By Katy Cameron, Carleton Graduate Student
Author’s Note: I would like to acknowledge that I am but one First Nations voice of many and recognize the diverse and unique experiences of Indigenous People across Turtle Island.
We are approaching two years since the initial discovery of the remains of 215 Indigenous children buried at the former Kamloops Indian Residential School in British Columbia, Canada. It came as shocking news for some and was a tragic confirmation for many Indigenous Peoples of what had long been suspected. For me, feelings of sadness and despair surfaced for my family and friends who experienced the Residential School system firsthand or were impacted by its legacy effects. Several of these schools were places that separated families, stripped children of their cultural traditions and knowledge, performed experimentations, and turned a blind eye to sexual and violent abuse. Only in the past decade or so has colonialization been acknowledged as a unique social determinant of health for Indigenous Peoples and efforts been made to understand its role in contributing to the disproportionate levels of chronic disease experienced by this population (Reading & Wien, 2009). But how exactly does colonization and its legacy impact the development of chronic disease, and why is this still a problem in 2023?
Diabetes, heart disease, arthritis, and cancer are all examples of chronic diseases in which environmental and/or individual factors promote the development of health conditions that are present for extended periods of time (Earle, 2011). It is commonly known that practicing healthy habits such as eating nutritious foods, getting enough sleep, and regularly exercising contributes to healthier outcomes and reduces the risk of developing chronic diseases and illnesses. Sounds easy enough, right? For many Indigenous people, however, the reality is that there are numerous social barriers to engaging in healthy behaviours. In the first-ever Indigenous Services Canada Annual Report to Parliament in 2020, Indigenous Peoples, especially First Nations living on-reserve, reported lower incomes, less education, reduced employment rates, worse housing conditions, and decreased life expectancy compared to non-Indigenous counterparts. They also reported greater likelihood of being in foster care and higher infant mortality rates, as well as higher rates of violence, victimization, and incarceration. This exemplifies the magnitude of the inequities experienced by this population, and it is understandable why Indigenous Peoples are at greater risk for developing disproportionate rates of disease, illness, and even deaths. Conversely, a study conducted by Anand et al. (2019) found that First Nations communities with higher incomes, better education, increased access to healthcare services, and robust social support mechanisms displayed fewer risk factors for cardiovascular disease compared to communities with overall lower socioeconomic status. Moreover, other research indicates that socioeconomic and lifestyle factors contribute to the high proportion of First Nations who suffer from diabetes (Halseth, 2019). These findings support the position that the social determinants of health play a significant role in contributing to the subsequent development of chronic disease amongst First Nations and other Indigenous groups.
So, how does colonization and its legacy effects tie into chronic health disparities? According to one article, there are proximal, intermediate, and distal social determinants at play. Proximal determinants are those that directly impact healthy behaviours (e.g., physical environment), intermediate determinants are institutional or system-specific (e.g., education level and health care accessibility), and distal determinants are the bigger-picture issues from which many of these factors stem, such as colonialism and racism. Colonialism has been defined as the exploitation, control, and settlement of one country by another (Blakemore, 2019). In Canada, this involved removing autonomy from Indigenous Peoples and using assimilation strategies such as Residential Schools, separating children and families through the Sixties Scoop, and continues today by disproportionately placing Indigenous children in the Child Welfare System (Hobson, 2022). For many Indigenous families, the proximal effects of these initiatives resulted in broken-family dynamics and unstable living situations, depression and overall poor mental health, a loss of sense of self, and substance use. Furthermore, intermediate effects such as a lack of access to, or affordability of, adequate treatment services for these outcomes have ultimately led to intergenerational traumas, and high rates of suicide (Bombay et al., 2014), and we are now seeing higher prevalence rates than ever of chronic diseases like diabetes amongst First Nations youth (Halseth, 2019). If we know that colonialism has shaped both the social determinants and direct health outcomes of Indigenous Peoples (i.e., increased chronic diseases), why do these issues continue to persist?
