CONSULTATIONS ON PUBLIC HEALTH GOALS FOR CANADA

Meeting Summary

Welcome and Overview
(Ministers Bennett & Aglukkaq)

The Honourable Minister of State, Carolyn Bennett (Public Health); Leona Aglukkag, Minister of Health and Social Services, Nunavut; and Martha Michael, Elder were introduced by Victor Tootoo. Martha Michael opened with a prayer. Minister Aglukkaq formally welcomed Minister Bennett and the assembled guests to the territory. She stated she appreciated the opportunity given by the government to listen to eclectic input so Nunavut and other provinces and territories can assist with the goal-setting. She thanked Minister Bennett and Minister Teresa Oswald (co-chair) for their joint leadership and for spearheading this initiative.

This consultation is not about reforming the existing system, but about building a health care system that works in and for Nunavut, raising our health status to the level enjoyed by other Canadians. The federally led system is as strong as its weakest link and Nunavut is the weakest. We intend to change this. The Care Close to Home strategy will improve care locally. Focusing on the social determinants is important. Canada needs a seamless public health system. We welcome formation of a pan-Canadian system.

Aboriginal people accept a broad definition of health. We live by Inugatigittiarniq, health of mind and body, to be alive and healthy in everything, to live well, and not to harm. Inuit were healthier when they lived on the land, but now face new environments and new challenges. Here, we must improve conditions and access to the range of basic services. We need commitment from the Government of Canada to ensure Nunavut health equity with other Canadians.

Martha Michael, elder , related her experiences with health and with Inugatigittiarniq. When she was a young girl her mother and father brought her up by seal oil lamp. As elders right now we know that many young people have no knowledge of many issues, which, in the past, would have been passed on by watching and listening to elders. I sympathized with my mother. She had many children and when my father was away catching seals, tending the lamp and keeping us warm and bright must have been hard for her. Sometimes the flames were very low, but meals were slow-cooked so that when our father came back dinner would be ready and the flames burning brighter and warmer. I am alive today because I was told how to live appropriately. I have tried to live a healthy life as taught by my ancestors. I am still doing this, practicing knowledge by memory. We remember things from the past, positive things, how we dealt with hardships. Young people are starting to understand what we've gone through. Our knowledge can be utilized in everyday life, even now.

You people working on health are very strong. You are working on very hard issues. You must remember the spirit, the higher power who is helping you to go on with your work. The first time I had to deal with death, to not let it overcome me, was when my father's brother died of starvation while hunting. This happened long ago, but I remember and it helps me pass on. You, who have to deal with death often, are strong. I still cry at death, but I get over it too, and am grateful to be here today.

Minister Bennett thanked Martha Michael for her prayer and her knowledge. Minister Bennett stated she is impressed by the dignity and pride of people in Nunavut, the majesty of the land, and how they go together. Integration makes sense up here. These consultations have made her realize the harmony present on this issue of keeping people well rather than patching them up when they're sick. We have focused on the tyranny of the acute, but lifestyle is integrated with the land and with wellness. So much of wellness comes from a sense of belonging and being treated with respect. At a meeting here we were told that we couldn't do health without fixing justice, poverty, education and so on. In the last decade an understanding has emerged that the only way the health care budget will be stabilized and sustainable is by having all the other departments do the things that keep health costs down. SARS, because of the economic kick in the head it gave Toronto, even affected equalization payments. It precipitated a new understanding of integration. In that climate, aboriginal teachings and traditional knowledge keep coming to the fore. Because of this, we will produce a uniquely Canadian set of goals. First Nations peoples had it right all along. Now we have this opportunity. It is time to push the reset button.

Dr. Isaac Sobol, CMO, Nunavut , said the government of Nunavut is committed to the principles of Inuit Qaujimajatuqangit (IQ), traditional knowledge which leads to healthy communities. This is a golden opportunity to establish Nunavut as a trendsetter for the rest of the country.

Objectives

• Review proposed theme areas.
• Review, consider and discuss sub-theme areas.
• Recommend goal statements for theme areas.

Themes

Discussions took place in an open forum and then in small groups around the proposed theme areas and the sub-themes as they appear in the consultation workbook. Each table was asked to discuss one theme area, and rework or develop new sub-themes, draft goal statements and address any values or principles they felt should be included. Other comments were also noted. Each theme as it appears in the consultation workbook and the suggestions (or sub-themes) around how they can be addressed appear in the text boxes and are followed by a summary of each of the small group discussions as reported back in plenary. Each theme has a section called Values, Principles, and Practices which illustrates the universality of many themes, the practical examples cited and Inuit Qaujimajatuqangit (IQ).

