The territory of Nunavut was created in 1999 as a result of a long and arduous land claims process. Nunavut is home to one of the youngest populations of any territory or province in Canada (Marchildon & Torgerson, 2013). This information should be reassuring as it is assumed that youthful people require fewer medical services than aged communities. Unfortunately, due in part to relatively negative socioeconomic determinants of health, the need for improved services is higher for this demographic than the Canadian average (Marchildon & Torgerson, 2013). Poor health conditions are also reflected via the widening life-expectancy gap between Nunavut’s population and the remainder of Canada, with the territory on the lower end of longevity (Marchildon & Torgerson, 2013). Between the years 1994 and 1998, the gap was 9.1 years for the average male and 9.0 years for the average female. By 2013 these numbers increased to be 11.9 years for males and 12.3 years for females (Marchildon & Torgerson, 2013). Despite an overall youthful demographic, this gradual decline of life-expectancy is concerning and suggests a relative deterioration in health status for this population (Marchildon & Torgerson, 2013).
Low health status in Nunavut is strongly influenced by comorbidities that result from the severe socioeconomic strain. Reports of crowded living conditions have cumulated in higher teen pregnancy rates, mental and physical illness, injury, and suicide (Marchildon & Torgerson, 2013). Higher comparative rates of smoking and drug use are also common, and health essentials such as fruits and vegetables are historically inaccessible as foods must be imported for residents to buy (Marchildon & Torgerson, 2013). To further illustrate, 57% of households in Nunavut were found to be food insecure between the years 2017 and 2018 (Tarasuk & Mitchell, 2020). Lastly, low participation in fitness activities has led to a heavy burden of health complications related to sedentary lifestyles (Marchildon & Torgerson, 2013).
Apart from a lack of necessities, Nunavut also struggles under the lingering weight of colonialism. Nunavut is the only sub-state of Canada in which a single Indigenous group, the Inuit people, make up a significant majority of the population; the territory’s character is defined by its being a cultural homeland for its residents (Marchildon & Torgerson, 2013). Past attempts to establish westernized health-services based on colonial beliefs in a majoritarian First Nations territory have proved damaging to the population (Quinoñez, 2012). Attitudes amongst Inuit service users, Inuit health care providers and non-native health care providers stationed in Nunavut reflect a lingering history of discrimination and trauma (Møller, 2010). Inuit care providers often withdraw from practice and necessary education because they are discriminated against by western medicine for being “superstitious” and “unscientific” (Møller, 2010). Inuit service users feel they are being talked down to and sometimes avoid healthcare interactions to their detriment (Møller, 2010). Lastly, Euro Canadian practitioners disproportionately hold Inuit people responsible for their ailments, actively blaming stereotypical behaviours, like drinking and gambling, for health complications (Møller, 2010). Overall, colonization’s socio-political side effects have shaped the delivery of services resulting in culturally incongruent health care practices that are not informed by Inuit ways and values and are therefore detrimental to Nunavut’s population (Møller, 2010).
To build a more substantial domestic healthcare force, Nunavut invests in instructive programming for aspiring Inuit service workers. However, low completion rates in both primary and secondary schools have limited the possibility of attending available courses (Marchildon & Torgerson, 2013). These factors dangerously constrain the attempted development of a domestic workforce, leaving the demand for culturally appropriate services unanswered. The issue of low graduation rates is not unrecognized, the report resulting from the 2017 Nunavut Roundtable for Poverty Reduction includes the following statement on the matter:
“We need to improve our attendance and graduation rates in all learning programs. There is also a need to strengthen our formal education system, including K-12, high school completion options, and post-secondary. We also need to increase support for learning outside of formal schooling, including in our workplaces, communities, and families” (n.d, p. 23)
Alongside the territory’s difficulties in creating a domestic workforce, Nunavut struggles to maintain its foreign physicians. A study conducted between 2014 and 2016 found that more than half of the physicians working in Nunavut were contracted for fewer than 20 days at a time (Cherba, Akearok, & MacDonald, 2019). Socially, patients are dissatisfied as they exhaust themselves re-explaining their medical histories to a revolving door of professionals (Cherba, Akearok, & MacDonald, 2019). Poor retention hinders the creation of respectful and trusting relationships between service users and providers, which are essential values in Inuit culture for providing community-centred care (Cherba, Akearok, & MacDonald, 2019). While practitioners are being attracted to the area for its beauty and culture, they are having trouble staying due to expensive travel, limited job opportunities for spouses, and inadequate personnel training (Cherba, Akearok, & MacDonald, 2019).
