Imperfect offerings : For an ethics of solidarity

Andrew Bresnahan MD, MSc, MPH, FRCGS

October 2020

PPHS 511: McGill University, Dr. Madhu Pai Fundamentals of Global Health Learning Objectives:

•Orientation to Inuit Nunangat and Inuit democracy in Canada. •Explain the production of health (in)equity in Inuit Nunangat and Canada. •Apply an ethics lens to the practice of solidarity. “This is a traditional practice I want to follow, that Inuit elders from across Inuit Nunangat have stressed: speak about what you have experienced, and don’t speak about what you have not seen or experienced. That’s a really challenging thing to follow.” Natan Obed, President of Inuit Tapiriit Kanatami ᑭᓇ Who? First principles…

• ᑭᓱ What are the four tenets of medical ethics? • first… • ᖃᓄᖅ How might these principles apply to solidarity practice? Inuit homelands in Canada

• 33% landmass of Canada • 50% coastline of Canada • 65,000 Inuit in Canada • 53 communities • Inuit Land Claims Regions: Nunatsiavut Nunavik Nunavut Inuvialuit Qikiqtani region in Nunavut

• +17,000 Inuit • 13 communities • ~1,000,000 km2 • Qikiqtani Inuit Association is a Designated Inuit Organization under the Nunavut Agreement. ᖃᖓ Inuit + Qallunaat

Inuit futurism: What future do Inuit want to create? Social determinants of health

• conditions in which people are born, grow, live, work, play, and age

• shaped by distribution of money, power, and resources at global, national, and local scale

• determinants are highly connected SocialSocial + Economic and Economic inequity in Inuit Inequities Nunangat Inuit Nunangat All Canadians 39% of Inuit in Inuit Nunangat live in crowded homes1 4% of non-Indigenous people in Inuit Nunangat live in crowded homes1 29% of Inuit aged 25 to 64 in Inuit Nunangat have earned a high school diploma 1 85% of all Canadians aged 25 to 64 have earned a high school diploma1 70% of Inuit households in Nunavut do not have enough to eat2 8.3% of all households in Canada do not have enough to eat3 $17,778 the median individual income for Inuit in Inuit Nunangat4 $77,68392,011the median individual income for non- Indigenous people in Inuit Nunangat4 30 the number of physicians per 100,000 population in Nunavut5 119 the mean number of physicians per 100,000 population in Urban Health Authorities5 45.6% of Inuit in Inuit Nunangat are employed1 60.9% of all Canadians are employed1 70.8 the average life expectancy for residents of Inuit Nunangat*6 80.6 the average life expectancy for all Canadians6 “Social justice is a matter of life and death” (WHO 2008)

• Health inequities • “are health differences between population groups - defined in social, economic, demographic or geographic terms - that are unfair and avoidable” (NCCDH 2013; cf WHO 2005). • Structural violence • “is one way of describing social arrangements that put individuals and populations in harm’s way. The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people (Farmer et al 2006). • Solidarity • “implies a willingness to confront the causes and conditions of suffering that persist in destroying dignity, and to demand a minimum respect for human life. • Solidarity also means recognizing the dignity and autonomy of others, and asserting the right of others to make choices about their own destiny” (Orbinski 2011) • Pragmatic solidarity: “a commitment to struggle alongside the destitute sick and against the political and economic structures that cause and perpetuate poverty and ill health” (PIH 2006). Mapped onto colonial governance, even “good” ideas can cause harm.

Good ideas, articulated through colonialism, stop being good ideas. Case study: Hebron + and the Grenfell Mission

• Grenfell Mission (1892-1981) • Hebron (1831-1959) • Labrador Inuit community founded by Moravian missionaries. • Memo highlighting concerns about social determinants of health, mapped onto colonial governance, ultimately resulted in the forced relocation against Inuit wishes.

Disclosure: In 2013 I received a $1,000 International Grenfell Association Scholarship for work on TB surveillance in Labrador. Mapped onto colonial governance, even “good” ideas can cause harm. Good ideas, articulated through colonialism, stop being good ideas.

“Preventive medicine is, to us, quite as sacred a duty as the curative.” - Dr. Harry Paddon “I have personally found more inspiration in the cottages of fishermen than in the palaces of the rich.” - Sir Wilfred Grenfell “I want to heal these people, to help them help themselves. It is time enough to preach when their stomachs are full.” - Sir Wilfred Grenfell “the broad, social, medical, spiritual concept of the Mission was Grenfell’s idea of ‘the whole person.’” - Horace McNeil “When the government of this country is will and able to take over the maintenance of medical work, the Mission will have justified its existence by its elimination. - Sir Wilfred Grenfell “Considerable effort is under way at this time to improve their health. Considerable effort is under way at this time to improve their health, and large amounts of money will be spent on the treatment of disease. There is no evidence at this time that any plans are in preparation to prevent the conditions responsible for disease, or to help the Eskimo in his future adaptation to changing conditions in the north." “the people of Hebron lack fuel to keep themselves warm…the shocking result is overcrowding in order to keep warm. The people of Hebron in general are verminous, apt to be covered with sores and ulcers, and to harbour and spread tuberculosis…” - Dr. Tony Paddon 27 Feb 1955 Inuit democracy in Canada

Inuit Nunangat Inuit Region Regional Inuit Inuit Population, 2016* Communities Area Association (within region)

