Indigenous persons (First Nations, Metis and Inuit) are a vulnerable population that have been described as being at greater risk for developing complications from influenza infection (Government of Canada, 2018). While the Indigenous account for only 3.8% of the Canadian population, from April 2009-April 2010 they accounted for 7.4-10% of hospitalizations, 7.8-10.4% of ICU admissions and 7.1-10.4% of deaths which represents a 3-8 fold elevated risk of hospitalization and deaths from influenza related complications (Public Health Agency of Canada [PHAC], 2009, as cited in Boggild, Yuan, Low and McGeer, 2011); 43% had underlying health conditions (PHAC, 2009, as cited in Rubinstein et al., 2011). During the 1918 influenza pandemic, indigenous communities experienced a mortality rate that was 3-9 times higher than other Canadian ethnic groups (Humphris, 2013 as cited in Jung et al., 2017). Given this disparity and severe consequences to outcome, it is important to reflect how we can better serve this vulnerable population through targeted prevention strategies by first understanding the reasons that place them at greater risk for acquiring influenza.
Indigenous people have several risk factors that predispose them to influenza infection. Canada’s National Advisory Committee of Immunization (NACI) states that obesity and chronic health conditions such as diabetes, kidney disease, chronic lung disease and other illnesses are more common in Indigenous populations and all increase the risk of flu infection (as cited in Bryce, 2015). Further, several studies (Houston, Weiler and Habbik, 1979; Banerji et al., 2001; Banerji et al., 2009; Herbert et al., 1967) suggest smoking/smoke exposure, poor diet and socio-economic factors such as lower education, housing, residential crowding, geographic isolation and family size are risk factors associated with increased rates of acute respiratory infections in the Indigenous populations (as cited in Boggild, 2011). Every year, influenza spreads from person-to-person, indiscriminate of race, age or geographic location but when it meets conditions that favour transmission it can have devastating outcomes in communities that have little or poor access to healthcare.
The burden of influenza is only one health inequity for Indigenous peoples. According to Gionet and Roshanasfshar (2013), Olding et al.( 2014) and the University of Ottawa (2017), the Indigenous fare more poorly than the remainder of the population on virtually every health indicator (as cited in Toronto Indigenous Health Advisory Circle, 2016; University of Ottawa 2017). Several other studies (McCaskill et al., 2011, NCCAB, 2013, Olding et al., 2014 and Steward et al., 2013) demonstrate the Indigenous experience higher rates of poverty, unemployment, homelessness, involvement with child welfare, food and water insecurity, poor access to healthcare and education deficits which all contribute to adverse health outcomes and the inability to meet basic fundamental needs known as the social determinants of health (as cited in Toronto Indigenous Health Advisory Circle 2016). These inequalities have resulted from a combination of socioeconomic deficits as well as a past history related to colonization, racism, globalization, migration, loss of language and culture, environmental deprivation and spiritual, emotional and mental disconnectedness (King, Smith and Gracey, 2009). Requirements for reversing effects of colonization and disconnect from their land and culture require us to engage and empower their communities to lead these efforts (King et al, 2009). This history recognizes that any health challenge requires a deep level of healing and reconciliation needs to occur before we will achieve success with any targeted health strategies.
Understanding Indigenous health involves appreciating their philosophy towards well-being. The medicine wheel (Figure 1), Wilson (2007) reports, represents elements that are woven together and interact to support a strong and healthy person (as cited in King et al., 2009). Imbalances in these elements refer to an absence of well-being which requires traditional native healing strategies (King et al., 2009). Dapice (2006) provided a detailed review of how past history and experiences have directly altered the balance of this wheel. It can be conceived that if one were to heal imbalances, chronic diseases and risk factors associated with diseases such as influenza should decrease and narrow gaps between indigenous and non-indigenous people.
