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Proceedings of the Subcommittee on Population Health

Issue 5 - Evidence


OTTAWA, Friday, June 1, 2007

The Subcommittee on Population Health of the Standing Senate Committee on Social Affairs, Science and Technology met this day at 9 a.m. to examine and report upon the impact of the multiple factors and conditions that contribute to the health of Canada's population — known collectively as the social determinants of health.

Senator Wilbert J. Keon (Chairman) in the chair.

[English]

The Chairman: I would begin by thanking you all very much for coming here and participating in this round table discussion. Our objective, when we undertook the population health study, was to get an overall improvement in the health status of Canadian people. As you know, the World Health Organization rates us thirteenth in the world at this time in health status, and I feel we should be first. In a huge country such as this with a small population and everything going for us, we should be first. The only way we will get there is by looking at the health status of everyone in the country, analyzing the health status of those groups in the country that are not enjoying as good a health status as some other groups, and then coming in at the ground level and putting tools in the hands of the people in their own communities to improve their health status.

As you know, we can only improve health status by fixing a dozen or so variables and those variables include adequate income, jobs, housing — the whole nine yards that you have heard over and over. This, we believe, can only be accomplished at the community level with assistance from government to put the instruments in the hands of people in the community to solve their own problems.

With that in mind, it is important that we hear from all of you. Even though it will take a few minutes, I want to start at my left and go around the table and have each one of you take a minute to tell the other people around the table about yourself, because some of you may not be known to others.

Dr. Malcolm King, Professor, Department of Medicine, University of Alberta: I am Malcolm King from the University of Alberta. I am a member of the Mississaugas of the New Credit First Nation and a professor who specializes in pulmonary research at the university.

Senator Cook: I am Senator Joan Cook, and I represent the Island of Newfoundland and the piece called Labrador.

Barbara Van Haute, Acting Director of Health, Métis National Council: I am Barbara Van Haute, and I am currently the acting director of Health for the Métis National Council. I am originally a Manitoba Metis, and it is a pleasure to be here.

Anna Fowler, Project Coordinator, Department of Health, Inuit Tapiriit Kanatami: I am Anna Fowler, an Inuk from Iqaluit, Nunavut. I am a project coordinator in the Health Department at Inuit Tapiriit Kanatami.

Valerie Gideon, Director of Health and Social Development, Assembly of First Nations: I am Valerie Gideon, the senior director of Health and Social Development at the Assembly of First Nations. I am Mi'kmaq from Gesgapegiag First Nation in the Quebec region.

Dr. Evan Adams, Aboriginal Health Physician Advisor, Office of the Provincial Health Officer, B.C. Ministry of Health: I am Evan Adams, and I am a family doctor with the Ministry of Health, the Office of the Provincial Health Officer. I am from the Sliammon First Nation, Coast Salish.

Dr. Chandrakant P. Shah, Professor Emeritus, University of Toronto: I am Chandrakant Shah. I am a professor emeritus at the University of Toronto in the Department of Public Health Sciences. I also work as a staff physician at Anishnawbe Health Toronto, which is an urban health centre.

Dr. Judy Bartlett, Director of Health and Wellness Department, Manitoba Métis Federation and Associate Professor, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba: I am Judy Bartlett, a family physician and an associate professor at the University of Manitoba in Community Health Sciences. I am the director of the Health and Wellness Department at the Manitoba Métis Federation, where I am building a policy research unit. I do clinical work at the Aboriginal Health and Wellness Centre in Winnipeg one day a week, and I am Metis.

Julie Lys, Director, NWT Region, Aboriginal Nurses Association of Canada: I am Julie Lys, a Metis nurse from Fort Smith, Northwest Territories. I am a nurse practitioner there, and today I represent the Aboriginal Nurses Association of Canada.

Erin Wolski, Health Policy Program Coordinator, Congress of Aboriginal Peoples: I am Erin Wolski. I am from the Cree Nation, Treaty No. 9 in Ontario. I am here on behalf of the Congress of Aboriginal Peoples. I am the health policy program coordinator there.

Alfred J. Gay, Policy Analyst, National Association of Friendship Centres: I am Alfred Gay, and I am the policy analyst for the National Association of Friendship Centres. I am also a citizen of the Gull Bay First Nation, which is located 200 miles into the swamp from Thunder Bay, Ontario.

Jennifer Dickson, Executive Director, Pauktuutit Inuit Women of Canada: I am Jennifer Dickson. I am the executive director of Pauktuutit Inuit Women of Canada, which represents all Inuit women across the North.

Willie Ermine, Professor, Writer-Ethicist, Indigenous Peoples' Health Research Centre: I am Willie Ermine, and I am a researcher with the Indigenous Peoples' Health Research Centre. I am a Cree from Saskatchewan.

Claudette Dumont-Smith, Senior Health Advisor, Native Women's Association of Canada: I am Claudette Dumont-Smith. I am an Algonquin from Kitigan Zibi. I am a nurse by profession and the senior health advisor of the Native Women's Association of Canada.

Senator Cochrane: I am Senator Ethel Cochrane, and I am from the province of Newfoundland and Labrador.

Audette Madore, Library of Parliament: I am Audette Madore. I am the analyst with the subcommittee.

Barbara Reynolds, Committee Clerk: I am Barbara Reynolds. I am the committee clerk.

The Chairman: We will begin this morning with Dr. Malcolm King, professor in the Department of Medicine, University of Alberta.

Dr. King: Thank you for the privilege of making these opening remarks. It is a great honour. As I said, I am an Aboriginal person. I was born in Ohsweken on the Six Nations Reserve in Ontario and grew up on the Mississaugas of the New Credit, which is adjacent. My father was born and raised on the reserve as well and lived his whole life there. My mother came from Switzerland, so I had the benefit of two cultures growing up. Most of my career has been spent in the field of biomedical research, but, gradually over the last 15 years or so, my attention has turned increasingly toward Aboriginal health research.

You have some handouts in your package, and the first of them is a diagram of the determinants of health. I will not spend much time on this because you have heard many presentations. In my experience, Aboriginal people in Canada are at least as aware of these determinants of health as the general public. However, I want to give three brief examples that illustrate these non-biomedical factors. I will focus on only one of them, which is income.

Just two weeks ago, I attended the annual international research meeting in my specialty. It was the American Thoracic Society that deals with lung diseases. As at many meetings of its kind, about 90 per cent of the presentations were devoted to the biological, pharmacological and genetic factors that relate to respiratory health, and no doubt at least 90 per cent of the research funding that led to these presentations was related to these same medical determinants of health.

However, there were some interesting presentations that dealt with the other determinants, factors such as race, culture, housing and social conditions. The one that particularly struck me is illustrated on a slide here. It was presented by a young man from Columbia University in New York. His study showed that if people lived in a poor neighbourhood in New York, their chances of dying from his disease of interest, which is pulmonary arterial hypertension, were four times greater than if they came from one of New York's more affluent neighbourhoods. That is an outstanding difference — four times the risk of death related to income.

The presenter was not able to tell me what led people living in a poor neighbourhood to have that extra risk. They defined the poverty factor as the percentage of people in that neighbourhood living below the poverty line, so it was not exactly income, and I doubt that it is as simple as income. Can you imagine what a boon it would be to have a drug or medical intervention that could turn a 30 per cent death rate into a 7 per cent death rate? It would make billions for drug companies, too. Drug companies normally deal in lowering risk by a few percentage points.

I am showing you this data from New York in part because it tells us something important and also because there is not so much data from Canada, which is part of the point I want to make. The data does not say anything about Canadian Aboriginal health. It probably says something about the health of African Americans, but that was not explicit. On the other hand, it speaks volumes about the potential health gain to be realized if we can only learn how to deal with the social determinants of health.

My next slide tells the same story, but from the city of Edmonton, where I presently live. It is again in the field of cardiovascular disease. The graph shows the chances of dying in the first year after a heart attack in Edmonton. There was a very clear gradient with income. The lower quartile of income had more than a 30 per cent chance of dying in the first year after a heart attack while the upper quartile had a 15 per cent chance of dying. That is double the chance of dying in the first year after a heart attack if a person is in the lower quartile of income, which is pretty scary.

This study was led by Dr. Paul Armstrong, a distinguished scientist in this field. It held out some hope, because the heart attack patients who survived the initial attack and who received the right treatment, which was revascularization, had a significantly reduced risk of dying in that first critical year. The risk went down to about 5 per cent. The marvellous thing is that the income disparity totally disappeared. There was the same risk of dying in the poor quartile — 5 per cent — as there was in the upper quartile.

It is not easy to understand how one would get there. It is not as simple as fixing income or social circumstances and not a simple case of access to health care because this is in the Canadian system. We might have understood it in other countries. There were many other factors built into that income disparity. Again, the study did not say anything specifically about Aboriginal health, but now it is more tantalizing. Those who know Edmonton will be thinking that there are more than likely Aboriginal people living in those poor neighbourhoods where the risk was higher, but we do not know that, which is part of another point I would like to make.

We need better data. We need to be able to find data about urban Aboriginal people, about Metis people and so on. Most of the data we have applies to First Nations living on-reserve.

The third study actually deals with Aboriginal people. It is a very well done study that comes from McMaster University and the Six Nations reserve, where I was born. This study was a collaboration between McMaster University and the people of Six Nations and was published in The Lancet, a very prestigious journal. The senior author was Dr. Salim Yusuf, another distinguished cardiologist.

The researchers interviewed people who were Six Nations band members as well as European Canadians living in the Brantford area. They were the control group. They asked people their income — which is perhaps a bold thing to do, but it was important for this study — and they also asked for blood samples to analyze for cardiovascular risk factors, such as cholesterol.

We have the cardiovascular disease risk as a function of family income. The black bars on the graph represent the European Canadians, the control group, and at each increase in income level cardiovascular disease risk goes down. It is a beautiful demonstration of the predictive effect of income on disease, in this case cardiovascular disease such as heart attacks and strokes.

There was this same kind of income gradation in the European Canadians and the First Nations people of Six Nations, but the First Nations data are all elevated at any given income as compared to the European Canadians. There is an extra risk associated with being First Nations.

What is this risk? The study was not able to address this and, again, it is undoubtedly complex. It could be a combination of many of those factors on the social determinants diagram. It could be factors that are not even on the diagram, which is something we need to talk about it. More important is that neither this study nor the other two addressed how we can use the knowledge we have gained from collecting this data to reduce the risk, which is the key question. This research and the other two are excellent starts, and the one from Six Nations is the best example of which I am aware. However, they require follow-up to understand the complexity of the observations and, more critically, to design, test and carry out intervention that could eliminate the disparities. In my opinion, it is not just a matter of remedying the income disparity, even if we could do that.

I will move to the stages of research. This comes from my personal perspective as an Aboriginal researcher. Most of our attention as a research community has been devoted to highlighting the problems, and I have shown you some examples of that. That is only the first step in research. The second step, which we have dealt with to a lesser extent, is understanding the problems. The problems, especially when it comes to social determinants, are always complex, and it is difficult to understand the interaction between them, but we really need to do that.

Finally, we need to move on to the third stage of research, which is the one that will actually produce gains in health, and use our knowledge to address these issues.

This is how it works in the biomedical field, and this is how it can work in the social determinants field as well. In a way, I do not see it as anything different. One can design experiments, conduct trials and analyze them, whether one is talking about a biomedical determinant or a social determinant. However, this third step can only be accomplished through working together with the people directly involved, namely, the First Nations, Metis and Inuit peoples of Canada. This is a continuous process, and we cannot forget the fourth step, which is the passing on of this knowledge to others who would use it. That is where we have perhaps the most to gain, by involving Aboriginal communities in this process.

The Chairman: Thank you, Dr. King. You were in the same audience as I was within the last couple of weeks when we heard that we have to start to move even further down the line in population groups and get to ethnicity and so forth to solve some of the problems. It is interesting the way the universe is unfolding.

Our next speaker is Valerie Gideon, Director of Health and Social Development, Assembly of First Nations.

Ms. Gideon: Thank you for the opportunity to be here. I would also like to express my appreciation for this opportunity on behalf of National Chief Phil Fontaine and members of the Assembly of First Nations executive.

I have tabled with you a PowerPoint presentation. Members of the Senate have received a lengthy document, which I will not be summarizing in five minutes. There are extra copies for people at the back. This is the submission that the Assembly of First Nations has made to the World Health Organization Commission on Social Determinants of Health. It was co-authored by Dr. Jeffrey Reading, who I believe has testified before the committee, Dr. Andrew Kmetic from the University of Victoria, and me.

I will spend the five minutes I have in segueing nicely from Dr. King's presentation, and particularly his last comments about how to use knowledge to address these issues with respect to social determinants of health among Aboriginal peoples, and specifically First Nations.

From the perspective of the Assembly of First Nations, you can imagine that it is challenging to work and advocate with federal departments for recognition of the importance of taking on a population health approach to policy development as well as program and service implementation, as it is a challenge for the entire Canadian health care system.

We have attempted to develop a public policy development approach within a holistic policy and planning model, which we feel is concrete and practical enough that it can hopefully influence future public policy development. That is what I will present here.

As First Nations governments and communities, we face unique public policy challenges. We have a dynamic and complex environment. It is challenging for us to get long-term sustainable and comprehensive policy, and program commitments from federal agencies as well as provincial and territorial agencies. While we have found that expertise has conveyed effectively the importance of public engagement in the development of public policy, we do not feel that those approaches necessarily reflect the unique First Nations interests, rights and considerations that we have put forward. We do not consider ourselves stakeholders in public policy development; we consider ourselves to be governments positioned in the nation-to-nation relationship with the Crown that originated with treaties and that is recognized in the Canadian Constitution.

We feel that a more comprehensive policy response is required that would be grounded in three main components: understanding the historical foundation in our relationship; flexibility, which would account for the diversity of First Nations peoples in this country of geographic locations, cultural and traditional characteristics, and languages; and innovation.

One of the most challenging areas is how to promote outside-the-box thinking and recognition of the importance of social determinants of health, which is grounded in evidence, and how to translate that into local and regional policies and programs.

I do not have the time to fully explain the historical foundation and relationship. There is a slide that attempts to capture some of the key principles. Certainly, as you are aware, treaties have set the fundamental principles of our relationship. There is also the important recognition of the distinction of First Nations peoples in section 35 of the Constitution Act, which establishes our inherent jurisdiction in self-government as well as in areas such as health, education, housing and so forth. We have had many challenges with recognition of this historical foundation at the federal level, as well as at the provincial, territorial and other levels, but we continue to advocate for that as the fundamental and core element of any type of joint or collaborative initiatives.

We have also tried to translate the importance of this recognition in a five-stage public policy development process, which you see outlined in the presentation. The first stage is obtaining a mandate from First Nations leadership for public policy development. The second stage is having an open national dialogue, by which we mean not necessarily one national forum but the opportunity nationally for First Nations to engage, which could be regionally or at the community level.