13 Inuit Tapiriit Kanatami Nunavut Qikiqtani Inuit 14,875 Arctic Bay, Kinngait, Clyde River, Grise Fiord, 2 Hall Beach, Igloolik, Iqaluit, Kimmirut, 989,879 km (NTI) Association (18,988) Pangnirtung, Pond Inlet, Qikiqtarjuaq, Resolute Bay, Sanikiluaq Inuit in Canada: 65,030 Inuit in Nunavut: 30,145

Inuit in Inuit Nunangat: 47,330 7 Kivalliq Inuit 9,370 Arviat, Baker Lake, Chesterfield Inlet, Coral 2 Harbour, Naujaat, Rankin Inlet, Whale Cove 444,621 km Inuit outside Inuit Nunangat: Association (10,413) 17,690 Kitikmeot Inuit 5 5,900 Cambridge Bay, Gjoa Haven, Kugaaruk, 2 Association Kugluktuk, Taloyoak 443,277 km (6,543) 5 Nunatsiavut 2,285 Nain, Hopedale, Postville, Makkovik, Rigolet 69,371 km2 14 Nunavik 11,800 Akulivik, Aupaluk, Inukjuak, Ivujivik, 2 Kangiqsualujjuaq, Kangiqsuajuaq, Kangirsuk, 443,685 km (Makivik) Kuujuaq, Kuujjuarapik, Puvirnituq, Quaqtaq, Salluit, Tasiujaq, Umiujaq

6 Inuvialuit Settlement 3,115 Aklavik, Inuvik, Paulatuk, Sachs Harbour, 2 Tuktoyaktuk, Ulukhaktok 435,000 km Region (IRC) *Statistics Canada , Census of Population 2016. Includes Inuit population living in Inuit Nunangat. Inuit-Crown Partnership ICPC Priorities

1. Inuit-Crown Land Claims 6. Education, Early Learning, and 2. Inuit Nunangat Policy Space Training 3. Housing in Inuit Nunangat 7. Health and Wellness 4. Revitalization, Maintenance 8. Environment and Climate and Promotion of Inuktut Change 5. Reconciliation Measures 9. Infrastructure Pandemic Response

“Indigenous self-determination, leadership and knowledge have been successful in protecting Indigenous communities in Canada during the COVID-19 pandemic, and these principles should be at the forefront when planning public health approaches with Indigenous Peoples” (Richardson & Crawford 2020)

What does Inuit-Crown partnership during the COVID-19 look like? • Coordination + information-sharing* • Flowing funding via Inuit orgs/governments. • Inter-agency coordination. • Inuit leadership in program delivery. Inuit solutions Options: Case studies for discussion

• COVID-19 Pandemic response • Suicide prevention • TB elimination • Housing for all • Decolonizing research • Oceans protection and Inuit health • Other Affirming life: suicide prevention every clinical story has a social story Eliminating TB in Inuit Nunangat by 2030

Agent: Mycobacterium tuberculosis Reservoir: humans Transmission: aerosolized droplets Portal of exit/entry: respiration of infectious particles Incubation period: 2-10w from infection to demonstrable lesion or +TST. <10% develop disease; ½ of those within 2y of initial infection. Communicability: number of bacilli aerosolized; duration of exposure; adequacy of ventilation; exposure of bacilli to UV light. Host susceptibility: immunodeficiency, undernutrition; DM, renal disease, HIV/AIDS, history of TB infection. Eliminating TB in Inuit Nunangat by 2030

Nunavut’s TB Elimination Action Plan • Commitment + investment • Reduce barriers to testing + treatment > > • Social care programs • Poverty reduction: housing, nutrition, training, employment • Community healing • Inuit-led TB research Housing for all Problems • Colonial governance + design. • Direct Investment Gap. • Outcome Gap.

Solutions • Inuit governance (e.g. INHS) + design (e.g. RAIC) • Close investment gap. • Close outcome gap. Decolonizing Research

Priority areas: 1. Advance Inuit governance in research 2. Enhance the ethical conduct of research 3. Align funding with Inuit research priorities 4. Ensure Inuit access, ownership, and control over data and information 5. Build capacity in Inuit Nunangat research Science Policy in Inuit Nunangat Moving towards Inuit self-determination in Research

"Despite being characterized as part of a progressive research agenda, the focus on Indigenous knowledge all too often maintains the status quo of limiting Inuit involvement in research to the role of passive research subjects. Inuit seek to permanently transform this colonial paradigm through the advancement of Inuit self-determination...this entails shifting away from research about Inuit, to investing in and supporting research partnerships with Inuit that reflect Inuit research priorities. This is the only means to ensure that Inuit Nunangat research is effective and can positively inform policies that impact our day-to-day lives.” Natan Obed, ITK President 17 November 2019 Inuit Health Survey

• Inuit governed • Inuit questions + answers • Inuit governance in research • For every 3 Inuit, there is one Inuit Nunangat-related publication. • Budget 2018: $82M/10y + 6M/y ongoing • Stable, predictable, multi-year funding + data Circumpolar health is global health First principles…

ᖃᓄᖅ how might we apply principles of non- maleficence, beneficence, justice, and autonomy to solidarity practice? ᐊᓕᐊᓇᐃᑦ Alianait!