hiiiiiiiiiiiiiiiiiiiiii

Chapter 5

Diversities and Health

Age, Gender, Sexualities, Racialization, and Indigenous Peoples5

Chapter Overview

•Inequity in a society impacts health at the level of the individual and of the population as a whole. It affects people of diverse socially constructed identities and social statuses differently.

•The social determinants of health discussed in the previous chapter operate through cross-cutting or intersectional social identities and statuses such as age, life stage, gender, sexual identities, and marital status, as well as ethnic and racialized identity membership.

•The most significant change in life expectancy over the last century and a half has been in infant and child mortality. This factor has been important in the overall aging of the population. Age and age identity are linked to morbidity and mortality.

•Gender identity, marital status, sexual identity, and “race” are associated with wellness, sickness, and death in predictable ways.

•Indigenous peoples in Canada—including First Nations, Métis, and Inuit—face particular health hazards linked to the history of colonialism, the “Sixties Scoop,” the residential school system, the lack of autonomous governance on reserves, and so on. These issues have created ongoing inequity along all of the social determinants of health, among other factors.

Jeff Whyte/Shutterstock.com

Introduction: Social-Structural Positions and Health

Socio-economic status is a fundamental cause of health disparities. This is because of the higher rates of illness and earlier death among those lower on the socio-economic status hierarchy or living in more unequal societies. It is also because of the inequitable and uneven access to care and treatments. All of the socio-economic (social) determinants of health discussed in the previous chapter impact people with varying social identities, cultures, and social-structural positions differently. We will look in more depth in this chapter at gender and sexual identities, age and stage-of-life identities, and racialized and ethnic identities and their relationships to morbidity and mortality. The second half of the chapter focuses on the particular situation of Indigenous peoples in Canada.

In discussing diversities, identities, and health, we will examine one variable at a time and the interaction of several variables at once. An intersectional approach is fundamental to understanding the effects of multiple variables at one time. For example, the social determinant of health, occupational insecurity (an aspect of one’s social-structural position), will likely affect income levels and this may operate differently among those identified as male and those identified as female. Occupational insecurity may also affect those with LGBTQ identities differently than it does heterosexually identified people. Notice the use of the term “identities” here. This idea reflects the notion that the taken-for-granted essentialized social statuses such as male and female, as biologically given and unquestionable, need to be critiqued. Whether a person is seen by himself/herself as a male or female and in turn whether others see individuals as belonging to the gender they would like to be seen as is sometimes a very complicated issue. Until recently we, in our society, and we, as sociologists, have failed to carefully examine the complexities of various identities such as gender. Now, however, we are coming to understand more fully the pervasiveness of the social in the construction of the ways that persons act, think, feel as cis- or transgendered men or women. Sexualities, sexual preferences, age or life course stage, racialized and other identities are also being deconstructed and their health impacts studied with more nuance and depth. We will review some of the literature on the health effects of various diverse identities in this chapter.

Underlying the following analysis is the argument that the social determinants (as discussed in the previous chapter) affect those with different identities differently. The social determinants and different identities interact and this leads to an increase or a decrease in impacts. This means that poverty, for example, can have a different effect on an elderly person who is less able to get a job, retraining, or an education than on a younger person who may have more freedom to make a change. Furthermore, we must underscore the idea that the effects of identities such as gender, sexualities, life course, age, racialization, and Indigenous group status are not applied to individuals and groups within society one variable at a time. Every woman, for example, as well as having a gender identity also has an age, a sexuality identity, and is racialized (or has a racial identity) both by herself and by others within the society. She will also have a certain level of income, a particular type and level of education, and so on. Therefore, it should be emphasized that we are simplifying the picture of the causes of health and illness for purposes of discussion. Readers must recognize that, empirically and theoretically, the situation is more complex in any given case. It is also important to note that there are other cross-cutting sources of identity, inequality and status such as religious group membership, neighbourhood, language preference, occupational status, and country of origin. Think of yourself for a moment. What do you consider to be your primary social identities? Do you think that your ideas correspond to those of others?

Among other questions, this chapter considers the following: Are women more often sick than men? Do men and women suffer from different illnesses? Why are children in the first years of life particularly fragile with respect to illnesses? Does old age bring increasing infirmity and illness? Are the elderly over-prescribed medicines by their doctors? Do the elderly feel that their health is poor? Are racialized groups more likely to be sick and/or to die early? What is the health profile of various Indigenous peoples in Canada?

Age, Gender, and Life Expectancy

Age is associated with morbidity rates and life expectancy in both predictable and surprising ways. You have probably heard of “the grey tsunami” or “the greying of the nation.” These terms point to the most obvious projected change in the Canadian population over time, as shown in Figure 5.1. This shows the overall aging of the population and the corresponding decrease in the younger proportion of the population. This population pyramid is the most basic graphic method used to describe the age distribution of a population. Figure 5.2, which includes population pyramids for Canada from 1925 to 2050, illustrates the demographic shift in the population over more than a century. The rapid growth of the older population is especially evident among women (the right side of the pyramids). The last two graphs, for 2025 and 2050, show the flattening of the middle ages and the gradual increase in the older ages. There is an especially dramatic increase by 2050 in the age group over 80 years.

Figure 5.1Population Projections for Canada, Percentage of the Population Aged 60 and over, 2001–51

Figure 5.2Population Pyramids for Canada, 1925–2050

Source: For 1925–2000: Statistics Canada, Age pyramid of population of Canada, July 1, 1901–2001, www12.statcan/english/cencus01; for 2025–2050: US Census Bureau, International Data Base, Population pyramid survey for Canada, www.census.gov/cgi-bin/ipc/idbpyrs.pl?cty=CA&out=s&ymax=25

Source: Commission on the Future of Health Care (2002, p. 22).

A number of explanations have been offered for these complex and changing phenomena. The most important factor in population aging is the overall decline in the birth rate. As people have fewer babies, there are correspondingly fewer young people. The presence of fewer young people in the population results in a greater proportion of elderly. A second and somewhat less important factor is the increase in life expectancy in Canada.

Life expectancy increases are the result of a number of changes. As we discussed in Chapter 2, first and most important is the rapid decline in the infant mortality rate. The average life expectancy for Canadians over the last 160 years or so has grown substantially. Women’s life expectancy has increased more than that of men. Significantly, men, in all of the years recorded, have lived shorter lives than women. Women’s mortality rate has declined so that it is almost half the rate it was in 1921. The drop is not so dramatic for men. The most significant decline for both sexes is in the early years of life. An important part of women’s increasing longevity in particular is improved nutrition and other public health measures linked to pregnancy and childbirth.

Overall, though life expectancy has grown significantly over the last century and a half, some obvious questions remain. How much more is it likely to grow? Will new diseases such as Ebola or SARS, or new outbreaks of common illnesses such as pandemic influenza seriously threaten the health of the world or the Canadian population? What will be the longer-term consequences of the COVID-19 pandemic that swept across the globe in 2020? How much will the opioid crisis impact the current trend in increased life expectancy? Will the medical and technological advances of the past continue into the future? If these advances do continue, can we expect that the additional years will be lived in a state of disability or will people live increasingly lengthier and healthier lives, becoming ill only in the short term just before death?

The answer to one question is now available. In the US and in British Columbia there has been a slowing of the overall trend towards a continuing increase in life expectancy due to deaths (at a relatively young age) from drugs, most especially opioids. Without the recent opioid crisis the life expectancy in Canada from 2000 to 2016 would have increased an estimated 3.15 years as compared to 2.99 years from 2000 to 2016 (Government of Canada, 2019). Further, for the first time there has been a decrease in average life expectancy in British Columbia. As the problem of opioid use continues, this trend can be expected to spread across Canada as it has already in the US unless dramatic changes occur (Government of Canada, 2018).

None of the causes of the dramatic decline or increase in mortality rates are necessarily sex-specific, with the exception of birth control and pregnancy management. Moreover, the early and more rapid increases in life expectancy for women as compared to men have diminished since about 1978 (Nault, 1997, p. 36). The difference between the life expectancies of males and females is due partly to the changing incidence of certain diseases as causes of death. For instance, while the rate of heart disease has declined for both men and women, the absolute decline has been faster among men than women. Still, men are more likely to die from a variety of causes.

Why, then, do men today live shorter lives than women? Several lines of inquiry might be followed to answer this question. First, the genetic superiority of women is an aspect of the explanation. More males are conceived and yet more male fetuses die (Doyal, 2003; Waldron, 1981). Males, in a number of different species, have higher death rates than females (although this is not universal). However, even if genetic predisposition plays a part in the mortality differential, it cannot be the only factor. For one thing, as Rutherford (1975) points out, the changes in the sex-mortality differential over the twentieth century, which continues today, could not be due entirely to genetics because genetic structures do not change that quickly. Furthermore, men are less likely to be ill than women. If the cause of the mortality differential were genetic, surely it would be paralleled in differences in morbidity rates for men and women.

Second, to explain this anomaly—that men are more likely to die, even though women are more likely to get sick—we must look at the causes of mortality by sex. Some of this difference in life expectancy between men and women is related to stereotyped machismo masculinities, which tend to put men more at risk in certain circumstances than women. As Doyal says, “constructing and maintaining a male identity often requires the taking of risks that can be serious hazards to health” (Doyal, 2003, p. 934). This sex-mortality differential is reflected in the important distinction between male and female causes of mortality during early to middle adulthood: males are almost three times more likely to die as the result of motor vehicle and other accidents and suicide; men are about 40 per cent more likely to die from all accidental deaths; and men are more than twice as likely to die from cirrhosis of the liver (Statistics Canada, 2011). Men and women are about equally likely to be victims of (reported) violent crime (Statistics Canada, 2008). In addition, men are almost three times more likely to die in any of the many wars fought around the world. Otherwise, men and women die from essentially the same causes, although at different rates and ages: cancer in general and lung cancer in particular, cardiovascular disease and stroke, accidents and adverse effects associated with motor vehicle accidents, chronic obstructive pulmonary disease, influenza and pneumonia, and Alzheimer’s disease are the top causes of death (Statistics Canada, 2016) (see Table 5.1).

