Health Committee on May 26th, 2015

[The Chair, Conservative, Ben Lobb]

Good afternoon, ladies and gentlemen. We're ready to start our committee meeting this afternoon.

We have two guests appearing by video conference and will start with them, as is our norm.

Before we begin, though, I'd like to get consent from the committee members. We have votes this evening at 5:15. If we can, we will probably cut a few minutes off each panel from the questions part of each so we can have two relatively complete panels, and then head to votes promptly at 5:15. Do I have consent for that?

[Some hon. members]

Agreed.

[The Chair, Conservative, Ben Lobb]

Thank you very much. That's good.

Today we'll start with those farthest away, starting with Dr. Lalonde, professor of psychology at the University of Victoria.

[Dr. Chris Lalonde, Professor of Psychology, University of Victoria, As an Individual]

Thank you for the invitation to appear before the committee.

I'm talking to you from the territory of the Coast and Straits Salish peoples, whom I want to acknowledge before I begin.

For over 20 years I've been studying identity development in adolescents and young adults. My work has come to focus on the relationship between identity development and well-being among first nations youth in British Columbia and Manitoba. More specifically, I've been studying how failures in identity development are associated with youth suicide. What we've been trying to understand is why suicide rates vary so widely across first nations communities, from rates of zero in some communities to rates many times higher than the provincial average in others.

We managed to collect data on every suicide that took place in British Columbia between 1987 and 2006. We calculated the suicide rate of nearly 200 first nations communities in British Columbia. What we found was that some communities seem to have solved the problem of youth suicide. In fact our first wave of data collection showed that more than half of the communities had no youth suicides. Others had rates that were below the provincial average, and a minority had rates that were far above the B.C. average.

Our research has been guided by the idea that communities that have enjoyed success in preserving their cultural traditions and in gaining control over their collective social and political future would be better able to provide an environment that protects their youth from the risk of suicide.

We developed a set of indicators to measure what we called “cultural continuity”, things we could assess and verify about each first nation in B.C. We measured whether communities had a building devoted to cultural purposes and events, or had managed to foster the use of their traditional language, or had managed to include their own culture in the school curriculum. We looked at the participation of women in local governance. We looked at the extent to which communities controlled basic civic services—police and fire services, health services, and education. We looked at the history of land claims negotiation and litigation and efforts toward self-government.

We found that the variation in suicide rates is not random. Communities that scored higher on these measures of cultural continuity had lower youth suicide rates.

It shouldn't come as a surprise that higher levels of community control and maintenance of culture are associated with better outcomes for youth, but you need hard data to prove that. That's what we've been doing in B.C., and now in Manitoba.

I could go on about my research, but I want to address the final two points in the invitation I received.

The first concerns the availability of statistics about suicide, and the second asks for comments on best practices for mental health care and suicide prevention.

Since data for first nations people or status Indians are held by the federal government, it was extraordinarily difficult for us to access the suicide data we needed for British Columbia. We benefited from cooperative relations between the B.C. Coroners Service, the Office of the Provincial Health Officer, and what was then Indian and Northern Affairs Canada. We face similar challenges in Manitoba.

Both of these projects I've done are special one-off projects. There's no ongoing surveillance of suicide at the level of individual communities. Even the communities don't know where they stand on the issue of suicide, or any other health outcome relative to other communities, or to the province or the country as a whole.

What I believe we need is a system that creates annual health report cards for each first nation community. Every community should get a report that shows where it ranks in terms of suicide, mental health, addictions, and other health outcomes relative to other first nations, the province, and the country as a whole.

I need to stress that these reports shouldn't be made public. There's nothing to be gained by identifying on the front page of every newspaper in Canada the community with the highest suicide rate in the country, but if communities have no access to their own data, how can they plan or create interventions?

These report cards could also be used to better deploy resources to communities that desperately need them and avoid wasting them on otherwise healthy communities. At the moment, no one can tell those communities apart.

My final comment concerns best practices.

Our research demonstrates what many first nations already understand, that programs aimed at reducing suicide need not target suicide. If we support culture, we support health.

