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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.  Source: Kamloops This Week, 2021 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?  Source: Crown-Indigenous Relations and Northern Affairs Canada, 2022 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. References:
This blog was originally written as part of the HLTH5402 course.
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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.  (Lindeman, 2022) [@traceylindeman] 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. References:
This blog was originally written as part of the HLTH5402 course
Angel Xing, CHAIM Centre Communications and Strategy Intern  Three CHAIM Centre Affiliates shared their experiences as Asian researchers for Asian Heritage Month in May, discussing social and cultural health inequities, particularly in mental health. Dr. Melissa Chee, an assistant professor in Carleton's Neuroscience department and principal investigator at The Chee Lab, said she started reflecting more on how her Southeast Asian identity affects her professional career when the 2020 Black Lives Matter movement sparked discussions about systemic racism. "It's still a discovery process for me," she said. "I know that lately I've been more aware, and I sometimes pause to ask; am I not part of that, or am I part of that because I'm Asian?" Asians are often treated as the "model minority," a stereotype that characterizes Asians as academically and economically successful compared to other minority groups. According to an article by NPR, this undermines anti-Asian hate and creates a racial divide. Dr. Chee commented on the impact of this stereotype. "Asian women are actually underrepresented in science, and I feel I need to succeed in my role so others will continue to have the same opportunity," she said. Ajani Asokumar, who identifies as Tamil and is currently pursuing her Ph.D. in Neuroscience at Carleton, agreed. "It made me really nervous because I have these expectations and pressures on me that I have to fulfill," she said, adding that sometimes she felt like she was being treated differently in academic and social settings. "You can detect it in the comments people make." In addition to the pressures, Asokumar also pointed out that Asian immigrant families don't often discuss stress and mental health, both heavily stigmatized topics. "In the Asian cultures typically, mental ill health is looked upon as almost shameful, a reflection of laziness," said Dr. Zul Merali, former scientific director of the University of Ottawa's Institute of Mental Health Research. Dr. Merali identifies with the South Asian community. "But mental illness is an illness like any other," he said. "It is not something you need to blame yourself for." Unfortunately, the pressure from Asian stereotypes combined with cultural mental health stigmas makes the Asian community more vulnerable to poor mental health. In 2016, CAMH reported that Chinese and South Asian patients had more severe mental illnesses when they were admitted to the hospital. Another issue the CAMH report identifies is that there is limited data on Chinese and South Asian patients in mental health research and general health research. Dr. Chee and Asokumar said an issue lies in the "Asian" categorization. "The Asian community is really diverse in Canada," Dr. Chee said. Besides different ethnicities and cultures, variables also include time spent in Canada and language barriers. "The experiences of someone new to Canada are very different from my experiences. I've been here my whole life." Asokumar added that mental health help is often only designed for Western people and feels alienating because the professionals don't have the same cultural understanding. "The help that's given is so general," she said. "We need better access to people who are better suited to help our needs." "When you present an opportunity, it might not be accessible to everyone equally." Dr. Merali said there are also great challenges in getting admission and treatment into the healthcare system, particularly for mental health, because the system is under-resourced. He said this affects all marginalized groups, especially because support like psychological counselling often requires private insurance. "All marginalized populations pay the price," he said. Since people from these communities cannot access mental health resources as easily, Dr. Merali said they are underrepresented in collected data for mental health studies. That said, Asokumar said she does feel like there are more people of colour in her program than there were in 2013 when she first came to Ottawa. She said there had been significant changes compared to when she was one of the few people of colour in her program. "I'm seeing more people who look like me, so it's a very positive thing that's happening," she said.
