INTRODUCTION

In recent months, several isolated and remote First Nations communities have expressed their deep and ongoing frustration with the level and quality of federal health care services provided to their citizens. For 17 days during the winter of 2016, Norman Shewaybick of Webequie First Nation in northern Ontario, walked more than 1,000 kilometres of icy roads carrying the oxygen tank that would have saved his wife’s life when the nursing station in their community ran out of oxygen. The walk, which was completed by Mr. Shewaybick in the company of his four sons, hoped to bring awareness to the quality of health care services provided to northern Ontario First Nations communities. The story of Mr. Shewaybick and his family is not unique.[1]

On 24 February 2016, Grand Chief of the Nishnawbe Aski Nation (NAN), Alvin Fiddler, along with representatives of the Sioux Lookout Area Chiefs Committee on Health, declared that “the remote First Nation communities in northern Ontario and the broader NAN Territory are in a state of Health and Public Health Emergency.”[2] Following this declaration, members of the House of Commons Standing Committee on Indigenous and Northern Affairs (the Committee), adopted a motion to examine “the state of the health emergency declared in communities of the Nishnawbe Aski Nation and the Mushkegowuk Council regions.”[3] On 14 April 2016, the Committee convened a meeting with First Nations leadership and now reports its findings to the House of Commons.[4]

BACKGROUND

The Declaration of Health and Public Health Emergency in Nishnawbe Aski Nation (NAN) Territory and the Sioux Lookout Region is the latest of many similar resolutions that have been issued over the past several years in relation to health matters.[5] Like the other resolutions, the declaration highlights concerns with the state of the health care services provided to First Nations peoples, noting in particular that many do not receive adequate medical diagnosis and treatment for preventable diseases such as diabetes, hepatitis C, rheumatic fever, as well as bacterial diseases. The declaration also highlights the troubling social conditions in many remote First Nations communities, including the suicide epidemic and the high rates of prescription drug abuse.[6]

In response to these conditions, the NAN declaration calls upon the federal and provincial governments to undertake prompt and sustained action to address health care challenges on reserves. Nine actions to be carried out within the 90 days following the issuing of this declaration are identified, including: the need for investment and intervention plans; access to safe, clean and reliable drinking water; implementation of the recommendations in the Spring 2015 Auditor General’s report; the need to assess health system deficiencies; the establishment of a long-term care facility for the Sioux Lookout Regions; compliance with Jordan’s principle; the allocation of resources for the development of long-term strategies to crisis situations; as well as the need to address the discriminatory and unethical policies and practices associated with the Non-Insured Health Benefits program.[7]

The concerns identified in the declaration are not new. Numerous reports from governmental, Indigenous and other sources have likewise identified gaps in health outcomes between Indigenous and non-Indigenous communities in Canada, and have called for concerted measures to address these gaps.[8] Most recently, in 2015, the Office of the Auditor General of Canada found that First Nations peoples living in northern Ontario and Manitoba did not have comparable access to clinical and client care services as other provincial residents living in similar geographic locations. Notably, the audit found that the vast majority of the nurses surveyed had not completed Health Canada’s mandatory training courses, and that nurses often worked outside their legislated scope of practice in order to provide essential health services.

In addition to the nursing station deficiencies, the audit also found that many First Nations individuals were being denied access to medical transportation benefits because they were not properly registered in the “Indian Registration System.” Under Health Canada’s medical transportation benefits, the transportation costs of eligible First Nations individuals are covered in order to ensure access to medically-required health services. Those benefits consist of ground, air and water travel; living expenses; transportation costs for health professionals; emergency transportation; transportation and living expenses for an escort; as well as transportation to addictions treatment and traditional healers. Of significant concern, the audit also found that Health Canada had not taken into account the health needs of remote First Nations communities when allocating its support.[9]

HEALTH CARE SYSTEM IN FIRST NATIONS COMMUNITIES: WHAT THE COMMITTEE HEARD

Witnesses appearing before this Committee identified a number of broadly shared concerns with respect to the provision of health care services for northern Ontario First Nations communities. In identifying the challenges many communities experience in accessing appropriate medical and clinical care services, they emphasized the need to “return the humanity”[10] to the health care system, a system they described as “broken,”[11] “discriminatory” and “dysfunctional.”[12]

