The health system in Canada’s North is failing — but not by accident. ‘It is designed to do what it is doing’

TheStar.com – News/Atkinson Series
Oct. 19, 2018.     By

SIOUX LOOKOUT, ONT.—Dr. Mike Kirlew meets me at the Sioux Lookout Airport because it is -40 C and my rental car won’t start. During the winter months, cars need to be plugged into power outlets overnight or their batteries will freeze. Mike laughs as he tries to jam the key into the ignition of the Toyota-turned-ice-block, but the key won’t move. The steering wheel won’t budge. Everything is frozen.

The sun blazes in the cloudless blue sky, but it gives us no warmth as we scurry to his car and hop in. Mike takes off his thick, beautifully beaded moose-hide mitts and pushes back his beaver fur hat before he starts the car and turns up the seat warmers. He pops in some Bob Marley. The smooth sounds of reggae evoke images of a climate about 80 degrees warmer, a perfect antidote to the harsh realities of the Canadian winter.

Mike, who was born in Ottawa to Jamaican immigrant parents, is a physician who has devoted his entire life to living and working in Sioux Lookout. He arrived here by fluke  —  he had hoped to go to Moose Factory, along the James Bay coast, but he was told the medical residency program was full and instead he had to go to the Sioux. He, his wife, Yolaine, and their three children make this their home. For nearly 11 years, Mike has been grappling with the suicide crisis in northern Ontario, and he sees no end in sight. He is the one who, on a moment’s notice, drops everything to respond to a health crisis in Canada’s remote North. He cared for Jolynn Winter and Chantell Fox in Wapekeka when they were toddlers. He sees first-hand how a lack of the determinants of health  —  education, basic services, a safe environment, and employment  —  debilitates these communities.

“Let me take you on the five-dollar tour of town,” he says, then laughs: “OK, maybe it’s the $4.99 tour.”

Sioux Lookout is a modest town of nearly 5,000 located halfway between Thunder Bay and Winnipeg, high up on the Canadian Shield. Carbon dating has uncovered evidence that Sioux Lookout has been home to various First Nations for the past 8,000 years.

Sioux Lookout gets its name from the top of a hillside near Pelican Lake. As the story goes, the Ojibwe who lived around Gichigami, or Lake Superior, were constantly under attack from the Sioux, who lived on the western plains. One day, the Ojibwe devised a plan. When their lookout spotted the Sioux on Frog Rapids, he sent a warning to those camped below. When the Siopelux landed, the Ojibwe ambushed them, and a great battle ensued. All but one Sioux boy were drowned or killed.”

Sioux Lookout today is a picturesque town full of American fishermen and adventurers in the summer, and forestry and health-care workers all year round. Throughout the day, float planes land on Pelican Lake and pickup trucks stream past the drive-through window at the Tim Hortons. But the best coffee and home-baked goods can be found at Roy Lane Coffee, on Sioux Lookout’s main drag, Front St., also known as First Ave. N., depending on which direction you’re travelling. The town’s quiet is broken only by the frequent sound of trains rumbling along the Canadian National Railway’s transcontinental main line. Lac Seul First Nation, made up of three communities  —  Frenchman’s Head, Kejick Bay and Whitefish Bay  —  is located about 40 kilometres outside of town.

During the 1920s, the government began to build segregated Indian hospitals. Many community and city hospitals refused to treat Indigenous patients or relegated them to separate wards, basements and poorly ventilated areas. Missionaries had established Indian tuberculosis sanitoriums, which were then taken over by the government and later converted to general hospitals for Indigenous people. For nearly a century, the prevailing belief was that TB became more virulent when an Indigenous person was infected.

According to the Canadian Public Health Association, during the 1930s and 1940s, TB death rates were 700 per 100,000, among the highest ever reported. The death rate from TB among children living in residential schools was even worse, with 8,000 deaths per 100,000 kids. Residential school children lived in a state of neglect, inadequately clothed and fed. When they complained of feeling ill, they were often ignored, or they were sent to the school nursing station, which routinely failed to provide adequate care.

In 1907, Dr. Peter Bryce, the chief medical officer of Canada, visited 35 residential schools and found them overcrowded, unsanitary and poorly ventilated. In Report on the Indian Schools of Manitoba and the North-West Territories, he noted, “Of a total of 1,537 pupils reported upon nearly 25 per cent are dead, of one school with an absolutely accurate statement, 69 per cent of ex-pupils are dead, and that everywhere the almost invariable cause of death given is tuberculosis.” He laid blame on the churches and government officials.

