Indigenous and Northern Affairs Committee on Oct. 17th, 2016

[The Chair, Liberal, Andy Fillmore]

Good afternoon and welcome, everybody. We'll come to order now.

This is the Standing Committee on Indigenous and Northern Affairs. We're continuing our study of suicide among indigenous peoples and communities.

We're meeting today on the historical land of the Algonquin people, for which we're very grateful.

We have two panels today. The first is the First Nations Health Managers Association, who are seated with us in the room, and the second is the Canadian Indigenous Nurses Association, who are joining us by teleconference.

We're happy to have you all here.

The way this works is that each organization has 10 minutes to present. I see in both cases we have two people from each organization. You can share that 10 minutes between you any way that you see fit. When you get to around nine minutes, I'm going to hold up a yellow card. It means we're nearing the end. Then when you're out of time, I'll hold up the red card. I'd ask you to please finish up at that point, and then we'll move into questions from committee members.

With that explanation, I would welcome Marion Crowe, executive director of the First Nations Health Managers Association, to take the floor.

[Marion Crowe, Executive Director, First Nations Health Managers Association]

Thank you.

As mentioned, my name is Marion Crowe. I'm a Cree woman from the Piapot First Nation in Saskatchewan, and I'm here in the capacity of the founding executive director of the First Nations Health Managers Association.

With me, of course, is Mr. Calvin Morrisseau, board executive member and Ontario representative of the First Nations Health Managers Association. Mr. Morrisseau works as the executive director of the Fort Frances Tribal Area Health Services.

As you indicated, Chair, we are on Algonquin territory, and we would like to acknowledge that territory on which this hearing is being held today. We also want to send our condolences to the families who are impacted by and grieving due to the very reason we're here.

Our thanks to the Standing Committee on Indigenous and Northern Affairs for the invitation to speak and to provide our testimony related to life promotion strategies. It really is a responsibility we carry with humility and pride.

The First Nations Health Managers Association, which I will refer to as FNHMA, was founded in September 2010. We're a national professional organization providing certification and professional development opportunities to health managers and directors who work in and with first nation communities from across Canada.

We have over 300 members and a network of approximately 1,200 first nation health leaders, representing grassroots health professionals who administer, advocate, and in some instances are clinicians practising health services in our communities. There are over 100 certified first nation health managers across Canada designated by our organization. We are a certification program that is built on core competencies that were created and led by grassroots health leaders.

Right now we're the only organization in Canada that has a curriculum built around relevant health services and practices, and a governance that is actually reflected in our communities and incorporates and respects culture as part of our competencies. This makes us unique as we celebrate and share our inherent knowledge while balancing and maintaining management principles.

We have brought with us today evidence that speaks to our subject matter expertise in first nation health service delivery, and it will be distributed. It's the textbook written by FNHMA, largely authored by our certified members from across Canada.

We are uniquely positioned to share the experiences of grassroots health managers on the ground in our communities. The issue that has brought us here today is suicide prevention. We usually don't speak from a deficit position, so we'll refer to it as life celebration, please. We bring forward four recommendations for consideration as a really small part of the larger strategy required to make inroads into this issue.

Before we get into our proposed solutions, in reviewing previous witness testimony, we know you have had 42 witnesses prior to us, and we feel obligated to note that Thunderbird Partnership Foundation is absent from the witness testimony. Thunderbird Partnership Foundation is an FNHMA partner, and they are committed to working with first nations and Inuit to further the capacity in communities to address substance abuse and addictions. We would implore the committee to consider their participation in this very important work.

As regards the very first recommendation we bring to the committee, we already know from previous testimony, research, and academic studies that we are facing an issue that is pervasive in our communities. We are specifically speaking to the testimony that has already been provided on the first nations mental wellness continuum framework. It identifies a continuum of services needed to promote mental wellness and provides advice on policy and program changes that will enhance first nation mental wellness outcomes. This framework enables us to adapt, optimize, and realign mental health wellness programs and services based on our own priorities.

The framework includes a number of elements that support the health system, including governance, research, workforce development, change and risk management, self-determination, and performance measurement. Health services integration among federal, provincial, and territorial programs is critical to its success. Discussing how to implement the framework in our communities is really important to us as an organization and it will be a highlight at our national annual conference this year. Our delegates are at the forefront of life celebration, and suicide prevention will be a very valuable resource when discussing the implementation of this framework.

We also refer to previous testimony that cites the urgent need to implement the Truth and Reconciliation Commission of Canada's 94 calls to action in order to redress the legacy of residential schools and advance the process of Canadian reconciliation, but you have heard that already.

