平特五不中

This article presents a portrait of some of the challenges that Inuit encounter in contemporary healthcare systems. It explores the distinctive constitutional and legal framework that encompasses Inuit in Canada and the important work being done by Inuit entities to describe Inuit social determinants of health.

Introduction

I am honoured to have been asked by the editors to be one of the contributors to attempt to answer this question:

From your vantage point, how can the healthcare system address the challenges that Indigenous Peoples often face when interacting with the healthcare system?

In answering the question as posed, my first response would have to be that it is the wrong question. For better or worse, there is no 鈥渉ealthcare system鈥� in Canada; there is, instead, a disparate collection of administrations and institutions, organized variably throughout the 13 provinces and territories. And, to answer the question fairly with respect to 鈥淚ndigenous Peoples鈥� is practically impossible: Inuit, M茅tis and First Nations peoples have diverse relationships with healthcare entities and differing visions of our own health and well-being.

In Canadian scholarship, journalism and everyday perceptions, a conflation of all Indigenous Peoples, their histories and contemporary realities into those of First Nations happens frequently. In that erroneous conflation, the Indigenous Peoples to whom I belong, the Inuit, are ignored and made invisible聽鈥� as are the M茅tis.

Throughout Inuit Nunangat聽鈥� the Inuit homeland stretching across two territories and northern portions of Newfoundland and Labrador and Quebec聽鈥� Inuit inhabit a wide variety of jurisdictions and use diverse healthcare systems. Inuit are also a global circumpolar community in four nation-states, with a population of 180,000 spread from Kalallit Nunaat (Greenland) in the east through Canada, Alaska (United States) and Chukotka (Russia) ().

Inuit and Contemporary Healthcare

Quebec, where I live, is the home of the second-largest Inuit population in Canada, residing mainly in Nunavik, the northern one-third of Quebec's landmass. Inuit and other Indigenous Peoples in Quebec face barriers in healthcare. The 2021 coroner's inquiry into the tragic death of an Atikamekw woman, Joyce Echaquan, in a hospital in Joliette, Quebec, concluded 鈥渢hat the Quebec government [should] [a]cknowledge the existence of systemic racism within our institutions and commit to helping eliminate it鈥� (Kamel 2020: 20). The Quebec government has refused to acknowledge the existence of systemic racism in provincial government services.

In the early 2020s, the Quebec government nevertheless decided that its employees聽鈥� including those in healthcare 鈥� should undergo some Indigenous cultural sensitivity training via an online course called Sensibilisation aux r茅alit茅s autochtones (sensitization to Indigenous realities). Disappointingly聽鈥� but typically聽鈥� most of the speakers in the online module are non-Indigenous, and the distinctive realities of Inuit are all but completely ignored (Budgell 2022).

Inuit have a spectrum of points of entry or contact in healthcare systems. For the two-thirds of the Inuit population that live in Inuit Nunangat (Statistics Canada 2022), a first encounter with healthcare providers would likely take place at a local clinic, health centre or聽鈥� much less commonly聽鈥� a hospital in their own community. Depending on the seriousness of their health condition, it often leads to medical transportation to healthcare institutions in southern Canada, over distances that may exceed 3,000 km. In 2019鈥�2020, 5,000 patients, from a population of approximately 13,000, were transported from Nunavik to southern Quebec for their healthcare needs (Hendry and Shingler 2022).

This marked dependence on medical transportation is true across all of Inuit Nunangat, and healthcare entities spend hundreds of millions of dollars annually to pay for it. For example, the Government of Nunavut projected expenditures of $107 million on medical travel in 2020鈥�2021 (Deuling 2020) or $2,903 for each of the territory's 36,858 inhabitants (Statistics Canada 2023). Medical transportation has essentially become entrenched as the healthcare paradigm throughout Inuit Nunangat聽鈥� to the exclusion of other models or methods.

Medical transportation as a preferred method of treatment of Inuit has historical roots going back to the mid-twentieth century. Pat Saniford Grygier, author of the very thorough A Long Way from Home: The Tuberculosis Epidemic among the Inuit, concludes that during medical evacuations of tuberculosis patients by ship in the 1940s and 1950s, Inuit 鈥渨ere treated much like serfs or sick animals鈥� (Grygier 1994: 176) and there was a 鈥渓ack of any attempt to prepare the patients for their entry into the alien southern life, to provide for their dependents left up north, or to ensure future communication between the relatives and both patients and doctors鈥� (Grygier 1994: 176). She states there was a 鈥渞efusal of [the federal department of Health and Welfare] to develop hospital treatment in the North, despite the presence of the mission hospitals and some mining company and American military hospitals already operating there鈥� (Grygier 1994: 176).

