Nunavut: A Health System Profile 9780773588844

Table of contents :
Cover
Title Page
Copyright Page
Table of Contents
Tables and Figures
Preface
Abbreviations
1. Nunavut: Health in Comparative Context
2. Organizational Structures
3. Health Benefits, Funding, and Expenditures
4. Nunavut’s Health Infrastructure
5. Nunavut’s Health Workforce
6. Service and Program Provision in Nunavut
7. Mental Health and Addictions
8. Evaluating Policy, Planning, and Performance
Appendices
A: Territorial Laws Related to Health and Health Care in Nunavut
B: Scope of Practice for Community Health Nurses in Nunavut
C: Links to Websites
Notes
Bibliography
Index

Citation preview

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n u n av u t

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Nunavut A Health System Profile

g r e g o ry p . m a r c h i l d o n

and renée torgerson

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

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© McGill-Queen’s University Press 2013 ISBN ISBN ISBN ISBN

978-0-7735-4147-4 (cloth) 978-0-7735-4148-1 (paper) 978-0-7735-8884-4 (ePDF) 978-0-7735-8885-1 (ePUB)

Legal deposit third quarter 2013 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Marchildon, Gregory P., 1956–   Nunavut : a health system profile / Gregory P. Marchildon and Renée Torgerson. Includes bibliographical references and index. ISBN 978-0-7735-4147-4 (bound). – ISBN 978-0-7735-4148-1 (pbk.) ISBN 978-0-7735-8884-4 (ePDF). – ISBN 978-0-7735-8885-1 (ePUB)   1. Medical care – Nunavut.  2. Public health – Nunavut.  3. Health services administration – Nunavut.  4. Health surveys – Nunavut. I. Torgerson, Renee, 1970–  II. Title. RA450.N85M37 2013  362.109719'5  C2013-901327-X Typeset by Jay Tee Graphics Ltd. in 10/13 Sabon

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Contents

Tables and Figures  vii Preface ix Abbreviations xiii 1  Nunavut: Health in Comparative Context  3 2 Organizational Structures  22 3 Health Benefits, Funding, and Expenditures  32 4 Nunavut’s Health Infrastructure  45 5 Nunavut’s Health Workforce  57 6 Service and Program Provision in Nunavut  85 7 Mental Health and Addictions  110 8 Evaluating Policy, Planning, and Performance  120 Appendices A Territorial Laws Related to Health and Health Care in Nunavut 131 B Scope of Practice for Community Health Nurses in Nunavut 133 C Links to Websites  136 Notes 139 Bibliography 151 Index 167

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Tables and Figures

ta b l e s

1.1 Population of Inuit inside and outside Inuit Nunaat, 2006  10 1.2 Population and Growth of Communities, 1981–2006  12 1.3 Selected Health Indicators for Children and Youth in Inuit Nunaat, 2001  13 1.4 Social Determinants of Health: Behaviours and Living Conditions 15 1.5 Health Conditions Based on Latest Available Data  19 1.6 Morbidity, Mortality, and Avoidable Mortality Indicators  20 3.1 Comparison of Non-Insured Health Benefit Expenditures  34 3.2 Federally Funded Population Health Programs and Initiatives in Nunavut 35 3.3 Number and Cost of Medically Related Flights in Nunavut  37 3.4 Estimated Health Expenditures in Nunavut, by Category, 2008–2009 39 3.5 Health Expenditures in Nunavut, 2000–2010  40 3.6 Private Sector per Capita Health Expenditure by Territory and for Canada  41

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viii

Tables and Figures

3.7 Public Sector per Capita Health Expenditure by Territory and for Canada  42 5.1 Percentage of Inuit Beneficiaries in Health and Social Services Positions, Nunavut  78 5.2 Nursing Vacancy Rates in Nunavut by Community  82 6.1 Publicly Funded Immunization Programs for Infants and Children, Nunavut  94 6.2 Percentage of Residents Aged 12 and Over Reporting Influenza Immunizations, 2005  94 6.3 Distribution of Family Physicians, Nunavut, 2008–2009  95 6.4 Infant Mortality Rates per 1,000 Live Births, Canadian Territories, 2007  102 7.1 Self-Rated Mental Health in Canada’s Territories, 2009  112

figures

1.1 Canada’s Northern Territories  5 1.2 Inuit regions of Canada  6 1.3 Circumpolar peoples and languages  8–9 1.4 Nunavut’s administrative regions  14 2.1 Organization of health services in Nunavut  28 3.1 Private sector per capita health expenditure by territory and for Canada 41 3.2 Public sector per capita health expenditure by territory and for Canada 42 3.3 Medical air links  44 5.1 Age of physician workforce, Canadian territories, 2006  59

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Preface

This volume has been written and structured as an “advance pilot” for a planned series of books that will focus on health systems administered by provincial and territorial governments because most of the programmatic responsibility for public health care services in Canada resides largely with those governments. Since there have been no comprehensive studies of the health systems of any province or territory, such studies should fill a critical gap in our understanding of one of our most important and expensive social policies. At the same time, the studies will not focus solely on provincial ministries or departments of health. In many cases, administration and (most certainly) delivery are decentralized, and the arm’s-length or private organizations involved will be carefully examined as part of this series. In addition, the federal government continues to play a niche role in key areas (e.g., in prescription drugs, research funding, data collection) and a major role in terms of some populations (e.g., eligible First Nations and Inuit), and as a consequence, these health system studies describe and assess these federal roles and activities where relevant. Since this study is a prototype for the planned series, we have tried to ensure that it adopts an approach that will set a standard for the volumes in the series. Although it has been adapted to the Canadian context, the approach bears some resemblance to the template used in health-system-in-transition (HiT) country studies published by the WHO Regional Office for Europe on behalf

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x Preface

of the European Observatory on Health Systems and Policies. The profiles will provide the reader with an overview of governance and administrative organization, funding and expenditures, health infrastructure, workforce issues, and sector-specific services and programs, and with an evaluation of program and policy performance using the provincial and territorial health systems as the key unit of analysis. For this study alone, an extra chapter on mental health was included because of the abnormally high rates of suicide and the challenges posed by rapid cultural and economic transitions. We also feel that a warning is appropriate. While major – what some call transformational  – change is rare in health systems, provincial and territorial governments are always engaged in a significant amount of incremental change. As a consequence, we can only provide a time-limited snapshot of the health system. In this case, because most of our data collection in Nunavut, including key informant interviews of department staff and front-line providers and a comprehensive inventory of services, occurred in 2009 and the first half of 2010, these data will be outdated. But we have tried to present trends wherever possible in order to give the reader some idea of the broader trend lines. We regret that it was not possible to present longer-term trend data more often. We want to thank the Department of Health and Social Services for supporting this research and allowing us privileged access to all personnel. In addition to our regular meetings and discussions in Iqaluit, we also appreciated the opportunity to travel to almost all of Nunavut’s twenty-four hamlets. This gave us a remarkable, on-the-ground opportunity to observe the workings of the health system in all its complexity. The community health nurses that form the core staff of the community health centres took time out of their sometimes very hectic schedules to answer our numerous questions. We are also grateful to the many others – public health, home care, and long-term care nurses, community health representatives, clerk-interpreters, social workers, and other community health centre and department staff – who also provided their time to us. We want to single out two individuals in the department who were immensely helpful from the beginning. Alex Campbell, then deputy minister, believed in the value

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Preface xi

of this research project from the beginning. Dr W. Alexander (Sandy) Macdonald, then director of medical services, became our key contact for the department, and facilitated access to key personnel and health facilities. Outside the department, we were helped by Kue Young who put us in touch with Peter Bjerregaard, professor of arctic health at Denmark’s National Institute of Public Health and the leading expert on the Greenlandic health system. At our request, Peter and his Greenlandic colleague, Ingelise Olesen, conducted an inventory of health services in Greenland that allowed us to make some comparisons with a very different “Inuit” health system. We truly appreciate the feedback we received from key department personnel – Monique Charron (Health Canada) and Julia Abelson (McMaster University), as well as the three anonymous referees who reviewed earlier versions of the manuscript. Because of their careful reading, we were able to avoid some major errors. They also made suggestions and asked questions that pushed us to go further in critical areas. Of course, none are responsible for the final interpretation or any remaining errors. Finally, we would like to thank our editor, Kyla Madden at McGill-Queen’s University Press, for her work on this volume and her ideas on the future series, as well as Philip Cercone, the executive director of the press, for his support of the health profile series.



Gregory P. Marchildon, Regina, Saskatchewan 26 May 2012

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Abbreviations

AHRN ASIST CADTH CAMRT CASLPA CCHS CHC CHN CHR CNA DEW DHSS EHO EHR FNIHB FNIHCC FPC

Arctic Health Research Network Applied Suicide Intervention Skills Training Canadian Agency for Drugs and Technologies in Health Canadian Association of Medical Radiation Technologists Canadian Association of Speech-Language Pathologists and Audiologists Canadian Community Health Survey community health centre community health nurse community health representative certified nursing assistant Distant Early Warning: used in conjunction with DEW line of radar stations Department of Health and Social Services, Government of Nunavut environmental health officer (Government of Nunavut) electronic health record First Nations and Inuit Health Branch, Health Canada First Nations and Inuit Home and Community Care Program, Health Canada Family Practice Clinic, Iqaluit, Nunavut

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xiv Abbreviations

FP GN HTA ICT IIU IQ ITQ LPN NAC NAHO NBDC NIHB NIICHRO NLCA NMU NP NTI PIPEDA QGH RNANTNU RN RPN TTF

family physician Government of Nunavut health technology assessment information and communications technology Ikajuruti Inungnik Ungasiktumi Telehealth Network, Nunavut Inuit Qaujimajatuqangit Inuit Taparit Kanatami licensed practical nurse Nunavut Arctic College National Aboriginal Health Organization Nunavut Broadband Development Corporation Non-Insured Health Benefits, funded by the Government of Canada National Indian and Inuit Community Health Representatives Organization Nunavut Land Claims Agreement Northern Medical Unit, University of Manitoba nurse practitioner Nunavut Tunngavik Inc. Personal Information Protection and Electronic Documents Act Qikiqtani General Hospital, Iqaluit, Nunavut Registered Nurses Association of the Northwest Territories and Nunavut registered nurse registered psychiatric nurse Territorial Formula Financing, Government of Canada

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n u n av u t

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1 Nunavut: Health in Comparative Context

i n t r o d u c t i o n t o n u n av u t

Little more than a decade old, Nunavut is the newest political jurisdiction in Canada. It is also unique. As the only substate in Canada in which one Indigenous group makes up a significant majority of the population, its character is defined by it being an Inuit homeland. It is also the only northern territory without any roads connecting even the largest communities, and except for a few weeks in the summer, when shipping is possible, travel between and beyond the territories is limited to air. The territory of Nunavut covers one-fifth of Canada’s land mass – in excess of 2.1 million square kilometres – and includes much of Hudson Bay as well most of the islands and marine areas of the Canadian Arctic up to the North Pole. If Nunavut were an independent nation state, it would be the twelfth largest country in the world (Légare 2008). Nunavut also has the coldest weather of any province or territory in Canada. Winter lasts an average of nine months each year and the sea routes through the territory are frozen for most of the year. Among Arctic populations in general, a cold climate is significantly associated with higher rates of mortality and fertility (Young and Mäkinen 2009). The population of Nunavut consists of thirty thousand residents living in twenty-five widely dispersed communities. No roads connect Nunavut’s isolated communities, and almost all residents, supplies, and equipment are transported by air. In

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A Health System Profile

c­ ontrast, most communities in the Northwest Territories (NWT) and Yukon are linked together by roads. As a consequence, health service delivery in Nunavut is the costliest in Canada. It is also the costliest jurisdiction in the circumpolar world as measured by per capita government health spending (Young 2012). The government of Nunavut provides access to a full range of sophisticated and costly health services inside and outside the territory to geographically dispersed populations with relatively low health status. Inuit residents comprise almost 85 percent of the population of Nunavut. Although English is used extensively in the bureaucracy of the territorial government, almost four out of five Inuit residents identify Inuktitut and Inuinnaqtun as their first languages.1 In some communities, the majority of Inuit residents have a limited ability to communicate in English. In contrast, most frontline health providers in Nunavut are non-Inuit and therefore rely on translators to communicate with a large number of residents. Although the territorial government has invested heavily in the training and educating of Inuit for key provider roles, low graduation rates and poor educational attainment at the primary and secondary school levels limit the possibilities for such programs. To facilitate a better understanding of these health system complexities, this chapter introduces the general socio-­demographic, economic, and cultural context in which health services are administered and delivered in Nunavut. A brief overview is provided of the health status of the residents of Nunavut as well as key indicators of health service utilization. Where possible, a comparative approach is used, measuring services as well as resource inputs, outputs, and outcomes against comparative jurisdictions or populations, adapting a template previously established for similar analyses of health systems (Marchildon 2006; Marchildon and O’Fee 2007). When comparing Nunavut to other political jurisdictions in Canada, it makes sense for reasons of geography and demographics, as well as health system features, to examine the territory’s outcomes and expenditures to the Northwest Territories and the Yukon, even while using the Canadian average as a general proxy for the provinces further south. Admittedly, there are

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Health in Comparative Context 5

Figure 1.1  Canada's Northern Territories

important differences among the territories, including transportation, the degree of urbanization, and demographic and ethnolinguistic factors. However, the territories share other important features, including higher health-care delivery costs, the legacy of the federal nursing station system, and a shortage of specialized health professionals in most communities. There are nearly fifty-five thousand Inuit living in fifty-three communities in the northern reaches of Canada. Therefore, it would be useful to compare Nunavut (translated as “our land”) to the three other Inuit regions of Canada: the Innuvialuit (“the real people”) land claim settlement region of the Northwest Territories, the Nunavik (“place to live”) region of northern Quebec, and the Nunatsiavut (“our beautiful land”) region of coastal Labrador. Unfortunately, we are limited by data shortages from making numerous comparisons using the four Inuit homelands in Canada, collectively known as Inuit Nunangat. One exception to this is provided by life-expectancy outcomes.

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A Health System Profile

Figure 1.2  Inuit regions of Canada

The life-expectancy gap for residents of Inuit Nunangat relative to the rest of Canada has grown since the mid-1990s. In ­1994–98, this gap was 9.1 years for males and 9.0 years for females, a gap that increased to 11.9 years for males and 12.3 for females in the next five years, demonstrating a relative (if not absolute) deterioration in health status. The rise in cancer rates among Inuit throughout northern Canada is the single most important contributing factor to the gap (Peters 2010). In theory, it would also be useful to extend this comparison to other regions of the world with similar Arctic Aboriginal populations including Greenland’s Inuit (known as Kalaalit, or Greenlanders), Alaska’s Inupiat and Yupik, Nordic Europe’s Sámi, and northern Russia’s Yupik.2 Unfortunately, owing to incompatible definitions and data sources, as well as the practice in the Nordic countries of not separating Indigenous populations for statistical purposes, this is rarely possible (see Young and Bjerregaard 2008).

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Health in Comparative Context 7 the political context

Nunavut was created as a territory in 1999 as a direct result of a lengthy land claims process that began in 1973 with the Calder v. British Columbia case.3 As a consequence of the Supreme Court of Canada’s decision in Calder recognizing the continuing legal existence of Aboriginal title to traditionally occupied land for non-treaty indigenous groups, the government of Canada established a comprehensive land claims policy. This new policy stated that in exchange for relinquishing Aboriginal rights to land, the Canadian government would (1) grant exclusive ownership over large tracts of land within traditional territories; (2) provide financial compensation for other lands and resources within the land claims area; and (3) establish co-managed public boards to administer all lands within the settlement area (Légare 2008). In 1993, the Nunavut Land Claims Agreement (NLCA), signed by Inuit representatives and the government of Canada, came into effect. The content of the NLCA, including the establishment of a new territory out of the existing Northwest Territories, was approved in a referendum by 69 percent of the Inuit living in the central and eastern parts of the Canadian Arctic. The NLCA is perhaps the most far-reaching and comprehensive land claims agreement ever signed between an Indigenous group and a national government. The NLCA deliberately coupled the “economic self-determination offered by a land claim” with the “political self-determination made possible” by the creation of a new political jurisdiction (Henderson 2009, 11). The NLCA conferred ownership rights to 353,610 kilometres – including 36,257 kilometres with subsurface mineral rights – in the central and eastern portion of the Northwest Territories to Nunavut Tunngavik Inc. (NTI), the Inuit organization established to implement the NLCA. In addition, five co-managed, public boards were established to manage both Inuit-owned and public lands in Nunavut. In 1999, as a result of the NLCA, the government of Canada passed the Nunavut Act to create the Territory of Nunavut. Nunavut has the same political institutions (a legislative assembly, a public service, tribunals, and a commissioner) as the two

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Figure 1.3  Circumpolar peoples and languages. Originally compiled by W.K. Dallman,    N

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   Norwegian Polar Institute, and P. Schweitzer, University of Alaska, Fairbanks

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Table 1.1 Population of Inuit inside and outside Inuit Nunaat, 2006 Geographic Area

Number of Inuit

Nunavut Nunavik (northern Quebec) Inuvialuit region (NWT) Nunatsiavut (Labrador)   Total in Inuit Nunaat Rest of Canada (outside Inuit Nunaat)   Total in Canada

24,635  9,565  3,115  2,160 39,425 11,005 50,480

Source: ITK (2008).

other northern Canadian territories. Like the NWT, the Nunavut government is largely run on the Westminster parliamentary model but relies on consensus politics in place of partisan party politics (White 2006). Just like its sister territories to the west, Nunavut has most of the social policy and economic development responsibilities of the ten southern provinces, despite its constitutional status as a territory created by, and subservient to, the federal government. At the same time, it is even more dependent than the NWT and the Yukon governments on federal transfers to fund its programs – including the delivery of public health care. Although the federal government does not directly deliver health programs in Nunavut, Health Canada and the Public Health Agency of Canada nonetheless fund a suite of population health programs. In addition, Health Canada transfers some administrative funding to allow the government of Nunavut and the local hamlet governments to manage these programs as well as portions of the Non-Insured Health Benefits (NIHB) program for Inuit residents (see the final section in chapter 2). the socio-demographic context

Nunavut’s population of approximately thirty thousand is spread over twenty-five communities. Inuit residents make up 84 percent of the total population of the territory. Moreover, the Inuit in ­Nunavut constitute the largest concentration of Inuit in C ­ anada

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Health in Comparative Context 11

(table 1.1). The population of the territory has doubled since 1981, largely owing to a baby boom in many of the twenty-five communities (see table 1.2). Nunavut had the highest population growth rate in Canada between 1981 and 1996. Since that time, a lower fertility rate combined with higher rates of out-­ migration, has slowed population growth in the territory (Nunavut Economic Forum 2008). One legacy of the baby boom is that Nunavut has the youngest population of any territory or province in Canada. Over 50 percent of Nunavut’s residents are under twenty-five years of age compared to a Canadian average of 31 percent. Typically, such a young demographic should translate into lower health care costs. However, because of relatively negative socio-economic determinants of health, the need for health care is higher than the Canadian average for this demographic. This poorer health status is reflected in the lower life expectancy for Inuit throughout Canada; outcomes are particularly poor in Nunavik (northern Quebec) and Nunatsiavut (coastal Labrador), as shown in table 1.3. Furthermore, it is now understood that an individual’s social environment can have a greater impact on health outcomes than the quality or availability of health care. For this reason, the (non-medical) social determinants of health  – including early life, education, food intake, smoking and drinking behaviours, gender, housing, income distribution, the social safety net, and employment and working conditions  – require careful assessment (Raphael 2009). Since most of our analysis in subsequent chapters focuses on health care, it is useful to try to compare at least some of the broader social determinants of health outcomes in Nunavut to the Northwest Territories and the Yukon, as presented in table 1.4. As can be seen, Nunavut residents smoke far more than Canadians on average, including residents of the other two northern territories. While the level of heavy drinking is lower than in the rest of the country, in part because of the high cost of alcohol and the policy of some communities to ban the sale of liquor, our key informant interviews of community health centre staff revealed high rates of illicit drug use, particularly marijuana. Since fruits

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Table 1.2 Population and Growth of Communities, 1981–2006 (in order of size)

Nunavut Iqaluit Arviat Rankin Inlet Baker Lake Cambridge Bay Pond Inlet Igloolik Pangnirtung Kugluktuk Cape Dorset Gjoa Haven Repulse Bay Clyde River Taloyoak Coral Harbour Arctic Bay Sanikiluaq Kugaaruk   (Pelly Bay) Hall Beach Qikiqtarjuaq Kimmirut Whale Cove Chesterfield  Inlet Resolute Grise Fiord

2011

2006

2001

1996

1981

% Change (1981–2011)

31,906 6,699 2,310 2,266 1,872 1,608 1,549 1,454 1,425 1,450 1,363 1,279 945 934 899 834 823 812 771

29,474 6,184 2,060 2,358 1,728 1,477 1,315 1,538 1,325 1,302 1,236 1,064 748 820 809 769 690 744 688

26,745 5,236 1,899 2,177 1,507 1,309 1,220 1,286 1,276 1,212 1,148 960 612 785 720 712 646 684 605

24,730 4,200 1,559 2,058 1,385 1,351 1,154 1,174 1,243 1,201 1,118 879 559 708 648 669 639 631 496

15,572 2,333 1,022 1,109 954 815 705 746 839 809 784 523 352 443 431 429 375 383 257

89.3 165.5 101.6 112.6 81.1 81.2 86.5 106.2 57.9 60.9 57.7 103.4 112.5 85.1 87.7 79.3 84.0 94.3 167.7

546 520 455 407 313

654 473 411 353 332

609 519 433 305 345

543 488 397 301 337

349 378 252 188 249

87.4 25.1 63.1 87.8 33.3

214 130

229 141

215 163

198 148

168 106

36.3 33.0

Source: Nunavut Economic Forum, 2008, and Statistics Canada Census 2011 at www12.statcan.gc.ca/ census-recesement/English-eng.cfm. Note: Includes all hamlets and the city of Iqaluit but not settlements that were virtually unpopulated in 2011, such as Nanisivik (10), Umingmaktok (5), and Bathhurst Inlet (0).

and vegetables must be imported at very high cost to Nunavut, consumption is considerably lower than the Canadian average and a little lower than in the Northwest Territories, which benefits from being able to truck food products into at least some communities. Residents also report that they get less exercise during their leisure time than residents of the other territories.

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Health in Comparative Context 13

Table 1.3 Selected Health Indicators for Children and Youth in Inuit Nunaat, 2001 Indicator

Nunavut

Nunavik

Inuvialuit

Nunatsiavut

Life expectancy in years Respiratory problems: asthma, bronchitis, emphysema (%) High blood pressure, heart problems, effects of stroke (%) Ear infection/problem (%) Children playing sports one or more times a week (%)

68.2

62.8

70.2

65.3

6.6

6.2

7.9

14.5

10.9

11.4

13.8

15.8

11.4

15.3

10.0

15.3

72

71

64

61

Source: Inuit Tapirit Kanatmi (2008). Note: Life expectancy is for Inuit and non-Inuit residents of communities. Other results are for Inuit residents only.

