Indigenous Health

There are perhaps fifty million Indigenous people in North and South America, almost everywhere dispossessed, poor and powerless either today or in the past. In the past they refused to die; today they will not be assimilated or ignored. They insist that we must address the issues of colonization, racism and inequity that have pursued us since Columbus made his landfall in the West Indies (Boyer, 2000). (1) In recent years Indigenous peoples have been gaining their own voice in the western academic world and have developed methodologies of their own to facilitate the appropriate collection, analysis and dissemination of knowledge (Tuhiwai Smith, 1999,Smylie et al. 2003, Snarch 2004).

In Canada in 2001 there were approximately 976,310 aboriginal people living in Canada, about half of whom live on reserves and half off(Statistics Canada 2001). This population includes First Nations, Inuit and Metis,whose relative proportions are shown in Chart 1. By many standards,life for Aboriginal Canadians is much more difficult than for non-Aboriginals. They are younger (Fig 2.2 from Health Canada, Statistical Profile of the Health of First Nations, 2001), more likely to live in rural or remote parts of the country (although many live in urban areas as well) and less likely to enjoy many of the privileges and amenities the majority of Canadians take for granted. In 1986 forty five percent of Status Indians were without any high school education (compared with seventeen percent for Canada as a whole) (4) . A federal 1984 study of housing documented that forty seven percent of housing were inadequate; thirty eight percent lacked one or more of the following basic amenities: running water, indoor toilet and bath or shower, and thirty six percent were overcrowded (compared with less than three percent for Canada). (5) Twenty years later, little has changed. The prelimary results of the First Nations Regional Longitudinal Health Survey, the first major survey of the health of Aboriginal Canadians by an Aboriginally controlled organization (NAHO) found that 32% of Aboriginal Canadians participating rated their water supply as unsafe, 24.6% reported overcrowded living conditions (vs 1% of the general population)and 32.9% were living in housing requiring major repairs (vs 8.2% of the general population)(NAHO 2004).

Health indices all clearly indicate that Aboriginal Canadians are not as healthy as other Canadians (although many of these are likely inaccurate given the lack of a uniform and standard process for collecting and linking data on ethnic group status to the health information databases generally used for generating these statistics). In 2000 status First Nations men had a life expectancy 7.4 years shorter and women 5.4 years shorter than other Canadians(Health Canada, 2001). Aboriginal Canadians have a higher incidence of such infectious diseases as gastroenteritis, tuberculosis, diptheria, pertussis, rheumatic fever, respiratory problems, STIs, and infectious hepatitis, many of which are preventable(Health Canada, 2001). Chronic diseases are also becoming an increasing problem with an epidemic of diabetes(3-4 times the national average), obesity (up to 90-95% of people over the age of 50 in some studies), metabolic syndrome and the subsequent cardiovascular(2-3 times higher) and renal complications of these diseases hitting many aboriginal people and communities with devastating results(Howard et al 1999, Shaw et al 2000, Young et al 2000, Ananad et al 2001, Green 2003, Tonelli et al 2004). Even more concerning than the prevalence of infectious and chronic diseases are the problems of intentional and unintentional injury, which are the number one causes of potential years of life lost for Aboriginal people in Canada (Figure 3.8 from Health Canada, 2001). 

This category includes a number of sub-categories, including motor vehicle accidents, fire and flames, drownings and suicides, all of which are major contributors to the category. It is the number one cause of death for all age groups under 45, with all of the 3 top causes of death in these age groups being sub-categories of injury(Health Canada, 2001). The young ages of the victims is a major factor in its major contribution to the potential year of life lost. Within the general category of injury, that of suicide warrants particular attention. It results in more potential years of life lost than all cancers, and over 50% more than all circulatory diseases. Rates of suicide overall are about twice the national average, but in the younger age groups they are much higher (in the neighbourhood of 4-5 times the national average for 25-39 year olds and 5-8 times for those 15-24)(Health Canada, 2001). Social, cultural, economic and environmental influences are all important in this area, with some communities being relatively unaffected, while others experience rates of suicide up to 50X higher than the national average (Health Canada, 2001, Chandler and Lalonde, 1998). Both suicide and other unintentional injuries have at least some relationship to substance abuse, which is also an issue that is more prevalent in the aboriginal population (Health Canada, 2001). 

Thus, there are many significant health and social issues facing Aboriginal communities and their health care providers. Physicians interested in serving Aboriginal populations need to be better prepared; not only should they be clinically competent, but also culturally sensitive and politically aware of the variety of issues that impact on the health of Canada's Aboriginal peoples.  

While Queen's University has trained health science students in Aboriginal contexts for some time, (in particular through the Queen's University Weeneebayko program in Moose Factory), this optional third year of training for physicians in Aboriginal Health is unique. The resident will have the opportunity to explore the historical roots of the health issues facing Aboriginal communities as well as participate in the delivery of care in different Aboriginal settings in Canada today. The potential benefits of this third year program are many. Firstly, family physicians who are specially trained in Aboriginal health issues will be better prepared to serve Aboriginal communities and provide more culturally sensitive care. Secondly, the existence of a unique program devoted to Aboriginal Health will provide enhanced educational opportunities in crosscultural medicine for both the core two year residency program in Family Medicine as well as the undergraduate medical curriculum. The sensitization of all physicians to the broad social determinants of health should be a recognized educational objective. The knowledge base and skills developed in working with Aboriginal people will be of use to physicians practicing in many areas of Canada among people of different cultures than themselves. 

The following pages describe the objectives and curriculum of this unique third year program in Aboriginal Health. One of the principle objectives of this program is to increase the number of well-trained and culturally attuned family physicians available and interested in establishing practices in Aboriginal communities. Through this year of postgraduate education, residents will contribute their clinical expertise to communities in which they choose to do their clinical placements. Thus, commitment to Aboriginal Canadians as well as resident educational needs, is a focus of the program. In summary, it is hoped that this document will stimulate thought and dialogue about Aboriginal health issues and the appropriate education of physicians to deal with these issues.