Some first nations elders and newspaper editors warn against talking about suicide for fear of creating copycat suicides. As a researcher, I'm not sure that media reports of suicide, or suicide prevention programs, somehow plant the seed or somehow cause suicides. I am convinced that efforts to promote and support culture work to prevent suicide.

We have the data to prove that. We just we need to do a better job of getting that message across, and we need to do a better job of recording and reporting suicide data. Unless we know what's happening at the community level, we're left with no action plan. Knowing that the suicide rate, the diabetes rate, or the injury rate is higher in aboriginal people tells us nothing. We need to know and, more importantly, specific communities need to know where they stand and what they can do. At the moment, there's no way for any of us to know, and that needs to change.

Thank you for your time. That's all I have to say. I'm happy to take your questions.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

Next up we have Janet Smylie from St. Michael's Hospital.

Can you hear us okay, Janet?

[Dr. Janet Smylie, Director, Well Living House, Centre for Research on Inner City Health, St. Michael's Hospital, As an Individual]

Yes, I can.

[The Chair, Conservative, Ben Lobb]

Go ahead.

[Dr. Janet Smylie]

Good afternoon.

I want to acknowledge my colleague, Dr. Lalonde.

[Witness speaks in Cree]

My name is Janet Smylie. I'm a family doctor and public health researcher living here in Toronto, the land of the Mississauga people.

I want to touch on four content areas.

The first one is the burden of mental health challenges and the inequities that face indigenous people in Canada compared to non-indigenous people. I'm glad to follow Dr. Lalonde, because he has talked about suicide and put it in a good context for us. I think most Canadians are aware of the disparate rates of suicide experienced by indigenous people and indigenous youth.

I want to discuss some emerging evidence that we have been able to develop in partnership with provincial and local aboriginal health service providers here in Ontario. With the majority of aboriginal people now living in urban areas, we were able to use respondent-driven sampling over the past couple of years, in partnership with an urban aboriginal health access centre called the “De dwa da dehs nye>s Aboriginal Health Centre”, to develop population-based estimates in looking at the determinants of urban indigenous health as well as health status and mental health status indicators.

Respondent-driven sampling has emerged in urban health as a major source of population-based data for hard-to-find groups of people. Unfortunately, in urban areas, our federal statistics are very poor at getting actual counts of aboriginal people, and that's gotten worse with the switch of the indigenous identity question from the long form census to the national household survey. I recently published on this topic in an international journal of statistics.

With respect to this study, which is under final review for the Canadian Journal of Public Health, we found out that 42% of the self-identified first nations adults in Hamilton had been told by a health care provider that they had a psychological and/or mental health disorder. I should mention that the dataset is owned by the aboriginal community, and they gave permission to share the data.

Using the recognized tool, the Kessler, we found high rates of depression and anxiety. Shockingly, though, using a PTSD screener, we also found that 33% of the adult population, or one in three self-identified first nations people in this urban centre, met the criteria for post-traumatic stress disorder. Also, 41% had suicidal ideation and over half had attempted suicide. Then, and not surprisingly, I guess, given this high burden of mental health challenges, half the sample reported marijuana use in the last 12 months, one out of five reported the use of cocaine, and one out of five reported the use of opiates.

One remarkable thing, given this and other burdens—including, for example, that 16% of adults in a non-age-adjusted sample had diabetes, and that over half of respondents reported making suicide attempts and one in three had symptoms of active PTSD—we found, using the tool that was developed for veterans, that 25% reported excellent or very good health and 33% reported overall good health. When we asked specifically about mental health, 21% reported excellent or very good mental health and 43% reported good mental health. Three-quarters of the people, if you ask them in a self-reporting way, would say they're doing fine or good.

There are things I wanted to mention. I'm going to drill down a bit on the issues about post-traumatic stress disorder just because I think this is something that we really need to be thinking about if we're going to think about adequate responses to these inequities in indigenous and non-indigenous mental health.

Basically, it's an inadequate measure because what we're really looking at is complex trauma. On this, we have some distinguished scholars, including Dr. Renee Linklater here in Toronto, who's published a book about the nature of the trauma experienced by indigenous people. It's linked to the impacts of multi-generational trauma and trauma in family of origin, as well as ongoing trauma and insults. The PTSD screener was developed for veterans of war who, of course, would have experienced a very severe trauma, but it would have been for a limited period of time.