High school completion rates in Nunavut are well below the Canadian average and are also low relative to those of the Northwest Territories and Yukon. However, these completion rates tell only part of the story. A mere 37 percent of teachers in Nunavut are Inuit, and as a result Inuktitut is used as the language of instruction only until grade 3 in most schools. For the rest of primary school, Inuktitut instruction is offered for only fortyfive minutes per day  – even less time is offered in high school (grades 9 through 12). Moreover, given current high school completion rates, there may be not enough new Inuit teachers coming on stream to fill the positions of those retiring or leaving the profession (White 2009). Post-secondary education completion rates pose a puzzle, since they actually exceed, however modestly, high school graduation rates, the opposite of the situation in Yukon and the Northwest Territories and the Canadian provinces, where high school graduation rates exceed post-secondary graduation rates. Judging by the Canadian results of an international adult literacy and skills survey in 2003, close to 75 percent of Nunavut’s working-age residents do not meet the minimum level of literacy

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Figure 1.4  Nunavut’s administrative regions

and numeracy usually required to participate in a modern economy (Nunavut Economic Forum 2008). As a consequence, Nunavut residents suffer from high unemployment rates, while the public and private sectors in the territory are chronically short of

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Health in Comparative Context 15

Table 1.4 Social Determinants of Health: Behaviours and Living Conditions ( % of population, last year available)

Smoking, self-reported, 2010 Heavy drinking, selfreported, 2010 Fruit and vegetable consumption, selfreported, 2010 Physical activity during leisure time, selfreported, 2010 High school graduates, 2006 Post-secondary graduates, 2006 Long-term unemployment rate, 2006 Government transfers, 2005 Teen pregnancy, 2005 Lone-parent families, % of population, 2006

Nunavut

Northwest Territories

Yukon

Canadian Average

54.4

41.7

27.9

20.8

12.9*

35.5

26.3

20.8

22.8

26.9

52.5

43.3

46.1

50.5

61.7

52.1

42.4

69.9

78.7

86.7

43.9

58.6

63.4

62.6

10.6

 5.3

 5.2

 3.4

11.2

 6.1

 8.7

11.1

12.6 27.6

 6.0 21.4

 2.7 20.7

 2.5 15.9

Source: Statistics Canada, Census 2006, CANSIM, and Statistics Canada 2012. * Use statistics with caution.

qualified, skilled employees. Low incomes, low education levels, and crowded living conditions are associated with higher rates of teen pregnancy, mental and physical illness, injury, and suicide (see the next section). These factors constrain the development of a domestic health workforce, particularly in terms of educating and training Inuit residents to become health care providers and health system managers. the economic context

There is a tension in Nunavut between the traditional, subsistence sea-based hunting economy and an associated Inuit sense of social and cultural well-being, on the one hand, and the new

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A Health System Profile

wage-based economy that is driven largely by southern technology and imperatives, on the other. The assumption underpinning the creation of the territory was that the two economic types would find a sustainable balance or compromise over time. The focus of the traditional economy is harvesting sea mammals (mainly seals, walruses, and whales) and fish (Arctic char), as well as the herds that roam the Arctic tundra (mostly caribou and muskox). This economy is associated with a higher consumption of domestic foods. Commonly known as country foods, they are healthier than the packaged and prepared foodstuffs imported from the south. Moreover, hunting and fishing is associated with great community cohesion, cultural identity, and social equality (Nunavut Economic Forum 2008). In contrast, the focus of the new economy is on growth, primarily through mining, mineral exploration, construction, tourism, and government services. From 2001 to 2007 spending on mineral exploration, for example, rose five-fold, from $50 million to $250 million. These activities, in combination with new mine construction and exploration (for diamonds, gold, nickel, lead, zinc, iron, uranium, and copper), have led the Nunavut Economic Forum to forecast Nunavut’s real growth rate at 10 percent per year from 2011 to 2015 (2008, vi).4 Should this forecast prove correct, workers in the wage-based economy will likely enjoy even greater material prosperity in future years. In addition, public revenues should grow, allowing for higher-quality public services and infrastructure, including health care services and facilities. Wage-based economic development is associated with a “southern” way of life, one that is more sedentary, as well as dependent on the consumption of southern foods. Compared to the traditional Inuit diet, the southern-influenced diet is often high in sugars, fats, and sodium but low in vegetables and fruits, in part because of the cost of flying in perishable foodstuffs. While country foods can offset some of these nutritional deficiencies, the southern-style economy and lifestyle has led to an increased reliance on imported food (Sharma et al. 2009; Boult 2006; L ­ ambden et al. 2007). Combined with a reduction in physical activity, the southern diet leads to an increased risk of diabetes, high blood

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Health in Comparative Context 17

pressure, heart problems, and similar ­conditions. Although these conditions are less acute in Nunavut than in other jurisdictions in Canada, their incidence is increasing. t h e c u lt u r a l c o n t e x t

The government of Nunavut has committed itself to working within the ancestral knowledge of the Inuit, which is known formally as Inuit Qaujimajatuqangit (IQ), or “that which has been long known by Inuit” (White 2009, 75). The guiding principles of IQ are the following: Inuuqatigiitsiarniq: respecting others, relationships, and caring for people. • Tunnganarniq: fostering good spirit by being open, welcoming, and inclusive. • Pijitsirniq: serving and providing for family and/or community. • Pilimmaksarniq/Pijariuqsarniq: developing skills through prac­­tice, effort, and action. • Piliriqatigiinniq/Ikajuqtigiinniq: working together for a common cause. • Qanuqtuurniq: being innovative and resourceful. • Avatittinnik Kamatsiarniq: respecting and caring for the land, animals, and environment. •

For Nunavut’s Department of Health and Social Services, IQ requires the use of traditional knowledge to ensure healthy communities and families (Pauktuutit Inuit Women of Canada 2007). For example, IQ encourages the recognition of traditional midwifery practices and knowledge, and there is now a movement to incorporate midwifery into the continuum of health services offered in the communities. Applying IQ means that elders and other residents are included with government officials in planning health services in individual communities. Moreover, as part of the government of Nunavut’s legal commitment under the Nunavut Land Claims Agreement and the territorial government’s desire to ensure that residents receive services by individuals who understand Inuit culture and language, the

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A Health System Profile

Department of Health and Social Services (DHSS) is committed to ­increasing the proportion of Inuit within the health workforce (see chapter 5). h e a lt h s tat u s

The incidence rates of a number of diseases and conditions reveal that residents of Nunavut are at no higher risk than residents of the other territories. In some cases, such as arthritis, asthma and high blood pressure, residents are actually at or below the Canadian average for such conditions. The rate for colon cancer is well below the rate in the two other territories, while Nunavut’s rate of lung cancer lies somewhere between the rates in Yukon and the NWT (table 1.5). However, a higher percentage of babies born in Nunavut have a low birth weight – which is often associated with complications of other illnesses – compared to babies born in Yukon and the NWT. While the incidence rate for diabetes in Nunavut is well below the Canadian average, the figures must be used with great caution due to the small size of the sample. In general, Inuit throughout Canada have had a lower agestandardized prevalence of diabetes than Canadians overall and considerably lower rates of diabetes than residents in southern Canada. This difference can be explained in part by the fact that being overweight or obese is a relatively new development in Nunavut. Interestingly, trends among Inuit males mirror patterns in developing countries, where obesity is more prevalent among males of higher socio-economic status. In contrast, obesity among Inuit women (who have higher rates of obesity than Inuit men) is associated with lower socio-economic status, a trend associated with developed countries, including Canada. Judging by the self-reported results in the Canadian Community Health Survey administered by Health Canada, Nunavut residents do not feel that their physical and mental health is as good as other Canadians or other northern residents. In fact, Nunavut’s mortality rate is over double the Canadian average and considerably higher than mortality rates in the Northwest Territories and Yukon. As for mental health, the self-reported view of Nunavut residents is not captured in data on repeat

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Health in Comparative Context 19

Table 1.5 Health Conditions Based on Latest Available Data (% of population, except cancer rates) Nunavut Overweight or obese, adults self-reported, 2010 Diabetes, age 12+ selfreported, 2009 Arthritis, age 15+ selfreported, 2010 Asthma, age 12+ selfreported, 2009 High blood pressure, age 12+ self-reported, 2010 Limiting injuries, selfreported, 2010 Low birth weight, 2005-7 Colon (excluding rectum) cancer, per 100,000, 2009 Bronchus and lung cancer rate, per 100,000, 2009

60.1 4.3* 12.0* 3.5*

Northwest Territories 54.2 5.2* 13.4 6.4*

Yukon

Canadian Average

51.8

52.3

4.2*

6.0

15.0

16.1

10.4

8.1

9.0*

11.9

11.3

17.1

16.3*

13.7

18.3

15.1

7.7 18.6

4.4 29.8

5.2 23.8

6.0 –

49.7

32.1

71.3

–

Source: Statistics Canada (2012), online Health Indicators (Statistics Canada and CIHI) * Use statistic with caution. Canadian averages not available in some cases because of the lack of data from some jurisdictions. This is a very partial list of health conditions because of the lack of data availability when results for Nunavut were deemed to be too unreliable to be published as a consequence of sample size.

­ ospitalizations for mental illness, perhaps owing to the lack of h hospitals in Nunavut, but it is borne out in the extremely high suicide rates, some of which are captured in the higher self-injury hospitalization rate in table 1.6. In addition, the territory’s infant mortality rate is three times the Canadian average. Judging by the avoidable-mortality data – that is data concerning the number of deaths that could be prevented if only the appropriate intervention (either medical treatment or incidence reduction) were available – it does appear there is much room for improving overall health system outcomes in Nunavut. Because of data limitations, table 1.6 does not capture the high incidence of respiratory-tract infections. However, health service utilization data collected by all community health

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A Health System Profile

Table 1.6 Morbidity, Mortality, and Avoidable Mortality Indicators (most recent years) Nunavut Self-injury hospitals, agestandardized rate per 100,000, 2010–11 Patients with repeat hospitalizations for mental illness, risk adjusted rate (%), 2009–10 Infant* mortality rate per 1,000 live births, 2008 Perinatal** mortality rate per 1,000 births, 2008 Mortality rate, agestandardized, per 100,000, 2006–8 Persons years of life lost per 100,000, agestandardized, 2006–8 Avoidable mortality from preventable causes, age-standardized per 100,000, 2006–8 Avoidable mortality from treatable causes, age-standardized per 100,000, 2006–8

296

Northwest Territories 260

Yukon 178

Canadian Average 66

7.4

13.3

4.7

10.8

16.1

9.7

5.4

5.1

8.7

13.8

8.0

6.2

603

403

367

259

12,371

7,523

6,745

4,533

344

190

184

120

130

100

86

66

Source: Statistics Canada and CIHI (2012). * Infant mortality is defined as death of a child less than one year of age. ** Perinatal mortality is defined as death under 7 days or a stillbirth of 28 or more weeks of gestation.

c­entres ­indicate that at least 15 percent of all clinic visits are for respiratory ailments (Marchildon and Torgerson 2010). Inuit children, in particular, suffer the highest rates of illness, hospitalization, and death in the world from lower-respiratory-tract infections. This high morbidity and mortality is associated with overcrowded and poorly ventilated housing  – caused in part by the extremely cold environment, tobacco consumption by

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Health in Comparative Context 21

­ others, and ­second-hand smoke – and the lack of breastfeeding, m ­particularly in the case of adopted infants (Orr 2007; Kovesi et al. 2007; Jenkins et al. 2004; and Owen et al. 1993). The high incidence of respiratory illness imposes large direct costs on the health system. Judging by an estimate of hospitalization costs calculated between 1999 and 2002, the average hospital admission cost for infant bronchiolitus in the Baffin region was $12,029 per infant hospitalized in Iqaluit and $45,688 per infant hospitalized at the Children’s Hospital of Eastern Ontario in Ottawa (Creery et al. 2005). These high costs, particularly the treatment costs outside the territory, are a consequence of the extremely high costs of getting patients to the hospital combined with the cost of accommodating escorts who also act as translators. How the health system is organized to respond to these illnesses and other needs is the subject of the next chapter. These health outcomes highlight the challenges that the health system in Nunavut must address. The following chapters will canvass the various aspects of the current health system, including organizational structures (chapter 2), funding, benefit entitle­ments, and expenditures (chapter 3), health infrastructure (chapter 4), workforce supply and challenges (chapter 5), as well as service and program delivery (chapter 6). Chapter 7 is devoted to mental health and addictions because of the high and growing level of suicide, drug and alcohol addictions, and mental illness in the territory. Finally, chapter 8 analyzes possible changes in terms of policy, planning, and evaluation for the future.

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2 Organizational Structures

h e a lt h c a r e s e rv i c e s i n t h e e a s t e r n a r c t i c i n t h e t w e n t i e t h c e n t u ry

The regions of the Eastern Arctic that now comprise the territory of Nunavut were the last in Canada to be affected by modern medicine. Before the Second World War, the Inuit of the Eastern Arctic largely relied on traditional methods of care. There were a few exceptions, mainly the Roman Catholic mission hospital in Chesterfield Inlet, the Anglican mission hospital in Pangnirtung, and the annual summer visits of the Eastern Arctic Patrol ship. Although the main functions of the Eastern Arctic Patrol were to assert Canadian sovereignty in the far north and provide transportation for Hudson’s Bay Company personnel and other traders, the ship also carried staff to provide physician, dental, and nursing services to community members in each port of call (Duffy 1988). During the Second World War, the United States established military bases and offered paid employment. To obtain paid employment, some Inuit moved closer to the bases, where they also received basic medical treatment from American health providers. After the war, the Department of National Health and Welfare filled the void that was left on the American bases by gradually expanding health services. Although the two new hospitals originally proposed for Cape Dorset and Kimmirut (then known as Lake Harbour) were never built, both communities

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Organizational Structures 23

received nursing stations where community health nurses provided a range of primary care services based on an expanded practice role that was necessitated by their remoteness from physician services (MacLeod et al. 1998). Patients requiring specialized hospital treatment were flown south to Quebec City. In addition, a new Eastern Arctic Patrol ship, making its maiden voyage in 1950, was outfitted with an operating room, a six-bed sick bay, a dental office, an x-ray room, and a drug dispensary (Duffy 1988). The introduction of trading posts, missions, and military bases was accompanied by a clustering of Inuit in these same sites. With the Cold War came a new influx of American – and to a lesser extent Canadian  – military and civilian personnel and infrastructure through the construction and operation of the Distant Early Warning (DEW) line of radar stations, beginning in 1957. The DEW line stations were an even greater draw for Inuit, who moved from outlying areas to seek employment, than the military bases had been during the Second World War (Damas 2004). The Canadian government was also directly involved in the establishment of two communities. In 1953, approximately eighty-seven Inuit were moved from the community of Inukjuak (then known as Port Harrison) in northern Quebec to Grise Fiord and Resolute Bay. They were joined by three families from Pond Inlet who had been recruited to teach the Inukjuak Inuit how to survive above the Arctic Circle (about two thousand kilometres north of their original homes). While there are sharply conflicting accounts of what occurred, most of the Inuit who were moved believe that the principle reason for the relocation was the government of Canada’s desire to exercise sovereignty in the High Arctic (Tester and Kulchyski 2004).1 In the communities established around existing bases, the US and the Canadian military provided some health services to Inuit employees and their dependents. However, as the number of Inuit increased, pressure was exerted on the Department of National Health and Welfare to provide additional services. In response, Canadian nurses employed by the department travelled to DEW line stations to provide services to Inuit who were coming there for treatment.

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Partly as a consequence of substandard housing and crowded living conditions, tuberculosis spread rapidly, reaching epidemic levels in a number of Arctic communities. By 1956, nearly 10 percent of all Inuit in Canada were receiving long-term institutional treatment in southern Canada.2 Although a similar outbreak prompted the Danish government to construct a frame house for every family in Greenland, in Canada the response was slower, and despite a major immunization program provided by the Eastern Arctic Patrol, the rates fell only gradually. The practice of sending tubercular Inuit to sanatoria or hospitals in the south was criticized by both Inuit and northern administrators, including the Anglican bishop of the Arctic at the time, who wrote to the prime minister about the “inhumanity of this policy” (quoted in Duffy 1988, 71). In less than a generation, enough Inuit had congregated near military bases, including DEW line locations, to form settlements. In response, the government of Canada established nursing stations in all settlements with more than two hundred people during the 1960s. These stations would not only become the backbone of the health system in the Eastern Arctic, they would also form the template for what would subsequently become known as community health centres. In 1964, the Department of National Health and Welfare established the Frobisher Bay General Hospital to serve the Baffin Island region. Through an agreement with McGill University and the Montreal Children’s Hospital, specialist, diagnostic, x-ray, and laboratory services were provided at the hospital. In 1982, the federal government transferred the responsibility for the administration of the hospital to the government of the Northwest Territories as part of devolving policy and program responsibility to the territorial governments. Beneath the veneer of territorial devolution, however, was a desire for greater community control. In one settlement, local residents pushed for control over their nursing station. Known as the Gjoa Haven gambit, the effort ultimately led to the government of the Northwest Territories to devolve the responsibility for health care delivery to regional boards (O’Neill 1990; ­Quiñonez 2006). In 1987, the same year that the boards were

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Organizational Structures 25

created, the Baffin Regional Health and Social Services Board terminated the McGill-Baffin program (Baxter 2006; Duffy 1988). n u n av u t ’ s h e a lt h s y s t e m s i n c e 1999

In 1999, based on Inuit traditional occupancy and land use, the Eastern Arctic was carved out of the Northwest Territories (Légare 2008), and a new territory – Nunavut – was established. Regional boards of health under the old territorial government were disbanded, and in their place, Nunavut’s Department of Health and Social Services (DHSS) became responsible for the organization of the health system throughout the Eastern Arctic. Adopting the recommendation of the Nunavut Implementation Commission, the DHSS took over direct responsibility for the community health centres, and all community health nurses and support staff became employees of the government of Nunavut (GN). However, this did not mean that the health system would be centrally administered by the DHSS in Iqaluit. Because of the vast distances within the territory, the DHSS has three regions responsible for administering health services: the Qikiqtaaluk Region (Baffin Island and the far north); the Kivalliq region (the communities of northern Hudson Bay as well as Sanikiluaq3 in eastern Hudson Bay); and the Kitikmeot Region (the westernmost part of the territory). It was intended that each region would have a hospital or a regional health facility capable of being extended into a small hospital in the designated regional centres. In the first phase, this meant a hospital in Iqaluit and regional health centres with extended primary care services in Cambridge Bay (the Kitikmeot) and Rankin Inlet (the Kivalliq), but with both regional health centres eventually providing basic in-patient services for residents of these regions. As a consequence of its size and importance as the capital of the territory, Iqaluit is often treated as its own “region” from an administrative perspective. Like all other GN departments, the DHSS was required to disperse civil service jobs by housing sections of departments in the ten largest communities. This policy was an integral part of the original blueprint for the territory and was intended to distribute

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A Health System Profile

the economic benefits of employment and ensure a workforce more representative of Inuit culture in all its regional diversity. In the case of the DHSS, the policy has meant dispersing administrative responsibilities for key areas, such as medical travel and social services (Nunavut 2002). Many DHSS positions require specific credentials and highly specialized knowledge and skills, so it was not surprising that the DHSS had the highest vacancy rate in its decentralized positions relative to other GN departments. For example, in the first stage of decentralization, the DHSS filled only three of the fourteen positions earmarked for Kugluktuk (Nunavut 2002). Not only have the logistics of establishing and staffing regional offices resulted in an enormous drain of time and resources, but the expected benefits from the employment of resident Inuit in the communities have not materialized in cases where employees were simply moved from Iqaluit or southern Canada. The policy of bureaucratic decentralization has always been subject to intense criticism. Many observers have questioned whether the policy has actually achieved its goal or whether it has simply resulted in relocating Iqaluit-based employees to other communities (Henderson 2009). As well, there are serious concerns about the policy’s impact on efficiency and effectiveness, particularly given the acute shortages of knowledgeable and skilled human resources and the intense competition between federal, territorial, and local governments  – as well as the NTI and the private sector – for Inuit employees. Nunavut is unique among provinces and territories because it has such a direct employee-employer relationship with the health workforce, a relationship that “makes for distinctive problems and opportunities” (White 2009, 67). While managing relations with its employees absorbs considerable time and energy, the DHSS also has the control necessary to make major changes in how work is organized in the territory, as well as to experiment with new health delivery models. Skilled labour force recruitment and retention is perhaps the greatest challenge faced by the DHSS. From the time the territory was established, the DHSS has had the highest vacancy rates of all GN departments and agencies. As of October 2009, for example,

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Organizational Structures 27

the DHSS had 97 of its 238 nursing positions unfilled, and a large part of its senior executive positions were vacant (Nunavut 2009d). In fact, high vacancy rates combined with rapid turnover rates contributed to the decision by the Canadian Council on Health Services Accreditation (now Accreditation Canada) to withhold accreditation for the Qikiqtani Hospital in Iqaluit (White 2009). Unlike provincial ministries of health in Canada and owing to the lack of self-regulation within the territory, the DHSS is directly responsible for the accreditation of a number of health professions. d e pa rt m e n t o f h e a lt h a n d s o c i a l s e rv i c e s , g o v e r n m e n t o f n u n av u t

Under the administrative structure of the GN, the DHSS is responsible for virtually all administration and service delivery throughout the territory. The GN is unique among provincial and territorial governments in Canada because of its direct service delivery and responsibility. In addition to directly administering the community health centres, the GN also directly manages the territory’s main hospital and two regional health centres. However, long-term care facilities for elders and the disabled are managed by community or land claims organizations. In 2011, the Department of Health and Social Services was divided into five lines of business: 1 the Directorate, which includes the deputy minister’s office, corporate services, central management and leadership for the DHSS’s regional operations, and programs and standards, as well as overall policy, planning, and evaluation; 2 social services, which includes child protection, adoption, guardianship, support for vulnerable adults, and family violence services; 3 treatment services, which includes hospital services, community health centre services, physician services, mental health, dental hygiene and preventative dental health ­services, ­medical transportation, home care and continuing care, and the credentialing, registration, and licensing of health care providers;

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Figure 2.1  Organization of Health Services in Nunavut

4 health insurance services, which includes payment of outof-territory hospital and physician services, extended health benefits, and vital statistics; and 5 public health, which includes a chief medical officer of health, communicable disease control, environmental health, tuberculosis prevention, and a suite of other health protection and promotion services (Nunavut 2010). At the heart of the territory’s health care system is the community health centre (CHC). The CHCs are descendents of the ­outpost nursing stations first established by the federal ­government in

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Organizational Structures 29

the decades following the Second World War, particularly in the 1960s and early 1970s (Tester 2002; O’Neil 1979). In the majority of Nunavut’s twenty-five communities these clinics provide almost all the available health services. CHCs are supported by environmental health officers, communicable disease nurses, nutritionists, and other public health staff (Moloughney 2007). Relying on the skills of community health nurses (CHNs) – previously known as outpost nurses  – and their auxiliaries, community residents receive a range of basic health and wellness services provided in the clinics Monday through Friday, from 9 a.m. until 5 p.m. However, through the on-call services provided by the CHNs for urgent matters, the clinics provide services around the clock, including weekends. The vast majority of CHNs are originally from the south, with limited or no ability to speak Inuktitut or Inuinnaqtun, so they rely on Inuit clerk-interpreters and community health representatives to communicate with their patients. In addition to the CHCs, regional health centres offer a broader array of acute health services in Cambridge Bay and Rankin Inlet and serve the Kitikmeot and Kivalliq regions. These regional health centres are, in effect, small hospitals, although the range of services they provide is considerably less than those provided by the larger Qikiqtani General Hospital in Iqaluit (see chapter 6). Unlike hospitals in other provinces or territories, the thiryfive-bed Qikiqtani General Hospital is administered directly by the DHSS. Patients requiring more specialized services than those offered in CHCs, regional centres, and Iqaluit are flown to hospitals outof-territory with physician referrals. Most patients living in the Kitikmeot region are flown to Yellowknife or Edmonton, patients from the Kivalliq region are flown to Churchill or Winnipeg, and patients from the Qikiqtaaluk region are flown to Ottawa. the government of canada

The originators of the Nunavut project sought to create a self-governing territory to replace federal administration and

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s­tewardship. Tagak Curley, a founding member and the first president of the Inuit Tapirisat of Canada (eventually minister of health and social services in the government of Nunavut) stated in 1982: “Gradually we see the federal government’s influence over the north decreasing, until we manage our own house, and run our own affairs” (Curley quoted in Légare 2008, 336). The single largest obstacle to the GN assuming greater responsibility is that it relies on federal transfers for more than 90 percent of its annual budget, making it the most fiscally dependent jurisdiction in Canada (see chapter 3). Moreover, as is the case for all territories, because the GN does not own public lands within the territory, it cannot obtain royalties from the exploitation of mineral and other land-based resources. These are divided between the government of Canada, which owns the majority (82 percent) of public lands, and Nunavut Tunngavik Inc., which holds 18 percent of public lands on behalf of all Inuit in the territory through the land claims settlement. Despite this fiscal dependency, the critical decision through the land claims process to create one public government representing a majority Inuit population has created a less fragmented health policy and planning environment than the one that exists in those provinces and territories where there are a number of federally administered services for First Nations or federal transfers to Aboriginal organizations for the delivery of health services. In these latter cases, responsibility and accountability is divided between the provincial or territorial government and Aboriginal governments. This also means that the federal government has much less of a role proportionately in the administration and delivery of health services in Nunavut than in any other province or territory, although it still has an role in funding Non-Insured Health Benefits (NIHB) for Inuit as well as community-based population health programs. At the same time, the DHSS administers First Nations and Inuit health programs on behalf of Health Canada. In return, Health Canada allocates some funding to the DHSS in order to accommodate this additional administrative burden. The Public Health Agency of Canada also funds a modest suite of children’s health

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Organizational Structures 31

programs. In most cases, this program funding is discretionary in the sense that communities – principally the hamlet governments – must apply for funding and provide adequate resources to administer the programs.

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3 Health Benefits, Funding, and Expenditures

coverage and benefits

As is the case for all Canadians, residents of Nunavut have access to all “medically necessary” or “medically required” health services free of financial barriers, as required under the Canada Health Act. The Government of Nunavut (GN) provides insured hospital services pursuant to the Hospital Insurance and Health and Social Services Administration Act, and insured medical and related health care services as stipulated in the Medical Care Act (this volume, appendix A; Health Canada 2009a). This basket of fully covered services includes all the primary health care services delivered in community health centres and includes physician and hospital services, whether provided in the territory or, with a referral, outside the territory. Providing publicly funded hospital and physician services constitutes the single largest expense for the government of Nunavut, an actual expenditure of $93 million in 2008–09 (see below). Roughly 40 percent of this amount was spent on hospital and physician services outside the territory. In contrast, community and regional health centres, including nurses, community health representatives, and all other support staff and equipment, cost $43.6 million in 2008–09 (see table 3.4). This operating expense was spread over the territory’s twenty-two community health centres and two regional health centres in Rankin Inlet and Cambridge Bay.

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Benefits, Funding, and Expenditures 33

In addition to these insured services, all Inuit residents of Nunavut  – 84 percent of the territory’s population  – receive Non-Insured Health Benefits (NIHB) for prescription drugs, dental care, vision care, and medical travel. Although funded by the First Nations and the Inuit Health Branch (FNIHB) of Health Canada, the government of Nunavut is responsible for managing medical travel, dental provider travel, and vision care, for which it receives some funding ($700,000 in 2008–09) for program management from Health Canada (GN Memorandum, April 25, 2008). At the same time, FNIHB administers all dental and drug reimbursements to service providers. Table 3.1 compares NIHB expenditures in Nunavut, with its 29,668 NIHB beneficiaries in 2010, to the Northwest Territories (24,991 NIHB clients) and Yukon (8,087 NIHB clients). While Nunavut is the single largest recipient of NIHB funds among the territories, individual (per capita) payments are only slightly above those flowing to residents in Yukon, though well above the average payment to eligible residents in the Northwest Territories. In absolute terms, total NIHB payments flowing to Nunavut ($42.5 million) in 2010 were dwarfed by the total NIHB payments flowing to other provinces with sizeable First Nations populations, such as Manitoba ($195 million), Ontario ($175 million), Alberta ($131 million), and Saskatchewan ($141 million) (FNIHB 2010). Since the vast majority of residents in Nunavut are NIHB beneficiaries, thus highlighting the non-eligible status of a minority of residents, the GN provides extended health benefits to nonAboriginal residents of Nunavut that are similar to the benefits received by NIHB-qualified residents in the territory. Non-Inuit residents who have a debilitating long-term disease or condition, are over the age of sixty-five, or have exhausted their third-party health care benefits are eligible for coverage for some ­dental services, eye care, and pharmaceutical services through the Extended Health Benefits Program. Residents who are receiving income support may also be eligible for Indigent Health Benefits. The GN budgeted $360,000 for these non-NIHB beneficiaries in 2008–09 (Nunavut 2009a).

42.3

Total

1,426

752 344 276 54

$ Per nihb Beneficiary

25.5

  8.5   7.1   8.6   1.3

Total $Millions

1,020

340 284 344 52

$ Per nihb Beneficiary

Northwest Territories

10.1

  3.8   2.3   3.7   0.3

Total $Millions

Yukon

Source: FNIHB (2011). Results for per capita expenditures calculated by dividing expenditures in 2009–10 by number of NIHB clients in March 2010.

22.3 10.2   8.2   1.6

Total $Millions

Medical Tranportation Dental Pharmacy Vision Care

Category

Nunavut

Table 3.1 Comparison of Non-Insured Health Benefit (NIHB) Expenditures by Category, 2009–10

1,249

470 284 458 37

$ Per nihb Beneficiary

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Benefits, Funding, and Expenditures 35

Table 3.2 Federally Funded Population Health Programs and Initiatives in Nunavut

Program First Nations and Inuit Health and Community Care Program Mental health and addictions programs (Brighter Futures Program, Building Healthy Communities/Solvent Abuse Program, National Native Alcohol and Drug Abuse Program, and National Aboriginal Youth Suicide Prevention Strategy) Children and youth programs (Canadian Prenatal Nutrition Program and Fetal Alcohol Spectrum Disorder Program) Chronic disease and injury prevention (Aboriginal Diabetes Initiative and Injury Prevention Program) Total federal funding

Budgeted Amount, 2009–10, in $   5,278,140   4,343,711

  1,721,689

  1,453,880

12,797,420

Source: Government of Nunavut, confidential DHSS Briefing Note on Federally Funded Health Programs in Nunavut, 19 May 2009. Note: The total does not include carry-over of funds ($628,841) from the previous fiscal year; nor does it include Health Canada’s payment to the DHSS for program management and support ($988,883).

