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HEALTH CARE IN NORTHERN CANADA - AN HISTORICAL PERSPECTIVE
J.D. Martin Health and Welfare, Yellowknife, Northwest Territories, Canada
A brief histofY of health care development in Territories. Starting with their ro1ss1on at Fort northern Cal")8da Providence in 1867, they followed by providing Contact between the native people of northern the same services at Fort Resotvtion in 1903, Canada and f:uropeans occurred in the 1700's and hospital services were added at Fort Smith in 1800's and ttie whalers were of particular import 1914, Fort Simpson in 1916, Aldavik in 1925, ance. Althoygh thev did not set up anv permanent Chesterfield Inlet in \930, fon Re"OO\ution in settlements, they markedly influenced the health 1939 and Fort Rae in 1940. of the local iohabitants. The introduction of many The first hospital established in the Eastern communicable diseases, some of which were pre Arctic was St. Luke's, built by the Anglicans in viously unknown, in many cases, almost totally 1930 at Pangnirtung. Recruitment of federal eliminated the native peoples. Epidemics of small government physicians began in 19:Z2 as a result of pox, influenza and tuberculosis were not un firm and consistent representation by the church common. to Ottawa for staffing the growing number of Reverend Peck, an Anglican missionary. es mission hospitals ( 1 ). Dr. Livingstone, the first tablished a hut for the sick at Black Lead Island in government re$ident physician to the Inuit, was Cumberland Sound in the Eastern Arctic in the the first doct<1r at St. Luke's and as the only 1890's. In llcldition, he adopted syllabics for use doctor in the Eastern Arctic at that time, regularly by the Inuit and wrote the first definitive grammar travelled by dog team to isolated hunting camps used in the Eastern Arctic. on Baffin Island, an area o1 \9\,t\00 square miles A pioneering doctor from Alberta, Dr. W. N. and surely one of the largest medical practices in Mackay. was the first resident physician of the area in the world (2). North, when in 1867 he joined with the Hudson's In the Yukon, during the Gold Rush of 1898, Bay ComP8rty as a surgeon and set up practice and a number of private practitioners followed the Bay trading ;rt York Factory. Or. Mackay moved gold seekers to Dawson Qty and established the next year to Fort Simpson, some thousand practices there. Father Judge, a Roman Catholic miles west and from there to f:ort Rae where for missionary built the first hospital in Dawson City. nine months of 1866 he actively practised medicine This hospital was used until just tecently when a while still employed by the Hudson's Bay Com cottage hospital replaced it. Traditionally, private pany. Dr. Mackay frequently changed his location medical practice has been the pattern in the so as to afford a greater number of the native Yukon. people the breadth of his ministrations. The military has been involYed in the develop Coinciding with Dr. Mackay's arrival in the ment of healt!\ care facilities in ttle North until North was the establishment of the first nursing recently. An army hospital was built in White· station by the Roman Catholii:::s at Fort Providen
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Company posts, and a physician usually travelled lnuvik General, the Rae-Edzo Cottage Hospital, with the ship. In 1950, the Canadian Government the Fort Simpson Cottage Hospital and in addition built the Canadian Coast Guard Vessel C.D. thirty-fline nursing stations, eight health centers Howe. This ship was designed as a medical and and a number of health stations. The federal cargo vessel and had an ice reinforced hull. Faci health service provides public health services to all lities on board included an operating room and communities in the Yukon and Northwest Terri clinical area staffed by two dentists, an eye spe tories. The two Territorial Health Departments are cialist, a radiologist, nurses and two or three rapidly taking greater responsibility for healttlf:ilf"e general practitioners. This ship would sail annually and will eventually assume full control of health from Quebec City and the medical team on board service. would examine almost the entire population of In the Yukon, the 125-bed Whitehorse Gener the Eastern Arctic. Each person would receive al Hospital was opened in 1958. In addition, there a complete physical examination, laboratory is the Old Crow Nursing Station 'in the northern work, a chest x-ray, dental examination and eye Yukon, the Father Judge Memorial Cottage Hos examination. It was not unusual for an Inuit per Pital in Dawson City, the Mayo General Hospital, son to be evacuated immediately on board this the Watson Lake Cottage Hospital and several vessel and spend from one to two years in south health centres in smaller communities. ern sanatoria for the treatment of tuberculosis. In the Northwest Territories, the 35-bed The C.D. Howe was taken out of service in 1968 l=robisher Bay General Hospital serves as a regional when other means of servicing the eastern arctic hospital for the Eastern Arctic and the twelve Inuit were found to be more effcient and prac l"tursing stations in that area serving a population tical. of approximately 7500. The 55-bed lnuvik Gene ral Hospital in the Western Arctc serves a much Organization of health care services and facilities smaller area geographically, but has approximately