As a response to the high demand for services and the professional draught, Nunavut’s health care is outsourced via increasing numbers of medical evacuations (McDonnell, Lavoie, Healey, Wong, Goulet, & Clark, 2018). These evacuations are a result of numerous intersecting factors, including insufficient staffing, an inability to access specific forms of diagnostic practice as well as a lack of necessary treatment plans (McDonnell et al., 2018). Challenges related to the recruitment and retention of well-trained, culturally sensitive physicians also contribute to the prevalence of medevacs (McDonnell et al., 2018). Despite the apparent need for medical evacuations, this emergency procedure should not be a permanent or primary solution to the health crisis. A 2015 study on the psychosocial effects of medevacs in Nunavut revealed that Inuit patients experience an impactful lack of social support during their transfers (Mckenzie, 2015). Once they arrive in a southern hospital, Inuit patients report a lack of cultural sensitivity that results in feelings of homesickness and isolation (Mckenzie, 2015). These results demonstrate that medevacs cannot meet the psychosocial needs of Inuit patients and their families, which directly affects patients’ mental health and the medical outcomes of their treatment (Mckenzie, 2015). Nunavummiut people have the right to be treated in their communities, surrounded by family, friends and the healing comfort of home.
After conducting extensive research, it is clear that the current climate of healthcare services in Nunavut is not adequate to support a healthy population. A history of colonialism rooted in discriminatory stereotypes has disadvantaged the Inuit people (Møller, 2010). Socioeconomic barriers to health, such as high cost of living, overcrowded housing, low exercise, and inadequate dietary control, have created a strong need for health services (Marchildon & Torgerson, 2013). Moreover, care is being increasingly outsourced to surrounding provinces, as the territory is not equipped to handle care complications (McDonnell, Lavoie, Healey, Wong, Goulet, & Clark, 2018). Lastly, a revolving door of culturally unequipped physicians adds to the lack of community-sensitive care (Cherba, Akearok, & MacDonald, 2019). Unfortunately, there is no universal consensus on how this problem should be solved. However, it will involve an overhaul of current practice and policy to create an approach that supplies the territory with the means to provide sustainable care.
Recommendations
- Invest in education and training of Nunavummiut medical staff through the creation of more supportive and culturally inclusive learning environments from K-12, to high school, to post-secondary and in the workplace.
The Inuit people are best equipped to care for their communities, as they are knowledgeable about their cultural practices, values and sensitivities. There needs to be a plan to dismantle the educational barriers that prevent the Inuit people from obtaining the training necessary to participate in care work. Providing more support to children as they move through primary and secondary school could increase the historically low graduation rates, which can lead to a larger pool of viable candidates for health care training (Møller, 2010). Increasing the number of Inuit health practitioners could also be achieved through decolonization measures in political and social spheres. As mentioned, students often leave their medical training due to discrimination they experience in primarily westernized programs (Møller, 2010). Increasing the inclusivity of these programs in terms of content and bridging in more Inuit professionals as instructors could help alleviate the discomfort felt by Inuit students and promote more Nunavummiut doctors. Further, supporting new local doctors could provide an alternative to medical evacuations and circumvent the costs of building facilities outside of Nunavut.
- Invest in the retention of non-Nunavummiut staff by creating a strong, supportive community for rural physicians and their families.
The Society of Rural Physicians of Canada (SRPC) is attempting to combat those barriers faced by foreign physicians (n.d). The SRPC is a not-for-profit, non-governmental organization that invests in rural health care (n.d). The assembly is a voluntary professional community that provides culturally sensitive education to professionals and advocates tirelessly for more appropriate health delivery mechanisms in rural communities (SRPC, n.d). This organization’s primary goal is to foster communication among rural physicians and other groups interested in rural health care to build a network that promotes informed physicians and professional retention (SRPC, n.d). More efforts need to be made to ensure a professional network that sustains healthy outcomes for Nunavut’s population. The existence of the SRPC demonstrates that this need is not being wholly ignored. Physicians are organizing themselves to stay where they are needed most. Together with more effective promotion of healthcare education in the Inuit population, these efforts could produce a diverse, well-equipped staff to handle Nunavut’s healthcare demands.