Table 5.1Leading Causes of Death, All Ages, Both Sexes, Canada

Leading Causes of Death Characteristics 2013 2014 2015 2016 2017

Malignant neoplasms Rank of leading causes of death 1 1 1 1 1

Number of deaths 75,112 77,059 77,054 79,084 79,844

Diabetes mellitus Rank of leading causes of death 6 6 7 6 7

Number of deaths 7,045 7,071 7,172 6,838 6,882

Alzheimer’s disease Rank of leading causes of death 8 8 8 7 8

Number of deaths 6,345 6,410 6,587 6,521 6,675

Cardiovascular diseases Rank of leading causes of death 2 2 2 2 2

Number of deaths 49,891 51,014 51,534 51,396 53,029

Cerebrovascular diseases Rank of leading causes of death 3 3 3 3 4

Number of deaths 13,400 13,573 13,795 13,551 13,893

Influenza and pneumonia Rank of leading causes of death 7 7 6 8 6

Number of deaths 6,551 6,597 7,630 6,235 7,396

Chronic lower respiratory diseases Rank of leading causes of death 4 4 4 5 5

Number of deaths 11,976 11,876 12,573 12,293 12,847

Chronic liver disease and cirrhosis Rank of leading causes of death 11 10 10 10 10

Number of deaths 2,961 3,126 3,176 3,385 3,425

Nephritis, nephrotic syndrome, and nephrosis Rank of leading causes of death 10 11 11 11 11

Number of deaths 2,978 3,098 3,129 3,054 3,270

Accidents (unintentional injuries) Rank of leading causes of death 5 5 5 4 3

Number of deaths 11,452 11,724 11,833 12,524 13,894

Intentional self-harm (suicide) Rank of leading causes of death 9 9 9 9 9

Number of deaths 4,054 4,254 4,405 3,978 4,157

Assault (homicide) Rank of leading causes of death 24 23 23 25 22

Number of deaths 446 439 456 396 459

Source: Statistics Canada, Table 13-10-0394-01: Leading causes of death, total population, by age group, https://doi.org/10.25318/1310039401-eng

The most important contributions to higher male mortality may be related to causes associated with the performance of masculinities. The higher rate of cigarette smoking among men has had a significant and long-term impact on the sex differential for lung cancer, cardiovascular disease, and respiratory diseases. This sex differential is narrowing as women have taken up smoking and the smoking rates of men have declined. Another important contribution to the respiratory and lung cancer differential is likely linked to the higher risks of breathing toxins at men’s employment venues. Men are more prevalent in the workforces of industries involving work with carcinogenic substances. It is worth noting, however, that some cleaning, hygiene, and beauty products used primarily by women in the home and on their bodies have been found to be carcinogenic and of significant potential danger to women’s health. Risk factors for heart disease include smoking, high-fat diet, overweight, and stress resulting, in part, from the performance of hegemonic masculinities. These risk factors are more prevalent among men than women (Rosenfeld & Faircloth, 2006). Higher alcohol consumption among men is implicated in several causes of mortality—but chiefly accidents and suicide. Men drive more than women and less safely. Almost one-third of automobile accidents are associated with alcohol consumption (US Department of Transportation, 2017). The probability of other accidents, assaults, homicides, and suicides is increased by alcohol consumption. Liver diseases associated with alcohol ingestion are more than twice as common as causes of death among men.

Thus, while there may be gender-based genetic differences, male lifestyles—including a higher rate of cigarette smoking, industrial employment, excess alcohol consumption, and high-fat diet—clearly contribute to male mortality. In addition, the male proclivity to engage in violent, aggressive, and high-risk sports and other activities cannot be overlooked in gender-specific mortality rates. Such gendered behaviours are also implicated in the much higher suicide rate among men. Women are more likely to attempt suicide, but men, in part because they tend to choose more violent means, are more likely to succeed at dying by suicide.

It is also worth noting that the health issues faced by transgendered people are much less understood, although it is evident that the stigma, discrimination, and stereotyping that are both internalized and experienced by transgendered people would tend to lead to exacerbated vulnerabilities to all manner of diseases. A heightened vulnerability among trans people would inevitably result, too, from medical interventions that many will have chosen, including hormonal, surgical, and other pharmaceutical treatments. Research on the long-term effects of such treatments is in its early stages and a great deal remains unknown (Boghani, 2016).

Age

Infancy and Youth

Age is paradoxically related to morbidity and mortality. Everyone dies, and as people live to old age they will get sick and inevitably die. That statement is obvious. What is less obvious is that infants, children, and youth are particularly susceptible to sickness and death, especially when they also are poor, have darker skin and resultant racialized status, belong to families headed by lone mothers, and experience other negative social determinants of health. Rates of infant and childhood mortality, accidents, and sickness are correlated with social class. Poorer mothers are more likely to give birth to undersized babies. Despite various types of preventive strategies, such as prenatal programs for pregnant women at high risk, the rate of low-birth-weight babies is still problematic. Mothers who smoke and experience various forms of social disadvantage during pregnancy are more likely to have low-birth-weight babies (Dennis & Mollborn, 2014). Indigenous babies have poorer outcomes across a number of variables including being born with lower birth weight on average (Smylie et al., 2010).

The weight of newborn babies is a “key predictor of their survival chances” (Millar et al., 1993, p. 26). Low birth weight, said to be less than 2,500 grams or about 5.5 pounds, is associated with physical and mental disabilities and infant death. Low birth weight is linked to various types of intellectual and cognitive delays that impede success in learning and in school. Low birth weight is associated with a number of poor physical health outcomes, including (perhaps ironically) overweight and obesity in later years. These conditions, in turn, are linked to diabetes and cardiovascular disease. Mental health challenges are also associated with low birth weight (American Psychological Association, 2017). The first three years of life are also significant to subsequent health. During this time children’s brains and nervous systems are growing and developing, and they are acquiring language and other essential skills.

The social status of women has significant consequences for the health of their children. This is true around the globe, and is especially the case with respect to women in developing nations with less access to reliable birthing and maternity infrastructure. Women’s status is also important for the health and nutrition of their children (Abuya et al., 2012). Investment in women’s education has been shown to significantly reduce mortality rates among children. Many studies confirm this finding, for instance, Koenen and colleagues (2006) examined this relationship in the US. They defined women’s status through four complex, composite indices, including women’s political participation, economic autonomy, employment and earnings, and reproductive rights in 50 states. The well-being of children was measured according to the percentage of low-birth-weight babies, infant mortality rate, teen mortality, high school dropout rate, and teen birth rate. The health and well-being of children was found to be positively associated with women’s political, economic, and social status. Other research, using a similar model of women’s status, found that the health of adult men and women is better in states where women have higher status (Kawachi et al., 1999). This is also true around the world where women with higher education experience fewer maternal and child deaths, tend to have fewer children, use contraception, and marry later and are likely to be better informed about nutrition and other needs of their children (Population Reference Bureau, 2011). Today in Canada approximately 21 per cent of single mothers and 7 per cent of single fathers are raising their children in poverty (Canada Without Poverty, 2016).

Youth, too, are particularly vulnerable to health challenges. Young men, for instance, tend to take more risks and to be more aggressive and more stoic in the face of pain and distress (Spitzer, 2005). Male youth are more likely to suffer various injuries associated with binge drinking and to take greater risks in regard to frequent and multi-partnered sexual activity. The majority of traffic fatalities among youth in Canada are young men and many of these deaths involve alcohol or drugs or both (MADD, 2019).

Older Adults

Health problems affecting those over 65 years of age are of growing concern as the population ages. Older adults go to the doctor more frequently than young people and are more likely to be hospitalized and to be prescribed medications. In addition, evidence indicates that older people are more likely to be given prescriptions inappropriately (Ferguson, 1990; Shorr et al., 1990; Brook et al., 1989). In fact, approximately 9 per cent of hospital admissions result from inadequate or inappropriate drug prescriptions or utilization (Oscanoa et al., 2017). Some of the problems associated with pharmaceutical use among the older population result from the fact that the drugs have been tested on much younger people. Metabolic and other changes due to aging affect the absorption rates of drugs. Moreover, side effects from multi-drug use associated with the simultaneous treatment of several problems are particularly problematic among the elderly, not only because of the rate of drug absorption but also because of the increasing numbers of memory, visual, or motor problems, which may make taking medications, particularly multiple medications, more challenging (Tamblyn et al., 1994). Medications may be prescribed to be taken with or not with meals, before or after meals, with or without water or milk, at different times of the day, and so on. Managing a multi-drug regime is difficult at the best of times for the most alert persons. Managing complicated scheduling is even more difficult for the elderly (especially those whose literacy is compromised) and for the elderly sick. Thus, the elderly may inadvertently use their prescribed drugs inappropriately, causing additional health problems. Falls are also a major cause of suffering and hospitalization among the elderly and their probability is often increased as a side effect of medication.

Approximately three-quarters of a million Canadians suffer dementia of various kinds, including vascular dementia and Alzheimer’s disease. By 2031 it is estimated by the Canadian Institutes for Health Research that 1.4 million Canadians will suffer dementia.

Canadian elderly people have more chronic conditions, are more likely to be hospitalized and medicated, and yet are still likely to self-report excellent or good health and health satisfaction. Perhaps surprisingly, seniors continue to report greater life satisfaction than other age groups and women report more life satisfaction than men at these ages (Uppal & Barayandama, 2018). This may be because they see and evaluate themselves in relative terms in comparison with others of the same age. Psychosocial factors among the elderly, such as a sense of purpose in life, a sense of control, social participation, and life satisfaction (Anstey et al., 2001; Pinquart, 2001; Ranzijn, 2001), as well as socio-economic factors, are positively related to quality of life and longevity. The elderly who live in long term care institutions have proven to be especially vulnerable as demonstrated by the fact that the vast majority of deaths (between 82 and 86 per cent) from COVID-19 occurred in long term care facilities. People in for-profit facilities were especially susceptible.