The other thing I wanted to say about this PTSD screener is that one out of three adults in this population is experiencing three or more of the following four symptoms on a regular basis: nightmares of traumatic experiences; actively needing to suppress memories of trauma or avoid situations that remind them of trauma; feeling constantly on guard, watchful, or easily startled; and feeling detached from others or surroundings.

To me this is really a huge and mostly hidden burden. Substance use has been a way of self-managing this huge burden of complex trauma, grief, depression, and anxiety for generations.

Of course it's important to note, as I've mentioned, that there are physical co-morbidities that make it even more complex. What we found in addition to the high rates of diabetes were rates of hepatitis C that were over ten times the rate of those in the general population. Actually 52% of adults and three-quarters of those over the age of 50 report activity limitations.

Given all this burden, there is also an incredible degree of resilience in the self-reported measures, but I would raise concern then, and I have been for years, around the use of these self-reported measures. So here we have one-third of the population experiencing active symptoms that you could compare to those of acute war vets and over half of them having activity limitations, but there's this huge under-reporting when you ask people how they're doing. We see that kind of reporting used still in the reports that are being generated by the federal government, based on studies like the “Aboriginal Children's Survey” and the “Aboriginal Peoples Survey”.

Turning to the root causes, another resource that I would like to bring to your attention is a report that we released in February of this year, commissioned by the Wellesley Institute, a non-partisan institute in Toronto, and called “First Peoples, Second Class Treatment: The role of racism in the health and well-being in Indigenous peoples in Canada”. In this report, with my co-author Dr. Billie Allan, who's another indigenous scholar with a doctorate in social work, we were able to draw on the extensive work of my scholarly colleagues and community members and a council of grandparents.

We detailed the impacts of specific historic and ongoing colonial policies, including the Indian Act, land dispossession and political persecution of Métis, the forced relocations of the Inuit, as well as the traumas of residential schools, the sixties scoop, and the ongoing and contemporary overrepresentation of indigenous children in the child welfare system. As many of you may be aware, there are now more children in care than at the height of residential schools. In the province of Saskatchewan, for example, aboriginal children represent 80% of the children in care.

In this report we were able to detail the pervasive nature of ongoing systemic attitudinal and epistemic racism and its adverse mental health impacts, including trauma and re-traumatization when someone tries to access services.

The adverse impacts of racism on health and mental health have been well documented in the literature internationally for other racialized populations. In fact, we had an international gathering associated with the release of the report so we were able to invite Dr. David Williams, a pre-eminent scholar who developed the measures of racism in the U.S. at Harvard University, as well as our international indigenous colleagues. For example, our indigenous public health colleagues, including Ricci Harris, have been able to demonstrate—because the New Zealand health survey asks about racism—that if you control for class and racism, health inequities actually disappear. Their research has been published in The Lancet.

We have less data in Canada, and in the report we discuss the strong stigma that interferes with acknowledgement of racism. However, there is evidence that has been generated, for example, about “racial battle fatigue” among aboriginal students in Edmonton, and a level of perceived racism, described by my colleague Dr. Annette Browne in her study of an inner-city emergency room, that was so severe that clients actually regularly strategized on how to manage racism in their encounters with emergency room staff in advance of their visits. In the Hamilton study that I previously cited, the respondent urban sampling study, we found that half of the self-identified adults had recorded experiencing unfair treatment as a result of racism.

In terms of other routes, of course, one also needs to be thinking about the gendered impacts of colonial policies and how this intersects with—

[The Chair, Conservative, Ben Lobb]

Excuse me, Ms. Smylie, I'm sorry to interrupt you. We're over 10 minutes now. Do you think you can conclude in the next minute or so?

[Dr. Janet Smylie]

Yes, I could.

[The Chair, Conservative, Ben Lobb]

Okay. Thank you.

[Dr. Janet Smylie]

Basically, in terms of the roots of these issues, there are the gendered impacts as well as poverty, overcrowded housing, dislocation from traditional lands, and residential school attendance by family members, which have also been linked to negative mental health impacts.