In 2015, the Canadian Government accepted the final report released by the Truth and Reconciliation Commission of Canada, which outlined 94 Calls to Action targeted at improving Indigenous health, education, and other domains. Although efforts have been made towards addressing these Calls, colonialism persists through current Westernized structural and governance frameworks, policies, and practices that continue to perpetuate the disadvantages and inequalities experienced by Indigenous Peoples in Canada (Blanchet Garneau et al., 2021; Czyzewski, 2011). Prime examples of this can be seen with policing issues, the overrepresentation of Indigenous People in the Canadian criminal justice system (Clarke, 2019), and insufficient culturally sensitive health educational programming, which can result in discrimination and harmful stereotyping (Blanchet Garneau et al., 2021). Increased collaboration and open communication between different levels of government and Indigenous leaders are needed to act on the chronic health disparities we know disproportionately affect Indigenous Peoples. Targeting the social determinants that impact this population, by increasing employment and educational opportunities and guaranteeing equitable access to basic necessities such as adequate healthcare and clean drinking water, is needed in order to ensure better health outcomes for future generations.
As we are reminded of the horrific truths about the history of the Residential School system and the effects of colonialization through continued media reports of more unmarked graves, remember that the effects of colonialism are not a thing of the past. In fact, we still see the legacy effects on Indigenous health today, if we are willing to look.
This blog was originally written as part of the HLTH5402 course.
By Sebastian Steven, Carleton University Graduate
Living in downtown Ottawa means never being far from a demonstration. The nation’s capital is the ideal venue for protests against invasions or displays of solidarity for climate action and social justice. A different kind of demonstration, however, was organized here in early 2022. Stepping outside my apartment near Bank Street dropped me into the “Freedom Convoy.” The Convoy first labelled itself as a protest against a COVID-19 vaccine mandate for truckers crossing the border into the United States but shifted almost immediately into an unlawful occupation of Ottawa streets set on ending all COVID-19 vaccine mandates and removing public health restrictions.
The Convoy occupation rallied against undeniably lifesaving measures. There have been significantly fewer deaths due to COVID-19 in individuals who have been vaccinated. Moreover, public health measures (PHMs) for masking, social distancing, and isolation of positive cases have reduced COVID-19 infection. Combined, vaccines and PHMs have spared many from both mild symptoms and severe months-long disabilities that could come from COVID-19 infection.
Individuals with ties to and involvement in hate groups organized and participated in this Convoy. However, of interest to this post, some Convoy occupants were more focused on simply opposing PHMs. This subset of participants demonstrated a fundamental misunderstanding of science guiding the pandemic response in Canada during their displays of opposition. Despite aiming to highlight perceived issues with vaccine mandates and PHMs, occupants instead highlighted that some Canadians may not have strong enough knowledge of science and health.
Jordan Klepper’s interview with occupants of Rideau St, for example, includes one unvaccinated man who was bewildered that his status means “[he] can’t go to the restaurants, can’t play hockey, and can’t go watch the [Ottawa Senators].” He seemingly views vaccination simply as a method to bar certain individuals of the population from public spaces without acknowledging the science informing these policies. Other knowledge gaps in science and health were seen in Convoy propaganda. Signs questioned scientists' motivations, discounted the value of PHMs, and drew unsupported concerns about deaths from surgeries delayed by COVID-19.
These individuals displayed low health literacy during their participation in the Convoy. Health literacy is defined by the World Health Organization as:
People’s knowledge, motivation, and competences to access, understand, and appraise health information in order to make judgments and take decisions in every-day life concerning health care, disease prevention, and health promotion to maintain or improve quality of life during the life course.
Equipping Canadians with skills in health literacy can enhance one’s ability to understand their health status and improve it. Health literacy is displayed, for example, when one can collect and understand information surrounding the risk of COVID-19 to then take steps to mitigate infection. The ability to do this, though, varies among Canadians. Estimates from 2008 show that 60% of Canadian adults are unable to obtain, understand, and act upon health information shared with them. This alarming statistic is more problematic with no national update to this estimate since 2008.
Granted, the number of participants in the Convoy was minimal compared to the entire population of Canada. However, the occupation made it obvious that there are still Canadians who have not achieved sufficient health literacy. Convoy propaganda showed that low health literacy continues to be a significant problem in Canada into 2022. Some occupants who rallied against PHMs, for example, may not have the knowledge to take in the evidence showing that these measures increase safety for an entire population. The unvaccinated man interviewed by Klepper may not have been exposed to accessible health messaging describing that entering high-risk environments without being vaccinated puts himself in much higher danger of being infected with and dying from COVID-19. Shifting from a mindset that lacks concrete health and science-related knowledge to a more informed viewpoint would demonstrate improved health literacy.
