Volume 2 | Issue 1 | Article 4 – Gabel, DeMaio, & Powell Towards healthier Indigenous health policies? Navigating the labyrinth for answers Volume 2 | Issue 1 and the efforts of the Canadian government to form collaborative arrangements between Article 4, June 2017 Indigenous communities, organisations and Chelsea A. Gabel government? What does an inclusive and McMaster University, Hamilton, Ontario, Canada comprehensive Indigenous community- controlled health care system look like? The Peter DeMaio purpose of this article is to explore how McMaster University, Hamilton, Ontario, Canada Indigenous people and community stakeholders in Canada understand terms such as self- Alicia Powell determination and health and draw conclusions McMaster University, Hamilton, Ontario, Canada about collaborative efforts between the government and Indigenous communities to Abstract support community-controlled health care. It further explores participant narratives and This research is based on two years of describes their experiences, particularly, the community-based participatory research that strengths and weaknesses of community- draws on Indigenous understandings of health government health policy developments. policy in five First Nations in Ontario, Canada. While a number of policies have been put in place Keywords: Indigenous people, North America, to increase Indigenous control over community health and wellbeing, health care administration, health services, we argue that policies enacted to health policy/policy analysis, social promote Indigenous self-determination in health equality/inequality, self-determination, care have been counterproductive and qualitative research. detrimental to Indigenous health and wellbeing. Instead, we suggest that Indigenous health policy Acknowledgements. We would like to thank exists on a continuum and aim to balance the the five Indigenous communities, government need for including diverse Indigenous groups and non-government organisations for their with comprehensive control from program invaluable contributions to the research. We have funding and design to implementation. This a tremendous amount of respect for all the poses some difficult questions: How do Indigenous and non-Indigenous people who Indigenous peoples perceive the concept of self- work across Canada with their devoted determination, community-controlled health care commitment to improving Indigenous health. 47 Published by Te Rau Matatini, 2017 Introduction the result of disparities among the social determinants of health (SDOH), or the social and Canada is one of the healthiest countries in the physical environments, structures and world, however it has one of the greatest institutions that affect the health of the disparities in the quality of health care across its Indigenous population in Canada (Reading & population. The 1.4 million Indigenous peoples Wien, 2010). The SDOH affected include accounting for 4% of Canada’s population are the socioeconomic status, housing conditions, fastest growing segment of the population.1 employment, education level, exposure to Indicators of economic, social, health and environmental hazards, access to healthcare wellbeing among Indigenous peoples living in services, and ultimately affect the health-related Canada compare unfavourably with the Canadian behaviours and attitudes of individuals and population overall (Adelson, 2005; Cooke, communities (Reading & Wien, 2010; Richmond Mitrou, Lawrence, Guimond, & Beavon, 2007; & Ross, 2009). These determinants of Indigenous Stephens, Porter, Nettleton, & Willis, 2006). health are interactive and are affected by unequal Indigenous peoples around the world continue to power relations stemming from a long history of bear a disproportionate burden of physical and colonialism, which affects dominant Canadian emotional illness (Bartlett, 2003). Historically, ideologies, policies and decision-making practices they were not only displaced physically from their (Adelson, 2005; Richmond & Ross, 2009). The land through colonisation but also made subject picture of health conditions that emerges to intensive missionary activity with the indicates that Indigenous peoples are increasingly establishment of the residential school system, living with chronic conditions as a result of the purpose of which was to assimilate inequalities in the SDOH, requiring access not Indigenous Peoples into mainstream Canadian only to primary but also to secondary and tertiary society. These assimilationist activities prevention interventions (Lavoie, O’Neil, undermined the social and cultural fabric that is Reading, & Allard, 2008). central to Indigenous identity, as they forbade families from sharing the cultural practices that Access to healthcare is an important determinant tied Indigenous Peoples to their traditional of Indigenous health, however, disparities in environments, including water, plants and access that are experienced by Indigenous people animals (Richmond & Ross, 2009). are in stark contrast to Canada’s portrayal of its health care system as one of the best in the world. Currently, Indigenous peoples in Canada Often the services that are provisioned to continue to experience the health effects related Indigenous communities, as well as those to colonial and post-colonial legacies (Adelson, mainstream services found off-reserve, do not 2005). These legacies undermined Indigenous offer traditional or culturally safe care and fail to people’s cultures, languages and social structures address the health inequalities specific to the and resulted in widespread marginalisation Indigenous population (Adelson, 2005). Further, (Anderson, Smylie, Anderson, Sinclair, & Indigenous clients continue to have negative Crengle, 2006). As a result, Indigenous peoples experiences within the health care system, such as face higher rates of injury and accidental death discrimination and stigmatisation, marking the than the non-Indigenous population and persistence of colonial attitudes and beliefs continue to report being at an increased risk of within this institution (Allan & Smylie, 2015; infectious disease. Further, cardiovascular Hole et al., 2015). These disparities are also due disease, cancer, metabolic disorders (diabetes) in part to the way in which healthcare services are and respiratory and digestive disorders, along funded and provisioned to Indigenous people by with other chronic diseases are significant various levels of government. problems in Indigenous illness and death (Richmond & Ross, 2009). These inequalities are 1 We prefer to replace the use of the word “Aboriginal” with the more uniting and less colonising term “Indigenous” to refer to First Nations, Inuit and Métis peoples of Canada. 48 Volume 2 | Issue 1 | Article 4 – Gabel, DeMaio, & Powell The relationship between the government of reserve community in northern Manitoba Canada and Indigenous peoples is unique in that (Lavallee, 2005). As a result of this dispute, it is characterised by a complicated legislative and Jordan was never given the chance to experience constitutional regime. This regime has resulted in home and community, succumbing to his illness an unequal and fractured manner of delivering in hospital while the federal and provincial services and the outcome has been that of governments argued over who would pay for his jurisdictional confusion and policy vacuums foster home care (Lavallee, 2005). It is not regarding many aspects of Indigenous people’s surprising to see that most provinces view First lives (Macintosh, 2006). In Canada, primary Nations health as an Indian issue and as such health care services for on-reserve First Nations within federal jurisdiction and an issue to be are under federal jurisdiction while primary addressed through federal funding and health care for other Canadians and all other programming (MacIntosh, 2006). The Indigenous peoples are under provincial participation of all three levels of government jurisdiction. This current national health care creates a highly complicated and uncoordinated system is a publicly-financed, publicly-delivered system (Lavoie et al., 2005) characterised by gaps system, managed by the provinces under the in service and overlapping coverage. It also umbrella of the 1984 Canada Health Act. On- results in program duplication and reserve services for First Nations in the form of inconsistencies (Minore & Katt 2007). health centers now complement this system, but they remain separately funded by the federal For decades, Indigenous peoples in Canada have government. Physicians who are paid by the sought greater self-determination, for example; provinces visit the health centers, however, control over local health services (Belanger & Indigenous patients who are in need of secondary Newhouse, 2008). Three notable changes have or tertiary care in between health center visits are occurred in the landscape of Indigenous health transported to the nearest provincial referral policy and politics in Canada in the last forty center. This moves Indigenous patients out of years, increasing Indigenous control over their communities, often at great financial and community health services. These shifts hold emotional cost, and disrupts their continuum of more promise for Indigenous communities care. Indigenous people living on-reserve may seeking self-determination, as they move away also choose to seek health care through the from top-down approaches to policy that provincial system because access to services may perpetuate colonial control.