Highlighted Issues

Box 5.1 • Viagra

Women’s health has been and continues to be an important issue. However, men’s health should not be ignored. There was a near-epidemic of desire unleashed with the marketing of Viagra, a drug designed for the treatment of angina but that, instead, was found to produce an erection in men. This discovery soon led to a multitude of diagnoses of erectile dysfunction. This is just one indication of how little is known about the ways that men may be suffering in their bodily functions. Until Viagra was introduced into the market in 1998 (soon to be followed by similar drugs, such as Cialis and Levitra), few knew of the extent of erectile dysfunction among men. Perhaps men weren’t talking about it with their doctors and were thus not getting counted in morbidity figures. Perhaps this is best seen as a case of a drug in search of a problem, disease-mongering, or the medicalization of masculinity (Moynihan et al., 2002; Rosenfeld and Faircloth, 2006). Sometimes it appears to be used in the absence of problems. One of the most dramatic examples of the voluntary or discretional use of Viagra is among some men who have sex with men and use it (sometimes along with other drugs such as amyl nitrate, a “popper” that gives a burst of dizzying energy) to enhance their sexual pleasure. One community-based study in San Francisco found that the rate of Viagra use among men who have sex with men was 32 per cent (Chu et al., 2003). Thus, Viagra and its counterparts are now used to enhance sexual pleasure as well as for erectile dysfunction. The success of the medicalization of sexual dysfunction among men has led to a new focus on the existence and biology of female sexual dysfunction along with the marketing, called the “pinking” of Viagra, and use of pharmaceutical interventions to enhance female sexual pleasure (Moynihan, 2003; Hartley, 2006).

Gender, Poverty, and Mortality/Morbidity

Women and female children are particularly likely to be ill, to die, or to be killed when they live in impoverished circumstances. Women are more likely, within their own domestic spheres, to become ill and die because they tend to take responsibility for ensuring that others are provided for ahead of themselves when there is a relative absence of necessary foodstuffs, water, or other necessities of life. When poorer women are pregnant they are less likely to have access to the essential nutrients, social support, and prenatal care. They are more likely to live with chronic hunger and lowered resistance to various chronic and infectious diseases. This situation is true around the world (Wermuth, 2003; UN Women 2019). Women usually have the responsibility of feeding their children. Inequalities in the valuation of men and women in all classes, but particularly among the poorest people, lead to higher esteem or value being placed on boy babies in many cultures. Sometimes this results in the intentional death of female babies or the abortion of female fetuses. There is no evidence of this occurring in Canada, but a survey of women in Madras, India, found that more than half reported having killed a female child (Wermuth, 2003). China, for many years, limited couples to only one child per family. This, in effect, led to the deaths of baby girls because females were less desired. In some cultures, women who are unable to produce male heirs are sometimes killed, maimed, or sent away from their families. Poor families sometimes sell their girl children into sexual slavery because they cannot support them or because they are told that their daughters will then be able to send money home to support the rest of the family. Rape is more common among poor women (Wermuth, 2003). Female genital circumcision or mutilation, depending on cultural beliefs, may be considered another type of violence against women or a sign of female beauty and desirability. It causes pain, infection, disability, and sometimes death, and interferes in the possibility of women experiencing sexual pleasure when they do engage in sexual relations. This practice affects female children not only in the countries in which such practices originate but also in countries such as Canada because of the numbers of immigrants and refugees from areas of the world where this practice is accepted and where women are thought not to be marriageable unless this is done. In the absence of female circumcision, their genitals are considered “ugly.” The social policy and ethical issues raised by the desire of some newcomers to continue this practice in Canada are worthy of serious thought and discussion, not least under a nationally funded and supported medical care system.

The conclusion that must be drawn from our research on gender differences in health is that women are more likely to suffer from a variety of illnesses than are men and that men at every age are more likely to die than are women. Which is the better measure of parity: to live longer and be chronically ill or disabled or to die earlier? What will the future bring? Are women actually “dying to be equal,” as evidenced by their rates of cigarette smoking, alcohol consumption, cannabis consumption, opioid use, high-risk lifestyles, and increased involvement in high-stress careers?

Transitions and the Life Course

Life course transitions offer additional opportunities for increased health as well as additional potential for stress and illnesses of all sorts. All transitions include the potential for health changes and stresses but especially transitions that occur out of the typical order or at a non-normative time. The transition that has garnered the most research is that of single teenage women embarking on a pregnancy and then on to child-rearing. The consequences of this trend are significant both for the mother and for her offspring. Similarly, young men who drop out of school before completion usually face greater economic and social challenges as they age. Young widowhood, early retirement, late childbearing, job loss, and educational interruptions all offer additional challenges to those that are inevitably already a part of any transition. It is also important to note that while transitions may create stress and thus a greater likelihood of illness, there is always room for individuals to cope exceptionally well.

Marriage

Marriage is a social status and identity with important links to health and illness. Married people tend to be healthier and to live longer lives. Single and divorced or separated people are more likely to become ill and to die. Nevertheless, the rates of (heterosexual) marriage are decreasing, from 70.5 per cent of Canadian families in 2001 to 65.8 per cent in 2016. However, the rate of same-sex marriage has increased: 16.5 per cent of same-sex couples married 2001 and 33.4 per cent did so in 2016. At the same time, in 2016 there were more single-person households than there were those with married couples (Eichler & Pederson, 2018). Marriage appears to offer men particular protection from illness (Robards et al., 2012). This outcome may be related to the higher social status of married men, as illness is associated with being in a subordinate position in the social structure (Thoits, 2011). It may also be linked to the fact that they are living with someone who is expected to care for them. Whether this overall positive association between marriage and health for men is a result of healthier lifestyles among the married (such as healthier eating, more controlled alcohol consumption, routine exercise) or because healthier people are selected into marriage is another issue under investigation. Loneliness has been linked to ill health (Hawkley & Cacioppo, 2010). Certainly, too, the periods of transition into and out of marriage are times of heightened vulnerability to illness. Furthermore, particular types of caring, for instance, for gravely ill or disabled partners, can have negative health consequences for the carer and at times these can mitigate the benefits of marriage. Longitudinal research is needed on the impact on health of changes resulting from divorce and of the single people living alone. Also, nearly all research to date has focused on heterosexual couples and, thus, research on same-sex couples is needed. In addition, more research is needed on the impact of unhappy marriages on the health of the partners. Negative emotions, characteristic of unhappy marriages, are linked to elevated blood pressure and heart rate and increased levels of stress hormones (Robles & Kiecolt-Glaser, 2003), among other deleterious effects.

Lesbian, Gay, Bisexual, Transgender, and Queer Identities and Health

In the past couple of decades, a significant increase has occurred in research and policy development for people with non-heterosexual sexual identities and ambiguities in sex and gender identities. The rapid spread of the legalization of same-sex marriage is among the most important social forces enabling the growing public acknowledgement of sexual diversity. The openness of some prominent celebrities of diverse sexual identities, such as the television host Ellen Degeneres, has also played an important role in the “mainstreaming” of various differences. However, acceptance is not universal and LGBTQ people continue to experience significant amounts of stigma and discrimination in Canada and elsewhere in the world. “Coming out” to parents and to peers continues to be fraught for many Canadian young people. Research has shown that LGBTQ people have higher rates of some types of illnesses. For instance, some LGBTQ people struggle with mental health challenges such as depression, anxiety, and trauma (Zwiers, 2009). It is no wonder because protective factors for these conditions include a sense of social inclusion, freedom from discrimination and violence, and other social determinants (Canadian Mental Health Association [CMHA], 2019). Bisexual and trans people are more likely to be of poorer socio-economic status (CMHA, 2019). Hate crimes are a problem in Canada and one of the groups most likely to suffer from hate crimes is LGBTQ people (CMHA, 2019). Gay men and lesbian women are more vulnerable to certain types of cancers, excess alcohol consumption, and cigarette smoking. Gay men are more susceptible to various sexually transmitted infections and lesbian women have a greater likelihood of certain problems associated with reproduction (for instance, the side effects and after-effects of hormone ingestion sometimes used to enable artificial insemination). Health care itself may be more challenging for those with diverse sexual identities because of stigma and discrimination in the health-care system (Colpitt & Gahagan, 2016). Internalized shame and lowered self-esteem can also threaten the health and well-being of those whose identities do not adhere to heteronormativity. Compounding all of these problems is the lack of adequate education and training for health-care providers about sexual diversity and the possible homophobia, heterosexism, and other stereotyped and discriminatory practices to which the LGBTQ community is subject. Further, LGBTQ people may be less likely to seek health care because of their own fear and discomfort resulting from anticipated discrimination.

Racialization, Ethnicity, and Minority Status

“Race,” ethnicity, culture, and minority status are important factors affecting health in Canadian society and around the world. They should be defined and distinguished. Furthermore, it is essential to acknowledge that their implications have arisen out of a context of white supremacy and reflect the actions of the white population to define race, in part, to keep racialized people in an unequal position as compared to white people. “Race” is a social and political construct that has been used to distinguish people on the basis of physical characteristics such as skin colour, hair colour and texture, bone density, blood types, and facial structure. Historically, there were thought to be three broad categories of race: Caucasian, Mongoloid, and Negroid. In fact, there are no pure races and the concept is outdated. However, the false beliefs about race continue and produce racialization and the prejudice called racism. “Ethnicity” refers to a common cultural background. Culture is a fundamental category for understanding similarities and differences in peoples around the world and within diversified countries such as Canada. There are numerous definitions of the concept of culture. Broadly speaking, “culture” refers to the total way of life of a group or aggregate of people. It often includes a unique language or “accent” and a world of everyday living based on a distinct language. “Minority status” refers to the numerical distribution of different ethnic categories of people within a total population. Those with minority status are statistically or numerically less than one-half of the population under discussion. Of particular relevance to the topic of health is the idea that health is socially and culturally constructed, as are signs and symptoms of ill health, attitudes to those who are well and those who are ill, and different types of health care.

CRITICAL THINKING

Box 5.2 •Movember

In 2003 a couple of men in Australia asked themselves what had happened to moustaches. In response, they decided to grow them and asked a bunch of their friends and acquaintances to join them. Each person was charged $10. They decided to use this adventure into face hair to raise money for charity and, inspired by the breast cancer movement, they chose men’s health and prostate cancer as their charity of choice. The movement grew from 30 in 2003 to 4 million in 2013.

The Movember movement continues. In 2018–19 the movement raised $102.9 million and had 321,975 participants around the world (Movember, 2019). The Movember campaign is held every November in the involved countries. It essentially includes men supporting one another and raising funds through growing moustaches. It has become a major funder for research and programs for men’s health in general and prostate cancer and depression more specifically.