Health literacy, though, is not an issue of solely individual level factors. It is a social determinant of health (SDoH). This term refers to the unique living conditions one experiences that shape their health. SDoH are often influenced by systemic issues (e.g., socio-economic status, education level, etc.) that cause general societal inequities. Health literacy falls in line with this. Lower-income Canadians, for example, tend to have lower health literacy skills. A similar trend has been seen in Canadians with no post-secondary education. Individuals with little educational background are more likely to have insufficient health literacy skills. Children, even, receive most of their knowledge related to COVID-19 from parents, suggesting that one’s health literacy may be influenced by and sustained through generations. In total, research has demonstrated how engrained health literacy is as a SDoH.
Importantly, gaps in health literacy have direct effects on the health of an individual and the population. Individuals who have both chronic obstructive pulmonary disorder and low health literacy skills, for example, tend to have a lower quality of life. Other general findings show that individuals with combined chronic illness and low health literacy skills have higher rates of mortality from their illness. These findings are especially troubling knowing that the proportion of older adults in the Canadian population will increase in the coming years. Improving national health literacy could therefore reduce the burden on the Canadian health care system for the care of chronic illnesses that will become increasingly prevalent in an aging population. Improving health literacy across a population could also empower individuals in subsequent pandemics to understand public health messaging and incorporate it into health behaviours that keep all members of society safe.
Many existing definitions of health literacy do not adequately acknowledge the very real influence of the SDoH. As a result, interventions to improve health literacy may be too narrowly focused on individual factors. The Convoy shows, instead, that population-level interventions guided by the SDoH make more sense. The occupants did not exist solely within themselves but were members of diverse families, earners of varying incomes, and with varied educational backgrounds. These factors are large-scale SDoH that influence health literacy levels and overall health. This may be why previous attempts at improving health literacy in a one-on-one clinical setting have largely failed to make great impacts on health outcomes; issues influenced by large systemic factors cannot be fixed by small-scale individual level interventions.
Community-based interventions have been suggested as a possible method by which to bolster skills in health literacy. Attempting to improve the health literacy skills of entire communities aligns with the knowledge that health literacy is a SDoH and addresses previously stated concerns. Research suggests that programs should be tailored to the unique SDoH of each community. This would require developing intervention tools that are specific to the community’s culture. This could include pairing health literacy skill workshops, for example, with programs that aim to improve other influential SDoH like education and income. Population-level interventions like these could have a much broader effect on the health of Canadians because they would inherently account for the large systemic influences that dictate skills in health literacy.
Downtown Ottawa continues to be a stage to discuss current issues in Canadian society. Though the Freedom Convoy occupants may have felt they were putting on a performance solely to rally against pandemic-related issues, they were, in fact, bringing a different fundamental Canadian issue to the spotlight. The Convoy showed that we must improve the health literacy of Canadians. Doing so is imperative because health literacy is a SDoH with definite influence over the general health of individual Canadians. Health literacy must be addressed if we wish to improve the health of Canadians. Taking action on this issue could even prevent future disruptive occupations during public health crises. The exasperated residents of Ottawa and those occupying the city streets could both be helped by viewing such issues through the lens of health literacy. Though, I admit, this is a difficult mindset change to make, speaking as one of those exasperated Ottawa citizens living in the middle of the occupation. That being said, my background in health sciences has taught me that addressing issues at the systemic level is often the best way to bring about meaningful change.
This blog was originally written as part of the HLTH5402 course
Look out below! Investigating the impact of aviation emissions on the area surrounding the Ottawa International Airport
By Kieran Aston
Researchers are aware that when it comes to outdoor airborne particulate matter, smaller types of particles are more harmful because they can enter the bloodstream when inhaled. Ultrafine particles (UFPs) are a type of air pollution particulate matter of nanoscale size (less than 100 nm in diameter). To put this into perspective, UFPs are about 1/1000 the diameter of a single strand of human hair. There is growing evidence that long term exposure to UFPs increases the risk of serious health outcomes including cancer, respiratory diseases, hypertension, and diabetes. As we learn more about the dangers of long-term UFP exposure, it becomes increasingly important to learn more about the different sources of UFP emissions and their health impacts. We need to look for ways to reduce exposure.