With respect to the insufficiencies of existing services and programs and next steps to take, from what I've said already with respect to systemic and attitudinal racism, it should be clear that there are gaps in the availability of non-stigmatizing and culturally secure services. In fact, the large majority of patients are at high risk of re-traumatization.

If I might, I want to drill down for a second. If we thought about one-third of adults in the country experiencing complex trauma that meets the PTSD criteria I described above, that would be 300,000 people that any health care provider or community member would want to refer for urgent supports, including access to counsellors and therapists with expertise, and culture-based counsellors and supports. We've heard from my colleague Dr. Lalonde about effectiveness, and we know this around identity and culture-based supports. Yet in my clinical work here in Toronto, there's not a single therapist I can refer people to. So I do part-time work as a family doctor focusing on mental health supports and therapy. There's not a single person I can refer people to, yet I would estimate that there would be 10,000-plus aboriginal people needing those kinds of supports.

In summary, complex trauma over hundreds of years impacting hundreds of thousands of people requires lifelong, comprehensive systems. Truth and reconciliation requires restitution and remedies. Acknowledgement is important, but in the current acknowledgement process there are inadequacies, even of the supports, for the survivors who have been reporting, and their re-traumatization has become apparent. An investment in the Aboriginal Healing Foundation from 1998 to 2014 was just a beginning, yet it's been cut.

I believe I've presented evidence for a substantive investment in mental health that includes both aboriginal-specific services and mainstream services. Thank you.

[The Chair, Conservative, Ben Lobb]

Thank you very much, Ms. Smiley.

Now we have Carol Hopkins, executive director from the National Native Addictions Partnership Foundation.

Ms. Hopkins, you were here for our prescription drug abuse study as well.

[Carol Hopkins, Executive Director, National Native Addictions Partnership Foundation]

Yes, I was.

[The Chair, Conservative, Ben Lobb]

Thanks for coming and taking the time again.

[Carol Hopkins]

Yes.

[Witness speaks in Ojibway]

Good afternoon and thank you. I'd like to begin by thanking you for the opportunity to speak with the committee. Thank you for the invitation.

I'd like to discuss with you mental wellness from a first nations' perspective. I've introduced myself to you in terms of my cultural identity. I am from the Delaware first nation. It's a small community in southwestern Ontario, and I was acknowledging the Anishinaabe people on whose land we are meeting.

I'm excited to share with you a research project that we just finished this past year. It was a CIHR-funded research project that explored the role of culture in addressing substance use issues. The mandate for this research came from “Honouring Our Strengths: A Renewed Framework to Address Substance Use Issues Among First Nations People in Canada”, which said that the approach to research needs to reflect indigenous culture and values.

We constructed a methodology to do just that, and the outline of the priorities for that research is articulated in the Honouring Our Strengths renewal framework. We applied that mandate and conducted research with the national native alcohol and drug abuse programs and the national youth solvent abuse programs across Canada. There were 15 different language and cultural groups participating in our research, from the east coast to the west coast, from the Mi'kmaq, Malaseet, Cree, and Ojibway first nations all across the country to the west coast first nations of Coast Salish, Nuu-chah-nulth, Kwakiutl, Carrier Sekani, and Chilcotin.

Participating in the research were elders, cultural practitioners, and indigenous knowledge keepers. A priority for the research was indigenous knowledge and demonstrating how knowledge development and evidence do exist within culture. We can find the evidence outside of peer-reviewed journals and such, but we did go to the literature as well, and we conducted a scoping study. We found that about 4,500 articles, which talked about culture and its role in addressing substance-use issues, existed in the world.

From that search, we extracted only 19 studies and applied them in our research. In the research we looked at, none of the measures to demonstrate the impact of culture measured wellness from a whole-person perspective. Nine of the 19 studies measured the impact of culture, and most of those focused on physical wellness and behavioural changes. Most of the literature examined changes based on deficits. It didn't talk about wellness; it talked about changes in deficits: How much of a substance are you using today? How much will you be using tomorrow?