While the Movember movement was founded by non-medical people and is lay-based, it has grown to be a global foundation with the goal of tackling a broad range of men’s health issues beyond prostate cancer. It now includes fundraising for prostate and testicular cancer, suicide, and mental health issues. The organization has supported thousands of creative projects in these areas.

Us TOO, another movement, in this case for prostate cancer in particular, primarily focuses on providing education and support to those diagnosed with this disease and is now heavily funded, including by pharmaceutical companies. Us TOO was started soon after the early days of the breast cancer movement. It was initially instigated by men who were tired of all of the attention going to breast cancer, a mostly women’s disease. They wanted their disease of prostate cancer included in large fundraising and research efforts.

These examples of gendered, disease-based fundraising lead us to ask a number of questions. Should medical research, and associated programming, be determined by lay people? Should research direction be determined by the efficacy of a social movement? Should “gender wars” enter into funding allocations? Should disease funding be determined by its incidence, age of the diagnosed, probability of a cure or prevention in the near future, severity of impact of the disease, or something else? Should pharmaceutical companies be allowed to contribute to lay organizations or does this inevitably lead to a conflict of interest?

These are just a few of the ethical issues and questions raised by health-related social movements. What do you think?

The relevance of race to health is primarily due to the pervasive and systemic realities of racism experienced by racial minorities. This racism is evident in interactions with major institutions such as the educational, criminal justice, and health-care sectors. The constant and often invisible structural and systemic racism also accumulates in the day-to-day experiences of racialized people through microaggressions such as casual and seemingly minor slurs, slights, and interpersonal assumptions endemic in white privilege (Sue, 2011). These microaggressions happen so commonly that they are often outside of the conscious awareness of perpetrators and possibly even the recipients. Yet, they build up and are internalized and can lead to both mental and physical health problems through processes that will be described further in the next chapter. Microaggressions are a fundamental part of racism and the suffering it causes.

CRITICAL THINKING

Box 5.3 •Functional Health

It is one thing to talk about the incidence of cancer, heart disease, diabetes, and other chronic and acute conditions. It is quite another to consider the question of functional health. This refers to the ability of individuals to engage in everyday life and to enjoy the simple things. Functional health includes things such as the ability to hear, see, and be mobile. It involves being able to care for oneself and one’s daily needs. It also includes basic memory functioning. A Canadian Community Health Survey from 2017 found that 18.1 per cent of Canadians over 18 years had some memory or concentration challenges, 14.3 per cent had some challenges with their vision, and 15 per cent had some challenges walking. Females were more likely to have certain of these difficulties and males others. As well as gender the survey looked at age differences and found that the percentage of Canadians with challenges increased as people aged. Thus, 59.8 per cent of Canadians over 65 had at least one area of difficulty in functional health. Functional health is also related to socio-psychological conditions such as life satisfaction and a sense of being a member of a community. Those with functional limitations also experienced poorer socio-economic status. They are more likely to be unemployed and are likely to have a lower level of education. Such socio-economic and socio-psychological challenges often restrict the overall quality of life of people and make change in these social determinants of health even more intractable than they usually are.

Source: Community Health Survey (2018).

At the same time as Canadians extol our diversity and Americans articulate the value of their melting-pot society, violence against racial minorities continues in both places and under both political philosophies. Recently, for example, a resurgence of attention has been paid to racially based police brutality and racial profiling, especially after the death of George Floyd in Minneapolis set off protests around the world and a resurgence and expansion of support for the Black Lives Matter movement. There are many examples of this in each country. Other forms of racism include systemic violence, racially based hate crimes, and so on. All sorts of racism and even anticipated racism can be linked to poorer physical and mental health among racialized minorities.

The term used most frequently in relation to racial discrimination is racism. It is a part of other “isms,” including ableism, ageism, sexism, and phobias such as homophobia and transphobia with their constant companions of stigma, discrimination, and prejudice. We need to understand that racism wearies and hurts those who are insulted and distanced and can lead to higher rates of disease. Although less investigated, the perpetrators of racist acts likely also are hurt and made sick by engaging in this behaviour.

For all of these reasons associated with racism, a close and persistent relationship exists among racialization, ethnicity, and class. Significant economic inequality can be attributed to differences in ethnic background. Racialized groups are more likely to be poor, homeless, or inadequately housed and to experience discrimination and barriers in access to health care (Access Alliance, 2005; Colour of Justice Network, 2007; Nestel, 2012). One in five racialized families live in poverty in Canada, while one in 20 non-racialized families live in poverty (Canada Without Poverty, n.d.).

Ethno-racial minorities in urban centres have lower levels of income as a result of historical and continuing discrimination in the labour market (Galabuzi, 2001; McGibbon & Etowa, 2009). Racialized groups tend to live in different and poorer neighbourhoods in Toronto (Contenta, 2018). Poverty is especially endemic among immigrant and refugee groups from Africa, South Asia, and Southeast Asia. Among racialized groups, unemployment rates are higher and they are over-represented in low-wage sectors of the economy as well as in unregulated and temporary work. This may even be a more prominent issue today given the increases in racialized minority immigrant and refugee populations in Canada and particularly in the largest Canadian cities. However, heartening news in this regard indicates that despite the recent increase in the number of refugees admitted to Canada in response to civil war in Syria, the attitudes of Canadians remain positive (Perreaux, 2018). This is important because how others view an individual has important consequences for self-esteem, stress, mental health, and well-being. Today, 40 per cent of Canadian children are foreign-born (Statistics Canada, 2019). Their well-being and integration are fundamental to the future of Canada.

To the extent that ethnicity is related to occupational status, income, education, and other social determinants of health, people of different ethnic groups will differ in their morbidity and mortality rates. Furthermore, according to the 2016 census, racialized people are twice as likely to be poor in Toronto, the most ethnically diverse city in Canada (Joshi, 2017).

Immigrant Health

There were 5.4 million immigrants enumerated in the census of Canada in 2001 (Ng et al., 2005). Each year since 2001 an average of about 250,000 immigrants came to Canada until 2016, when, in response to the Syrian crisis, new policies were developed that included admitting about 323,000 immigrants and refugees to Canada in 2016, 272,000 in 2017, and 303,000 in 2018 (Statista, 2018). Immigration is a significant component of the growth in the population and labour force. Because of low fertility rates among native-born Canadians, immigration protects Canada from population decline as it maintains at least a slow population growth and contributes to economic prosperity. At times the population increase from immigration is much greater than that from native-born increase. In fact, Canada’s growth is determined largely by immigration (Canada Population, 2018) and the argument can be and has been made by the Conference Board of Canada that Canada would benefit from increasing immigration levels (Keung, 2017).

People of colour made up about 22.3 per cent of Canada’s population in 2016 (Grenier, 2017). However, gathering statistics about this sensitive topic is not easy, nor are the results as valid as would be ideal. That said, by 2030 both Vancouver and Toronto are predicted to have almost or above 60 per cent of their populations representing visible minority groups (Statistics Canada, 2010). Obviously, the term “minority” will take on a new meaning in this situation.

Considerable research in Canada, the United States, the United Kingdom, and Australia documents the relatively good health of new immigrants, partly as a result of selection (Kennedy et al., 2015; Vang et al., 2015). The notion of selection suggests that individuals who are healthier will be more likely to face the myriad challenges involved in immigrating to a new country. It also reflects the fact that new immigrants must pass a medical test and Canada is more likely to accept/select those people who are in good health. This phenomenon has been called the healthy immigrant effect (Beiser, 2005). The process of planning for, organizing, and executing the move for immigration demands a high level of intelligence, skill, energy, money, and overall well-being. Moreover, Canada’s immigration policies (and those of other receiving countries) favour the educated, occupationally skilled, and young. In addition, immigrants are screened for various diseases prior to being accepted to Canada and may be denied admissibility solely on medical grounds. Even after they arrive in Canada in generally better health than the average Canadian, as immigrants adjust to life in Canada their health tends to deteriorate.

The situation is similar in many ways among refugees, even though, by virtue of their status as refugees, they have experienced highly stressful living conditions prior to coming to Canada. Nevertheless, the health of refugees is likely poorer than that of other immigrants and they are, for example, more susceptible to infections and parasitic diseases. Tuberculosis is a case in point. This highly contagious disease has incidence levels among refugees of approximately three times that for those born in Canada (Caring for Kids New to Canada, 2019). Canada continues to screen refugees for physical and mental illnesses so that they can be immediately treated. One study, for instance, found that new refugees to Toronto had higher rates of various infectious diseases such as HIV (2 per cent) and Hepatitis C (<1 per cent), along with several other less familiar diseases (Caring for Kids New to Canada, 2019).

Another way to consider the issue of the relative health of immigrants is through a comparison of their subjective reports with those of other Canadians. Ironically, perhaps, immigrants report that they perceive themselves to be healthy to a greater extent than do other Canadians, regardless of socio-economic and demographic characteristics when they arrive. However, the longer they remain in Canada the closer their self-reported health status comes to the rest of the population. Indeed, their overall health in general moves towards the Canadian average over time.

A Brief Overview of Indigenous Peoples in Canada

The one minority “group” for which current and historical data are becoming available now is Indigenous peoples in Canada: First Nations, Inuit, and Métis. The variety of terms, including the older “Indians” and “Eskimos,” reflects the struggle to find a name that best reflects the history and identity of peoples whose cultures were colonized by people of European origin over the past hundreds of years. Designations such as “savage,” “redskin,” “half-breed,” “squaw,” “buck,” “brave,” and “papoose” reflect something of the racist history to which Indigenous people have been subject by various generations of Euro-Canadians (Vowel, 2016). Some debate whether Indigenous peoples in Canada ought to be considered an ethnic group or not. Canada’s Indigenous peoples are not considered “visible minorities” by the Canadian government. Those who favour the “ethnic group” designation argue that there are significant similarities among all Indigenous peoples despite their 70 or so different languages and the more than 600 registered “Indian” bands. In 2012 there were 3,169 reserves across the country, although some lacked inhabitants (Sawchuk et al., 2018). The chief similarity among all of the First Peoples in present-day Canada, who totalled just under 1.7 million in 2016, is that they share the powerful effects of subjugation through having been colonized (Sawchuk et al., 2018; Statistics Canada, 2018). This is a reason to consider them an ethnic group. Others, however, argue that, because the cultural diversity of the Indigenous peoples at colonization was seriously compromised by the dominance of the state, they should not be considered one cultural or ethnic group. Many different languages, cultures, and geographies distinguish them. Indeed, the majority (56 per cent) of all Indigenous people live in urban areas today (Sawchuk, 2018), and only 44 per cent of registered First Nations people live on reserves. Like First Nations and Métis people, the Inuit are also migrating south to the cities, with 27.2 per cent of Inuit, who in 2016 totalled over 65,000, residing outside of Inuit Nunangat (i.e., Arctic Canada) (Statistics Canada, 2020). Overall, wherever they live, Indigenous people continue to face much poorer life chances, more disease, higher infant mortality, and lower life expectancy rates than non-Indigenous people in Canada.

