Country in Focus: health disparities in Indigenous Canadians

Abstract

Indigenous populations around the world have been ravaged by diabetes at rates that greatly exceed national averages. Canadian aboriginal people (which includes First Nations, Metis, and Inuit) make up a mere 4·3% of the population, yet they have a rate of diabetes that is 2·5–5-times greater than that of the general population and experience more comorbidities and complications, which strike at younger ages. According to a 2011 national report by the Public Health Agency of Canada, the age-adjusted prevalence of diabetes was 17·2% among First Nations communities living onreserve and 10·3% among those living off -reserve, and 7·3% among Metis. The rate among Inuit matched the national average of the nonAboriginal population, which is 5%. When the staggering health disparities are analysed, it is hard to ignore the environmental and sociohistorical context that has shaped the present, suggests Paul Hackett, Assistant Professor in the Department of Geography and Planning at the University of Saskatchewan. His research on the historical roots of the type 2 diabetes epidemic in various First Nations communities in Manitoba and Saskatchewan points to what he describes as rapidly occurring “sociocultural disruption”. Hackett and colleagues have shown that diabetes was almost unknown among Aboriginal people in those provinces 60 years ago. Although a genetic predisposition has been suggested, it cannot alone account for the surge of metabolic diseases over the course of a few decades. “There must be something in the environmental context that has changed”, says Heather Dean, a pediatric endocrinologist based in Winnipeg, Manitoba, and member of the Canadian Diabetes Association’s Clinical and Scientifi c Section. Dean suggests that rapid changes away from the traditional ways of life over the past 50 years, intrauterine exposure to maternal obesity and type 2 diabetes, and unique genetic polymorphisms are involved. Findings from a recent study of the Believing we can Reduce Aboriginal Incidence of Diabetes (BRAID) research group in the province of Alberta suggest that cultural loss has fuelled the diabetes epidemic among some Aboriginal communities. Led by Richard Oster, at the University of Alberta’s Faculty of Medicine and Dentistry, the study involved interviewing ten First Nations leaders and examining diabetes prevalence data from databases of the Health Ministry of Alberta for 31 First Nations communities. Diabetes prevalence ranged from 1·2% to 18·3%, while Indigenous language retention ranged from 10·5% to 92·8%. Strikingly, traditional language use, which was regarded as a proxy for retention of Indigenous culture, was a negative predictor of diabetes, even after controlling for socioeconomic factors. Communities with the highest preservation of Indigenous culture and traditions had the lowest rates of diabetes, even lower than some nonAboriginal populations. Culture and tradition shape people’s concepts of health and illness, thus playing a pivotal role in Indigenous health, suggests Anita Ducharme, Executive Director of the National Aboriginal Diabetes Association. “Culture and traditional practices and ceremonies, such as powwows, sweats, community feasts, and sharing-circles, provide connectivity—a sense of community, caring, belonging, respect, and calm, which are all aspects of holistic healing”, she says. First Nations leaders in Oster’s study also reported that self-determination was important for health, but seriously lacking. Evan Adams, Chief Medical Offi cer with the Vancouverbased First Nations Health Authority in the province of British Columbia notes that self-determination has been eroded through colonisation, which “marginalised Original people, stripped them of much of their wealth, and undermined their knowledge systems”. The infl uence of those cultural assaults on health became clearer when provinces, geographical areas, and communities were compared—type 2 diabetes incidence is as high as 250 per 100 000 people in some Aboriginal communities in Manitoba and Saskatchewan, whereas the rate in British Columbia is equal to that among non-Aboriginal people. “We haven’t given away our material wealth and real estate”, says Adams, “so we have a lot of economic and thus political clout, meaning we can really rally to have equal health outcomes.” Culturally appropriate interventions that are community-based and led, go beyond conventional social determinants, consider traditional Aboriginal ways of understanding health, and promote cultural connection and celebration, are needed. But it’s not about addressing one disease, says Hackett. “Whether it’s diabetes, tuberculosis or obesity, these are all just symptoms of a bigger problem, which requires solutions that attack the issues in a more holistic way in partnership with communities and that acknowledge historical inequities.”