Aboriginal Holistic Policy and Planning Model Explains Prevalence of TB among Aboriginal Communities

Our health, disease, and mortality patterns are phenomena that are largely predetermined by factors outside our control long before we need medical care (First Nations Health Council, 2017). A literature review by the Canadian Council on Social Determinants of Health (2015) identified 36 models and frameworks of determinants of health from various regions. The First Nations Holistic Policy and Planning Model is one of those models, which, in addition to highlighting key factors leading to disease patterns and health outcomes in Canada’s Aboriginal communities, also identifies the impact of social exclusion as a determinant of health and its impact on Canada’s Aboriginal Peoples during and post colonialism (Canadian Council on Social Determinants of Health, 2015).

Figure 1: First Nations Holistic Planning and Policy Model (Reading, Kmetic, & Gideon, 2007)

According to reports from the National Collaborating Centre for Aboriginal Health (2013), health disparities among Aboriginal communities in Canada date back to the start of colonialism, which not only destroyed centuries old and fully functional systems of Indigenous health knowledge and ways of knowing and being, it also introduced new diseases that the Aboriginal people were not familiar with, such as tuberculosis (TB) (Canadian Public Health Association, n.d.). This has led to prevalence of major health problems among the Indigenous people in Canada, and at rates much higher than non-Indigenous populations (National Collaborating Centre for Aboriginal Health, 2013). Some examples include:

high infant and young child mortality; high maternal morbidity and mortality; heavy infectious disease burdens; malnutrition and stunted growth; shortened life expectancy, diseases and death associated with cigarette smoking; social problems, illnesses and deaths linked to misuse of alcohol and other drugs; accidents, poisonings, interpersonal violence, homicide and suicide; obesity, diabetes, hypertension, cardiovascular and chronic renal disease (lifestyle diseases); and diseases caused by environmental contamination (for example, heavy metals, industrial gases and effluent waste). (National Collaborating Centre for Aboriginal Health, 2013)

This paper will examine the prevalence of TB infections among Canada’s Aboriginal populations, and identify systemic culprits leading to such health disparities, as identified above, in Aboriginal populations than non-Aboriginal populations. The First Nations Holistic Policy and Planning Model will be used in this analysis.

The Role of the Community

The Aboriginal Holistic Policy and Planning Model was created to close the gap in health inequalities that are prevalent in Aboriginal communities than other Canadian communities (First Nations Health Council, 2017). As a result, the community’s role is prominent and at the core of this model. According to Reading et.al. (2007) individuals are an extension of their communities, and all treatment modalities should be based on this premise. During the TB epidemic of 1930s and 1940s Aboriginal communities were dismantled in various ways, leading to high infection and mortality rates (Canadian Public Health Association, n.d.).

Aboriginal communities first encountered TB in the 1700s with the migration of European settlers starting in southeast Canada and expanding to the west coast over the span of 100 years (Canadian Public Health Association). Establishment of the Canadian Pacific Railway and the reserve system further exacerbated the spread of TB among First Nations and Metis on the Prairies (Canadian Public Health Association, n.d.). The community, which had historically served as a source of great strength through centuries of health knowledge and ways of doing and knowing, became a weak link in addressing the TB epidemic due to unfamiliarity with the disease, which was further exacerbated by lack of infrastructure and overcrowded reserves. (Canadian Public Health Association n.d.). This resulted in death rates in excess of 700 deaths per 10000 among the Aboriginal communities in the 1930s and 1940s (Canadian Public Health Association) and continue to have a disproportionate mortality rate of 26.4 times the rate of Canadian-born non-Aboriginal People (National Collaborating Centre for Aboriginal Health, 2013). Applying the Aboriginal Holistic Policy and Planning Model to close this gap, requires preparing Aboriginal communities through education, allocation of resources, and infrastructure improvement to get a handle on this situation that has been a problem for nearly a century.

The Medicine Wheel

The Medicine Wheel is the second layer in the Aboriginal Holistic Planning and Policy model, has a longstanding reputation and is an accepted symbol of health and healing among the various tribes of Native Americans (Native Voice, n.d.). While it can be applied to many different contexts, in this context it plays a relatively central role “with the four directions clearly articulated as spiritual, physical, emotional and mental” (Reading, Kmetic, & Gideon, 2007). A balance between the four elements is essential to preserve health at the individual as well as the community level as a whole (Native Voice, n.d.).