Figure 5.3The Indigenous Population in Canada

Source: Canadian Press (2017). The Aboriginal population in Canada. http://thecanadianpress-a.akamaihd.net/graphics/2017/static/cp-census-aboriginal-pop.png

Remembering Our History

Box 5.4 • The Great Dying

The numbers have been debated and are difficult to be sure of, but the most reliable recent estimate is that the New World (First Nations) peoples likely numbered between 90 and 112 million before they were devastated by the diseases and warfare that Europeans brought with them to North and South America. Not only were the Amerindians numerous, they also enjoyed good health. Before contact they may have been in better health, in some ways, than Europeans. They did not have measles, smallpox, leprosy, influenza, malaria, or yellow fever. For most, staying healthy and living well were essential tenets of their religion. Hygiene included regular bathing and the peoples of the New World kept themselves very clean. The Europeans could not help noticing the “good smells” emanating from the healthy, robust people. Apparently, they especially admired their even white teeth and clear complexions, “something most pockmarked Spaniards, Portuguese and French had lost at an early age” (Nikiforuk, 1991, p. 80). At this time, the average life expectancy of Europeans was about 20 years less than that of the Amerindians. It is suggested that their good health was the result of the origins of these people, who had crossed the land bridge that spanned the Bering Strait to the New World at a time of lower sea levels. Because of the harsh cold, the diseased immigrants and their germs were killed. Only the fittest survived.

Into this context of good health the new disease smallpox entered—an unknown yet dangerous predator that spread as an epidemic until it and other diseases such as the plague and tuberculosis killed upwards of 12 million people in North America. This “great dying” occurred over the course of about one century. Some historians rank this as the greatest demographic disaster in the history of the world. It is estimated that between 1492 and 1600, 56 million people died as a result of the arrival of the European settlers (Koch et al., 2019).

Numerous explanations can be found for the compromised life chances and relatively poorer health indicators of Indigenous peoples residing in Canada. The Truth and Reconciliation Commission of Canada, under the leadership of Justice Murray Sinclair, pointed to several of these causes in its 2015 report:

For over a century, the central goals of Canada’s Aboriginal policy were to eliminate Aboriginal governments; ignore Aboriginal rights; terminate the Treaties; and, through a process of assimilation, cause Aboriginal peoples to cease to exist as distinct legal, social, cultural, religious and racial entities in Canada. The establishment and operation of residential schools were a central element of this policy, which can be described as “cultural genocide.” (Truth and Reconciliation Commission of Canada [TRC], 2015, p. 10)

Before colonization, Indigenous peoples were largely dependent on fishing, hunting, and foraging (First Nations Health Authority, n.d.). There was some manufacturing of such items as tools, chiefly for personal use. Many had very complex and sophisticated methods of harvesting and preserving foodstuffs over the seasons. People tended to be well because they had to be active to maintain life and because they usually had a varied and nutritious diet. According to oral history, during pre-contact time Indigenous people had very good health and longevity. Moreover, what they considered health was much more than merely biological functioning. It encompassed spiritual, social, and ceremonial elements of life, whereby the individual needed to be in good relations not only with other humans but with the land and with the animals and plants that shared the environment. Various types of healers incorporated some of the different components of health, and these healers included midwives, shamans, and herbalists. There was no diabetes or dental caries at this time, although there is evidence of arthritis and of abscess in the jaws of some. Spiritual wellness, which was the domain of the shaman, was considered to be essential to well-being. The people thrived with the combination of healthy foods and lifestyles and holistic health care.

After contact, widespread epidemics of smallpox, influenza, measles, and whooping cough occurred. Populations were decimated. In some villages the mortality rate was as high as 90 per cent. Chronic diseases such as tuberculosis and venereal disease arrived. The work of the traditional healer and the shaman was relatively ineffective in dealing with these new diseases. The immune systems of the remaining people were compromised. With the population losses, many aspects of the oral culture and the histories of healing also were lost.

Treaties were signed that outlined nation-to-nation relationships and friendship agreements between the British Crown and Indigenous groups (Sawchuk, 2018). Then, in 1876, the Indian Act, which pulled together and enlarged on earlier colonial policy, was enacted. This legislation, which has undergone small and major revisions over the past century and a half, provided that the government would be responsible for funding social services and programs to the First Nations people who registered as Indians with the federal government. Treaties stipulated landownership and responsibilities. The funding was under the control of band administrators, that is, white Indian agents employed by the federal government.

Before we consider the health and medical care of Indigenous people in Canada today, we need to look at four significant factors that affect the mental and physical health of Indigenous peoples in Canada and are unique to their circumstance: (1) the experience of residential schools; (2) the “Sixties Scoop”; (3) continuing questions regarding autonomy and authority in governance structures and landownership; and (4) the quality of the physical environments upon which people who live on reserves depend.

Residential Schools

From a very early date there were some residential schools for Indigenous children in New France. But beginning in 1874 the Canadian state, with the help of various churches, established residential schools across the country. The aim was the education of Indigenous young people to enable their assimilation to the majority society. More than 100,000 Indigenous children were taken from their homes and educated in more than 100 residential schools across Canada over the next century. This practice reflected the government’s desire to incorporate Indigenous people into the mainstream culture and was supported by the desire of Christian churches and their missionaries to Christianize the Indigenous peoples. The strategy was to remove young people from their families and cultural roots. The residential school era caused immense suffering for the children, their families, and their communities. Not only did the residential school experience disrupt the family life of these children, it also diminished their ability to parent when they grew to be adults (Barton et al., 2005; TRC, 2015). The children lost their culture, language, and identity. Their education was severely hampered by their physical mistreatment and by the racist limitations and assumptions upon which the school administrators based the curriculum. Indeed, for older children, especially, these schools often were less institutions of education than forced labour camps. Many of the children were expected to put in long days of labour tilling the soil, growing crops, and making repairs for the school.

The government and the churches designed specific training programs to manage the Indigenous children. The prime minister of the time, Sir John A. Macdonald, made the rationale very clear when he spoke to the House of Commons in 1883:

When the school is on the reserve the child lives with its parents, who are savages: he is surrounded by savages, and though he may learn to read and write his habits, and training and mode of thought are Indian. He is simply a savage who can read and write. It has been strongly pressed upon myself, as head of the Department, that Indian children should be withdrawn as much as possible from parental influences, and the only way to do that would be to put them in central training industrial schools where they will acquire the habits and modes of thought of white men. (TRC, 2015, p. 2)

The children and their families were virtually powerless to resist. Many children were sexually and physically abused. They were unable to speak their own languages and were forced to always communicate in English. They could not communicate with the family they had been forced to leave behind. Their own cultures and languages were denigrated and their previous way of life despised and vilified by those in power, the teachers and administrators. They were fed inferior food. Sugar and starch were added to their diets. In some cases, deleterious and even dangerous experiments in nutrition were carried out with the children as the subjects. Many young people died in the residential schools, and sometimes the parents were not informed of the deaths of their children. Some children ran away from the schools, and some of these died trying to reach their homes. The Indian Act, buttressed by the state, assumed the right to force compulsory hospitalization and treatment and to intervene with the imposition of modern medicine. This power was rationalized as a way to prevent the spread of epidemic disease. The legacy of this brutalization continues today.

In order to survive and psychologically avoid the pain, many children experienced dissociation (TRC, 2015). Today, many residential school survivors suffer symptoms of post-traumatic stress disorder (PTSD), such as recurrent and intrusive memories, nightmares, flashbacks, sleep difficulties, anger management problems, a tendency to abuse drugs and/or alcohol, and difficulties in relationships. PTSD is associated with marital instability, educational failure, and unemployment (Barton et al., 2005; TRC, 2015). Some children who died at the schools were interred in unmarked graves. Tuberculosis was a leading cause of death. In one community, the Nuxalk Nation, 52 per cent of all deaths between 1917 and 1983 involved people under the age of 25. Most likely, many of these deaths were among children in residential schools.

The government of Canada, as part of the 2006 settlement for the individual, family, and community harms caused by the residential schools, established a $350 million Aboriginal Healing Fund and the Truth and Reconciliation Commission, which began hearing the stories of survivors in 2009. The government has paid damages of about $2 billion to individuals taken from their families as children, deprived of their cultures, languages, and values, and sometimes sexually or otherwise abused. The churches that ran these government schools—Anglican, Roman Catholic, United Church, and Presbyterian—worked out their degree of responsibility with the federal government (the Anglican Church, for example, paid reparations of $25 million) and, except for the Catholic Church, all of the churches made formal apologies in the 1990s (Frideres, 2020, pp. 69–72). In 2009 Pope Benedict expressed “sorrow” and “regret” for the harm caused, but the Catholic Church has refused to make a formal, official apology. According to the Canadian Conference of Catholic Bishops, this is because neither the church as a universal whole nor the entire Canadian church made the decisions to be involved in the schools. This, they state, is because the church in Canada has a decentralized structure and only 16 out of 70 dioceses in Canada were implicated (Canadian Conference of Catholic Bishops, n.d.).