In addition to individual entitlements, residents of Nunavut also benefit from a series of extended-care and population-level health programs aimed at promoting health and preventing illness and injury. Many of these programs and population-based initiatives are funded by the federal government through Health Canada and the Public Health Agency of Canada. The single largest expenditure by the federal government is on long-term and home care in Inuit communities through the First Nations and Inuit Home and Community Care Program­ (FNIHCC) (see table 3.2). The purpose of this program is to ensure that Inuit receive home and community care services that are comparable in quality to those received by the majority of Canadian residents and to enable disabled, chronically ill, or elderly Inuit to receive the care they need in their home communities without relocating south.

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Nunavut residents consider medical travel to be an integral part of insured services in the territory. While the GN must ensure that residents have access to “medically required” or “medically necessary” hospital and physician services under the terms of the Canada Health Act and territorial legislation, public coverage for expenses that go beyond what is required to transport a patient for such services are within the discretion of the GN. These extra expenses include lodging while receiving more specialized medical treatment in the south or in larger northern centres such as Iqaluit or Yellowknife (Northwest Territories) and Churchill (northern Manitoba), as well as an accompanying client escort who is generally a family member to assist the patient. Some of these costs may also be reimbursed to eligible individuals through the NIHB program.1 Client escorts are individuals who are authorized by the GN to accompany a resident who is unable to travel without assistance or who provides some other service while the resident receives a required treatment.2 Client escorts are authorized according to six distinct criteria: when, in the case of minors, legal consent by a parent or guardian is necesary; when a mental or physical condition prevents the resident from travelling unassisted; when language assistance is required but interpreter services are not available; when the resident is a unilingual Inuit-language-­ speaking elder over the age of sixty (unless the elder states that he or she does not require an escort); when the escort will participate in the resident’s treatment program and will receive instructions on specific and essential home medical or nursing procedures that cannot be given to the resident alone; and when the resident is medically incapacitated. Owing to the absence of roads and the distance between communities, no jurisdiction in Canada has higher per capita costs for transporting residents to receive medical services not available within their communities. These costs, divided between scheduled medical travel and emergency medical evacuations (medevacs), amounted to roughly $50 million in 2008–09 (table 3.3), almost $1,400 per resident in the territory.

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Benefits, Funding, and Expenditures 37

Table 3.3 Number and Cost ($ million) of Medical Travel by Region in Nunavut, 2008–09 Scheduled Flights Region Qikiqtaaluk Kivalliq Kitikmeot Total Nunavut

Number

Cost ($millions)

20,206 17,906   8,138 46,250

10.5   8.9   5.8 25.2

Medevacs

Total Cost

Number

Cost ($millions)

($millions)

824 584 325 1,733

  8.3 10.1   5.6 24.0

18.8 19.1 11.4 49.3

Source: Government of Nunavut, non-audited estimates of actual expenditures on medical travel by Department of Health and Social Services. Note: Scheduled trips are defined as a leg of a journey (e.g., a round trip from Iqaluit to Ottawa would count as two trips.

There are two main ways to reduce the volume and cost of medical travel. The first is to provide more specialized primary care services in individual communities and to increase the range of acute care services in Iqaluit and the two new regional facilities in Rankin Inlet and Cambridge Bay. The major constraints on substituting out-of-territory services for in-territory services are the high vacancy and turnover rates among the existing health workforce in Nunavut and challenges in educating, training, or importing workers with the expertise required to provide a broader range of health care services (see chapter 5 for a fuller discussion). The second way is to increase and improve the use of telehealth diagnosis and consultation. Launched in 1999, the Ikajuruti Inungnik Ungasiktumi (IIU) Telehealth Network was developed in order to facilitate access to health services within individual communities (see chapter 4). In 2008, Canadian Health Infoway made a $2 million investment to expand access to telehealth in Nunavut (NunaWorks 2009).3 This telehealth network was designed to reduce the need to transport residents in order to see a physician or specialist – through increasing communication between patients and health providers in the north and specialists in the south and improving diagnosis and supervision to allow more to be done on site in the community health centres.

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Although responsible for providing most health services, including medically necessary services as defined under the Canada Health Act, the government of Nunavut depends on the government of Canada for most of its revenues. To some extent, this fiscal dependence is a structural feature of the political economy of Nunavut, in that the GN does not have any ownership claim on the mineral wealth of the territory. As a consequence, the GN does not gain any direct taxation benefit from public lands and resources in the territory. At the same time, the GN’s base of income and consumption taxation is shallow, since it is limited to a small percentage of the population. For 2009–10, the GN’s own-source revenues amounted to only 7.2 percent of total revenues. The enormous gap was filled through transfers from the government of Canada. Most federal transfers to Nunavut are through an unconditional block grant known as Territorial Formula Financing (TTF). In 2009–10, slightly more than $1 billion was budgeted for TTF, while a further $109 million was budgeted for other federal grants. Relative to these revenue sources, the Department of Health and Social Services (DHSS) had a budget of $263 million in 2009–10, which amounted to almost 23 percent of total expenditures by the GN (Nunavut 2009a). Table 3.4 tabulates actual health expenditures in Nunavut by the territorial and federal governments. It shows that the GN’s expenditures on health services alone are more than double the territory’s own-source revenues. It is also interesting to note that although the community health centres and their staff are the heart of the health delivery system in Nunavut, spending on the CHCs and staff constitute slightly less than one-fifth of total expenditures by the DHSS on health services. expenditure trends

Both total and public health expenditures have more than doubled in Nunavut since 2000 (see table 3.5). Moreover, ­Nunavut’s health spending has grown more rapidly than that

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Benefits, Funding, and Expenditures 39

Table 3.4 Estimated Health Expenditures in Nunavut, by Category, 2008–9 Category Medical travel: medical evacuation (medevac) and scheduled Community health centres Hospital services, including regional facilities (Iqaluit, Rankin Inlet, and Cambridge Bay) Out-of-territory hospital services Non-Insured Health Benefits (nihb) funded by Health Canada DHSS senior administration, policy, and planning (directorate) Physician services in Nunavut Health Canada fnihb public/population health programs Mental health programs as well as counselling, treatment, and referral Public health programs, including health protection, promotion, and disease control Physician services outside Nunavut as well as private feefor-service within Nunavut Public Health Agency of Canada (phac) children’s health programs Home care and continuing care: chronic care and disability care Dental services Vital statistics Extended benefits: supplement to Nunavut Health Care Plan (and NIHB) Profession practice: managing the credentialing, registration, and licensing of providers Total: government of Nunavut Total: government of Canada* Estimated health expenditures in Nunavut by the governments of Nunavut and Canada

Expenditures ($000) 49,215 43,576 36,888 34,761 34,090 18,106 16,248 14,415 8,814 6,307 5,124 2,596 1,380 1,246 1,219 777 501 224,162 51,101 275,263

Source: Estimates of actual DHSS expenditures from department. Estimates of federal expenditures based on confidential memorandum from government of Canada. Note: Programs funded by the government of Canada are highlighted in italics. In the case of NIHB, the figure of nearly $34 million is based on data provided to the GN by the government of Canada on 25 April 2008. NIHB includes the government of Canada’s expenditure on medical travel of $15.75 million (not to be confused with the GN’s medical transportation expenditures), drugs, and dental reimbursements ($14.3 million), dentalprovider travel ($2.3 million), and vision care ($1 million).

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Table 3.5 Health Expenditures in Nunavut, 2000–10 ($ millions, current dollars)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Total Spending

Public Spending

168.5 184.3 214.9 292.5 307.9 304.3 335.0 353.7 367.2 383.5 402.8

159.2 173.7 203.7 279.2 294.0 287.6 317.3 332.8 346.1 359.2 377.9

Source: CIHI (2010). Note: The CIHI estimates of public spending are considerably higher than the actual estimates, as shown in table 3.4.

of the other territories. Over the last decade, Nunavut’s nominal growth rate of public health expenditures was 10.5 percent, compared to 8.7 percent in Yukon, 5.6 percent in the Northwest Territories, and 7.4 percent in Canada as a whole (CIHI 2009). Because of the paucity of private health care services and the access to and availability of public health care services, Nunavut has the most public-sector-oriented health system of any jurisdiction in Canada. Moreover, as discussed in chapter 2, most of the health system is under the direct ownership and control of the GN. Table 3.6 and figure 3.1 demonstrate the extent to which Nunavut has the lowest level of per capita private health expenditures among the territories, less than one-half of what is spent per capita in the Northwest Territories and the Yukon – a consequence of the limited supply of private health care services in isolated locales more generally and the lack of past exposure to such services and therefore an absence of demand. In contrast, public-sector per capita public health care spending (table 3.7 and figure 3.2) is not only much higher than the spending of the Northwest Territories and the Yukon, but it has been growing much more rapidly than spending in the rest of Canada. In fact, public sector per capita spending on public

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Benefits, Funding, and Expenditures 41

Table 3.6 Private Sector per Capita Health Expenditure by Territory and for Canada, 1999–2010 (current dollars) Year

nu

nt

yt

Can Average

1999 2000

338.43 338.32

519.57 484.88

548.37 813.89

888.01 950.2

2001

378.42

645.24

911.33

1,033.52

2002

388.55

692.07

1,100.78

1,115.53

2003

456.07

708.13

1,056.96

1,163.95

2004

469.23

708.29

1,151.06

1,230.10

2005

556.13

1,179.97

1,177.12

1,296.50

2006

572.83

1,346.79

1,220.89

1,401.20

2007

670.48

1,582.85

1,592.96

1,450.27

2008

665.23

1,419.50

1,516.39

1,522.01

2009

756.35

1,501.64

1,597.63

1,586.37

2010

762.16

1,565.51

1,673.45

1,657.08

Source: CIHI (2010).

Figure 3.1  Private sector per capita health expenditure by territory and for Canada, 1999 to 2010, current dollars

health care is more than three times higher than the Canadian average, although the growth trend line of the last four years is very similar to trends in the Northwest Territories and the Yukon (CIHI 2009). This too is a consequence of a number of factors.

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Table 3.7 Public Sector Per Capita Health Expenditure by Territory and Canada ­1999– 2010 (current dollars) Year

nu

nt

yt

Can Average

1999 2000

  4,979.28   5,787.57

4,967.45 4,664.19

2,981.92 3,250.61

2,078.29 2,256.84

2001

  6,175.93

5,232.80

3,848.40

2,417.69

2002

  7,088.56

5,708.20

4,090.57

2,548.43

2003

  9,572.26

5,522.20

4,069.99

2,735.84

2004

  9,921.71

5,924.66

4,274.69

2,884.34

2005

  9,583.75

6,273.08

4,867.57

3,053.02

2006

10,303.08

6,611.61

5,498.87

3,228.01

2007

10,640.62

7,252.92

5,495.75

3,418.04

2008

10,946.08

7,875.18

5,757.51

3,632.22

2009

11,161.09

8,242.56

6,456.47

3,810.81

2010

11,593.33

7,699.54

6,303.87

3,956.55

Source: CIHI (2010).

Figure 3.2  Public sector per capita health expenditure by territory and for Canada, 1999–2010, current dollars

One obvious cost driver is the fact that the territory’s small population of thirty thousand residents is distributed among twenty-five communities over a vast land area. As in other circumpolar populations in Alaska, Greenland, the Faroe Islands, northern Norway, northern Sweden, northern Finland, and northern

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Benefits, Funding, and Expenditures 43

­ ussia, health expenditures tend to be higher – sometimes conR siderably so – than the national average, and the smaller and more isolated the communities and the more extreme the climatic conditions, the higher the cost. For example, Nunavut’s per capita health expenditures were 2.3 times the national average between 2005 and 2009. Among the circumpolar jurisdictions, Greenland and the Faroe Islands are the only exceptions to this rule (Young 2012). Though the reasons for this exceptional status have not yet been identified, medical travel expenditures in Greenland are a fraction of similar expenditures in Nunavut, whether measured on a per capita basis or as a share of the government’s budgetary outlays for health (Niclasen and Mulvad 2010). This is a result of Nunavut’s extremely low population density, the lowest of any circumpolar region in the world (Young 2012). Moreover, unlike the majority of communities in the NWT and the Yukon, Nunavut’s twenty-five communities can be accessed only by air, thereby substantially adding to the cost of travel. With the exception of residents of Iqaluit, community residents rely on accessing hospital and specialized medical services in larger urban centres thousands of kilometres from home. Inhabitants of the far western (Kitikmeot) region of Nunavut must fly to Yellowknife or Edmonton, while residents living on the western edge of Hudson Bay (the Kivalliq region) are required to travel to Winnipeg or Churchill, Manitoba. For those who live on Baffin Island or above the Arctic Circle, this situation once meant travelling to Montreal, but it now means flying to Iqaluit or Ottawa (see figure 3.3). These distances go far to explain why medical travel is the government of Nunavut’s single largest health expenditure (see table 3.4) and why it constitutes the single largest health expenditure by the federal government in Nunavut. For the 2008–09 fiscal year, these two outlays amounted to almost $65.5 million, an expenditure of almost $2,200 per resident. The expenditure on travel amounts to almost 24 percent of all public – government of Nunavut and government of Canada – outlays on health in Nunavut. As has been the case throughout Canada, there is a lively debate concerning the fiscal sustainability of government health

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Figure 3.3  Medical air links

care expenditures in Nunavut. As a consequence of expenditure trends in the last decade, budgetary allocations to health continue to outstrip other categories of public spending. At the same time, based on recent practice, residents have clear expectations concerning service delivery within communities and the government’s responsibility for medical travel outside the communities.

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4 Nunavut’s Health Infrastructure

Nunavut’s health infrastructure is largely shaped by the challenge of providing a wide range of health care services to a small population dispersed across a vast geography. It is not feasible to make available in each of Nunavut’s twenty-five communities the wide range of services, especially specialized medical care, that are available in more urban southern locations. At the same time, as the chief funder of health care in the territory, the government of Nunavut has every incentive to reduce its substantial expenditure on medical travel by providing more health services closer to home. In fact, each community is provided with a basic primary care infrastructure, including a community health centre and accompanying providers and services. This chapter describes the physical and informational infrastructure in Nunavut that allows for the delivery of most essential health services. We begin with the community health centres (CHCs), the locus of acute care, primary care, public health, pharmaceutical services, and basic diagnostics in the territory’s communities.1 Each of the CHCs is configured to meet the needs and capacity of the local population. At the same time, many of the communities in Nunavut are growing rapidly, placing an additional burden on the existing facilities. For example, in some CHCs, rooms originally designated for one purpose (e.g., an examining room) actually serve two or three other functions. Decisions about capital expenditures and equipment purchases reflect local needs and the capacity of the equipment. To

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i­llustrate, because only the larger settlements of Rankin Inlet, Cambridge Bay, and Iqaluit have ultrasounds, residents from other communities have to fly to these or southern cities for this ­service. However, it should be noted that the constraining factor is more likely to be the availability of skilled human resources than physical infrastructure, and in this case, the inability to hire additional sonographers prevents the provision of more ultrasound devices. Information and communication technology are vital aspects of health infrastructure. In Nunavut, the potential for telehealth is particularly striking, given the distances separating communities from more specialized services and health professionals. Since making decisions about resource allocation, programming, and policy requires good evidence and information, the final section outlines the state of performance monitoring and research within Nunavut. physical infrastructure

Community Health Centres Every one of Nunavut’s communities outside the larger regional centres of Cambridge Bay and Rankin Inlet and the capital city of Iqaluit has a community health centre. Each CHC is equipped with basic medical devices and equipment for diagnosis and patient care, including defibrillators, aspirators, electrocardiographs, nebulizers, basic laboratory equipment (microscopes and centrifuges) for blood work, and x-ray machines capable of x-raying the chest and extremities. Every CHC also has an emergency room, which typically doubles as a birthing room or an in-patient room on an as-needed basis, and at least one examination room for use by the community health nurses and visiting physicians. Some larger CHCs also have clinic rooms designated for visiting specialists, as well as public health rooms with a small library and informational resources. There is always a small pharmacy room stocked with the most common medications, vaccines, and a medicinal refrigerator. Most CHCs have a telehealth room or at

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least a room that doubles as a telehealth unit. Many CHCs also have a dental room with basic dental equipment, a dental chair, and an x-ray machine. The dental room is used by visiting dental teams and in some instances by the visiting eye care teams. Regional Health Centres In addition to providing the basic suite of CHC services, the Kivalliq Regional Health Centre in Rankin Inlet and the Kitikmeot Regional Health Centre in Cambridge Bay deliver specialized health services for residents within their respective regions. Both were built in 2005, but a fire at the Kitikmeot Health Centre in 2007 made it necessary to rebuild part of it. Designed to provide in-patient services, including nursery and palliative care services, it has taken time to bring the most basic overnight hospital (inpatient) services on stream.2 At the Kivalliq Health Centre, for example, a day-hospital program providing up to twelve hours of care, five days a week, was introduced before overnight hospital stays were introduced.3 Nonetheless, the two regional centres have the equipment, human resources, and capacity to provide around-the-clock (24/7) emergency care as well as endoscopy services, birthing services, ultrasounds, specialist services, and a broader scope of laboratory services. Both health centres also have incinerators to burn biohazard waste. Qikiqtani General Hospital Opened in 2007, the Qikiqtani General Hospital (QGH) in Iqaluit replaced the older Baffin Regional Hospital. This first hospital was constructed in 1962, and the older facility continues to be attached to the QGH and is used for physician offices, specialized out-patient services, and a pharmacy. The QGH has thirty-five acute care beds, four birthing rooms, six day-surgery beds, an emergency department, two operating rooms, and four recovery beds for the operating rooms. The QGH’s imaging unit is equipped for ultrasounds, diagnostic mammographies, and more advanced imaging tests, including a CT scanner (Nunavut 2009i). The laboratory has the equipment

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to perform most advanced laboratory testing, including hematology, coagulation, chemistry, and microbiology. In addition, there is a blood bank that carries units of whole blood and platelets for surgical procedures and patient stabilization, if needed. The QGH also houses an out-patient clinic that provides a range of specialist and ambulatory care. In addition, there are three general practitioners in the hospital that provide family physician services. Family Practice Clinic The Family Practice Clinic (FPC) in Iqaluit houses five clinic rooms shared by salaried nurse practitioners and visiting physicians from the hospital. As with the CHCs, there are several examination rooms at the FPC used by both the nurses and the visiting physicians. Unlike the CHCs, however, the FPC does not have an emergency room or birthing room, since these services are provided at the QGH. Long-Term Care Facilities Long-term care facilities providing around-the-clock care for special needs adults and children are available in selected communities. The four centres for physically disabled adults are located in Igloolik, Gjoa Haven, Rankin Inlet, and Iqaluit. The Isaccie Group Home in Iqaluit provides level 2 care for up to eight physically and developmentally disabled patients aged 18 years and older from the Qikiqtaaluk region.4 Similarly, the Rankin Inlet Group Home provides level 2 care for up to eight adults. In 2004, the Interdepartmental Continuing Care Task Force, which was comprised of staff from Nunavut’s Department of Health and Social Services, the Department of Education, and the Nunavut Housing Corporation, as well as a community elder, was created to examine the need for continuing-care services in Nunavut. The recommendations included the need to create more long-term care spaces, beginning in Gjoa Haven and Igloolik. Both facilities opened in the fall of 2009 and provide constant access to nursing for up to ten elders and other adults.

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Box 4.1 The Naja Isabelle Home in Chesterfield Inlet Operated by the Pimakslirvik Corporation, the Naja Isabelle Home provides level 3 care for up to ten children with physical disabilities caused by cerebral palsy or oxygen deprivation during birth. Some of the clients have also had environmental causes during the prenatal stages, including assault on the mother during pregnancy and alcohol and drug abuse during pregnancy. Care for the mainly juvenile clients is provided by three licensed practical nurses with experience in long-term care, which is necessary for the provision of level 3 care. Some children who have grown into adults have remained in the care of the Naja Isabelle Home. All the staff in the home are employed by the Pimakslirvik Corporation, a local economic development corporation, though their positions are funded by the GN.

Long-term care facilities for children are located in Iqaluit, Rankin Inlet, Cambridge Bay, and Chesterfield Inlet. The ­Illagiittugut Group Home in Iqaluit provides level 2 care for up to eight children with special needs. There are also children’s group homes in Cambridge Bay and Rankin Inlet that provide level 2 care for up to twelve children. The Chesterfield Inlet facility provides care for more severely disabled children (see box 4.1). Elders’ Centres There are three elders’ centres in Nunavut.5 The Martha Taliruq Centre in Baker Lake is an eight-bed facility that provides hospice care to elders as well as limited respite care for caregivers. There is also an elders’ centre in Iqaluit, the Pairrijat Tigumivik Centre, and the Andy Aukatjut Elders Centre in Arviat. All the elders’ centres provide level 2 care for up to eight clients aged fifty and over.6

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Other Facilities Public health services in Rankin Inlet, including wellness clinics, immunizations, sexual health services, and communicable disease control, are provided in a separate building known as the Old Health Centre. The Old Health Centre also houses Rankin Inlet’s midwifery services. Other facilities in Iqaluit include a public health unit and a rehabilitation clinic. The Public Health Unit and the Family Practice Unit share the same building and medical records. The Public Health Unit provides space for the public health nurses to conduct TB tracing and treatment, immunizations, and wellness clinics. A number of rehabilitation services in Iqaluit, including occupational therapy, physiotherapy, and speech-language pathology are available at the Timimut Ikajuqsivik (“a place to heal your body”) Centre. i n f o r m at i o n a n d c o m m u n i c at i o n t e c h n o l o g y

(ict)

infrastructure

Nunavut faces unique challenges to service delivery. The sheer vastness of the territory, coupled with the remoteness of the communities, means that it is expensive to fly in specialized health professionals, as well as to fly out patients for specialized care. Making investments in a telecommunications infrastructure, which links each CHC with the services of an out-of-territory specialist, has created a virtual service delivery model intended to provide residents with more timely and less costly access to some forms of diagnostic testing, postoperative care, and consultations. There are two main components of Nunavut’s E-Health solution. The first is the Ikajuruti Inungnik Ungasiktumi (IIU) Telehealth Network, a “tool to help people that are far away.” Second, there has been a move towards developing an electronic health record with the capacity to link providers both in and out of the territory with up-to-date diagnostic and medical information. While this telehealth network has been in development since the late 1990s, the development of an electronic health ­record is still in its infancy.

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The Ikajuruti Inungnik Ungasiktumi (iiu) Telehealth Network Telehealth has been defined as the “use of information and communications technology (ICT) to deliver health services, expertise and information over distance, geographic, time, social and cultural barriers” (Muttitt et al. 2004, 402). Telehealth employs a range of ICT, from the telephone to the interactive videoconference, in order to link patients with health providers. Telehealth seems particularly useful in Nunavut, where both patients and health professionals are often separated by thousands of kilometres of air travel (Sevean et al. 2008). During the past decade, both federal and territorial governments have made significant investments in telehealth and broadband in Nunavut. Since 2004 all of Nunavut’s twenty-five communities have had access to telehealth services through the IIU Telehealth Network, including specialist consultation services, health education, continuing medical education, family visitation, and administrative functions.7 As part of the overall E-Health initiative, the IIU Telehealth Network provides real-time transmission of audio/ visual data via satellite from Nunavut to out-of-territory providers located in Manitoba, Ontario, Alberta, or the Northwest Territories (Ho and Jarvis-Selinger 2006).8 The network permits families in Nunavut to connect with patients in out-of-territory facilities and transmits professional development courses for providers working in Nunavut (including “lunch and learn” sessions offered through the Children’s Hospital of Eastern Ontario for community health nurses). The network is also used to facilitate medical rounds, including maternal rounds. Several clinical areas, principally rehabilitation services, have been offered in Nunavut through the IIU Telehealth Network. These services include dietetics and nutrition, telepsychiatry, geriatrics, speech-language pathology, post-operative patient followups, and occupational therapy (Hailey et al. 2005).9 In 2006–07, there were 2,984 telehealth hours recorded; 1,181 of these were used for clinical services and 1,075 for educational purposes (McKinnon 2008). By 2007–08, the use of the network increased to almost 4,000 hours, of which 1,812 hours were for clinical services (Canada 2008).

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In 2008, Canada Health Infoway made a $2 million investment in the Nunavut Telehealth Expansion and Change Management Project to upgrade telehealth sites, add supplementary sites at the Naja Isabelle Home in Chesterfield Inlet, and upgrade outof-territory boarding homes to allow patients to communicate with their families (Canada Health Infoway 2008). The project is a gn collaboration with the MBTelehealth Network in Manitoba, involving the development of a new telehealth site at the boarding home in Winnipeg. The partnership also improves discharge planning between the southern facilities and Nunavut communities, especially those in the Kivalliq and Kitikmeot regions. In addition, Nunavut’s Department of Health and Social Services (DHSS) is planning to integrate teleradiology and launch a pilot project for a tele-ultrasound initiative. The latter should allow the DHSS to assess the feasibility of transmitting ultrasound examinations via satellite to a radiologist based in a southern location (ProMed Associates 2009). Electronic Health Records Electronic health records (EHRs) provide a lifetime record of an individual’s key health history. EHRs provide point-of-care access by authorized health care professionals across sites and service areas to current and past medical test results, home care information, immunization records, birth records, chronic disease management information, and prescription drug history. The EHR strategy in Nunavut includes the development of a repository for clinical reports, individual patient information, laboratory results, diagnostic imaging orders and results, communicable disease information, and in-patient and out-patient diagnoses including digital imaging and drug profiles, and immunization. The goal was for 100 percent of Nunavut residents to have access to EHRs by 2012. In September 2008, Infoway and Health Canada’s Wait Time Fund invested over $11.6 million for a five-year initiative to implement EHRs in Nunavut. Patient registrations and the drug information system are accessible at the facilities in Rankin

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Inlet, Cambridge Bay, and Iqaluit. As well, physicians at QGH can access electronic client and laboratory information (CMA 2009). Challenges with Telehealth and Electronic Health Records The most obvious challenge faced by the DHSS in achieving its E-Health goals is the sheer cost of the broadband backbone for the IIU Telehealth Network and electronic health records. Nunavut is the only jurisdiction in Canada fully dependent on satellite networks for broadband, making it critical to improve both the affordability and availability of broadband. However, there are extremely high costs associated with satellite transmission, which are many times more expensive than fibre optic networks in the south (Nunavut Broadband Development Corporation 2008).10 To address this shortfall, Infrastructure Canada and the Nunavut Broadband Development Corporation (NBDC) signed a five-year contribution agreement to provide investments in enhanced satellite bandwidth, starting in 2008.11 That same year, Industry Canada provided additional funding to increase broadband capacity in Nunavut through the National Satellite Initiative (­ Christopher and Fast 2008). The second major challenge for the DHSS is protecting patient privacy, particularly in light of the inter-jurisdictional flow of patient information, considering the many service providers outside Nunavut’s borders. Privacy and the protection of personal information in Nunavut are governed through the Access to Information and Protection of Privacy Act. However, there is no law that regulates EHR privacy that is specific to Nunavut. The federal Personal Information Protection and Electronic Documents Act (PIPEDA) governs the privacy of both non-digital and electronic forms of personal information collected by private companies. In 2002, PIPEDA was extended to the health sector. Nonetheless, according to the Information and Privacy Commissioner of Nunavut (2009), legislation is needed in Nunavut to specifically address the privacy of information captured in the EHRs.