Speaking to the deficiencies of the current health care system, witnesses highlighted the often irreversible negative impacts that the Non-Insured Health Benefits (NIHB) program can have on First Nations individuals. Designed as a national program to provide coverage to registered First Nations for a limited range of medically necessary items and services not covered under other plans or programs, witnesses suggested that the NIHB program aggravates the suffering of patients more often than it relieves it. The Committee was told, for example, that the NIHB Medical Transportation Policy Framework excludes certain types of travel, benefits and services from coverage under the program, such as travel for compassionate reasons, and provides no mechanism to appeal a decision made under the policy. In addition, witnesses indicated that the practice of having to notify NIHB program officials seven days before a medical appointment, often results in people missing appointments that may have taken months to secure.[13]

Dr. Michael Kirlew, of the Sioux Lookout First Nations Health Authority, described the daily challenges of patients subject to the NIHB program. He explained, for example, that children who are not registered as Status Indians under the Indian Act may be denied transportation benefits, even in circumstances where the nursing stations or local health authority may not be properly equipped to deal with the particular medical issue at hand. Dr. Kirlew suggested that, without this transportation subsidy, some children are not able to access the essential health services they need in order to recover and, as a result, may see their condition aggravate.

Dr. Kirlew also spoke to Committee members about children suffering from developmental difficulties, who may need special services such as speech language pathology or occupational therapy, but who face barriers to obtaining transportation out of their communities. Further, he described how some pregnant women are denied escorts and may have to give birth under very difficult circumstances, while patients in palliative care often struggle with the fear that they may die alone.

In his testimony, Dr. Kirlew also raised issues regarding the timely access to medication and the delays associated with Health Canada’s medication approval process. He described instances where nursing stations have run out of oxygen or rationed what remained; he told the Committee about children suffering from asthma and gasping for breath while they wait for the medication to arrive. Similarly, he spoke of individuals suffering from pneumonia, or fractured bones, often having to endure extreme pain while they wait for the arrival of the plane carrying the pain medication.

Witnesses highlighted the mental health aspects that emanate from, or are exacerbated by, the deficiencies in the health care system and the NIHB program. Ontario Regional Chief Isadore Day, for example, spoke about a ten-year old boy who took his own life after travel barriers prevented him from accessing much-needed mental health services. Making reference to multiple suicide epidemics plaguing First Nations communities and involving many Indigenous children, witnesses noted that the story of the ten-year old boy who committed suicide is but one example. Grand Chief Alvin Fiddler and Sioux Lookout First Nations Health Authority representative, John Cutfeet, spoke of the importance of ensuring appropriate access to mental health services and programs, suggesting that many communities, such as the one Chief Day spoke of, suffer from what they describe as collective post-traumatic stress disorder consistent with what is seen in war zones.

Reflecting upon the nature of the health care system in place for First Nations communities on reserve and the need for change, witnesses reasoned First Nations health can no longer be dealt with in isolation. Factors such as developing community infrastructure, ensuring that individuals have access to clean drinking water and sufficient energy resources, as well as allowing First Nations communities to share in resource development, are essential to healthy communities, as they contribute to a person’s physical and mental well-being. Grand Chief Jonathan Solomon of the Mushkegowuk Council, for example, stressed the importance of developing infrastructure to improving health outcomes given overcrowding issues facing First Nations communities. Stressing that a social determinants of health approach is necessary, Dr. Kirlew did caution against using technological innovations – such as tele-health – as a replacement for on-site medical resources.

Concerned that the approach of conducting studies and program evaluations has for too long failed to address the growing health care needs of First Nations communities, Grand Chief Alvin Fiddler recommended that the Government of Canada take the following actions to address the health needs of First Nations communities. These recommendations, which are summarized below, were broadly endorsed by the other witnesses.