The third stage is acquiring independent expertise, which would include independent research findings that we can bring to the table to solidify our ideas and proposals. The fourth stage is to obtain a clear mandate for change from the federal government side. We have engaged in many joint tables over the years. Some of them have not been as successful in getting political momentum and commitment. As a result of that, reports are sometimes shelved for decades, and unfortunately there are no concrete outcomes from those. Certainly, we do not want to repeat that type of process. The fifth and most fundamentally important stage is a joint process that is grounded in that nation-to-nation relationship.

I will briefly describe the holistic policy and planning model that we developed and a bit of the context for that. We developed this model during the negotiation of the 2005 Kelowna Accord. We first presented it to the Council of the Federation in July 2005. The main driver for this model was our struggle with ensuring that the agenda items for the First Ministers Meeting on Aboriginal Issues would recognize health determinants, as that was how the meeting had initially been positioned in 2004. We started with a discussion that was focused on relationships, housing, education and health. We and our governments felt that economic development was extremely important. By presenting this model and taking the premiers through it — and eventually the federal side — we were trying to convey the importance of what Dr. King's examples in research demonstrate, which have been accepted certainly by the international community.

The model itself is specific to First Nations. It is based on a social determinants model. However, it also incorporates First Nations' traditional knowledge and approaches, which are diverse. The model tries to balance some of the concrete community levels of activity, traditional knowledge approaches, and the recognition and reconciliation principles of our relationship with the Crown. It also tries to ground some concrete areas where we feel changes need to occur in order to improve the overall health and well-being of our population.

For example, the policy of self-government requires significant reform. We also need to address the fiscal discrimination to which our communities are currently subject through caps on federal program budgets.

The presentation brings forth some examples of evidence that has confirmed that self-determination and self-government aligned with greater institutional and community capacity for First Nations governments really will enhance health status and well-being within First Nations communities. I do not have the time to go through the very important and fairly well-known research and federal government initiatives and reports, but they are outlined here on the slide for your perusal.

The model itself is self-explanatory. First Nations communities are at its core. It takes us through all the dimensions of the lifespan. It positions all key elements of self-government, from the jurisdictional aspects to fiscal relations to a rights-based agenda, and finally to the capacity to undertake those joint negotiations. It also takes us through the key social determinants of health that have been well recognized in evidence whether specific to First Nations peoples or not, and then takes us through the elements of social capital with which you may be familiar. These are studies from the University of Manitoba, from which Dr. Bartlett is here as a faculty member. It tries to demonstrate and capture in a succinct way the impacts of relationships among First Nations communities, within the communities themselves and with external agencies such as the federal government; and how those relationships actually do impact on the ground the ability for First Nations community members to become healthy and empowered, and to address income, education and other factors.

The presentation takes us through a case in point to what I have been trying to express as clearly as possible; that if we adopt the lens of social determinants of health to something such as First Nations children's health, we can see the gap even more dramatically between First Nations and non-First Nations health and well-being. It takes us through key elements of our data. We have a national First Nations health survey, which is known as the regional longitudinal health survey. We have reports available on that. It effectively demonstrate a direct correlation between First Nations family income or other indicators of poverty, overcrowding, poor nutrition or lack of food security, lower levels of physical activity and educational achievement among First Nations children.

I do not have time to take you through all the specifics. They are fairly self-explanatory. When we go to a federal government meeting, for example, we try to show that, if do you this, this is the policy lesson that you should learn from it. It is trying to convey in a practical perspective how federal officials can be influenced to think about policy development and program implementation.

In conclusion, the data does shows that unless we can change some fundamental determinants of, for example, our First Nations children's health and well-being, we will never be able to break the cycle of poverty and poor health that exists in our communities. Very simply put, we know if we raise income and education levels in our communities and reduce overcrowding today, we will improve employment, education and our First Nations population health for future generations. It is a simple statement, but it is a complex process to arrive at that.

Finally, we have proposed a three-stage process for an agenda for change to implement a population health approach among First Nations policy, program and services development. The first stage is grounded in joint processes. Again, going back to the historical foundation of the relationship, there is respect for the government-to-government approach. The second stage is recognition of the holistic policy considerations that I have outlined, both the underlying theoretical and also the policy premise. The final stage is to build future directions on solid information and capacity — for example, the national health survey we have been able to develop. That is fundamental for federal and First Nations accountability processes as well as monitoring our progress and success.

The Chairman: Thank you very much, Ms. Gideon. That is encouraging information. I have been observing this scene from afar now for 15 years. It is interesting the way the universe is unfolding. It is interesting to see the evolution of thinking, the convergence of thinking and the formation of a system that can really work. This was a great summary of it.

Marc LeClair is not with us yet; he will be here later. Barbara Van Haute will speak to us. She is from the Métis National Council.

Ms. Van Haute: It is a pleasure to be here. I have to thank the Senate Subcommittee on Population Health for the invitation to the Métis National Council to present today.

Just to make sure we are all on the same page, the Métis National Council, MNC, represents the Metis people of the historic Metis homeland, which is defined as those Metis who resided in Northern Ontario, the three Prairie provinces and Northern British Columbia. That distinction needs to be made upfront.

For the last two years, MNC has been trying to get a handle on the factors and conditions that contribute to the health of the Metis people. We have undertaken extensive research in this area, and we have developed some visible outcomes. You will all be able to see them shortly when we get our Métis National Council health and well-being portal up and running on the website. You will be amazed at the information we have gathered. You will also be amazed to know how much more information we need to gather, which takes much organization, capacity building and funds.

Today, I would like to share with you some of the barriers that have impeded the development of our population and eroded the health status of the Metis population. As I mentioned in our portal, we have been able to find thus far that our health status is well below that of non-Aboriginal populations in Canada in many regards. It is also below other streams of the Aboriginal population. Our population is growing, it continues to, and our population is aging. It is an issue that will not go away. We must continue to collect that data and attempt to understand what all the influences are to that.

The greatest impediment to our development began — there is a historical emphasis to this — with various levels of government not really wanting to deal with the Metis issue, and this goes back to scrip policy of the 19th century and land claim failures in the 20th century. Those policies and the failure of recognition on behalf of various levels of government have left the Metis people in a situation where our identity has been eroded, and it has undermined our self-confidence in our own capabilities. As a result, it has left the majority of us unable to take advantage of economic opportunities that emerged as Canada developed, and continue to emerge.

As a result of that, the Métis National Council welcomed the recent Aboriginal Committee's report on Aboriginal economic development. That is without a doubt a key factor from what our own statistics tell us and from what Dr. King and Ms. Gideon have said. Everyone seems to concur: Economic security is an important factor in health determinants. This has led to poor health conditions and, if they are not dealt with now, there will be a tremendous cost to not only the Metis people and culture but also to the Canadian government and Canadian people — a huge cost.

We want to do whatever we can to work with various levels of government to ensure that no one has to pay that cost, most certainly the Metis people, but also the people of Canada.

For this to happen, the Métis National Council has come up with a five-part system of actions that needs to take place to help us work with various levels of government to ensure that we deal with the improvement of the health status of the Metis people overall. The first part is an acknowledgement that all levels of government — namely, federal, provincial, territorial and Metis — share responsibility to address the health needs of the Metis people, and that is an overall mindset change. The Metis health status is the responsibility of everyone — the Metis themselves, Metis governments as well as federal, provincial and territorial governments.

Second, Metis governments and institutions should be supported to ensure that Metis play an effective role in the design — both at the federal and provincial level — delivery and implementation of health policy. We are not talking about developing a separate system but rather enhancing the current system.

The third part is a commitment to sustainable funding over a period of years. We are pleased to say that Health Canada has opened its doors to us. We have longer-term funding than we have ever had before from any government department at the federal or provincial levels, and we are pleased about that. Nonetheless, the funding only extends to 2010. At this point in time, we have no indication that it will go beyond that.

We are beginning to work with the Public Health Agency of Canada as well as Statistics Canada to ensure that funding continues in other areas, so we can develop a better understanding and better statistics about Metis health status and the factors influencing our health. It is no mean feat because we lack the capacity. We are not sure of funds continuing so we can have people on the ground who can work with federal and provincial government departments to help develop this capability.

The fourth part is we need to look at this in terms of outcome. What can we give back to federal and provincial governments as we develop this understanding of the Metis health status and the factors that influence the health condition? One example is information sharing, so that when we come to the table for policy development, we are informed, know what we are talking about and have specific action plans in mind.

The fifth part is to generally increase our knowledge, referring back to what I mentioned earlier about working with various provincial and federal government departments to develop a better understanding of where we are, why we are here, and how we can improve it. That is limited to or includes continued or increasing support for research and information-sharing projects.

That might seem theoretical, but it all relates to two basic components: first, recognition of the Metis people by federal and provincial governments; and, second, increasing support and acceptance of responsibility, that all of us are responsible for the health of our people, the people of Canada, which includes the Metis people of Canada.

Ms. Fowler: Thank you for the opportunity to present here today. We have included a paper by the Inuit Tapiriit Kanatami with respect to the work being done through the World Health Organization Commission on Social Determinants of Health. We just added today the Inuit action plan document. The Inuit of Canada and the Her Majesty the Queen in Right of Canada signed a partnership accord on May 31, 2005. The Inuit of Canada are represented in the partnership accord by Inuit Tapiriit Kanatami, ITK, and the Queen is represented by the Minister of Indian Affairs and Northern Development.

This initial action plan will identify activities and initiatives to be conducted over a three-year period with revisions as needed, and subsequent action plans will be reviewed and priorities negotiated about every three to five years.

As I have indicated, I am a project coordinator in the health department at ITK. We Inuit are a young and growing population of roughly 53,000 living in 35 remote, isolated communities spread across approximately one third of Canada's land mass. ITK's primary role is to secure a more equitable place for Inuit within Canada. We are the national voice of Inuit in Canada and address issues of vital importance to the preservation of Inuit identity, culture and way of life.

One of the most important responsibilities of ITK is to promote Inuit rights and ensure that we are properly informed about issues and events that affect their lives. That process is purporting to ensure that Inuit interests are properly informed by Inuit knowledge perspectives and vision.

There are many key public policy changes facing Inuit communities as they struggle to achieve improved standards of living, family and individual well-being. I would like to highlight the necessity of all of us making commitments to improve the health status of Inuit by developing and delivering concrete policies and programs that respond to the needs. That is crucial to ensure there are improvements in closing the gap.

Inuit do not separate mental and physical health; rather, we speak of total well-being. Inuit support a holistic population health approach. Total well-being cannot be improved by health services alone. Improvements to economic opportunities, housing, education, language and culture, environment, justice and infrastructure, and relationships with many stakeholders are needed as well. Programs based on unique circumstances, culture and the needs of Inuit regions and communities will improve health status. Inuit are experiencing fundamental changes to their way of life and well-being.

It is well known that, as with other Aboriginal groups in Canada, there are vast health inequalities between Inuit and the rest of the Canadian population. For example, the gap in life expectancy between Inuit and other Canadians is vast, a difference of about 15 years. While the Canadian population is aging with people living longer, it is not the case for Inuit. It is likely that Inuit life expectancy has decreased in recent years. There is a need for sound, accurate statistics to inform evidence-based decision making. Information that many Canadians take for granted is not available for Inuit. For example, the infant mortality rate is one of the most basic measures of health impacted by socio-economic conditions, public health practices, access to and quality of health care, et cetera. However, there is no Inuit-specific information available from vital statistics. We have no infant mortality rate for the Inuit in Canada. The figures that exist are often for one region or for all residents of Inuit communities and exclude Inuit in the southern parts of Canada. Survey information is often for all Aboriginal people or for First Nations. Some people use these figures to incorrectly describe the landscape for Inuit.

Acculturation has occurred rapidly for Canadian Inuit from a traditional way of life to a modern and industrialized one. The movement from traditional forms of subsistence to a dependence on a wage economy has radically disrupted Inuit social and environmental relationships and is recognized as contributing to social marginalization, stress and higher incidences of suicide. In spite of the socio-cultural upheaval the Inuit have experienced, one indicator of cultural well-being remains strong: use of the Inuit language. Today, Inuktitut remains one of the most resilient Aboriginal languages in the country. The federal government is being urged to play a role in protecting and enhancing Inuktitut by making it an official language of Canada.

Productivity was identified as an important Inuit-specific social determinant of health and is a more accurate term for Canadian Inuit as opposed to employment, since many Inuit men and women still work informally by harvesting country food, producing goods for their families and providing voluntary services in their communities. Although these services are not usually considered employment, they should be considered when addressing the social determinants of Inuit health and in the development of new policy.

Concrete steps are being taken to increase employment prospects in Inuit communities through the use of impact and benefit agreements, IBAs, between developers in Inuit communities before any major development projects go forward in Inuit land claims areas. IBAs are considered an essential measure for Inuit to achieve self-determination, diversify their local economies, earn revenue and gain training and employment opportunities. Another program that has had some success in addressing Inuit employment issues is the Aboriginal Human Resource Development Strategy.

Support is needed at the community level for access to appropriate school curriculum and educational opportunities, vocational training, career counselling and other employment programs. Furthermore, to establish long-term sustainable employment opportunities in communities, growth and diversification of the private sector is vital. Harvesting activities and survival skills are being supported by regions through harvester support programs. More funding and new programs are needed to ensure that this teaching is provided to Inuit youth.

Another key social determinant of Inuit health is the social safety net. This term refers to the availability and quality of family, community and societal supports. Communities are working to find ways to strengthen social supports to deal with the social ills that have recently arisen. As with health services, social services should actively engage youth and families in the development of their programs, integrating Inuit-specific knowledge and traditions, and increase awareness among community members about available services.

Overall financial assistance from the government is insufficient because it is not adjusted to the high cost of living in the Arctic. Ultimately, the federal government must tailor its assistance programs to the unique needs of Inuit living in the arctic.

Our total well-being continues to be affected by past and ongoing societal transition. We ask the committee to consider the impacts of these factors on Inuit well-being and recognize that, to improve health, we need to implement strategies both within and outside of the health system.

Policies and programs that work best for Inuit are initiated, designed, delivered and administered by Inuit. Inuit knowledge and culture is central to our health and well-being. A population health approach is consistent with the Inuit-specific approach advocated by all Inuit organizations. We need to promote life and well-being and build strong communities. For example, holistic suicide prevention strategies must include employment and transitional programs, programs for trades and high school equivalency, housing for young adults and more. New and existing early childhood programs strengthen a child's foundation for total well-being. Positive media campaigns directed by youth could encourage discussion and reduce stigma. Regional crisis lines and youth and elder centres in each community can provide access to support personnel.

In summary, Inuit will make their own decision about maintaining and improving our total well-being, but we need individuals like you who are listening and making recommendations to help us. We hope you have heard today that Inuit know what is needed, are committed to addressing the issues of health and well-being and need resources and partnerships that will implement positive changes to the system.

To protect Inuit lifestyle, we need to work together and with governments and organizations to plan effectively for the long term. No longer can we accept jurisdictional barriers as an excuse. The Inuit way forward is through the lens of a population health approach where the focus is on improving the health status of an entire population.

