Indigenous and Northern Affairs Committee on Feb. 16th, 2017

[Dr. James Irvine, Medical Health Officer, Mamawetan Churchill River Health Region]

Good morning. I'm James Irvine. I'm the medical health officer for three northern health authorities in Saskatchewan, roughly the northern half of the province. David Watts and Denise Legebokoff work with Mamawetan Churchill River Health Region. We're on Treaty 6 territory here in northern Saskatchewan. Thank you very much for the opportunity to present to you.

The northern half of Saskatchewan has roughly 40,000 people. It has some of the highest proportions of indigenous people in Canada, with about 87% being self-identified as indigenous and about 49% of those living on reserve. We have 12 first nations living in multiple communities, all of which have had health transfers, and we work in partnership with them.

Northern Saskatchewan faces, like many other northern or mid-northern areas, challenges related to social determinants. We've provided information on some of those determinants, such as the income levels and poverty.

Fifty per cent of the individuals in northern Saskatchewan live on 20% of the average income of the average Canadian. Crowding in northern Saskatchewan on average is more than six times that of crowding within other Canadian homes. All of those things are indicators that show the challenges related to some of the social determinants of health.

With regard to the longer-term incidence of suicides in northern Saskatchewan, since about the mid-1970s we've had rates two to three times the crude rates in Saskatchewan. On average across the north, with about 40,000 people, we have about 12 suicide deaths a year. Youth account for most of these deaths. This slid shows that across Canada, the highest group at risk of suicide are the middle-aged or elders, whereas in northern communities and many indigenous communities the rates are highest within youth. For data up until 2014, for males and females combined, in northern Saskatchewan the suicide rate for youths age 15 to 24 is almost seven times greater than the Canadian average.

Hospitalizations for self-harm tend to be greater among females. In the last 10 years, suicide deaths have been higher in males, while in the French version, you see that females have a higher rate of hospitalization for self-harm.

We've just experienced a cluster of suicides in the north that was somewhat different from what we had in the past. These suicides were predominantly young girls under the age of 15. There was a cluster. We've experienced clusters in the past, with one community experiencing this and then several years later there was another community. That tends to be the pattern. We've noticed over the last few years that those clusters have spread geographically, and it's thought that part of this may be because of social media.

Six deaths occurring within about a two-week period has had a tremendous impact, and that impact was sustained in the following several months, with fairly serious attempts and serious ideations. We've provided a graph showing the significant effect on emergency departments and other mental health teams.

We've also provided a breakdown of this last cluster of attempts and ideation following these deaths. It's hard to comprehend that girls between the ages of 12 and 14 would find themselves in this situation. I would be happy to respond to questions about this later.

Generally across the north, we've had the issue of suicides for decades, and this will continue unless really long-term supports and strategies are enhanced and sustained.

These events have been occurring on and off reserve, in Métis communities, and in first nation communities. In general, communities work closely together, and we do well at times of crisis, pulling together and responding and getting support from provincial and federal governments. It's really the longer, sustained, culturally based preventive strategies that need to be strengthened and resourced.

We also talk about the many faces of the issue. Suicide is one. Others are self-harm, assaults, injury, unresolved grief, previous trauma, bullying, substance abuse, and addictions. Social issues of poverty, intergenerational trauma, and cultural ties and loss are also important.

We also looked at risk factors. As you're very well aware, there are the individual factors and social factors, as well as community culture and continuity. In our circumstances, we find that it tends to be much more involved with the social and community and cultural perspectives and that it's often not an individual issue. It ends up being much more of a community issue, and it's often in clusters.

It's the same with the sense of protective factors. There's the sense of community cohesion, family cohesion, family communication, social supports, engagement in things like schools and sports, but there's also a lot of evidence in British Columbia and Alaska, and anecdotally around the country, that it's the community engagement in maintaining cultural continuity that's so important for that self-identity.

In general, we've put together a couple of recommendations that you see before you, but really, one of the areas is that big area of prevention and looking at those social determinants: poverty reduction, housing, early childhood intervention, indigenous language and cultural identity, and intergenerational knowledge sharing, and really learning what's working in other indigenous communities through rigorous evaluation, along with culturally based early childhood development, supporting parents, enhancing coping skills, and strengthening and supporting communities to strengthen the family and cultural identity.

In the area of more clinical connections, there is working together between the biomedical and indigenous systems, enhancing training of mental health workers and mental health professionals, increasing the availability of team approaches and multidisciplinary teams, and coordinating across jurisdictions. We have several first nation health authorities and several regional health authorities provincially, and it's so important to be working together there, as well as with social services, the RCMP, and education.

