Healing winds: Aboriginal child and youth health in Canada

Despite decades of reports calling for changes, Aboriginal children and youth continue to face significant health and social disparities compared with their non-Aboriginal counterparts. The 1964 Hall Report (1), the 1996 Royal Commission Report on Aboriginal Peoples (2) and the 2002 Romanow Report (3) all called for improvements in health services and social circumstances for Aboriginal peoples in Canada. In 2008, Canada's Chief Public Health Officer Report on the State of Public Health in Canada (4) and the WHO (5) recommended reducing health and social inequities for this population. In 2011, based on the Human Development Indicators of health (6), education and living standards, Canada ranked sixth out of 187 United Nations member countries (7). Yet in the same year, Canada's Auditor General reported (8) that conditions on some First Nations reserves had actually deteriorated since earlier reports, with increasing educational gaps and more housing in disrepair. To further Canada's shame, regions of the country with the worst indicators of housing disrepair and crowding, low income, low educational attainment and health disparities, are areas with the highest proportion of First Nations, Métis and Inuit people. Ironically, these are the same areas where significant natural resource developments are supporting prosperity for Canada. Canada's Aboriginal children experience higher rates of injury, suicide, obesity, infant mortality and health conditions such as community-associated methicillin-resistant Staphylococcus aureus and various respiratory conditions such as tuberculosis. In this special issue, articles in Evidence for Clinicians (pages 385–386) and Clinician's Corner (pages 387–390) and an article dealing with respiratory illnesses (pages 376–380) aim to help clinicians diagnose and treat conditions that commonly affect Aboriginal children and youth. As paediatricians, family practitioners, public health physicians and other primary care providers, we need to ask why do these Aboriginal health disparities exist and what are the root causes? Why are there such disparities in education, employment, housing, income and social status? Greenwood and de Leeuw (pages 381–384) discuss the impact of the social determinants that affect the health of Aboriginal children and youth, yet positive changes could yield definite benefits. The multigenerational impact of colonization and restrictive government policies that lead to the loss of Aboriginal lands, culture, language, traditions and spirituality is now well recognized for its negative outcomes (9,10). Consider the Aboriginal children taken from their family and placed in a residential school for several years, forbidden to speak their language or practice their traditional activities and ceremonies. Many of these children witnessed or suffered physical, emotional and/or sexual abuse by adults in positions of power in these schools. Considering that the last residential school was closed in 1996, it is not surprising that identity crisis, poor self-esteem, substance abuse and mental health issues prevail today. Articles on youth suicide (pages 371–372) and inhalant abuse (pages 391–392) portray these unfortunate sequelae. Health care professionals who want to become culturally competent and practice with cultural safety (11) must begin their journey by learning and appreciating these historical factors and disparities. Saylor (pages 365–367) outlines a curriculum for paediatric residents that aims to do just that, preparing trainees to work with Aboriginal children, youth, families and communities. As Aboriginal and non-Aboriginal Canadians, we need to recognize the past, acknowledge it, and help those affected to heal and move forward. We need to improve government policies and address the systemic racism that continues to exist today. The Truth and Reconciliation Commission of Canada hearings provide a forum for individuals to share their stories from the past, some for the first time. The hope is that this process will help all Canadians move past this tragedy through a deeper understanding of the plight of Aboriginal populations at the individual, family, community and national levels. Sadly, history suggests that these stories may not be enough. In 1996, the Royal Commission on Aboriginal Peoples heard similar stories, but progress since then has been limited. In fact, two initiatives recommended by this Commission have recently lost their funding – the Aboriginal Healing Foundation and the National Aboriginal Health Organization. We must now garner support for the needed changes in policy, funding, health care, education, housing and self-government to address these disparities. There is great heterogeneity among Aboriginal peoples, their stories and their needs – Inuit, Métis and 614 distinct First Nations. While many live in rural and remote areas, increasing numbers of people now live in larger urban centres. Along with diversity of culture, language and community, there are substantial differences in the provision of health and social services, resources and community engagement. In some situations, there are resilient, innovative people with a strong sense of family, community, culture, traditions and connection with the land. Some have used holistic approaches to health, social and economic development to improve social conditions in their communities. In these settings, health care workers may be given the privilege to have a glimpse into this different world view. Much can be learned from these successes to help facilitate the change that other Aboriginal communities desire. Self-determination, or the power to make decisions over one's own life, can impact the health of