As I said at the beginning of this presentation, we have included the Inuit action plan document, which really outlines the social determinants approach and necessary actions to achieve Inuit well-being.

The Chairman: Thank you very much, Ms. Fowler. You made an interesting statement at the end. For a number of years, I have been trying to think of how to express that thought; in other words, looking at health through the lens of population health. It would be very interesting for the front of our report if someone could come up with a catching concept of this, because it revolutionizes our traditional thinking about health. Maybe someone around the table will be able to do that.

Our next presenter is Ms. Claudette Dumont-Smith, Senior Health Advisor, Native Women's Association of Canada.

Ms. Dumont-Smith: Good morning. Thank you for inviting us to speak to this group today.

I would like to begin by introducing the Native Women's Association of Canada, NWAC. We have been in existence since 1974. We are a not-for-profit organization that represents all Aboriginal women in Canada, including First Nations, status, non-status, living on- and off-reserve, as well as Metis women. Our purpose is to improve, promote and foster the health, social, economic, cultural and political well-being of Aboriginal women within both Aboriginal and Canadian societies. We are made up of a collective of 13 provincial-territorial member associations, and we are governed by a 22-member board of directors.

Our objectives are to be the national voice for Aboriginal women; to address issues in a manner that reflects the changing needs of Aboriginal women in Canada; to assist and promote common goals toward self-determination and self-sufficiency for Aboriginal women in our roles as mothers, grandmothers and leaders; to promote equal opportunities for Aboriginal women in programs and activities; to serve as a resource among our constituency and Aboriginal communities; to cultivate and teach the characteristics that are unique aspects of our cultural and historical traditions; to assist other Aboriginal women's organizations, as well as community initiatives in the development of their local projects; and to advance concerns particular to Aboriginal women.

Looking at the health of Aboriginal women from a health determinants perspective, most Aboriginal peoples believe that to be healthy, one has to live in balance with nature — external factors — and with oneself. The self, according to Aboriginal peoples, includes spiritual, mental, emotional and physical spheres. Being unhealthy signifies an imbalance in either the self and/or with nature. This concept of health is well-aligned to the population health approach, which recognizes that the health status of a population is also influenced by both internal and external factors. These factors have been identified as determinants of health.

The application of a population health approach is a broad approach in that it acknowledges that the health of a population is influenced by one and/or the complex interactions of several health determinants.

To change the status quo, that is, if the health status of Aboriginal women, who are a specific population, is to improve multiple interventions must be implemented simultaneously. For example, if the high rate of diabetes in the Aboriginal female population continues to be addressed solely from a medical perspective without acknowledging or attempting to fix those issues related to the onset of diabetes, such as income and social status, culturally-appropriate health promotion and prevention activities, availability of health services, and the list goes on, then there is little hope of changing the status quo.

However, if a multi-interventionist or population health approach is implemented, then the chances of success in lowering the rates of diabetes among the Aboriginal female population will undoubtedly increase as well. Recognizing the fact that health determinants affect health, it should not be surprising that the health status of Aboriginal women in Canada is as poor as it currently is. In nearly all of the health determining factors, Aboriginal women are sorely lacking in most areas in comparison to the rest of the Canadian population.

The reality for the majority of Aboriginal women is based on the following health determining factors. The income and social status of Aboriginal women is poor. With respect to social support networks, many Aboriginal women are victims of the colonization process and residential schools and consequently they have none or fewer traditional social support networks available to them. On the whole, they are less educated. As to employment working conditions, they have high unemployment rates and are part of the working poor. They have been forced to leave their social milieu and are living in unstable, male-dominated social environments. They live in deplorable physical conditions in situations where the water and sewage systems are contaminated and the dwellings are overcrowded. They live in non-supportive social environments where health practices and good coping skills are not promoted and encouraged. With respect to healthy child development, they lack in adequate prenatal care and all that it entails. Biology and genetic endowment is being affected because they are obligated to purchase and consume non-traditional foods. They are missing essential health services, especially in the more remote and Northern communities. There is a need to implement a culturally-based, gender-based process in all policies and programs; there are hardly any in existence today. The women are short of culturally-relevant and appropriate health care policies, programs and services. Many of them live out in rural or remote villages and communities where they do not have accesses to services or programs. We regard violence as another health determinant, and the rates of sexual, racial, systemic and domestic violence are very high in our population.

If the health determinants and good health were measured on a continuum with better health being quantified at one end, then the conditions of Aboriginal women would surely register at the opposite end of the scale.

NWAC is in full support of the implementation of a population health approach as a sound and logical move toward improving the health of Aboriginal women. Silo-type approaches have proven ineffective. Although the implementation of a population health approach might appear to be more complex and costly in the short term, the outcomes in both the short and long term will be beneficial toward improving the health of women and will also result in being less of an ever-increasing burden on taxpayers' dollars. With the high levels of chronic health conditions, the cost of providing health care rises dramatically.

In conclusion, the poor health status of Aboriginal women, which lags well behind that of the rest of the Canadian female population, is linked to a variety of causes. Chief among them is the colonization process. It is well-documented that prior to the colonization period, Aboriginal women had more of an egalitarian status with their male counterparts. They had the power to make decisions on matters that affected their health and well-being as well as that of their family members and the community as a whole. Their decision-making responsibilities continued to diminish with the implementation of the Indian Act as they were relegated by law to second class status. Aboriginal women must reclaim and regain authority and control over matters that affect them; otherwise, the status quo will prevail.

Aboriginal women must be at all tables where decisions that affect them are being made. We believe that the health of Aboriginal women can improve if they regain control over all aspects that affect their lives, and this means the identification, implementation and evaluation of needed health policies. Aboriginal women must be involved at all levels of processes that strive for change.

The Chairman: Thank you, Ms. Dumont-Smith. This is something for you to think about later in the discussion. There is enormous room for improvement in society in general in maternal health, so that healthy babies are born every place instead of unhealthy babies that are such a problem to themselves, their families and society.

Ms. Wolski: I am very honoured to be here to have this opportunity to speak to you all today. I would like to acknowledge the Algonquin people, in whose territory we are gathered here as well today. I would like to acknowledge my fellow presenters, many of whom, similar to me, have dedicated their lives to increasing the quality of Aboriginal peoples' health. Ours is certainly the good fight.

Finally, I would like to thank the committee for providing the Congress of Aboriginal Peoples, CAP, the opportunity to present our views on this most worthwhile topic. CAP supports the population health approach. We support an approach that is inclusive and status-blind.

CAP works to advance off-reserve Aboriginal perspectives on health in a balanced, positive manner by fostering partnerships and collaborative approaches to health and healing. CAP maintains a grassroots approach to health issues to ensure real change is sustained for future generations. While CAP's work in the area of social determinants on health began just a few short weeks ago, we are hopeful that this valuable work will continue to be supported and eventually become the foundation for all the good work in which CAP is engaged.

Throughout the course of the day, various health determinants will be identified and discussed within the scope of the realities of the people represented here today. We will discuss the fact that the health of Aboriginal people in this country is far inferior to that of non-Aboriginal people and the implications this has on future generations.

CAP acknowledges the realities presented by my respected colleagues here today and, while some issues may impact specific populations to varying degrees, they very much impact all of us, as Aboriginal people. We all share the same reality.

As a very brief example, consider the following: Aboriginal people who live off-reserve are generally in poorer health than non-Aboriginal people — one and a half times more likely to report their health as fair to poor. Thirty-four per cent of the off-reserve First Nations households and 27 per cent of the Metis households were found to be in core housing need compared to 18 per cent in the general population. These groups are less likely to own their own homes, and over 50 per cent report that they have experienced discrimination at the hands of potential landlords. Over 55 per cent of the urban Aboriginal population lives in poverty. This rate is as high as 66 per cent in some urban areas. Fifty-two per cent of urban Aboriginal children live in poverty. These children are four times more likely to be hungry and are more likely to suffer health problems as a result. Forty-six per cent of urban Aboriginal children live in lone-parent homes. Urban Aboriginal children are over seven times more likely to live with a relative other than their parent than a non-Aboriginal child.

While these statistics are but a snapshot of the realities that off-reserve populations face, they have helped CAP identify housing, poverty and early childhood development as our initial determinants of concern. In addition to these, CAP has identified one determinant that overrides all of these, and that is social exclusion. Social exclusion refers to the process by which people are denied opportunity to participate in aspects of cultural, economic, social and political life. This exclusion has manifested itself in three ways: First, like all Aboriginal people, CAP constituents face racism and discrimination in their daily lives. This occurs at the hands of mainstream populations. It contributes to and perpetuates negative stereotypes which in turn create barriers that prevent many Aboriginal people from accessing services, including health services.

Second, we experience exclusion through the perpetuation of colonial policies, laws and legislation that serve to undermine the life chances of Aboriginal people. Until these issues are resolved in a manner that is inclusive of the needs of all Aboriginal peoples and in a way that is respectful of the inherent right of Aboriginal people to self-determination, we will not see meaningful change.

The final and perhaps most detrimental form of social exclusion that CAP and its constituents face occurs as lateral violence. This type of violence manifests itself in our families, communities and organizational structures. It can be disguised and subtle in its delivery, but I can tell you from personal experience that it has been a significant obstacle for me in my day-to-day duties at CAP. We are responsible for bringing an off-reserve perspective on health issues to the table, but we are unable to do this unless we are at the table.

Lateral violence is a product of colonization and is typically used to describe the conditions of oppressed minority groups. For us, it amounts to a situation where the oppressed become the oppressors. It is a well-known, well-researched phenomenon that has effectively divided us as Aboriginal people into small factions, ultimately preventing us from becoming a stronger, more unified people. It is a very serious issue, rarely discussed openly, much less in a forum such as this. However, I sincerely believe that if we, as Aboriginal people, are to ever achieve optimal wellness, we need to stop the violence.

Sitting at this table today are some of the best and the brightest in Indian country. We are all very passionate in our work, and we hold the people we serve dear to our hearts. As we have heard today, each of us has valid points to make, and each issue is well worth addressing. While we may vary in distinction, status and place of residence, we should all agree that there is a health crisis occurring in our communities. We cannot change how severely impacted our people were and are by colonization, but we can certainly limit the future impacts by working together. Let us fight the good fight together, create a united front, collectively take responsibility and move forward in a positive and productive manner.

We might want to look back and remember who we are as people and as trained technicians and remember why we chose a career in health. When you think about the realities seen in the face of a hungry Aboriginal child, do you ask whether they have a status card or whether they live on a reserve? I see the face of a child who is desperately depending on me to get on with the task at hand. In the spirit of getting on with it, I invite you all to support the following recommendations: That the government immediately make it a priority to contribute to the creation of an environment that is conducive to the development of healthy working relationships between and among Aboriginal peoples and organizations by addressing the barriers that have been created and perpetuated through the existing legislation and policy — and that the efforts to do so include all Aboriginal people as full partners; that the government address the immediate and long-term health capacity needs within Aboriginal communities and organizations in an equitable manner; that the government take immediate measures to address population health information and health data tracking methods currently in use that are representing only a small portion of the total Aboriginal population in need; that the government develop, in partnership with national Aboriginal organizations, a report-card mechanism that will allow us to monitor progress.

Ms. Dickson: Thank you for the opportunity to contribute to today's discussion. I bring greetings from Pauktuutit's 14-member board of directors, especially from our chair, Martha Greig, who lives in Kuujjuaq, Quebec and sends her wishes for success.

Pauktuutit is the national organization that represents all Canadian Inuit women. For today, Pauktuutit and ITK have agreed to capitalize on the short presentation time by sharing topics. ITK covered acculturation, productivity and social safety nets, and I will introduce the topics of quality of early life, housing, and gender-based analysis, all in the context of population health.

Today, the average age of Inuit is less than 20 years. Over the past 50 years, rapid changes to family structure and way of life have led to the need for parents to work beyond the family to support their children. According to the 2001 Statistics Canada census — from which all my numbers come, as those are the most recent numbers we have — half the Inuit population is women or female children under the age of 15. In addition, almost 20 per cent of Inuit males are under the age of 15. Therefore, almost 70 per cent of the entire Inuit population is Inuit women and children.

In 2000, Nunavut reported the highest teenage pregnancy rates in the country, 161.3 per 1,000 births, compared to a national average of 38, or four times the Canadian average. The Canadian Perinatal Health Report 2003concluded that younger mothers are more likely to smoke and binge drink and less likely to breast feed, or breast feed for shorter periods of time than older mothers. The report states that a higher percentage of teenage mothers are victims of physical and sexual abuse during pregnancy.

Today, many families in Northern communities rely on child care arrangements outside the home or extended family. Program staff at licensed daycare centres, Aboriginal Head Starts and nursery schools now serve approximately 2,000 children across the entire North.

Families and communities advocate for programs that implement parenting and support services with the belief that healthy parents and families make healthy children and communities. Early childhood education programs in Northern communities do more than provide care while parents work or train; they have the capacity to pass on the knowledge, values and beliefs of Inuit ancestors. At their best, programs in the early years give children hope, strength and pride in who they are as Inuit. However, only 29 per cent of Inuit children have access to licensed daycare compared to 54 per cent of all Canadian children who receive it.

The second item I will address is housing. National statistics tell the story: Half of Inuit live in overcrowded conditions and almost 40 per cent of them are considered to be in core need, meaning they do not live in and cannot access acceptable housing. The North is locked into a housing crisis that is worsening daily as the population booms and existing housing stock ages. In 2004, it was estimated that 3,000 public housing units were needed immediately just to bring overcrowding in Nunavut on a par with the rest of Canada.

A unique set of factors intersect in Canada's North that complicate the current housing crisis, shaped by several key socio-economic and environmental factors: A harsh climate, remote geography, extremely small population base, lack of road or rail access, underdeveloped infrastructure systems and the high cost of labour and materials combine to prevent the development of the kind of housing market that encourages private investment in Southern Canada. Consequently, the creation of new housing supply is heavily dependent on public sector involvement.

Over 99 per cent of public housing residents in Nunavut are Inuit, and many of their names are on lengthy public-housing waiting lists. For many people, this means years of waiting while multiple families live together and sleep in shifts in homes that average less than 1,000 square feet. Public-housing waiting lists continually exceed 1,000 families or about 3,800 people. Suitable, adequate living space has become a scarce resource rather than a basic right, and appropriate solutions for women in transition in abusive circumstances are almost unheard of.

In addition to existing levels of overcrowding, Canada's high North faces a birth rate of more than twice the Canadian average. Another factor relevant to the escalating housing crisis is that the median age of the Inuit population is 19.1 years old.

Inadequate, unsuitable, overcrowded housing has long been linked to community and social well-being. There is increasing evidence, for example, that overcrowded conditions have direct health effects upon household members, especially infants. According to Health Canada, overcrowded housing conditions are directly associated with the transmissions of such infectious diseases as tuberculosis.

