Indigenous Health and Chronic/Communicable Disease Management Notes

Indigenous Health in Canada: Demographics and Terminology

  • Demography of Indigenous Peoples:     * Indigenous people represent nearly 5%5\% of the total population in Canada.     * There are three main distinct groups: First Nations, Inuit, and Métis, each with diverse traditions, languages, and cultures.     * The population is notably younger than the general Canadian population, with an average age of 32 years32\,years.     * A vast majority of Indigenous people now live in urban environments.

  • First Nations:     * This term came into common usage in the 1970s as a replacement for the word "Indian."     * First Nations people represent approximately 60%60\% of all Indigenous people in Canada.     * The group is highly diverse, consisting of over 5050 cultural groups living in more than 100100 communities and speaking over 5050 languages.     * Over 50%50\% of First Nations people reside in the Western Provinces.

  • Inuit:     * Inuit are an Aboriginal people primarily of Arctic Canada.     * They inhabit four specific Canadian regions: Nunavut, the Northwest Territories, and the northern sections of Québec and Labrador.     * They comprise approximately 4%4\% of the Indigenous population in Canada.

  • Métis:     * Historically, the Métis emerged from the mixing and intermarriage of First Nations and European people, a process dating back to the 17th century.     * They have developed a distinct culture and language.     * They represent approximately 35%35\% of the Indigenous population in Canada.     * The vast majority of Métis people live in the province of Ontario.

  • Status vs. Non-Status Indians:     * Status Indians: Aboriginal people who are registered or entitled to be registered as "Indians" with the federal government based on specific criteria outlined in the Indian Act.     * Non-Status Indians: People who consider themselves Indians or members of a First Nation but who are not recognized by the federal government as Status Indians.

Socio-Cultural Concepts and Determinants of Indigenous Health

  • Key Definitions of Social Power Dynamics:     * Cultural Hegemony: The process by which the dominant or ruling class maintains its dominance through cultural or ideological means (e.g., the prevalence of Western culture over others).     * Ethnocentrism: The tendency for people to judge another culture as inferior based on the values and standards of their own culture (e.g., viewing the food or eating habits of another culture as "disgusting").

  • Structural Racism:     * Structural racism manifests as lower rates of investment in essential Indigenous infrastructure: education systems, housing, and water treatment systems within communities.     * Inequities in the Justice System: Indigenous people are overrepresented in the prison system and are more likely to be imprisoned when convicted of a crime compared to non-Indigenous people.

  • Colonialism and Intergenerational Trauma:     * Colonialism: The imposition of systems (including policies, laws, and cultures) by settlers on Indigenous people, resulting in thought patterns that support and perpetuate occupation and subjugation.     * Intergenerational Trauma: This results from the exposure to residential schools and the forced removal of children from their families and communities. This trauma is often exacerbated by high poverty rates, illness, and addiction within surviving communities.     * Root Cause Analysis: Often described as a "delayed tsunami effect," where historical colonial policies lead to modern health disparities.

  • Historical and Political Developments:     * 1985 Amendment: Changes to the Constitution and the Indian Act allowed nearly 60,00060,000 people to regain their status.     * 1991 Royal Commission on Aboriginal People: Recommended investment in healing, economic development, human resource building, and Indigenous-led institutions.     * 2015 Truth and Reconciliation Commission of Canada: Published 94 Calls to Action94\,Calls\,to\,Action focusing on child welfare, education, health, language, culture, and justice.

  • Self-Determination and Social Movements:     * Self-Determination: Defined as the right for Indigenous people to maintain control over their own political, cultural, and social institutions.     * Idle No More Movement: Started in 2012 by four women in Saskatchewan; it is one of Canada's largest social movements aimed at educating and supporting civic dissent against policies that oppress Indigenous communities.

Health Gaps and Specific Determinants of Health

  • Economic and Social Determinants:     * Income: 81%81\% of First Nations people living on reserves have a median income below the national poverty line. The poverty threshold is defined as $22,000 per person−year\$22,000\,per\,person-year.     * Social Support Networks: Indigenous people often have larger relative and friend networks compared to White or immigrant Canadians. Inuit people reported a very strong sense of community belonging compared to only 65%65\% of non-Indigenous people.     * Employment: Employment rates for Indigenous people are approximately 7%7\% lower than the non-Indigenous population; they are significantly underrepresented in professional, technical, and managerial roles.     * Education: Only about 50%50\% of Indigenous people have a postsecondary certificate or diploma, compared to 70%70\% of the non-Indigenous population.     * Early Childhood Development: Indigenous children make up nearly 50%50\% of all children in foster care in Canada and are twice as likely to live in lone-parent families or with grandparents.     * Housing: Nearly 1 in 51\,in\,5 Indigenous people live in housing requiring major repairs, and 18%18\% live in overcrowded conditions.