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Health technology assessment is the systematic evaluation of the clinical and economic effectiveness of health technologies, devices, and medications. The government of Nunavut is a member of the Canadian Agency for Drugs and Technologies in Health (CADTH), an intergovernmental agency that provides participating governments with evidence-based advice about the effectiveness and efficiency of drugs and new medical technologies and equipment. The Common Drug Review component of CADTH provides assessments for new pharmaceuticals and recommendations for their inclusion into drug formularies, including the Non-Insured Health Benefits formulary (Health Canada 2009b). CADTH’s work in health technology assessment (HTA) provides the DHSS with access to information about the clinical and costeffectiveness of prescription drugs and new medical technologies and devices. Owing to the high cost of conducting HTAs, it is only through this intergovernmental arrangement that the DHSS can obtain HTAs to help it determine if new medical technologies should be introduced and if new prescription drugs should be added to the territorial formulary. h e a lt h c a r e p e r f o r m a n c e m o n i t o r i n g i n n u n av u t

Policy decisions are more effective when supported by highquality data and evidence. The use of health indicators as an instrument for monitoring health system performance and accountability in the health care system has developed rapidly over the last decade. Increasingly in Canada, these indicators are used to monitor and evaluate health service quality and availability and also to pinpoint areas of greatest population health need. In 2000, for example, the provincial and territorial governments agreed to develop, and report on, comparable indicators to monitor health status, health outcomes, and the quality of health service provision. In the 2003 federal-provincial-territorial Accord on Health Care Renewal, the prime minister of Canada as well as the premiers of the thirteen provinces and territories agreed

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to report publicly on health system performance while building and extending the infrastructure needed to collect and distribute health data. Accordingly, they targeted several indicators to measure the timeliness of access and wait times, health service quality, the effectiveness and efficiency of health services and value for money, and health status and wellness. As part of the provincial-territorial obligation to provide residents with performance reports by 2004, the government of Nunavut released a report on health indicators for primary care, home care, health human resources, and health status (Nunavut 2004a). As a consequence of infrastructure and human resource limits, Nunavut’s report (like the reports of its sister territories) is less fulsome than equivalent provincial reports. As noted by the Canadian Health Services Research Foundation, decision making in territorial ministries of health has been hampered by the lack of indicator data and the DHSS in particular has lacked the capacity for using and managing available data to inform clinical, management, or policy decision making (CHSRF 2008). At the same time, some performance indicators pertinent to the Inuit population are being developed. The Inuit Tapairiit Kanatami (ITK) commissioned work on a health information framework for developing and using health data that it determines useful and relevant to Inuit populations, with the objective of achieving healthy communities (Anderson and Smylie 2009; Smylie et al. 2006).12 Using a small set of indicators based on this framework, the ITK released a statistical profile comparing Inuit populations in Nunavut, northern Quebec, Labrador, and the Northwest Territories (ITK 2008).13 h e a lt h r e s e a r c h

Health research in Nunavut is often conducted by researchers from other jurisdictions, though there has been some effort to develop a local capacity for the design and implementation of research projects.14 This nascent research infrastructure includes the Nunavut Research Institute, first opened by the Department of Indian and Northern Affairs in 1978 to provide a space for the Eastern Arctic Marine Sciences Project. In 2005, the National

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Research Institute was amalgamated with the Nunavut Arctic College in Iqaluit, and has provided support for several research projects on Nunavut, including health care. The Nunavut Research Institute encourages research conducted in a manner that is respectful of traditional knowledge in Nunavut and that includes Inuit residents within the design and implementation of the research project (Gearheard and ­Shirley 2007; Healey 2008; ITK 2002; ITK and Nunavut Research Institute 2006). To this end, the territory is a member of the Qaujigiartiit Arctic Health Research Network (AHRN), a pan-­territorial initiative aimed at promoting community-driven research on health care issues specific to the north, including addictions, mental health issues, life circumstances, lifestyle choices, access to health services, and poverty (Healey 2008). More specifically, AHRN supports research that values both traditional knowledge and the Western sciences, providing outlets to share findings, and train local researchers (Healey 2008).15

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5 Nunavut’s Health Workforce

workforce challenges

The principle health workforce challenge for Nunavut, which is to ensure the right balance in human resources in order to provide adequate access to health services, is one that taxes every provincial and territorial government in Canada. However, Nunavut faces additional challenges. The lack of any road access between communities means that transportation is expensive and subject to delays owing to weather. This increases the challenges faced by health providers working in isolated communities: community health nurses (CHNs), for example, require the education, training, experience, and confidence to provide a broad range of services with relatively little on-site support from physicians or other health professionals. High vacancy rates and staff turnover often compromise the continuity of care and services. Four obvious health system features have a direct impact on the workforce. First, the nurse-based community health centre (CHC) is the locus of most service delivery in the territory. With the important exception of agency nurses, the majority of CHNs reside in Nunavut, but most other professionals  – physicians, rehabilitation staff, most dental and eye care providers  – are contracted from southern Canada or the Northwest Territories to work in Nunavut on a rotational basis.1 Second, because of the size and isolation of the communities, health providers enjoy little separation between their personal and professional lives.

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As a consequence, resident health staff are often “on duty” even when participating in “off duty” community events or visiting community members. Third, because most CHNs are not Inuit (and cannot speak Inuktitut or Inuinnaqtun) and spend the vast majority of the working day in the health centres, they rely on community-based personnel to perform key roles. Each CHC has at least one clerk/ interpreter2 who interprets for unilingual residents. As well, each CHC has a minimum of one community health representative (CHR) intimately familiar with the community who is responsible for health promotion and prevention services (ranging from offering smoking cessation programs to providing nutritional advice to pregnant women). Fourth, there are challenges in increasing Inuit representation in the health workforce, including low secondary and post-­ secondary educational attainment in the Inuit population. Efforts are under way by the Department of Health and Social Services (DHSS) to meet these challenges through the provision of educational supports, focused recruitment, and career-laddering initiatives. However, overcoming other challenges, such as poor health status caused by a deficient diet or crowded housing conditions or low educational attainment, requires a longer-term and multidepartmental approach. In general, there is a cultural and linguistic divide between health providers who originate from (and keep their principal residences in) southern Canada and health providers and support staff (much less clients and patients) who live on a permanent basis in Nunavut. The effectiveness of the CHC team in any given community depends in part on the respective exposure, knowledge, and cultural sensitiveness demonstrated by members of the CHC team to bridge this linguistic and cultural gap. However, for the immediate future, Nunavut will continue to be highly dependent on attracting health professionals from the south, an enormous short-term challenge given the pan-Canadian (and international) shortage of nurses, physicians, and other health professionals, and the consequent bidding war among jurisdictions for these skilled individuals.

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Figure 5.1  Age of physician workforce, Canadian territories, 2006. Source: CIHI (2008a)

physicians

Every physician wishing to practise (temporarily or permanently) in Nunavut must be registered through the Medical ­Registration Committee, as required under the Medical Profession Act (see appendix A). The committee is comprised of three practising physicians and one government of Nunavut (GN) employee, who are appointed by the minister of health (who is the designated registrar of health professions), and a further individual who is neither a physician nor a government employee. Unlike the situation in other Canadian jurisdictions, full-time physicians in Nunavut are not paid through fee-for-service remuneration (still the dominant form of payment in southern Canada) but, rather, are compensated through alternative payment methods that can take into consideration patient load and complexity. In 2007–08, there were twenty-three full-time physician positions in Nunavut, including the position of a director of medical affairs. Eight percent of the positions were filled, mostly by short-term locums3 of between two and four weeks, and the average length of stay for physicians in Nunavut during the 2007–08 fiscal year was sixty days (MacDonald 2009). Nunavut’s physician workforce is young relative to the workforce in the rest of Canada; the average age was only 42 in 2006 (see figure 5.1). As well, only 11 percent of Nunavut’s physicians were i­nternational

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­ edical graduates in 2007. There are also more female physicians m working in Nunavut – almost 67 percent are women, which is double the Canadian average (CIHI 2008a). In 2011, there were no Inuit physicians working in Nunavut. Family Physicians Family physicians (FPs) provide specialized primary care support to the community health nurses. They provide telephone support to the CHNs in CHCs and also fly to communities on scheduled visits. The regional centres of Cambridge Bay and Rankin Inlet have almost continuous access to FP services, though the positions are filled by physicians working on short-term locums. The FPs based in Iqaluit have a somewhat different role. In addition to providing primary care and 24/7 emergency services at the Qikiqtani General Hospital (QGH) and in-patient services, these Iqaluit-based physicians are also responsible for providing support to the community health centres throughout the Qikiqtaaluk region either by phone or in person on a scheduled basis (MacDonald 2009). They also provide the bulk of prenatal and postnatal care for women in Iqaluit and perform the majority of deliveries for the Qikiqtaaluk region. In 2008–09, there were twenty-one FP positions in Nunavut (MacDonald 2009). Of these, 14 positions were in the Qikiqtaaluk Region, 4.5 in the Kivalliq region, and 2.5 in the Kitikmeot region. Family physicians in Nunavut work under a contract with the government of Nunavut.4 Most residents of Nunavut who require secondary and tertiary care services are sent out-of-territory. However, Nunavut’s DHSS contracts for the services of various specialists on either a scheduled or an as-needed basis. Several specialist physicians have been contracted through Ottawa Health Services Network, Inc., to run five-day clinics at the QGH. The services available during these clinics include pediatric and adult cardiology, dermatology, pediatric and adult neurology, obstetrics and gynecology, pediatric and adult orthopedics, otolaryngology (ears, nose, and throat), oral surgery, ophthalmology, rheumatology, and urology. Specialists are also contracted through the Stanton Hospital in

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Yellowknife to visit the communities in the Kitikmeot region.5 As of 2011, specialist services were provided to the residents of the Kivalliq region through a long-standing arrangement with the J.A. Hildes Northern Medical Unit (NMU) of the University of Manitoba. In 2008, there were two full-time specialists at the QGH: a general surgeon and a family practice anesthesiologist. The surgeon provides general surgery services, endoscope services, and several gynecological and obstetrics procedures, including caesarian sections, dilation, and curettage procedures, and repairs of complicated vaginal tears (MacDonald 2009). nurses

As of March 2010, Nunavut had 238 nursing positions, including CHNs, public health nurses, home care nurses, mental health nurses, and nurses working in acute care at the QGH in Iqaluit and the two regional health centres in Rankin Inlet and Cambridge Bay. In January 2009, 50 percent of nursing positions were vacant, filled only on a temporary basis by agency or government of Nunavut casual nurses (Nunavut 2009d).6 The DHSS has been working towards filling vacancies by increasing the number of indeterminate (permanent) nurses through the initiatives outlined its Nunavut Nursing and Recruitment Strategy (Nunavut 2009d, k). As a result, Nunavut had 141 of its capacity of 238 nursing positions filled with indeterminate nurses by the end of October 2009 (Nunavut 2009k). Agency nurses – nurses normally resident in southern Canada who are contracted through companies – are brought in at high cost to fill urgent gaps in services if and when it is not possible to fill vacancies with either indeterminate or casual nurses. The rapid turnover of nurses and the use of temporary agency nurses can have detrimental consequences for the continuity of care in the communities, and the evidence in other rural and remote indigenous communities in Canada suggests that agency nurses have a narrower scope of practice and more limited knowledge of and communication with local residents (Minore et al. 2005). As a consequence, the government of Nunavut has expended

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c­ onsiderable effort to reduce its reliance on agency nurses. As net gains are made in the hiring of indeterminate (i.e., permanent) nurses, there has been a decrease in agency nurses – from 53 on 31 December 2008 to 39 in January 2009 to 35 on 30 September 2009 (Nunavut 2009d, 2009k). Despite this decrease, agency nursing persists in the territory, in part because of a nursing shortage but also because some nurses prefer working for the agencies rather than the GN. Agency nurses can choose when and where they work and their rent and moving costs are paid by the agency. Moreover, several of the agency nurses are reportedly former GN nurses who prefer dealing with agencies rather than the GN, complaining about inaccuracies in payment, late payments, and other GN payroll problems. Even if they are willing to work directly for the GN, a few nurses prefer casual over indeterminate status. Though employees of the DHSS, casual nurses have more choice of location than indeterminate staff, and they are more highly subsidized for their rental costs. In contrast, indeterminate nurses have less choice of location and are responsible for their accommodation (RNANTNU 2006). Despite these problems, job satisfaction is relatively high among nurses in Nunavut. Of those responding to a 2005 survey covering the Northwest Territories and Nunavut, 90 percent reported a high level of satisfaction with the opportunities to use their skills and abilities to their fullest potential, close to 70 percent expressed satisfaction with working conditions in general, and 81percent felt that the facilities were either somewhat adequately resourced or adequately resourced. Most nurses (70 percent) were also satisfied with their working conditions, but nurses in Nunavut reported inadequate nurse staffing levels and regular overtime work (RNANTNU 2006). In 2009, almost one-fifth of the workforce was long-term (≥8 years), indicating that some nurses have chosen to practice in Nunavut for longer periods (Nunavut 2009d). On the other end of the spectrum, 32 percent of the indeterminate workforce in 2009 had only been working in Nunavut only for less than two years. As in other jurisdictions in Canada, the nursing workforce is aging. In 2009, 24 percent of nurses were aged 50 to 59 and

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17 percent were 60 years of age and older (Nunavut 2009d; ­Marchildon and Torgerson 2010). Registered Nurses RNs require a bachelor of nursing degree from a Canadian university or recognized equivalent or a nursing diploma from a recognized Canadian nursing institution or equivalent. They ­ must have a current registration with the Registered Nurses Association of the Northwest Territories and Nunavut, as required under the Nursing Profession Act. Registered nurses and nurse practitioners are regulated in Nunavut through the Registered Nurses Association of the Northwest Territories and Nunavut (RNANTNU 2006). RNs work mainly as CHNs in CHCs throughout Nunavut, but some do work as public health nurses, home care nurses and acute care nurses. While the vast majority of nurses practising in Nunavut received their training outside the territory, there is a bachelor of science in nursing (Arctic nursing) offered through the Nunavut Arctic College in partnership with Dalhousie University in Nova Scotia that is intended to make it easier for Nunavut residents to become nurses. The program, which began in 1999, is designed to promote the participation of the Inuit population in the nursing profession.7 In 2008, eighteen students graduated from the program, nine of whom were Inuit (Nunavut 2008b).8 As of June 2009, there were fifty-one RNs working in the QGH in various units, including the in-patient and ambulatory care units and the operating room. There were also four acute care nurses at the Kivalliq Health Centre in Rankin Inlet and eight acute care nurses at the Kitikmeot Health Centre in Cambridge Bay. These centres also have public health nurses: three in Iqaluit, two in Rankin Inlet, and one in Baker Lake (Marchildon and Torgerson 2010). In addition, there is, on average, one home care nurse in every community with more than five hundred people. While some of these positions are funded through the GN, most are funded through the Home and Community Care Program

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administered by the First Nations and Inuit Health Branch of Health Canada. Community Health Nurses CHNs are either registered nurses working in expanded scopes of practice or nurse practitioners. Their scope of practice is well beyond that of nurses working in Canadian provinces (see appendix B). CHNs provide the bulk of primary care services, including initial assessment and basic treatment.9 They also provide the majority of pre- and post-natal care and chronic disease management, deliver clinical public health services, and provide emergency and patient stabilization services. If patients require basic diagnostic work, CHNs take x-rays and collect samples. Some of the more experienced CHNs will even do minor surgeries on occasion. If a patient requires critical care or in-patient services, CHNs will observe their patient’s condition through the night if necessary. They also prescribe and dispense medications based on their delegated authority within the Nunavut formulary. CHNs have also been known to suture sled dogs and euthanize animals when requested. They often transport patients to the airport and, on rare occasions, accompany extremely ill patients on long flights south. CHNs are self-governed through the Registered Nurses Association of the Northwest Territories and Nunavut (RNANTNU). A small number are also members of the voluntary Community Health Nurses Association of Canada. By 2008, there were 61 CHN positions in Nunavut, 27 of which were in the Qikiqtaaluk region, 23 in the Kivalliq region, and 11 in the Kitikmeot region. The number of CHNs stationed in each CHC depends on the size of the population in the community, but they range from seven CHNs in the largest communities to two CHNs in the smallest communities.10 Every CHC has one nurse in charge, officially titled Supervisor: Community Health Programs. These CHN supervisors manage the CHC, including the work schedules of the other nurses as well as of allied and support staff. In the smaller CHCs, the CHN supervisors are also responsible for some clinical work.

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Nurse Practitioners Nurse practitioners (NPs) in Nunavut are governed by the Nursing Profession Act of the Northwest Territories and amendments to the Nunavut Nursing Profession Act (see appendix A). Under the Nursing Profession Act, NPs are eligible to perform the following tasks: To make a diagnosis identifying a disease, disorder or condition; • To communicate a diagnosis to a patient; • To order and interpret screening and diagnostic tests authorized in guidelines approved by the Minister; • To select, recommend, supply, prescribe and monitor the effectiveness of drugs authorized in guidelines approved by the Minister; and • To perform other procedures authorized in guidelines approved by the Minister. •

NPs may prescribe drugs listed in the Non-Insured Health Benefits (NIHB) formulary.11 Under special circumstances, NPs may also issue “maintenance” medications initially prescribed by physicians (RNANTNU 2004). There are several NPs working as CHNs in Nunavut, though their scope of practice as NPs is restricted in the CHN role. There are also three NPs in Iqaluit with the Family Practice Clinic, one of whom manages the clinic. To work in Nunavut, NPs require registration with the RNANTNU and must be graduates of an accredited NP program. They must have worked 1,125 hours as an NP in the last three years to maintain their NP status. Though most of the RNs working in Nunavut have the requisite experience, there is no program in place in Nunavut for RNs to challenge the registration requirements to qualify as NPs. Nunavut also does not have a formal process in place to assist RNs wishing to attain NP status through NP educational programs, although the DHSS is examining a prior learning assessment and recognition process for those CHNs who wish to qualify as NPs (Ashton 2006; Canadian Nurse 2009; RNANTNU 2006).

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Registered Psychiatric Nurses/Mental Health Nurses Registered psychiatric nurses (RPNs) provide clinical and counselling services in Nunavut under the job titles of mental health consultant or psychiatric nurse and mental health specialist. Working in conjunction with CHNs, social workers, and the Royal Canadian Mounted Police, RPNs provide clinical shortterm in-patient care and both emergency and non-emergency mental health treatment services. Most RPNs serve several communities and thus provide services by telephone or email to their clients, with site visits on an as-needed basis. For example, the RPN living in Arctic Bay also provides clinical mental health services and makes referrals to psychiatrists on behalf of residents in Resolute Bay, Grise Fiord, and Pond Inlet. To practise in Nunavut, RPNs must be registered in a jurisdiction with self-regulation, such as British Columbia, Alberta, Saskatchewan, or Manitoba. Certified Nursing Assistants/Licensed Practical Nurses Before 2012 there was no law governing the certification of licensed practical nurses (lpns) in Nunavut, and consequently, those with lpn qualifications worked as certified nursing assistants (cnas). In order to practice as a cna in Nunavut, an individual had to be the graduate of a recognized certified nursing assistant program or licensed practical nurse program in Canada. In 2009, there was one certified nursing assistant in Iqaluit at the Family Practice Clinic, and there were ten cnas at the Kitikmeot Health Centre in Cambridge Bay. Three lpns were employed at the Naja Isabelle Home in Chesterfield Inlet, and one lpn was at the Kitikmeot Health Centre in Cambridge Bay. In 2010, the gn introduced the Licensed Practical Nurses Act to regulate the practice of LPNs in Nunavut (see appendix A).

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The Midwifery Profession Act was passed in 2008 with supporting regulations approved in 2009. Midwifery legislation regulates registered midwives in Nunavut. In 2009, the Department released the Maternal and Newborn Health Care Strategy, which sets out the action plan to integrate new maternity care workers and midwives into the health system and enhance maternal and newborn health outcomes. Registered midwives counsel, support, advise, examine, monitor, and care for women during pregnancy, labour, delivery, and the postpartum period (Nunavut 2009f). They are accessible to clients without referral or supervision from another health care professional. Maternity care workers provide primary health care and assist in community wellness programs and in providing a range of prenatal and postnatal resources and support to expecting mothers, including lactation consulting. The Maternity Care Worker and Midwifery Program at Nunavut Arctic College (NAC) offers a “laddered” program in which courses for the one-year Maternity Care Worker Certificate are also considered to be the first year toward a three-year diploma in midwifery. With the successful completion of a fourth year of studies, a BSc in midwifery is obtained. Graduating students can become registered midwives after year three upon passing the national exam. This education program is supported by the University of Alberta and Laurentian University. The Maternity Care Worker Program was offered twice in Rankin Inlet and will be offered in Cambridge Bay in 2010. Ten Inuit maternity care workers graduated in October 2009 from Nunavut Arctic College (NAC); two of them graduated as midwives. At the time of writing, the DHSS, along with the regions, is finalizing a traditional-knowledge Inuit midwifery project that will collect information on traditional practices. This knowledge will be incorporated into midwifery training and practice in Nunavut. In 2009, there were four midwife positions and two maternity care positions at the birthing centre in Rankin Inlet. There was one maternity care position in Arviat, and a midwife

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from R ­ ankin Inlet visited Arviat periodically (Marchildon and ­Torgerson 2010). There was also one midwife position and one maternity care position at the Kitikmeot Regional Health Centre in Cambridge Bay and one midwife position in Iqaluit. Not all of the positions were consistently staffed. o t h e r m e m b e r s o f t h e h e a lt h w o r k f o r c e

Depending on the region, the availability of permanent employees, and the profession affected, the health workforce in any given community will be some combination of GN employees and contracted employees. To illustrate, all of the environmental health officers, laboratory and imaging diagnostic technicians, and pharmacy technicians were GN employees in 2009, while most of the rehabilitation staff in the Kitikmeot and the Kivalliq regions provided services on contracts with either the NMU at the University of Manitoba or Stanton Hospital in Yellowknife. In contrast, the occupational therapist, physiotherapists, and speech-language pathologist serving the Qikiqtaaluk region were GN employees living in Iqaluit. Pharmaceutical Workforce Under the Pharmacy Act (see appendix A), pharmacists can disseminate information about the safe and effective use of drugs; monitor drug therapy provided to patients; and sell, store, and dispose of prescription and non-prescription drugs. Most pharmacists in Nunavut work at retail pharmacies in the larger centres of Rankin Inlet, Cambridge Bay, and Iqaluit. Pharmacist technicians dispense at the Kivalliq and Kitikmeot health centres and at the QGH in Iqaluit. CHNs dispense medications in the smaller communities, where medications are flown in from retail pharmacies in larger centres. Public Health Workforce There is a regional nutritionist in the Qikiqtaaluk region responsible for the overall development of nutrition strategies for the

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region and the development of clinical interventions for patients. There is also a regional diabetes dietician who manages nutritional supports for preventing and managing diabetes, a position funded through the federal government’s Territorial Health Access Fund. The DHSS requires nutritionists to have an undergraduate degree in food sciences or nutrition, but a graduate degree in public health or adult education is preferred. Dieticians must have a bachelor’s degree in food sciences or nutrition, along with a dietetic internship and related experience. Both nutritionists and dieticians must be members of the Dieticians of Canada and be registered with a professional association. Environmental health officers (EHOs) in Nunavut are appointed health officers under the Nunavut Public Health Act, giving them the statutory obligation to enforce the act and its accompanying regulations (see appendix A). Their duties include the inspection of public facilities and institutions along with food, water, and sewage, and waste management. They also manage some communicable disease outbreaks, including rabies in sled dogs. EHOs must have a degree in environmental health science and be certified with the Canadian Institute of Public Health Inspectors. While there are five EHO positions in Nunavut (three in the Qikiqtaaluk region and one in each of the Kitikmeot and Kivalliq regions), it has been difficult to recruit and retain EHOs. Only two of the five EHO positions in Nunavut were filled in 2009 (Marchildon and Torgerson 2010). Mental Health Workforce In Nunavut, the mental health workforce embraces several professional and paraprofessional groups: mental health nurses, psychiatric nurses, community wellness workers, mental health specialists, mental health workers, and drug and alcohol counsellors. RPNs and RNs with additional mental health training and experience provide the bulk of clinical mental health services in Nunavut. Social workers with a bachelor’s degree or higher education, along with three or more years of psychiatric or mental health practice, may also occupy the role of mental health consultant.

