Pan-canadian public health network council report and policy recommendations on the use of antivirals for prophylaxis during an influenza pandemic

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Annex 3.8–First Nations and Inuit Considerations

Submitted by:
Kim Barker
Physician Advisor, Assembly of First Nations

Intended for: Task Group on Antivirals for Prophylaxis

BACKGROUND/CONTEXT

One of the most important responsibilities any nation has is to ensure that the health of its most vulnerable group is included in any health promotion, disease prevention and health protection activities. The health of First Nations and Inuit populations remains indisputably poorer than the rest of Canadians, and, when considering the value of antivirals for prophylaxis, requires unique consideration.

Input to this paper was requested from Assembly of First Nations Health Technicians from each Region, ITK, and Regional Medical Officers of Health from First Nations and Inuit Health Branch of Health Canada.

1. First Nations

Primary Health Care and Public Health to First Nations on Reserve are currently provided by the Federal Government, while secondary and tertiary care services are provided by the Provinces and Territories. As such it might seem obvious that First Nations and Inuit Health Branch (FNIHB) of Health Canada would be the most obvious provider of antiviral prophylaxis to First Nations living on reserve. However, the logistics of prescribing and dispensing of medication under supervised medical care poses a challenge to current FNIHB resources and systems. There is a multitude of questions that need to be considered when developing a Pan-Canadian Strategy to deliver an antiviral prophylactic strategy that would include all First Nations living on or off reserve.

2. Inuit

Inuit receive their primary and public health through the Federal Government and the Provincial /Territorial Governments. This is the result of both transfer agreements and Land Claim Agreements. In the regions of Nunatsivtu and Nunavik the delivery of health services is currently provided by regional health boards/governments within their settlement areas. FNIHB provides some services south of 60, such as TB and HIV/AIDS programming, but the majority of FNIHB funded programming is related to primary prevention and promotion.

Outlined below are the six categories of issues that need to be considered in the development and role out of any antiviral prophylaxis strategy.

a) Decision Making Process

The current consultative intentions of the Canadian Government to engage Canadians in the discussion around the purchasing and providing of antivirals for prophylactic use is one that will require a unique approach with respect to First Nations. Ideally First Nations leadership should be aware of the process and included with the ensuing discussions. Similarly, First Nations communities need to be included in the target groups of the Canadian public when conducting focus groups and interviews.

The risk of not including First Nations leadership in the decision making process is significant as they have a responsibility to their community membership as democratically elected leaders. This responsibility includes the notification of emergency preparedness plans including pandemic influenza.

A unique approach is also required for Inuit communities. It will be essential to engage Inuit leadership in the process and discussions. Currently there has been limited engagement of the Inuit in the development of emergency preparedness plans or pandemic planning. This is a gap that must be addressed.

b) Jurisdictional Considerations

The current method of delivering public health programs and services to First Nations on reserve is by the Federal Government in the absence of any federal public health legislation. As such, there is a significant amount of confusion over the responsibilities that Provincial Governments have with respect to their legislative authority given the sense that by default First Nations fall under the jurisdiction of Provincial and Territorial Public Health Acts. Whilst this issue has been a longstanding one with most recent exacerbations in the areas of water and tobacco control it is without question that a pandemic emergency is not a time for jurisdictional debate. As such, it is more appropriate to aspire to a collaborative framework of federal purchasing and provincial delivery style models, which could be reflected in tripartite MOAs that detail roles and responsibilities of Federal Agencies, Provincial and Territorial Governments, and First Nations leadership.

As discussed previously, Inuit communities access the majority of health services through provincial and territorial processes. The issue that has been identified is that currently there are not enough processes in place to ensure that Inuit communities are included in the development of plans. There have been concerns raised that the provinces and territories may make decisions regarding such things as quantity of antivirals to go to Inuit communities without having enough knowledge of those communities. Any jurisdictional decisions that are reached only on a per capita basis without considerations for the health impacts and the risks related to any outbreak will negatively impact the ability of the health system within Inuit communities to respond. There is a crucial need for trilateral agreements between Inuit/Provinces and Territories and the Federal government to have successful interventions.

c) Remoteness Factor

Whilst it can be argued that several non-First Nations communities are in similar remote and isolated situations, the jurisdictional confusion outlined above is further exacerbated by the challenges that come with living remotely in a First Nations Community.