in the North the same number of nursing stations and health Ultil 1967, healt serviC8$ in the Northwest Terri centres. tories were provided by Regional Offices of The 75-bed Stanton Yellowknife Hospital Medical Services Branch of the Federal Depart operated by the Government of the Northwest ment of National Health and Welfare situtated in Territories provides services to Yellowknife and southern centm namely. Edmonton, Winnipeg the Great Slave Lake area and admits referrals and Ottawa and responsible for Indian health from the Mackenzie and Central Arctic. Two services in the provinces a well as north of 60°. $1'Tlaller hospitals in Hay River and Fort Smith are In 1967, Northern Region was created with head operated by the Northwest Territories Govern quarters in Edmonton and responsibility solely for ment. the Yukon and Northwest Territories. In 1974, The nursing stations are staffed with from one Yukon Region was established in Whitehorse and to four nurses depending on the size of popu in 1980, Northwest Territories Region was moved lation. The nurses are well trained in treatment, from Edmonton to Yellowknife. mid-wifery and public health. At the present time, the responsibility for Health stations are smaller facilities which health care is shared with the two territorial provide overnight accommodation for visiting departments of health. In the Northwest Terri nurses and doctors in those communities too small tories, the Department of Health, Government of to warrant a nursing station on the basis of popu the Northwest Territories is responsible for three lation. hospitals, the Stanton Yellowknife Hospital. the Hay River Hospital and Fort Smith Health Centre. Northern health care professionals In addition, that Government maiages the hos From the experience gained in providing service to pital insunn:e and health care plan and supple native people across Canada, the federal health de nwttary health care benefits. including a phsma partment has developed three new health care care program to residents 65 years of age and over. workers who have found a unique place in the The Federal Health Department manages four hos Canadian health care system, the dental therapist, piUlls including the Frobisher Bay General, the the nurse practitioner, and the conmunity health 82
representative. Arctic by providing consultant and resident staff The School of Dental Therapy began in 1971 from Montreal. This has developed over the years at Fort Smith in the Northwest Territories to and now there is a very active affiliation with train dental therapists in a two-year training McGill. At the Frobisher Bay General Hospital, program. On graduation the dental therapis there is, in addition to five staff physicians, a resi lives in northern communities and provides treat· dent in pediatrics on rotation from the specialty ment and preventive dental programs to the school training program in pediatrics at the University. age population. In addition, the therapist pro In addition, there is usually one medicafstuclent vides emergency dental treatment to adults. This spending eight weeks of an elective progrant in is carried out under the direction of a dentist who Frobisher Bay. Specialists representing the various visits the therapist in the field at regular inter· medical sub-specialties spend two to four days vals prescribing treatment which is then carried each month in Frobisher Bay. Regular surveys are out by the therapist. This has meant that many carried out by an eye team including the ophthal northern communities now have full-time dental mologists and an optician. Surveys are also carried services previously unavailable. out by an ear, nose and throat specialist and audio Northern nurses have for many years provided logist from Montreal. the backbone of treatment and public health ser Similar programs are provided to the Kee vices to their communities. To upgrade treatment watin by the Northern Medical Unit of the Uni skills a four-month clinical training of nurses versity of Manitoba and to the Western Arctic by program is available at the University of Alberta the University of Alberta. in Edmonton. These university programs have been ex In Health Education, an attempt has been tremely helpful in assisting the northern medical made to train the native people as community practitioners in the delivery of health care. They health representatives. These individuals work have also helped to create a most stimulating closely with the nurse practitioners and because of environment for medical practice through day their understanding of the native culture and to- I 83 a multitude of temptations can rapidly be viewed Gall bladder disease and gall stones are some as a juvenile delinquent. ten times more frequent in urbanized western In the settlements, alcohol has played a con arctic Inuit than in the eastern arctic population. siderable part in contributing to the rapid dis The Western Arctic has, of course, had longer integration of the close family ties of traditional contact with the southern Canadian lifestyle. Gall Inuit society resulting in child neglect. Similar to stones in native people appear closely related to the southern experience, there have been large obesity and adult onset diabetes mellitus. numbers of suicides in young people. The Inuit The incidence of hypertension and coronary explained that this is the inevitable result of artery disease