Modules

Indigenous health

Part 2

One month later, Clyde visits Dr. Nyrit for the second time. Dr. Nyrit has been thinking about her early experiences at the reserve and how she should proceed. (See “Reflective exercise 2” below). Clyde talks to his cousin Sandy about his visit to the physician.

  • Clyde: Saw the doctor again today.

    Sandy: What did he say?

    Clyde: Uh, it’s a new doctor. It’s a lady. She told me I have diabetes, and I’m supposed to start exercising and eat healthy. I’m not supposed to eat sweets.

    Sandy: Yeah, that’s what they told me too. And where do they want us to walk? In the summertime, the roads are too dusty. In the winter, too much snow. It’s not like when our elders were young. Do you know where they used to get their dessert from? The bush. Used to walk around, picking berries, used to laugh. Auntie said they were always laughing.

    Clyde: Doctor said I’m supposed to eat lots of fruits and vegetables, you know. And less fat. Gave me this stuff to read. You know, nobody eats that stuff around here. It doesn’t taste good at all, and it’s expensive. It’s crazy, because if everybody is getting sick, how come the doctors aren’t doing more?

    Sandy: They say it’s from our ancestors. That’s where we’re all getting it. But it’s not that. Back in the days, we were the same people. We were healthy. It’s not the old days; things have changed. Clyde, you are young, listen to the doctors. They know about these things.

“I can’t stand salad. I take the lettuce out of my hamburger, I hate it so much. I will eat salad from time to time, but don’t count on me to eat it four times a day … But I could eat bread everyday … Or molasses. Sometimes I’d like to have something fatty, with home-made bread and then some sugar, brown sugar.”

(B. Roy and K. Fecteau, 2005)

Social suffering and diabetes

Why is diabetes so much more common among Indigenous people? Sandy brings up two of the frequently mentioned theories: genetic predisposition and change in lifestyle. A change in lifestyle refers to more than a change in diet and exercise, although those certainly play a role. There is a compelling body of evidence suggesting that social suffering may be an important component. This term primarily refers to loss: loss of cultural identity, loss of heritage language, loss of homeland, loss of meaningful work, loss of respect and loss of hope. Such losses are thought to cause chronic stress in individuals, leading to metabolic abnormalities that result in hyperglycemia. The implications of this relation of social determinants of health to biological disease are that a change in diet and exercise — even an attempt to return to a previous hunter-gatherer lifestyle —  may not result in glycemic control. We will further examine the implications of trying to institute lifestyle change in “Reflective exercise 2” below.

Other theories about the epidemiology of type 2 diabetes invoke genetic predisposition. Amy had gestational diabetes, which is also more common in Indigenous women than in non-Indigenous women. Experts are still unsure whether this, and low birth weight as a predisposition to develop diabetes, is genetic, environmentally-induced, or multifactorial.

 

Read the following articles for more information about socio-economic disparities, health inequities and diabetes in Indigenous peoples:

 

Reflective exercise 2

Preventive medicine and behaviour change

Counselling patients about health maintenance and disease prevention is one of the most important tasks of any physician, especially those in primary care.

As noted in the article by Elder (J.P. Elder,1999): “Primary care providers have traditionally relied on persuading patients to change through ‘informational power’ (sharing facts about health and illness) and ‘expert power’ (using professional credentials at least implicitly to impress patients with the potential effectiveness of the prescribed behavior change).” These tactics often fail, leaving both patient and physician frustrated and unsatisfied. Why?

Often, the physician tries to do too much, too soon. Without some knowledge of a patient’s life situation, values and beliefs, flooding them with information is fruitless. This is illustrated in this case as all the physicians try to deal with the difficult issue of diabetes in Indigenous people. The principles of behaviour modification apply to all patients, however.

In this exercise there are four video scenarios illustrating different ways in which a physician might approach behaviour modification in a patient with diabetes.

First, read: “Theories and intervention approaches to health-behavior change in primary care” by J.P. Elder, G.X. Ayala and S. Harris.

In each scenario, Dr. Nyrit is trying to utilize one or more of the models of behaviour change. Each option could potentially lead to a change in Clyde’s relationship to his diabetes. As you watch the scenarios, consider the following questions:

  • What was the quantity of information exchanged?
  • What was the quality of information exchanged?
  • Did Dr. Nyrit use the “informational” or “expert power” approach, or something else?

Watch all four scenarios. Select the one you feel is the best choice. After making your selection, read the commentary related to each option.