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In the Qikiqtaaluk region, community wellness workers provide counselling for clients experiencing severe emotional disturbance, mental illness, or substance abuse problems. Wellness workers must have a bachelor’s degree in psychology, social work, or a related field, with at least one year of experience, or a diploma in community mental health with at least one year of experience working in the mental health field. Nunavut Arctic College has a two-year certificate program in human services that develops the applied skills needed for entrylevel positions as social workers, school counsellors, addictions counsellors, and youth workers or elders. There is also a mental health diploma program for community wellness workers. The program includes courses on conducting basic mental health assessments and on counselling for sexual abuse, drug and alcohol abuse, domestic violence, grief and loss, depression, and suicide. Psychologists, psychotherapists, and psychoanalysts practising in Nunavut are regulated under the Psychologist Act (see appendix A). Psychologists who have graduated with a master’s degree or its equivalent from a Canadian university are eligible for registration in Nunavut through the DHSS. One regional psychologist stationed in Iqaluit provides psychological services for the Qikiqtaaluk region in various settings, including corrections, schools, and community organizations. Diagnostic Workforce While CHNs perform basic diagnostic tests, including x-rays of the chest and extremities, they depend on caretakers (in most cases) or clerk/interpreters (in a few cases) who maintain the equipment and assist in taking the x-rays. More advanced diagnostic tests are performed by diagnostic specialists located in Iqaluit at the QGH and at the regional health centres in Cambridge Bay and Rankin Inlet. The diagnostic imaging staff at the QGH includes a radiation technologist (mammography), an ultrasonographer, a radiation technologist, a radiology worker, and a manager of the unit. A radiologist, supported by an assistant, takes most of the x-rays at the Kitikmeot Health Centre, while a radiologist and an

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assistant work at the Kivalliq Health Centre. A sonographer is on contract from Winnipeg to travel to Rankin Inlet for two weeks every month to perform ultrasounds. In order to practise in Nunavut, medical radiation specialists must have graduated from an accredited program in medical radiation technology from another jurisdiction, be eligible for registration with the American Registry for Diagnostic Medical Sonography, and be registered as a member in good standing with the Canadian Association of Medical Radiation Technologists (CAMRT). Likewise, the medical radiation technologist/ultrasonographer must have successfully completed an accredited and recognized college program in the discipline of medical radiological technology or a degree in medical radiation technology with the completion of a recognized and accredited one-year program in diagnostic medical sonography. These individuals must also be members of good standing with CAMRT, the Canadian Society of Diagnostic Medical Sonographers, or the Canadian Registry of Diagnostic Medical Sonographers. As with the diagnostic imaging workforce in Nunavut, the laboratory workforce is also centralized at the QGH and the two regional health centres. In order to practise as a laboratory technologist in Nunavut, technologists must have a recognized diploma or degree in medical laboratory technology and be registered with the Canadian Society of Medical Laboratory Science. In 2009 there were six laboratory technologists, one laboratory manager, and one laboratory assistant at the QGH. One of the laboratory technologists at the hospital was certified in blood bank operations. There were also three laboratory technicians and one laboratory assistant at the Kivalliq Health Centre, as well as two laboratory technologists and one laboratory specialist at the Kitikmeot Health Centre.12 Rehabilitation Workforce The rehabilitation workforce in Nunavut is regulated by the DHSS. Each practitioner is required to apply for registration with the Professional Practice Unit of the DHSS. In addition, a physiotherapist must be registered in one of the provincial colleges of

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physiotherapy. A speech-language pathologist must be certified by the Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA) or be licensed to practise in a province with a self-regulatory association. An audiologist must be certified by CASLPA. Respiratory therapists must be graduates of a recognized school of respiratory therapy and registered in the Canadian Society of Respiratory Therapists. Finally, occupational therapists must have a degree in occupational therapy and be registered with the Canadian Association of Occupational Therapy. The rehabilitation workforce in the Qikiqtaaluk region is largely comprised of indeterminate staff employed at the Timimut Ikajuqsivik (“a place to heal your body”) Centre in Iqaluit. In 2009 the staff at the centre included four physiotherapists, three occupational therapists, and one speech-language pathologist. These professionals flew to other communities in the region once a year, or more often if needed. There was also an audiology assistant at the centre who assisted with the processing of hearing aides for the region, and there was a respiratory therapist stationed at the QGH who did not travel outside Iqaluit. As of 2010, the University of Manitoba’s NMU administered the rehabilitation staff in the Kivalliq region through a contract with the DHSS. Based in Rankin Inlet, two physiotherapists, one occupational therapist, and one speech-language pathologist visited communities on a scheduled basis or as needed. While most residents of the Kitikmeot region requiring rehabilitation services were sent to the Stanton Hospital, when required, therapists were flown from Yellowknife to the five communities in the region. Recently, a community-therapy-assistant program has been developed at Nunavut Arctic College. The objective of the program is to train therapy assistants to work with the physiotherapists, occupational therapists, speech-language pathologists, and audiologists in the territory. Dental Workforce Dentists practising in Nunavut are regulated through the Dental Profession Act, while denturists are governed by the Dental

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Mechanics Act (see appendix A). Most dentists, orthodontists, denturists, and oral surgeons from southern locations are contracted to provide dental services. For the Qikiqtaaluk region, the dental workforce was contracted through Aqsaqniit Dental Services, while Kivalliq Smiles and Jorsyn Dental Services held the contracts for the Kivalliq and Kitikmeot regions, respectively. In 2009 we identified four private-practice dentists working in two independent, private practices in Iqaluit – Arctic Circle Dental Services and Iqaluit Dental Services. Dental therapists and hygienists in Nunavut are regulated through the Dental Auxiliaries Act (see appendix A). Under the supervision of a dentist, dental therapists can perform the following tasks in Nunavut: uncomplicated dental restorations, uncomplicated removal of teeth, dental prophylaxes, application of topical fluorides or other anticariogenic agents, and the administering and developing of dental x-rays. Both dental hygienists and therapists are licensed and registered by the DHSS.13 Dental hygienists work in the two private dental clinics in Iqaluit. There is only one program of dental therapy in Canada, the National School of Dental Therapy at the northern campus of the First Nations University of Canada located in Prince Albert, Saskatchewan. The course is two years in length and is geared towards preparing students for employment in First Nations and Inuit communities (FNU 2009; NAHO 2003). It has proven extremely difficult to attract dental therapists from southern Canada. In 2009 only five of the twelve dental therapy positions were filled, despite the evident need for the service in every one of Nunvaut’s twenty-five communities (Marchildon and Torgerson 2010). Eye Care Workforce There are no resident optometrists or ophthalmic technicians in Nunavut. Instead, they are contracted through Polar Vision and the University of Ottawa Clinic to serve the Qikiqtaaluk Region, and Polar Vision and Stanton Hospital in Yellowknife to serve the Kivalliq and Kitikmeot Regions.14 Opticians from Polar Vision in Yellowknife and Iqaluit often travel with the

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­ phthalmic t­echnicians to fill eye care prescriptions. The arrival o dates of the eye care teams are often advertised at the CHC or in local stores. Ancillary Workforce Each of the health facilities in Nunavut has a complement of caretakers who are responsible for equipment assemblies, maintenance, and repairs in the CHCs. Many also have training in basic radiography and assist the CHNs with taking x-rays of extremities and chests. Janitors and housekeepers provide cleaning and laundry services for the facility. They too can serve as x-ray assistants, though they rarely do so. The x-ray assistant program is available for CHC support staff through a joint Mohawk College– McMaster University program delivered through three modules. Home care nurses are supported by home and community care workers (level 1 and level 2) and home care representatives. Level 1 staff members provide homemaking services to ensure that the basic needs of patients are met. These services include cooking nourishing meals and preparing food for special diets as required, light housekeeping, and grocery shopping. They are also responsible for observing and reporting any changes in the patient’s condition to the home care coordinator or nurse. Level 2 workers deliver basic hygiene services, including bathing, grooming, and toileting, as well as medication reminders, and they assist patients in moving and walking. Home and community care representatives provide interpretation services for nonInuit home care nursing and other staff. For the most part, home and community care staff work parttime, often providing care for residents on an as-needed basis. In 2009, for example, two workers helped provide home care services for one resident in Arctic Bay, while a third provided ten hours of home care per week. Nunavut Arctic College has a six-month home and community care worker certificate program to train workers to provide personal care and home care support. The courses in this program are delivered through the various campuses and community sites across Nunavut.

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Nunavut’s Health Workforce 75 the community-based workforce

Community-based workers link health care professionals, who are largely educated and trained in the south and have limited ability to speak Inuit languages, with community residents. Community health representatives and clerk/interpreters are selected because of their knowledge of their home communities, local culture, and local dialects. Community Health Representatives Community health representatives (CHRs) have a relatively long history in Canada. The position was established in the 1960s by the Department of Indian Affairs and Health and Welfare in order to improve public health in Aboriginal communities.15 CHRs are generally from the community in which they work, so that public health education and preventative services are predicated on local needs and culture and delivered in the local language and dialect (McCallum 2006). The position serves as a bridge between non-Aboriginal nurses, physicians, and other health care workers and the community (NAHO 2008). In 2009, every community in Nunavut has a minimum of one CHR. CHRs provide the majority of health promotion and education services in Nunavut. Working under the general direction of the supervisor of health programs (the head CHN),16 CHRs promote and provide public health education in schools and provide healthy lifestyle advice to individual families. They are a key liaison between health care professionals in the CHC and the community at large. CHRs are responsible for prenatal, maternal, and newborn-care education (including nutrition and lactation); health education for infants and preschoolers; family nutrition counselling; smoking cessation counselling; weight loss counselling; dental hygiene counselling (because of the lack of dental therapists); and human sexuality and disease transmission education and counselling (NAHO 2002). They display bulletin boards in the local stores, schools and community health centres, and they may provide talks on the local radio on healthy lifestyle choices or other health-related topics. CHRs also assist CHN staff

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with screening for disability and disease and support physicians in their dealings with community members. Since CHRs have their offices in the CHCs, they can spend considerable time supporting CHNs (e.g., measuring vital signs or assisting with blood work). As a consequence, their community outreach and public health roles are subject to some confusion and questioning (Moloughney 2007). This complexity can produce frustration among CHRs, as well as between CHRs and other CHC staff, particularly CHNs. Before 2005 Nunavut Arctic College offered a CHR certificate program aimed at assisting CHRs with the skills, attitudes, and knowledge necessary for their role. Courses in the CHR certificate program included nutrition, human growth and development, social and mental health issues, and body systems and diseases. Not all CHRs took this certificate program, and it has not been delivered since 2004. Depending on the CHRs’ background skills and knowledge, they may not have the necessary skills and training to provide key health promotion and illness prevention services. The National Indian and Inuit Community Health Representatives Organization (NIICHRO) has worked on preparing a set of core competencies for CHRs. In 2007, for example, after consultation with CHRs and other stakeholders across Canada, NIICHRO recommended that CHRs be reclassified as “wellness and primary health care providers” with a defined set of core competencies (Hammond and Collins 2007). Clerk-Interpreters Each facility in Nunavut has at least one clerk-interpreter, whose role is to provide interpretation between the health providers and unilingual residents. More specifically, in addition to their clerical duties and providing overall assistance in the CHCs (e.g., transferring and feeding patients as instructed), clerk-interpreters explain the treatment plans and health counselling from doctors, nurses, and other professionals to unilingual patients. Clerk-interpreters also explain medications to patients and write instructions in syllabics as required.

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Nunavut’s Health Workforce 77 i n u i t r e p r e s e n tat i o n

According to the National Aboriginal Health Organization, several expectations underscore the training and education of Aboriginal community members in health care professions (NAHO 2008). First, Aboriginal health care professionals are more likely to have a vested interest in those communities, and as a consequence they may stay longer than non-Aboriginal health care providers. Second, if they have grown up in Aboriginal communities, they will be more understanding of the culture and proficient in the language and dialects. Third, as permanent community members, they should be more sensitive to the health needs of residents and advocate more effectively on their behalf (Nunavut 2005a). While not all Inuit in Nunavut are Nunavut land claim beneficiaries, the vast majority are beneficiaries not only with a legal right to specified services but with a legal expectation that services will be delivered by a representative workforce. The GN has an Inuit Employment Plan in place to meet their obligations under article 23 of the Nunavut Land Claims Agreement (NLCA) “to increase Inuit participation in government employment in the Nunavut Settlement Area to a representative level.”17 This objective applies to “all occupational groupings and grade levels” within government. Moreover, article 23 requires preemployment training for Inuit.18 Under the terms of the NLCA, 85 percent of the public service should eventually be staffed by Inuit residents, based on a strict calculation of the proportionate share of the territory’s population. This target is to be achieved through instruction of all staff in Inuktitut, access to local training and education opportunities and apprenticeships, and recognition of Inuit culture and lifestyle. There should also be increased career laddering opportunities for Inuit paraprofessionals to increase the number of Inuit professionals and managers and to provide more opportunities for core competency assessment and credit for prior learning (Nunavut 2005a). An example of this objective is the new Training Ladders initiative, which is designed to increase access to health and social service careers through modular programs and increased transferability of course credits (Nunavut 2009e).

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Table 5.1 Percentage of Inuit Beneficiaries in Health and Social Service Positions, Nunavut, 2001 and 2009

Executive Senior management Middle management Professional Paraprofessional Administrative support

2001

2009

 0  7  4  6 49 79

 0 15 14 20 77 93

Sources: Nunavut (2009c, 2001).

Article 23 of the NLCA stipulates that the GN must monitor progress in meeting Inuit representation by collecting, maintaining, and updating labour force data. As a consequence, there is some data on Inuit representation in the health professions, though the data are not separated according to profession. The DHSS has made visible progress in ensuring more Inuit representation in the DHSS in all areas except for the executive level over the past decade (see table 5.1). At the same time, most beneficiary positions are highly concentrated in the paraprofessional and administrative support positions. There is a critical shortage of Inuit nurses. As of March 2010, there were only ten nursing positions filled by beneficiaries: three in Rankin Inlet, three in Iqaluit, two in Arviat, one in Qikiqtarjuaq, and one in Pond Inlet. Five of these nurses were community health nurses, and five were registered nurses working in other capacities.19 There are no Inuit physicians, dentists, optometrists, or rehabilitation professionals. There are major impediments to achieving higher levels of Inuit representation. First, most health care profession programs require not only a grade 12 certificate but also course completions in science. In 2006, only 10 percent of the Inuit population older than 15 in Nunavut had a high school certificate or diploma as their highest educational attainment, and 69 percent had no degree, diploma, or certificate at all (Statistics Canada 2006). Moreover, there is anecdotal evidence that high school graduates

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in Nunavut often need upgrading in order to succeed in postsecondary programs (Nunavut 2005a). According to the National Aboriginal Health Organization (NAHO), it is critical to provide students with the necessary skills in mathematics and sciences required by most health care courses, in addition to support and counselling in order to give them the motivation necessary for success. Practical solutions include support for child care (many Inuit students have children), support services and skill teaching, improvements in preparing students for advanced study (e.g., the availability of high school courses appropriate to advanced health careers), and increased awareness of the types of health care professions available that extend beyond nursing and medicine to counselling and technical jobs. NAHO (2004) also suggests that a better understanding of the motivations and skill sets that lead to the successful completion of post-secondary health care educational programs is required in order to improve completion rates in predominantly Aboriginal communities. i n t e r n at i o n a l ly e d u c at e d a n d t r a i n e d p r o f e s s i o n a l s

The internationally educated health workforce in Nunavut is small, and there have been few attempts to actively recruit foreign-educated or foreign-trained health professionals from other countries. For the most part, recruitment and retention initiatives are targeted at southern Canadian professionals. One exception was Nunavut’s campaign to recruit nurses from the Philippines and India. Although thiry-five nurses were recruited, twenty-three of them left Nunavut within two years (Dumont et al. 2008).20 As of 2011 Nunavut was the only jurisdiction in Canada without an immigrant nominee program to fast-track immigration to fill skilled workforce gaps, including shortages in key health professions. collective bargaining

The majority of the health workforce directly employed by the GN is unionized. Unlike most provinces, where collective

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­ argaining involves numerous health unions, health workers b in Nunavut belong to a single union  – the Nunavut Employees Union, which represents all GN employees. Collective agreements include the provision of a northern allowance, which varies with the cost of living in individual communities. For example, in 2009, the northern allowance for Iqaluit was onehalf ($14,289) that provided ($32,814) in the more remote community of Grise Fiord (Nunavut 2009b). Under the collective agreement, nurses receive signing bonuses as well as bonuses for continuous services. Nurses are also compensated for working in more isolated CHCs. For example, in 2009 a CHN working in a one-nurse CHC received $19,500, compared to $16,350.00 for a two-nurse CHC (Nunavut 2009a). At the time other health professionals and paraprofessionals did not have arrangements similar to nurses. workforce planning

Working in Nunavut poses several challenges: high living costs, inclement weather, professional and personal isolation, potentially stressful working conditions, sparse spousal employment opportunities, and unaffordable or unavailable housing.21 These challenges are often exacerbated by administrative problems. For example, delays in advertising positions or in responding to requests for information or applications are common (RNANTNU 2006). As a result, there is a high vacancy rate, typically 30–40 percent for nurses (Nunavut 2008b). Workforce planning in Nunavut has tended to follow two tracks, recruitment from the south and development of a home-based workforce. The principal challenge faced by the DHSS is the extent to which there is a nursing shortage throughout Canada and the resulting competition for nurses. The DHSS regularly advertises in nursing and medical journals to recruit nurses and physicians, appealing to the opportunity for them to fully use their skills. Attractive compensation packages and retention allowances have been negotiated for nurses through the Nunavut Employees Union as a means of recruiting nurses to the remote communities. As a result, nurses in Nunavut

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are the highest paid in Canada.22 In addition, Nunavut (2008b) suggests that a pool of relief nurses be established to provide relief services when nurses take vacations, participate in professional development courses, or take extended leaves of absence. At the same time, there may be opportunities to increase the staffing levels of many CHCs to reduce exhaustion and turnover rates. Many CHCs have had the same nursing complement for the past two decades despite increases in population size and patient acuity. The second avenue requires the DHSS to increase access to training and education, providing more avenues for residents to become health providers, thereby reducing dependence on southern-based providers (Nunavut 2008b). The key constraint on this approach is the availability of a pool of applicants with the necessary high school education for many health care professions. In addition to an extremely low graduation rate, limited knowledge of mathematics and sciences also put Nunavut high school students at a disadvantage to other Canadians. To attract Inuit youth to nursing, the GN has an Inuit Nursing Recruitment Promotion Program that uses television, radio, and print advertising; photograph galleries; presentations at career fairs; and middle- and high-school role models. Other initiatives are aimed at improving the school experience for Inuit students while they attend Nunavut Arctic College, including assistance with child care and the presence of an elder. In addition, learning opportunities have been expanded in several communities. Other avenues being implemented include increased opportunities for skills upgrading at NAC community learning centres across Nunavut. For instance foundation studies, which give students the necessary math and science skills for nursing education, are offered in several communities, including Iqaluit, Cambridge Bay, and Rankin Inlet (Nunavut 2008b). Other Nunavut Arctic College courses and training opportunities are available through community learning centres such as the mental health worker diploma program in Iqaluit, the community therapy assistant diploma program in Iqaluit, and the home and continuing care worker certificate program in Gjoa Haven and Igloolik.

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Table 5.2 Nursing Vacancy Rates in Nunavut by Community, as of January 2009 Community Qikiqtaaluk Region Kivalliq Region Kitikmeot Region Total for Nunavut

Total Positions

Vacancies

Positions Reported Vacant (%)

117   61   46 224

  42   29   29 100

36 48 63 45

Source: Marchildon and Torgerson 2010.

Another consideration is the growing leadership gap in Nunavut created by an aging managerial workforce (Nunavut 2005a). Several strategies are currently employed in Nunavut to address leadership capacity, including internships, mentorship, and access to advanced management courses for future leaders – particularly Inuit residents (Nunavut 2005a). Recruitment and Retention Initiatives Within the context of a global shortage of health care professionals, especially nurses and physicians willing to work in rural and remote areas in southern Canada, the situation in Nunavut is more acute, owing to climate, isolation, and the high cost of living, as well as unaffordable, unavailable, or inadequate staff housing. As shown in table 5.2, high vacancy rates for nursing positions have been prevalent in every region of Nunavut. Other professions with high vacancy rates include physiotherapy, dental therapy, pharmacy, and audiology (Nunavut 2008c, 2009d). The GN released the Nursing Recruitment and Retention Strategy in 2007. It outlines strategies to recruit and retain nurses in Nunavut and to build an Inuit nursing workforce (Nunavut 2007d). One of the strategy’s main objectives was to improve the stability of the nursing workforce by reducing the use of agency nurses and generating a more dependable, resident-based nursing workforce (Nunavut 2009k). The Nursing Strategy itself includes short-, medium-, and longterm actions to improve the stability of the nursing workforce

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in Nunavut through recruitment activities, including the recruitment of a chief nursing officer. Several actions to recruit southern nurses to Nunavut include a new website, job fairs, and a print advertisement campaign. Strategies aimed at retaining the existing workforce include job-share arrangements, opportunities for mentorship of new graduates and nurses new to Nunavut, clinical education to support new and existing nurses, and a new professional-development initiative guideline and application (Nunavut 2009k). The Nursing Strategy proposes child care subsidies for students, tutoring supports, and the expansion of the nursing program to Cambridge Bay and Rankin Inlet. Each year, $100,000 is allocated to assist nursing students through bursaries and assistance with attending workshops and conferences. Each student is eligible for $1,250 to $6,000 through achievement-­ based scholarships, depending upon the year of study and grade point average (Nunavut 2008a). In 2008 the GN launched a nurse recruitment website – Nunavut Nurses  – which includes information for prospective nurses regarding salaries, working conditions, opportunities for partners, and types of nursing opportunities for registered nurses (e.g., community health nursing, public health nursing). There are indications that the GN’s Nursing Strategy has had some success in bolstering the nursing workforce. For instance, there was a net gain of 31 new nurses from June 2008 to October 2009, which exceeded the GN’s Year I provisional target of 20 new nurses, as outlined in the Nursing Strategy (Nunavut 2009k). Several strategies have been employed in recent years to bolster the number of full-time physicians. Physicians are actively recruited through professional journals and publications, and recruiters are sent to job fairs across Canada. There is also a physician recruitment website – Nunavut Physicians – that provides interested physicians with testimonials about working in Nunavut, the requirements for practising in Nunavut, and descriptions of northern practices. Several physicians also have return-of-­service contracts with the DHSS, as do medical students, who must commit to providing three to six years of service in Nunavut in return for the funding of their education. In

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addition, flexible physician contracts were introduced in 2008, permitting a degree of freedom with regard to scheduling. The budget for physicians recruitment has been between $60,000 and $80,000 per year, with the bulk of the money spent on advertisements in medical publications (MacDonald 2009). Other targeted professions include dental therapists and environmental-health officers. To address the shortages in dental therapy, Uswak (2007) recommends that the territories explore recruitment and retention mechanisms aimed at dental therapists, including return of service agreements.

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6 Service and Program Provision in Nunavut

Demography and geography do much to shape the mix, type, quality, and accessibility of health services and programs in Nunavut. While the population in Nunavut is young relative to other Canadian jurisdictions, many of the communities are dealing with major health challenges, including high rates of suicide, infant mortality, and communicable diseases (including outbreaks of tuberculosis created by overcrowding, poor housing, and food insecurity). High levels of unemployment and poverty exacerbate these health challenges. At least some of the current burden of disease, including high rates of lung cancer and sexually transmitted infections, is preventable through effective action at the community level. As well, while the rates of infant mortality and life expectancy are gradually being lowered, they remain much higher than in other Canadian jurisdictions. Many of the health care services are delivered by southernbased providers who, by virtue of not being residents, may not be as aware or knowledgeable about local service needs, culture, and relationships as are permanent community members. This gap has created a scenario where the service needs of the community members are being delivered by individuals who do not necessarily understand the complexities of Inuit history, culture, and community dynamics. Community members, including business owners, elders, women, and youths, are valuable resources in identifying health issues, and they are critical to communitybased program development. Examples are the Embrace Life

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Council, a community-based initiative addressing the high rates of suicide among young Inuit people, and the Healthy Foods North Initiative, another community-based program aimed at increasing nutrition. There are obvious gaps between health needs and the services available in most communities (Marchildon and Torgerson 2010). There is a large gap in preventative dental care for children. Many children have high rates of dental caries, which often require expensive evacuation to Iqaluit or southern facilities for extraction under anesthetic. Some health problems require services that go beyond those provided through the Department of Health and Social Services alone: these include extremely high rates of tobacco use, high-risk teen pregnancies, low self-esteem, suicide, and sexually transmitted infections (Nunavut and Nunavut Tunngavik Incorporated 2006). c o m m u n i t y h e a lt h c e n t r e s

In southern Canada, primary care reform has tended to focus on the need for interdisciplinary groups of health professionals working together to provide a range of services to a given population.1 While the composition of the services might vary, it would ideally include nurses, physicians, mental health professionals, rehabilitation professionals, and pharmacists (Bowerman 2006; van Oosterbos 2006). Although the concept of community health centres (CHCs) initially emerged in southern Canada in the 1960s and 1970s as part of a group-based practice favouring community-based primary health care, the actual implementation of CHC-style care occurred years earlier in northern Canada. The CHC model in Nunavut is built on nursing stations and outposts, which were established by the federal government shortly after the Second World War to ensure service provision to remote and rural areas. Nurses in these outposts and now in the CHCs provide a comprehensive set of services for the community that extend far beyond the scope of practice for registered nurses working in southern jurisdictions. For example, community health nurses (CHNs) conduct independent assessments and diagnosis, provide pre- and post-natal care and deliver

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babies, do minor surgery (e.g., stitches), and provide in-patient care when needed. In short, they are the core service providers in most Nunavut communities. While the term “primary care team” is not commonly used in Nunavut, several providers, including nurses, physicians, mental health workers, social workers, and rehabilitation providers, often work as a team  – regularly by phone and email or, if possible, through the telehealth network. CHNs typically arrange and coordinate most of this patient care. CHNs are on call 24/7, and thus most basic services are accessible to the residents whenever they are needed. For the most part, people in the remote communities do not have to wait long for basic services, and services are also largely patient-centred – the services delivered and coordinated by the CHNs are predicated on the specific needs of the patient and his or her family. Overall, the CHC is a cost-effective model of service delivery that provides a comprehensive set of services to communities that may not otherwise have access.2 It is important to note that there are some challenges to the effectiveness of the CHC model, including a lack of continuity of care in some communities owing to the heavy use of agency or casual nurses who have a very temporary connection to the residents. The provision of effective community care services, which require knowledge of the local communities, is not possible in a scenario where mainly southern nurses stay in the community between only three weeks and three months. CHNs are expected to take the lead in providing community-based services. If they do not understand the culture, relationships, and experiences of the community members, then these programs, as well as partnerships between the CHC and the community, including the individuals and organizations responsible for administering and delivering the hamlet’s population health programs and services, will not live up to their potential effectiveness. The number of nurses in each community is largely the same, despite population growth, since the 1980s. Because of these staffing issues and the increasingly complex paperwork expected of them, nurses are required to spend an increasing proportion of their time on administration and illness care rather than wellness care. Thus, community-based wellness programming, which

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is central to the CHN service delivery model, is often squeezed or neglected because of more urgent acute care needs. Given the extent to which Nunavut’s burden of disease is related to environment and lifestyle behaviours, one of the critical needs for many communities is strengthening and coordinating public and population health programs. p u b l i c a n d p o p u l at i o n h e a lt h