is still low, particularly in the East family breakdown and child neglect often occurr ern Arctic but both diseases are increasing rapidly ing several years previous to the suicide. So often in the West, although it is still less prevalent there with the first love affair gone wrong, the youths than in non-native residents and southern Cana suddenly find themselves in the midst of a severe dians. depression and unable to cope with it adequately Cancer mortality has shown some alarming reach for the always-available firearm and end it trends. In the Northwest Territories for Inuit all rapidly and impulsively. It is unfortunate that males over 40 years of age for the period 1967 to the younger people seem to find the most diffi 1972 a lung cancer mortality rate of 204 per culty in adapting to modem life in the Arctic. hundred thousand was found, much higher than One would think that the elders would have this the 96 per hundred thousand in all Canadian problem, but the fact that these people have men of the same age group. For Inuit women the learned to cope with hardship through most of lung cancer mortality rate was 220 per hundred their lives seems to be reflected in their ability thousand compared to 15 per hundred thousand to better withstand the vicissitudes of everyday in all Canadian women. There have been many life .. The young people have been nurtured in a attempts to explain this and certainly important protective settlement environment where every contributing factors are the length of time spent thing has been found for them, and they are just by Inuit women over seal oil lamps and heavy not able to cope with hardship as their parents cigarette smoking. are. This does not differ greatly from adolescents Cancer of the colon and rectum is found less in southern society. frequently in the Inuit than in other Canadians. Maladaptation to changing social patterns In a series from 1950-1974 this diagnosis com includes alcoholism, the illicit use of drugs, prised six percent of neoplasms recorded - for gasoline and glue-sniffing, mental illness, and rising the province of Alberta the comparable figure accident and injury mortality and morbidity (3). is 10 - 11 %, but when the native group is com· pared to the rates of an earlier period from 1950 Changing morbidity patterns in the Inuit to 1966 with the rates from 1967 to 1974, the The disease pattern seen in the native population total age adjusted incidence of cancer of the colon of the Northwest Territories, until recent times was and rectum more than doubled in the later period. that of an underprivileged society. Infectious Breast cancer, fortunately, is rare in Inuit diseases of which tuberculosis was very important, women. A traditional practice has been to lac conditions associated with overcrowding, chest tate each child until the next one was born an and ear, nose and throat infection, impetigo and average of three and one-half years later. This gave skin conditions, and those diseases linked to practically all Inuit women age 35 and over a poor sanitation, gastrointestinal upsets and in lactation experience in excess of 200 months. This fectious hepatitis type A. These conditions still is reflected in the low annual death rate from occur, because native people, on the whole, are breast cancer - 5 per hundred thousand in Inuit still underprivileged in many respects, but their women 35 years of age and over as compared impanance is lessening and other conditions are to 60.7 per hundre thousand in Canadian women making their appearance. These conditions are generally (5). related to lifestyle, the change in diet and occu There have been interesting changes in other J)lltion, and must be expected to become more disease entities as well. There was relatively pnwalent in the future. little ear disease present in the Inuit prior to 84 1950. However, about 50 percent of those born available to the Inuit came from the arctic seas, after that date have suffered or are suffering from seals, walrus and whales. Some well-defined groups middle ear disease. It is interesting again to specu relied on caribou hunting and fish as their main late on the cause of this, but it could well be the food supply. marked increase in crowding with the associated Aside from the sea mammal harvest, many high temperatures and almost absent humidity in groups moved in early summer and again in the fall southern type homes. It has also been suggested to fishing camps thus adding arctic char, grayling, that this may be related to the high incidence of whitefish and other species to their diet. In the bottle-feeding. Interestingly, a recent ear survey nesting areas, ducks, geese, murres and seagulls as carried out in the Eastern Arctic indicates that the well as the eggs of ducks and seagulls provided incidence of middle-ear disease in the pre-school important seasonal foods. and school age populations is decreasing. Small scale preservation of game meat and fish In eye disease, there has been a dramatic was practised in many areas, either in caches, increase in myopia. It is speculated whether this covered with rocks or in undergound ice houses. is due to a change in diet from a high protein Drying strips of caribou and split fish on racks or meat diet to a high carbohydrate diet. However, rocks also took place. epidemiological studies have also related years The Inuit also used whatever vegetable ma spent in