provision against years of great starvation….and the small pox (that) took away many of our people, the old, young and children.” Keeping in mind that the intent of the Treaties, from the Crown’s perspective was to obtain from First Nations “the surrender of large tracts of land to establish friendly relations with the Indians in return for promises of aid in respect to education, farming, hunting, medicine, annual cash payments and other matters.” The Crown’s Treaty negotiations offered medical doctors and medeicine prior to, during an dafter the signing of the Western treaties. The Treaty 6 Medicine Chest that “shall be kept at the house of each Indian agent to the use and benefit of the Indians” was understood to mean that the Crown was now responsible for the provision of health services and resources to First Nations.
Treaty negotiations made arrangements fo rhealth services supplied and maintained by the Governor. The supply of medicine simply meant that whatever is required to maintain proper health would be provided, including provisions for the poor, the unfortunate and the handicapped. Today, the federal government pays for non-insured health benefits.
Currently, First Nation benefits include transportation to the nearest hospital or treatment site, prescription drugs listed on the drug formulary, dental coverage predetermined by government policy, vision care, mental health crisis intervention and medical supplies and equipment. In the view of the federal government, regardless of the Treaties, a determining factor in the approach to First Nations health status is the continuing and active participation of the provinces. Therefore, the provincial government also continues to provide insured Health Services for First Nation people.
Government Health Care
The emergence of government health services began in 1857 when the British North American Act transferred the responsibility of Indians and the lands reserved for Indians to the new federal government. However, it does not mean that the federal government began providing health services to First Nations immediately.
In 1945, Indian Health Services wwere transferred from Indian Affairs to the Department of National Health and Welfare — the dawning of a new era in health care for First Nations. The government has always maintained strict control over the lives of First Nation people. In 1967, the government
released the White Paper. The intent of the paper was a proposal to assimilate Indian people into the general Canadian population. A year later First Nation people responded with the Red Paper, stating that First Nation people would be in control of their lives and government systems.
The Indian Health Transfer Policy was adopted on April 11, 1986 by the Minister of National Health and Welfare, Indian Banks, Tribal Councils, Agencies and District Chiefs were given the go ahead to submit proposals to transfer health services from the federal government to Indian Control. Agreements have now been signed for the funding to be decentralized from Medical Services Branch to Indian Bands.
Health Services Facilities
In 1917, an Indian Hospital opened in Fort Qu’Appelle with 70 beds expanding to 325 beds in 1925. Other Indian hospitals emerged in different areas in the province. In the 1930s, Northern Saskatchewan nursing outposts became the means by which Native Health Care was provided in the remote north. In 1946, free Air Ambulance Services was offered in the northern settlements, providing access to doctors and better equipped hospitals. In 1950, the Province of Saskatchewan had four Outpost Hospitals. Later they became nursing stations.
There were hospitals that served the First Nation communities, such as Standing Buffalo, Piapot and other southern bands by the Fort Qu’Appelle Hospital. The North Battleford Indian Hospital served the surrounding reserves of Red Pheasant, Mosquito, Sweet Grass, Poundmaker, Little Pine, Moosomin, Saulteaux and Thunderchild.
Service Context Today
“Health care for First Nations and Inuit in Canada is delivered in the context of a complex, dynamic and interdependent health system government by federal, provincial, territorial and First Nations and Inuit jurisdictions.” First Nations and Inuit Health Strategic Plan. A shared path to improved health http://www.hc-sc-ca/fnishh-spnia/pubs/strat-plan-2012/index-eng.php.
Both the British North American Act and the Treaties gave responsibility of First Nations peoples and the health of First Nations people to the Federal Government. As such, Health Canada funds primary health care in First Nation communities are remote or isolated and funds First Nations public health nursing, health promotion and disease prevention programs and home and community care programs. Health Canada also provides First Nations and Inuit with identified health benefits if they lack alternate coverage for services, such as prescription drugs, medical supplies and equipment, dental care, vision care, short-term mental health crisis counselling an dmedical transportation.
Within this complex health system, provinces deliver the hospital, physician, and public health programs to residents, but do not generally operate direct health services on-reserve.
Before moving onto the specifics of this project, it must be emphasized that this arrangement has been fraught with problems. Aboriginal people have time and again fallen through the cracks of this jurisdictional disputes.
The Truth and Reconciliation Commission has identified a number of Calls to Action, seven of which are directly related to the provision of health care. These include the following:
19. We call upon the federal government, in consultation with Aboriginal peoples, to establish measurable goals to identify and close the gaps in health outcomes between Aboriginal and non-Aboriginal communities, and to publish annual progress reports and assess long term trends. Such efforts would focus on indicators such as: infant mortality, maternal health, suicide, mental health, addictions, life expecteancy, birth rates, infant and child health issues, chronic diseases, illness and injury incidence, and the availability of appropriate health services.
20. In order to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves, we call upon the federal government to recognize, respect and address the distinct health needs of the Metis Inuit, and off-reserve Aboriginal peoples.
21. We call upon the federal government to provide sustainable funding for existing and new Aboriginal healing centres to address the physical, mental, emotional, and spiritual harms caused by residential schools.
22. We call upon those who can effect change within the Canadian healthcare system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients.
23. We call upon all levels of government to:
I. Increase the number of Aboriginal professionals in the healthcare field
II. Ensure the retention of Aboriginal healthcare providers in Aboriginal communities
III. Provide cultural competency training for all health care professionals.
It is within this context and call for understandable and direct services to Aboriginal people that the current and complex system of health care delivery for Aboriginal and First Nations people is described.
Health Regions and the PAGC Boundaries
In Saskatchewan, there are 13 Health Regions. The First Nations of PAGC are geographically within five of them: Athabasca Health Authority, which is jointly funded by the provincial and federal government, Mamawetan Churchill River Health Region, Kelsey Trail Health Region, and Prince Albert Parkland Health Region.