The main issues that need to be considered are:

• transportation of medical supplies from any central depot in a timely fashion that reflects an equal access situation as compared to the rest of Canadians;
• lack of available human resources to oversee the provision of drugs;
• lack of storage capacity
• Potential isolation from other communication strategies that explain the role of antivirals and the methods of qualifying and obtaining them.

Inuit face many of the same issues that have been raised above in regarding to isolated First Nations communities. Specific concerns have been raised regarding the human resources required to administer any antiviral prophylactic strategy.

d) Communication of Strategy

No matter the ultimate decision that the F/P/T governments arrive at with respect to antiviral prophylaxis, there will most definitely need to be a unique communications strategy outlining the decision specific to First Nations and Inuit. This is best achieved in cooperation with FNIHB and National Aboriginal Organizations (NAOs) but also needs to be communicated to Regional Health Authorities and Public Health Units across the country that often appear out of the loop with respect to public health issues for First Nations and Inuit.

It is also important to note the general lack of awareness in Inuit communities of preparations and response plans. The realities related to the remoteness need to be considered and, depending on the recommendations of the advisory group, it will be essential to put in place not only appropriate anti-viral prophylaxis strategies but also to ensure there is a focus on other measures that would be effective in minimizing the impacts of a pandemic such as containment, quarantine and awareness of basic hygiene practices.

(e) Unique Social Determinants of Health

Several factors that may contribute to increased likelihood of infection and transmission can be predicted through examining some relevant social determinants of health.

First Nations housing and infrastructure is in crisis. Apart from the severe shortage and, in many cases, deplorable housing structure and air quality, the most recent Regional Longitudinal Health Survey noted that First Nations have overcrowding rates 25 times that of the rest of Canadians.

Nutrition is recognized as a key health promotion issue in First Nations communities. An unbalanced diet and food insecurity, changes in diet from traditional to processed food, environmental contaminants, and nutritional deficiencies are linked to increased susceptibility to disease.

The prevalence of smoking among First Nations is 62 per cent, twice the rate for Canadians in general. Tobacco use and exposure to second hand smoke are known risk factors for more serious sequelae for any respiratory disease.

Although not a social determinant of health, diabetes and other chronic diseases are more prevalent among First Nations and often with associated complications such as chronic renal failure, highlight the fact that First Nations communities often harbour large burdens of chronic disease issues that already stretch their fragile health care system.

Childhood vaccination rates may be considerably lower than for the Canadian population. First Nations children have higher rates of respiratory tract infections. The incidences of tuberculosis among First Nations on-reserve rates in 1999 were 18 times higher than the Canadian born, non-Aboriginal population.

f) Respect for Cultural Differences

There are many practices that do not readily translate across linguistic, cultural, social or economic divides between western style medicine and First Nations and Inuit. Cultural differences in how we come to understand what health means, the value of human life, all elements that must be considered in concert with more traditional western style decision making in a situation such as the provision of antivirals for prophylaxis. The role of the Elders, traditional healers, and wholistic approaches to illness and community health need to be considered when deciding whether to extrapolate a decision made on the provision of antivirals for prophylaxis to be a similar method of deciding for First Nations and Inuit.

Conclusion

The decision to provide antiviral for prophylaxis to all Canadians, none, or a predetermined subset is a hugely complex decision to make. When one then reflects on the applicability of this decision to First Nations and Inuit it is essential that their unique circumstances be taken into consideration. These circumstances include cultural differences and self governments, social determinants of health and current realities of disease burdens, jurisdictional ambiguity and remote locations. It may be that a decision to provide or not provide antivirals for prophylaxis to all Canadians may have to contain elements of exception to ensure the unique circumstances of First Nations and Inuit living in their communities is addressed.

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