Goal Statement

Meet basic needs.

• Food : money for food, healthy food, enough food, skills to prepare food, environment.
• Shelter : adequate housing, safe housing, healthy housing.
• Security : personal security, no violence, safety in the community, emotional security.

Sub-Themes

• Address malnutrition. In Nunavut last year there were 17 cases of rickets (vitamin D deficiency) in a population of 30,000. This is a public health crisis, yet there is one dietician in the territory. The conditions of malnutrition in Nunavut are appalling, and it is shocking that the food security situation here can be compared to that of the Third World.
• Address adequate, safe shelter. Set minimum standards. It is unacceptable that 11 people live in a two-bedroom house.
• Teach within the community. Community learning would include: parenting, cooking skills, land skills, healthy pregnancy and breastfeeding, child development, training, skills sharing, community input, using community expertise (elders, respected people, role models), volunteering, sustainability, and healthy relationships, which circle around to parenting. Everything is connected and important.
• Develop a system to support this, containing: human resource capacity, inter-governmental collaboration, community assets, leadership. Fund for the long-term. Make it more sustainable by mentoring, using community capacity and grassroots input. Share skills. Bring out elders, leaders, and role models. Train people within the community to be speech pathologists, midwives, optometrists, or whoever is needed. Right now community health representatives have too much work piled on them. Perhaps a speech pathologist is not needed, but local people could be trained to help get kids who cannot speak ready for school.
• Share assets, do not rigidly protect or horde them.
• Demonstrate leadership by articulating minimum standards for health.
• Recommended reading: The Solid Facts of Health, Dennis Rafael.
• Vulnerable populations are the target audience; they're the people not meeting their potential. Focus on vulnerable populations is woven through all themes. Healthy living is for everyone, not just middle-class Canadians.
• Bring in Inuit priorities. Move past the idea of aboriginal people being treated as something separate, put on a shelf, and looked at later.
• Use funds in an integrated way. eg. put prenatal/parenting/early learning together with traditional skills.

Values, Principles, and Practices

• If basic needs are not being met, we cannot hope to look at things like smoking cessation and TB eradication.
• We need to develop a community system which meets the needs of early learning, in a non-confrontational way. A more positive environment is needed. eg. people are adverse to the case worker visiting their home because of negativity associated with government officials (with good reason). Use the skills present in the community.

Goal Statements

Support healthy communities and healthy working environments with:

• Partnerships: government, NGOs, NTI, media, private industry. eg. cooperative airline scheduling rather than competing airline scheduling.
• Economics: women's groups, childcare, a system comparable to HTO, encouraging entrepreneurial, small business and cottage industry economies.
• Technology: connect to the world, get an outside perspective. eg. Telehealth
• Community mindedness: care about neighbours, practice IQ
• Work environment: training, encouraging health, flexibility
• Circumpolar linkages: best practices, news, knowledge
• Cultural appropriateness: develop policy frameworks that are flexible and culturally appropriate. Integrate with NGOs, government of Canada and government of Nunavut.

Sub-themes

• Encourage entrepreneurs in small business and small cottage industries. This can be within tourism too. eg. supporting a good sausage maker who uses caribou meat.
• In Nunavut the word community translates to a geographic community. From the Inuit perspective community is a geography and every person who lives within that geography belongs to that community. Iqaluit has sub-communities such as long-term residents and transients, but they all belong to the community of Iqaluit. (Note: In Nunavut a community is a hamlet or village with a population of 100-2500. They are isolated, without people living around them, except for small [20] outpost camps.)
• Recognize the value of women's work. In traditional economies we have the HTO (Hunters and Trappers Organization) which enables someone hurt while hunting on the land to get Workers Compensation. But if a woman breaks her leg and can't go berry-picking there is no help for her.
• Keep the community safe from what it does not yet have. eg. Inuit society is relatively HIV free. How do we prevent HIV from getting a foothold?
• Emphasize the positive. eg. if there is a disaster on the land, report on how the community came together and helped out, rather than the number of deaths.
• Beware the formal workplace. When moving people out of traditional lifestyles and into formal working environments they are often crammed into cubicles and into unhealthy lifestyles.

