Injuries in Aboriginal children

During a walk on a beautiful Sunday morning in the James Bay Cree Territory of northern Quebec, I saw several families enjoying the unusual warm weather for that time of year (−5°C). There were many snowmobiles pulling large wooden sleds that resembled large bathtubs. Other children were sledding and others were just having fun in the snow. It was truly a picturesque day in a beautiful part of the country. But at that point, the paediatrician in me started to wonder about the safety of those children who had such huge smiles on their faces. They were truly enjoying a freedom not known to many people in Canada – the freedom that comes with living in rural, northern areas, freedom from the large city buildings and highways and freedom from many of the constraints of being governed by municipal and provincial authorities. This freedom is essential to the way of life of Aboriginal people. It is also one of the reasons they suffer from such high rates of injuries. As an Aboriginal paediatrician, I understand the need to respect this freedom. At the same time, my heart feels the pain every time a child is admitted with a preventable injury. The families are distraught; there is a sense of hopelessness and a great sense of fear for the future. Children are held in the highest regard in Aboriginal communities, partly because of what they represent. The children are the future for these people who have struggled through so many difficulties in their lives and continue to struggle for things that are taken for granted by most others. Truly, every member of the community feels the loss of a child. Thankfully, most injuries do not result in death. Someone may ask what is so different about Aboriginal children with regard to injuries? What makes them different may not be obvious to many. To begin with, their rates of injuries and deaths from injuries are very much higher than those for non-Aboriginal Canadian children. This is especially true for motor vehicle accidents, drownings, poisonings and burns. In British Columbia, among First Nations people from 1991 to 1998, 28% of deaths were due to injury compared with 7.6% for the province as a whole (1). The injury death rate for First Nations children in the mid-1990's was nearly four times higher than the rate for all of Canada (1). Injury hospitalization rates in Manitoba showed that First Nations people were hospitalized three times more often than the provincial average and, in Saskatchewan, First Nations children have the highest rates of hospitalization from injuries (1). Motor vehicle accidents are the leading cause of death due to unintentional injury for First Nations people as for other populations, but the rates are much higher. For example, from 1991 to 1998, age standardized mortality rates of motor vehicle accidents were four times higher than the provincial average in British Columbia (1). This may be due to the need for travel over water, icy conditions in winter, flooded roadways in spring, unpaved roads, older vehicles not optimally maintained and inconsistent safety procedures, such as failure to use seat belts and improper child restraint practices. There is also the need to travel by snowmobile and all-terrain vehicles (ATVs), which are often overloaded due to lack of other means of transportation. Unfortunately, alcohol continues to be a factor in unsafe driving practices. Drowning also continues to be a major cause of death in First Nations people. Aboriginal people had a drowning rate six times higher than other Canadians in 1996 (1) and children under the age of five had rates of drowning 15 times the national average between 1991 and 1996 (1). In Manitoba, the rate was 22 times higher than the provincial average, while in British Columbia, it was four times the provincial average (1). Drowning rates are particularly high in Aboriginal people in the Northwest Territories, the Yukon and the Atlantic provinces (1). Drownings in children less than five years old are chiefly associated with boats and falls into open water. Differences in lifestyle is a major contributing factor. Aboriginal people represent between 3% to 5% of the Canadian population but account for 26% of all snowmobile drownings, 16% of all drownings by falls into water, and 9% of drownings due to boating mishaps (1). Water is much colder in northern regions, thus hypothermia likely plays a role in many of these fatalities. Other sources of unintentional injury also have rates far greater than those for non-Aboriginal children. Poisonings, falls and injury due to fire continue to be major sources of morbidity and mortality for Aboriginal people (1). Although, as for most Canadians, most injuries are due to falls, the rates for poisonings in Aboriginal people actually increased between the periods 1979 to 1981 and 1991 to 1993 (1) (Figure 1). Leading causes of death in First Nations by age group, 1999. Adapted from reference 2 Leading causes of death in First Nations by age group, 1999. Adapted from reference 2 Suicide and suicide attempts are another major problem in many First Nations communities, accounting for up to 25% of all injury deaths (1). Although the rate has been stable in most age groups over the decade following 1980, in one- to 14-year-olds it has increased by 45% (1). Suicides have been noted to occur in clusters in some Aboriginal communities. In the Sioux Lookout zone of northwest Ontario, the rate in males 10 to 19 years of age was over 50 times higher than the Canadian average (1). This extreme rate is not seen in all Aboriginal communities, but the national Aboriginal rate for males