But she said she still sees mostly white men in authority positions. "I think more needs to be done. I do want to see more action," Asokumar said. Dr. Chee agreed there should be an increase in the diversity of people who sit on committees. "It's always on the back of your mind whether you were included because you're the token minority. Was I included because I am a minority and a woman? Or was I included because of my ability or expertise?" "We don't know whether our identity has hindered our ability to accelerate in our field," Dr. Chee said. "We think that we are here because we earned and deserve it, but how do we know that we didn't deserve more?" "We need more research. We need information and advocacy."  Genderqueer Pride Flag Jaya Rastogi, Health Science, Technology, and Policy MSc Student “For me, going to the doctor is scary and dangerous,” said a genderqueer undergraduate student accessing healthcare in Ontario. “I called my family doctor to ask about [a health service that is unique for genderqueer individuals]. He said ‘I’ve never heard of that. What is that? I don’t know how to do that.’ This says to me that my doctor hasn’t educated himself enough, which seems irresponsible.” The genderqueer and trans community Genderqueer and trans individuals face unique barriers when accessing health care. In 2018, Carleton University’s independent newspaper, the Charlatan, reported on an Algonquin College student, Ashton Schofield, who faced multiple challenges accessing trans-inclusive healthcare in Ottawa. He faced numerous barriers to care including limited providers with enough knowledge to treat trans patients, long wait times for the limited providers, and an incorrect hormone medication prescription (1). Schofield’s story is not unique. As many as 1 in 200 Ontarians are trans and 11% of LGBTQ+ youth are genderqueer/gender nonconforming (2,3). Like Schofield, both genderqueer and trans individuals often face challenges accessing healthcare (4). Genderqueer is a term used to describe an individual who does not conform to one of the two binary genders⁵. Trans is an umbrella term used to describe people who move away from the gender they were assigned at birth (5,6). Some genderqueer individuals identify as trans, while others do not (7). Barriers to access and exclusion from healthcare Genderqueer and trans communities face several barriers to accessing trans-inclusive healthcare in Canada, including a lack of relevant and easily available information, self-esteem and mental health issues, challenges finding help, and ongoing experiences of transphobia (8,9). Genderqueer individuals face health-related challenges at even higher rates than binary trans people, including avoiding care due to a fear of discrimination and providers refusing to treat them (10). Genderqueer young people are becoming increasingly visible in healthcare and our communities but are paid little attention when it comes to their unique healthcare needs (9). Trans and genderqueer Canadians also experience social exclusion from healthcare (8). Many medical clinics only have male and female washrooms (11), which communicates to genderqueer individuals that their identity is not welcome in the space. Medical intake forms typically ask patients to select their sex and provide the options of male and female without asking about gender or providing any space for further elaboration (11). This says to genderqueer individuals that their identity is not acknowledged or respected in the health system. Commenting about health intake forms, the genderqueer youth quoted earlier said, “the last medical form I filled out was a form for a blood test and the options were male and female. Since I’m genderqueer I think female and male are just two really small categories.” They continued, “it’s very hard for others to respect me being androgynous. Being genderqueer is the most freeing thing because I’m not confined to these little boxes of sex or gender. Scientists and doctors are supposed to help me, but they’re the ones confining me to these little boxes. They’ll say, ‘you have to pick one or we’re going to pick for you.’ ”  Improving health intake forms Health forms are not set in stone and should be improved to better serve the genderqueer and trans community. Improving health forms is an important step in breaking down barriers to care for genderqueer and trans individuals. A recent Ontario Medical Association (OMA) report (2020) highlighted that a number of factors can lead trans youth to avoid health care (13), including the system’s focus on the gender binary and medical intake forms that ask only if a patient is male or female. A majority of trans youth criticized medical forms for being very male/female centered in a recent Manitoba-based study on trans youth’s experience in the healthcare system (12). Improving health forms would generate accurate data and provide visibility to the genderqueer and trans community. Demonstrating that genderqueer and trans people exist in local hospitals, medical clinics, and communities is important when advocating for inclusive policy, inclusive program creation and funding, and other resource allocation (12,14). The 2-step method for asking sex and gender One tool to improve visibility and accessibility in healthcare is the 2-step method for asking sex and gender, which was developed by the Gender Identity in U.S. Surveillance Group (14). This 2-step method would replace the current 1-step method that only asks a person’s sex and offers male or female as the only response options. In the 2-step method, individuals would be able to differentiate between their sex assigned at birth and their current gender identity while also having multiple options to select for current gender identity. See below for 2-step sex and gender questions (7):   Progress Pride Flag This 2-step method was originally created for surveys but is also recommended for use in health intake forms (15). Recent Canadian research found that the 2-step method captures genderqueer and trans people’s identities better than the 1-step method, validates these identities, and was not confusing to people who are not trans (also called cis) (7). However, the 2-step method was not sufficient for some Indigenous people, and other response options may need to be added to the questions, such as two-spirit (7). There is not enough research to understand if intersex people find that the 2-step method correctly captures their identities (7). Intersex refers to individuals whose hormones or chromosomes create characteristics that are not consistently male or female (7). Additionally, some scholars argue that sex and gender markers should be eliminated wherever they are not necessary (2). While more work needs to be done to ensure questions about sex and gender accurately capture genderqueer and trans peoples’ identities, implementing the 2-step method in health intake forms is a promising step towards making healthcare more accurate and validating for trans and genderqueer individuals.
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