• That Health Canada, NAN and Manitoba Keewatinowi Okimakanak (MKO) jointly develop a course of action to fully implement the recommendations in the Auditor General’s report of 2015;
• That Health Canada acknowledge that the present policies, services delivery and funding models are failing First Nations; that an overall health system transformation is required; and that Health Canada along with the Ontario Ministry of Health and Long-term Care work collaboratively with NAN towards solutions that address urgent, intermediate and long-term health and infrastructure needs.
• That the Minister of Indigenous and Northern Affairs participate, along with NAN and Health Canada, in an ongoing political oversight body established to monitor progress;
• That NAN and the Mushkegowuk Council leadership work in collaboration with Health Canada, Indigenous and Northern Affairs Canada (INAC) and other departments to establish a Special Emergency Suicide Task Force to address the growing suicide epidemic in NAN territory; and
• That NAN leads a collaborative process with Health Canada and Ontario that will redefine Jordan’s Principle, and that the result of this work form a basis from which Canada will create legislation that will compel other jurisdictions to a uniform implementation process.[14]

Finally, witnesses called for immediate and strategic investments that respond to the specific needs of First Nations communities and that are done in full partnership with First Nations. While acknowledging the fact that a full health economic assessment has not been yet conducted, Chief Isadore Day called for an immediate adjustment to the federal 2016 Budget. Specifically, he asked that 80 mental wellness teams and 80 community health teams, estimated at a cost of $500,000 per team, be supported, noting that the “cost of doing nothing is huge.”[15]

SUMMARY

Access to adequate, appropriate and timely health care is essential to improving the health outcomes of Indigenous people and communities. As documented by the Auditor General, Health Canada has not taken into account community health needs when allocating its support to remote First Nations communities. The result is that far too many First Nations individuals are denied access to essential medical services.

Having considered the testimony before us, the Committee is profoundly concerned that the provision of health services to First Nations communities, particularly in northern Ontario and Manitoba has, in too many instances, failed to meet the most basic health needs of individuals and that the current system is in need of meaningful reform. Committee members recognize that these issues are complex and that effective solutions will involve the coordinated efforts of federal, provincial and First Nations governments, working together toward a renewed patient-centred approach to the delivery of on-reserve health care.

While an exhaustive study of the on-reserve health care system was beyond the scope of the present motion, the Committee was seized with the testimony that the NIHB program is not meeting the health needs of on-reserve First Nations residents. Members agree with those who appeared before the Committee that no woman should be forced to give birth alone, hundreds of miles away from home, because she may not be able to have an escort travel with her under the policy. We agree that no child should have to wait for medicine to relieve their suffering, and that no Canadian should have to watch their spouse die because of a lack of oxygen. In a country as rich and compassionate as ours, these stories should not have to be told.

The Committee is aware that Health Canada has developed an action plan to implement the findings of the Auditor General’s 2015 audit.[16] Given the importance of the Auditor General’s findings and the need for immediate resolution of the matters raised in his audit, the Committee recommends:

Recommendation

That, as part of the Government’s comprehensive response to this report, Health Canada include a progress report on steps taken to address the findings of the Spring 2015 audit of the Auditor General of Canada on access to health services for remote Indigenous communities.

Committee members are also aware that Health Canada and the Assembly of First Nations are conducting a joint review of the NIHB program and that a report is expected to be tabled in March 2017.[17] Nevertheless, the needs of First Nations people are immediate and the gaps in benefits are reasonably well-understood and documented. Pending a full review of the NIHB, the Committee believes that immediate action must be taken to ensure access to essential medical services and accordingly recommends as follows:

Recommendation

That Health Canada immediately ensure that all nursing stations are capable of providing essential health services to remote Indigenous communities.

Recommendation

That Health Canada take immediate steps to ensure that medical transportation benefits are available to all residents of remote Indigenous communities and, where appropriate, that residents be entitled to bring an escort.

Finally, witnesses appearing before the Committee provided us with a number of well-prepared and thoughtful recommendations for moving forward on improving the on‑reserve system of health care and delivery of services. These recommended actions and observations are appended to the Committee's report. The Committee believes that these proposals merit serious consideration and therefore recommends as follows:

Recommendation

That Health Canada take note of the recommendations provided to this Committee by witnesses, as appended to this report, and respond to them in the Government’s comprehensive response to this report.