Samir Shaheen-Hussain聽鈥� in his book about contemporary medical evacuations of unaccompanied Inuit children from Nunavik and the Eeyou/Eenou (Cree) territory by airplane聽鈥� notes that it has historical parallels with other colonial practices, such as the non-consensual removal of children placed in residential schools (Shaheen-Hussain 2020).

Decolonizing and Disaggregating Indigenous Categories

The generic 鈥淚ndigenous鈥� categorization often risks perpetuating colonialism, rather than undermining it, and the frequent conflation of 鈥淚ndigenous鈥� with First Nations only worsens that framing. 鈥淔irst Nations鈥� is essentially a construct that corresponds to the Constitution Act, 1867's use of the term 鈥淚ndian鈥� (Government of Canada 2021). A more appropriate and less colonial framing would be to use the Indigenous 鈥渘ation鈥� concept discussed by the Royal Commission on Aboriginal Peoples that proposed:

[鈥�] the right of self-determination is vested in Aboriginal nations rather than small local communities. By Aboriginal nation we mean a sizeable body of Aboriginal people with a shared sense of national identity that constitutes the predominant population in a certain territory or group of territories (Royal Commission on Aboriginal Peoples 1996: 172鈥�73).

While Indigenous histories, including those of Inuit, precede the creation of Canada by millennia, the starting point for the relationship between the modern Canadian state and Indigenous Peoples is Confederation, which began in 1867, and has continued up to the creation of Nunavut in 1999.

Inuit were not acknowledged as coming under federal responsibility until 1939, as a result of a Supreme Court of Canada case known as Re: Eskimo (Supreme Court of Canada 1939). The decision was a response to a challenge brought by the Government of Quebec that was seeking compensation for expenditures it was making in relation to Inuit. The Supreme Court deemed that Inuit in Quebec (and by extension, elsewhere in Canada) were 鈥淚ndians鈥� under section 91.24 of the British North America Act (now known as the Constitution Act, 1867) (Supreme Court of Canada 1939).

Modern treaties and legal frameworks

Modern treaties, also known as land claims agreements, are absolutely foundational to Inuit lives, territories, governance and healthcare institutions. The first of these was the James Bay and Northern Quebec Agreement (JBNQA) of 1975 (Qu茅bec [Province] 1976). Similar to its successors, the JBNQA delineated lands, defined rights and created governance institutions for its Indigenous signatories聽鈥� the Eeyou/Eenou (James Bay Cree) and the Nunavik Inuit.

The JBNQA created healthcare institutions for the Nunavik region, which consisted initially of the Kativik Health and Social Services Council, under the authority of the regional administrative body, the Kativik Regional Government. 鈥淐ommunity service centres鈥澛犫�� clinics or nursing stations聽鈥� were established in each Inuit community, as were hospital centres serving the two regions of Nunavik, the Hudson's Bay coast and the Ungava Bay coast. The JBNQA made clear that 鈥渢he Kativik Health and Social Services Council and the establishments shall be governed, mutatis mutandis, by the provisions of the [Provincial Health] Act鈥� (JBNQA 1975: 197, as cited in Quebec [Province] 1976).

While legislative power remained with the Quebec government, the Kativik Health and Social Services Council along with the Cree Regional Board of Health and Social Services聽鈥� also created by the JBNQA聽鈥� were arguably the first Indigenous-managed health entities in Canada. The Kativik Health and Social Services Board was replaced by the autonomous Nunavik Regional Board of Health and Social Services in 1995.

Inuit went on to sign other modern treaties: the Inuvialuit Final Agreement (1984) (Inuvialuit Regional Corporation n.d.); the Nunavut Land Claims Agreement (Nunavut Land Claims Agreement Act 1993), which resulted in the creation of the territory of Nunavut; and the Labrador and Inuit Final Land Claims Agreement (2005) (Office of Indigenous Affairs and Reconciliation n.d.). All these treaties resulted in various levels of Inuit involvement and control over healthcare systems.

Inuit social determinants of health

A number of Inuit and First Nations institutions in Canada exercise significant control over the health and well-being of their populations. Some examples are the (Labrador Inuit) Nunatsiavut Government's Department of Health and Social Development or, in the First Nations world, the British Columbia First Nations Health Authority or the Cree Board of Health and Social Services of James Bay.