Then there's working closely and supporting indigenous approaches to wellness.

There are a couple of things as well that we've learned recently. One is the importance of having suicide cluster response plans, and having the surge capacity to deal with that. Learning to use some common assessment tools and training across jurisdictions have been found to be valuable as well. We also support the development of quality data systems for surveillance, very much led or incorporated with first nation and Métis collaboration.

Thank you very much, and we'll be happy to respond to questions.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you, I appreciate that.

Now we're moving on to the Indigenous Health Alliance, with Dr. Alika Lafontaine.

[Dr. Alika Lafontaine, Collaborative Team Lead, Indigenous Health Alliance]

Thank you very much for inviting me here today. Thank you for the comments that were just shared, and for the acknowledgement that it is unceded Algonquin territory on which these meetings are being held.

My name is Alika Lafontaine. I'm an Ojibwa-Cree anesthesiologist, currently practising in northern Alberta, Treaty 8 territory. I am the immediate past president of the Indigenous Physicians Association of Canada and I currently work with the Indigenous Health Alliance, which is a collaborative approach to health transformation, currently led by more than 150 first nations from the territories of Manitoba Keewatinowi Okimakanak, the Federation of Saskatchewan Indian Nations, and the Nishnawbe Aski Nation.

As I have reflected on the unique contribution that the IHA could provide to these hearings, I believe that connecting the suicide crisis with the current health system we exist in as indigenous peoples would likely have the greatest utility.

In these hearings, you've heard a lot of testimony about a broken system. I'd like to suggest that, based on what community has taught me over the past several years that I've been involved in this project, the system is actually not broken. It does exactly what it is designed to do, but it will never be able to respond appropriately to a suicide crisis in our communities, or any other crisis, until we transform our health system.

In order to understand what the status quo is, I would like to share a very brief story. It's a story about a system we're all trapped in, not because we can't change, but because we choose not to change. As with any story, there are three truths that I would like to suggest you accept.

The first is that our communities are in perpetual crisis, and that crisis is worsening. You can see from the suicide crisis that suicides have become suicide pacts, and suicide epidemics are now becoming pandemics. This is happening in real time in the Nishnawbe Aski Nation, the Manitoba Keewatinowi Okimakanak, and the Federation of Saskatchewan Indian Nations.

Our indigenous systems were originally designed for colonial outcomes. That's the second truth. Colonial outcomes mean that the rights of indigenous peoples to land and resources are eventually extinguished.

The third truth I suggest you accept is that indigenous people are at a place where we need to change. We have no option but to create a different type of system because of the morbidity and mortality affecting our communities.

We'll begin our story in what I'll call a crisis.

If you look at the crises that happened in La Loche, Attawapiskat, Cross Lake, or any of the other communities that have been affected by suicide and mental health crises across the country, you will see that these crises usually lead to a meeting.

I remember the meeting that happened in La Loche. The Prime Minister attended, along with several ministers. The provincial government was represented. The meeting was supposed to lead to solutions, and those solutions were supposed to lead to an expected impact, which was a decrease in the suicide crisis.

In a review of La Loche and the amount of federal government spending that has happened there over the past 12 years, we've seen from our data that over $500 million has been spent in that small community of about 4,000. The question we have asked ourselves is why that didn't have an effect. Where did all the money go?

From both federal and provincial levels, $650 million was allocated to Nishnawbe Aski Nation since it declared its suicide crisis last February. Why has there not been the expected impact?

I would like to suggest that what communities think is happening—crisis meetings, solutions, and impact—is not really what's happening. This is simply what our communities are led to believe. Between the crises and the meetings, there are side conversations that occur between governments at provincial and federal levels, as well as with outside agencies that suggest they can assist with the crisis.

These side conversations occurring between the meetings and the solutions lead to a pre-allocation of funding.

It's interesting that of the $650 million that was allocated to the Nishnawbe Aski Nation, most of it was spent before it ever actually made its way into the community.

As an example of how this was spent, for the crisis teams, the federal government assigned specific suicide task forces that came into the community at a cost of about $2 million for three months. Once that pre-allocation of funding dried up, those crisis teams disappeared.

Between the solutions and the impact, outside agencies are almost always tasked with providing the solutions for our community issues.