Duncan Campbell Scott, the superintendent of Indian Affairs, confirmed that he knew the children were dying in record numbers . Still, he refused Bryce’s repeated requests for aid: “It is readily acknowledged that Indian children lose their natural resistance to illness by habituation so closely in residential schools and that they die at a much higher rate than in their villages. But this does not justify a change in the policy of this Department which is geared towards a final solution of our Indian Problem.” Scott then went on a campaign to undermine Bryce, pulling his funding and attempting to ruin his reputation and career. In 1921, Bryce was forced out of the government.

The conditions in the Indian hospitals were universally horrific. The hospitals were overcrowded with patients suffering from TB and other contagious illnesses and infections. One doctor called a ward full of women and children a “pest house.” Hospitals struggled to find nurses, and one had one nurse for 75 beds.

Harmful medical experimentation and questionable therapies were practised on patients. From 1949 to 1953, doctors at the Charles Camsell Indian Hospital outside of Edmonton performed 374 experimental surgeries, all under local  —  not general  —  anesthetic, to treat TB.

One 16-year-old Blackfoot patient watched doctors remove three of his ribs. “They used a saw. I was awake and I could hear the saw,” he later recounted. “They got part way and then they told me, ‘Now we are breaking the ribs off.’ ” He also remembered they scraped three other ribs and extracted a part of his lung, then used wax in the cavity to hold everything together.

Surgery was painful and left many patients deformed. In Manitoba, the Sanitorium Board reported, “One-third of the patients died, one-third half recovered, and one-third were cured.”

If a patient died in hospital, their family was responsible for paying the cost of transporting the body home for burial. Many could not afford to, and the bodies lie in unmarked graveyards far from home.


While most of the Indian hospitals were shuttered in the 1960s, Indigenous people continued for decades to receive inadequate treatment. In 1988, Josias Fiddler, who was chief of Sandy Lake First Nation in Northern Ontario, staged a hunger strike with Peter Goodman, Allan Meekis, Peter Fiddler and Luke Mamakeesic to protest substandard treatment of the 28 surrounding First Nations communities at the Sioux Lookout Zone Hospital. Of the 18,000 living in the area, only 4,000 were not Indigenous, yet the community complained of inadequate translation services, poor treatment and frequent delays of emergency medical transports.

The two-day hunger strike prompted a report completed in 1989. It noted rising “racial tensions” as a result of the increased number of First Nations people who had come to Sioux Lookout for school, work and health care. It also pointed to family breakdowns due to the residential school experience, a loss of traditional spirituality, a serious rise in mental health issues and “alarming” rates of youth suicide.

A single regional hospital was recommended, as was access to clean water and proper sewage treatment and power systems. (That is still far from a work in progress.)

By 1997, Nishnawbe Aski Nation, the municipality of Sioux Lookout, the province of Ontario, and the federal government agreed on the new hospital. The Sioux Lookout Meno Ya Win Health Centre opened in 2010. The hospital board was made up of five First Nations people, five people from the town, two doctors, and a traditional healer. The 60-bed hospital included a circular healing room constructed from cedar. A 100-bed hostel for patients flying in from the North, and for those who need detoxification services, is attached to the hospital. The new hospital is just down the street from the old Indian Hospital, which Mike Kirlew passes daily on his way to work. “It is a constant reminder of colonization’s grip,” he says.

The health system in northern Ontario is still in crisis. And it isn’t just northern Ontario; the United Nations special rapporteur on the rights of Indigenous peoples says the crisis exists throughout Canada, and significant improvements in funding and policy changes are desperately needed. The need for relief and change is overwhelming.

When Mike Kirlew looks at the way health care is administered in the North, he sees people who have been denied services from the very start. “The system isn’t broken; it is designed to do what it is doing,” he says.

One of his patients, an Elder, once told him, “I don’t want to talk about reconciliation. I want to talk about rights.” Mike couldn’t agree more: “The goal of reconciliation isn’t just to be friends. Civil rights legislation needs to occur here.”

He believes that structurally the system  —  the health and social services system  —  is designed to fail Indigenous children. He sees children routinely taken away from their parents by social workers and shuffled from home to home to home. He knows of one small child who was moved 46 times. “What is the fundamental mindset of doing that?” he asks. “How do you even vaccinate that child?” Time and time again, the children are taken away and the parents are left to their own devices. “I don’t see bad parents,” he says. “I see parents with addictions.”