Dr. Nyrit: Clyde, people who have diabetes can do a lot to help themselves. How much do you know about diabetes?

Clyde: Everybody has it.

Dr. Nyrit: Well, I mean, you have it, but I have said that with lifestyle adjustments, you can control your diabetes. Have you given this any though whatsoever?

Clyde: They say it’s … uh … They say it’s being Indian. Nobody … can do anything about it.

Dr. Nyrit: Well, your genetic make-up is only part of it. It plays a small role. Being overweight, eating the wrong foods, not exercising …

Clyde: Wrong foods? You know, we can eat what we can get from the northern store. We eat better when we hunt, but there is no gas so we can’t get out to the bush.

Dr. Nyrit: But there is an opportunity right there. If you can’t drive, walk. The exercise will do you good.

Clyde: Do you know how long that is?

Dr. Nyrit: Clyde, are you not even going to think about a shift in your diet or exercise? Just take it slowly. That’s all. You can do it.

Oh boy. I’m not sure what state of change he is in. He seems to know something about diabetes. I think he is pretty contemplative. He is not very interested. It’s definitely going to take a lot longer to move him along.

Dr. Nyrit: Thanks for coming, Amy. I thought it would be helpful for all of us to get together and talk.

Amy: Yeah. I’m worried about Clyde.

Dr. Nyrit: Well, last week when he came to my office, we talked a little about how diet and exercise could control his diabetes. Perhaps we could talk about diet. Did you happen to read the pamphlets I send home with Clyde?

Amy: Yeah, I looked at them. It won’t go away, will it? He’ll need the pills?

Dr. Nyrit: Well, his sugar levels can be controlled by diet and exercise, so he may not even need pills. But, it will be a lifelong problem and if it’s not under control, there will be complications, and that doesn’t have to happen.

Clyde: People here take the pills. They still go down to the hospital and they never come back.

Amy: Clyde!

Dr. Nyrit: Well, we’re just going to have to work on that. About diet … could he have more vegetables and less sugar and fat?

Clyde: Have you seen the vegetables in the store? They’re gross. She said she doesn’t know how to cook and still make it taste good, okay?

Amy: I’m trying.

Dr. Nyrit: Well, we’ll just have to work on that too. But, Clyde says he is not working. So, he could have more time to go for walks and exercise at the gym to maintain his weight.

Clyde: Uh. I guess I could get a job again. I like working at the school. That would be some exercise.

Amy: Going for a walk around here, people wonder. There is no equipment in the gym. It’s not easy.

Dr. Nyrit: But isn’t there anywhere? I mean, Clyde, couldn’t you go down to the dock by the lake, where the planes come in? We could keep a journal and keep track of how far you go and how many times a week. It’s a possible thought.

Option 3

Dr. Nyrit visits the reserve the next month and asks to see Clyde again.

  • Dr. Nyrit: Clyde, thanks for coming in today. Gives me the opportunity to get to know you better, since I’m new here.

    (Clyde nods)

    Dr. Nyrit: Um, well, have you lived here long?

    Clyde: All my life.

    Dr. Nyrit: Do you speak Ojibway?

    Clyde: Of course. (Clyde responds in Ojibway) My grandmother taught me.

    Dr. Nyrit: Wow. Your grandmother. I should learn a few words, since I’m living here. Must have lots of family here?

    Clyde: Yeah, lots of family. Pretty much everybody is related to everybody. Everybody knows each other.

    Dr. Nyrit: You must get together often, you know for meals, for just hanging out, or chatting.

    Clyde: Yeah. I like to take my family out fishing … and you know, out on the lake.

    Dr. Nyrit: Wow, they must actually be concerned about your diabetes, aren’t they?

    Clyde: Uh, yeah. Yeah, they’re worried about me.

  • Option 3

  • Dr. Nyrit: Well Clyde, I’m happy we got together and had this talk today. Especially learning about your family. But the next time we meet, I would like us to have a plan about your diabetes. And I actually think it would be best if you met with the community diabetes worker. This person can help you with reviewing the pamphlets and informing you about what’s going on with your body. You could also learn about healthy eating and exercise. What do you think?

    (Clyde nods)

    Dr. Nyrit: It could work.

    Clyde: Okay.

    Dr. Nyrit: So, I’ll set up an appointment?

 

“They were showing horrible pictures of people having their legs and feet cut off and all that. And I said: ‘Oh my god!’”

(B. Roy and K. Fecteau, 2005)

Option 4

Clyde is the fourth patient with new onset diabetes that Dr. Nyrit has seen in the past month. Having heard that the community is important in the health of Aboriginal patients, she decides to speak to the local chief about her concerns.