school to the increase in myopia - the terial was available, berries, herbs, willow buds, longer the educational period the greater the some roots and predigested reindeer moss and probability of myopia - which does not negate other herbs from the stomachof caribou, arctic the effect of diet (4). Interestingly, acute angle hare and ptarmigan. Seaweed was regularly col closure glaucoma has been very common in the lected by women and children. Inuit. However, with the increase of myopia, the Part of the influence of whalers and fur glaucoma incidence has been reduced consider traders led to stable carbohydrates such as rolled ably. oats and flour becoming a traditional part of the Inuit diet. Amongst the changes in the traditional Change in dietary patterns and effect on pattern of nutrition which increasing acculturation native health of the dominant ethnic group has produced is the Precontact northern Indians lived, as did the Inuit, reduction of the amount of protein consumed primarily from subsistence hunting and fishing with an increase in carbohydrate and fat content, and their carnivorous diet was rich in proteins and and the addition of readily absorbed carbohydrate low in carbohydrates. The aboriginal Indians' diet in the form of sugar. was also low in fat as the main meat supply from Secular growth acceleration and advancement caribou, moose and other deer has lean meat and of sexual maturation are conditions relating to limited fat stores. Such fats as this diet contained health, certainly not disease. This advance has had quite different characteristics from lard, which been noted in affluent societies over the last became an important food staple during the era of century and is often considered a beneficial fur trading and the dairy fats which are being change brought about by civilization • ascribed increasingly used. Caribou has a seven-fold higher mainly to better nutrition, in particular more content of unsaturated fat than beef. Fats derived protein consumption. Indians were affected from fish and beaver are also less saturated than longest followed by western arctic Inuit and then those from dairy products. Vegetable resources in by those of the Eastern Arctic at a rather slower the North, mainly herbs, roots and berries, often pace. With the change comes an alteration in the dried for year-round use were essential sources of shortness for weight as compared to North vitamins. Berries, plant saps and roots and wild American growth norms. Direct observations rice provided more carbohydrates than were avail· suggest that this growth acceleration is most able to the Inuit. Indians were introduced earlier strikingly related to times and places character· to flour and cereals by way of the fur trader, than ized by increased sugar consumption and decrease were the Inuit, the change starting nearly two of protein intake and accompanied by deterio hundred yean ago. rating nutritional state as reflected in hemoglobin The traditional food resources most readily levels. The secular growth acceleration, the altered I 85 nutritional status and the increase of diseases nisms, as iron supplement sometimes meets with associated with affluent western lifestyle may be slow or unsatisfactory response. The relationship more than a chance association. of vitamins A and C to iron absorption and utili Until recently, Indian and Inuit women had zation may also be relevant. adopted the unfortunate southern practice of In respect to Vitamin C, this is in short supply bottle feeding and this has been problematic for from natural sources in the tundra. As it is readily native babies. Until recently, in Frobisher Bay, destroyed by oxidation, the practice of eating there were massive outbreaks of gastroenteritis meat and fish raw conserved supplies of this vita in infants under one year of age and most of min. The traditional preference of the Inuit for this was directly attributed to the fact that the organ meat, which is an important source of vita mothers had not breastfed their infants. Fortun mins and trace minerals has declined due to the ately, the trend to bottle-feeding has been turned decrease in native meat consumption generally, around to the extent that the majority of native but also because of the influence on the younger women are once again breast-feeding their infants. generation of the culture of southern Canada (6}. Attempts are now underway to educate native women in the various food groups and their A reaction of the health care system to changing importance in nutrition. Colour coding of foods social economic and political developments is now being carried out across the Northwest Territories, and increasingly native group are taking part in nutrition programs within their Recognizing the dramatic impact on the health of communities. the native people as a result of social, economic, Perhaps the easiest observed and accepted and political developments, Medical Services example of deleterious health effects of nutri Branch of the Federal Department of National tional. changes in Indians and Inuit is dental Health and Welfare, and the Northwest Territories caries. Complete extractions are often necessary Government Department of Health are working for many children and young adults. Old natives, dosely with native groups to encourage the devel who live in remote places often retain their teeth opment of their own unique solutions to health