While communities are stuck in the middle of a cycle—remember, we look at crisis, meetings, solutions, and impact—there is an outside circle that's happening at the same time, where we have side conversations, pre-allocation of funds, and outside agencies providing all of the care that is required to solve our crises. What this leads to is a lack of accountability within our communities and to our communities, a lack of resource allocation that goes directly to our communities, and a lack of responsibility and no role in implementation when it comes to solving our crises.

The guaranteed outcomes of this system, which I'm going to call the status quo, are worsening crisis and escalation by indigenous people in the form of political pressure, media, litigation, and civil unrest. The current system of government response has grown to recognize these outcomes and respond in kind. By keeping indigenous peoples within the cycle of crisis, meetings, solutions, and impact, the systems we work in are able to utilize their resources to de-escalate indigenous people through meetings, round tables, MOUs, and joint action tables. However, most of these activities have very little impact on the community crisis.

For example, although there is a joint action table with the Nishnawbe Aski Nation that has been established for more than a year, there are minimal, if any, real resources that have been established on the ground. The joint action table, from our point of view, is simply a mechanism to de-escalate indigenous peoples' move towards political pressure, media, litigation, and civil unrest.

That's not to say that any of these things are desirable. No community wants to move here, but this is where we are forced to move with the status quo. Quite literally, there are insufficient resources left to prevent the worsening crisis, because the attention is instead spent on de-escalating the indigenous peoples' response.

If we compare this to crises that have happened historically, we see that the response of the mainstream system was much different. After we recognized the prevalence of iatric injury to patients—that's physician and health care provider injury to patients—in the late nineties, a quality crisis led to the creation of health quality councils across the country. When we look at the SARS crisis, we see that the effect it had was the creation of the Public Health Agency of Canada. The crises in safety that we had in the mainstream system led to new rules for regulatory and accreditation bodies.

If we want to get out of the suicide crisis, we need to recognize that we need to write a different story, like the one I just shared, and we have to acknowledge our shared truths that our communities are in perpetual crisis, whether or not we receive media coverage; that our system is designed to produce the outcomes of worsening crisis and escalation by communities in order to get a response; and that we must change what we are doing. We need to re-task our bureaucracies from doing the job of incremental change to broad system transformation. It has been said in the past that the electric light bulb was not the result of incremental improvement of the candle.

In the Indigenous Health Alliance, we take on this task wholeheartedly in trying to address the indigenous health system, and we observe that this task is taken on wholeheartedly in the mainstream medical system. Patient-centred care is a complete transformation of the physician-patient relationship. You're talking about a national pharmacare program, which would reconstruct the way every patient in this country accesses drugs. We are not a country of incremental health system improvement; we are a country of health system transformation.

Indigenous communities are trapped in a system where worsening crisis and escalation are inevitable outcomes. Last week, representatives from more than 150 first nations presented their plan for health transformation of the indigenous health system to the ministers of indigenous affairs and health. It's in order to address the crisis in our communities, which includes suicide and mental health.

The IHA will continue on regardless of the role of the government, but our first nation leadership has been told that the bureaucracy only has the tools for incremental improvement of the existing colonial system. To be very straightforward, bureaucracy has no tools, no process, and no plan for health transformation, and that's what we need to move ourselves out of these crises.

A question I am often asked by communities is how severe a crisis must get and how high escalation must proceed before investment in health transformation finally happens and we work our way out of the status quo. My only answer to them right now is, “I guess we'll have to see.”

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you very much. These are very powerful presentations. I appreciate your time and effort.

We'll now move to the questioning period from MPs here in Ottawa. Our first MP is Michael McLeod.

[Michael McLeod, Liberal, Northwest Territories, NT]

I want to start by thanking both presenters here today. I appreciate all the work you've done on this issue and the attention you bring to this very serious issue we're experiencing in our communities.

I chair the northern caucus, and this is an issue that is very challenging for us to address. As we look across Canada at what the different provinces are doing with some success, it's mostly for the non-indigenous population. It's a great concern that this seems to be escalating only in the aboriginal communities. Quebec has done some good work for the general population, but not with the aboriginal population, and that seems to be happening right through Canada.

In the north we don't have the same level of attention as the rest of the population seems to get. Of the hundreds of millions of dollars of funding announced for indigenous people, none of it goes to the north, and that's really shocking. This is only money for reserves. We don't have any treatment centres in the north. We don't have any programs for trauma, yet a good part of our aboriginal population went through residential schools and are experiencing lots of difficulties surviving in this new world we live in.