With many residential school survivors in attendance, then Prime Minister Stephen Harper formally apologized in a special sitting of Parliament in June 2008, stating in part: “The Government of Canada sincerely apologizes and asks the forgiveness of the Indigenous peoples of this country for failing them so profoundly. We are sorry” (AMMSA, 2008). Leaders of the other federal parties also presented statements of apology, and the leaders of the five major national Indigenous organizations spoke in response. The response of Beverley Jacobs, at that time the president of the Native Women’s Association of Canada, cut to the heart of this significant issue in Canadian health and society:

Prior to the residential schools system, prior to colonization, the women in our communities were very well respected and honoured for the role that they have in our communities as being the life givers, being the care takers of the spirit that we bring to mother earth. We have been given those responsibilities to look after our children and to bring that spirit into this physical world….

I want to say that I come here speaking from my heart, because two generations ago, my grandmother, being a Mohawk woman, was beaten, sexually beaten and physically beaten, for being a Mohawk woman. She did not pass that on. She did not pass it on to my mother and her siblings, and so that matriarchal system that we have was directly affected. Luckily, I was raised in a community where it has been revitalized by all of our mothers.

I want to say that as mothers, we teach our boys and our girls, our men and our women equally…. It is not just about women’s issues, it is about making sure that we have strong nations again. That is what I am here to say. (Hansard, 11 June 2008)

The long-term effects continue in the generations being born and raised now.

The “Sixties Scoop”

Another disaster followed the calamitous effects of residential schools. The “Sixties Scoop” or the “lost generation” refers to the policy begun in the 1960s and ended in the 1980s that had similar goals to those of the residential school system (Vowel, 2016). It was initiated by an agreement between the federal and provincial governments to take over the responsibility for child welfare of First Nations children across the country. Rather than taking children forcibly from their homes and depositing them in schools miles away, this policy involved taking children from their homes on the presumption that their parents, their extended communities, and the homes they provided for their children were not good enough. In this case the children were seized by the child welfare agencies mandated to ensure that the needs of Indigenous children were being met. If the agencies decided that their needs were not satisfied, children were removed from their families and communities and adopted out or fostered to “homes across Canada, in the United States, and even overseas” (TRC, 2015, p. 138). The idea was to provide the children with homes that reflected the values of the social workers who were judging the suitability of Indigenous parenting. On a lesser scale, this policy continues. In 2011 Statistics Canada reported that 3.6 per cent of Indigenous children were in foster care as compared to 0.3 per cent of non-Indigenous children.

The United Nations Committee on the Rights of Children has stated its concern about the removal of Indigenous children from their homes as a first response “in cases of neglect, financial hardship or disability” (TRC, 2015, p. 138). The care of children of Indigenous parents is also more likely to be investigated than that of those from other families. One study found that there were 140.6 investigations of child maltreatment per 1,000 Indigenous children versus 33.5 investigations per 1,000 non-Indigenous children (TRC, 2015, p. 139).

At the same time as child welfare authorities have taken a disproportionate number of Indigenous children into care, they also have failed to protect them adequately in their foster and adoptive homes. Some foster parents have been found to physically and sexually abuse their charges. Fostered Indigenous children were significantly more likely to die in care than non-Indigenous children. In one study 78 per cent of the children who died in care were Indigenous (TRC, 2015, p. 141). There is a lack of adequate funding for supervision and child placement, and jurisdictional disputes between the federal and provincial and territorial governments about who ought to pay for various services only complicate matters. A bill called Jordan’s Principle was introduced into and passed by the House of Commons in reaction to one such dispute. Jordan was an infant born with complex medical needs. He spent his short life until he died in hospital in the midst of jurisdictional arguments regarding which level of government was responsible for his medical care (TRC, 2015, p. 142).

That the Sixties Scoop was a significant movement and had a large impact is illustrated by the fact that in one province alone, British Columbia, the numbers of First Nations children removed from their homes went from almost none to about one-third over the course of a decade. Approximately 11,132 status Indian children were removed from their homes between 1960 and 1990 (TRC, 2015). This is very likely an underestimate: knowledgeable commentators put the number, including Métis and non-status children, at 20,000. “Being from an Indigenous family was often enough to have a child declared in need of intervention” (TRC, 2015, p. 182). Furthermore, by 2002, 22,500 Indigenous children were in foster care across the country. Indigenous children were six to eight times more likely to be placed in foster care than other children. For 46 per cent of Indigenous children taken from their homes and placed in care the explanation has been “neglect.” This is quite a bit higher than the 29 per cent of non-Indigenous children who are taken from their homes because of neglect. On the other hand, non-Indigenous children are more likely to be removed from their homes because of physical abuse (23 per cent versus 9 per cent) or because they have witnessed parental violence (36 per cent versus 33 per cent). “Neglect” is an ambiguous term, but what it generally means is poverty, poor housing, and substance abuse within the household. Clearly, poverty and poor housing are both subjectively determined and caused by government policies.

Governance Structures for Indigenous Peoples

Continuing conflicts exist between the Canadian government and different Indigenous peoples regarding a number of issues, including broken treaties, a lack of respectful consultation on a nation-to-nation basis, and the expropriation of land for resource extraction and development. Such disputes have been accompanied by changing terminology. One response, through a new federal Act in 2017, has been to divide the former Department of Indian and Northern Affairs into two separate portfolios: Crown–Indigenous Relations and Northern Affairs Canada, and Indigenous Services Canada. The mandate of the former is to oversee the “big-picture” issues concerning relations between Ottawa and Indigenous peoples, including self-government and treaty agreements and economic growth in Canada’s North. The Indigenous Services ministry, on the other hand, aims to give the right to self-determination and management back to Indigenous communities both by improving health and social services and by supporting and empowering them to independently deliver services and address the socio-economic conditions in their communities (Sawchuk et al., 2018). The legacy of the Indian Act and the Department of Indian Affairs is long, though, and it will take time for the potentially positive aspects of these changes to be manifest.

The Physical Environments of Traditional Lands

One of the other effects of racism is the environmental destruction of the lands of Indigenous peoples. Various threats to the environment have been documented, including flooding as the result of the construction of dams and hydroelectric projects, water contamination, and depletion of fisheries. Corporations from southern Canada and other parts of the world, with the blessing of governments, seek profits from resource extraction and hydroelectric development in northern Canada without due consideration of what such megaprojects as the Alberta tar sands, diamond mining in the Northwest Territories and northern Ontario, nickel and gold mining throughout the provincial and territorial North, and the damming and diverting of water courses such as in Labrador, northern Quebec, and Manitoba will do to environments and to the long-term sustainability of livelihoods.

These various risks are linked not only to the immediate health of the people living on reserves but also to the generational degradation of the environment. As Beverley Jacobs noted in her response to the residential schools apology, we must ask what effects our actions and decisions today will have “seven generations from now.” The ongoing environmental deterioration threatens the entire natural world, including animals, birds, plants, and people. The soils in some communities are infused with toxic heavy metals such as mercury and lead, a result of previous mining and other resource extraction activities. On at least one reserve, Aamjiwnaang, just south of Sarnia, Ontario, the sex ratios have been changing—the number of girl babies born is significantly higher than the number of boys. This shift is related to a number of nearby industries that produce endocrine-disrupting chemicals linked to the functioning of the immune system, organ and tissue growth, metabolism, behaviour, and sexuality, among other things (Shingler, 2013). There are ongoing problems with the physical and geographic conditions on reserves that have impacts on the health and well-being of First Nations people.

Demography and Health of Indigenous Communities

The Indigenous population is the fastest-growing population in Canada (First Nations Health Authority, n.d.). The 2006 census indicated that close to 1.2 million Canadians were of Indigenous identity, a 45 per cent increase over the previous 10 years. Ten years later, in 2016, there were 1,673,785 self-identified Indigenous people in Canada comprising 4.9 per cent of the total Canadian population (Statistics Canada, 2018). Of these, 977,230 reported being of First Nations ancestry, 587,545 were Métis, and 65,025 were Inuit.

Some of the recent growth in the Indigenous population can be attributed to more people acknowledging their Indigenous ancestry and to the change in the laws regarding women who have left the reserve being able to keep or resume their status. However, natural increase is the principal factor in population growth. The birth rate is increasing, as is life expectancy (Statistics Canada, 2018). However, Indigenous people in Canada live shorter lives than other Canadians (Figure 5.4) and experience a considerably higher birth rate. The average age of Indigenous people in Canada is 28 years old, about a decade younger than the rest of the population (TD Economics, 2015). This speaks to the relatively high birth rate. These factors are reflected in the fact that Indigenous communities tend to have a much greater proportion of people under 30 years old than other communities. This difference is shown in Figure 5.5, which compares the average age by province of First Nations and the total Canadian populations for 2011. About 61 per cent of the members of Indigenous communities are under 30 as compared to 38.8 per cent in the total population. The relative youth of the communities also reflects that the average life expectancy is shorter among Indigenous people: 64 for males and 73 for females according to Statistics Canada’s estimate for 2017 (Statistics Canada, 2015).

Figure 5.4Projected Life Expectancy at Birth by Sex, Indigenous Identity, 2017

Note: Estimated data. “Life expectancy” is an estimate of the number of years a person is expected to live, for a given year. Most often reported as life expectancy at birth, it can be reported at any age, for different population groups.

Source: Statistics Canada (2015, Chart 13).

Figure 5.5Median Age, First Nations and Non-Indigenous Population, 2011

Source: TD Economics (2013).

In addition, Indigenous people are more likely to die violent deaths from automobile accidents (the leading cause of death overall), as well as from suicide, injuries of various sorts, poisonings, drowning, and fires (Fantus et al., 2009). Overall, First Nations adults under 75 years are more than twice as likely to die from what Statistics Canada calls avoidable causes (CBC, 2015). Three examples are tuberculosis, pneumonia, and breast cancer. These are “preventable” diseases in that death can be delayed or prevented through early detection and screening. Josée Lavoie, the director of the Centre for Aboriginal Health Research at the University of Manitoba, attributes avoidable death to the historical legacy of the residential schools, racism, lack of clean water, and food insecurity, as well as poor access to health care for those residing off-reserve (CBC, 2015).