was 2.6 times higher than that for all Canadian males from 1989 to 1993 (1). It was four times higher for females (1). For those 15 to 24 years of age, the difference was even greater, with a rate for First Nations men and women being higher by five and eightfold, respectively (1). The most common means of suicide were hanging, gunshot wounds and drug overdose (1). The rates for homicide, assault and family violence are also disproportionately high among First Nations people (1). Certainly, the numbers of injuries in Aboriginal children are overwhelming. The etiology of these high rates is multi-factorial. The rapid change in lifestyle is the most important factor, but the extent of this change must be fully understood. Aboriginal people previously lead a lifestyle of freedom, where children were raised not only within the primary family, but also by the extended family and by the community. There were no motor vehicles, weapons were less deadly, and their general surroundings were less hazardous. Cars, motorcycles, ATVs, snowmobiles, pavements and sidewalks did not exist in their world. Unlike in the non-Aboriginal world, these arrived much more abruptly in First Nations communities. Safety measures such as seat belts, car seats, helmets and other injury-prevention interventions were not introduced at that time. Even today, safe roads remain uncommon. Access to and availability of medical facilities are significantly limited compared with non-Aboriginal communities. Thus, relatively ‘minor’ injuries can become more severe. Ambulance services are sparse and, if present, distances cause delays in receiving adequate health care. The lack of roads make travel by snowmobile or ATVs a necessity. Safety standards for these means of travel are rarely enforced. Bicycle, motorcycle and ATV helmets, and even car seats, are not always available. Personal flotation devices are not commonly used. In the past, Aboriginal parents did not need to worry about finding a job or about many of the other stresses of modern life. Their lifestyle was by no means easy but they succeeded together as families and communities that shared a common lifestyle. Alcohol and other drugs were not a part of their world. This has changed dramatically in a short period of time. Although non-Aboriginal Canadians face many of the same challenges in life (educational needs for their children, maintaining a job and paying the bills), the Aboriginal family is expected to overcome these same challenges with much less experience, not only individually, but also as a people in general. The difficulties in dealing with the ‘new’ challenges facing the Aboriginal family is, in my opinion, a major factor leading toward many of the health and social difficulties experienced by Aboriginals in Canada. A high rate of injuries is one reflection of this added stress facing Aboriginals. So you may ask, what should I do as a practitioner? Answers are not easy but safety discussions must be high on the list for all well-child visits. But is this enough? The use of bicycle, ATV, motorcycle and snowmobile helmets must be strongly encouraged. Band councils, local stores, snowmobile and ATV dealers must provide affordable helmets for adults and children. Bicycle helmets should be readily available at reasonable prices. Bicycle, snowmobile and ATV manufacturers, especially those with an interest in Aboriginal issues, can be lobbied to supply helmets at cost. Practitioners can play a direct role with families and can also be advocates for children by encouraging stores to stock these items. Band councils can be encouraged to discuss local laws for safe recreation. Clearly, it is not enough to discuss safety at well-child visits. The Aboriginal children of Canada need strong advocates for their safety and paediatricians and family doctors are in a perfect position for the task. The audience for advocacy must not stop at local governments. At the heart of the lifestyle changes facing the Aboriginal people in Canada is the Canadian government. These imposed lifestyle changes have played a major role in the current health status of Aboriginals, including the high rates of injuries that we are seeing today. The government of Canada must not just acknowledge this relationship but must also take measures to correct the current level of inequity involving health and safety in Aboriginal communities. Funding must be provided to allow communities to build safe roads, recreational facilities and living conditions, and provide better access to health care. Hopefully Aboriginal leaders can act on the advocacy efforts of health care providers and provide safer communities with the resources of the government of Canada. And what about freedom? Certainly it must be maintained, but in as safe of an environment as possible. To not respect this freedom would be yet another non-Native imposition on the way of life of Aboriginal people. This is exactly why local Aboriginal leaders must be at the forefront in promoting safety within their communities. Practitioners must understand that they must partner with local leaders in the development and implementation of effective injury prevention interventions. It has been shown over and over that the health of the people follows the health of the community and this should be no different for the promotion of safety. A partnership between health care workers and Aboriginal communities is an absolute requirement for improvements in the safety of Aboriginal children. We can only hope that the Canadian government will also become a partner in this cause.

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