Overcrowding also affects families by increasing the risk of injuries, mental health problems, family tensions and, of course, violence. These stressors are powerful negative triggers for coping behaviours such as dependence on alcohol and drugs, and suicide. The rate of suicide in the North is six times higher than that for Canada as a whole. Such behaviours, in turn, are two of the most common recurring themes encountered within the justice system — behaviours with profound effects on the lives of the aggressors, their victims and Canada's North as a whole. Children in overcrowded stressful homes often exhibit low attendance and success rates in school.

Poor indoor air quality in overcrowded homes is a major cause of respiratory ailments, so tuberculosis rates fluctuate from 17 to 25 times higher than the rest of Canada — depending on outbreaks — and Northern communities have the highest incidence of bronchiolitis in the world. Dr. Anna Banerji's work at the Baffin Regional Hospital found that respiratory tract infections among Inuit infants were 306 per 1,000. This number is unheard of in the First World. Housing and income examples will show a more accurate assessment of Inuit health conditions only if Inuit indicators are separate from non-Inuit indicators.

I would like to touch on culturally relevant gender-based analysis that my colleague from NWAC mentioned as well, that being medical and social health differences between Inuit women and men in the four regions. Inuit women and families have specific health issues and needs based on their unique social, cultural and environmental situations that may vary greatly in comparison to the health and social issues facing Inuit men. The main conceptual approach employed by policy-makers and governments to uncover and explain these differences is gender-based analysis, GBA, an analytical tool that systematically integrates a gender perspective into the development of policies, programs and legislation. It is a general policy across the Government of Canada, but it is implemented almost nowhere with regard to Inuit matters.

One of the striking observations from Pauktuutit's research is that although there is a disaggregation of data by sex, there is little or no research on gender — on social or cultural roles of Inuit women and men and how these might impact health. The gap speaks to the need for an Inuit GBA and indicators that capture the interaction between gender roles and the health of Inuit. For example, we need an indicator that inquires whether the gender division of traditional land-based activities — women staying at home or in camp and being more sedentary, while men are more active in hunting — puts Inuit women at greater risk for developing diabetes. Similarly, there should be indicators related to diet and gender. Do gender roles impact Inuit women's increased or decreased access to and consumption of country food? An indicator that may shed light on domestic violence is one being used by researchers looking at overcrowding in Kinngait, Nunavut Territory. The Kinngait study discovered that the lack of access to outpost camps or hunting equipment for men significantly increased anxiety in women in overcrowded homes. The study speculated the following:

. . . that women may be anxious about the impact that not having equipment might have on the men in their lives and the implications for them of the depression, boredom and anger that this generates. Women may also be anxious about not being able to provide food for Elders and children, for whom they are entirely responsible.

This issue and indicator raise another point of departure from southern gender-based analysis of issues such as domestic violence and prevention of abuse. As Pauktuutit's national abuse project — Nuluaq Project — shows through its research with Inuit women elders, the approach to abuse prevention in the Inuit way operates from a different perspective than southern abuse prevention. Indicators that shed light on these differences should also be part of Inuit GBA on women's health.

I have touched on these three areas; I am sorry to be so brief.

Canadian population health is the foundation for the future of the country. For Canada's Inuit, precarious health is undermining the very existence of this ancient culture. Thank you for listening to the briefest of presentations. Identifying old, new and emerging issues for Inuit is often complicated by a lack of hard data and by a reluctance to use innovative anecdotal indicators in research. Inuit-specific health data is often extrapolated from larger pools of Aboriginal data collected mainly in Southern Canada. For Inuit to adequately plan and prioritize health issues, to identify changing trends and disease, data must be collected for Inuit. Pauktuutit would be glad to help any way we can.

Mr. Gay: Good morning. I am a policy analyst for the National Association of Friendship Centres, NAFC. Today, I wish to provide brief remarks on the themes that shape our work in addressing the social determinants of health. I will provide comments on urban Aboriginal children; key determinants; poverty and securing a better start in life; policy options; and the friendship centre advantage.

The committee has received an earlier submission form the NAFC, which I will reference briefly. More detailed numbers are available in that document from March 10, 2007.

The committee has heard extensive testimony on what the most appropriate social determinants could be. There is ample existing evidence garnered from earlier efforts such as the work done for the Ottawa Charter for Health Promotion and more recently the Bangkok Charter for Health Promotion done under the auspices of the World Health Organization.

Significantly, there is increasing international recognition of urban Indigenous peoples as a distinct community requiring a more thorough examination of their specific challenges, strengths and steps for improving quality of life as evidenced by this year's work by the World Health Organization Commission on Social Determinants of Health and, more importantly, the United Nations Permanent Forum on Indigenous Issues, which took place May 2007.

The NAFC is pleased to appear before the committee as we believe that our expertise, insight and knowledge can provide invaluable insight into the challenges and opportunities that lay ahead in addressing the urban Aboriginal population.

The National Association of Friendship Centres is Canada's only urban Aboriginal service delivering infrastructure dedicated to improving the quality of life for Aboriginal peoples in an urban environment by supporting self-determined activities that encourage equal access to participation in Canadian society, and which respect and strengthen the increasing emphasis on Aboriginal cultural distinctiveness. Self-determination is the core value at the heart of our organization, and everyone here reflected that that is probably the principal determinant thus far.

It must be considered that 71 per cent of all Aboriginal people in Canada live off-reserve. The results of the 2006 census will show further important gains for the urban Aboriginal community.

There was a good discussion on poverty and income levels. More than 100,000 Aboriginal children do not live on-reserve but reside in urban, rural and remote communities that struggle under the weight of poverty. The reality is stark with poverty rates faced by Aboriginal people exceeding 50 per cent. In these communities, 52.1 per cent of all Aboriginal children are poor. We can agree that Statistics Canada has pointed out some troubling numbers. Over the course of the current year, the National Council of Welfare will be doing a special study on Aboriginal poverty.

Ensuring that Canada's Aboriginal children are born healthy, provided with healthy preschool environment with quality infant and child development programs that incorporate measures that provide adequate and appropriate nutrition to be able to grow and learn are undisputed positive investments.

In response to the substantial scientific and economic evidence in support of early learning programs and services, many friendship centres deliver a wide spectrum of programs, including the Aboriginal Head Start, the Community Action Program for Children and the Canada Prenatal Nutrition Program, in urban communities. We provide a focused suite of services dedicated to our Aboriginal children. We would like to see those suites of services available in many more communities.

The persistence of staggering inequalities in Aboriginal children's opportunities continues to be Canada's shame. I will address some policy options. I noticed your first discussion on this with Dennis Raphael, Dr. John Millar and Ronald Labonte. They talked importantly about the existing health barriers to addressing the work that you want to do. I will offer some suggestions focused on that thematic approach. We recommend that we invest early and heavily.

Investments in early learning and child care programs are one means of guaranteeing the rights of young children, by improving their well-being in part and preparing them for primary school. The immediate and long-term benefits make such programs a cost-effective strategy for reducing poverty and offsetting disadvantage. Situating these investments in a family-focused environment, such as friendship centres, generates considerable spillover, both in impact and outcome.

Current social and economic trends, including mobility, increasing urbanization and urban Aboriginal women's increasing education and economic independence are transforming Aboriginal family structures and spurring the demand for more organized early learning, child care and education services.

Today, nearly universal coverage in urban Aboriginal communities remains a distant reality. Early childhood programs are accessible by just a fraction of the population, typically affluent urban families.

We also recommend that you provide, given choices, targeted investments. Targeting of urban Aboriginal childhood investments and ensuring universal coverage are promising approaches to improve the equity and reduce inequalities and disparities that show no positive progress. In fact, the evidence demonstrates that a rising tide does not lift all boats. Ensuring universality of these investments produces both qualitative and quantitative gains.

Many friendship centres have developed significant expertise in policy program design for urban Aboriginal child services and supports. Rather than reinvent the wheel time and again, it might be worthwhile to evaluate those efforts that are proving to have positive impact, then deciding whether these efforts could be replicated in other communities, leading to scaled-up strategies both at the regional and national levels.

There are two possible approaches to scaling up such interventions, which include the expansion of publicly funded programs focused on urban Aboriginal and other children by enshrining such rights in legislation. This would have significant funding implications, but the benefit is potentially widespread support from the middle-class and poorer families with children. It would be more costly.

Another approach would be to target urban Aboriginal children and their families. The evidence suggests that larger gains can be realized from interventions targeting urban Aboriginal children and their families. However, the prospect of inaction should be troubling for all Canadians.

We need to strengthen oversight. Most of Canada's urban Aboriginal children's programming, aside from kindergarten to grade 12 education, is discretionary, leaving these programs increasingly vulnerable. Demographics, political and ideological shifts and competing government priorities at all levels put these resources at risk.

Arguments suggesting that tax incentives would supplement these reductions to government budgets are tenuous at best and certainly arguable on their merit. If we are to learn from the recent past, tax cuts and incentives distort reality, which regularly demonstrates that such cuts ultimately translate into the reduction of services and programs, particularly those that serve Canada's most vulnerable citizens.

I would like to comment on the fiscal pressures that Canada faces, in light of the aging population, from the increased need for health and social services for the elderly and a shrinking labour pool resulting from the retirement of the baby boom generation. These fiscal pressures will impede our ability to ensure that urban Aboriginal people have the ability to address the full range of the social determinants of health.

I note that there appears to be a shared expert opinion in Canada that we should maintain an attitude of "Don't worry, be happy." I am sure there is good reason for Canadians to be optimistic on the sustainability of their pension and health care system. However, I am uneasy when the U.S. Comptroller General has been touring their nation with some sobering numbers about their impending economic meltdown.

What will be the macroeconomic spillover effects when the 1,000 pound gorilla south of our border starts to panic? I wonder what the impact will be on our domestic health care professionals, as they are increasingly poached from our universities, colleges and communities.

Then again, are we acting responsibly when we recruit from the Third World? I wonder what it does to our credibility when we tell others to do what we say and not what we do.

My main point here is that there will be an increasing demand for Canada's skilled health care professionals from south of our border, the consequence being that costs will increase, access will be reduced and investments in discretionary services addressing the social determinants of health will become increasingly vulnerable to nervous parliamentarians, if not eliminated outright.

These macroeconomic realities will leave urban Aboriginal peoples and all Aboriginal peoples increasingly vulnerable. Ideology and partisanship have infused an emotional component into which should be an evidentiary-based and thoughtful discussion. The absence of independent and rigorous economic analysis of government proposals and expenditures should be of concern for all parliamentarians, and it is a concern for the public.

The creation of a parliamentary budget officer as set out in the new Federal Accountability Act that has explicit responsibility for analysis related to Parliament's consideration of government budgets, as well as the cost implications for private member's bills and parliamentary initiatives, is seen by many as a logical step mirroring the Congressional Budget Office in the U.S. As a positive consequence, investments and budgetary plans such as those called for under the most recent federal budget would be closely scrutinized, debated and subject to rigorous oversight. This may translate good intentions into progressive policy.

I turn now to the friendship centre advantage.

In many urban centres, friendship centres are the institutions that are most frequently used by urban Aboriginal residents, after health and educational institutions. If you walk into any Aboriginal community, any Aboriginal high school, and ask the students or individuals whether they have been to a friendship centre, all of them will at least acknowledge that they know what a friendship centre is. Our brand is similar to the United Way; everyone knows what we do and what we deliver.

Many friendship centres support healthy urban Aboriginal children and families that are delivered through innumerable programs nationwide. By no means are these investments insignificant insofar as the reported funding is $15 million. These investments are included with the more than 1,200 distinct programs and services with funding exceeding $89 million.

A commitment to transparency, accountability and results has garnered our continued support of governments at all levels. Strong support has come from our friends at the Federation of Canadian Municipalities and the Assembly of First Nations in championing the enrichment and expansion of the friendship centres.

In conclusion, the NAFC is pleased to be working with the Aboriginal Reference Group of the Canadian Reference Group, contributing to Canada's submission in the upcoming World Health Organization Commission on Social Determinants of Health next month in Vancouver. Of course, we would be delighted to be delegates in these important discussions, but have not succeeded in getting status in these crucial deliberations.

Our concern remains that the unique perspectives of urban Aboriginal communities will not make it into the final document resulting from these discussions. As noted earlier, the United Nations Permanent Forum on Indigenous Issues met May 14 to 25 of this year, which presented a historic opportunity to address urban indigenous issues with a dedicated half-day discussion highlighting the excellent work done by thousands of dedicated staff, volunteers and community partners in friendship centres from the five corners of this land. I will take this opportunity to quote from the Government of Canada directly. The following statement was made by Fred Caron, Assistant Deputy Minister Indian and Northern Affairs Canada, May 21, 2001, New York City, to the UN forum:

As indicated earlier, the Friendship Centres provide important services to Aboriginal people living in cities across Canada. Moreover, the Friendship Centres paved the way for a number of other programs and initiatives designed by governments to address and respond to the needs of Aboriginal people living in cities.

We have been developing culturally appropriate services and supports addressing a number of key determinants that have led to considerable success over the course of the past 40 years. The story of friendship centres in Canada's largest cities is one of resilience, hope, dedication and hard work that is a source of pride to the Aboriginal community, as it should be for all Canadians.

It is our hope the honourable senators here today support our ongoing efforts in addressing the social determinants of health.

The Chairman: Thank you very much, Mr. Gay. That is a nice place for us to end this. I want to thank all of the participants. We have three themed discussions that feed right off what Mr. Gay was just talking about.

There is a tremendous problem with the Metis and with many other Aboriginal groups in that your populations are becoming disseminated. It is easy to talk about programs on the ground when we can get them to a community, but when a community becomes something in downtown Toronto, Winnipeg or someplace else, the friendship centres are helping, but it becomes a very complex problem.

The first themed discussion will be around how a population health approach applies to Aboriginal realities. The second discussion will be around the information gaps that create barriers to concrete action on the determinants of health.

The third discussion will be about the immediate policy and programmatic changes that need to be made to advance a population health approach for Aboriginal peoples. Make no mistake about it, our report is advancing a population health approach, and we want to advance one that will work. That is what we are searching for.

As I mentioned, we are totally committed to this approach to health in all of Canada, including Aboriginal peoples. Whether we manage to convince people or not, I do not know, but we are committed.

I believe we can learn more from Aboriginal peoples than from any other population group in Canada, because they are further along in looking at health from a population health point of view. Your documents are evolving in that direction, and we can apply your model to the rest of the country.

However, coming back to reality, there is the problem that Aboriginal peoples are increasingly moving into big cities, as well as into smaller communities, but living off-reserve. The Metis, for example, are spread around. There is a challenge there as to how one can solve the problems with determinants of health on a broad basis and bring the health status to where it should be.