  • Health Behaviors and Access:     * Behaviors: On-reserve populations show higher rates of physical inactivity and smoking, largely due to the adoption of European lifestyles and a lack of access to affordable fresh foods.     * Access: Indigenous people face higher odds of having difficulty accessing immediate care for minor health problems and routine, ongoing care.

  • Health Status (Morbidity and Mortality):     * Mortality: Higher rates of premature and avoidable deaths. Infant mortality and stillbirth rates are higher than the rest of the Canadian population.     * Morbidity: Higher rates of both noncommunicable and communicable diseases, alongside significant issues related to mental health and addiction.     * Self-Perceived Health: Indigenous people consistently rate their health lower than the general population.     * Utilization: Higher rates of hospitalization.

  • Financing and Delivery of Care:     * Medicine Chest Clause: A historical reference used in Indigenous health rights discourse.     * Non-Insured Health Benefits (NIHB) Program: Provides specific benefits to registered Status Indians and recognized Inuit.

Indigenous Views on Health and Systemic Reorientation

  • The Indigenous Medicine Wheel: Health is viewed holistically through four interconnected quadrants: Spiritual, Emotional, Mental, and Physical.

  • Strategies for Reorienting the Health Sector:     1. Policy and Systems Change: Negotiating and implementing health transformation agreements and advocating for systemic shifts.     2. Community Engagement: Identifying stakeholders, building relationships, and integrating engagement into strategic plans.     3. Recruitment and Retention: Mentoring and hiring Indigenous health care staff and providers.     4. Anti-racism and Cultural Safety: Providing mandatory education on cultural safety and creating respectful clinical learning environments.     5. Client Care and Outcomes: Implementing Indigenous Navigators, providing traditional foods/healing practices, elder support, and land-based healing. This also requires appropriate Indigenous data-stewardship agreements.

Noncommunicable Diseases (NCDs): Burden and Frameworks

  • Definition and Global Economic Impact:     * NCDs are also called "chronic diseases." They cannot be transmitted between people or between people and animals.     * The projected cost to the global economy is approximately $47 Trillion\$47\,Trillion by the year 2030.     * The Sustainable Development Goal (SDG) indicator 3.4.13.4.1 aims for a one-third reduction in death risk from NCDs among people aged 30–69 years30\text{--}69\,years by 2030.

  • Specific NCD Statistics in Canada:     * Heart Disease: Estimated that 90%90\% of adults over 20 years20\,years old have at least one risk factor, and 40%40\% have three or more.     * Cancer: The leading cause of death in Canada. 1 in 21\,in\,2 Canadians will develop cancer, and 1 in 41\,in\,4 will die from it. Most common (excluding nonmelanoma skin cancer) are Lung, Breast, Colorectal, and Prostate cancer.     * Chronic Respiratory Diseases: Includes asthma, COPD, emphysema, cystic fibrosis, and occupational lung disease. Note: Tuberculosis (TB) is a communicable disease that results in respiratory issues, thus an exception to the NCD categorization.     * Diabetes:         * Type 1: Insulin-dependent, starts in childhood/adolescence.         * Type 2: Non-insulin-dependent, usually starts after age 4040. Accounts for 90%–95%90\%–95\% of global cases.     * Major Neurocognitive Disorder: Formerly known as dementia. An umbrella term for cognitive deterioration including memory loss and changes in mood and judgment.     * Chronic Pain: Linked to leading morbidity causes. Includes low back pain, migraines, and arthritis.

  • Lifestyle Interventions - Tobacco (WHO MPOWER Package):     * M: Monitor tobacco use.     * P: Protect people from smoke.     * O: Offer help to quit.     * W: Warn about dangers.     * E: Enforce advertising bans.     * R: Raise taxes.

