Improving cancer control in First Nations, Inuit and Métis Communities in Canada

There are three distinct Indigenous populations in Canada: First Nations, Inuit and Métis, each with their own languages, histories, cultures and traditions. According to the 2011 Canadian Census, there are almost 900 000 people who self-identify as First Nations, living throughout Canada (Statistics Canada 2011) and just under 60 000 people who identify as Inuit, the majority of whom live in the far north of Canada. An estimated 452 000 self-identifying Métis people, of mixed European and First Nations ancestry, live predominately in western Canada and Ontario. The current complexities of cancer control among Indigenous peoples living in Canada can only be understood by looking back at the impact of the country's colonial history on health and well-being. Policies put in place during colonial times eroded Indigenous rights, ways of governing and Treaties, attempting to eliminate Indigenous peoples as distinct legal, social, cultural, religious and racial entities in Canada. These policies became the focus of the Truth and Reconciliation Commission established to examine the residential school system, which was designed to forcibly assimilate First Nations, Inuit and Métis children by denigrating and suppressing their language and distinct cultures and traditions. After 6 years of hearings and testimony from more than 6000 residential school survivors and their families, the commission released a comprehensive report in December 2015 that detailed how, from the early 1800s to the late 1990s, at least 150 000 First Nations, Inuit and Métis children were removed from their families and communities. Many were exposed to harsh discipline and sexual, physical and emotional abuse. The 139 schools were often poorly heated and inadequately ventilated, offering a meagre diet of reduced quality. The schools, among other factors, created a deep sense of mistrust and betrayal, a sentiment that grew as land belonging to Indigenous peoples was forcibly seized and populations were resettled, often to land in remote, resource-poor areas. Treaties signed between early settlers and Indigenous peoples were often ignored or invalidated, leading to further mistrust. As well, traditional treatments practised for centuries were dismissed as ineffective and unsophisticated compared to Western medicine. The health impacts of colonial policies have been profound. High rates of infectious disease in the 1800s resulted in widespread population loss, weakening the capacity of communities to provide food, shelter and care to their members. Infectious disease gave way to chronic conditions, including cancer. Studies show that cancer incidence has risen dramatically in each of the First Nations, Inuit and Métis populations in the last few decades. (Marrett & Chaudry 2003; Friborg & Melbye 2008; Morrisseau 2008). From being nearly unknown a few generations ago, cancer is now among the top three causes of death among First Nations, Inuit and Métis people (Health Council of Canada 2005; Assembly of First Nations/First Nations Information Governance Committee 2007; Morrisseau 2008). Yet, at the community level, a lack of culturally relevant educational materials and expertise (Calam et al. 1999; Loppie & Wein 2005; Inuit Tapiriit Kanatami 2009) contributes to a reported lack of awareness about cancer and successes in its prevention and treatment (Calam et al. 1999; Cancer Care Ontario 2002; Loppie & Wein 2005; Inuit Tapiriit Kanatami 2009; O'Brien et al. 2009). Lack of access to prevention and screening programmes (Cancer Care Ontario 2002; Wardman et al. 2005; Premier's Consultation for Improved Cancer Care in Northern BC 2006; Bent et al. 2007; Inuit Tapiriit Kanatami 2009) and mistrust or apprehension towards health service providers has led to poor cancer outcomes and created barriers to open discussions about the disease (Loppie & Wein 2005; O'Brien et al. 2009). About half of all cancer deaths are related to commercial tobacco use, diet and physical activity. Smoking rates among First Nations, Inuit and Métis people are much higher than in the Canadian population at large (O'Donnell & Tait 2003; Health Canada: First Nations and Inuit Health 2009; Statistics Canada 2008; Tait 2008). Lack of consumption of fruits and vegetables and physical inactivity are also reported to be higher in the First Nations, Inuit and Métis populations studied. Within the health system, lack of awareness and understanding of important cultural and historical elements can reduce the effectiveness of treatment (Loppie & Wein 2005; Jensen-Ross 2006), while a lack of healthcare resources in communities and poor coordination of care between hospitals and primary care providers can undermine follow-up and palliative care (Calam et al. 1999; Premier's Consultation for Improved Cancer Care in Northern BC 2006; Sutherland 2008). Additionally, government policies with origins in colonialism create added complexities for First Nations, Inuit and Métis patients when accessing, or attempting to access care. Depending on where a person lives, their identity as First Nations, Inuit or Métis and their status under the Indian Act, health care is either a provincial or federal fiduciary responsibility. Conflicts between the federal and provincial governments over