Questions and Answers:

• What contributes to sustainable, diverse and safe environments? Infrastructure (basic, cultural, recreational), money (capital, O&M), education and training (knowledge, coping with technology, understanding ramifications of choices and decisions), government policies and government at all levels, community empowerment (capacity, knowledge, understanding).
• What is sustainability? Nothing is sustainable without effort. What we want to sustain now may not be what we want in the future. What is sustainable in one set of circumstances may not be sustainable, or even desirable, in another.
• How do we factor in diversity? It must be accommodated and it can be used positively.
• What is the role of government? At what levels? Coordinate the effects governments can have on health. eg. tax cigarettes to subsidize milk.
• Who will criticize employers when there are so few? Employers provide many jobs and put money into the economy.
• How do we build safe environments? How do we encourage stewardship rather than ownership?
• How do we expand without destroying the natural environment?

Values, Principles, and Practices

• Keep the water supply clean. Treat sewage.
• Decontaminate and do not contaminate further.
• Make partners of employers to preserve the natural environment. Reward those who act responsibly. Punish those who do not. Do not continue to allow big companies to come in, do what they want, destroy and contaminate, then leave. Make them pay a deposit to be applied to clean-up and rehabilitation of the site.
• Dispose of garbage responsibly.
• We are still at a very basic level of providing the requirements to a healthy lifestyle. Build capacity according to community requirements.
• We cannot work in isolation. We cannot ignore what we now know.
• Researchers who come up and get information must give something back to the people and places they studied.
• Train staff in proper handling and delivery of water and food.
• Train staff and employers on the impacts of their product or service on people and on the environment.
• Work on the problem of the creation of waste. Who bears financial responsibility for packaging, vehicles, containers? At what point does it become critical?
• Community can respond to environmental issues.
• Consider the least safe areas of communities as a priority.
• The logistics of ensuring the integrity of the environment are monumental.
• Subsidize food so that the north pays the same as the south. eg. Northerners can buy cigarettes for the same price as someone in Ottawa, but food costs 3-4 times as much. In Ottawa milk costs about $5.00 for three litres, in the far north three litres costs $14-$16. Many people cannot access food mail because they don't have a credit card, or internet access, or transportation to the airport.

Sub-themes

• The definition of Vulnerable Populations is: "The absence of one or more of the determinants of health, or the inability to access the determinants."
• Every child should have equal access to health, meaning health care and healthy social determinants.

Values, Principles, and Practices

• We don't discuss social marketing, yet that's where values come from. We need to "sell" health. Educating people isn't enough. With too much rhetoric, people tune out. So people must be involved in small groups at lower levels.
• Canadians identify with health care. Our values drive our policies. We are willing to bear the weight of vulnerable populations and have decided that all Canadians shall have access to health care, regardless of their ability to pay.
• We have a lot of indicators at our fingertips but there is a knowledge à doing gap.

Goal Statement

• Enhance the ability to make good choices, with concepts like spiritual health and self-respect.
• Reduce disease and injury. This is within our power if we provide adequate front line staff, who can help people prevent disease and injury, but only if they have time for something besides acute care. When there is an outbreak nurses are exhausted, so programs like well baby or well elder clinics fall by the wayside.
• Enhance healthy choices rather than limit them. Economics, education, housing, spiritual health, and self-respect all affect choices. An enabling environment is a prerequisite for healthy choices.
• Bring IQ to bear on current realities.

Values, Principles, and Practices

• For a mother to raise a child a social support network must be available.
• You can't have morality if you don't have grub.
• Children are happier if there is no conflict eg. between home and school. In the north there seems to be a chronic depression among teens and they are prone to impulsive behaviour, so the suicide and attempts rate is very high. If we start poking around, though, we almost always find that the family life is disruptive, with abuse, neglect, adoption, or violence in the home. Counselling the person who attempted suicide puts a band-aid on them, when the mess is at home.
• There is not just one solution to a problem. eg. an audiologist tested children in school and 67 did not pass the audio test. How much does their lack of hearing affect their lack of understanding in the classroom?
• There is definitely a role for selective technologies, such as HIB vaccine which prevents meningitis. eg. we're hoping Prevnar will help reduce hearing impairment (by preventing multiple ear infections). Technology can also prevent injury. eg. welded aluminum boats.
• Healthy homes are crucial – a good family environment, in good housing, supported by a healthy economy produce people with self-respect and self-determination.
• There are drugs to combat TB (tuberculosis) but what gets rid of TB is good shelter, three square meals daily, and a decent job.
• Make people feel embarrassed to make bad choices. eg. smoking in public, or pediatric caries (their children's bad teeth).
• Communities need healthy economies, these do not have to be huge, just reasonable.
• The conversion of subsistence living to wage-based economies has created many problems.

Goal Statement

• A quality public health service would be holistic, well-funded, well-resourced, and culturally aware.
• The health care system in Nunavut and the Arctic Inuit-occupied region is unique in every way and should be treated uniquely.