  • Option 4

  • Dr. Nyrit: Chief, thanks for coming today. I really do appreciate it. I’ve been here for a while and I’ve been able to assess the health situation here. There are a lot of health problems. There is family violence, alcohol, and a lot of people are suffering from diabetes. I just saw a patient today that has diabetes, and I think it’s an issue that we have to deal with.

    It’s about lifestyle change. People need more exercise. The adults and the children, they are overweight. They even take a skidoo three or like six blocks just to go to the store. We need to create programs. Maybe build a hockey rink, or develop a sports club. We could even have a class, like an exercise class at the gym.

    Chief: There is logging at Deer Lake next year, and they maybe build a store.

    Dr. Nyrit: I’m really not talking about a store. I’m talking about diabetes and exercise.

    Chief: Yes, I know. I know about diabetes and exercise.

    Dr. Nyrit: Okay. Um, well, I’ve assessed the store and it really has, like very little healthy choices available to the people. There is hardly any vegetables, no grain products. There is more like pizza, pop, chips. Does band council have anything to say about what’s in the store, because if it’s not available, then people are not going to buy it. I would be more than happy to talk to the band council.

    Chief: I hear you saw Clyde in the clinic. Is his diabetes very serious? He is so young.

    Dr. Nyrit: I really can’t talk about Clyde. I’d be betraying his confidentiality. Is there any way that we can just talk about diabetes and exercise and maybe develop a program? I mean, exercise class would be ideal, or walking club. Just anything really.

Commentaries

Commentary on option 1
In this option, Dr. Nyrit attempts to use the Stages of Change model, one of the behaviour modification techniques discussed by Elder. This model has several stages:

  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance

It reminds us that patients are unlikely to change unhealthy behaviour if they have not even thought about it. Unhealthy is, after all, a point of view. The patient has to feel that the change is not only a good idea for them, but that it is possible to undertake. In this scenario, Clyde seems to react angrily when Dr. Nyrit suggests lifestyle changes. Why do you think this happens?

  • He does not like her because she is a “white physician.”
  • He has thought about making changes, but knows it is impossible and that makes him angry.
  • He does not want to make changes in his life, and resents her interference.
  • He thinks that making changes will not make any difference to his health.
  • Her ignorance of his situation alienates him (“walk to the bush — it’s too far!”).
  • Clyde cannot read well enough to understand the pamphlets, and is ashamed to admit it.
  • How might Dr. Nyrit find out which of the above are going on in this conversation?
  • Do you think Dr. Nyrit should acknowledge Clyde’s emotion?

Visit Stages of Changes for additional information.

This article, “A critical examination of the application of the Transtheoretical Model’s stages of change to dietary behaviours,” explains some of the reasons why this, or any model, is not as simple to use as it first seems.

 

Commentary on option 2
The people around us, and who matter to us, play an important role in our decision making. Dr. Nyrit understands this and tries to enlist Amy’s help, which she is eager to give. However, the physician again reveals her ignorance of the social and environmental situation in which her patient lives. Her response to information about the barriers to change is: “Well, we’ll have to work on that.” She is approaching the situation from a biomedical point of view. Clyde and Amy see it as “being Indian,” and “people go away and don’t come back.” Amy recognizes that she does not have the skills to cook proper meals, but Dr. Nyrit is unable to acknowledge that and help her with realistic suggestions. Amy also brings up the importance of the community. People will talk if you do something unusual, like take a walk. We might say: “So what?” But in a culture in which the community, not the individual, is the unit of importance, this is a significant barrier.

Thus, although enlisting social support is crucial for Clyde, Dr. Nyrit is unlikely to succeed in helping Clyde and Amy manage his diabetes in this option.

Commentary on option 3
We observed in “Reflective exercise 1” that communicating with Aboriginal patients takes time, patience and an understanding of their cultural values. Note in this option the difference in information exchange. Dr. Nyrit speaks more slowly and asks Clyde questions about his language, family and community. She expresses an interest in learning some Ojibway words, and Clyde responds in his native language (but actually using a derogatory term). Note that he is not unwilling to talk, and as the interview proceeds, he interacts more with Dr. Nyrit. This is the beginning of a therapeutic alliance.

Which way does the information flow this time: from physician to patient or from patient to physician? The interview does take more time, but at the end, Clyde seems willing to at least consider thinking about managing his diabetes, and Dr. Nyrit promises a definite follow-up. Will Clyde return? Is it more likely than in options 1 and 2? Also, if a therapeutic alliance has been formed, then the strategies employed in options 1 and 2 might be more successful.

