Modules

Indigenous health

Part 1

  • Clyde: It’s not going to do any good. I’m fine.

    Amy: You’re not fine. I can tell. You’re getting thin and drinking more. I’m worried! It’s just what happened to your dad.

    Clyde: Dad’s dead.

    Amy: You want to go the same way? You need to see the nurse at the health station. She can help.

    Clyde: Dad was always seeing the nurse at the nursing station. Didn’t do him any good, did it?

    Amy: It’s because he didn’t listen. I told the nurse you’d stop by today and get checked. She says maybe you’ve got it because I had something called gestational diabetes when I was pregnant with you.

    Clyde: Can I just have some more bacon?

    (Amy sighs)

  • Nurse: So, Clyde. How are you feeling?

    Clyde: I’m fine.

    Nurse: Your mother is worried about you. She thinks you might be developing diabetes. I know it runs in your family.

    Clyde: Everybody has it now.

    Nurse: Yeah, it is common here nowadays. So, we need to catch it early before you develop any complications. Can I ask you a few questions?

    Clyde: Yeah.

    Nurse: Okay. Um, your mother said you were losing weight. Do you know how much you usually weigh?

    (Clyde shakes his head)

    Nurse: Okay, well, we can weigh you. Uh, what do you think? Do you think you’re losing?

    Clyde: Hmm, I don’t know. Is that supposed to be a good thing though?

    Nurse: Well, sure, if you are too heavy, but it can be a symptom of diabetes. Uh, what about thirsty? Are you drinking more?

    Clyde: Uh, yeah. I guess so.

    Nurse: Okay. And how about peeing? Are you going more often?

    Clyde: Yeah.

    Nurse: Okay. Well, why don’t we get your blood pressure?

    Clyde: (nods)

    (after measuring blood pressure)

    Nurse: Okay, Clyde you do have some of the symptoms of diabetes, but your blood pressure is good. So, you know, that’s good. I would like to get a blood sugar test done and make an appointment for you to see the doctor when she comes in. Okay?

    (Clyde nods)

    Nurse: Okay.

  • Dr. Nyrit: Hi, I’m Dr. Nyrit. Are you Clyde?

    Clyde: Yeah.

    Dr. Nyrit: How are you doing today?

    Clyde: I’m great.

    Dr. Nyrit: Well, I’m glad to hear you think you are great, but according to these tests the nurse did with you last week, your blood sugar level is high. It’s 11.2 and you have some symptoms. What can you tell me about diabetes?

    Clyde: Everybody has it. Everybody out here anyway. Some people have to go to the hospital, get their legs cut off. My dad had to go down to get his kidneys checked out.

    Dr. Nyrit: Well, yes. It is serious, and you do have it. But we caught it in its early stages. It’s the perfect time to make some changes, and you know with some lifestyle adjustments, you may not even have to have any pills. I have some literature here for you. Here we go. Here. Take these. And then maybe we can work out a plan. How about it?

    Clyde: Uhh, yeah. I guess so.

    Dr. Nyrit: Okay.

“Each time I saw the doctor, he would say: ‘You have to pay attention or you are going to die from this.’ It made me sad … I was sad.”
(Roy and Facteau, 2005)

Reflective exercise 1

Communicating with Indigenous patients

The general principles of communication between physician and patient are no different with Indigenous patients; the patient-centred model applies. However, many non-Indigenous physicians feel unsuccessful and/or uncomfortable when interviewing Indigenous patients. In spite of good intentions, things do not seem to go well. In many cases, this is not due to a language barrier since Indigenous people often speak English. If they do not, then working with an interpreter is necessary, as discussed in the “Medical communication skills module.” The challenges in communicating with Indigenous patients relate primarily to two issues:

  • The history of the relationship between Indigenous peoples and the government, including health services
  • Cultural differences between Indigenous and western worldviews

How these two issues impact upon the physician-patient relationship is explored in the following article, which you might want to read before doing “Reflective exercise 1”:

After watching the first scene between Clyde and Dr. Nyrit, answer the following questions. There is nothing to submit for this exercise.

  • What is Dr. Nyrit’s worldview of diabetes?
  • What is Clyde’s worldview of diabetes?
  • Do you think Dr. Nyrit understands Clyde’s worldview of diabetes? Why or why not?
  • Do you think Clyde understands Dr. Nyrit’s worldview of diabetes? Why or why not?
  • What can Dr. Nyrit do to find common ground?

Commentary on reflective exercise 1

One way of thinking about a physician-patient conversation is to divide it into three parts or functions (M. Lipkin, 1996):

  • Information gathering
  • Building rapport
  • Counselling or management

Interviewers often make the mistake of jumping to the third function before thoroughly exploring the first two. In such cases, the advice or counselling is much less likely to be followed. The patient’s story has not been heard and a therapeutic relationship has not yet been established. The mistake is compounded when the patient returns and is labeled “non-compliant” by the physician, who feels they gave clear and reasonable instructions.

  • How much information does Dr. Nyrit obtain from Clyde?
  • She is obviously eager to help him. Does she build rapport?
  • How does she handle the characteristic presentation of an Aboriginal patient, as described in the literature?