Senator Cook: I hear a theme running through your presentations, and the word "policy" comes back to me. All of you in your own way seem to be talking about policy. I sense that you have prepared yourselves well to take care of your people, and you know what the determinants and issues are. I am searching for the barriers that we need to address so that policy flows. You know that we can all operate in our own little corners, but just for a minute, I will go back to what helps me to understand, which is the study we did on mental health. We worked hard to understand, and the surprise came to me when my people said, "You have done wonderful work." I was trying to be the academic, but the message was simple. They told us that we legitimized mental health in this country, and that is good. We are moving forward. We struck a chord with the people; the people heard us. With respect to all the policy, goodwill and everything else, unless we can bring to the rest of the nation compassion for who we are and what we are trying to do, our story will not get told and nothing will change at a government bureaucracy level. I believe that. I hear the words "policy," "innovation" and "empowerment." I know that you were working in different geographic areas, for example, urban and rural; I heard my friend Ms. Gideon talk about a nation-to-nation approach. That is commendable. For me, that was a barrier, and maybe she would like to comment on that and how we can break down this barrier.

I heard Ms. Fowler talk about supporting the holistic approach, and I certainly can identify with that.

Ms. Dumont-Smith talked about living with a balance, and you are all advocates in your own way.

I would like to hear about the ending, but I suspect that that will be late night reading. I have never read it and do not know what is in it, but it seems to me to be a barrier for progress for you in order to achieve what we are trying to do.

With respect to other areas, such as housing, Ms. Dickson talked about sleeping in shifts. That really touched me, in this day and age, not to have adequate housing where young populations — you are the fastest growing population — are sleeping in shifts. If that does not touch a chord with people, we have to tell the story.

When we did the health studies, at every opportunity that we got, Senator Cochrane and I spoke at conferences, health summits, nurse practitioner annual meetings and so forth — you have to tell that story. We can do so much, but you have to do yours.

I hear you have large amounts of data. Is the data concentrated in one area, or all in your own silos? Maybe that database should be a part of the Canadian Institutes of Health Research, CIHR. I do not know; I am just talking. It is your turn, and I feel I have given you enough to start you off.

Ms. Dickson: I could add to the data point. The reason that the Inuit talk much about disaggregated data is that Statistics Canada and other data collecting agencies for the government — and even the private sector — tend to use the term "Aboriginal" in Canada, meaning everyone who is of the older so-called nations. The Inuit are different, and, therefore, many aspects of the data collected for Canada give a bad picture, which then becomes misunderstood as to what happens in the North. In fact, the data is now getting old. It is from 2001.

There is an opportunity now for Canada to look at its data collecting policies and do what we call "disaggregated" or "Inuit-specific" data, so that people can say for sure that this is the housing situation or this is the birthing situation or this is how many elders there are or how much abuse there is. The reason for that is the policy-makers ask you. When you make a dramatic statement, they are impressed as though you have entertained them, but then they want that data to make decisions and we do not have very much appropriate and accurate disaggregated data. That is the reason you will keep hearing it come up.

Senator Cook: The data will formulate your policy. Is there a way that the data can be collected and kept pure, not put into a melting pot and used to develop the policies? Is that an option? How do you see that working out? Sooner or later, population health will become the purview of Health Canada, fragmented a bit more and become a delivery of the provinces. Those are the realities; are they not? If you could keep your data pure, not all mixed up, would that be an option?

Ms. Dickson: Yes, of course, that would go a long way toward it. The problem is getting that data from the perspective of Inuit, a demographic that is so remote and isolated even from each other, let alone from anybody else, becomes very expensive and challenging.

Inuit, over the last 100 years, have been looked on as sort of a — I do not want to use any pejorative term. They have been researched so much by outsiders that they are tired and do not want yet another southern white person to get off a plane, ask them personal, intimate questions and then get back on the plane. They do not know what with that information will be used for. It is problematic as to how to get the correct data and have it disaggregated. Do you train Inuit to get their own data, or do they know what they want to have researched on themselves? A partnership must be developed and funded. Everything is expensive. I believe it is about the broader policy issues in Canada, first, and knowing how important that whole culture is and committing to serving it.

Senator Cook: With your indulgence, I do not feel we should talk about money; we will talk about what is right. We will do it from that perspective and then see who funds it after that. I should tell you that when Senator Kirby was chairing this committee and looking at mental health, he said one day that we would have to see how we will fund this. He managed to do it. He recommended a tax of a nickel a drink on all alcohol or beer that was consumed, and then there would be enough money. We did not go forward with just a proposal that would cost; we showed them how it would be costed out, and there was joy in the house.

If you are collecting data for your people, with climate change, you will not have access to the land to live off. The land is changing, and it is changing faster than we see it. You have much time there. I would like to hear from you on that aspect of it. What can we do with your data? Should we consolidate it and put it into one? Should we keep it safe within an umbrella and try to develop policy? Where do we go with it?

Ms. Van Haute: I wanted to respond specifically with regard to data collection analysis and dissemination. The most common source for all of us for data collection is the census. The problem with that, though, is that Aboriginal identity does not come until the long form. Only 20 per cent of the Canadian population receives the long form. Whatever information comes out is limited, whether it is aggregate data or not, it is still limited. The analysis that comes out is somewhat limited. If federal policy, and perhaps provincial, is based on that, then it will obviously be missing something.

We have suggested in our deliberations with Statistics Canada that the Aboriginal identifier question be placed on the short form so we would at least have some more accurate basic statistics. That process is a long one, apparently, and it has to go through Statistics Canada and then has to be presented to cabinet and decided upon.

From our perspective, we would appreciate support as a base element to start being able to collect more accurate and more full data. That is the base element of it because, as we collect more accurate data on the global perspective, we can use that basis to perhaps encourage provincial and territorial governments to include those same identifiers on provincial forms. For example, for health utilization services within the provinces, there is no identifier — and certainly no Metis identifier — on them, so the statistics that we will collect from them will also be limited. If provincial health policy is based on that, we have a double problem there in terms of how informed that policy is.

Our whole objective in trying to push for this and hoping for support is to help us understand our conditions better. That is Metis, and that may apply to all Aboriginals, but help us understand our conditions better so that we can share that information with federal, provincial and territorial governments in a language they understand and respect. Therefore, in the end, we will get more informed and efficient health and social policy, and essentially something more practical that works and has a positive outcome that we can evaluate and measure.

Dr. Bartlett: I want to respond to the first question and the further question that was posed about how we look at population health. What do we mean by this lens of population health? What could we say to describe that? It is important as we have this discussion to have an understanding of population health and the evolution of it, because we have to be clear about what we mean. We were talking population health in the 1970s with the Lalonde report. We went through some very interesting movements to bring the whole concept through. Initially, it was in government, and then it moved through the academic world. The academic world started writing more papers about it. It got into the health policy world. I was involved in the community health movement in Manitoba. It got through to primary care, bringing in world health concepts of primary care, and eventually it got back into the legislatures to say we will do population health and determinants of health models. We are in the same place we were in 1974, and we are still trying to figure out what it is exactly.

From an Indigenous or Aboriginal perspective, there is no such thing as population health without individual health. We have to do both of them at the same time. Whatever we come up with, from my experience with the population health promotion frameworks, we went from population health to health promotion, which was social marketing, to population health promotion. We have come up with these complex ways to describe this.

From my experience in my clinical work, that individual that is sitting in front of me hears a different story from every provider and every sector with which they interact. Their only rational choice is to listen to no one because, cognitively, they cannot integrate it. We must think about how we work not only with the population but within the population, and how we develop mechanisms and frameworks so that every individual understands the big framework and, therefore, understands it on a personal level. No human being will walk off a cliff if you say, "It is out there, just walk." They will not walk in a direction based on a particular type of logic model that has been developed in an academic environment if they do not understand what that means. They are just not going there. We have to think in our big frameworks about what it means to individuals. Can they see it themselves? How is their identity reflected in that framework so they can feel safe in making that journey? We need to bring some sense of perspective around what we are talking about.

Ms. Gideon: From a First Nations perspective, chiefs have passed resolutions and mandates in all 10 of our regions. They do not support externally-driven data collection processes. They favour models that set up First Nations capacity and institutions in collaboration with the academic research community and other federal-provincial-territorial agencies, because it is very important to have comparability of First Nations data with mainstream data and also for the practicality of being able to bring to the table the expertise that will undertake the work.

In the U.S., there are tribal governments that govern their own epicentres that collect population health data. It is not a perfect model, but it is the model we have been working on with Minister Clement's office in trying to develop a joint plan for the future direction in First Nations health information and infrastructure. We are building on the successful foundation that we have been able to establish with the national health survey I mentioned earlier.

From our perspective, we are less concerned with enhancing Statistics Canada processes because we do not support that type of process. We support First Nations conducting health research and collecting health data that will help them in their own planning and service delivery, because the majority of them have taken over responsibility for health care in their communities.

That is a distinction I wanted to bring to the committee.

Dr. Shah: We have been talking about the holistic approach. Although I read most of the reports, I did not see much on spirituality as a determinant of health. In the Aboriginal population, health is grounded in mental, physical, emotional and spiritual components. I have been working with the communities for almost 33 years. I saw the term "social capital" used a couple of times. Social capital is lacking in terms of the development of the spiritual component, be it sweat lodges, special places for ceremonies or other things. This is a very important part of the determinants of health. It is grounded there in the Aboriginal culture as well as in many non-Aboriginal cultures.

I am a first-generation immigrant. The first things that the settlers of this country did was build a school and a church. There was a rule in this country at one time that every new development would have a church. Newcomers now build mosques or temples in order that they will have a spiritual grounding.

I provided you with an article about India. If you changed "India" to "Canada", it would be equally accurate. We have systematically destroyed the cultural and spiritual institutions of the Aboriginal population.

There is much hunger for that now. Last week, I was fasting with an Aboriginal group. There is a great pent-up demand for the social capital of these institutions. We should think about that as a part of the social determinants of health.

Mr. Gay: Evidence alone will not get us over the hump. We have seen that in the child care debate and are seeing it in the criminal justice debate in both Houses of Parliament. We talked about measurement, but unfortunately even that has been hijacked by the academic and policy community. We have the human development indices and child well-being indices. The Federation of Canadian Municipalities has quality-of-life indices. We are doing the same thing; we are creating our own silos based on our own priorities and specifics. There is no consensus, and we need to think about consensus on these measures.

The Aboriginal community functions as many other communities. Sometimes we do not have consensus when we need it. That is something we are working toward, which is why we have moved toward partnership.

Access also affects evidence. There is a tremendous amount of research focused on Aboriginal communities but, unfortunately, it is buried in academic journals, which are too costly for most grassroots people and even for some of the more developed Aboriginal organizations.

The Canadian Medical Association Journal is one of the few resources that is open access. I am glad that they have supported the policy of open access, which is gaining momentum worldwide with online journals. The Canadian Paediatrics Society offers a journal called Canadian Paediatrics and Child Health, which is pay-as-you-go, as is the American Journal of Public Health. These are invaluable tools. They contain information for which the taxpayers have already paid. That evidence must be available to the Aboriginal communities.

We were talking about data and indicators. Many of the organizations here sit on a vast resource of untapped data. Last year, at each of our 117 friendship centres, we collected data elements on 4,200 specific items. That is a huge burden. What are we doing with that data? Are we making any use of it or just collecting it for the sake of collecting it? Over the course of the year, we did a data rationalization exercise and decided to collect the data we needed and focus on that nationally. We are down to about 280 specific elements, and now we need to collaborate with partners on that.

With regard to setting out the policy framework for the determinants of health, building into the Kelowna Accord, the federal government has already done some heavy thinking on this. They have created the Aboriginal Horizontal Framework, which situates all the federal spending and programs into five or six domains. That would give you a stunning visual, so I encourage you to go next door and shake some heads.

Dr. Bartlett talked about the necessity of addressing the individual and population health approach, and that is the foundation of what friendship centres do. Every year, 1.1 million people come through our doors, often with multiple contacts. Once the individual is engaged in the population health discussion, they have a sense of ownership. With that ownership, they can create a sense of responsibility to themselves and to the community. Those are the best resources to have, because from there we can build toward action. This is something that many of us do very well, and we already have that strength in the Aboriginal community. It is not as though the government needs to do something. All you need do is break the bonds that tie us down.

The Chairman: That is an extremely interesting concept.

My thinking on this has evolved and I want you to nudge me in the right direction. I was involved for 35 years in building a health system that people fell into when they got sick. Then they were totally preoccupied with getting their illness cured. We are now confronted with a situation where we cannot afford this system anymore. We cannot deliver it equitably to everyone and it is not working, because in many segments of our population it is not producing healthy people. However, we cannot throw the baby out with the bath water. We have to preserve the health care delivery system. Through population health we must find a way of maximizing the health care delivery system, of stopping it from doing bad things to people, such as giving them medications they do not need or drugs that might damage them. We need to get them on the right critical path for a return to health.

I am terribly impressed with the friendship centres. I listened to their presentations earlier. Senator Cook and Senator Cochrane were commenting during the break on what a great community model they can be for the issue I raised earlier of the off-reserve Aboriginals or the Metis people. This is a great idea that can be built into tremendous community access centres for all the social services.

Mr. Ermine: I wanted to add a few things in light of your questions. I think about the bigger picture of health determinants and population health. In terms of a framework idea, the Canadian Institutes of Health Research, CIHR, have done considerable work in the Aboriginal Capacity and Developmental Research Environments, ACADRE, program around indigenous and Aboriginal people's health. They did considerable work trying to identify the relevant processes we should follow to understand Aboriginal health. I know Dr. King has been involved with the Alberta ACADRE, and Dr. Bartlett in Manitoba and others across the country. A lot of discussion has occurred identifying how we can formulate our ideas and understand this notion of health.

The framework idea that has been contributed to CIHR — the notion of dialogue — is at the discussion stage with the Tri-Council Policy Statement. We are talking about Aboriginal peoples. I would like to latch on to Ms. Gideon's presentation on the historical foundation and treaty relationship. There is an affirmation that indigenous peoples societies and cultures do come from a certain kind of knowledge system and health system. The framework idea talks about dialogue. How do we understand the different perspectives that come to the table? One of them is health. As a researcher in Saskatchewan I have done considerable work with communities, with Cree thought and indigenous thought, around coming to terms with the notion of health. For example, when we are talking about health, the first impulse is to review statistics that talk about the pathology of our people. We are presented with statistics about how sick and how pathological we are. That is not really a discussion of health. It is a discussion of sickness.

How then do we talk about health? We need to talk about the optimum conditions of our people. We start from that premise. Dr. Hampton, who sent me here today, and I are just finishing a paper considering health from the Cree language. What does the Cree language have to say about the notion of health, and what is a healthy individual?

The dialogue is around ethical space. You can find CIHR literature on that. It calls for a dialogue on health and what is important about indigenous health. Indigenous thoughts are the ideas contained in our languages and in our cultural knowledge systems. We have not yet done this in this country. We have not yet achieved identifying what those ideas on health are. How do we get access to those ideas?

In research we are starting to do that. We are starting to get access to elders who talk about the knowledge system and how people are maintained in health. We are arriving at a position and at a time when we are starting to discuss those very important ideas that are contained in our communities with our people and our notions and ideas on health.

Everyone has mentioned that determinants of health are policy discussions. Very clearly an important policy that needs to be considered is the notion of dialogue. The people themselves must identify and start talking in terms of health. How do we shift this sense of ownership of health back to the people? Those are my comments.