Our second recommendation that we bring increases the efforts in certification and accreditation in our communities. These are key elements to FNHMA. We see in health services accreditation recommendations all the time around governance and capital. Investments need to be made in our communities on capital assets to even be able to reach health services accreditation, investments such as the repairing of our existing facilities, and also the creation of new treatment and quality health centres. Having certified health managers in our communities will contribute to increasing accreditation goals made by this very government, Health Canada's first nations and Inuit health branch.

Our third recommendation is around strengthening the existing networks that are already in place, such as FNHMA and the Canadian Indigenous Nurses Association, who are also here to testify today, and the other national indigenous organizations that are leading capacity building in our communities. We have to reinvest in them and redress the cuts that were made in 2011. This will increase the supports to our health professionals who are on the ground, who are leading, advocating, and creating partnerships to implement the health services integration in our communities that's required. Our existing national indigenous organizations require equitable support to continue the journey of capacity building.

[Calvin Morrisseau, Board of Directors, Executive and Ontario Representative, First Nations Health Managers Association]

Thank you, Marion.

Our fourth recommendation is investing in the capacity of our front-line workers to further contribute to strengthening our health service delivery. This transfer of health services to first nation control, as demonstrated in the B.C. tripartite agreement, is pivotal in enabling communities to decide where to invest their own health resources and self-determine.

I wish to note here that one of the four pillars in the creation of the tripartite agreement was solely focused around health directors, underpinning the importance of their role in delivering health services. This, in conjunction with having a certified workforce place, will contribute to achieving these solutions.

In addition to these potential four solutions, we can take a small step in moving forward with having meaningful foundations that contribute to indigenous life promotions and quality health systems.

[Marion Crowe]

A very specific example that we wanted to bring to the committee around this is demonstrated in the 2015 budget where the Government of Canada renewed the aboriginal health human resources initiative, AHHRI, but with a reduced ongoing budget of $4.5 million nationally. The renewed AHHRI funds are intended to support capacity building and to increase the number of aboriginal people entering into health careers.

This program is delivered through two streams. One is scholarships and bursaries that are provided to aboriginal students pursuing health careers, such as nurses and doctors, but these aren't the folks who are necessarily going back into our communities. The other stream is training and certification for community-based workers, including first nation health director or health manager positions. While this current investment is being made, the second stream is the only existing program for our community-based workers who are on the ground to apply to.

Three million dollars of the $4.5 million goes to scholarships and bursaries, a vehicle through Indspire, and the remaining $1.5 million nationally is split among the Health Canada first nations and Inuit health regional offices. This amount is insufficient to meet the current professional development and certification needs in our community.

A specific component of the mental wellness continuum framework underpins the need for capacity and that will play a key role in ensuring the continuum of mental wellness programs and services that are relevant, effective, and meet our community needs.

[Calvin Morrisseau]

We are well positioned to establish being leaders in the first nations health service and professional development. The First Nations Health Managers Association is an organization that has an existing knowledge circle that collects, promotes, and shares meeting practices to assist in strengthening the capacity of our members at a local level.

We are committed to being a part of the solution, and we can be a valuable partner in strategies moving forward. We are the credentials made for and by first nations. Our members are front-line workers and subject matter experts in first nations health service delivery.

We give you heartfelt thanks for your time today, and it's been an honour and a privilege to be called upon to be witness to this discussion, because it really impacts the current and future lives of our nation.

[The Chair, Liberal, Andy Fillmore]

Thank you very much, Ms. Crowe and Mr. Morrisseau, for your presentations. They are very much appreciated.

[Marion Crowe]

Hai, hai, merci.

[The Chair, Liberal, Andy Fillmore]

We'll move right into the presentation from the Canadian Indigenous Nurses Association. From that organization, we have Dr. Lisa Bourque Bearskin, president, and Lindsay Jones, who is an indigenous nursing student.

Welcome to you both. I'm happy to give the floor to you for 10 minutes to share between yourselves either way.

[Dr. Lisa Bourque Bearskin, President, Canadian Indigenous Nurses Association]

Thank you very much. Tansi. Hello. Bonjour.

[Witness speaks in Cree]

I want to thank the chair and the committee for this invitation to present on behalf of the Canadian Indigenous Nurses Association and to support the families who have lost loved ones.

I'd like to begin by honouring the traditional territory of the Algonquin people, as you've mentioned.

I am from Beaver Lake Cree Nation in Treaty 6 in northern Alberta, and as you mentioned, I am the president of the Canadian Indigenous Nurses Association. I have worked in health care service delivery my entire life, as a nurse. I am now an associate professor at the school of nursing at Thompson Rivers University. Today I have Lindsay Jones with me. She is one of our CINA nursing members and a student here at Thompson Rivers who is studying community health within indigenous communities.