responsibility for care often complicates and slows access to cancer care for First Nations, Inuit and Métis patients. It was in this environment that the Canadian Partnership Against Cancer, an organisation created by the federal government in 2007 to steward the Canadian Strategy for Cancer Control, hosted a 2009 National Forum on First Nations, Inuit and Métis Cancer Control. Forum participants met to discuss the disproportionate impact of cancer among First Nations, Inuit and Métis people. Participants at the 2009 forum delivered a very clear message that in order to resolve these issues and improve cancer outcomes within these populations, an action plan guided by First Nations, Inuit and Métis people would need to be developed. This forum acted as a catalyst to collaboratively create the First Nations, Inuit and Métis Action Plan on Cancer Control, which guides work by the Partnership with and for First Nations, Inuit and Métis patients and partners. The action plan outlines the importance of closing gaps around culturally responsive care, addressing language and geographic barriers, and building greater cancer awareness within communities. As well, since many First Nations and Inuit cancer patients in remote and northern communities must travel away from their families and communities to receive care in southern cities, the plan seeks to address poor transitions between communities and care settings. Today, the Partnership is documenting best and/or promising practice models of Indigenous health supports working in synergy with biomedical approaches, such as health centres that connect patients with Elders, healers and/or navigators to provide First Nations, Inuit or Métis-specific supports through the cancer journey. This may also help improve understanding of protocols, agreements, relationship building and cultural proficiencies required to advance improved collaboration with Indigenous practices and knowledge keepers. An additional project using recorded dialogues of cancer patients reflecting on their experiences and physicians responding to those experiences is helping to build understanding between communities and cancer care providers. The Partnership is exploring opportunities to raise awareness about patient self-identification, a sensitive area given the history of data misuse and systemic discrimination against First Nations, Inuit and Métis people. The principles of reconciliation will be of particular importance to this work. In the arena of prevention, Partnership-funded smoking cessation projects in the Northwest Territories and Nunavut are intended to build capacity in communities to support cancer patients and their family members as they attempt to stop smoking. A Nourishing School Communities Initiative aims to change the way First Nations students think about food by developing school gardens and increasing access to local, sustainable, healthy foods. Working on Wellness in Strategic Populations, meanwhile, works with employers and employees in predominantly First Nations, male-dominated workplaces in British Columbia, Northwest Territories and the Yukon to improve healthy living policies, and increase awareness, education and access to information on healthier choices. To ensure the work described above is guided by regional and national level-engagement, the Partnership works in collaboration with the National Aboriginal Organization Caucus, which includes representatives from the Métis National Council, Inuit Tapiriit Kanatami and the Assembly of First Nations, as well as the Partnership CEO and VP Strategy and the Aboriginal member-at-large from the Partnership Board of Directors. A smaller working group, which includes representatives from three National Aboriginal Organizations as well as from the Partnership, meets on a more frequent basis to advance the work prioritised by the Caucus. Building on the Partnership's commitment to work with and for First Nations, Inuit and Métis peoples and partners, the Partnership is developing a reconciliation framework in response to the recent Truth and Reconciliation Commission, which documented the Residential School experiences of survivors across Canada. Reconciliation is a process of acknowledging past acts and building or rebuilding relationships to effect deep change. We are optimistic that a reconciliatory approach will promote improved cancer control for First Nations, Inuit and Métis patients. The challenges First Nations, Inuit and Métis people face in cancer control are complex and varied, and shaped by a history of colonial policies with long-term impacts on physical and emotional well-being. However, partners across Canada have committed to not only working together to address key cancer care issues with and for First Nations, Inuit and Métis people but also to track and measure the impact of the work together. The Partnership's focus on improving the cancer journey of First Nations, Inuit and Metis people has indicated its priority status, commanding millions of dollars in investment to enable teams to work within their jurisdiction and come together to share knowledge about how change is occurring. It is an approach that is unique and impressive – and what is needed if cancer outcomes in First Nations, Inuit and Métis populations are to improve.

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