Clear transmission by the expert does not mean that the message has been understood, accepted or can be acted upon by the patient. The analogy to the teacher-learner dialogue is apt. All of us have listened to what the teacher feels is a clear lecture, but which is not understood by the less expert student. In both cases, the person receiving the message is blamed for the poor outcome.

We will visit this issue again in “Reflective exercise 2” when we discuss behaviour modification in more detail.

Before continuing with the case, listen to the Indigenous elder describing her view of the physician-patient relationship.

  • I really felt that she honoured me because I lived in my body and I knew what was happening with it. Because she really listened to what I had to say as a person about my personal well-being. It is very, very difficult to find somebody that will give you that extra five minutes, ’cause sometimes that’s all it takes. Sometimes it takes less than five minutes … and to explain the procedures.

    How do you express a feeling? How do you express somebody that respects you when you come in? You just know it, you just feel it in the energy and stuff … hey I mean something to this person. They recognize me as a living, breathing human being. I’m not just another patient with a number and maybe she will remember my name or maybe she won’t, or he, whoever it is. And other times if I was having difficulty, I would phone and say “Can you get her to phone me because I have to ask her about something?” And you know “Well, she might not be able to call you until after she’s finished with her patients.” And she would call!

    And it’s like you’re in partnership with … helping you get well. That’s how I felt with her. She was in partnership with me, you know, to help me get well.

Knowledge check 1

The meaning of health and the burden of illness

Health, which is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, is a fundamental human right and the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. (Declaration of Alma-Ata, WHO, 1978.)

Check only one answer unless instructed otherwise.

Commentary

Question 1
According to data from the last National Household Survey published in 2011, 1,400,685 people had an Indigenous identity, representing 4.3% of the total Canadian population. Indigenous people accounted for 3.8 per cent of the population enumerated in the 2006 Census, 3.3 per cent in the 2001 Census and 2.8 per cent in the 1996 Census.

For additional information, visit the Statistics Canada website.

Census data from reserves is often incomplete because of the lack of participation; however, an estimate can be made based on location information. Respondents are not required to answer questions on their ethnic origin, therefore it is possible that Indigenous people living off-reserve are not accounted for, even if they did respond.

Question 2
The Indigenous population is much younger than the rest of Canada. The birth rate is higher, and at the other end of life, they die younger. While children are seen as the hope for the future, and an important part of Indigenous self-determination, education is a major challenge on many reserves. Keeping children in school, or having to send older children away for high school, are frequent problems.

In 2011, children under the age of 14 represented 28 per cent of the total Indigenous population and 7 per cent of all children in Canada. Indigenous people between 15 and 24 years old represented 18.2 per cent of the total Indigenous population and 5.9 per cent of all youth in Canada. In the non-Indigenous population, youth represent 12.9 per cent of Canada’s total population.

For more information, visit the Statistics Canada website.

Question 3
The residential schools have been described as the lowest point in the history of relations between First Nations people and the government. Although they began to be phased out earlier, the last school was closed only in 1996, and the settlement for survivors was even more recently completed in 2007. The “Sixties Scoop” is a related episode of government action in which Aboriginal children were removed from their homes and placed in foster care, or even adopted, against the wishes of their parents.

Question 4
Indigenous children represent 40 per cent of the children in child welfare out-of-home care in Canada, according to a 2003 study.

Blackstock, C. (2003). First Nations child and family services: Restoring peace and harmony in First Nations communities. In K. Kufedlt and B. McKenzie (Eds.), Child Welfare: Connecting Research Policy and Practice. 331-342. Waterloo, Ontario: Wilfred Laurier University Press.

Question 5
While all of these choices are higher in Indigenous youth than the general population, suicide leads the list, especially in males.

[Translation] “Injuries and poisoning were the main causes of death for people between the ages of 1 and 44. Accidental injury was the main cause of death of children under the age of 10. Suicide and self-mutilation were the main causes of death for young adults and adults up to the age of 44. For people 45 years old and up, problems with the circulatory system were the leading cause of death. These statistics are similar to those of the general Canadian population.”

University of Ottawa website, La société, l’individu et la médecine. Updated September 12, 2014.

Question 6
The prevalence of type 2 diabetes varies considerably among Canadian Indigneous people, depending on geography, length of contact with Europeans and other factors. Most overall estimates are of two to three times the non-Indigenous rate.

Adelson, N. (2005). “The Embodiment of Inequity: Health Disparities in Aboriginal Canada.” Canadian Journal of Public Health 96: S45-S61.

Question 7
The Indian Act decreed that if a First Nations woman married a white man, or moved off the reserve, she lost her status — essentially became a “non-person.” At the same time, non-First Nations women who married First Nations men were granted status. In both cases, this legislation often resulted in the separation of families and great difficulties for those who no longer had status. This statute was changed only in 1985, with bill C-31: An Act to Amend the Indian Act. It restored status to a variety of First Nation people, mostly women.

Question 8
Increased fat is felt to be the major dietary factor in the “epidemic” of diabetes in Indigenous peoples. It is a major contributor to the metabolic syndrome.

 


 

Next: Part 2

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