The medical system that operates in Canada is not structured to look at the historical systemic racism that affects Indigenous families every day. “Our mindset is that the families are deficient,” he says. “But what we need to ask is ‘How do we support these families and keep them together? How do we surround these children with care?’ ”

It is now in vogue for Canadian federal politicians to talk about how the system needs to be indigenized, culturally adapted for First Nations, Métis, and Inuit. In April 2017, Health Canada finally agreed to cover the cost of providing an escort to the hospital for women who are about to give birth. Previously, a pregnant woman was sent alone on a plane to a city hospital, even though doctors always request that the mother have someone to assist in the labour. When the government announced the change and called it a great success, Mike’s response was, “That is not innovative; it is just not hurting people today. Health care and education are need-informed care.”

Mike points to the story of Brian Sinclair, an Indigenous man who died of a treatable bladder infection after waiting 34 hours in a Winnipeg emergency room in September 2008. Sinclair was a double amputee, confined to a wheelchair. The staff assumed he was drunk or homeless and killing time in the ER, said his cousin Robert Sinclair. No one checked on him, even when he vomited on himself.

Brian Sinclair died during a 34-hour wait in a hospital emergency room at Winnipeg's Health Sciences Centre.
Brian Sinclair died during a 34-hour wait in a hospital emergency room at Winnipeg’s Health Sciences Centre.

The inquest resulted in 63 recommendations, including a review of all emergency-department floor plans to ensure that patients requiring medical care are visible from the triage desk and that health authorities check that those waiting in emergency are awakened at regular intervals.

“It wasn’t what we saw; it was what we thought we saw that killed him,” Mike says. “If you are conditioned not to care, you are conditioned to indifference. And there is a violence to that indifference.” Maybe the question Canadians need to ask themselves is deeper, he says: “Why don’t we care? Maybe that is the issue. Not just ‘What can we do?’ ”

Children in the North are dying of preventable diseases. Two children recently died from strep throat. In 2014 two 4-year-old children died of rheumatic fever that had not been diagnosed. According to a medical study published in 2015, rheumatic fever rates are 75 times higher in northern First Nations communities.

Opioid use is rampant, and First Nations are unable to deal with the epidemic. In some communities, opioid use is especially high, at 80 per cent or more. Addictions counsellors are rare, and opioid substitution programs are in high demand.

The availability of mental health care for children everywhere is an issue, but in Indigenous communities the situation is even worse. If a child needs immediate help they have to be flown out to a city centre. Thunder Bay, the regional referral hospital, has only 1.2 dedicated child psychiatrists for the entire region. The 0.2 represents a psychiatrist who works part-time with children and spends the rest of her work time on research.

The existing mental health services are barely coping with what in some communities is an acute suicide crisis among children and youth. The Thunder Bay Regional Health Sciences Centre is the only hospital in all of northwestern Ontario that provides in-patient psychiatric care. It is also the only institution that has staff trained to work with children 15 or younger.

The facility has only eight beds, and it is always at capacity. In some cases, the overflow is sent to the pediatric department. For those over the age of 15, the psychiatric beds are in Thunder Bay and Kenora. Both are almost always functioning over capacity.

Dr. Peter Voros, the executive vice-president of in-patient care programs in Thunder Bay, explains that children need a transitional space, a step-down unit where they can be stabilized. Once the children are treated, however, there is no place to send them, so they stay in hospital. Some mentally fragile youth are sent alone to a facility thousands of kilometres from their home communities.

Voros says the community also needs a secure treatment facility solely for mental health and addiction patients, and ideally seven child psychiatrists to handle the patient load. He needs four to just barely function. And he needs them yesterday.

Identifying risk factors for suicidal behaviour begins with examining the age at which a person first attempts suicide. Those who try it in their teens or 20s are more likely to have “cumulative risks,” such as anxiety disorders, a history of emotional and sexual abuse, or cannabis misuse. If a 15-year-old comes from a poor, unstable household, suffers from malnourishment and abuse, is bullied at school, and suddenly receives news that a friend has died or has gone through an emotional breakup, they are at greater risk of suicide than a 50-year-old who has just lost their job.