Unfortunately, colonialism tipped the balance of the medicine wheel and disrupted centuries old harmony between the elements that the Aboriginal people of Canada had perfected and relied on for their survival. During the TB epidemic, each of the four components of the medicine wheel was perceived to be violated. Traditional spiritual practices of healing were not respected; instead, patients were forced to go south, against their consent, to be treated with non-traditional practices (Canadian Public Health Association, n.d.). In some instances, those who passed during the treatment period in the south, never returned home to their families (Canadian Public Health Association, n.d.). This further compromised the physical, emotional and mental health status of the Aboriginal people of Canada, as they no longer felt in control. They were isolated from the families and familiar territories, dismantling the balance of the components of the medicine wheel as identified above (Canadian Public Health Association, n.d.).

Influence of Generations

The four cycles of the lifespan are also explicitly identified (child, youth, adult, elder) in the Aboriginal Holistic Policy and Planning Model as a determinant of health. It’s interesting to note that age is not identified as a hierarchy in this model; rather the four generations are placed on the same plane, which highlights the interdependence of each of the generations on each other, as well as the importance of a systemic approach in promoting health that is universal to all age groups.

In the case of TB infections and prognosis in Aboriginal communities, the intergenerational connectedness was unfavorable for Aboriginal communities. Confinement on crowded reserves spread the disease rapidly among the different age groups (Canadian Public Health Association, n.d.). While the youth had a better chance at fighting the infection, prognosis in the elder population was further complicated in the context of other chronic health conditions that weaken the immune system, such as prevalence of HIV, diabetes, substance abuse, and other factors (Canadian Public Health Association, n.d.). Given the contagious behavior of the tuberculosis bacterium, and its impact on the elder Aboriginal population, the Aboriginal Holistic Policy and Planning Model explains the influence of the generations and its impact on health outcomes of Aboriginal communities in Canada (Canadian Public Health Association, n.d.).

Importance of Self-Governance

The importance of self-government forms the fourth layer of the Aboriginal Holistic Planning and Policy Model as determinant of health. The four components of the First Nations self-government comprise of self-government/jurisdiction, fiscal relationship/accountability, collective and individual rights, capacity/negotiations (Canadian Council on Social Determinants of Health, 2015). As the TB epidemic soared through the northern communities between 1950 and 1969, the notion of self-governance became a concept with no practical application (Canadian Public Health Association). Each of the four components were violated as thousands of Inuit were sent south for treatment without their consent – the doctor essentially decided who boarded the ship, and according to a report by Canadian Public Health Association, in most cases “patients were not even given permission to go ashore to collect belongings or say goodbye to family and friends. Some were never seen again” (National Collaborating Centre for Aboriginal Health, 2013). These practices violated the notion of self-government/jurisdiction as identified by the Aboriginal Holistic Planning and Policy Model and negatively affected the outcome of the TB epidemic (Canadian Public Health Association, n.d.). Canadian Aboriginal communities no longer had control over their jurisdiction; there was no accountability as some of the bodies of the victims of the TB epidemic were never returned to their families from the south; and collective and individual rights were violated as patients were transferred for treatment against their will with no capacity for negotiations (Canadian Public Health Association, n.d.).

Social Determinants of Health

Understanding that determinants of health extend beyond an individual’s choice of lifestyle and eating habits, the First Nations Holistic Policy and Planning Model identifies 15 social determinants of health as follows (Canadian Council on Social Determinants of Health, 2015). While it is beyond the scope of this paper to examine individual elements at extent, a brief overview is needed to further explain TB infection patterns in the Aboriginal communities.

· Historical Conditions and Colonialism

· Community Readiness

· Language, Heritage & Strong Cultural Identity

· Self Determination & Non-Dominance

· Legal & Political Equity

· Environmental Stewardship

· Social Services & Support

· Lands & Resources

· Lifelong Learning

· Economic Development

· Housing

· Employment

· Urban/Rural

· Racism & Discrimination

· On/Off Reserve

There is no doubt that socio-economic disparities exist in Aboriginal communities than non-Aboriginal populations in Canada. This is supported by several decades of data showing stark differences in experiences and in particular health patterns and prognosis of Aboriginal people in Canada (National Collaborating Centre for Aboriginal Health, 2013). Determinants of poor health continue to remain prevalent in this population leading to high TB infection rates.