The Chairman: That is so true. An individual's health is his or her responsibility. Sometimes we forget about that and we blame governments and everyone else for our health. Our health is our own responsibility.

Yesterday I had the privilege of meeting some people from Cuba because I am very interested in their maternal and child health program. Through the kind of thing you were just talking about, they have a superb maternal, infant and child development health program, even though their health delivery system, compared to ours, would be considered very poor.

For example, autism is 100 times higher in Canada than it is in Cuba. It is absolutely fascinating that the ultimate sophistication in science in a laboratory in Toronto studying the neurological development of babies from birth through electroencephalography and so forth is coming out with the same information that family physicians are ferreting out in Cuba simply by looking after a mother through her pregnancy and following the child in early development and getting to know the families by going into homes.

There is profound wisdom in what you have just said. It has come out around the table. In the next arc of this we are talking about the information-gathering process, which is only half of the initiative. The other half must be to get back to the ground with the proper systems that will change things.

Forgive me: I am talking too much for a chairman. I am out of order.

Ms. Lys: I would like to build on some of the comments about the holistic vision of health. My colleagues in the Aboriginal Nurses Association of Canada have a basic philosophy that involves a different vision of health from the mainstream health care system in Canada. Ours is a more holistic version that includes emotional and spiritual health.

In terms of balanced holistic health, if you do not have mental, emotional and spiritual health, if you are not healthy in those ways, often the symptoms will come out in a physical way. The medical system in Canada deals with physical symptoms only — a little bit of mental health maybe, but not spiritual or emotional health. The spiritual and emotional health of Aboriginal peoples have been affected greatly by the history of our role in Canada and what has happened to us as Aboriginal people. The loss of culture has been very significant and is not talked about enough in relation to health.

To make a difference in health care in this country, we need to understand what has happened to Aboriginal people. Everyone must understand that. The people, the Aboriginal people, the politicians, the health care workers — everyone who has contact with Canada has to understand that history and how it has affected us.

I have been a health care worker in the system for over 20 years. The biggest change in my way of practising came about when I met a medicine woman who explained what happened to our people in Canada. After you hear the true history of our people, it is impossible to sit on your hands and do nothing. The politicians and the health professionals in Canada have to understand that. They have to get the same message. They have to understand where we are coming from to understand where we are going.

Before we can have healthy Aboriginal people, we must have healing. We must bring healers into our communities. The Aboriginal people must heal first. We will not get physical health without first going through the emotional, social and spiritual consequences of the near loss of our culture in this country. That is what we need help with. We need help to get healers into our communities; we need support for that. In my community you could get a prescription to go to a medicine woman. That makes the doctors the gatekeepers of our way of healing. Many of the doctors would not agree with that so they would not give a prescription to go to a healer. We did manage to get that changed. However, the government wanted the traditional healers to have workers' compensation. They wanted them to have insurance before they could work with the people, which does not make sense because they are two different systems. It did not fit. In a way, it does not lend us to support the traditional healers in our community, but they are who we need to support because they are key players in changing the position of Aboriginal health in this country.

If there is a message to bring to the government, it is to have those positions in place to support Aboriginal healing in our communities. It is outside the box of the traditional health care system, but we have to think outside the box. What we are doing is not working.

Going back to the root cause of the loss of culture in the Aboriginal community, a key determinant of health and probably the biggest determinant of health is the relationship between the Aboriginal people and the federal government. You hear it always on the news that Aboriginals want an apology. In our community, if you do something that hurts someone else, you apologize. It is clear that the actions of the federal government have hurt Aboriginal people, but no apology has come. I do not understand it because I would think it is a simple thing, and it is the road to healing. For some reason there is a big roadblock. I probably do not understand the politics, but as an Aboriginal person from an Aboriginal community, that is the way we were raised. If you have hurt someone else, you say you are sorry and move on to mend the relationship. The relationship between Aboriginal people and the federal government must change. That is where the healing has to begin to change the health care of Aboriginal people.

Senator Cochrane: Ms. Lys, I believe in the healing practices of the Aboriginal people. When I was in the Northwest Territories, Senator Sibbeston, who is from there, would go to the mountain to heal — I do not know if that is the correct word — but to tell all of his concerns to an older man with whom he would stay for a while until he felt he was healed. I thought that was fabulous. These practices are good.

I am trying to get some information now from you that will complete our study on population health. I would like to know how traditional Aboriginal healing practices fit in here. How does a population health approach interact with the traditional health framework? Do population health approaches account for indigenous traditional knowledge? Can you give us examples of where this has been the case? Can you identify for the committee the benefits of incorporating the traditional health and healing practices within the population health approach?

Ms. Lys: When you look at things from a traditional healing perspective and from a traditional health perspective, you look at them in a whole way. How has history affected Aboriginal people in a mental, spiritual and physical way? It helps you to understand the big picture. In health care we tend to look only at physical health. Even in terms of population health, we look at physical ailments, things that affect us physically. We do not know enough about the spiritual part of it. That is where the healing comes in. Medicine women and medicine men work with us to make us understand that there is a spiritual component to every single thing we do and that we are connected to every other thing. Aboriginal people are very much connected with the government. We are all connected. Everyone in this room is connected in one way or another.

It makes us approach things differently and treat people differently when we are all equal and interrelated. Personally, I work with a medicine woman. As a healer myself, as a nurse practitioner, I find that I have to be strong to work with other people and to help them heal and be healthy. I work with a traditional healer myself to keep me grounded.

Senator Cochrane: Perhaps others would like to contribute.

Dr. Shah: I will give you first the evidence. We had been looking at the literature for the impact of spirituality on health, not necessarily religion, but spirituality. Back in 2000 we made some presentations and it came out that we could "avert 42,000 deaths a year" if we were to be more spiritual. This is for all the Canadian population. That is equivalent to smoking-related deaths. It has also been shown in the literature that if you are "spiritual," you will have less mental illness, there will be fewer admissions to psychiatric hospitals and you will take less medication. That is with respect to the mental health area. On the physical level, there is much evidence indicating that you will have fewer occurrences of disease. I can provide that framework for you. That is the science part of it.

I have worked for the last 10 years in a clinic associated with the Aboriginal Health Centre, and there is a traditional healer located three doors down. We refer patients back and forth. There has been a loss or suppression of the spiritual concept. People tend to avoid it. There is a lot of anger and resentment at the individual level in the patients I see. Western medicine does not have much to offer there. We are very fortunate to have healing facilities available in downtown Toronto, and I have sent patients to the healer or elder there. After their visits, they have come out healed.

I want to make an important differentiation. Healing and curing mean two different things. In medicine, we cure people. If you have strep throat, I give you penicillin and you will be okay. However, in certain situations you may not be completely cured where you may be healed. Therefore, people have a feeling of resolution.

Aside from sending my patients to healers, I also send many of them to a naming ceremony, for example. If I could accomplish one thing with my patients, it would be for them to regain self-identity.

Senator Cochrane: Where do you send your people?

Dr. Shah: These facilities are located at or near the same clinic. At the Aboriginal Health Centre, we have elders, traditional healers and I call my assistance paratraditional services. In medicine, it is known as paramedical services.

That is what we do there. These are important elements in terms of the whole healing process because it is important for people to regain self. When people regain self-identify, they become much healthier.

Senator Cochrane: I am reading a book and listening to tapes about something called The Secret, and that is what it is all about.

Ms. Wolski: First I have a couple of things to say about the traditional approach to healing, and then I want to address the data question.

With respect to practical ways to address these issues, Health Canada has implemented the Aboriginal Health Human Resources Initiative. They are looking at increasing the number of doctors, nurses, health practitioners and that kind of thing in Canada. Of course, the traditional piece is left out. There are significant dollars available if you want to become a doctor or a nurse, but there is nothing available if you want to follow your traditional healer around in your community and learn from that person. There is nothing there to encourage students and youth to take that route. There is also no support for the Aboriginal healers in our communities to ensure that information and knowledge get transferred. There is nothing right now, although something could have been made available under that initiative.

The second thing I wanted to talk about was the data question. I wanted to touch on what the Assembly of First Nations, AFN, had said and what the Metis nation had talked about as well as the Inuit in Canada. From a First Nations and Inuit perspective, they have been researched to death. However, from the Metis and off-reserve perspective, there is almost a request to research them back to life. As you know, data drives policy development. If the data is not there, there will not be any policy for off-reserve, non-status Aboriginal people in Canada. I wanted to drive that point home.

I know Dr. Kue Young from the University of Toronto testified before you I believe in April or May. I will read a quote from him:

The proportion of papers does not reflect the demographic composition of aboriginal people in Canada, with severe under-representation of Métis, urban aboriginal people, and First Nations people not living on reserves . . .

This person who has been a lead researcher in Canada for 35 or 40 years is telling us that we need to get data for that off-reserve population because right now the lack of data would seem to indicate that there is no need off reserve.

The Chairman: I hope to get more of that figured out today before we leave here.

Dr. Adams: I will speak from a mainstream perspective as a public health official for the province of British Columbia and as a Western-trained family doctor.

There are perhaps limitations to the population health approach that we have been encountering. A public health approach is really quite complex, looking at Aboriginal populations over a large area. It has certainly been difficult in my role to determine what the priorities are. We have mentioned a couple hundred already.

To try to focus on the goal, looking at healthy communities and healthy individuals simultaneously is difficult. However, it is something that we have done as indigenous people forever. A population health approach from an Aboriginal perspective does make some sense.

I hope that we all understand that health is more than just health services. In population health, we struggle to distinguish between the two.

Population health theory also does not quite understand the diversity of Aboriginal populations yet. We are diverse. We have talked about how we live in the cities and in rural areas; we are Metis, Inuit and First Nations peoples. Some of us are working on the ground, some are experts working in city centres, some in centres of knowledge or in silos.

In British Columbia, we have managed to work with the provincial and federal governments in a spirit of trust, recognition and respect for Aboriginal rights and title. I hope the time of making decisions on Aboriginal health without Aboriginal people is over. We are not just advisors in our health. We are equal partners with provincial and federal governments. Therefore, our indigenous ways of knowing in health must be front and centre. This idea of a persistent dialogue and consultation needs to be there.

Unfortunately, we have very poor data about Aboriginal people. The whole idea of public health is about evidence-based medicine, which actually fails terribly in Aboriginal communities because we have terrible evidence about Aboriginal people. For instance, we do not know how hypertensive drugs affect Aboriginal people. Do they affect us the same as, for example, the Framingham study participants in the U.K.? We do not know. We do not know what is happening with Aboriginal women and diabetes. We do not even know how many Aboriginal people there are in Canada.

Even if Statistics Canada were responsive to us — and they are trying — how could we access that data? For instance, for three years Indian and Northern Affairs Canada has not shared their data on how many Metis there are and how much they pay out for us in the province of B.C., let alone for Aboriginal peoples.

The theory of public health is still just a theory. The lion's share of the work for Aboriginal peoples has been done by front-line workers in Aboriginal communities. I would hate to see the idea of public health becoming reductionist again and pushing aside indigenous realities of how we are accomplishing our health status, and I would hate for public health to become so rarefied that it excludes the workers.

I am a public health official in the province of B.C. I am an advisor to all the Aboriginal workers in the province. It is unfortunate that a public health theory means that the elders and the workers in the communities feel they do not understand the work they are doing. Those workers are important, and I would hate to diminish their authority and efficacy. We need to empower them. Along with acceptance of a public health approach, we need to build capacity, and that is an important idea.

Second, our relationships and governance with other health officials and organizations need to continue. Unfortunately, we have been working in relative isolation, with few health officials putting part of their brainpower toward Aboriginal health, and that needs to change.

The Chairman: Allow me to focus your remarks. I have been of the impression that to gain control of your destiny in the way you are speaking about, we need community health and social services centres because they can be tailored to meet the needs of a community, whereas the big programs and hospitals — public health from 30,000 feet, so to speak — do not get to the ground and do not take on the persona that is necessary to change the situation in a community from being unhealthy to healthy.

Do you have any such structure in B.C.? What is your interface with the ground in B.C.? By "the ground" I mean the people you work with hands on.

Dr. Adams: The most important idea I wish to convey is that it is about relationships and governance, that we are equal players and sit equally with our provincial Minister of Health, George Abbott, and our federal Minister of Health, Tony Clement. We need to have recognition of the Aboriginal leaders who represent our interests in regard to health service gaps and information gaps, and we need recognition of indigenous ways of knowing. That is fundamental before we tackle the more complex issues brought up today of Aboriginal health, human resources, beefing up services such as the friendship centres, how to deal with a lack of information about Metis people and how to bring Aboriginal women's health to the fore. We cannot do that unless we are equal players. The recognition of our governance needs to occur first before we start the nuts and bolts of this public health care theory. Aboriginal people have been in charge of their own health for a long time. Our expertise and our front-line workers are unrecognized for doing the majority of the work, unfortunately.

The Chairman: You are not integrated with the provincial and federal services.

Dr. Adams: Exactly, and that is where we need to be better connected.

The Chairman: My point is that no matter what your governance structure is in the great Canadian mosaic, I do not think you can bring about control of your destiny in terms of health promotion and health services unless you can develop it at that level.

Dr. Shah: Quebec has done that. I visited the James Bay Cree community last week. They have a local community social services centre called CLSC. They have organized health services very well for a whole Cree community. That might be a model for you to look at.

The Chairman: I am familiar with the CLSCs. As a young doctor, I worked at a CSLC during the summer. They have been going more than 35 years.

Dr. Shah: Aboriginal communities have no models that combine public health and health and social services, and I was impressed to see that model there.

The Chairman: It is a very good model; you are right.

Cynthia Stirbys, Research and Policy Analyst, Assembly of First Nations: I am here in place of Ms. Gideon now. I appreciate the opportunity to speak.

Many have talked about whether traditional approaches can be incorporated into the population health model and about holistic approaches to health. We have been speaking about the gaps in health, and Dr. Adams spoke about the indigenous ways of knowing.

I would like to provide an example. In my final research for my master's degree, I wrote about Aboriginal midwifery. I think this example will illustrate many of the comments brought forward today.

Earlier today, Ms. Dumont-Smith mentioned gender. At the Assembly of First Nations we are developing a gender-balanced analysis. It is quite different from a gender-based analysis. We are talking about balancing the roles between men and women, and health comes into that. We talk about four areas: spiritual, mental, physical and emotional.

I want to use the midwifery model as an example of holistic health and to illustrate some of the gaps that exist today. Health begins at birth. It does not happen when you enter kindergarten or grade school or when you go through puberty; it begins early on. When we look at health and gender and the impacts between men and women, it is often the women and children who are further marginalized because of legislation and policy that unfortunately creates the gaps through which they fall.

In the past, Aboriginal women were strong. They worked together to sustain the health of their communities. If the women in the community are not healthy, the whole community disintegrates, as do the children. Indian residential school is a good example of what has happened in our communities in terms of the disintegration of our relations.

Historically, girls were trained in midwifery, traditional knowledge and medicines early on. By the time they were 10 to 12 years old, they would know hundreds of herbal medicines. By the time they were teenagers, they were delivering babies. By the time they were 20 years old, they were already very experienced. The standard is high in our communities.