Jack Hicks, along with his colleague Dr. Allison Crawford, director of the Northern Psychiatric Outreach Program at the Centre for Addiction and Mental Health,  conducted a study comparing Indigenous communities with high incidences of youth suicide to those that have lower rates. They found that early childhood adversity may be “understood as a key mechanism by which disruption and loss related to colonization is mediated into suicidal behaviour”; as examples of colonization, they cite residential schooling and forced relocation from ancestral land.

A child born into a home affected by colonization  —  a home that has experienced the loss of language or connection to its cultural history, knowledge and traditions  —  enters an environment marked by unresolved intergenerational trauma. Parents may be grappling with their own adverse childhood experiences. Childhood adversity, Hicks and Crawford note, includes exposure to family violence; physical, emotional and sexual abuse; neglect; and lack of access to interventions or medical care. All these factors can lead to increased risk for suicidal behaviour.

“We must appreciate relevant early life risk and protective factors, and find novel and efficacious ways of intervening,” Hicks and Crawford conclude. “We need to address upstream risk factors by promoting optimal early childhood development and reducing socioeconomic and early life disadvantage.”

Doing nothing is not an option, yet Canada is the only G8 country without a national suicide strategy. In Scandinavia, Gunn Heatta helped establish the Sami Psychiatric Youth Team in 1990 in the small town of Karasjok, Norway, in response to a suicide cluster of young Sami men in the mid-1980s. By 2001, it had become a crucial part of the Sami National Centre on Mental Health and Substance Abuse (SANKS).

Karasjok, which has a population of roughly 3,000, lies deep in the interior of Finnmark, near the northern Finnish border. This is rugged terrain sprinkled with tall white birch and fir trees and fast-moving clear-water rivers. Inner Finnmark resembles in both look and feel the remote regions of northern Ontario.

Tromsø, about 400 kilometres north of the Arctic Circle, is the only large town in the area. Brightly coloured homes are nestled among the fjords lined with white-capped mountains, and the settlement clings to the coastline. It’s famous as an ideal location to see the Northern Lights or go whale-watching. Those who live in Karasjok and the adjacent town of Kautokeino are Sami. There are small wooden homes belonging to the reindeer herders, and if you’re lucky, you’ll catch a glimpse of reindeer wandering across the road or grazing in the valley.

I met Gunn in May of 2018. She began her career as a therapist 40 years ago, and has since felt compelled to do something to stop the suicides. There are no official statistics on how many Sami have taken their lives. That is part of their battle  —  trying to collect accurate numbers from health officials, which is difficult because of international borders and differing national protocols. A social worker by training, Gunn formed a team of practitioners who fanned out, visiting schools, clubs and other local spots to convince youth to seek counselling with Sami-trained professionals instead of turning to the traditional medical system.

If any young person had suicidal thoughts or struggled with alcohol addictions, Gunn gave out her private cellphone number and said to call, whatever the time. Everyone told her she was crazy, but no one abused the privilege. She received calls only from teens in dire need of help. “I know we saved lives when people called us,” Gunn says.

Gunn never thought that she would still be leading the SANKS team that administers mental health and addiction services. SANKS prides itself on not being part of the Norwegian health system. Its treatments are based on Sami values and culture, conducted in Sami language according to traditional teachings, and include trips to provide youth with a holistic understanding of who they are and where they come from.

In 2001, the government provided funding to address the mental health and substance abuse issues. Gunn and her team formed a Sami competency centre and worked specifically with those afflicted by suicidal behaviour, broken families, substance abuse, and the aftermath of family violence.

The SANKS program runs a treatment centre for children and their families that includes one month of residential care for children and families in crisis. Entire families are moved into one of a half-dozen IKEA-inspired townhouses. The families are not penalized by their employers while they live at the facility, where they receive in-patient clinical care by trained mental health workers. The belief is that in order to treat the child or adolescent, you must also treat the parents.

The program has had incredible results, but it hasn’t been easy to set up or maintain. SANKS is in a constant tug-of-war with its government funders on the cost efficiency and necessity of Indigenous-led and -created programs.

“We haven’t had suicides here in the Karasjok region for several years now. But the young Sami reindeer herders in southern Sweden and Norway are now feeling it,” Gunn says.

If you’re experiencing emotional distress and want to talk, call the First Nations and Inuit Hope for Wellness Help Line at 1-855-242-3310. It’s toll-free and open 24 hours a day, 7 days a week.

https://www.thestar.com/news/atkinsonseries/2018/10/19/the-health-system-in-canadas-north-is-failing-but-not-by-accident-it-is-designed-to-do-what-it-is-doing.html

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