In Canada, the primary source of UFPs is gasoline powered vehicles, but there are many other exposure sources such as diesel emissions and wood burning. That said, one crucial and understudied source of UFPs is aircraft use. Epidemiological studies found that airport related UFP emissions are substantial and may increase the risk of adverse birth outcomes. Since airport-related UFP emissions can spread significantly farther into the surrounding area than roadway-traffic emissions, they pose greater health risks and need to be specifically studied.
By design, airport runways run parallel to the prevailing wind direction to create optimal landing and takeoff conditions. Unfortunately, residential areas downwind of airports are subjected to aviation emissions, particularly in cities with little variation in wind direction.
During the summer of 2022, I helped collect data for a pilot study of Health Canada’s “Characterization of Aviation-Sourced Air Pollution (CASAP)” project to address UFPs research gaps. The project is led by Keith Van Ryswyk of Health Canada in collaboration with Dr. Paul Villeneuve of the CHAIM Center at Carleton University. The main component of the CASAP study will take place at Toronto’s Pearson International Airport, focusing on investigating the effect of airport-related emissions on the urban areas downwind of the airport. The project will also examine how new, more fuel-efficient landing technology can affect aviation emissions.
The pilot study at the Ottawa International Airport was intended to provide an opportunity to fine-tune the methodology for data collection and analysis in preparation for the main study. We set up fixed-site monitoring equipment near a runway at the airport by installing a tripod-like contraption fitted with various instruments that continuously collecting data on pollutants, noise and weather. The site we chose is in line with the runway, and lies to the east of the airport, which is ideal for catching air pollution plumes from aircraft with the prevailing western winds in this area.
I was responsible for ensuring that the monitors at the site had everything they needed to collect data on noise, black carbon, and particulate matter at the site. I also contributed to the analysis of the collected data. This meant making weekly visits to the site to replace depleted batteries, clean dirty filters, sync clocks, and offload data, battling mosquitoes and the keep the tech dry during the occasional freakish downpour. I also had to deal with any unexpected errors and mishaps with the devices, of which we had our fair share.
A typical Monday for me started with driving out to Albion Road and heading down a more-than-a-little bumpy gravel road to the monitoring site. Once I made my way up a small hill to the monitoring setup, I connected my laptop to each of the devices, downloaded the data, cleared each device’s memory, and synced their clocks. Then, I replaced the devices that were out of battery with fully charged spares and replaced the dirty parts with clean ones. Finally, before leaving I thoroughly checked each instrument to make sure everything was in working order.
Since flight data were not yet available at the time of my work on this study, my analysis of the collected data was limited to the effect that wind direction had on UFP concentrations. Some of my preliminary findings showed that UFP concentrations were in general higher during winds that put the monitoring site downwind of the airport (i.e., western winds) than when the monitoring site was upwind of the airport (i.e., during eastern winds), as shown in the graph below. In addition, when comparing UFP concentrations during hours of higher flight traffic (6:00 am – 11:59 pm) and lower flight traffic (12:00 am – 5:59 am), differences seen in both the variability and levels of UFP concentrations were much larger when the monitoring site was downwind of the airport than when it was upwind of the airport. For example, during western winds the standard deviation of recorded particle number concentrations (PNC) was 51.0% larger from 6:00 am – 11:59 pm than it was from 12:00 am – 5:59 am. Conversely, the difference in the standard deviation of PNC during eastern winds was more comparable, being 13.2% larger between 6:00 am – 11:59 pm than it was between 12:00 am – 5:59 am.
The project’s next steps include comparing the collected data with flight data to be received from Nav Canada. Flight data allows for a more detailed analysis, and we hope that such an analysis can serve to better inform our methodology for the main portion of the study at Toronto’s Pearson Airport. Our pilot project was the first to collect data on UFPs from aircraft, and in time, we hope to assess whether these exposures impact the health of residents.
Angel Xing, CHAIM Centre Communications and Strategy Intern
"There are so many barriers that queer and trans people face in getting access to health, so to say that the healthcare system is working well isn't right," says Dr. Julia Sinclair-Palm, a sociology professor at Carleton University.