We were excited by what the research produced, which was a native wellness assessment instrument. We've also developed a number of other tools, one being an indigenous wellness framework based on indigenous knowledge. We tested the instrument across 18 treatment centres out of 54 nationally to ensure that the instrument was psychometrically sound. In the pilot test of the instrument, we found that it performed well across age and gender. We saw that those with native language dominance reported higher overall levels of wellness. The instrument also demonstrated that clients had been in treatment at least five times prior to the current episode of treatment. Progression of wellness was equally meaningfully demonstrated between repeats and new clients in treatment, which validates the purpose of repeat admissions in the national native alcohol and drug abuse program and the national youth solvent abuse program.

We saw that the length of treatment made a difference as well in achieving different levels of wellness. Programs that were at least 12 to 16 weeks in length achieved the best results, with programs of seven to 11 weeks showing the least amount of change.

Part of this native wellness assessment instrument is self-rating as well as observer-rating, and the combined measure of change between the two demonstrated at least an 18% increase in wellness between an entry and an exit assessment.

The wellness assessment instrument and the indigenous wellness framework does measure wellness from a whole-person perspective, and we have put forward in this framework culturally based indicators that reliably measure wellness and change over time.

The culturally grounded definition of wellness, as I said, is based on the whole person. So it looks at wellness from a spiritual, emotional, mental, and physical perspective, and the indicators of wellness are hope, belonging, meaning, and purpose. Investments in spiritual wellness through identity, values, and connection to belief produce a level of hope. And investments in emotional wellness—those being connection to culture through family or cultural definitions of family, community, relationships, and having an attitude toward living—produce a level of and a sense of belonging.

Investments in mental wellness, being rational and intuitive and thought-based in culture, when those two are put together, create an understanding, which is an outcome of meaning for and about life. Finally, physical wellness is achieved through a sense of wholeness and understanding a unique way of being and a unique way of living from the culture, which achieves purpose.

When we presented this indigenous wellness framework across the country in many different venues, it resonated well in both the community and treatment centres that did not participate in the research. We also found that there were 22 common ways of talking about culture as an intervention. This is significant in that there is no homogeneous culture but are distinctions across the land based on language and connection to the land. Nonetheless, across those cultures there are 22 common ways of talking about culture.

In our limited data in the national native alcohol and drug abuse program, we know that 90% of people who complete treatment have had access to cultural interventions. What's important about this is that treatment centres have been using culture for a long time, but it hasn't been well defined and it hasn't been documented. Now, this wellness assessment instrument is going to be embedded in a national database we've developed called the addictions management information system. This national information management system was deployed last year across all treatment centres.

A challenge in the full use of the database is that there were no resources nationally to build capacity among treatment providers to use the addictions management information system, so we're relying on things such as webinars to teach people in the treatment centres to use the full capacity of the addictions management information system.

Our hope is that over time we can demonstrate the significance and importance of the AMIS system so that we have service providers fully utilizing the system. Then we'll have an evidence base that we build across the country to demonstrate the importance of culture and the strengths of the NNADAP and the NYSAP programs in addressing substance abuse and mental health issues.

We've also developed a cultural adaptation of the drug-use screening inventory, which is both a screening and an assessment tool that has been adapted to measure trauma from a first nations perspective that considers not only the long-term intergenerational effects of trauma but the community aspects of trauma that layer onto people across generations as well.

As I said, the addictions management information system needs more support in terms of building capacity across this system to be able to use it.

This fall we're also going to pilot test the native wellness assessment instrument in the Indian residential school health supports program and the mental wellness teams.

A good example I wanted to offer around collaboration and partnerships—and also to demonstrate the impact of the conversation around these wellness indicators of hope, belonging, meaning, and purpose—is the development of the national first nations mental wellness continuum framework. When we presented the research, across the regions those indicators resonated with people as well. So they've been embedded in the first nations mental wellness continuum framework. Also, what people have said is that culture has to be the foundation of whatever investments we make in wellness or towards wellness, and the outcome should be measured in terms of hope, belonging, meaning, and purpose.

The other point I wanted to make about the collaboration—

[The Chair, Conservative, Ben Lobb]

Sorry, Ms. Hopkins. We're over time. Would you be able to summarize quickly. Thank you.

[Carol Hopkins]

Sure.