The problem today is the evacuation policy. When Aboriginal women are evacuated at 36 weeks of pregnancy, they are taken away from family, support systems and their children, and when they are taken into the hospital they are going into a place perhaps for the first time. They are spending weeks alone; there is foreign food; they do not understand; and they are in an urban setting. I still walk into hospitals and am a little afraid of the noises and the smells. Imagine how unnerving that is for someone who has never been in that environment.

Through this research, I took the Bronfenbrenner socio-ecological model and adapted it to a midwifery socio-ecological model, and it demonstrated that when legislation is brought in, the medical systems and all those components do not come together in a holistic way to create an environment for a woman to have a healthy birth. For example, when women come out of their communities, there are many added stressors, such as being separated from support systems and being unfamiliar with their surroundings. Often in that stressful environment, women are not able to give birth easily. Before the medical model came in and women were moving away from midwifery, many women could give birth without pain and without assistance because it was an easy, natural process. In a hospital setting when there are schedules, many women are forced. They do not have the option of saying, "I want to have a traditional, natural birth," or "I want to have that combined Western model with the traditional model, so I can have the best of both worlds." That choice is often not given. Many women will have C-sections, and some are not aware they have had their babies because they are not fully awake when it happens.

The socio-ecological model shows that your spiritual health is practically non-existent when you are evacuated from a community. The element of celebration of birth is taken away. Traditionally, giving birth in our communities was a celebration because you are giving birth to future leaders. In terms of emotional state, a woman does not feel safe or secure, which makes it a much more difficult situation for her. That goes to the physical as well. Of course, the mental stressors of being in a strange, foreign environment and being unsure of the process that is happening can be difficult.

The biggest thing I wanted to note, and it was stated already, is that not until that birth remains in the community and is in the control of the women and the community can you make big changes. This research showed that when women are evacuated, the effects are long-term, not just for a couple of weeks. It might take up to three months before the family is introduced to the baby. Therefore, you have lost all that time and opportunity for bonding, and long-term bonding impacts people's health and their relations in the future.

Health begins at birth, and it is possible to work with the communities to ensure safe births. The Inuit are leaders in this area. They have shown how it is possible to merge the two models together.

The Chairman: This is tremendously important stuff, Ms. Stirbys. I used to say that, too. I was a heart surgeon. I do not know anything about birth, but when I first started thinking about this, I used to say that life begins and we have to get to the baby. Then Fraser Mustard took me to task on that when I was speaking in Toronto. He said that I was missing the whole point. Life begins at conception. You must take care of the mother if you are going to take care of the child. A child born of a physically and mentally healthy mother will most likely be a healthy child and will have a great future. A child born of a mentally and physically unhealthy mother has terrible problems. They have something like a dozen times the incidence of cancer before age 30 and a dozen times the incidence of congenital heart disease, et cetera.

You are on the right path. I would back it up further because the care of the mothers in the community is one of the most important things we can do. I want you people to straighten out old senators like us. I am convinced that you have to control your own destiny at the community level from the point of view of health and social policy.

On that note, we will take a brief break, and I would like you to think about the kind of policy and programmatic changes we need to advance the population health agenda in your communities. What changes do we need? What are we doing wrong here? As Dr. Bartlett pointed out, there is nothing new about population health. We have been talking about it for 35 years. Why has it not worked?

Senator Cook: I listened carefully this morning to attempt to understand whether there were any peculiar determinants of health, because I saw them as barriers. I would like you to comment on them.

Will we ever be clean of residential schools? How long will we struggle with that phenomenon? I belong to the United Church and we issued an apology in 1984.

I heard about the issue of violence — domestic, racial and sexual — and that is common in any society. I heard about colonization, and some of our people are living with that. I heard that seven times more children are likely to live with a relative other than parent. I would like your comment on that to see how that makes a problem for you. Ms. Dickson talked about teenage pregnancy and said that the rate is twice the Canadian average. I heard about overcrowded housing. The day before yesterday a witness said "mediocre schools" and in one of your presentations I heard "lower quality schools." That really disturbs me. All of that seems to say it is precarious health that we are looking at today. These are practical things we need to address because this is about the individual.

Mr. Ermine: For Aboriginal people, and I think this goes for the mainstream population as well, we have relinquished our sense of our own health to the state, and more so in our communities, where we lose all power when we encounter the medical establishment. This goes on and on. I do not have to worry about my own health if Dr. Keon is looking after my health.

This situation cuts across the whole country. It weighs heavily on the financial structures. The Aboriginal community, my home community and others have been trying to understand what enables or constrains our own health establishment in our communities that existed before Confederation, our own knowledge about health as it was. What enables that to function? Many people in our home communities still abide by those principles, which have survived through all these years. Health is much bigger than the individualization that we accord in the medical establishment and some of those issues have been talked about this morning.

If your child is sick, that affects your own well-being and health. The holistic ideas of how spirituality, emotions and everything else about individual health come into the picture have not been explored. All those are traditions are in our own communities, but we have not had the resources to do the necessary evidential building that was talked about here or the capacity building. We have not had resources to do the memory work necessary in our communities to really get a good grip on the concept of health as being the optimum capacity of human beings.

As human communities we have those knowledge traditions in our communities, but the medical establishment, the health systems, being based on Western, scientific evidence, cannot reconcile with this notion of spiritual health that our tradition speaks about. It is a matter of context.

Pardon me, senators, but in terms of policy development, the ideal — and I am speaking about a very high ideal — or the optimum for me would be that the First Nations, the Metis and Inuit be given the resources to develop the policy that you are looking for in terms of our health. The unspoken thoughts, unspoken aspirations that we have in our communities would come out.

Senator Cook: We have not been good at listening.

Mr. Ermine: As Ms. Lys mentioned, we have been discussing these things for many years and it is a matter of capacity building; somehow the dialogue and the partnership must happen.

This morning Ms. Gideon mentioned the Two-Row Wampum, canoes travelling side by side. That, to me, is coexistence. What we see in this country instead is a monoculture where one side of the partnership dominates the discourse on health policy and what it is to be healthy. They hold the purse strings and own everything. In the meantime, we are languishing in our communities with none of the resources. We are not begging for them, but the resources have to flow from the Constitution of this country. This is the struggle we have. We must understand that we are talking about partnership and dialogue, and not everyone in Canada needs to understand what Aboriginal health is. It is not necessary.

Ms. Van Haute: I would like to address three issues based on what we discussed earlier and also respond to Senator Cook's questions.

The first issue is traditional knowledge. It must be recognized that there are various types of traditional knowledge. It is based on Aboriginal or indigenous streams. There are varying degrees of appreciation of it based on the same difference in the Aboriginal streams. In modern times, Metis groups and communities perhaps do not have as much recognition and appreciation of it as First Nations communities do, especially on-reserve. This is not to minimize anyone's appreciation or understanding of it. It just needs to be recognized that it is different. It does not remain the same over the Aboriginal communities.

Second, I would like to move from that to address Senator Cook's question regarding social outcomes of residential schools. The social outcomes will be long-term. They must be addressed at both the community level and a more universal level. In some sense, the social outcomes are common and it would be the same whether in Aboriginal or non-Aboriginal communities. However, in terms of what outcome may dominate in a particular community or group, we need to do community research on that. That goes back to what Dr. Bartlett mentioned this morning. The research and data collection and understanding and policy development and application that we do have to occur on two levels — the universal and the community perspective.

Some of those outcomes have already been noted by various Aboriginal and non-Aboriginal groups as well as various components or departments of federal and provincial governments. The first would be domestic abuse or abuse in the domestic context, physical, sexual and emotional, which often leads, from a mental health perspective, to depression and high tension. High tensions lead to hypertension and cardiovascular issues, which in the end result in higher rates of addiction as coping mechanisms, from alcohol to drugs to food to various other things.

That particular combination or circle of outcomes must be recognized by both federal and provincial governments, as well as Aboriginal organizations and people. We all need to be prepared to deal with those from a long-term perspective and to deal with them in terms of getting Aboriginal people to understand how these things work. Aboriginal researchers share that information, and share it not just at an academic or social or community level, but at a government level. Then, when policies are developed, all Aboriginal streams are at the table in the application process of those policies to ensure that the policies that do come out are efficient, compassionate and community-sensitive but, in the end, ultimately practical.

Third, Senator Keon said earlier that he wanted the group to tell the subcommittee what to do. From a Metis perspective, let me be so bold as to tell you there are four things you should do: One, encourage the government to give full and recognizable appreciation to all Aboriginal streams — not just one or two, but all Aboriginal streams — and to remove the word "Aboriginal" to cover everyone. In this room, the people who represent Aboriginal organizations are not all just Aboriginal. We are each different. Two, encourage governmental support for research by Aboriginals regarding health status and health determinants. Three, encourage the dissemination of that information to government sources, and provide support or confirmation that that material, once disseminated to government, will actually be read and understood by government officials. If it is not understood, there should be a request for more information. Four, encourage the acceptance of the idea at the federal government level that the basic fact of population health is that poverty challenges the good health of any population, Aboriginal or non-Aboriginal. As a result of that, equitable national economic development must occur.

The Chairman: Thank you very much. That is a nice summary for us.

Ms. Dumont-Smith: As I said in my paper this morning, the Native Women's Association of Canada is very much in support of a population approach that addresses the determinants of health. We are looking at health more in a silo approach. To improve the situation, we must include the social and educational aspects. Why are the departments of Indian affairs and human resources development not here? These agencies have policies that influence the social standing of Aboriginal people. It is only when we have those people at the table and work collectively at developing policies that will complement each other that we will change the status quo.

If we just address the economic situation of Aboriginal people by improving their education, that is a good priority, and it is good to focus on that, but that takes time. It takes four or five years to get a university education, and then you have to get into the employment system. I would like to see more players from those different sections involved in the health determinant population health approach and we should all embark upon it at the same time so that we have a multiple-intervention approach. I would be more in support of that.

I believe that overarching of all this we would have our cultural component. By that I mean that Aboriginal people, Aboriginal women, would be involved with all the different components in the development of the policies. I think that is where we have failed so far. Policies are developed at the national level and there is no input from Aboriginal people. As a result, we may have a good policy but it does not fit us, and we know the result is poor health, lack of education, et cetera.

When we look at health, we must look at root causes, and they are all couched in terms of health determinants. We must address each one. Income and social status are causal factors of poor health, so let us develop policies to improve those but at the same time not leave the others to lag behind. Approach the factors collectively.

Dr. King: What I have to say is partly an announcement and also a recommendation. The announcement part is that there is a process going on this year and next in Canada and the U.S. There is a course coming up this summer that several people in the room have been involved in, Ms. Gideon, Ms. Fowler and Ms. Commanda in particular. It is a social determinants of health course for Aboriginal people that will take place this July at Johns Hopkins University and then next year at the University of Alberta. It will be taught mainly by Aboriginal people, including Dr. Jeff Reading. Twenty Aboriginal students from Canada and a similar number from the U.S. will attend the course. Half of those will be nominated by Aboriginal communities and the other half will come from universities. They will learn and work together and take the same evaluation.

The object of the course is to teach the social determinants approach to health from a research perspective. At the end, the students should be able to apply that knowledge to a particular problem in their community or to a research project. The problem can be anything they can imagine. It could be something around health knowledge and literacy, spiritual health, or early childhood education.

If we are successful, the students will be able to apply a social determinants lens to a research project. That will address many of the issues around capacity, ownership, access and control. This is an Aboriginal-driven initiative. There will be only 20 students this year with a similar number next year. Obviously that is not nearly enough. In order for this to be successful, those students will have to be the teachers of the next round of students. That is how it will work.

The recommendation is around research and relates to what I was talking about this morning. Huge health gains could be made by addressing social determinants. It is not easy. It is much more complex than a graph that shows income as a determinant, because many other things feed into income.

This is not to negate the idea of basic biology and genetics. Those continue to be important. It is important to study stem cells and proteomics, but we have the wrong balance in this country, which is where I would like to be provocative. We have the wrong balance in how we determine research funding. We do not do it rationally based on disease burden and health gain. I would rather we did it on health gain than on disease burden, because that is a positive approach.

This applies not only to Aboriginal health but to the general population. Many people's asthma gets worse because guidelines are not followed. We do not need very many new drugs for asthma. Doctors and nurses need to learn how to get the drugs we have to the patients and how to get patients to take control of their own asthma. In Aboriginal health, we need to develop much more than that, but we need to re-examine our health funding. I know that would upset much of the establishment, and I do not want to do that. I would like the establishment to join in the social determinants of health.

I am a recent convert myself. I spent most of my career in the biomedical research industry. It is possible to combine both. You have the basic training to carry out intervention research. Why not apply that to social determinants? We have a huge pool of talent, 90 per cent of our biomedical research establishment, that we could draw on. That is what I would do if I were the president of the Canadian Institutes of Health Research.

The Chairman: Many people agree that it is time for a new look at where we are going. There is no question that we have a tremendous research platform in Canada. I am in the process of preparing a speech for the Senate on research in Canada. This year we will spend almost $9 billion on research in Canada, which is a huge amount. We are now second only to America.

Also, we are the leading country in the world in industrial spinoffs from our research. There are more start-up companies in Canada than there are in America. There is no question that we have been doing some things right, but regardless of great things like CIHR, we have not been doing enough pragmatic things.

Dr. Bartlett: I want to caution about several things and give some advice on some other things.

Regarding the funding mechanisms, one of the problems with any policy initiative is the tendency to try a project out for a very short time and then move on to trying something else. You only begin to build capacities that way in things such as research.

That goes back to the question of whether the problem of the residential schools will ever go away. It will not go away because they are a symbol of the inherent clash of cultures. One culture said that their way was better and everyone should live it. Indigenous researchers worldwide are having conversations about what is inherently different about the way we want to do research versus the way the mainstream does research.

The whole idea of competition is abhorrent to me. I grew up in a family with 11 children. There was no competition; you just lived. There are dichotomies of cultures. For instance, the funding bodies say that we must compete. They throw a little money in and try to get the best product by competition rather than by dialogue and relationship building. We, as Aboriginal researchers, are struggling through that dialogue and relationship building despite the competitive environment of CIHR. It is a very different culturally.

We talk about the need to heal the Aboriginal community. We need to talk about the idea of validating the Aboriginal community. There is nothing wrong with us. We experience stress with the cognitive dissonance of constantly hearing that we should be different. As Metis we are doubly stressed as we are tugged between the First Nations and the European culture, both of which say that we should be like them. It is about validation as opposed to healing.

The concept of healing means more than curing, which is a physical thing. The concept of healing is much broader. We have to think about identity and meaning. We have to think about whether we are using tools for apples to measure oranges. When we think of teen pregnancy, what does it mean? We have not done that research to see what things actually mean to us. We take a population health framework and we stick in 60 or 70 potential things to measure and they might be good things to measure but we do not know what they mean. We measure and then we interpret the indicators from a Western perspective and policy-makers interpret that way as well.