Canada’s 2006 Census data shows that fewer Aboriginal people between the ages of 25 and 34 obtained high school diplomas (68.1%), than non-Aboriginal people (90.0%), The 2005 median income for Aboriginal people was almost $10,000 lower ($16,752) than for non-Aboriginal people ($25,955), and the unemployment rate for Aboriginal people in 2006 was still more than twice that for non-Aboriginal people (13% compared to 5.2%). (National Collaborating Centre for Aboriginal Health, 2013)

An increase in low income, household overcrowding and poor housing conditions are some of the other factors that have contributed to higher TB infection rates, prolonged recovery, and high mortality among the Aboriginal communities (Canadian Public Health Association). Eliminating health inequalities is inevitably required to reduce the overall burden of diseases, such as TB, on our societies.

Tripod of Social Capital

While the role of the community is undoubtedly central to this model, the success of such communities also relies on their relationships with other communities, which is well reflected in the Aboriginal Holistic Planning and Policy Model. The model is anchored on a tripod of social capital highlighting the importance of the relationship within, between, and outside the community, namely bonding, bridging, and linkages (Reading, Kmetic, & Gideon, 2007).

Although there has been some improvement in this area over time, during the TB epidemic there were a lot gaps in this area. Relationships with the outside were nearly non-existing, and relationships within were disrupted with the introduction of overcrowded reserves and boarding schools. Disruption of these relationships, undoubtedly contributed to poor health outcome for the Aboriginal people in this area.

Summary

In Summary, the First Nations Holistic Policy and Planning Model is a multilevel approach aimed at identifying the various layers of determinants of health as it relates to the health of Canadian Aboriginal communities. Its elements include the use of a holistic and inter-sectoral approach, recognition of social exclusion, understanding the role of individuals and communities, recognizing the importance of upstream action, and identification of interactions between determinants (Canadian Council on Social Determinants of Health, 2015).

The TB epidemic in the Aboriginal communities in Canada serves as a great example, highlighting the need for culturally sensitive approaches to health promotion and delivery services. Given Canada’s expanding diversity, the issues discussed above are no longer limited to Aboriginal communities, but also affects the expanding visible minority communities as Canada opens its doors to more and more migrants of different backgrounds.

To close this gap, we must first acknowledge that inequalities exist in our health care industry and must take steps to close that gap because “Life is short where its quality is poor. By causing hardship and resentment, poverty, social exclusion, and discrimination cost lives” (Wilkinson & Marmot, 2003).

References

Canadian Council on Social Determinants of Health. (2015, 05 20). A Review of Frameworks on the Determinants of Health. Retrieved from Canadian Council on Social Determinants of Health: http://ccsdh.ca/images/uploads/Frameworks_Report_English.pdf

Canadian Public Health Association. (n.d.). History of Public Health: TB and Aboriginal people. Retrieved from Canadian Public Health Association: https://www.cpha.ca/tb-and-aboriginal-people

First Nations Health Council. (2017). Social Determinants of Health - Discussion Guide. Retrieved from First Nations Health Council: http://fnhc.ca/wp-content/uploads/FNHC-Social-Determinants-of-Health-Discussion-Guide.pdf

National Collaborating Centre for Aboriginal Health. (2013). An Overview of Aboriginal Health in Canada. Retrieved from https://www.ccnsa-nccah.ca/docs/context/FS-OverviewAbororiginalHealth-EN.pdf

Native Voice. (n.d.). Medicine Ways: Traditional Healers and Healing. Retrieved from Native Voice: https://www.nlm.nih.gov/nativevoices/exhibition/healing-ways/medicine-ways/medicine-wheel.html

Reading, J. L., Kmetic, A., & Gideon, V. (2007, April). First Nations Wholistic Policy and Planning Model. Retrieved from Association of First Nations: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.476.9397&rep=rep1&type=pdf

Wilkinson, R., & Marmot, M. (2003). Social exclusion. In R. Wilkinson, & M. Marmot, Social Determinants of Health: the solid facts (p. 16). Denmark: World Health Organization.