What we heard in the development of the mental wellness continuum framework, in terms of moving forward in addressing mental wellness and promoting culture, is that we have to move forward from a systems perspective from an examination of deficits to a discovery of strengths. We have to move from using evidence that is absent an indigenous world view, values, and culture to indigenous knowledge setting the foundation for evidence. We have to move from a focus on inputs for individuals, based on those deficits, to a focus on outcomes for families and communities. Then we have to move from uncoordinated and fragmented service to integrated models for funding and delivery of services.

One more point I wanted to make about suicide is that we've heard from young people across the country—and this came from a conversation that the AFN facilitated in one of their health forums—that they need more conversation about how to live life than about suicide and dying. So they've put forward the concept of life promotion versus suicide prevention. That also was validated in the Chiefs of Ontario health forum two years ago, in 2013. The youth are saying that they want to talk about living life and want more information about how to live life.

We also have evidence from the youth solvent abuse program, where young people report that they don't intend to commit suicide but they accidentally commit suicide because they see the attention that is given to other young people when they make these attempts. So they'll make attempts and then run back home so they can hear their names being announced on the community radio, for example.

I'll end there.

[The Chair, Conservative, Ben Lobb]

Thank you very much.

That concludes our presentations.

We'll likely have enough time for a round each for questions, of roughly seven minutes. We'll have to keep you tight to the time.

Mr. Rankin, go ahead, sir.

[Murray Rankin, NDP, Victoria, BC]

Thank you, Mr. Chair.

Thank you to all of the witnesses. This was a very moving presentation.

I guess the unifying theme I took from it is the importance of culture in some of the processes we might use to turn around some of these very disturbing conclusions.

I'd like to start, if I could, with Professor Lalonde and Dr. Smylie on a practical point. Dr. Lalonde, you talked about the availability of statistics on suicide being “extraordinarily difficult”, particularly from the federal government, even though they have responsibility for status Indians. Also, Dr. Smiley, you used the expression “gotten worse” when you described the move from the long form census to the household survey. I'd like each of you to elaborate, if you would, on those difficulties you've faced.

Perhaps, Dr. Lalonde, you could start.

[Dr. Chris Lalonde]

As I said, the problem is that the health data is held in different places. So the province has some data, the federal government has some data, and now in British Columbia aboriginal organizations are holding data. The problem is that no one feels they have the authority to actually share information at the community level. What we get told is that we need to create working relationships with the communities to access that data. Well, in British Columbia that's logistically impossible. You can't have personal relationships with 200 communities.

So I think the bottom line is that what gets recorded and reported gets worried about and acted on. I think the fact that we don't have a community-level surveillance of suicide is very troubling, and I think we should.

[Murray Rankin, NDP, Victoria, BC]

Dr. Smylie, I have a limited amount of time. Do you have any comments on that point of access to data you raised?

[Dr. Janet Smylie]

Yes. Canada is doing poorly internationally with respect to indigenous specific data.

There are two issues. One is the need to build partnerships with indigenous communities and governing organizations. We were moving well in that direction about five years ago, but it's gone backwards with the cutting of the resources of our national aboriginal organizations and health directors at provincial and territorial levels.

The other big issue, which makes us unique among relatively affluent countries with minority indigenous populations is that we do not identify indigenous people in our health data set. Here we lag far behind New Zealand, Australia, and the U.S., as I know from having sat on an international indigenous health measurement group. Every other relatively affluent country is able to identify indigenous people. We're hidden in our data sets.

The way you would develop good statistics would be to have indigenous identity on vital registration and health service records. We're hidden in there.

[Murray Rankin, NDP, Victoria, BC]

Thank you. That's troubling. I say that because, as Dr. Lalonde pointed out, there is such great variation amongst the communities, and if we can't get a handle on what the problem is we aren't likely be able to solve it. I found that a troubling part of your presentation.

I'd like to go to Ms. Hopkins, if I could. Thank you for your excellent presentation. You talked about the investment in spiritual wellness. I like that expression. You talked about how you've looked at communities from across the country. I assume Inuit people are involved in this as well in the north?

[Carol Hopkins]

No, it was first nations.