  • Lifestyle Interventions - Alcohol (WHO SAFER Package):     * S: Strengthen restrictions on availability.     * A: Advance and enforce drink-driving countermeasures.     * F: Facilitate access to screening and treatment.     * E: Enforce advertising bans/restrictions.     * R: Raise prices through taxes.

  • Nutrition and Physical Inactivity:     * Poor diet's economic burden is similar to tobacco and greater than physical inactivity.     * Inactivity is specifically linked to depression, anxiety, and falls in elderly people.

  • Health Economics of NCD Interventions:     | Intervention | Annual Benefit (mm) | Annual Cost (mm) | Benefit per 11 spent |     | :--- | :--- | :--- | :--- |     | Aspirin therapy for AMI (75%75\% coverage) | $836\$836 | $27.40\$27.40 | $31\$31 |     | HTN management (50%50\% coverage) | $11,410\$11,410 | $500\$500 | $23\$23 |     | Reduce salt content (30% reduction30\%\,reduction) | $12,121\$12,121 | $638\$638 | $19\$19 |     | Tobacco tax (125% increase125\%\,increase) | $37,194\$37,194 | $3,548\$3,548 | $10\$10 |     | CVD Polydrug (70%70\% coverage) | $13,116\$13,116 | $3,850\$3,850 | $3\$3 |     * Note: Values assume 1 DALY averted=$1,000 USD1\,DALY\,averted = \$1,000\,USD and 3% discounting3\%\,discounting.

Injury Prevention: Haddon's Matrix

  • Framework for Injury Analysis:     * Injuries are complex and require multi-sectoral approaches (sectors, disciplines, jurisdictions).     * Haddon’s Matrix Components:         1. Pre-crash Phase: Factors like information, attitudes, police enforcement (Human); Road worthiness, lighting, brakes (Vehicle); Road design, speed limits (Environment).         2. Crash Phase: Restraint use, impairment (Human); Occupant restraints (Vehicle); Crash-protective roadside objects (Environment).         3. Post-Crash Phase: First-aid skills, access to medics (Human); Ease of access, fire risk (Vehicle); Rescue facilities, congestion (Environment).

Mental Health and Substance Use

  • Definitions:     * Mental Health: A state of well-being where individuals realize potential, cope with stress, work productively, and contribute to the community.     * Mental Illness: Specific ailments affecting thinking, mood, or behavior associated with distress and impaired functioning.

  • Epidemiology and Burden:     * Three major illnesses: Mood disorders, Anxiety disorders, and Schizophrenia.     * Risk Factors: Genetics, stress, and Adverse Childhood Experiences (ACEs).     * Stigma: Involves labeling, stereotyping, and discrimination; addressed via anti-stigma campaigns.     * Caregiver Burden: Over 8 million8\,million Canadians provide care for ill family members.     * Economic Costs: 1 in 51\,in\,5 Canadians experience mental health/substance disorders; costs are at least $50 Billion per year\$50\,Billion\,per\,year.     * Expenditure (2015): Estimated at $15.8 B\$15.8\,B (7%7\% of total health expenditure, with a target of 9%9\% by 2022).

  • Substance Use Disorders (SUD):     * Nearly 22%22\% of Canadians meet SUD criteria in their lives.     * Opioid Crisis: Possible decrease in national life expectancy due to overdose deaths.     * 5 Es of Intervention Strategy:         1. Education: Awareness and marketing.         2. Environment: Limiting density of outlets, distance from schools, secondhand smoke protection.         3. Enforcement: Fines, age limits, decriminalization/legalization.         4. Economics: Raising taxes or imposing fines.         5. Engineering: Vaping vs. smoking, tamper-resistant opioid manufacturing.

Communicable Diseases and Pandemic Management

  • Key Epidemiological Definitions and Formulas:     * Communicable Disease: Illness caused by infectious agents transmitted from person, animal, or reservoir to a host.     * Attack Rate:         Attack Rate=Number of people who became illTotal population×100%Attack\,Rate = \frac{\text{Number of people who became ill}}{\text{Total population}} \times 100\%         Example: 50/500=10%50/500 = 10\%     * Secondary Attack Rate:         Secondary Attack Rate=New cases in householdsHousehold contacts−Primary cases×100%Secondary\,Attack\,Rate = \frac{\text{New cases in households}}{\text{Household contacts} - \text{Primary cases}} \times 100\%         Example: 20/(90−50)=50%20/(90-50) = 50\%     * Point Prevalence:         Point Prevalence=Total people reporting illness at a pointTotal population×100%Point\,Prevalence = \frac{\text{Total people reporting illness at a point}}{\text{Total population}} \times 100\%         Example: 70/500=14%70/500 = 14\%     * Virulence (Case Fatality Ratio):         Virulence=Number of deaths from the diseaseTotal number of casesVirulence = \frac{\text{Number of deaths from the disease}}{\text{Total number of cases}}         Example: 50/150=0.3350/150 = 0.33