Sub-themes

• Integrate traditional methods and health practices with western medicine. eg. midwives.
• Review and recommend changes to federal legislations, regulations and policies, to better reflect traditional practices and values.
• A quality public health service would be holistic, well-funded, provide education/training opportunities, be culturally aware, and would orient staff to Inuit traditions and welcomes. This would make public health user-friendly, not scary.
• Create a network that is one central point where questions/suggestions could be accessed by all.
• Have Inuit-specific health services – get away from the "aboriginal peoples" category.
• Food is an issue. Traditional Inuk food is nutritious, tastes great, and should be promoted and encouraged.

Values, Principles, and Practices

• Increase CHRs (Community Health Representatives). Train caregivers with more medical terminology and preventive techniques. Fund and open opportunities for other training, such as dental therapist, health promotion and prevention specialists, caregivers and social workers. This will help remove racial and cultural barriers, will automatically improve workplaces which will improve outlook/attitudes of the community we serve.
• Link with colleges, school and summer camps. Teach participants how to take responsibility for their own health.
• Teach about harm (alcohol, substance abuse, junk food, too much TV, etc.) but do it with fewer putdowns and less negativity.
• Learns about, promote, and appreciate Inuit ways, as we learn from you.
• Make it easier to get money to get small things that make a program work. eg. yogurt for the TB program, or prizes for the sewing group.
• Think outside the box, literally. eg. Public Health has a health teaching room. They look at it as "How many cubicles can I fit in here?" We look at it as a flexible space.
• Give parents time from work to come to the sewing group or attend a child's school concert.
• Equipment shortages in the north are a problem. eg. we have a person who must be in Ottawa because he needs dialysis, but there he's homeless. There is no reason dialysis, or chemotherapy, or many other things can't be done here. It is important for patients to have the support of their loved ones.
• Flexibility in programs is crucial to adapt to needs of communities. eg. the Aboriginal Diabetes Unit is geared towards First Nations communities and towards treatment. But diabetes in the Inuit population is not as bad as in First Nations, so we need to be able to use the small funds flexibly, focusing on prevention and health promotion rather than treatment. This will save money in the long run.
• Dying people can still contribute. eg. a man dying of lung cancer can talk to kids in schools about smoking.

"Health is the accountant for how we're doing socially, economically, and environmentally. Healthy public policy is good economic policy."

– Minister Bennett

General Discussion

Following is a summary of general discussion items raised in plenary before and after the small group discussions around the themes.

Inuit Qaujimajatuqangit
Includes:

• Inuuqatigiitsiarniq : respecting others, relationships, and caring for people
• Tunnganarniq : fostering good spirit by being open, welcoming and inclusive
• Pijitsirniq : serving and providing for family and/or community
• Aajiiqatigiinniq : decision making through discussion and consensus
• Pilimmaksarniq : development of skills through practice, effort and action
• Piliriqatigiinniq : working together for a common cause
• Qanuqtuurniq : being innovative and resourceful
• Avatittinnik Kamatsiarniq : respect and care for the land, animals and the environment

Food security
In the workbook determinants, healthy eating is listed as a modifiable risk. Put that in terms of food security. A pregnant woman said, "I don't need five ways to cook a chicken. I need the chicken." Overall Canada has a 14.5% rate of food insecurity. In the territories it goes up. Yukon – over 20%, NWT – 28%, Nunavut – 56%. Food is a basic need that is not being addressed.

Minister Bennett said that food insecurity has come up, including in her riding (downtown Toronto) where some families must spend 50% of their income on rent, meaning there's very little left for food. In remote northern communities, the costs of food are so high that even if rent was free food is not affordable.

We need to look at ways of getting the same nutritional benefit in less expensive foods. eg. milk is less of a calcium issue and more a vitamin D issue, so maybe we need a northern-accessible vitamin D source. Char and caribou, which Inuit people wanted and liked, also turned out to be healthiest for them.

Suicide
Suicide is a major problem in the north. When people and a community feel strong high suicide rates melt away.

Sense of control and being able to feel part of changes creates energy in people's lives, as opposed to taking it away.

Use local wisdom and local knowledge
Goals can be broad and aspirational, but must work community by community. Solutions should be evidence-based and community driven. (eg. from Minister Bennett: In Brazil communities decided not to let a whole generation die off due to AIDS, poverty, and illiteracy. They demanded that government provide people with drugs, then drew suns on paper to explain what time to take them. They made the Catholic Church hand out condoms. AIDS went down in Brazil when communities took charge. Compare that to Africa where AIDS is rising.