Some Inuit entities have begun valuable work to identify Inuit social determinants of health. I will focus on the original work done by Inuit organizations; a small number of academicians, notably Richmond (2012), have also done some analysis of Inuit social determinants of health.

The national Inuit political organization Inuit Tapiriit Kanatami published Social Determinants of Inuit Health in Canada (ITK 2014). ITK says that the 11 factors were identified based on literature reviews and consultations with representatives of Inuit organizations and governments. ITK's Inuit social determinants are:

• quality of early childhood development;
• culture and language;
• livelihoods;
• income distribution;
• housing;
• personal safety and security;
• education;
• food security;
• availability of health services;
• mental wellness; and
• the environment.

The presentation is determinedly balanced: the discussion of each determinant identifies challenges and key positive efforts. ITK emphasizes that 鈥渢he determinants of health are highly interconnected. Therefore, the document emphasizes a holistic approach and uses examples when possible to highlight the relationship between the various determinants鈥� (ITK 2014: 12). The paper populates the discussion with examples from across Inuit Nunangat.

Building on ITK's work, in June 2021, the Nunavik Regional Board of Health and Social Services (NRBHSS)聽鈥� the Inuit-managed health services organization in the Nunavik region聽鈥� published Definition of an Inuit Cultural Model and Social Determinants of Health for Nunavik (Fletcher et al. 2022). Based on community workshops, interviews and a validation process, the study arrived at a conceptual framework for social determinants of health using Inuktitut vocabulary. As the authors say:

For many people, the true feelings of experience, joy and hurt, as well as the meaning of life can best be expressed in Inuktitut. [鈥�] This opens up the possibility of describing health in ways that contrast with the prevailing 鈥淲estern鈥� vision of the health care system, structured as it is according to southern provincial and national norms (Fletcher et al. 2022: 10).

The three defining terms in the conceptual framework are (Fletcher et al. 2022):

• The first term, ilusirsusiarniq, relates to the body and its maintenance of strength through consuming nourishing animal protein. It implies 鈥溾�榯hings taking their intended form,鈥� a concept which presumes that 鈥榟ealth is the normal state of human beings from birth onwards (p. 10).'鈥�
• The second term, qanuinngisiarniq, is about 鈥渇eelings of being comfortable, content, and without worries or pain鈥� (p. 11). It implies the ability to move and perform activities easily and comfortably.
• The final term, inuuqatigiitsianiq, describes an environment where there are good relationships among people inhabiting the same place. This includes 鈥渇amily, friends, neighbours, and people within the community (including non-Inuit)鈥� (p. 11).

The Nunavik determinants are characterized by a vision of individuality, community and factors through which people can exercise some agency.

Conclusion

All Indigenous Peoples in Canada, including Inuit, live in the complicated web of a 21st-century federal state聽鈥� where almost all direct healthcare services are provided by provincial and territorial government agencies. As the COVID-19 pandemic has waned, Canadians have become painfully aware of the strains in and inadequacies of healthcare systems.

The challenge for Inuit is this: How do we connect the large, varied and complex healthcare systems with which we interact to our own increasingly articulate conceptualizations of healthcare and well-being? Ultimately, how do we Inuit-ize healthcare and make concepts, such as ilusirsusiarniq, a governing principle of how we are treated in healthcare settings?

Discussion has been under way for a few years on the possible creation of federal legislation on Indigenous health. The obvious limitation of such legislation in reference to Inuit is the lack of federal jurisdiction where Inuit live聽鈥� in provinces and territories - unlike the context of some First Nations based on reserves, where there is a degree of federal jurisdiction. ITK has committed to 鈥渁 review of applicable health-related federal, provincial and territorial legislation, research on patient-centric healthcare delivery with respect to Inuit living within and outside of Inuit Nunangat, a review of health transfer agreements and regional funding [鈥�]鈥� (ITK 2022) without stating whether it is supportive of the development of federal legislation on Inuit health.

During the 2022 Quebec election, the governing Coalition Avenir Qu茅bec party (subsequently re-elected), promised to establish a new agency, Sant茅 Qu茅bec, which 鈥渨ould empower local health board directors to act on decisions more quickly鈥� (CBC News 2022). Nunavik Inuit and other Quebec residents will watch developments with interest.

What is certain is that healthcare systems cannot remain static and that change is necessary to provide better and more appropriate care to Canadians, including Inuit.