Several specialized front-line provider groups supply a broad range of public health services at the regional level. The larger communities of Rankin Inlet and Iqaluit also have a public health office that is staffed by public health nurses, while Cambridge Bay has a public health nurse who works in that community’s regional health centre. In addition to providing clinical services, the public health nurses also provide services related to health care promotion and prevention. The Public Health Clinic in Iqaluit provides several public health services for residents of Iqaluit, including travel and child immunizations, communicable disease control, and public health maternity care services (prenatal classes and lactation supports). Several more specialized front-line health care workers, including dieticians and environmental health officers, serve their respective regions from their community base. Community health representatives (CHRs) deliver a broad range of health promotion and education services in the communities, while community health nurses (CHNs) deliver a number of more clinically based public health services (e.g., immunizations and disease surveillance) as well as afternoon wellness clinics in the CHCs (Nunavut 2005b). However, according to ­Moloughney (2007), the constant pressure on CHNs to provide acute care leaves little time for community-based prevention and health promotion services. Several community wellness services that are funded by the federal and territorial governments are delivered by the hamlets. Residents and community-based organizations are eligible to apply for grants to provide programs such as school lunches, prenatal nutrition programs, “on the land” youth camps, and

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Box 6.1 The Ilisaqsivik Society Family Resource Centre in Clyde River Clyde River has one of the few dedicated community wellness centres in Nunavut. The services available at the Ilisaqsivik (“a place where one recognizes oneself”) ­Society Family Resource Centre include suicide prevention, prenatal nutrition, wellness counselling, supports for youth and elders, addictions and alcohol counselling, and health promotion and prevention. While they are employees of the hamlet, the staff of the Family Resource Centre is funded through federal funds. preschool programs. The grants are for a temporary period, often one year. As a consequence, these programs do not often have the permanence and sustainability of territorial programs based in the community health centres. Moreover, a number of communities do not have the capacity to prepare annual grant applications (Nunavut and NTI 2006). One popular example of these programs is the Canadian Prenatal Nutrition Program, which is intended to increase the access of pregnant women and infants to nutritious foods. A few hamlets, such as Cambridge Bay, Rankin Inlet, and Clyde River (see box 6.1), operate dedicated community wellness centres. The Cambridge Bay Wellness Centre provides a wide range of programs and services funded mainly through federal grants. The Pulaarvik Kablu Friendship Centre in Rankin Inlet, for example, provides addictions and family violence counselling and training in traditional skills and job readiness. Health Committees of Council At the hamlet level of government, Health Committees of Council have been established in order to assess community health needs and priorities and evaluate progress or success on a continuing basis (Nunavut 2008d). The terms of reference for these health

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committees were determined by the government of Nunavut and the Nunavut Association of Municipalities in 2007 (Nunavut 2009h). They were designed to provide community members with more of a voice in determining the services needed to achieve community health and well-being, giving practical effect to the GN’s commitment to inuuqatigiittiarniq (“healthy communities”) and namminiaq makitajunnaqmiq (“self reliance”) (Nunavut 2007a). While these health committees have some potential to change the future composition and mix of health services, there is little evidence concerning the establishment of the effectiveness of the linkages between the committees, on the one hand, and CHC service providers and community liaison officers who work out of the hamlet offices, on the other (Nunavut and NTI 2006).3 There are varying degrees of committee development and efficacy across the communities. Much depends on the willingness of local people to join these groups and, once formed, whether they see any value accrued to their participation. The following sections outline the most pressing public health issues facing Nunavut: high rates of food insecurity, malnutrition, smoking, sexually transmitted diseases, and communicable diseases including tuberculosis. Many of these health issues will continue to inform demands on health services unless coordinated and sustainable culturally relevant actions are developed and implemented at the territorial, regional and community levels. Nutritional Programs and Services To address malnutrition and food insecurity in Nunavut and to promote niqitti-avaknik nirinasuaqniq (“healthy eating”), the GN released an ambitious strategy to improve nutrition in Nunavut, a strategy involving several goals: eliminating the diseases (e.g., rickets) caused by nutritional deficiency; reducing nutritional deficiencies, especially for pregnant women and children; reducing the high cost of food from the south; facilitating access to traditional, or “country,” foods; and improving access to the services of registered dieticians.

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The federal government has funded a number of nutritional programs and services for years. At a cost of more than $25 million per year, the Canadian Food Mail Program reduces, through a substantial subsidy, the cost of perishable foods, particularly fruits and vegetables, which would otherwise not be available or would sell at many times their average southern Canadian price.4 The Canadian Prenatal Nutrition Program is another federally funded initiative aimed at improving nutrition. The GN implemented several strategies to address malnutrition. These include the Drop the Pop campaign (launched in 2004), which was aimed at reducing the high consumption of high-sugar carbonated (and similar) drinks among youth (Priest 2006), and a community food-hamper program facilitating access to country foods. At the community and regional levels, CHRs and CHNs provide advice about healthy food choices, although in the Kitikmeot and Qikiqtaaluk regions, patients may also be referred to regional nutritionists who often provide services through telehealth (Moloughney 2007). In 2008 the governments of the Northwest Territories and Nunavut introduced a program called Healthy Foods North, in order to promote healthy food choices and activity in selected northern communities. In Nunavut, Healthy Foods North is a collaborative project involving the hamlets of Cambridge Bay and Taloyoak, the North West Company, Arctic Cooperatives Ltd, researchers, the Kitikmeot Inuit Association, and the federal government.5 Tobacco Reduction Programs Over 50 percent of the adult residents of Nunavut are daily smokers, the highest rate in Canada and among the highest rates in the circumpolar world (Statistics Canada 2010; Young 2008). As a consequence of Nunavut’s alarmingly high rates of lung cancer among both men and women, the Department of Health and Social Services (DHSS) implemented several strategies to curb tobacco consumption. In 2003, the GN passed the Tobacco Control Act, banning the sale of tobacco products to youths under 19 years of age, as well as banning smoking in workplaces. The law

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also prohibits the sale of candy cigarettes or similar products. However, it is doubtful whether law enforcement officers have the resources to monitor compliance by retailers (Sobol 2006). In addition, public health and community health nurses regularly educate residents about the dangers of smoking and the potential damage children and others can suffer from the effects of second-hand smoke. Perhaps as a consequence of these programs and initiatives, there has been at least a modest decline in the daily smoking rates over the past decade. Based on the Canadian Community Health Survey, the percentage of daily smokers fell from 57.2 percent to 52.4 percent from 2003 to 2009 (Statistics Canada 2010). Environmental Health and Communicable Disease Programs and Services The Health Protection Unit at the GN provides advice and support to DHSS employees regarding communicable disease control, tuberculosis control, and environmental health. In addition, an environmental specialist within the Health Protection Unit provides overall recommendations and direction for environmental health programs in Nunavut and guides the environmental health officers in the development of policies around water and food safety and monitoring, waste disposal, sanitation in public places, and housing quality.6 The DHSS, through the Health Protection Unit, also provides a rabies prevention and control program and investigates instances of water- and foodborne illnesses. Owing in part to housing quality, inappropriate ventilation, and poor indoor air quality, communicable diseases, particularly tuberculosis (TB) and respiratory tract infections, are prevalent (Banerji et al. 2001; Jenkins et al. 2004; Kovesi et al. 2007; Orr 2007). Although TB rates are substantially below their peak in the 1950s, TB is still common in a few communities in Nunavut (Nunavut 2008f). In response to TB outbreaks in Iqaluit, a TB coordinator position was created at the Public Health Clinic. Outside Iqaluit, CHNs hold TB clinics and prevention services provided by both CHNs and community health representatives.

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Some of the CHCs have a room that doubles as a TB quarantine room. In Rankin Inlet, the public health nurse manager is responsible for communicable disease prevention and control. Some communities in the Qikiqtaaluk region such as Pangnirtung, Qikiqtarjuaq, and Cape Dorset have a TB assistant/ coordinator or a TB nurse often hired on a casual basis to deal with TB outbreaks. Once the outbreak is under control within a community, the TB nurse or coordinator is typically sent to another community. Nunavut has significantly higher rates of sexually transmitted infections such as chlamydia and gonorrhea than other jurisdictions, which has harmful consequences for the rates of pelvic inflammatory disease, chronic pelvic pain, tubal infertility, and ectopic pregnancies (Orr and Brown 1998; Steenbeek et al. 2006). In contrast, the reported incidence of HIV/AIDs is low, and there have been no recent cases of syphilis (PHAC 2006; Pauktuutit Inuit Women of Canada nd). A combination of CHNs, public health nurses, and community health representatives provide counselling and testing services for sexually transmitted infections. Reproductive Health Services Birth control devices and pills are available from the community health centres in Nunavut, while condoms are available free-ofcharge to residents. Emergency contraception, historically available from nurses or physicians at the community and regional health centres, is now dispensed at pharmacies in Rankin Inlet, Cambridge Bay, and Iqaluit without a prescription. Therapeutic abortions are accessible to residents of Nunavut at the QGH or out-of-territory. Immunizations and Vaccines Children and infants in Nunavut have access to publicly funded immunizations (see table 6.1). The GN provides coverage for all childhood immunizations and a number of adult immunizations. There is a small fee for most travel immunizations.

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Table 6.1 Publicly Funded Immunization Programs for Infants and Children, Nunavut (updated to 2008) Immunization

Age/Grade

Diphtheria/Tetanus/Acellular Pertussis (DaPT), Inactivated Polio (IPV) and Haemophilus Influenza Type B (HiB) DaPT and IPV Hepatitis B (Infant) Measles, Mumps, Rubella Td/dTap or Td/IPV Varicella Meningococcal Conjugate Pneumococcal Conjugate Influenza

2, 4, 6, 18 months

4–6 years 0, 1, 9 months 12 and 18 months, Grade 12 dTap, Grade 9 15 months 12 months, 14–16-year-old catchup 2, 4, 6, and 15 months > 6 months

Source: Canadian Nursing Coalition on Immunizations (2004); PHAC (2008a).

Table 6.2 Percentage of Residents Aged 12 and Over Reporting Influenza Immunizations, 2005 Influenza Immunization, Less than One Year Ago

Influenza Immunization, One or More Years Ago

Never Had Influenza Immunization

39.8 36.3 30.3 32.7

23.7 20.5 21.0 18.1

34.1 40.4 44.1 46.2

Nunavut Northwest Territories Yukon Canadian Average Source: Statistics Canada (2005).

The GN also provides free universal influenza immunization ­campaigns, especially targeting high-risk groups such as young children, elders, and those with chronic diseases. Residents of Nunavut reported higher rates of influenza immunization than those in the two other territories and than the Canadian average (see table 6.2). Approximately 65 percent of Nunavut residents reported getting immunized for influenza at least once in their lives, a higher level than those reported in the Northwest Territories and Yukon.

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Table 6.3 Distribution of Family Physicians, Nunavut (2008–9) Regions

Physician Service Days per Year

Qikiqtaaluq Kivalliq Kitikmeot Total for Nunavut

3,080 1,320 550 4,950

Source: Nunavut (2009g).

p r i m a ry h e a lt h s e rv i c e s

For most residents of Nunavut, the first point of access for almost all health care is at a community health centre where CHNs and ancillary staff provide almost the full range of primary health care services. The one major exception is Iqaluit where nurse practitioners at the Family Practice Clinic and family physicians based at the hospital provide primary care services to the residents of Iqaluit. The physicians providing on-call and community services for the Kitikmeot and Kivalliq regions are based in southern locations, although they are well versed in northern health service delivery and are experienced in working in Nunavut (MacDonald 2009). In their role of supporting and advising CHNs, as well as dealing with referrals from CHNs, family physicians provide scheduled services to residents throughout Nunavut. In 2008–09, family physicians provided almost five thousand service days in the territory (see table 6.3). At the time family physician staffing in Nunavut used a formula of five physician days per 1,000 population per four weeks for staffing and planning purposes. A community with a population of one thousand using this formula should have access to a physician for five days every four weeks (McDonald 2009). Access to physician services is an issue for Nunavut, though the data on accessibility needs to take into account the primary care service delivery model in the territory which places the point of contact for services with CHNs rather than family physicians. For

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example, in response to annual Canadian Community Health Surveys from 2007 until 2009, more than 80 percent of Nunavut residents said they did not have access to a regular medical doctor, a percentage that should not be surprising in a territory where nurses, rather than doctors, are at the centre of the model of primary health care (Statistics Canada 2010). h o s p i ta l a n d s p e c i a l i s t c a r e

Under an agreement with the Ottawa Health Service Network, the Qikiqtani General Hospital (QGH) offers a range of specialist services, including cardiology (pediatric and other), dermatology, neurology (pediatric and other), obstetrics and gynecology, ophthalmology, orthopedics (pediatric and other), oral surgery, rheumatology, and urology. Anesthesia and general surgery are available at the QGH on a full-time basis. In addition, some basic in-patient services are expected to come on stream in the regional health centres in Cambridge Bay and Rankin Inlent in 2010. Even with this new acute care capacity, most residents are flown out-of-territory for specialized medical services and appointments. Residents of the Kitikmeot region are commonly flown to Yellowknife or Edmonton. Residents of the Kivalliq region have access to some specialist services through regularly scheduled community visits by the specialists from the University of Manitoba’s Northern Medical Unit, but they are most often flown to Manitoba (either Churchill or Winnipeg) for treatment. Residents of the Qikiqtaaluk region are flown to Iqaluit during scheduled specialist clinics or to Ottawa if the treatment is not available at the QGH. The Stanton Territorial Hospital in Yellowknife is the major referral centre for the Northwest Territories and the Kitikmeot region of Nunavut. The GN and the Stanton Territorial Health Authority signed a memorandum of understanding to ensure that residents of the region have access to the several on-site services at the Stanton Hospital including out-patient units, intensive care units, psychiatry, obstetrics, surgery and pediatrics, day surgeries, and medical day care, including endoscopies, IV therapies, and chemotherapy (Nunavut 2008e). Specialists from the

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Stanton Hospital also travel to the communities in the region. Some specialist services such as psychiatry, internal medicine, pediatrics, and ear/nose/throat, are available to patients in the region through specialist outreach clinics. In the Kivalliq region, several specialist services, including obstetrics/gynecology, psychiatry, ophthalmology, general surgery, otolaryngology, and internal medicine, were contracted through the J.A. Hildes Northern Medical Unit at the University of Manitoba. In Rankin Inlet, some specialist services are available only during scheduled times during the year. Residents of the other communities in the region are flown into Rankin Inlet during the specialist clinic days or are sent out of territory. Ottawa Health Services Network Inc., a non-profit medical organization based in Ottawa, provides just over thirty weeks of on-site specialist clinics at the QGH, as well as telehealth-based services for residents of the Qikiqtaaluk region (Ottawa Health Services Network Inc. 2009). Several specialists in cardiology, dermatology, internal medicine, neurology, obstetrics and gynecology, and ophthalmology are available at the QGH for one to four clinic weeks a year.7 Residents in the other communities in the region are often flown to Iqaluit to access these services during the specified clinic week, though some specialists may fly to the other communities as needed. Residents of the region are sent outof-territory to hospitals in Ottawa or Montreal for most tertiary services. There were about 1,010 service days for specialists in the Qikiqtaaluk region in the 2008–09 fiscal year (Nunavut 2009g). In 2004, Canadian first ministers agreed to improve wait times in five priority areas, all involving physician specialists: cataract surgery, advanced diagnostic imaging (e.g., MRI and CT scans), cancer surgery and radiation therapy, cardiac care, and hip and knee replacements. In 2007, Nunavut received $4.5 million from the federal government to improve wait times for diagnostic imaging, in part because diagnostic wait times exceeded the Canadian average (Statistics Canada 2005).8 While Nunavut residents wait longer than other Canadians for some types of specialist care, owing largely to delays caused by travel, they actually wait less time for elective surgeries than most Canadians (Statistics Canada 2007).9

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Every community health centre has a well-stocked pharmacy, with CHNs dispensing and prescribing needed medications based on the Nunavut drug formulary. New prescriptions or refills are faxed by the CHNs to an attending physician or are collected before a physician visit so that they can be signed at the same time. Nurse practitioners and attending dentists also prescribe certain medications based on the Nunavut formulary.10 As a consequence, residents in most of the territory’s hamlets are highly reliant on their respective community health centres and the CHNs for prescription drug therapies. There are five retail pharmacies in Nunavut, located in Cambridge Bay, Rankin Inlet, and Iqaluit (IMS Health Canada 2009). They fill the prescriptions for CHCs for the communities located in their respective regions. Pharmacy technicians at the Cambridge Bay and Rankin Inlet regional centres fill prescriptions for the health centres. The pharmacist and pharmacy technicians at the QGH in Iqaluit fill prescriptions for all hospital patients. r e h a b i l i tat i o n s e rv i c e s

Access to rehabilitation services, including audiology, speech-­ language pathology, physiotherapy, and occupational therapy varies across the territory. Tertiary rehabilitation services such as those for burn injuries, acquired brain injury, and amputations are not available in Nunavut, nor are there any dedicated beds at the QGH for rehabilitation purposes. With the exception of Iqaluit, which has a rehabilitation team comprised of speech therapists, occupational therapists and physiotherapists, most rehabilitation staff are contracted to visit communities on a scheduled basis. In the Kivalliq region, the J.A. Hildes Northern Medical Unit’s office in Rankin Inlet provides most rehabilitation services, including speech pathology, occupational therapy, and physiotherapy, through a service agreement with the DHSS. The Stanton Hospital in Yellowknife has a similar service agreement to provide rehabilitation services for residents in the Kitikmeot region.

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The Iqaluit rehabilitation team travels to all the communities in the Qikiqtaaluk region once a year. At the QGH, a respiratory therapist, four audiologists, and an orthotist are contracted to provide services in Iqaluit. home care

Home care includes nursing care, respite care, palliative care, case management, rehabilitation services, homemaking, advanced foot care (if a home care nurse has the certification), and personal care services provided to individuals so that they can remain living in their homes rather than in long-term care facilities or other institutions. Services are delivered by four groups of workers. Home care nurses provide the clinical nursing services, including physician examinations, blood work, and advanced foot care if they have the necessary training. Level 1 home and community care workers provide basic services such as homemaking, cooking, and shopping. Level 2 home and community care workers provide basic hygiene services, including bathing and feeding. Finally, home and community care representatives or home and community care coordinators provide interpretation services for Inuit clients. The type of home care services available in any community depends on population size, health needs, and the availability of home care nurses as well as community care workers (level 1 and level 2). Most small communities have home care services available as needed, with home care workers or personal aides hired according to need, while larger communities have at least one home care nurse. long-term care

Residents requiring long-term care facilities are sometimes sent out of territory to locations across Canada because of the pressure on existing facilities in the territory. In 2009 there were eleven residential care facilities and group homes across N ­ unavut providing level 2 to level 5 care for both children and adults. While the GN provides the operational funding for the residential

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centres, the actual operations are the responsibility of not-forprofit organizations. The only exception to this is the Akausisarvik Centre in Iqaluit, which is staffed and operated by the government of Nunavut. pa l l i at i v e c a r e

Palliative services differ between communities based on community need and available staffing. Home care nurses provide most of palliative care services in the patients’ home. When home care nurses are not available, some CHNs will provide this service as needed. In some communities, such as Igloolik, home and community care workers also provide twenty-four-hour respite care services for the caregivers of palliative patients. This makes it possible for most residents from remote communities to die at home (Quality End of Life Care Coalition 2008). Institutional palliative care services are not available at the CHCs. There is a palliative care unit at the QGH in Iqaluit and an in-patient palliative bed at the Kivalliq Health Centre in Rankin Inlet. A DHSS hospice for palliative care patients is located in Coral Harbour. The hospice provides several services for f­ amilies and patients including home support services such as homemaking, nursing visits, respite care for caregivers, and pastoral services. d e n ta l s e rv i c e s

One of the serious gaps in service provision in Nunavut is preventative dental health care, especially amongst children. According to Schroth (2006) it is a common occurrence for children to be sent to Iqaluit or out of territory for treatment under anesthesia for the extraction of teeth because of tooth decay. Access to dental services is a priority area, especially for children. For example, about 57 percent of Inuit children in Nunavut received dental treatment in the twelve months before the 2006 Aboriginal Health Survey (Tait 2008). Access to dental professionals for teenagers and adults is lower than the Canadian average: 56 percent of Nunavut residents report contact with dental

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­ rofessionals, compared to 64 percent on average for residents p of Canada (Statistics Canada 2005). The DHSS provides some dental services, including prevention services – oral health, education, fluoride, rinses, screening, and referral – through dental therapists. These services target mainly children, although adults are also treated on an emergency basis (Quiñonez et al. 2005). However, judging by a recent inventory of health services, there is a critical shortage of dental therapists throughout Nunavut, despite the great need for oral health ­(Marchildon and Torgerson 2010; NAHO 2003). Only Iqaluit has resident dentists, through two private clinics. The DHSS contracts with dentists, denturists, and orthodontists in Canada to visit other communities on a scheduled basis ­(Quiñonez 2006; Schroth 2006).11 In all three regions, oral surgeons and orthodontists visit regional centres, and residents from outlying communities are flown in during clinic days. Dentists and denturists are contracted to visit all the communities periodically. In response to the need to improve dental service delivery in the territories, the governments of Nunavut and the Northwest Territories initiated a Pan-Territorial Oral Health Initiative (Uswak 2007). The final report of this initiative included recommendations for the more effective recruitment and retention of dental therapists (many of whom are being drawn into private clinics), the provision of oral health surveillance, and the development of best practice guidelines for dental health professionals (Uswak 2007). eye care

Most optometry services are provided through contracts with out-of-territory opticians and eye technicians who fly into the hamlets on a preset schedule. For example, in 2009 Pangnirtung was provided with a minimum of twelve days of vision care services per month. The Kitikmeot and Kivilliq regions are served from providers based in Yellowknife, while vision care services for the Qikiqtaaluk region are contracted through the ­University of Ottawa Eye Institute and optician services are contracted through the Polar Vision Centres’ office in Iqaluit.

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Table 6.4 Infant Mortality Rates per 1,000 Live Births, Canadian Territories, 2007 Territory

Rate

Nunavut Northwest Territories Yukon Canada

15.1   4.1   8.4   5.1

Source: Statistics Canada (2010). Note: Infant death is the death of a child under one year of age. Infant death rate is the number of infant deaths during a given year per 1,000 live births in the same year.

m at e r n i t y s e rv i c e s

Maternity care services in Nunavut remain a high priority because of the high rates of teen pregnancy and infant mortality. For instance, while the infant mortality rate declined substantially between 1999 and 2005, Nunavut still has a significantly higher infant mortality rate than the Northwest Territories and the Yukon (table 6.4). Finally, 23percent of live births in Nunavut in 2007 were to teenage mothers, in comparison with 9 percent for the Northwest Territories, and 5.1 percent for Yukon (Statistics Canada 2007). The majority of prenatal and postnatal services are provided by CHNs, some of whom have advanced training as midwives.12 In Arviat and Rankin Inlet, women have access to the services of midwives and maternity care workers at the Old Health Centre building, although deliveries are done at the Kivalliq Health Centre because of the availability of an emergency room in case of unforeseen emergencies (see box 6.3). In Iqaluit, nurse practitioners working at the Family Practice Clinic can provide limited pre- and post-natal care, but they generally refer women to family physicians at the QGH out-patient clinic. Obstetricians provide clinics in Iqaluit as well as visit communities, but as a rule, they do not deliver babies. The DHSS has a firm policy against CHNs providing care during labour and birth, even for low-risk pregnancies, at isolated CHCs owing to unpredictable weather conditions and the long

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Box 6.3  Rankin Inlet Birthing Centre In operation since 1992, the Rankin Inlet Birthing Centre provides family-centred care for low-risk expectant mothers in the Kivalliq region.13 The birthing centre is made up of two clinic rooms as well as birthing rooms. Over five hundred babies have been delivered since the centre opened (Nunavut 2009f). The centre is located in the Old Health Centre, although deliveries are done at the Kivalliq Health Centre in case of an emergency. Staffed by four midwives and two maternity workers, the centre provides care that is aligned with Inuit language and traditions. Although travel is required for a number of mothers in the region, the shorter distance means that family members are more likely to be present (NTI 2008; Couchie and Sanderson 2007).

flights associated with medevacs.14 In addition, the high number of low birth-weight babies in Nunavut often results in the need for more specialized services. Thus, while most CHCs have a birthing room set up for emergencies or an emergency room that doubles as a birthing room, women generally have to leave their home communities at least one month in advance of their due dates to give birth in southern Canada, at the QGH in Iqaluit, or at the regional health centres (Healey and Meadows 2007; PHAC 2009). As a result, these women are often alone in an unfamiliar place for up to five weeks before delivery. The dislocation caused by childbirth can create financial stress, child care problems for older children, and a painful separation from family during the birthing process (NAHO 2006).15 Recently, a movement has been under way in Nunavut to return the range of maternity care services back to the community and incorporate traditional methods in order to better meet the needs of Inuit women and, in the process, increase birth weights and reduce infant mortality rates (Douglas 2007; NAHO 2006). In 2009, the DHSS released a Maternal and Newborn

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Health Care Strategy in order to increase (1) local capacity and participation in Nunavut maternity care services; (2) the number of maternity care workers and registered midwives; and (3) the number of pregnant women receiving early, comprehensive, and culturally relevant prenatal and birthing services (Nunavut 2009f). Nunavut Arctic College trains midwives and maternity care workers, emphasizing Inuit midwifery practices and traditional birthing methods and protocols. In 2008, the Midwifery Profession Act was passed to regulate midwifery in Nunavut. The act states that it is the responsibility of the Minister of Health and Social Services to provide training on traditional Inuit midwifery knowledge, skills, and judgment, and it stipulates that traditional Inuit midwifery must be incorporated into education and training programs in the territory. c h i l d a n d y o u t h h e a lt h s e rv i c e s

Nunavut’s growing population translates into more pressure for child health and youth services. As noted throughout this chapter, children in Nunavut are at risk for dental caries, serious ear infections, malnutrition, and respiratory diseases owing to food insecurity, overcrowding, and second-hand smoke. Inuit youth in Nunavut have high rates of suicide, teen pregnancy, and sexually transmitted infection, which require more comprehensive mental health and public health services that involve not only community development but the active engagement of youth in program development. Child health services are provided through the CHNs, and the CHRs provide public health services directed at children and youth in the community, although the type and level of service depends greatly on the training and comfort levels of the CHR. As noted above in the section on public health, there are several federal programs aimed at raising the health outcomes of Aboriginal children, including the Canadian Prenatal Nutrition Program and the Aboriginal Head Start Program. There are also other programs funded through the government of Nunavut that are aimed at strengthening child-parent bonds, programs such