Beyond the symbolic ritual of place, this acknowledgement signals the urgent challenges we face in the era of reconciliation. The struggle for human rights and equitable health care for our indigenous children and youth is a collective and vitally important undertaking, so I come to you today as a survivor. I am reminded of what our elders and traditional knowledge holders continue to tell us. As we continue to reflect on our own philosophy, the spirit of wellness and the struggle for self-determination, we have to know who we are and where we come from, while walking in the footsteps of those who have moved on to the spirit world at the same time of creating footprints for those who come after them.

It is clear that the health of indigenous youth is intimately related to the history of colonization and residential schools, removal of the child from their home and their culture. We know the statistics are grim and that one of the most difficult things to face in life is the reality that somebody close to you has committed suicide. This harsh aspect of life is all too real for first nations, Inuit and Métis families. What we know is that indigenous youth suicide is the most significant public health issue facing our societies.

Our brief presentation today will address how the Canadian Indigenous Nurses Association, CINA, can contribute to addressing the crisis by offering three recommendations for the committee's consideration. These recommendations address the sustainable funding, about which you've heard extensively, to improve access to high-quality culturally responsive and integrated health service delivery by increasing the number of indigenous nurses working with individuals across lifespans, across the nation, and across our northern communities, specifically where the elevated risk of suicide is at alarming levels.

You've heard about the productive factors. You've heard about the risks. We stand united in support of our other indigenous-led organizations and researchers who have undertaken extensive inquiries into this topic.

Our first recommendation is to advocate for sustainable funding for CINA as a national leader on behalf of our front-line nurses and the communities they serve. Firmly rooted in this recommendation is the belief that the Canadian Indigenous Nurses Association can significantly contribute to the overall wellness of our indigenous youth by supporting and fostering the human potential, in creating community capacity to deal with the issues at the local level with front-line workers.

Most do not realize that CINA is the longest standing professional indigenous health organization in the history of Canada. It is a non-profit voluntarily run organization that is governed by 12 indigenous nurses whose vision is to be recognized as a bio-expert advancing the health of indigenous communities, with an end view to improving first nations Inuit, Métis peoples health and well-being.

Our organization began as a political support to Monique Bégin when she started to take this on back in the early 1970s. CINA members are the doorway to the indigenous communities and delivers its core strength from its membership base.

Currently there are approximately 9,000 indigenous nurses in Canada, which represents a huge untapped and underestimated resource. CINA holds real potential to expand its work as nurse members.

Our CINA nurses continue to bring their unique and diverse languages, understandings of culture and healing traditions to their practice. Their roles as stewards of indigenous nursing knowledge informs the ongoing development of local, regional, and national indigenous health policy and service programs around the country.

CINA believes that addressing youth suicide can be achieved by putting the health of its youth back into the trusted hands of its families, communities, nations and nurses. This includes indigenous leadership by promoting the development of practice of indigenous health nursing that is grounded in indigenous knowledge and the expertise that our members hold.

In advancing our mission, CINA engages in activities related to recruitment, retention, member support, and consultation. For the past five decades, CINA has traversed this ever-changing environment.

What we are experiencing is an urgent call for action on reconciliation, decolonization, and incorporation of traditional approaches to health and wellness. We need to apply the metaphor “culture is medicine”.

Unlike any other national aboriginal organization, CINA receives no core funding. Equity funding is an important discussion that has not been explored fully to date. We support Dr. Cindy Blackstock's human rights fight for equity funding for indigenous children. It is currently needed, and we stand strongly beside her.

The greatest potential that CINA has is its ability to deliver primary health care by investing and supporting nurses who work in each of the 655 different communities across the country. What we do know from the Auditor General's report is that one in 45 nurses is adequately trained to work in these northern communities.

As a result of growing requests, we have been working on a collaborative indigenous partnership framework, which I can discuss later, but it really establishes how we are better prepared and situated to work with non-indigenous communities and partners.

Our second recommendation is to support the implementation, as you've heard about...the mental health framework stemmed from the collaborative work together. CINA was a major contributor to that work, and we stand by that report. It really addresses the six continuums of care: community development, early identification, secondary risk, active treatment, specialized treatment, and facilitation of care. That is where nursing is often underestimated. We have the skills, the abilities, and the capabilities to foster that.