These premature or avoidable deaths result from difficult and impoverished living conditions. As McCormick et al. (1997) explain, “Everywhere in Canada [Indigenous peoples] are struggling to overcome the effects of colonialism and its associated assimilationist practices. Such effects include, but are not limited to, cultural loss, discrimination, unemployment, and poverty.” Colonialism, from first European contact to the present, has had broad and devastating health effects, with the repeated epidemics mentioned above killing large numbers of people over time. In the twentieth century the residential school system, reserve life, and extensive racism have played a part in high poverty rates among Indigenous peoples (Shah, 2004). Indigenous poverty is mirrored in high rates of morbidity and mortality. The continuing differences in income, education, employment, and housing are fundamental to the poorer health of Indigenous people in Canada. Indigenous seniors are particularly vulnerable, according to the Health Council of Canada (2013). First Nations people on reserves are not receiving adequate home care and long-term care in their communities and thus many must leave their communities and live far from home in culturally foreign environments. The situation for Inuit who live in remote northern communities is often especially dire as they age.

A lack of adequate and accessible food continues to pose a significant threat to the health of the Inuit and other northern Indigenous peoples, who historically lived on the land and sea and even today try to rely to a considerable extent on country or bush food. However, the movement away from the land into government-designated settlements and changing environments pushed by climate change, especially in the North, have led to dietary changes, costly store-bought foods, and a lack of fresh vegetables and fruits, where country foods formerly provided all of the necessary nutrients. To counter the sedentary, welfare-reliant settlement life, Quebec for a number of years has had a Cree Hunters and Trappers Income Security Program that paid couples and couples with children to spend much of the year on the land to acquire country food for themselves and their communities (Bone, 2016, ch. 7). Yet, as game, fish, and sea mammal populations dwindle, or as these animals at the top of food chains accumulate toxic substances in their systems that have been carried in the atmosphere from Asia, Europe, and North America, or mercury from hydroelectric dam projects, they become unsafe as the basis for human diets.

Specific Indicators of Health and Disease among Indigenous Peoples in Canada

The Indigenous birth rate is four times that of the birth rate of non-Indigenous people. Also, about four times as many Indigenous women become mothers in their teens, and the rates of both overweight and underweight babies are higher than those of other Canadian women (Kirkup, 2017). Further, the rates of fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE) are substantially higher among the Indigenous population. In fact, the incidence of FAS and FAE may be as high as one in five babies. Smoking rates, rates of substance abuse, problem gambling, nutritional inadequacy, physical inactivity levels, overweight and obesity, and rates of unsafe sexual practices tend to be higher in Indigenous communities (Shah, 2004). In addition, the incidence of various communicable diseases is considerably higher among Indigenous people than in the general population. For example, whereas the Indigenous population is about 4.3 per cent of the whole Canadian population it is burdened with 16 per cent of the cases of tuberculosis. Inuit receive 270 times the rate of new diagnoses of tuberculosis as other Canadians (Andermann, 2017).

Remembering Our History

Box 5.5 • Nutrition Experiments and Indigenous Health

Is there any ethical justification for the nutritional experiments with Indigenous people in the 1940s?

A doctor working for what was then called the Department of Indian Affairs was concerned because there was an epidemic of tuberculosis and blindness among the 300 or so Indigenous people who lived in Norway House in northern Manitoba in the 1940s. He decided, with the approval of the House of Commons, to capitalize on this situation and to undertake experiments with nutritional vitamin supplements to see if they would improve the health of the suffering people. He chose 125 of the 300 members of the community for treatment. He followed their health over two years and noted that vitamin supplements seemed to be associated with health improvements. This nutritional experimentation then spread to British Columbia, Alberta, Ontario, and Nova Scotia and encompassed about 1,300 Indigenous people. Included among the study’s protocols were keeping people on very-low-calorie diets, withholding vitamins and minerals, and denying dental care in order to observe the impacts of these strategies on the health of the people. At one residential school some children were given one-half the ration of milk to observe the influence of this on their health. Ian Mosby, a University of Guelph professor who researches the history of food policy in Canada, discovered and publicized these studies in 2014. Could this same sort of unethical research be carried out today? Or would the research ethics boards established across the country and governing research in Canada prevent such destructive research?

Indigenous people, generally, are slightly less satisfied with their lives than other Canadians. The picture of Inuit health, however, is somewhat different. They are less likely than all other groups to report a chronic condition, for instance, have a much greater sense of community belonging, and their level of life satisfaction is equivalent to that of non-Indigenous people.

Sexually Transmitted Diseases

Sexually transmitted diseases are also prevalent in Indigenous communities. The incidence of chlamydia, for example, is almost seven times higher than the rate among other Canadians. HIV/AIDS occurrence has risen dramatically; from 1 per cent of the Indigenous population in 1990 to 5–8 per cent in 2012, and 6–12 per cent of the new infections in Canada in 2016 were of Indigenous people. Although they constitute about 4.3 per cent of the Canadian population, Indigenous persons living with HIV/AIDS comprise about 11.3 per cent of the total Canadian cases (PHAC, 2018). As Frideres (2020, p. 141) notes, “while the overall rate of HIV in Canada is stabilizing, in First Nation communities the incidence continues to grow.” This is particularly significant and considered of epidemic proportions because of the small size of the communities and the amount of intermingling regarding both drug use and sex. Indigenous women are especially susceptible because of the higher rates of other sexually transmitted disease, inequitable gender relations, and high-risk sexual practices (Shah, 2004). The proportion of Indigenous people with an HIV diagnosis as the result of injection drug use is much higher than among other Canadians. Homosexual relations, according to these data, are a much less important cause of transfer of the virus in First Nations communities, although that may reflect a greater need in some communities to be “closeted.”

Spotlight on Ethics

Box 5.6 • The Case of Makayla Sault

Should the courts have taken Makayla Sault from her First Nation parents and community and forced her to have chemotherapy?

Makayla Sault, a 10-year-old Mohawk girl from the New Credit First Nation near Brantford, Ontario, was diagnosed with leukemia (acute lymphoblastic leukemia) in 2014 by the doctors at McMaster Hospital in Hamilton, Ontario. She was given a 75 per cent chance of survival and full recovery if she completed the chemotherapy treatments prescribed to take place over several years. Makayla was hospitalized for the first stage of the treatment and experienced very severe side effects in hospital. During this time in hospital Makayla thought she received a message from Jesus telling her that her body was healed. She told her parents, both of whom were pastors, and they agreed to remove Makayla from the hospital and to pursue other types of treatments that they felt were spiritually and culturally appropriate. In response, the doctors at McMaster argued that she would die without allopathic treatment and asked the Children’s Aid Society of Brant County to take Makayla into their custody so that she could receive the prescribed conventional medical treatment. The Indigenous community rallied behind the Sault family and supported their right to care for their daughter using “natural” treatments. The community remembered the spectre of children who had been taken away from their parents and forced into residential schools or gathered up in the detested “Sixties Scoop” and equated these incidents to forcing chemotherapy on Makayla. This case went to court to determine if Makayla’s parents had the right to care for their child as they saw fit or whether Makayla should be removed and hospitalized so that she would receive the scientifically well-documented medical treatment.

In what was an unusual decision, the judge rejected the claim by McMaster that the child should be removed in favour of the idea that Makayla’s parents had the right to choose what they considered to be appropriate care for their daughter. Makayla died less than a year later, in January 2015.

Was this a victory for Indigenous rights or a failure to protect a child?

Other Social Issues and Inequalities in Indigenous Communities

The health of Indigenous people is also related to gender, class, age, and area of residence (Wotherspoon, 1994; Shah, 2004). The same factors that explain health differences among other Canadians affect the health of the Indigenous people. Thus, those who are higher on the various social-structural indicators are more likely to have good health and, on average, the health of Indigenous people is poorer because, on average, they have lower incomes, have less education, and are more likely to be unemployed or underemployed than other Canadians. Indigenous people are also more likely to be incarcerated—22.8 per cent of all federal inmates are Indigenous. Of these Indigenous inmates, 96 per cent misused various substances (drugs, alcohol), 73 per cent noted a family history of residential school experience, and 88 per cent “had a family member struggling with alcohol or drug addiction issues” (Office of the Correctional Investigator, 2014).

The median income of $25,526 for Indigenous persons is considerably lower than that for non-Indigenous people ($34,604), and almost one-quarter live below the poverty line (Kirkup, 2017). Indigenous people are also more likely to be homeless and to be dependent on welfare, and they are disproportionately affected by housing considered inadequate. According to the National Collaborating Centre for Indigenous Health (2020), there has been no substantial improvement in Indigenous on-reserve housing. Twenty per cent of Indigenous people, a rate more than three times higher than that for non-Indigenous people in Canada, live in homes that need significant repairs. Among First Nations and Inuit, the rate of inadequate housing is closer to 25 per cent (Kirkup, 2017). Clean water for drinking and cleaning is still missing on a significant number of reserves. In consequence a group of Indigenous leaders have sued the federal government for their failure to provide clean drinking water. Between 2004 and 2014 about 66 per cent (400/618) of First Nations reserves were under at least one water advisory, which means that their water is unsafe to drink or use for washing. One reserve had not had clean water for 20 years (Levasseur, 2015). This sorry situation has been changing under the current Liberal government: as of February 2020, 60 long-term boil-water advisories continued to be in effect, with the federal government aspiring to have all such advisories lifted by March 2021. In the fall of 2019 there were 441 infrastructure projects underway to build, repair, and upgrade on-reserve water supplies (Government of Canada, 2020).

Canada as a whole stands in good stead in educational achievement and conditions globally. The situation is different for Indigenous people in Canada (Parkin, 2015), who are less likely to have achieved all levels of education from grade school to university. The gap between Indigenous people and other Canadians is widening over time. In 1996 there was a 12-percentage-point difference in educational achievement. In 2011 that gap had grown to 17 percentage points. However, Indigenous children are staying in school longer than in the past. As of 2011, almost half of the Indigenous population had some post-secondary education, as compared to 65 per cent among the non-Indigenous population (Indigenous and Northern Affairs Canada, 2011). There has been increased funding for band-operated elementary and high schools. In addition, Indigenous programs in universities have grown, including programs for training Indigenous people in the professions (e.g., medicine, law, and, especially, social work), in part so that they can work in the Indigenous community and provide services to their people. Also, the First Nations University of Canada, in Regina, was established explicitly for First Nations people. Still, substantially higher rates of unemployment remain. Unemployment, underemployment, and low incomes all contribute to the poverty of Indigenous people, as well as to their poorer health status. As Adelson explains, “It is the complex interplay of job market discrimination, lack of education, cultural genocide, and loss of land and sovereignty that affect employment status and, ultimately, the degree of poverty faced by those who are caught in a circle of disadvantage” (Adelson, 2005, p. S53; see also Indigenous and Northern Affairs Canada, 2011).