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as Moms and Tots. These services are often delivered through the hamlet office and are often siloed from the services delivered through the CHC. Pediatricians visit most of the communities in Nunavut for several days a year according to population need. In 2009–10, pediatricians and pediatric residents from the Children’s Hospital of Eastern Ontario were contracted to provide 620 service days to the Qikiqtaaluk region.16 Pediatricians contracted through the Northern Medical Unit at the University of Manitoba were budgeted to provide 67 service days for communities in the Kivalliq region for both 2008–09 and 2009–10. Finally, pediatricians from the Stanton Hospital in Yellowknife were contracted to provide 33 service days to the communities in the Kitikmeot region for the 2008–09 and 2009–10 fiscal years. Apart from the services provided by visiting rehabilitation staff and pediatricians, there are few supports and services available in the communities for special needs children, including those with fetal alcohol syndrome, autism, and other serious physical disabilities. Most children are flown to larger centres to access needed specialized services. None of the communities have any programs for parents of children with special needs. There are some facilities in Nunavut, however, that provide residential-care services for special needs children. As noted in chapter 4, level 2 residential care is available for special needs children at three centres: the Naja Isabelle Home in Chesterfield Inlet and the children’s group homes in Rankin Inlet and Iqaluit. e m e r g e n c y s e rv i c e s

Patient stabilization and emergency services are mainly provided by the CHNs at the CHCs. Emergency first aid services are also available in some communities from the Canadian Rangers, who are part-time reservists in the Canadian Army. All the CHCs have an emergency room, which is equipped with a defibrillator and pain relief medications. None of the CHCs, however, have units of blood, and many do not have satellite phones. Only Rankin Inlet, Pangnirtung, and Iqaluit have ambulances, which are operated through the municipal governments.17 Since

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there are no formal arrangements in most other communities through the DHSS, emergency ground services are often provided either through local taxis or by using CHC or home care vehicles. As is the case with other jurisdictions, the DHSS does not have responsibility for the costs of ground ambulance services; instead, the costs are covered through federally funded NonInsured Health Benefits (NIHB) for the Inuit population. Other residents must cover the costs out-of-pocket or through thirdparty insurance plans. diagnostics

Each health care centre has a portable x-ray unit, the majority of which were purchased between 1999 and 2006. The basic radiography unit and processor allow for x-rays of chests and extremities. The CHNs at the CHCs provide basic diagnostic services, although there is typically a janitor, caretaker, or clerkinterpreter who also serves as an x-ray assistant. At the Kitikmeot Health Centre in Cambridge Bay, a full time x-ray technologist and a basic radiography worker provide more advanced x-ray tests. All the films in the Kitikmeot region are sent to radiologists at the Stanton Hospital in Yellowknife. The regional health centre in Cambridge Bay does not have a sonographer, though ultrasounds are performed by the visiting obstetrician/gynecologist from Stanton Hospital every three or four months. There is also a full-time x-ray technologist and a basic radiography worker at the Kivalliq Health Centre in Rankin Inlet. A sonographer is on contract from Winnipeg to provide locum services to Rankin Inlet for two weeks every month. The QGH in Iqaluit provides diagnostic imaging services to support the clinical programs in its region. These diagnostic imaging services include general radiography (x-ray and fluoroscopy), mammography (diagnostic only), and ultrasound. While most radiography tests can be performed at the QGH, since the hospital did not have a radiologist on staff in 2010, images were sent from the hospital twice a week to radiologists from Diagnostic Imaging Consultants Inc., based in Ottawa. Once every three months a radiologist from Diagnostic Imaging Consultants

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travelled to Iqaluit and performed special examinations such as barium and upper gastrointestinal studies. Only diagnostic mammographys are available to women in Nunavut. Women wishing to have a screening mammography must pay for their own travel to a southern location. Diagnostic mammography is provided at the QGH for women in the Qikiqtaaluk region. The QGH also has an advanced laboratory that is able to perform hematology, coagulation, chemistry, and microbiology tests for the Kivalliq and Qikiqtaaluk regions. The laboratory team performs mycobacteriology tests (e.g., for tuberculosis) for the CHCs in the Qikiqtaaluk region. The Kitikmeot Health Centre in Cambridge Bay conducts chemistry, hematology, coagulation, and urinalysis tests for the Kitikmeot Health Centre. The four other CHCs in the region send all their laboratory tests to DynaLife Diagnostic Laboratory Services in Edmonton, which has held the contract with the government of Nunavut since 2005. The laboratory at the Kivalliq Health Centre in Rankin Inlet runs the same tests, although the tests are also conducted for the other CHCs in the region. More advanced tests, such as tests for microbiology or virology, are sent either to the QGH in Iqaluit or the DynaLife laboratory in Edmonton. Each CHC has a laboratory that is used by the CHNs to run basic tests such as manual white count, urinalysis, glucose testing, hemoglobin testing and wet-mount (trichomonas and yeast) testing. The CHNs also draw the blood for the blood tests and send the specimens to the laboratories in Rankin Inlet, Iqaluit, or Edmonton.18 Specimens for pap smears are collected by the CHNs at all the CHCs, and the specimens are all sent to the DynaLife laboratory. There is a higher-than-average uptake of pap smears in Nunavut, perhaps owing to regular testing during Well Woman clinics at the CHCs. Given the small size of the population, Nunavut’s residents benefit from a broad range of diagnostic services relative to the rest of Canada. By the same token, however, the inevitable time lags and delays that would be involved in relying on outof-­territory facilities and personnel for diagnostic services argue against outsourcing even more specialized services to out-of-­

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territory facilities despite the high cost of maintaining this infrastructure and specialized personnel in the territory. a f t e r d e at h s e rv i c e s

Body storage, transportation, and arrangement services vary across the communities in Nunavut. The CHCs in the larger communities such as Arviat, Igloolik, Pangnirtung, Rankin Inlet, Cambridge Bay, and Pond Inlet have morgues, as does the QGH in Iqaluit. According to a DHSS policy, the morgues at the CHCs provide temporary body storage – storage over the winter months is not the responsibility of the DHSS. Sheds, sea cans, community freezers, and garages  – especially RCMP garages  – are used to provide either short-term or long-term body storage in most communities. There are no embalming or cremation facilities in Nunavut. Because of the lack of funeral parlours in Nunavut, most body arrangements are made by family members, although church groups and women’s auxiliary groups assist on occasion. Body-arrangement services are occasionally provided by CHNs, depending on the community and situation. s p i r i t u a l a n d a lt e r n at i v e c a r e

There are no alternative-care practitioners, including acupuncturists, massage therapists, or herbalists providing services in Nunavut. Spiritual care is either provided by elders in the communities or as is the case in the majority of the communities, by ministers and lay ministers in the community. Most of the population in Nunavut in 2011 reported their main religion as either Protestantism (67 percent) or Catholicism (23 percent), mainly because of missionaries who arrived in the Canadian Arctic at the turn of the twentieth century (Laugrand and Oosten 2007). The intersection between spirituality and health service provision in the north requires further investigation. b l o o d s e rv i c e s

None of the CHCs have a stock of the blood that would be required for use in emergencies and patient stabilization.19 The

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QGH in Iqaluit has a blood bank, which carries units of whole blood and platelets for surgical procedures and patient stabilization, if needed. To this effect, the hospital has a blood bank incubator and a laboratory technician with a blood bank license. Of course, the long distances required to get blood products from Iqaluit or out-of-territory sites to remote communities in the territory remains a challenge in delivering timely and effective treatment.

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7 Mental Health and Addictions

t h e s tat e o f m e n ta l h e a lt h i n n u n av u t

As a consequence of the high incidence of suicide, as well as substance abuse, there is increasing concern about the state of mental health in Nunavut. Registering a rate of suicide that is among the highest in the world, Nunavut’s communities have become the focus of intensive study (Nunavut et al. 2009). Multi-­factor explanations vary, but most studies point to the association between rapid social change brought about by modernization and colonization and the resulting changes in family and community relationships, as well as a decline in self-esteem (Hicks 2007; Law and Hutton 2007). A further complication is the transitory nature of mental health services for many communities, since the professionals, who are drawn mainly from southern Canada, may lack an intimate understanding of Inuit communities, languages, and dialects. There are several specific risk factors for mental distress and suicide, including limited jobs and opportunities, a lack of social supports, disruptions in community control and self-­determination, and the interruption of the transmission of cultural tradition and identity. Inuit youth are particularly susceptible to these risk factors (Kirmayer et al. 1999; Kirmayer, Brass, and Tait 2000). Protective factors are the mental attitudes and assumptions that reduce distress and the risk of suicide, including high self-esteem; a sense of belonging; a strong sense of the value and meaning of

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life; a belief in the value of survival and coping; a fear of dying or of the act of suicide; moral or religious objections to suicide; stress management, communication, and problem solving; support from peers and family; family responsibilities; community support networks; and access to effective counselling and mental health services (Kirmayer et al. 1999; Mignone and O’Neil 2005; Nunavut et al. 2009; Royal Commission on Aboriginal Peoples 1995). More specifically, explanations for higher rates of mental distress in Nunavut centre on the collapse of whaling and the fur trade, resettlement and relocation, residential schools, the establishment of the Distant Early Warning (DEW) line sites during the Cold War, and the introduction of radio, television, alcohol, and drugs (Hicks 2007; Kirmayer et al. 2000; Kral and Idlout 2009; Kral 2003).1 The imposition of southern culture and lifestyle on the Inuit population undermined traditional values and support networks in a very short time (King 2006; Pauktuutit Inuit Women of Canada 2007). The residential school system, commonly known by the Inuit as “away schooling” because it separated Inuit children from their families, also had a negative impact on the mental health of individuals and the Inuit cultural fabric even though it operated in a less systematic manner in the eastern Arctic (Miller 1996; Milloy 1999; Kral et al. 2009).2 i n c i d e n c e o f m e n ta l i l l n e s s a n d a d d i c t i o n s i n n u n av u t

The residents of Nunavut were slightly less likely than Canadians as a whole to rate their mental health as either very good or excellent, though they were more likely to do so than residents of the Northwest Territories (table 7.1). At the same time, the residents of Nunavut were more likely to self rate their mental health as fair or poor than residents in the other two territories. Suicide Rates Suicides have occurred at least once a year in the region that is now the Nunavut territory since 1975, and the rate accelerated rapidly beginning in the 1980s. While the suicide rate among

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Table 7.1 Self-Rated Mental Health in Canada’s Territories, 2009 Territory Nunavut Northwest Territories Yukon Canada

Very Good or Excellent (%)

Fair or Poor Mental Health (%)

70.3 63.4 75.5 74.4

6.9 6.1 5.5 3.0

Source: Statistics Canada (2010).

other indigenous populations such as the Norwegian Sami and the Inuit population in Greenland peaked in the 1980s, the dramatic rise in the suicide rates for the Canadian Inuit began during this period and has continued (Silvekin and Kvernmo 2008; Tester and McNicoll 2004). Hicks (2007) argues that the “temporal sequence in which the ‘regional suicide transitions’ occurred is noteworthy, as it mirrors – roughly one generation later – the processes of ‘active colonialism at the community level’” (31). If this diagnosis is accurate, then the suicide rate should begin to decline within a generation, which would be similar to the pattern exhibited in northern Norway and Greenland. However, the question remains: what interventions, if any, might be effective in reducing the rate and mitigating the psychological and other health consequences in the next few years? Addictions and Alcoholism In 2009, Nunavut had a self-reported rate of heavy drinking that was lower than that of the other two territories and only slightly higher than that of Canadians as a whole (Statistics Canada 2010).3 Nonetheless, binge drinking, defined as having more than five drinks on a single occasion twelve or more times a year, is a concern throughout northern Canada (Korhonen 2004; Spien 2008), and Nunavut’s rate of binge drinking is higher than that of any other province or territory, with the exception of the Northwest Territories (Statistics Canada 2003). At the same time, interviews with health providers revealed the prevalence of

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illicit drug abuse, particularly the chronic use of marijuana – a drug that is light and relatively easy to transport compared to alcohol – and reported cases of drug-induced psychosis. m e n ta l h e a lt h s e rv i c e s

Mental health services range from the treatment of acute psychiatric disorders to mental health education and promotion. Other services include the support and rehabilitation of persons with severe and persistent psychiatric disorders and disabilities. The situation in Nunavut differs from more urban southern jurisdictions because residents with serious mental illnesses are often sent out of territory, while those with milder symptoms are generally seen by community or mental health nurses before they are seen by physicians or psychiatrists. The Department of Health and Social Services (DHSS) provides the overall direction for service delivery and programming related to mental health and addictions.4 Mental health and addictions services, such as counselling, group healing sessions, community wellness workshops, case management, and crisis management, are coordinated and delivered through the regional offices located in Rankin Inlet, Cambridge Bay, and Pangnirtung. In 2002, the DHSS launched its first mental health and addictions strategy, emphasizing prevention and community participation in program development (Nunavut 2002). In 2002, the Annirusuktugut Suicide Intervention and Prevention Strategy was introduced to address the high rate of suicide in the territory (Nunavut 2007c), but it was highly criticized for not incorporating evidence-based strategies or input from frontline mental health workers (Nunavut 2009j). In response, the Working Group for a Suicide Prevention Strategy for Nunavut, comprised of representatives from the government of Nunavut, the Nunavut Tunngavik Inc. (NTI), and the Embrace Life Council (see box 7.1) was formed to review the current knowledge of suicidal behaviour and suicide prevention strategies in Nunavut. In 2009, after meeting on a weekly basis, the working group recommended that several actions be implemented, including the development of an Office for Suicide Prevention and additional

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Box 7.1  Embrace Life Council The Inuusirmi Katujjiqatigiit (Embrace Life) Council, is a partnership between several organizations, including the government of Nunavut, Nunavut Tunngavik Incorporated, the Federation of Nunavut Teachers, the Qikiqtani Inuit Association and the Royal Canadian Mounted Police (RCMP). It provides community-based actions to prevent suicide and promote wellness. Established in 2004 though a Nunavut Legislative Assembly direction, the Embrace Life Council coordinates suicide prevention and community wellness principles, such as running youth camps that teach youth about coping strategies, suicide prevention, and depression. In addition, the council holds workshops in which success stories are shared and trains community volunteers to provide preventative and community mental wellness services (Embrace Life Council 2006; Kral et al. 2009). The philosophy behind the workshops is to get participants to focus on the more positive aspects of their communities and lives.

support for community-based groups and initiatives (Nunavut et al. 2009). In 2009, the Government of Nunavut and NTI announced a new program  – Uqaqatigiiluk! Talk About It!  – to assist caregivers, friends, and front-line workers with suicide prevention. The two-day training program is an adaptation of the Applied Suicide Intervention Skills Training (ASIST) workshops developed by the Calgary-based LivingWorks Education. The adaptation process and the initial training programs are funded through Health Canada’s Aboriginal Health Transition Fund (NTI 2009a). To a great extent, mental health promotion and suicide prevention have been largely community-based initiatives in Nunavut, based on the assumption that the most effective strategies are those in which community members take responsibility for service design and implementation. Much of the more recent

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Aboriginal health research describes successful examples of communities taking control of programs designed to reduce mental distress, restore community wellness, and reduce suicides among youths (Kral et al. 2009; Kral and Idlout 2009; Royal Commission on Aboriginal Peoples 1995). Community-based wellness services are available in some communities through funds from several federal programs, including Brighter Futures and Building Healthy Communities.5 In addition, the Embrace Life Council, in partnership with the First Nations and Inuit Health Branch of Health Canada and the National Inuit Youth Council, provides services and support for youth in order to reduce suicide rates. This initiative, called Inuusivut, Our Way of Life, builds community capacity to promote mental health as well as facilitate information sharing between governments and communities (Embrace Life Council 2008).6 Community-based organizations are also involved in providing suicide prevention, counselling, and crisis intervention throughout Nunavut, although the level and type of activity varies considerably across communities and regions. Several communities in the Qikiqtaaluk region have active elders’ groups that provide suicide prevention services, counselling, and crisis intervention that incorporate traditional Inuit knowledge and skills.7 There is also a helpline available in Nunavut that provides crisis intervention and support (see box 7.2). Finally, NTI runs a mobile treatment project that provides month-long treatment programs consisting of one-on-one and group counselling and traditional healing, as well as workshops on grieving, coping skills, anger management, and healing and sharing circles. Beginning in 2003 with funding from the Aboriginal Healing Foundation, the project focuses on addressing the needs of former residential-school students and their families, although it is open to anyone who needs healing from trauma or abuse (Aboriginal Healing Foundation 2008; NTI 2009b). Clinical Mental Health Services Clinical mental health service delivery at the community level varies according to community needs and available resources. Community health nurses (CHNs) are often the first point of

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Box 7.2  The Kamatsiaqtut Helpline The Kamatsiaqtut (“thoughtful people who care”) Helpline provides crisis response for Nunavut residents daily between 7 p.m. and midnight. Started in 1989 by community members as a response to the increases in suicides in the Baffin area, the helpline is staffed by volunteers, mainly women, who provide anonymous telephone counselling. An evaluation of the helpline in 2004 showed a high usage by Nunavut residents dealing mainly with boredom and relationship issues, although a small minority called about suicidal thoughts and intentions. Slightly more than half (54 percent) of the callers were female, and a small minority of the callers were either youth (15 percent) or children (3 percent) (Tan et al. 2004). The longevity of the helpline has been attributed to its origins as a community response to suicide and to the anonymity callers can enjoy when discussing concerns within often tightly knit communities (Levy and Fletcher 1998). The helpline is funded by private donations and the government of Nunavut.

c­ ontact for primary care delivery because they provide screening for mental health issues and are often on call after clinic hours if a crisis arises.8 CHNs do not provide these clinical services alone: they are supported by family physicians (often by telephone), as well as non-resident (travelling) mental health nurses, social workers, and community health representatives. Some of the larger communities have resident mental health nurses who are either registered psychiatric nurses or registered nurses with additional experience in mental health. While there are several titles for mental health nurses in Nunavut, these nurses often work within a broad scope of practice, from counselling to providing referrals for institutional treatment.9 Mental health nurses are often responsible for several communities, providing support to CHNs and counselling for patients by telephone or email.10

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Other than one psychologist who works in the corrections system, there are no psychologists employed in Nunavut. In contrast, psychiatrists make scheduled visits to communities throughout Nunavut; the number of visits and their duration depend on the size and needs of the community. Psychiatrists contracted from the University of Toronto Psychiatric Outreach Program visit the communities in the Qikiqtaaluk Region. In 2009, a psychiatrist was contracted to provide psychiatric services at the Qikiqtani General Hospital as well as to work part-time on developing mental health programming for the Qikiqtaaluk Region. Psychiatrists are also contracted through the Northern Medical Unit to provide services for the Kivalliq region, while those contracted through Stanton Hospital in Yellowknife serve the Kitikmeot region. Nunavut does not have an acute psychiatric care facility, nor is there a detoxification facility. Patients from the Qikiqtaaluk and Kivalliq regions are sent to out-of-territory institutions such as the Selkirk Mental Health Centre in Winnipeg. Patients from the Kitikmeot region are sent to the Stanton Hospital Mental Health Clinic in Yellowknife for treatment and rehabilitation. Assessments and treatment for youth in Nunavut are provided at various out-of-territory facilities (Nunavut 2007b). The Akausisarvik (“our place of healing”) Mental Health Treatment Centre in Iqaluit provides life-skills services for up to thirteen residents and six-day clients. The centre opened in 2002 and was initially operated by the Pairijait Tigumivik Elders’ Society. In 2005, the government of Nunavut took over operations and provides care for individuals with depression, anxiety disorders, bipolar disorder, and schizophrenia. The centre provides mainly life-skills services for the residents but also some basic mental health services when required. a d d i c t i o n s s e rv i c e s i n n u n av u t

According to the Inuit Tapiriit Kanatami (ITK 2008), 63 percent of the Inuit population reported consumption of alcohol in 2001. While this rate is less than the Canadian average, there is a higher-than-average incidence of binge drinking (Korhonen 2004; Spien 2008; Statistics Canada 2008). The response by

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many northern communities has been to restrict or ban the sale or consumption of alcohol. Some communities restrict alcohol by requiring residents to apply for a permit from local alcoholeducation committees. Some smaller communities such as Whale Cove, Sanikiluaq, and Gjoa Haven have a complete prohibition on alcohol. Interviews with health providers in these communities suggest that while prohibition impedes usage, it has also generated a black market in the transport and sale of alcohol. It has also raised the question of whether this policy encourages binge drinking or illicit drug use as a substitute for alcohol when it is unavailable or prohibitively expensive. While CHNs and mental health workers provide some addictions counselling and treatment, alcohol and drug workers employed by the hamlets provide most of the addictions counselling. These workers are community members who are able to provide services in Inuktitut, but their effectiveness is highly variable, depending on knowledge, skill, and individual initiative. Because there are no alcohol and drug detoxification treatment centres in Nunavut, residents are often referred to inpatient treatment centres out-of-territory. Addictions and trauma services are available through the Tungasuvvingat Inuit Mamisarvik Healing Centre, an Inuit-focused treatment centre located in Ottawa. The Healing Centre, funded by the government of Nunavut and the Aboriginal Healing Foundation, delivers counselling and addictions treatment that incorporates Inuit cultural practices, based on a model of care that considers unique Inuit trauma – for example, residential schools or forced relocations (ITK 2007). Residents may also be referred to the Isuarsivik Treatment Centre, located in Kuujjuaq, Quebec. The centre accepts a maximum of nine clients, and provides a twenty-day treatment program that incorporates Inuit language and culture. c h i l d a n d y o u t h m e n ta l h e a lt h s e rv i c e s

Very little is known about the need for – and gaps in – mental health services for children and youth. In particular, there is a limited understanding of the types of mental disorders currently

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affecting children and youth in Nunavut and what services might be most effective. There have been more general efforts, including the partnership between Health Canada and the government of Nunavut’s Department of Education to provide an overall analysis of mental health services pertinent to Inuit children and youth, with an emphasis on suicide prevention and crisis intervention. Under this initiative, several new programs, including the development of culturally appropriate assessments, school and family programs, and environmental control programs, have been established (Zamparo and Spraggon 2004).11 The feasibility and utilization of these programs in Nunavut is largely unknown. conclusion

Effectively addressing mental health and addictions in Nunavut involves much more than providing adequate mental health services. The Inuit residents of the territory have had to contend not only with rapid and destabilizing social change but also with unemployment, poor housing, food insecurity, and low educational levels. Any effective mental health strategy, including suicide and addictions prevention, must account for these factors.12 At the same time, the territory does not have adequate inpatient facilities for those suffering the severe effects of mental illness or addiction.13 As a consequence, some residents are required to spend long periods away from their families and communities, potentially slowing their recovery and making reintegration into their original homes more difficult. There is some ability to address these problems through mental health nurses, but at present, the large and dispersed case loads of the few mental health nurses working in the territory act as a major constraint.14

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8 Evaluating Policy, Planning, and Performance

Following the analytical description in the previous chapters, it is now possible to present a SWOT (strengths, weaknesses, opportunities, and threats) analysis of the health system in Nunavut. A final section addresses the potential benefits and challenges of comprehensive health service planning in Nunavut. The reader should be aware that this chapter is highly interpretive in evaluating strengths and weaknesses and necessarily speculative in identifying challenges and opportunities. Also, any identified weaknesses and threats must be put into the context that the territory has existed for a very short time relative to other provinces and even territories. current strengths

The clearest strength in Nunavut is the current state of primary health care delivery. Regardless of size, each hamlet in the territory has a professionally staffed community health centre (CHC). Unlike most of southern Canada, where the majority of primary care is still delivered by physicians providing a narrow range of medical services, the health care teams in every CHC provide a remarkably broad range of primary medical care services. In addition, each CHC delivers a suite of illness prevention, health promotion, and public health services that is much more extensive than is typical in the south, where most primary health care continues to be organized and delivered by family physicians in traditional medical clinics.