Our third recommendation is to support the reorientation of health services to focus on health care closer to home, health care that supports capacity building and health, economic, and environmental sustainability by giving children and youth the skills and capabilities to cope with the impact of intergenerational trauma from dislocation and displacement from their families, so they are much better able to handle that systemic violence that continues to impact the health and well-being of our communities. There is ample evidence to show the point that systemic issues continue to contribute to these inequities.

CINA has been able to develop some much-needed training. We propose that the federal investment in indigenous health and education be used to support the new health accord, which calls for the reorientation of health services. This training can help reduce racism and discrimination, which is found to have a significant impact on people's health. A study with which I am closely involved is examining rural access to health care. It has revealed that people living in these rural settings are even further marginalized by bias-informed care.

With the evidence, it is clear that we need to put in a whole-of-government approach that supports the people and puts the power back in their hands, and while there are new and promising partnership models, such as the First Nations Health Authority here in British Columbia, there is a lot to be done for a comprehensive, holistic approach as services continue to be siloed.

Now I'd like to give Lindsay an opportunity to discuss health care closer to home.

[Lindsay Jones, Indigenous Nursing Student, Canadian Indigenous Nurses Association]

Hi. I'm Lindsay Jones. I'm Nlaka'pamux from Kamloops, B.C. I'm a fourth-year nursing student attending TRU. I'm also a member of CINA.

I have three recommendations in response to the suicide epidemic among indigenous people in our communities.

Nursing understands that when working with such a marginalized and vulnerable population, it is salient to work on professional development with regard to building capacities within the communities. Nursing is more than psychomotor skills. It is a relational practice to work in culturally safe ways to build bridges to close the equity gaps.

Research shows that retaining highly trained and effective health care workers is important in providing quality, accessible health care to people living in rural areas. There also needs to be support systems in place for nurses providing care within these communities. Nurses know a community's strengths and how to build them, understanding that solutions come from within the community.

In the Truth and Reconciliation Commission of Canada, call to action number eight states:

We call upon the federal government to eliminate the discrepancy in federal education funding for First Nations children being educated on reserves and those First Nations children being educated off reserves.

While the social determinants of the health movement has helped to shift some of the blame off the individuals to political and economic systems, the focus is still on what is under-provided in the community and how those deficiencies negatively affect children and families.

My last recommendation is to build on the idea of health care closer to home. As a foster parent, I believe that instead of removing children from their families and their culture, we as a country and as health care providers need to start fostering the families in the traditional, appropriate ways.

Research has found that adolescents may also be less at risk for suicide if they experience the neurophysiological benefits of connectedness, like believing in one of the values for care for and able to better regulate their emotions through social affiliation and attachment with caring adults.

Starting at the grassroots, nursing can support families to empower their children to build confidence and nurture their opinions so they have a voice and develop coping skills, fostering the families to provide an environment where children thrive, instead of removing these children instead of going from foster home to foster home, which only perpetuates the ongoing issue.

Thank you for this opportunity.

[Dr. Lisa Bourque Bearskin]

In summary, we want to advocate for nurses to be perfectly situated on the front lines to provide immediate intervention, to teach about protective factors that stem from our own limited experiences.

I want to leave two words with the committee, kiyam ahkameyimo, which means enough has been said and that we must never give up. These actions are about resiliency and the internal power we each have to eliminate these escalating crises we face as Canadians.

We look forward to taking any questions from you.

Thank you very much for this opportunity.

[The Chair, Liberal, Andy Fillmore]

Thank you so much for that. Thank you very much, Ms. Jones.

We're going to move right into questions now. We have until 4:40. I think you might be in a different time zone, so we have 45 minutes for questions and answers.

The first question is coming from Gary Anandasangaree, please.

[Gary Anandasangaree, Liberal, Scarborough—Rouge Park, ON]

Thank you very much for your presentations this afternoon.

I'd like to pick up on the concept of health care closer to home. I know many of the challenges stem from the fact that there are very few health care providers in the communities. Earlier, you alluded to people who are studying in the health field are not going back to work in the communities. Often they're lured into the major centres because there may be better facilities and better conditions.

What do we need to do to make sure that we're able to get health care providers into the local communities, make sure that they're there for a longer period of time, and that they're part of the community, as opposed to those who are there on locums or who fly in and out for a shorter period of time?

[The Chair, Liberal, Andy Fillmore]

Who would like to take it?

Please go ahead, Doctor.

[Dr. Lisa Bourque Bearskin]

I think the evidence is very clear that when you're looking specifically at indigenous nurses who have been trained, you'll see the retention is higher for them to stay in their communities. Our indigenous nurses are staying and working within their own communities.