into senescence. problems in their communities. As a result of a Acne vulgaris was rare in traditional native new Indian and Inuit Health Policy enunciated by societies. Its appearance is probably related to the Federal Minister of National Health and Wel sweets and chocolate. fare in September of 1979, Medical Services Obesity occasionally occurred to moderate Branch is encouraging native communities across degree in older men and somewhat more fre Canada and in the North to take an increasingly quently in older women of Indian and Inuit greater reponsibility for health care with the societies. Obesity is increasing, and while excess eventual goal of total transfer of health service caloric intake in food, soft drinks, and alcohol to the native people. is perhaps the most important factor, there is a For some years now communities have been marked decrease of energy expenditure due to the encouraged to develop health committees. The decline of hunting activity. health committee concept has met with mixed Iron deficiency anemia is recognized as success across the Northwest Territories. However, occurring widely in Indians and Inuit. Its occurr in many communities the health committees have ence is related to the abandonment of the tradi taken a very active role in developing initiatives tional diet whith supplied iron in the meat of leading to improved health. game. Women and children tend to suffer most Native communities across the Northwest from iron insufficiency. When living off fish and Territories have developed many unique app imported staples with diminishing supplies of roaches to the control of alcohol, from total pro meat, the condition becomes widespread. There is hibition in some communities to regulation of perhaps more to it than simple iron supply. Inuit, distribution and access in others. One of the first who in earlier times were adundantly supplied communities to adopt control measures was with iron through eating marine mammal meat Frobisher Bay with the closing of the liquor store may have less efficient iron absorptive mec:ha- in July of 1976. Since that time, there has been I 86 a marked iryiprovement in the community. Cases operation of the lnuvik General Hospital and in of child ne1:1lect have reduced markedly and the due course the nursing station~. The Federal police have found their work more interesting Government will monitor the fulfillment of these as the daily chore of handling drunks has reduced. contractual obligations on behalf of the native Social worktirs have more time now to spend with people. their clien~ because of a reduced workload and The remarkable increase in recent years in re· the hospital outpatient department is not cluttered source development in the Beaufort Sea area and with drun~ crying for medication and treatment more recently at Norman Wells, 11as necessitated of the inevitable trauma resulting from over ongoing discussion with the resoi.irce companies ingestion of alcohol. This is not to suggest that to ensure that health care facilities and personnel such measu(es are the panacea for control of. are available to meet demands resl)ltant from this alcohol prot>lems. However, they are methods development. developed by native people in their communities in answer to these horrendous problems. The future of health care in north&fn Canada The hilll'l suicide rate in the Eastern Arctic It is difficult to look too far ahe There are those that despair for the native Dr. J. David Martin people. This is irrational in view of the record of Regional Director these people. EJCperience has proven them re N.W.T. Region sourceful and able to overcome great hardship, as Medical Services Branch, proven through their ability to survive the harsh Health and Welfare Canada, northern environment for many centuries without Sag 7777, the assistance of modern technology. This re Yellowknife, N.W.T. XlA 2R3 sourcefulness is already being expressed in many Canada ways including the rather unique approaches to solving alcohol problems. The people are willing to participate in the democratic process leading to community improvement. Most communities have many committet!S associated with their elected community councils, for example, health com mittees, social service committees, alcohol com mittees, education committees, etc. This willingness to actively participate can only lead to increased community involvement and awareness in measures leading to improved community health. Consistent with the Indian Inuit Health Policy, communities will gradually assume full responsibility and control of their own health service with inevitable improvement in health. REFERENCES 1. Covill, F.J. and McDermit, R.E.: The develop ment of public health in the northwest Territories. Canadian Public Health Association Annual Con ference, Winnipeg, Canada, June 1979. 2. Copland, D.: l-ivingstone of the Arctic. Cana dian Century Publishers 1967. 3. Covill. F.J. and Martin, J.D.: Northern health care - developing trend. Community Health Confe rence, Government of the Northwest Territories, Yellowknife, N.W.T., Canada, October 23-25, 1979. 4. Schaefer, Otto: The changing health picture in the Canadian North. Journal of Ophthalmology 8: 196, 1973. 5. Schaefer, Otto: In Trowell, H.C. and Burkitt, D.P. (Eds.): Western Diseases, 1979. 6. Schaefer, Otto: Dietary habits and nutritional base of native p0pulation of the Northwest Terri tories, 1979