In comparison with the rest of Canada the lowest childhood obesity rate is in Nunavut. First, city and southern lifestyles, with transportation, school, and work, do not encourage physical activity. Second, in extreme cold a person may burn 6000 calories a day, just by existing. Third, many remote communities eat traditional foods, which are right for the north.

Cascading Events
Go where people are for cascading events. eg. in the summer most Inuit are out on the land.

Honest feedback must come from people are working, who are unemployed, who are underemployed, and who are working but still poor.

Sharing
Successes, best practices, and innovative work, especially from the North, should be shared.

Good things happening in health promotion, such as changing behaviour and better results, must be celebrated in ways that involve the media.

The federal government has no moral authority to tell people what to do, so ideas must come from the bottom up.

Adjournment

Minister Bennett thanked participants for their time and the opportunity to learn from their expertise, and encouraged them to actively involve their networks, families and communities in the process of making Canadians healthier. She said that some key concepts came out in this meeting.

Denormalization is important. eg. making smoking denormalized for teens and replacing the natural tendency for teen rebellion with rebellion against the big tobacco industry, or the "drop the pop" campaign which denormalizes pop. Denormalize dental caries. Denormalize violence. She described a Canadian with Bedouin health (in the Negev desert). They held an assembly where children got together as a group and spoke to their parents saying they didn't want violence in their homes and their schools anymore. We don't want violence to be normal.

On food we must be more creative/innovative and must get the food industry on side. eg. juice and fruit drink should not be packaged in the same bottles. We must also research what actually comprises healthy diet. What is healthy for one group may not be healthy for another, and should be culturally sensitive.

We must combine traditional wisdom with western medical practice in the same way we must incorporate high-tech and high touch (the MRI and the cool cloth).

We must look carefully at determinants in the north. It is sad and shocking that food security, shelter, and suicide are such major factors up here.

She reminded the group that we must also look outside our own borders. The next Canadian health crisis might be avian flu now breeding in Vietnam.

She asked that participants stay in touch through the website (www.healthycanadians.ca), read the reports posted, and provide feedback.

Participants

Carolyn Bennett, Minister of State, Public Health
Karliin Aariak, Senior Health Policy Analyst, Nunavut Tunngavik Inc.
Leona Aglukkaq, Minister of Health and Social Services, Nunavut
Karen Beddard, Department of Health and Social Services, Nunavut
Mary Bender, Clinical Supervisor of Community Health Nurses, Baffin Regional Health and Social Services
Amy Caughley, Health Promotion Specialist, Department of Health and Social Services, Nunavut
Larisa Chernysheva, Health Information Analyst, Department of Health and Social Services, Nunavut
Terry Creagh, Manager, Public Health
Margaret Moyston Cumming, Assistant Regional Director, Northern Secretariat
John Dawe, Sr. Manager of Infrastructure, Department of Community Government and Services, Nunavut
Jennifer Dickson, Executive Director, Pauktuutuit Inuit Women's Group
Alfred J. Gay, Policy Analyst, National Association of Friendship Centres
Tricia Geddes, Director of Communications, Office of the Minister of State
Wayne Govereau, Executive Director Population Health, Department of Health and Social Services, Nunavut
Gordon Hawley, Project Lead – Policy, Public Health Agency
Monty Kehler, Policy Analyst, Department of Health and Social Services, Nunavut
Meeka Kilabuk, Commissioner, Nunavut Planning Commission
Dr. W. Alexander Macdonald, Territorial Medical Director, Department of Health and Social Services, Nunavut
Natasha Manji, Communications, Public Health Agency
Mournir Marhaba, Director Policy and Planning, Department of Health and Social Services, Nunavut
Martha Michael, Elder
Debbie Paine, Director of Communications, Ontario and Nunavut Region, Health Canada
Rhoda Palluq, Regional Wellness Programs Consultant, Department of Health and Social Services, Nunavut
Trudy Pettigrew, Acting ADM Education
Cathy Praamsma, Advisor to the Regional Director, Northern Secretariat
Elaine Randell, Regional TB Coordinator – Baffin, Department of Health and Social Services, Nunavut
Dr. Isaac Sobol, CMO, Department of Health and Social Services, Nunavut
Victor Tootoo, ADM, Department of Health and Social Services, Nunavut
Ben Van Den Assem, Department of Health and Social Services, Nunavut Director of Operations and Professional Practice,
Katerine Walters, Director Hospital Services, Baffin Regional Hospital, Department of Health and Social Services, Nunavut
Reginald Warren, Facilitator