We have to be cautious about taking an emotional approach to Aboriginal health, whether First Nation, Inuit or Metis. Pity only goes so far. It does not empower you. It might get you known out there but then that is what is seen. We want to be able to show what we have of value that is a value added to the Canadian society. We want a decolonizing approach; we need to say how are we valued.

Regarding policy, everyone around the table has talked about spiritual, emotional, physical and intellectual balance. We want to balance the good emotions with the bad emotions, the good spiritual aspects with the bad spiritual aspects. It balances back and forth all the time. So far the health system is focused on the physical body and we need to balance that out.

One-size-fits-all is something to be cautious about. We do not really want to go that way. No one population health framework will fit all. It has been said around the table quite a few times that it is really more about a process than about a product, and the process has to be at a local level. It is a local level of relationship building and dialogue.

We have to keep in mind the science of governance. The international literature makes it very clear that if you do not have self-governance you will have physiological responses to that in the form of the whole stress mechanisms. There is very good evidence to show that self governance, not just government but self-governance — governing one's self, being able to say what one's own destiny is — is as important to health as anything else. One of the most critical things in health is to be able to choose. As Metis we are always caught in the middle. There are so many examples out there that people grab onto but they may be Cree or Mi'kmaq examples. The policy will tend to see those as opposed to seeing the process around the local development of those examples. The process is so much more important than the product. The outcome then will be a changed health status.

This will take a long time. We need the dollars to put the infrastructure in place, to support our communities, to have dialogues with health systems and with other constituencies that live in the same area.

Mr. Gay: I wanted to address policy and programming. We are in an era now where we are talking about open federalism. I strongly urge this committee to come out with a recommendation that ensures that open federalism does not become chequebook federalism. As Canadians, we view our federal government not just as a giant ATM for provincial premiers, but rather as a notional thing for leadership, and not only political leadership, but also economic and moral leadership. Moral leadership might be a bit wavery but I will include it anyway.

"National standards" has become a bad phrase. I do not think that needs to be. We are finding that access to excellent programming stops at borders. Not only does it stop at the border from the reserve to the city, but it also stops between the provinces of Manitoba, B.C. and Prince Edward Island. That is a key lever for the federal government.

On program and policy, we are seeing this a bit but we are not seeing it enough. When we have these big discussions on negotiating health, child care, and housing agreements, our voice is in the interest group. We need our leadership to be part of those discussions, and I have not heard a convincing argument why our political leadership is not at those ministerial tables. I challenge the government to provide that business case or at least open the door. As a result, you would be much more likely to get a dedicated, Aboriginal-specific stream in those agreements as a final product, not an add-on or a little pot of money.

I want to make it abundantly clear that with respect to the Aboriginal community, and I will quote our Supreme Court justice in the Abella report, "equality is not sameness." Everybody thinks all Aboriginal people are all alike, but we are tremendously diverse and our needs are diverse. Recognizing that distinctiveness provides a platform to talk about who we are and to address the challenges we face. We are not afraid of addressing those challenges. That is a misperception in the Canadian world view.

Finally, I would like to say a word about access to elders. That came up from one of the senators earlier. What does that mean? I was reminded of that this spring when I criss-crossed the country on a whirlwind tour. I did focus groups with Aboriginal youth on education and staying in school. They talked about racism and the lack of access to elders. There are no elders in their communities to whom they can talk. The elders provide valuable insight and connection not only to the community but to who they are as individuals, to their identity.

From my experience, it seems that the great spirit has a great sense of humour. I was adopted and he plunked me London, Ontario, which must be Canada's whitest community. Being raised in that community with a big nose, beady black eyes and one hell of a good tan I was either a curiosity or a Wahoo or a wagon burner. There was no in-between. Until I was repatriated to my community I did not realize how hungry my spirit was to see people who looked like me, who talked the Ojibway language. I love the way people speak in my community. Even though I was raised by well-meaning parents, I did not realize how lonely I was until I made that connection. If I could change back time be and asked to do it again, never. That is an opportunity I have been blessed with and it has shaped a lot of my thinking as I get older.

The Chairman: That is very revealing. I must say that things are changing now. Some months ago I heard John Crosbie speaking. He was going on about the loss of the cod stocks off the Grand Banks. He said, "The cod on the Grand Banks are becoming as rare as Caucasians in Toronto." The universe is unfolding in the other direction in some cases, too. What you just said was very revealing.

Dr. Adams: I wanted to add to what others have been saying and to bring a different lens — the idea of resilience. This is not a new concept; we hear about it in indigenous health. We are constantly measured by other people's markers of success and we come in last. We come in last in many health indicators in the country. Many of us have had to leave behind the world we know, the places of our birth and our languages in order to attain success in the dominant culture. I hope we do not have to do that in health by looking at this health theory.

In the B.C. Office of the Provincial Health Officer, we follow about 200 health indicators, from breastfeeding rates to educational attainment of Aboriginal children in foster care, cancer rates, HIV rates of infection and alcohol-related deaths. Out of those 200 indicators, Aboriginal people will match the provincial averages within 10 years. There are really only about six indicators that are getting worse. We are keeping our eyes on them. We manage that with only 80 per cent of the resources of the average provincial population.

Chandler and Lalonde's research into adolescent suicide showed that 90 per cent of adolescent suicides had occurred in 10 per cent of the bands and that half of the bands had not had an adolescent suicide in five years. You could say that half of the bands in B.C. have solved the suicide problem.

This pathologizing of us — the populist notion of us as being the Indian problem in this country — needs to go the way of the dinosaur. Studying our resilience and our success stories and hearing how we are succeeding, instead of spending research money on how we fail, must occur. It can only occur by speaking to the experts, by speaking to Aboriginal people doing that work.

Last, I would like to recommend that there be tripartite memorandums of understanding to share and improve data between the provinces, the federal government — particularly the First Nations and Inuit Health Branch in Health Canada and Indian and Northern Affairs Canada — with Aboriginal people so that we learn and get a clear picture of what is occurring out there. That goes to the theme of questioning what information gaps create barriers to concrete actions on the determinants of health. We do not really know and we need to find out. That kind of data sharing and data improvement needs to rank high in our list of recommendations.

The Chairman: I mentioned in my brief opening remarks this morning that there is much that we can learn when we address the problem of population health on a national basis. There is a tremendous amount we can learn from the Aboriginal community. It is striking that you have the lowest suicide rates in some areas and the highest in others. If we were able to drill down and ferret out that information, we would discover some tremendous messages.

Ms. Wolski: I want to expand on what has been said about policies and list a few that have contributed to our being in the situation we are in today. There is the Canadian Human Rights Act. I would like to say that Bill C-44, which is in front of Parliament now, is a great step forward. There is the issue with matrimonial real property. There, again, positive steps are being made toward addressing those issues.

Then there is the Indian Act. I do not think I am alone in saying that this is a colonial piece of legislation that has contributed to our being where we are in terms of health and, as Dr. Bartlett was talking about, governance. The Indian Act stipulates that the federal government recognize only chief and council as representatives of a community. I think that successful and resilient communities are those that have found their traditional governance systems and have been able to reinvigorate traditional ways of being and traditional processes within their communities. If that was allowed to occur without these colonial pieces of legislation hanging over our heads, we would make great strides toward changing our health status.

Ms. Fowler: You asked us to make recommendations to address some policy and program priorities for change in order to advance a population health agenda. I will not go into detail because much of this has been said already. I do not want to echo everyone's words too much, but I have a few things for the committee to consider.

There needs to be clarification with respect to roles and responsibilities between provinces and territories and the federal government as they pertain to Inuit communities, as I am here on behalf of ITK. We need to build capacity at all levels, including government. We must examine the issues of jurisdiction and control. Research on determinants of health is key, as are baseline health data, partnerships with Inuit leadership and sustainable health care funding.

I would encourage the subcommittee to look at the Inuit action plan that has been provided. It was developed jointly by Inuit and the Government of Canada and focuses on the achievement of tangible and concrete results when working toward improving standards of living for Inuit. The plan can serve as a significant step in building a more sound, effective and sustainable relationship between Inuit and the Government of Canada. To highlight, if you open up to pages 12 and 13, you can see that a number of key social determinants of health are being discussed. As well, in each section there are key areas to be addressed with concrete next steps.

Senator Cochrane: How do we empower people — the children, the mothers, the fathers, all members of families? How do we help them change their attitudes and ways of thinking with a view to a more healthy and healthful perspective?

Mr. Ermine: This is one example. We were looking at issues of mental health in a community and also the traditional medicines. One thing we stumbled upon, going back to what I said earlier about ownership of health, was that the community has to approve everything that the health centre is trying to do.

The biggest struggle we had was to enable community people to believe that health issues are really in their hands and not in the hospital or anywhere else. They are in control of their own health. However, it takes a lot to enable people to believe that. What are the constraints for community people to believe that they are responsible for their own health? We decided that as soon as we got there, then we could have a rich dialogue on how people could maintain their health.

I mentioned a few Cree words. Our Cree words tell us what health is. There is a root word that points to where we can obtain that health. Usually, it points right back to our philosophical and cultural processes in the community: What makes us special as human communities with ideas, what makes each of our communities rich, what makes them unique, what gives them the diversity and what makes us different. In all of these questions, what is the value of human communities? That was the question that we basically stumbled upon. Policies, laws and regulations do not address these diversities. What are the knowledge systems within those diversities?

It takes people, the youth and children especially, to really believe in themselves as to who they are. Once we figure that out, then the real dialogue happens in the communities, which is a helpful dialogue and not one stuck in pathology.

Senator Cochrane: Did you obtain any positive results?

Mr. Ermine: Yes. It is there. Much like this discussion, once we get all the superficial things out of the way, then we can get into a substantial discussion about what health is as an optimum of humanity and the human condition, not the negative aspects of the human condition. The answer lies in those processes.

When we talk about resourcing communities in order to complete their own memory work and research, many times we wonder how we could get this community to talk about their health. How can research trigger community dialogue to happen so that, in essence, members are looking at themselves and capacity building as optimum human beings?

Ms. Wolski: Obviously, this is a complex issue. Over the past 500 years a cycle of dependence has been created where the government has imposed their way of being upon a population. As a result, our ways of being have been lost.

Key pieces are the revitalization and the traditional governance systems being allowed to return and legislation like the Indian Act being abolished.

Ms. Stirbys: The question was a difficult one to hear. It is not so much about people changing their attitudes.

This is one of the questions you asked us to consider: How can the federal government be a leader in the field of population health by developing and implementing a population health strategy for the Aboriginal Canadians who fall under its responsibility? That question goes to what has already been stated — the colonialist mindset that says you are under our control and jurisdiction.

Many of the speakers today have outlined that change comes by the empowerment of Aboriginal people. We have the knowledge and ways of remembering, but there are policies and legislation put in place hinder us; as soon as we become empowered and start making change for the betterment of our community, it somehow does not fall within the funding agreement or within those bureaucratic structures, and maybe funding gets taken away or we are not allowed to do certain things. Whenever we move forward, there is another loophole that pulls away from us.

I wanted to mention a book put together by Crystal Ocean. She is a well-educated woman who was moving forward. Two months before attaining a double Ph.D., a number of circumstances occurred that brought her down to live in poverty. My understanding is she is still living in poverty. Her book is entitled Social Exclusion, Poverty and Health. It consists of 21 women's stories. Aboriginal women are also included. The book basically shows the perceptions of people living in poverty.

The number one thing I got from the book is that if you are in those situations and are trying to move your way out of them, the system is set up so that you never get out. It keeps pushing you back down.

There are also myths about poverty. Therefore, when I heard that initial question, I thought that we have to stop blaming the victim. People have been victimized through colonization, and they want to prove that they have much to offer and are better than poverty. Our communities work hard to show what we have to offer, yet that is not being recognized. I think that was touched on here today.

I was also wondering if it is possible for people who develop policy and legislation to understand and put themselves in the shoes of people who live in Third World conditions today, conditions they must endure while trying to cope with their lack, including lack of nutrient dense foods — food security is a big issue — lack of health services, clean water and proper housing. The list goes on.

What do we do about changing poverty conditions? It is not necessarily about changing an attitude. It is more about structural changes that can happen within government, such as removing the 2 per cent cap on core services, self-government policy reform, land claims and building up that capacity to achieve accountability and clear information and governance.

In addition, as Dr. Adams mentioned earlier, having First Nations governments at the table with the ministers to discuss cross-jurisdictional agreements is an important aspect to focus on.

Solutions will involve creating that openness and environment to bring in new ideas. I think many people in communities today feel like we are back 500 years ago when settlers first arrived. We are bringing in our information and knowledge systems, which are being ignored and seen as inferior.

That is happening today. We are creating that openness. I must state my appreciation for that. It is a good beginning.

Laura Commanda, Assistant Director, Partnerships, Knowledge Translation and International Relations, Institute of Aboriginal Peoples' Health: I want to thank you for creating the openness. I am glad Ms. Stirbys brought up the issue of blaming the victim. Over the years, I have had the privilege of speaking with people around this table on similar topics related to data and health information. I continually hear that people do not want to be in the blame game; they want to be in the health development game.

I also want to acknowledge what Dr. Bartlett talked about, the need for validation in the communities of what is happening that is good, either through research or data. Communities want to know what kind of information governments have about them. It is not that governments are hiding information; it is just that there is not a consistent way to gather information that is meaningful to the community, whether at the national, regional or community level, or at a First Nations, Metis or Inuit level. The data needs to be meaningful and descriptive and it needs to be defined by the population so that they can address their information needs.

Dr. King: It has been a great process today. In the same vein, I wanted to say to Senator Cochrane that governments and government agencies cannot change attitudes; it has to come from the communities themselves.

A simple example, which I discussed with Senator Keon, is in regard to smoking inside the home in front of children. Of course, every doctor in the country would say not to do that, and pretty well every doctor's advice would be ignored. In this case, the elders in the community got together and said this is not acceptable behaviour anymore; go outside and smoke. They did not say not to smoke; they just wanted to get the smoke away from the children.

There is a community in Canada where this is working, and it has nothing to do with what any doctor or government agency did. Hopefully, other Aboriginal communities will learn about this and there will be a knowledge translation community to community. That is how things will change.

Senator Cook: Some of the witnesses will be coming to Newfoundland and Labrador for the Aboriginal health summit. We wish you well. Our premier is hosting the National Summit on Aboriginal Health in Corner Brook in July.

Ms. Dickson: Corner Brook is also hosting the National Aboriginal Women's Summit at the same time.

The Chairman: On behalf of Senator Cook, Senator Cochrane and myself, I want to express our deep gratitude to you for coming today and helping us with this task. You not only helped us in addressing population health from the point of view of your communities, but the information you have provided is of tremendous importance to us in the broader context for the entire country. Your messages were clear, that you have to regain control of our own destiny, that you need self-governance and empowerment, as well as partnerships and participation, and you do not need top-down pundits telling you what to do. You know how to solve the problems if you are given the instruments. We will reflect that.

Thank you all very much.

The committee adjourned.


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