Self-Perceived Health and Reported Social Problems

Indigenous people tend to define health as comprised of balance, harmony, holism, and spirituality. Individual pain, suffering, and disease, per se, do not necessarily alter this inner sense of well-being (Shah, 2004; First Nations Health Authority, n.d.). For some Indigenous groups, health is thought of as a “medicine wheel,” which includes physical, mental, emotional, and spiritual aspects (Shah, 2004). All are important to a truly healthy person. From the perspective of the Indigenous Corporate Training group, eight main social concerns need addressing: poorer health than the general population, unemployment, education, housing, income, suicide, harm to children from unintentional injuries, and higher levels of incarceration (Indigenous Corporate Training [ICT], 2019) as major social concerns, as follows. All of these issues, directly or indirectly, relate back to the first concern, poorer health.

Suicide rates, for example, are between five and seven times higher among First Nations youth than among others in Canada, and the suicide rate among Inuit youth is among the highest in the world. It is 11 times that of other Canadian youth. Suicide and self-inflicted injuries are the chief cause of death among Indigenous people until they reach the age of 45. Deaths from self-inflicted and unintentional injuries are three to four times higher than those of other Canadians death among Indigenous children (ICT, 2019). Indeed, the crisis of youth suicide is so grave that emergency measures have been called for and provided. In 2016, for example, Attawapiskat First Nation in northern Ontario called a state of emergency after 11 youth tried to kill themselves. These higher rates occur for both male and female youth, although the rate is somewhat higher for males. Figure 5.6 portrays the risk factors for suicide and thus suggests some of the changes that need to occur for its prevention.

Figure 5.6Suicide Risk Factors

Source: Crawford (2016).

Remembering Our History

Box 5.7 • The Ojibway of Grassy Narrows

The experience of the Ojibway of Grassy Narrows First Nation provides a poignant and trenchant critique of the disastrous impact the Canadian state and Canadian industry have had on a people and their way of life. It is just one example of a continuing problem. Until 1963, the Grassy Narrows Ojibwa lived a settled, traditional life, hunting and fishing on and around the English–Wabigoon River system in northern Ontario. Then, in 1963, they were relocated by the Department of Indian Affairs, so the reserve would be nearer to a road, thus, nearer to a number of services and amenities in modern life, such as schools, various social services, and electricity. Uprooting and moving the people had a tumultuous impact on their health and lifestyle. Before the Ojibway had time to adjust to this crisis, another hit. This time it was the discovery that the English–Wabigoon River system, which had been their main source of livelihood for many years, was poisoned by methyl mercury, the source of which was a paper mill at Dryden, Ontario, 170 kilometres upstream (Dickason, 2002, p. 394).

Before 1963, over 90 per cent of all deaths among the Ojibway were attributed to natural causes. By the mid-1970s, only 24 per cent of the deaths resulted from natural causes. By 1978, 75 per cent of the deaths were due to alcohol-induced violence directed against the self and others. Homicide, suicide, and accidental death rates soared. Child neglect and abuse grew rapidly, and numerous children were taken into the care of the Children’s Aid Society and placed in foster homes. As Shkilnyk (1985, p. 3) wrote 35 years ago: “Today the bonds of the Indian family have been shattered. The deterioration in family life has taken place with extraordinary swiftness.” Despite the good intentions of the Canadian government in relocating the people, their socio-economic conditions deteriorated. “All the indications of material poverty were there—substandard housing, the absence of running water and sewage connections, poor health, mass unemployment, low income, and welfare dependency” (Shkilnyk, 1985, p. 3).

The Grassy Narrows Ojibway experienced too much change, too quickly. Their autonomy and cultural traditions were destroyed. Because of mercury pollution, they were robbed of their health and their means of livelihood. Difficulties continue in Grassy Narrows as a result of these historical incidents, along with newer challenges such as logging by private commercial companies. Logging is a threat to the livelihood of the people who rely on hunting in the forests for their food, health, and well-being.

In 2014, the Supreme Court reaffirmed the right of the province of Ontario to use this land for industrial logging (Rennie, 2014). Perhaps most telling of government attitudes, however, is the extent of inaction in regard to the mercury pollution. No remediation of the river system has ever been carried out by the federal or provincial government, although mercury levels are still rising and the earlier claim that natural processes would clean up the contamination has proven to be false (Porter, 2015). No explicit government recognition of the negative health impacts of mercury poisoning on the people of Grassy Narrows (e.g., central nervous system and brain damage, with weakness and tingling in the limbs, difficulty swallowing and speaking, and loss of motor function) has been made. There is no ongoing Canadian research on the problem, nor had there been support for the people from government—yet Japanese researchers, from 1975 to 2014, visited the community on five separate occasions to examine the people and chronicle the consequences of mercury to the people and other life forms. They found that over 90 per cent of the people suffered the effects of mercury poisoning (Porter, 2017). Forty years ago a Japanese researcher identified numerous instances of Minamata disease, a neurological disorder caused by mercury poisoning, among the people of Grassy Narrows (Crowe, 2014). Finally, in 2017 the Ontario government announced funding to clean the English–Wabigoon system of mercury (Porter, 2017). In April 2020 the Grassy Narrows chief, Randy Turtle, signed a framework agreement with federal Indigenous Services Minister Marc Miller whereby Ottawa is committed to fund a new $19.5 million Mercury Care Home on the reserve, plus pay for operating costs for the next 30 years, to deal with a crisis that began some 60 years earlier (Bruser, 2020).

Indigenous adults are much more likely to be incarcerated. Twenty-six per cent of those incarcerated are Indigenous, and the over-representation of Indigenous youth in the criminal justice system is even higher than that of adults. Violence is a significant problem in Indigenous communities. Teenage mothers and their children are particularly vulnerable (ICT, 2019). As Adelson explains, citing a submission to the Royal Commission on Aboriginal Peoples, “up to 75 per cent of the victims of sex crimes in Indigenous communities are women and girls under the age of 18 (50 per cent of those are under age 14 and almost 25 per cent are under the age of 7).” Adelson also notes, “Racism coupled with sexism leaves Aboriginal women in a highly vulnerable position” (Adelson, 2005, p. S55). Indigenous people are more likely to live with spousal abuse and substance abuse, and they are more likely to be victims of homicide. As pointed out by the Royal Canadian Mounted Police, Indigenous women are more likely to be murdered due to their greater vulnerability, i.e., they are more likely to be unemployed, to have a criminal record, to work in the sex trade, to have consumed alcohol before the incident, and to made some of their money from illegal activities. The report of the National Inquiry into Murdered and Missing Indigenous Women and Girls (2019) documents how the excess of suffering and violence against Indigenous women and girls is the logical result of centuries of colonialism with the intention of assimilation or elimination of Indigenous people. The report calls the deaths of the murdered and missing women as well as of two-spirited (2S) and LGBTQ+ people illustrative of genocide.

Canadian Indigenous peoples on reserves often suffer from isolation and limited power in the control of their own housing, location, education, and occupation. The negotiations over the ownership of land and the governance of reserves continue (slowly) with the Canadian government. The consequences of this lack of autonomy and authority are problematic for the total way of life and well-being of people who live with such uncertainty and with experiences of racism that lead to low expectations of others and for themselves. Self-rule is an important factor in the health and well-being of any people, just as autonomy (or freedom) in decision-making is a value held by individuals. Indigenous people argue that their land was taken away from them through trickery in the treaty agreements and that, in any case, governments over the years have repeatedly failed to honour their treaty obligations. Thus, numerous First Nations are seeking reinterpretation of treaties, documenting errors in land transfers, and arguing land claims cases across the country (Frideres, 2020; see also Fenge & Penikett, 2014).

An installation of the Red Dress Awareness Campaign in Courtney, BC. The REDress Project, started by Métis artist Jamie Black in 2010, uses installations of red dresses to raise awareness about missing and murdered Indigenous women and girls in Canada.

StaceyL/Shutterstock.com

Evidence increases the potential power of organizing for change among First Nations, Inuit, and Métis, along with their supporters across the country. In response to the Conservative government’s omnibus budget bills of 2012, which severely weakened environmental protection and limited the requirements of the assessment of resource development projects, a new movement, Idle No More, was born in November 2012. The movement was bolstered by the hunger strike of the chief of the Attawapiskat First Nation, Theresa Spence, who protested the ongoing violation of treaty rights by Prime Minister Harper and the government of Canada, and by a rapidly spreading social media campaign. Idle No More has included non-Indigenous people in Canada and, to an extent, has spread internationally. Many have great hopes for change coming from this inclusive and widespread movement, especially in the context of the power of social media. In reaction to the significant over-representation of Indigenous women among those who have disappeared and/or who have been murdered, the call for a national inquiry was met with the establishment of the National Inquiry into Missing and Murdered Indigenous Women and Girls. Along with the 2015 final report of the Truth and Reconciliation Commission, we may be witnessing the beginnings of positive change for the health and well-being of Indigenous peoples in Canada, but real change, as is so often the case, will come from grassroots organizations like Idle No More, Free Grassy, and the 2020 nationwide protests against a natural gas pipeline project that would cross unceded Wet’suwet’en territory in northern British Columbia. Although 10 Indigenous MPs were elected to represent Canadians in the October 2019 federal election, by total population this remains an under-representation in the 338-member House of Commons.

Summary

1.Illness and death rates vary, depending on social-structural conditions such as age, gender, and visible minority status.

2.Canadians are living longer today than in the past.

3.The life expectancy and the morbidity rates for men and women continue to differ.

4.Men have shorter life expectancy and women live longer but with chronic illness and disability.

5.Relative poverty is an important explanation for gender differences in health.

6.Immigrants tend to arrive in Canada in an excellent state of health, but, over time, immigrant health tends to deteriorate to match the health of native-born Canadians.

7.Indigenous health is poorer than that of other Canadians in many different ways.

8.Schooling in residential schools, environments on reserves, and continuing governance and landownership issues with the Canadian and provincial governments have had negative health impacts.