I tried to calculate how many people are committing suicide in the north, and we don't have all the information, but in the Yukon, Northwest Territories, and Nunavut, we are averaging about one suicide every eight days. Every weekend we have a suicide. Most of the people committing suicide are male. We have more attempts by the female population, but the people who are succeeding are male. That points out the seriousness of the situation. Since we embarked on our suicide study, over 50 people have committed suicide in the northern territories, so solutions are needed.

We know that we don't have the same quality of life. We've heard that from many witnesses who presented to us. We don't have the Canadian standards that everybody else enjoys. We live in crowded homes. Housing is a real challenge. We have people in some territories who are living in boxes or sleeping on couches, and some are just wandering around, which is escalating the crime and violence in our communities.

We also have a small population getting high school diplomas. Our education is a challenge, and as for food, I think everybody has seen what's being reported in the media.

The reality is that money is being invested where the media is paying attention, and that's not bringing it into the Northwest Territories, Nunavut, or the Yukon.

I want to ask a couple of things. First, what are your top three recommendations to deal with this issue across Canada?

[The Chair, Liberal, MaryAnn Mihychuk]

Can you direct your question to somebody specific?

[Michael McLeod, Liberal, Northwest Territories, NT]

Dr. Lafontaine, maybe you could start.

[Dr. Alika Lafontaine]

I'm sorry to hear those stats. I'll say that first. As you said, I've known that the crises in the north, the far north, were obviously very severe, but even those numbers are worse than the studies that I've read.

Bill Tholl, president of HealthCareCAN, who has overhauled the health regions in Canada, of which I believe Yukon and Northwest Territories are members, said that the biggest problem in health delivery is a consolidation of accountability, resource allocation, and responsibility to the proper levels.

When you look at our status quo and the cycles that I mentioned, particularly looking at the side conversations that happen with government, which really is the largest funding agency in Canada for health, and the pre-allocation that happens to these outside agencies that are then supposed to go in and fix our problems as indigenous peoples, you see that the challenge we have in health is ensuring that those three things—accountability, resource allocation, and responsibility—are consolidated under the communities that have the issues.

We talk about this federal-provincial split in funding; in reality, the provinces and territories receive a per capita allocation for indigenous peoples. They are funded to provide care to indigenous peoples.

Though I appreciate the arguments from health ministers from our provinces that indigenous peoples tend to present with more advanced disease, sickness, or other things—yes, absolutely, that's shown in the research studies for all the reasons that you mentioned here, including things like food security, etc.—but before the money even gets to our communities, it's already spent. For every Health Canada program, they immediately take off 6%. That goes to government to allocate the money. Then there's another 15% or 20% that gets taken off the top to ensure that Health Canada is properly staffed to deal with our issues. If that money just went directly to our communities and there was infrastructure in place to ensure that it was properly monitored, and if there was follow-through on measurement, which doesn't even happen now with most of the programs that get administered in our communities, I believe you would see a big change.

That's what happens in the mainstream system. In the mainstream system, the health system does not sit there and take off a big chunk before the money and resources make their way to the communities that need the help. That's why the mainstream health system works: it's because there's an infrastructure there to ensure that accountability, resource allocations, and responsibility are consolidated at the proper levels. Is it as good as it could be? Absolutely not, but it's definitely a lot better than what's happening in our communities.

I think, from a broad system level, if we want to impact where resources flow and, more importantly, achieve the outcomes that we all want.... I know both government and indigenous communities are not happy with the results that we're getting right now with current levels of funding, despite being quite large in some areas. We have to look at accountability, which is who you answer to; we have to look at resource allocation, which is whose pocket the money goes into; and then we have to look at responsibility, at who is responsible for implementation. If we take those into our communities, we'll start seeing an impact.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you very much.

The questioning now moves over to MP Arnold Viersen.

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

Thank you, Madam Chair.

Thank you to our guests for being here as well.

My questioning is for Dr. Alika Lafontaine, who has really given us a large overview of the system dealing with situations and individuals. I really appreciate your testimony today.

I just want to step back a bit from that and address some of the things that you've said in the past to other committees. I know that you're from northern Alberta, Treaty 8 territory. You do significant work in my riding. Last year you gave remarks to the Special Joint Committee on Physician-Assisted Dying and you stated, “In a system where everyone is already dying, the effects of creating a literal program where patients intentionally die within the medical system will further disengage and disenfranchise indigenous patients and families.”