- Establish mandatory training on Inuit medicinal practices and cultural norms for all medical staff in Nunavut to ensure appropriate services are provided.
The SRPC’s Indigenous Health Committee is in the process of developing a series of virtual, educational events to bring awareness and provide learning opportunities for all SRPC members about Indigenous health education (n.d). Once completed, these video lectures will be made available to all members of the SRPC for self-guided learning (n.d). The goal of this series is to define cultural awareness, sensitivity, competency, safety and humility. It also seeks to explain the historical impact of colonialism and describe the demographics, health and social issues that affect Indigenous populations (SRPC, n.d). After completing the course, participants should be able to understand how racism has negatively impacted indigenous communities and use new skills to interact with and give culturally safe care to Indigenous patients, families, and communities (SRPC, n.d). Given these resources’ availability and the massive impact culturally insensitive care is having on Nunavut’s health status, this type of training should be mandatory for all incoming physicians. Larger scale seminars and learning sessions could be funded to ensure culturally-informed care is practiced.
References
Cherba, M., Akearok, G. H., MacDonald, A. (2019). Addressing provider turnover to improve health outcomes in Nunavut. Canadian Medical Association Journal 191 (13). Available from http://dx.doi.org.proxy.library.carleton.ca/10.1503/cmaj.180908
Marchildon, G.P., & Torgerson, R. (2013). Nunavut: a health system profile. McGill-Queen’s University Press. Available from https://books-scholarsportal-info.proxy.library.carleton.ca/en/read?id=/ebooks/ebooks3/upress/2014-01-23/1/9780773588844#page=47
McDonnell, L., Lavoie, J. G., Healey, G., Wong, S., Goulet, S., & Clark, W. (2018). Non-clinical determinants of Medevacs in Nunavut: perspectives from northern health service providers and decision-makers. International Journal of Circumpolar Health 78(1), 1571384. Available from https://www.tandfonline.com/doi/full/10.1080/22423982.2019.1571384
McKenzie, C. (2015). Medevac and Beyond: The Impact of Medical Travel on Nunavut Residents / ᑐᐊᕕᕐᓇᑐᒃᑰᕐᓂᖅ ᐊᒻᒪᓗ ᐅᖓᑎᒃᑲᓐᓂᐊᓄᑦ: ᓄᓇᕗᒻᒥᐅᑦ ᐋᓐᓂᐊᕕᓕᐊᖅᐸᑦᑐᑦ ᐊᑦᑐᖅᑕᐅᓂᕆᕙᑦᑕᖏᑦ. International Journal of Indigenous Health, 9(2) p.80-88. https://journals.scholarsportal.info/details/22919368/v09i0002/80_mabtiomtonr.xml
Møller, H. (2010). Tuberculosis and colonialism: Current tales about tuberculosis and colonialism in Nunavut. Journal of Aboriginal Health, 6(1), 38-48. Retrieved from http://proxy.library.carleton.ca/login?url=https://search-proquest-com.proxy.library.carleton.ca/docview/1138544856?accountid=9894
Nunavut Roundtable for Poverty Reduction. (n.d). The Makimaniq Plan 2: A Shared Approach to Poverty Reduction, 2017-2022. https://www.gov.nu.ca/sites/default/files/makimaniq_2_final.pdf
Quinoñez, C. (2006). A Political Economic History of Medical and Dental Care in Nunavut, Canada. International Journal of Circumpolar Health, 65(2), 101-116. Available from https://www.tandfonline.com/doi/pdf/10.3402/ijch.v65i2.18093
Society of Rural Physicians of Canada (n.d.). About Us. Retrieved from https://www.srpc.ca/about-the-srpc
Tarasuk, V., & Mitchell, A. (2020). Household food insecurity in Canada, 2017-18. Toronto: Research to identify policy options to reduce food insecurity (PROOF). Retrieved February 14th, 2021, from https://proof.utoronto.ca.
Author: Camille Houde