We need to create better support systems for them. Particularly in our rural and northern areas there is very limited support in terms of training. They can't leave the community to extend their training or professional development because they have no one to replace them. We need to build a pipeline or pathway to indigenous careers so that we're attracting students into health careers at grades 3 and 4. What I found out in a survey that I did with children is that by the time they're in grades 3 and 4, they're actually being deferred away from a health science background because the belief is that you're setting them up for success by encouraging them to go into education or social work. It creates this huge gap of interest for going into any kind of health career or health science programs. Even when you look at the education available to first nations kids on reserve, you see they don't even have an opportunity to have those courses at a higher level so that they are prepared to go right into a university.

I think it's very complex, but the evidence is really clear that if you support indigenous people to go into health careers at a very early age, they will stay, and they are staying in their communities providing a great service, but they are burning out at fast rates because of the lack of support for them.

[Gary Anandasangaree, Liberal, Scarborough—Rouge Park, ON]

Doctor, in relation to nurses, I think you mentioned there are about 9,000 indigenous nurses. What is the ratio for doctors who are of indigenous background, and what do we need to do to increase those numbers in order that they, too, can contribute to the whole overall health care, particularly the concept of health care closer to home?

[Dr. Lisa Bourque Bearskin]

Yes, that's a really good question. I can't speak for the Indigenous Physicians Association as to what their numbers are, but I know nursing has definitely had growing numbers.

I know when the recruitment and retention strategies are out in the community, there is a focus on medical training. I'm often advocating that we need more support in terms of advocating for nurses training.

Right now that 9,000 is underestimated, but that number only represents the number of nurses working within our province. Those do not actually include numbers of nurses who are working in first nations communities, because that data came from the family survey which was off reserve, so that's a gross underestimate of that.

In terms of national standards, if you look at how many patients registered nurses are able to have first contact with as opposed to indigenous physicians.... I work a lot with communities and I hear all the time that they need doctors, and I say that actually, no, they don't need doctors. Yes, we need doctors, but nurses can really help support the whole focus of care. Not everybody needs to go to a doctor because of a temperature or some investigation. A registered nurse, adequately prepared, can actually streamline some of the priorities faster. We can get appropriate care faster to the people who need it most if you implement a nurse pathway program starting right from health careers, to LPNs, to registered nurses, to degrees in community health, and to nurse practitioners. Nurse practitioners are a really underutilized group of nurses who have amazing skills.

We have one in Maskwacis in Alberta, and I know there is one who splits her time between Paul Band and Alexander. They've actually shown that they've been able to reduce...and improve the efficiency and satisfaction with clients' heath care contacts.

[Gary Anandasangaree, Liberal, Scarborough—Rouge Park, ON]

This question is for both of our guests today.

You mentioned the challenges with funding for these services. What are the specific challenges that you see with respect to increasing the pool of health care practitioners, including nurses and doctors?

Also, what other impediments do you see in terms of health care as a whole when people need a specialist or they need to go to a dentist, and so on? Maybe you could touch on that.

[Marion Crowe]

I'd like to address the question, Chair.

[The Chair, Liberal, Andy Fillmore]

Go ahead, Ms. Crowe.

[Marion Crowe]

Thank you, Chair, and thank you for the question.

The question is, from our perspective, how do we see supporting paraprofessionals and professionals in our first nation communities? I think it's, at the very beginning, looking at actually having positions that are recognized within our funding agreements to communities around health coordination and health supports, supporting the physicians, so it's really about dollars being recognized in the funding agreement. Some communities don't have a health coordination amount, so we would say that a defined scope of practice within our health directors and the communities should be offered.

One of the other things is once you have that health director who is trained and certified, wage parity becomes an issue as well in retaining those quality professionals in our communities.

[The Chair, Liberal, Andy Fillmore]

Okay. I think we're out of time unless, Mr. Morrisseau, you wanted to squeeze in a very short remark.

[Calvin Morrisseau]

I was just going to say that as far as retaining doctors is concerned, I think there's an issue, especially in the area I come from, in accessing the ability to even entertain bringing doctors into our area. We use nurse practitioners to a great degree; however, within our first nations there is a real discrepancy in terms of having doctors available to us.

It's not just a matter of funding. There's a system out there that recruits doctors, but we're not part of that recruiting system. We have to be part of that recruiting system if things are going to change.

[The Chair, Liberal, Andy Fillmore]

Okay. Thanks very much.

The next question will be from Arnold Viersen, please.

[Arnold Viersen, Conservative, Peace River—Westlock, AB]

Thank you to our guests for being here today.

Ms. Crowe, you mentioned earlier the acronym AHHRI.