Obviously, the government didn't heed your warning. Bill C-14 was adopted, and now we have a system in place. Do you still have concerns with this impact?

[Dr. Alika Lafontaine]

I think the perspective of not fixing the existing system and just piling on new programs leads to unintended results. We have no data with regard to medically assisted dying or the impact that it's had.

I do know that if there are no systems in place to support better mental health and to address the suicide crisis, a perpetual crisis inevitably results in worse and worse outcomes. This is true for any group, any demographic. If the SARS crisis in Ontario had continued without proper response, the entire medical system would have eventually crumbled and fallen apart, and that's what you're finding in most of our communities.

I still stand by that statement, but as I said, there is no data to show what's been happening, except for anecdotal data, and I believe that things are getting worse.

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

A number of the witnesses we've spoken with previously have indicated there may be a link between sexual abuse and suicide. Has your organization found anything like that as well?

[The Chair, Liberal, MaryAnn Mihychuk]

Who are you directing your question to?

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

It's for Alika Lafontaine.

[Dr. Alika Lafontaine]

In discussions with the three territorial organizations that we work with, sexual abuse is flagged as a major reason that these things occur. On the issue of sexual abuse in particular and the way we approach indigenous health in general is that we latch onto a core reason and then just paint it with a broad brush across all of our communities.

Sexual abuse is not a problem in every community within the Nishnawbe Aski Nation, and it's the same with FSIN and MKO. I'm sure our colleagues from La Ronge could comment on this with more specificity, but sexual abuse definitely has been flagged as a major issue, absolutely.

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

Would our other guests have any opinions on that?

[Dr. James Irvine]

There is certainly a wide variation between communities, and sexual abuse is one aspect. I think another way of looking at it is adverse childhood events in general, where multiple factors may be involved. Some may be the result of unhealed intergenerational trauma, things like witnessing violence within the home, separation within the family, and other challenges that may be faced within poor living circumstances.

I'll let David comment about the most recent event within the north.

I think the other part of it is supporting Dr. Lafontaine's talk about system change within health. I think often communities would look at health much more broadly than what we see in the traditional or conventional medical model. They would very much recognize the importance of community and the importance of healing and the importance of education and employment in offering real hope for our youth.

Do you wish to make a comment?

[David Watts, Executive Director, Integrated Health, Mamawetan Churchill River Health Region]

I completely agree that it's generations of untreated trauma. In the latest suicide cluster that we dealt with, we went into the school and we assessed every grade 7, 8, and 9 child there. The levels of untreated trauma in these youth is just immense,

We were able to do that because we had so much provincial support coming up. As we've mentioned several times, that soon goes when the crisis is deemed over, and then we're back to normal resources.

We feel terrible that we know there's so much need in our communities, but we're not able to actually deal with it because we don't have the resources to do so.

I completely agree with Dr. Lafontaine's saying that so much money is allocated at these times of crisis, but in reality nothing comes to us, and we are the ones who are dealing with the negative outcomes. I completely agree with that statement.

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

The previous witnesses talked about there having to be a balance between the physical health of individuals, mental health of individuals, and spiritual health of individuals.

I guess my definition of spiritual health is the reason for life and why we are here and these kinds of questions. Do you think that the spiritual aspect is a big component of the health and the current.... I know, Alika, you were saying we need to redesign the system. Is there a spiritual aspect we need to incorporate?

[The Chair, Liberal, MaryAnn Mihychuk]

We have about 30 to 40 seconds.

[Dr. Alika Lafontaine]

Absolutely. I think if you're looking at the literal situation of these kids, you have a kid who gets sexually abused in a crowded house, right? They have nowhere to go after they get impacted by the sexual abuse.

We also have a food insecurity crisis that's happening, which leads to an additional triggering by whoever is doing the abuse, so the abuse gets propagated because of the environment they live in.

It's difficult to have any self-worth or feel that life has any meaning when you live in that sort of environment. Absolutely, I think transformation includes all of those aspects.

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

Thank you.

[The Chair, Liberal, MaryAnn Mihychuk]

Thank you.

I'm going to suspend for a minute. We have a couple of business items that we need to take care of at the end of the meeting. We only have 15 minutes left of our allocated time.

Is it the will of the committee to extend beyond the time or keep...? No, it's a hard stop, so we'll continue with the regular process, and where it ends, it ends?

[Some hon. members]

Agreed.

[The Chair, Liberal, MaryAnn Mihychuk]

All right. That's very good.

The next question goes to MP Romeo Saganash.