children and youth. Studies in British Columbia have shown marked differences in suicide rates among First Nations communities – some with high rates of suicide, but others with rates substantially lower than in the general British Columbia population. The lower suicide rates correlate with the degree of cultural integrity in the community and with protective factors such as community involvement in self-government and/or community control of their own health and education services (12). Some degree of Aboriginal community control of health services supports primary care and community health initiatives that are more culturally accessible and suitable, as well as the incorporation of broader approaches to community wellness (13). Collaborative arrangements between federal, provincial, health region and First Nations health services, such as the Tripartite Framework Agreement (14) in British Columbia, may provide better coordinated systems that can improve access, resources and cost effectiveness to health services for First Nations communities. Unfortunately, many Aboriginal children are trapped in limbo because of jurisdictional funding disputes over social, education or health services, particularly on-reserve First Nations children. These very vulnerable children and youth often struggle to access services available to most Canadian children with special needs. Jordan's Principle upholds that the provincial, territorial and federal governments and departments work together to provide needed services for all First Nations children as are available for most Canadian children. While Canada's initial response to Jordan's Principle was encouraging, with unanimous support from Canada's Parliament (15), Blackstock (pages 368–370) suggests government funding and obligations remain unclear. Shannen Koostachin was a young teen from Attawapiskat First Nation, where the school she attended was contaminated and crumbling, with no play areas, and insufficient and inadequate housing in her community clearly demonstrate the gap between First Nations and mainstream schools and housing (16). Shannen advocated for ‘safe and comfy’ schools with quality, culturally based education for First Nations children. Despite her tragic and untimely death in a car accident, her call for change has become a broader social movement, referred to as Shannen's Dream: a dream for equity and quality education and facilities in all First Nations communities. These initiatives deserve our attention and support; particularly because education and housing are social determinants of health that are often taken for granted by most Canadians. As clinicians caring for Aboriginal children, we need to consider our work in the context of the realities of their communities. We must learn and practice with cultural safety and empathy, work collaboratively to improve timely access to services, and engage in health promotion and disease prevention initiatives. To support and facilitate improved health outcomes for Aboriginal children and youth we must: Learn about the cultures and diversity of Aboriginal Peoples, the historical realities and negative influences of colonization and residential school experiences. Understand the despair and hardships, as well as the strength of the culture and identity, which help Aboriginal children, youth and their families who struggle to overcome and reconcile. Acknowledge the resiliency of Aboriginal people and recognize the importance of culture, family, community and self-determination for the healing of children and youth. Communicate effectively by active listening and explaining at the appropriate educational level with patients, families and communities. Support the important role of early childhood development and parenting skills – in the context of the family, the culture, and the community, and foster the vital contribution of fathers, mothers, aunts, uncles and grandparents (See Ball, pages 373–375). Share, by engaging with multidisciplinary care team members, Aboriginal community leaders and families to collaborate and facilitate change within communities, utilizing and building on the communities' values and strengths. This can result in more suitable and sustainable solutions that are culturally supportive. Advocate for adequate funding, resources and services to address health, education and social disparities of Aboriginal children and youth in Canada, by supporting Jordan's Principle, Shannen's Dream and other campaigns to increase awareness and equity of these and related issues. To optimize the potential for a healthy and prosperous existence for all Canadian children and youth, collaborative relationships with First Nations, Inuit and Métis communities are essential. There are many opportunities for learning and teaching, sharing and caring, working together through action and advocacy, which will ultimately help to improve the health of Aboriginal children and youth. While there has been progress in some Aboriginal communities, many still need help and guidance to address current health and social conditions, and advocate for positive change and equity. Healing winds are beginning to blow across the landscape of the Canadian health care system, and particularly Aboriginal communities and nations. Health care professionals, Aboriginal families and communities can effectively partner and work toward sustaining these winds of change. Truth and Reconciliation Commission of Canada (www.trc.ca/websites/trcinstitution/index.php?p=26) Aboriginal Healing Foundation (www.ahf.ca/) National Aboriginal Health Organization (www.naho.ca/) Jordan's Principle (www.fncaringsociety.com/jordans-principle) Shannen's Dream (www.fncaringsociety.com/shannensdream)

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