  • Outbreak Management (Implementation Steps):     1. Confirm the existence of the outbreak.     2. Assemble a team.     3. Implement initial control measures.     4. Formulate a case definition.     5. Describe the outbreak (person, place, time).     6. Conduct active surveillance.     7. Generate and test hypotheses.     8. Declare the outbreak over.     9. Debrief the team.

  • Infection Prevention and Control (IPAC):     * Provider Controls: Hand hygiene, PPE.     * Administrative Controls: People, protocols, and practices.     * Environmental Controls: Cleaning surfaces and disinfecting equipment.

  • Other Communicable Disease Issues:     * Antimicrobial Resistance (AMR): Requires antimicrobial stewardship, laboratory surveillance, and rational prescription practices.     * Vector-Borne Diseases: Carried by mosquitoes/ticks (Malaria, Dengue, Yellow fever). Emerging in Canada: Lyme disease and West Nile virus.     * Foodborne/Waterborne: Canada sees approximately 4 million4\,million episodes, 11,00011,000 hospitalizations, and 200200 deaths annually.     * STIs and Bloodborne Infections: Increased since the 1960s (sexual behavior changes, birth control) and 1990s (HPV links to cervical cancer).     * Bioterrorism: Deliberate use of microorganisms for infection; requires emergency response plans and lab protocols.

Environmental and Occupational Health

  • Toxicity and Risk Assessment:     * Establishing Toxicity Sequence: Source →\rightarrow Environmental Media (soil, air, water, food) →\rightarrow Point of Exposure →\rightarrow Receptors →\rightarrow Route of Exposure (Inhalation, Ingestion, Dermal).     * Steps of Risk Assessment: 1. Hazard Identification, 2. Dose-response assessment, 3. Exposure assessment, 4. Risk characterization.     * Risk Management: Education, threshold setting, evidence-based guidelines, bans (voluntary/mandatory), regulation, and technology.

  • Environmental Issues:     * Electromagnetic radiation (EMR), Light pollution, Noise pollution, Climate change, Global warming.     * Waste Management: The "4 Rs" - Reduce, Reuse, Recycle, and Recover.

  • Occupational Health and Exposure Types:     * Chemical: Organic dust, Asbestos, Lead, Mercury, Alcohol, Secondhand smoke.     * Biological: Hepatitis B and C, HIV, Anthrax, Brucellosis.     * Physical: Noise, heat, cold, ionizing radiation.     * Mechanical/Ergonomic: Vibration, undue force, awkward posturing.     * Psychosocial: Workplace bullying, harassment, stress, precarious work.

  • Hierarchy of Controls (Most to Least Effective):     1. Elimination: Physically remove the hazard.     2. Substitution: Replace the hazard.     3. Engineering Controls: Isolate people from the hazard.     4. Administrative Controls: Change the way people work.     5. PPE: Protect the worker with Personal Protective Equipment.

Questions & Discussion

  • Guest Speaker Interview (Lecture 10):     * Guest: Dr. Sinead McElhone (Acting Director, Surveillance and Evaluation, Public Health Niagara Region).     * Topic: One-on-one interview regarding the COVID-19 pandemic response in the Niagara region.

  • Guest Speaker (Lecture 9 - Psychedelics):     * Guest: Hyder A. Khoja, PhD (Founder & CEO of Transcendent Therapeutics, Inc., and various other scientific advisory roles).     * Topic: Evaluating clinical effects of psychedelics and psychoactive compounds on mental illnesses and implications for public health.

  • Guest Speaker (Lecture 8):     * Guest: Bilal Ahmed, Pharm.D, MSc, PhD (Post-doctoral fellow, University of British Columbia).     * Topic: Noncommunicable diseases, determinants, and the importance of prevention in public health.