Over the summer, the CHAIM Centre released its first CHAIM Chats series discussing queer and trans experiences in Canada's health system. The three episodes focus on specific barriers faced by the trans community in accessing healthcare.
A 2021 article published in the Canadian Medical Association Journal found that LGBTQ+ communities still experience health inequities. Trans and non-binary people report that they often experience unmet needs or delays in receiving care.
According to Dr. Sinclair-Palm, one barrier to health is the expectation for trans patients to align their gender presentation with the binary.
"Medical professionals want a singular story about their transness," she says. "But it excludes non-binary, genderqueer and folks who don't present their gender in a binary way."
Dr. Sinclair-Palm says trans patients are often expected to prove that they are trans to their healthcare professional to receive the care they need. "Trans folk are smart and good at navigating those terrible health systems. They've learned that they have to tell a particular story," they say.
"But there's no singular queer or trans experience. There is no singular way to be trans, and when we other or cast trans folks as 'different,' we limit the understanding of the complexities of their lives," Dr. Sinclair-Palm says.
Christian Wright, Rainbow Ottawa Student Experience (ROSE)'s lead coordinator, adds that the trans community is frequently mistreated in healthcare. They can be misgendered, asked inappropriate questions, called the wrong name and experience stereotypical assumptions.
"People are afraid of going into these environments on top of the fact that accessing trans-specific healthcare is an incredibly frustrating and long process," Wright says.
Another significant barrier to healthcare is the wait time.
"Just to get an intake appointment at the premiere trans healthcare providing place in Ottawa, Centretown Community Health Center, is a two-year waitlist," Wright says. Then there is the wait time for actually receiving HRT or surgery.
"Once they enter the door, there's another host of barriers," Dr. Sinclair-Palm says.
"If they're seen as 'too mentally unstable,' they aren't granted access to the care they want. They're told they need to address those other issues when often, someone might be depressed or struggling because of the discrimination and violence they face."
Florence Ashley, a transfeminine bioethicist and jurist, says that the healthcare system does not support the trans community. They researched how medical professionals often take the authority in determining if their patients are trans and if they need hormone replacement therapy (HRT) independent of their patient's wishes.
"While science can be used to afford some degree of gender affirmation, it was also just as often used to limit it and expand medical power," they say. "The experts position themselves and accept their roles as authorities in accessing the child's gender and who is really trans."
Ashley said they noticed in decisions before the court about parental behaviour towards trans youth that the medical professionals speak on behalf of the child.
"They were the ones positioned as the spokesperson for the child to relate the 'true' views of the child," they say. However, when speaking for the child, Ashley says the experts would use ambiguous terms like "based on the child's feelings" so they can draw conclusions themselves.
"Being trans is something that shouldn't be within the sphere of authority of doctors," Ashley says. "It's not their business in the first place to determine who is trans and who isn't."
"It's harmful because it challenges trans people's fundamental self-knowledge about who they are."
Wright says the authority of medicine in someone's trans identity also relates to transmedicalism, the idea that being transgender means medically transitioning to resolve gender dysphoria, which is psychological distress due to a mismatch between the gender assigned at birth and gender identity.
Wright says, fortunately, the model of gender-affirming care is growing. Ashley adds that an Informed Consent Model (ICM) decenters clinical assessment, focusing on the client which removes the requirement to prove their gender identity to receive care.
According to the Institute of Gender and Health, the ICM would does not evaluate if a person is trans; instead, it focuses on the decision-making process and ensuring that the patient understands the risks and benefits of HRT.
Unfortunately, Ashley says ICM is limited by a lack of time. "We're in a consumerist medical system where doctors rarely get to have more than 15 to 30 minutes with you," they say. It is difficult to deeply discuss decision-making in a short session.
Wright says this can be improved if healthcare professionals at the first access point, like family doctors, are more educated about trans health. Learning about trans health shouldn't be an additional and separate piece from cisgender health.
"We need doctors who are preparing to be care providers and family physicians to be educated about HRT and options for surgery referrals," they say.
"There need to be more resources put into creating a system which allows trans people to participate as fully as cis people do, from navigation to advocacy to support."