Which of the behaviour modification models do you think is being applied in this option?

Which, if any, of the eight personal factors needed in behaviour change have been discussed? (See Elder.)

Commentary on option 4
In this option, Dr. Nyrit seems to understand, and attempts to influence, the socio-economic and environmental barriers to health promotion and disease prevention. But does she really understand the situation on the reserve? Is changing the type of food in the northern store the issue? What about building a hockey rink? These are good ideas, but are they realistic?

With the best of intentions, she again uses the expert, clinical voice: “People aren’t making healthy choices.” The band chief responds with a seemingly unrelated statement about logging and building a store. What is his point, and which of them knows more about the fundamental causes of poor health in this community?

To the chief, who has been asked to come to the physician’s office and who has been given a lecture about the problems on his reserve, this option may look like medical arrogance.

Finally, how should Dr. Nyrit respond to his question about Clyde, given the importance of community in this culture?

Read this article for more information about the health policy issues in lifestyle changes and diabetes. While written from an American point of view, it does bring up some of the issues in the broader health system that may impact local and individual behaviour.

The case continues

Clyde is put on oral hypoglycemic medication and is encouraged by the physicians and the community health worker to follow a diet and exercise program. He asks about a job at the school and is told there is no money to hire anyone. While Amy has a part-time job, Clyde is at home with the younger children. He muses on his situation.

  • So, am I sick or not? It’s been six months and I don’t feel any different. Doctors have been giving me pills, saying my blood sugars are bad. I guess that’s not good.

    I’ve been taking the pills, most of the time. Sometimes my mom has to remind me. The doctors say exercise. Younger kids, they play basketball and hockey, but nobody my age does that. I mean, tell me to exercise, but you know I’d like to get a job. That would be some exercise. But there is just no jobs around here.

    And my mom has been trying to follow the diet plan the doctors gave us, but then everyone else in the household complains, and then she has to make two different kinds of foods. You know, I don’t like it either, but they say it’s good for me. They say: “Don’t eat bannock at breakfast. It’s made with lard. Eat cereal like Corn Flakes or Rice Krispies.” But mom says it’s way too expensive. Costs like a whole day’s food from the northern store.

    I only have like one or two beers now, every time I go over to my friends, and they all make fun of me. I don’t say why, but it’s pretty crazy because everybody has it, right? I mean, it’s pretty stupid that we can’t even talk about it.

    My auntie said that I should try going to the sweat lodge, so I did and I felt really good after. But I had to stop taking the pills during the ceremony and I didn’t start taking them again for another two weeks, which I guess is not that good.

Interpretive commentary

This window into Clyde’s perspective on his diabetes brings up a number of points.

Knowledge of diabetes
Clyde clearly knows about the importance of maintaining a normal blood glucose level. He understands the role of medication and the necessity of taking it regularly, even if he feels no different.

Lifestyle modifications
Clyde recognizes the importance of diet and exercise in controlling his diabetes, but he also is aware of the barriers to any changes he might try to make in his life. He has no control over the lack of jobs and the cost of food. Such lack of control over one’s life may lead to a sense of hopelessness and even depression, which is thought to be more common in diabetics than the general population.

Social isolation
Eating together is an important part of First Nations culture. Clyde is isolated from his siblings and relatives at home, as the only one needing a special diet. He cannot talk to his friends, as they tease him for being different. Clyde’s question is important: “If we all have it, why can’t we talk about it?”

Indigenous medicine
In the past, the Canadian government made concerted efforts to prevent Indigenous people from using traditional medicine and healing ceremonies. The sweat lodge was outlawed, along with other cultural ceremonies like the Sun Dance, the Potlatch and the Shaking Tent. It was felt that the medical value was negligible, and that the holistic and spiritual aspects of these ceremonies should be suppressed in favour of Christianity.

Many Indigenous people lost knowledge of their cultural heritage. However, while it was driven underground, elders and other leaders kept the knowledge alive. Now that there is recognition of Indigenous self-determination, these same elders are helping their people reclaim these practices. Many Indigenous patients, like Clyde, access both western and traditional medicine with no sense of dissonance, although it can cause some problems.

  • Now that you have heard Clyde’s thoughts, go back and look at “Reflective exercise 2.”
  • Would you change your choice of action?
  • Can you think of another course of action that you might take if you were in Dr. Nyrit’s place?

 

Next: Part 3

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