Figure 1: The Indigenous Medicine Wheel
Using the social ecological model, levels of influence for the prevention of influenza in Indigenous populations is presented in Figure 2. This model considers the social determinants of health and further explores the forces that influence behaviors at each level. Distrust of the healthcare system is pervasive in a study that reviewed vaccination uptake during the 2009 influenza pandemic (Driedger et al., 2015). Previously I created a blog focusing solely on influencing vaccine uptake (Salt, 2018d). Work in this respect will have challenges with Indigenous populations given mistrust in the healthcare system. In parallel, focus should include working with community leaders to procure additional infection prevention supplies, diagnostic testing and education to prevent transmission. Best efforts in this regard however, will have little success if we continue to ignore their basic determinants of health. The most obvious impact and changes need to be seen at the policy level in order to effect changes, build trust and modify behaviours downstream.
Prompt access to healthcare and provision of services which include vaccination, diagnostic testing, antiviral treatment of symptomatic patients, prophylaxis for close contacts and instruction regarding infection control (hand hygiene, personal protective equipment (PPE), respiratory etiquette, social distancing) are cornerstones to mitigating the spread of influenza. Spence and White (2010) noted major breakdowns in the provision of services for the Indigenous during the 2009 pandemic which included: shortages of equipment and supplies, hand sanitizers and ventilators (Charania and Tsuji, 2011), inadequate health care, lack of human resources (Charania and Tsuji, 2011), insufficient training, poor epidemiological tracking and lack of leadership or communication (as cited in National Collaborating Centre for Aboriginal Health [NCCAH], 2016). Comparatively, Indigenous communities that were successful in lowering associated morbidity and mortality planned early and included access to diagnostic kits, antivirals, collaboration between multiple levels of government, epidemiological tracking, mobilization of staff and implementation of effective infection control measures (NCCAH, 2016). This achievement demonstrates that success in preventing the transmission of influenza can be attained when there is coordination and partnerships that are led by the indigenous communities.
Diagnosing influenza to initiate treatment with antivirals can be done by syndrome but testing is preferred for confirmation and epidemiological tracking. Currently, molecular testing using polymerase chain reaction is the gold standard for testing because it is able to identify specific strains of influenza, however, turn-around time for results may take hours and this methodology is used primarily by hospitals (Nicholas, 2018). Future developments include self-testing at home, direct communication with physician through an app which then communicates with pharmacy to deliver your prescription (Fox, 2018). The ease and lower cost of point-of-care testing in remote areas such as Indigenous communities may have great potential for containment of influenza and epidemiological tracking if connected to physician or public health databases.
The future holds guarded optimism. Health of the Indigenous (First Nations, excluding Metis or Inuit) is currently guided by the Indian Act created in 1876 (amended in 1985) and is managed federally; in contrast, health for the rest of the Canadian population is delivered by the provinces under the Canada Health Act (1984). Collectively, there are many gaps in this system leading to confusion regarding the delivery of healthcare which leaves provincial and federal governments arguing over fiscal responsibilities (Palmer, Tepper and Nolan, 2017). First Nations Health Authority in British Columbia was the first province to assume all programs and services, including those administered by Health Canada, and has already seen progress and improvements to primary care (Palmer et al., 2017). Ontario, in the advent of a suicide and mental health crisis, has also recently committed to a similar process (Galloway, 2018; Tasker, 2017). Federally, the “Truth and Reconciliation” commission issued a report (2015) containing 94 “calls to action” to redress the legacy of residential schools and to promote reconciliation (Truth and Reconciliation Commission of Canada, 2015). Subsequently, a new Ministry of Indigenous Services has been established and is making headway on important goals such as the provision of clean water, addressing a long-standing issue and basic social determinant of health (Rabson, 2018). The process to get to this point has been long and arduous, with many previous attempts and reports to improve relations with our Indigenous population (Palmer et al., 2017). The Canadian government needs to continue to prioritize this movement despite changes in leadership and set an example for global adoption.
In conclusion, many factors need to be considered when examining any health issue in a population. Using influenza as an example, it was demonstrated how health can be influenced by the social determinants of health, governments that create policy, legislation that is enabling or disabling and history of injustice. Simply providing antivirals or vaccine to the Indigenous without considering all levels of influence is analogous to leading a horse to the water who does not want to drink. Working with Indigenous communities to understand and support their needs is the better approach to implementing any health initiative, including that of decreasing the spread of influenza and associated complications.
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