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Reform efforts in other Canadian jurisdictions have sought this type of integrated downstream (illness) and upstream (wellness) care, but no provincial health system has been able to go beyond what has already been achieved in Nunavut. Moreover, even though the First Ministers’ Ten Year Plan of 2004 committed all provinces and territories to provide 24/7 primary care within a decade, Nunavut residents have been receiving 24/7 primary care since the territory was established. A further strength is Nunavut’s system of medical referral, travel, and accommodation for specialized treatment outside the territory. Though expensive and time-consuming to administer, this system ensures that all residents receive any specialized acute and chronic care treatment that is not available within the territory. This access to treatment, including the delivery of babies in medical centres hundreds, even thousands, of kilometres from home communities, has reduced historically high rates of mortality and morbidity. Given its more limited system of medical transportation, Greenland provides an interesting point of comparison. Although both Nunavut and Greenland have almost identical outcomes in terms of life expectancy, Greenland’s perinatal mortality rate is one-third higher than the rate in Nunavut and almost three times the Canadian and Danish averages (Young 2008). In recent years, the government of Nunavut has increased the range and number of medical services provided in the territory by physicians and other health professionals. This was possible in part because of long-term arrangements and partnerships involving the University of Manitoba’s Northern Medical Unit, the Ottawa Health Services Network, and the Stanton Hospital in Yellowknife. In addition, Nunavut’s Department of Health and Social Services (DHSS) has created a pool of family physicians that it has hired directly on contract. These physicians now provide services on a regular basis in the territory. An additional strength is the extent to which health services are organized and directed by the government of Nunavut. In contrast to all other jurisdictions in Canada, there is no division between Aboriginal residents and all other residents with respect to service administration and delivery. Even key aspects of the federal non-insured health benefits (NIHB) program for First

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Nations and Inuit are administered by the DHSS, offering the potential to minimize conflicts between territorial and federal program objectives. Perhaps the most unusual aspect of this control is the extent to which health professionals and paraprofessionals are regulated directly by the DHSS. This has created a degree of control that allows the government of Nunavut more potential than any other province or territory to shape its education and training requirements so as to facilitate its health reform and service delivery objectives. current weaknesses

The most significant weakness within the Nunavut health system is workforce capacity, in particular, the inadequate capacity to deliver the range of services needed to address some of the more pressing health disparities and manage a complex health system for a geographically dispersed population. On the delivery side, there is a constant struggle to recruit and retain sufficient CHNs. Retention is a key factor in ensuring continuity of care, but the shortage of indeterminate CHNs has forced the DHSS to rely on casual and agency nurses to fill positions on a temporary basis, despite the negative impact this practice has on the continuity of care within individual communities. As difficult as this problem may appear, it pales in comparison to the challenge of educating and training Inuit residents as CHNs. In contrast to Greenland, where the majority of nurses are Indigenous Greenlanders, Nunavut had only five Inuit CHNs in 2009 – only 3 percent of the CHN workforce. Inuit providers are likely essential for the ability of the territory to sustain a permanent workforce and continuity of care. Moreover, Inuit nurses who are drawn from the communities they serve are in the best position to provide culturally appropriate and effective services. At a minimum, they can deliver services to community members in their own language or dialect. At the same time, certain acute health care challenges will require the services of more specialized health personnel. Given the growing prevalence of dental disease, mental illness, suicide, and addictions, the absence of dental therapists and mental

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health nurses in most communities is a major gap in Nunavut’s primary health system. Without the professional skills of these individuals, too much pressure is exerted on CHNs, community health representatives, visiting physicians, and others who may not have the appropriate set of skills or the time to address these pervasive health challenges. Although there is an extensive telehealth network and supporting broadband, the territory’s ability to reap the full benefits of this information-communication technology (ict) remains constrained by limited operator (generally CHNs) and technical support (generally non-resident) capacity. A similar human resource capacity problem applies to the extensive data collection by CHC staff and other health care providers and administrators. Overall, the DHSS still lacks the capacity for managing and using this wealth of information to inform clinical, managerial, planning, and policy decision making. Other weaknesses in capacity relate directly to the ability of the DHSS to steer, manage, and administer the health system as a whole. They include the difficulty of recruiting and retaining employees, especially Inuit with the requisite education and experience, who can provide both policy and long-term planning advice and management. In the area of finance and contract management, continual turnover has limited the capacity of the Department of Health and Social Services to operate effectively and efficiently. f u t u r e o p p o rt u n i t i e s

As the cost of information and communications technology continues to decline, there will be increased opportunities to provide health services and referrals more rapidly and at less expense. The effective use of ICT, which will require improved ICT support and training of health personnel, could improve the delivery of care in Nunavut while reducing the need to fly residents out for diagnostic purposes. In economic terms, Nunavut is growing rapidly relative to the rest of Canada. With this wealth creation, own-source public revenues will grow, reducing (at least slightly) the government of

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Nunavut’s dependence on federal government transfers. In the more distant future, this shift should create a more sustainable domestic tax base from which health funding will be drawn. Increased economic activity will likely be matched or exceeded by the government of Canada’s strategic infrastructure investments in Nunavut, which are designed to more effectively exert sovereignty in the Arctic, thereby generating numerous employment opportunities for those residents with sufficient education and skills. Meaningful employment is one of the most important social determinants of health. If prosperity can be combined with some traditional features of Inuit culture to create an economy and society that maximizes the opportunities for Inuit youth while minimizing overall disparities, this combination will inevitably improve health status and reduce the need for at least some health care services. f u t u r e t h r e at s

Education is a key determinant of health. In Nunavut, the low levels and low quality of education translate into one of the most serious threats to the ability of residents to take advantage of future opportunities (McGregor 2010). Moreover, unless the gap in educational attainment between Nunavut and the rest of Canada begins to close over the next decade, it will continue to have a deleterious impact on health status and create an additional need for health services. As epidemiologists have demonstrated over the last three decades, increasing levels of illness and injury are associated with income inequality even more than they are with the absolute level of income and poverty (Wilkinson and Pickett 2009). Other determinants of health such as lifestyle and diet are also important. The current incidence of obesity and diabetes among Nunavut’s residents is lower than among residents of the Yukon and the Northwest Territories, as well as lower than the incidence among First Nation residents in the provinces. However, given current trends in diet and inactivity, it is only a matter of time before the territory faces an epidemic of obesity and diabetes and

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the consequent health care costs associated with treating these conditions and the illnesses with which they are associated. Nunavut’s health system is one of the most expensive systems in the world. The growth in costs, in particular the growing gap in per capita health spending in Nunavut relative to its sister territories, is not fiscally sustainable. If services are simply added without addressing underlying causes, at some point public-sector funding for health care will either crowd out spending on other critical public services, or health care funding will be cut in order to allow for other spending on essential public services. l o n g - t e r m h e a lt h s e rv i c e p l a n n i n g i n n u n av u t

At the time of writing, Nunavut did not have a comprehensive health plan that linked a set of clearly enunciated and transformative objectives and performance indicators with services, capital investments, and human resources. As well, there was no comprehensive performance management system by which progress could be monitored on an ongoing basis. Instead, the DHSS had several short-term plans concerning high-priority goals that included improving maternal and child health, improving mental health, reducing suicide and addictions, and improving the state of public health and nutrition. For the most part, these individual plans contained a set of defined goals to be reached in five to ten years. Included in some of these health sector strategies were evidencebased actions intended to meet the goals, along with performance indicators to determine whether the goals have been met. Although recent plans and strategies are not explicitly linked to each other, they do contain some common themes. First, they are focused on bolstering community wellness, emphasizing the connection between the social determinants of health and the ultimate health and well-being of the population, especially regarding such issues as suicide prevention. Second, they have emphasized the importance of achieving the best health outcomes for infants, children, and youth through public health initiatives (e.g., reducing smoking rates among pregnant women). Third, they have highlighted the need to reduce Nunavut’s dependence on southern institutions, workers, and services by developing a

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domestically based workforce and by having more health services in the communities. In terms of this third theme, it is important to note that the DHSS released the strategic plan Closer to Home in 2004. The plan’s objective was to increase workforce and service self-sufficiency in order to reduce the use of southernbased services, facilities, and workers. In particular, this involved increasing the number of residential care facilities and providing in-patient care services at new regional health centres in Rankin Inlet and Cambridge Bay (Nunavut 2004b). Longer-term planning requires robust data collection and management systems in order to monitor health system performance and pinpoint areas for improvement or resource reallocation. This planning includes the development of targets or benchmarks, mechanisms, and infrastructure by which to measure performance (Carroll and Dewar 2002). There are high costs associated with performance management, and the DHSS needs to carefully assess whether the potential benefits outweigh the costs, including the additional administrative burden this may place on front-line providers. The development of indicators in Nunavut is complex because several preset indicators and measures used by other Canadian jurisdictions are not transferable to the north or to the Inuit experience. Moreover, Inuit-specific data and indicators present a challenge, since most indicators used in evaluative research methodologies may not capture the realities of Inuit specific health outcomes. According to the Inuit Tapiriit Kanatami (2004, 7), the “lack of Inuit-specific data and resources for research hampers efforts to gather evidence for planning and program development.” Some of the health indicators defined as more important for Inuit (e.g., maternal health, infant health, and tuberculosis) are collected in every CHC. In fact, the DHSS has already invested significantly in collecting these data. The great challenge is determining how to use this rich data source in a more systematic and effective way to guide planning and policy for the future. Of course, the principal obstacle to implementing a sophisticated system of performance measurement and management is human resource capacity. The same could be said of all health system improvements but the challenge is more pronounced in

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Nunavut for at least three reasons. First, the territory is one of the coldest and most remote regions in the circumpolar world and, as a consequence, faces acute and chronic shortages of specialized health personnel, very few of whom are willing to live in the territory (Young 2012; Marchildon and Chatwood 2012). Second, owing to limited educational attainment and limited opportunities for health sector education and training in the territory, the indigenous pool that can be drawn on to work in the health system is extremely shallow. This forces the territorial government to rely heavily on out-of-territory personnel, many of whom leave after a few years of experience. Aside from the inevitable churn and lack of continuity this creates, it also perpetuates the ethno-linguistic divide between health system managers and clinicians and the population they serve. Finally, the fact that the government itself is little more than a decade old means that it is in the very early stages of building its own political and bureaucratic experience and thus capacity. This produces a conundrum, because in the absence of private, civil-society organizations that can take on some of the role of administering and delivering health services, even more pressure is exerted on the territorial government to do it all. While this governmental capacity in terms of health system governance, administration, and delivery will improve over time, it nonetheless exerts a real constraint on what can be accomplished in the immediate future.

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appendices

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appendix a

Territorial Laws Related to Health and Health Care in Nunavut

Table A1

Title of Law

Year Proclaimed or Adopted

Dental Auxiliaries Act, R.S.N.W.T., 1988, c. D-3 Dental Mechanics Act, R.S.N.W.T., 1988, c. D-2 Dental Profession Act, R.S.N.W.T., 1988, c. 33 (Supp.)

2001

Hospital Insurance and Health and Social Services Administration Act, R.S.N.W.T., 1988, c. T-3 Licensed Practical Nurses Act, S. Nu. 2010, c. 25 Medical Care Act, R.S.N.W.T., 1988, c. M-8

1998

Medical Profession Act, R.S.N.W.T., 1988, c. M-9

2001

2001

2001

2010

1998

Brief Description Governs the registration and licensing of dental hygienists and dental therapists in Nunavut. Governs the registration and licensing of denturists in Nunavut. Governs the practice of dentists and dentistry in Nunavut, including registration on the Dental Register. Governs the provision of insured hospital (as defined under the Canada Health Act) and other health services in Nunavut.

Governs the registration and licensing of licensed practical nurses in Nunavut. Governs the provision of insured physician services (as defined under the Canada Health Act) in Nunavut. Governs the practice of medicine in Nunavut, including registration of physicians (Medical Register).

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132 Appendices Table A1 continued Mental Health Act, R.S.N.W.T. (Nu.) 1988, c. M-10

2003

Midwifery Profession Act, S. Nu. 2008, c. 18 Nursing Act, S.N.W.T., 1988, c. 38, s. 4

2008

Ophthalmic Medical Assistants Act, R.S.N.W.T., 1988, c. O-2 Optometry Act, R.S.N.W.T., 1988, c. O–3 Pharmacy Act, R.S.N.W.T., 1988, c. P–6

1989

Psychologists Act, R.S.N.W.T., 1988, c. P-11 Public Health Act, R.S.N.W.T., 1988, c. P-12

1998

Tobacco Control Act, S. Nu. 2003, c. 13

2003

2003

2001

2001

1999

Governs involuntary psychiatric assessment, admission, and treatment in Nunavut, including the rights of patients concerning privacy and confidentiality. Governs the practice of midwifery in Nunavut, including registration (Midwifery Register). Governs the licensing and registration of registered nurses and nurse practitioners in Nunavut. Governs the registration of ophthalmic assistants, ophthalmic technicians, and ophthalmic technologists in Nunavut. Governs the practice of optometrists, including registration (Optometrist Register). Governs the registration and licensing of pharmacists in Nunavut, including registration (Pharmaceutical Chemists Register). Governs the practice of psychologists in Nunavut, including registration (Psychologists Register). Governs the roles and responsibilities of the chief medical officer and health officers in Nunavut, the establishment of municipal boards of health, the regulations and procedures for quarantine, and the medical care of work (non-resident) camp employees. Outlines the restrictions and prohibitions on the sale of tobacco products in Nunavut including sales to non-adults, advertisements in stores, and the sale of tobaccolike products.

Note: While there are circumstances in which this does not apply such as the Midwifery Profession Act, most laws were carried over (i.e., adopted) from the Northwest Territories as Nunavut statutes pursuant to the Nunavut Act (1999).

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appendix b

Scope of Practice for Community Health Nurses in Nunavut

Table B1 Comparison of Nursing Roles in Nunavut rn s

Duties and Functions Inform client of diagnosis Independent prescribing Independent ordering of diagnostic tests Independent treatment plans and orders Independent medical diagnosis Initiating treatment (utilizing guidelines) Ordering diagnostics (utilizing guidelines) Medical diagnosis (utilizing guidelines) Advanced health assessment Assessing clients with changing/ unstable needs Care for clients requiring complex care Basic nursing diagnosis/plans of care Transcription of medical orders Administering ordered medications Care for stable patients Basic nursing care Source: Nunavut (2008g).

Registered nurses (rns)

and nurse practitioners in chn role

Nurse Practitioners X X X X

x

X X

X

X

X

X

X X

X X

X X

X

X

X

X

X

X

X X

X X

X X

X X

X X

X X

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134 Appendices r o l e s a n d r e s p o n s i b i l i t i e s o f c o m m u n i t y h e a lt h n u r s e s

(chns)

i n n u n av u t

CHNs in Nunavut provide professional nursing care to clients by Applying the nursing process (assessment – including diagnosis, planning, implementation, and evaluation) to intervene in the disease process and restore health; • Providing short-term in-patient care as required; • Performing nursing, sanctioned/transferred medical and related practice functions according to the policies and procedures established by the department; • Conducting general treatment clinics and providing emergency treatment services; • Making decisions regarding client management, including crisis management and facilitating referral in consultation with the supervisor and/or other professionals; • Identifying and utilizing available support agencies and resource people; • Arranging for safe client transport in consultation with the supervisor or other health care professionals as required and acting as a medical escort when required; • Participating in individual/family case conferences with nursing staff, medical staff, and/or other health care providers; • Prescribing and dispensing pharmaceuticals in accordance with established regulations, policies, and safety procedures; • Participating in the delivery of health services to satellite communities, where applicable, by visits and through radio, radiotelephone, or telephone consultations; • Applying the nursing process to assess clients (individual, families, or community) in order to identify needs, develop programs and services, implement health-promotion and diseaseprevention strategies, including utilizing appropriate resources and methods of delivering information; • Conducting a wide variety of specialty public health clinics (e.g., prenatal, well-child and well-baby, and TB clinics); •

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Appendices 135

Participating in communicable disease control, chronic disease surveillance, home visits, health-education classes and sessions, and school health programs; • Promoting a safe and healthy environment in homes, schools, day care centres, boarding homes, worksites, and the com­ munity; • Maintaining an up-to-date knowledge of the working and community disaster plans and procedures and participating in disaster exercises; • Participating in interagency meetings to plan, implement, and evaluate joint projects related to the health and well-being of the community; • Assisting community health representatives in organizing, coordinating, and facilitating health-oriented workshops, seminars and health education classes and sessions for the community based on identified needs (e.g., prenatal, postnatal, healthy lifestyles, child safety, parenting, and AIDS); and • Enabling communities to identify and take action for the resolution of health issues and concerns (Nunavut 2001). •

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appendix c

Links to Websites (current to 2010)

Table C1 Links to Government Websites Name of Agency/Branch Indian and Northern Affairs Canada Public Health Agency of Canada, Health Canada First Nations, Inuit Health, and Aboriginal Health, Health Canada Food Mail Program, Indian and Northern Affairs Canada Canadian Prenatal Nutrition Program, Public Health Association of Canada Health Canada’s Home and Community Care Program Brighter Futures

Building Healthy Communities

Non-Insured Health Benefits, First Nations, Inuit, and Aboriginal Health Government of Nunavut Department of Health and Social Services, Government of Nunavut Department of Justice, Government of Nunavut Department of Finance, Government of Nunavut

Website Link http://www.ainc-inac.gc.ca/index-eng. asp http://www.phac-aspc.gc.ca/indexeng.php http://www.hc-sc.gc.ca/fniah-spnia/ index-eng.php http://www.ainc-inac.gc.ca/nth/fon/ fm/index-eng.asp http://www.phac-aspc.gc.ca/dca-dea/ programs-mes/cpnp_main-eng.php http://www.hc-sc.gc.ca/fniah-spnia/ services/home-domicile/index-eng. php http://www.hc-sc.gc.ca/fniah-spnia/ promotion/mental/brighter_grandireng.php http://www.hc-sc.gc.ca/fniah-spnia/ promotion/mental/brighter_grandireng.php http://www.hc-sc.gc.ca/fniah-spnia/ nihb-ssna/provide-fournir/indexeng.php http://www.gov.nu.ca/ http://www.gov.nu.ca/health/ http://www.justice.gov.nu.ca/ http://www.gov.nu.ca/finance/

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Appendices 137

Table C2 Links to National and Territorial Aboriginal Organizations Name of Organization Inuit Tapiriit Kanatami National Aboriginal Health Organization Irnisuksiiniq – Inuit Midwifery Network Inuit Tuttarvingat Pauktuutit – Inuit Women’s Association of Canada Nunavut Tunngavik Incorporated Aboriginal Healing Foundation National Inuit Youth Forum

Website http://www.itk.ca/ http://www.naho.ca/english/ http://www.naho.ca/inuit/midwifery/ english/index.php http://www.naho.ca/inuit/e/ http://www.pauktuutit.ca/home_e. html http://www.tunngavik.com/ http://www.ahf.ca/ http://www.niyc.ca/news.php

Table C3 Links to Out-of-Territory Service Providers and Facilities Name of Service Provider J.A. Hildes Northern Medical Unit, University of Manitoba, Winnipeg Ottawa Health Services Network, Inc., Ottawa Tungasuvvingat Inuit Mamisarvik Healing Centre, Ottawa Stanton Hospital, Yellowknife

Website http://www.umanitoba.ca/faculties/ medicine/units/northern_medical_ unit/ www.ohsni.com http://www.ontarioinuit.ca/html/ addictions.htm http://www.stha.ca/home/

Table C4 Links to Communities (where available) Community

Website

Cambridge Bay Cape Dorset Chesterfield Inlet Gjoa Haven Grise Fiord Iqaluit

http://www.cambridgebay.ca/ http://www.capedorset.ca/en/index.asp http://www.chesterfieldinlet.net/ http://www.gjoahaven.com/gjoa-haven-nunavut.htm http://www.grisefiord.ca/ http://www.city.iqaluit.nu.ca/apps/fusebox/index.php?fa=c. splash http://www.kimmirut.ca/ http://www.polarnet.ca/kugluktuk/ http://www.pondinlet.ca/ http://www.qikiqtarjuaq.com/qikiqtarjuaq-nunavut.htm http://www.rankininlet.ca/

Kimmirut Kugluktuk Pond Inlet Qikiqtarjuaq Rankin Inlet

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138 Appendices Table C5 Links to Human Resources Services, Organizations, and Programs Name of Service/Organization/ Program Registered Nurses Association of the Northwest Territories and Nunavut National Indian & Inuit Community Health Representatives Organization Nunavut Nurses Nunavut Physicians

Website http://www.rnantnu.ca/ http://www.niichro. com/2004/?page=index_e&lang=en http://www.nunavutnurses.ca/ http://www.nunavut-physicians.gov. nu.ca/

Table C6 Links to Training and Education Programs and Institutes Name of Program/Institute Nunavut Arctic College Dalhousie University Arctic Nursing Program

Website http://nac.nu.ca/ http://nursing.dal.ca/

Table C7 Research Institutes and Networks Name of Institute/Network Institute for Circumpolar Health Nunavut Research Institute Qaujigiartiit Arctic Health Research Network

Website http://ichr.ca/ http://www.nri.nu.ca/iqaluit.html http://www.arctichealth.ca/

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Notes

chapter one

  1 There is considerable debate about whether the Inuinnaqtun spoken by some two thousand residents in the far western region of Nunavut is a dialect of Inuktitut or a separate language (ITK 2008). In 2009, along with Inuktitut, English, and French, Inuinnaqtun was officially recognized as one of four official languages of the territory. Inuktitut is written using Cree syllabics modified by missionary Edmund Peck over a century ago on Baffin Island, while Inuinnaqtun is based on Roman orthography first introduced by Moravian missionaries in Greenland in the eighteenth century (Laugrand et al. 2006).   2 According to the Inuit Circumpolar Conference, a United Nations-recognized non-governmental organization, the broad definition of Inuit includes all these groups but it should be noted that, in general, the Yupik of Alaska and Siberia do not consider themselves to be Inuit and that they consider their languages distinct from the Inuit languages.  3 Calder v. British Columbia (Attorney General) [1973] S.C.R. 313. This was the first time that Canadian law accepted that Aboriginal title to land existed prior to the colonization of North America.   4 The measure for this inflation-adjusted growth rate is real gross domestic product, or real GDP. c h a p t e r t wo

  1 In the 1980s, the relocated Inuit and their descendents initiated a law suit against the Canadian government for the relocation. By the end of

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140

Notes to pages 24–47

that decade, the Canadian government had set up a program to assist those Inuit who wanted to return to their original communities, and in 1996 it established a $10 million trust fund for relocated individuals and their families.   2 A recent (2008) award-winning film – Ce qu’il faut pour vivre (The Necessities of Life) – is about an Inuk hunter who is sent to a sanitorium after being diagnosed with tuberculosis aboard a Canadian patrol ship in 1952. His recuperation requires such a lengthy separation from his family, language and culture that he becomes despondent.   3 In contrast to the Department of Health and Social Services, most GN departments treat Sanikiluaq as part of the Qikiqtaaluk Region. chapter three

  1 If the NIHB reimbursement is built into the GN’s medical t­ ransportation expenditures, then approximately 32 percent of medical travel expenses are paid for through the NIHB and the remainder by the GN. If the NIHB reimbursement is not included in the GN’s expenditures, then roughly 25 percent of medical travel costs are covered through the NIHB.   2 A client escort should be distinguished from a “medical escort,” who is usually a nurse, doctor, or social worker who provides professional care to the patient while travelling (NunaWorks 2009).   3 This is known as the Nunavut Telehealth Network Expansion and Change Management Project. chapter four

  1 The only exception is Iqaluit, which, in addition to a hospital, has a family practice clinic instead of a CHC.   2 The rollout of in-patient services depends on having the human resource capacity, including nurses and physicians, to deliver these services (Nunavut 2009i). At the same time, in-patient services provided in the regional health centres are limited to low-severity acute care services. Patients who are severely ill will still be referred to out of territory facilities.   3 The Kivalliq and Kitikmeot health centres also serve as training centres for orientation and mentorship for newly recruited community health nurses (Nunavut 2009i).

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Notes to pages 48–55

141

  4 Residents requiring level 1 care often require minimal nonprofessional personal care, including grooming and eating. People requiring level 2 care need moderate assistance with personal care and require some daily professional nursing care or supervision. Level 3 care entails heavier care requirements and additional nursing and other support staff time or supervision, while level 4 care requires maximum assistance with personal care and medical care.   5 The Martha Taliruq Centre in Baker Lake is an elders’ LTC home operated by the Baker Lake Hospice Society, a community-based organization that receives its funding from the GN.   6 The Pairrijat Tigumivik Centre is operated by the Pairrijat Elder’s Society; the decisions are answerable to a board of elders. This gives the services provided through the centre a unique Inuit perspective and ensures that operations coincide with Inuit culture, including the provision of country foods and service delivery in Inuktitut.  7 The IIU Telehealth Network began in 1999 with three videoconferencing systems in Iqaluit, Pond Inlet, and Cape Dorset. More communities were added until Nunavut became the first jurisdiction in Canada to have telehealth services provided in all of its communities (Ho and Jarvis-Selinger 2006).   8 There are multiple benefits of telehealth services. For example, while the purpose of the IIU Telehealth Network was to improve access to a wider range of services and to facilitate professional development for the health workforce in the remote communities, Nunavut reportedly saved over $1.6 million through reductions in medical travel in 2007 because of the network (Canada 2007).   9 Each community health centre in Nunavut has at least one CoderDecoder (CODEC) teleconferencing device. Many of the existing machines were replaced with newer models in 2009. 10 Communications in Nunavut are provided via an advanced satellite platform through the Qiniq network. 11 NBDC is a not-for-profit corporation directed by Nunavut residents including the general public, private sector companies, Inuit organizations, community organizations, and hamlets. 12 See Anderson et al. (2006) and Jeffery et al. (2006a, 2006b) on the development of performance indicators on Aboriginal health. While the indicators developed in these studies pertain to First Nations populations in northern Saskatchewan, they provide a potential starting

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Notes to pages 55–63

point for the development of community wellness indicators that are relevant to Inuit populations. 13 These indicators include life expectancy, rates of tuberculosis, breastfeeding rates, and lung cancer deaths (ITK 2008). 14 Research in Nunavut is governed by the Scientists Act, RSNWT, 1988. 15 According to Healey (2006), ethical health research in the north is predicated on trust, a respect for traditional values, and oral history. It is also holistic in its approach and connects the mental, physical, spiritual, emotional, and social aspects of the health and well-being of individuals and communities. c h a p t e r fi v e

  1 Some other professionals and paraprofessionals, including mental health nurses, dental therapists, maternity care workers, and home care workers, provide more permanent services at least in some communities. In the Qikiqtaaluk region, several rehabilitation staff members including physical therapists, occupational therapists, and speech-language pathologists are government of Nunavut employees.   2 These interpreters are not certified, nor have they received formal education in interpretation or translation.   3 Locum refers to the temporary doctor who replaces a permanent doctor for a specified time.   4 Until May 2009, all physician services in the Kivalliq Region were provided through the J.A. Hildes Northern Medical Unit (NMU) of the University of Manitoba.   5 There were 164 service days provided in the Kitikmeot for the 2008–09 fiscal year by specialists including psychiatrists and internal medicine specialists.   6 Excluded from the tally are the nurses working for air ambulance services such as Medflight and nurses working in residential care centres such as the Martha Taliruq Centre in Baker Lake.   7 The program itself builds on the outpost nursing program at Dalhousie, which began in 1967 and closed in 1997 owing to a lack of federal funds (Martin-Misener et al. 1999).   8 By the end of 2009, twenty-three students, ten of whom were Inuit, had graduated from the program (personal communication, Fred Montpetit, Chief Nursing Officer, Government of Nunavut).

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Notes to pages 64–78

143

  9 The expanded role of nursing in northern nursing stations and CHCs often extends beyond the scope of practice for nurse practitioners (Tarlier et al. 2003). This has become a grey area that is rarely addressed by licensing bodies (Vukic and Keddy 2002). 10 An exception is Grise Fiord, which had only one CHN in 2009. 11 Except where there are exclusions or limitations as listed in Schedule A of the Nursing Profession Act. 12 The laboratory specialist provides laboratory services, in addition to being responsible for the administrative operation of the laboratory and supervision of the lab personnel. 13 Hygienists must be graduates of programs accredited by the Canadian Dental Association or registered as a dental hygienist in a province or in the Yukon Territory, 14 Optometrists and ophthalmic technicians are governed under the Optometry Act and the Ophthalmic Medical Assistants Act (see appendix A). 15 The community health representative (chr) program began in 1962 through the Medical Services Branch of National Health and Welfare as a means of delivering health services to First Nation and Inuit people by promoting local human resource capacity (NAHO 2002). At the national level, the National Indian & Inuit Community Health Representatives Organization (NIICHRO) is moving towards the development of core competencies for CHRs across Canada to ensure consistency in training and expertise (Hammond and Collins 2007). 16 As of April 2010, CHRs report to local public health nurses and, ultimately, to the director of population health in each region, rather than to the local supervisor of health programs. 17 The Bathurst Mandate’s goal was to attain a representative workforce by 2020. 18 According to Nunavut (2005a), a representative workforce does not mean just filling positions with Inuit people. Rather, the transition to a representative workforce will entail a cultural change in the workplace: “The presence of an Inuit workforce will on its own exert a powerful influence on how programs are experienced by patients and clients, and on the integration of Inuit ways of caring and helping” (5). 19 These Inuit RNs included a TB nurse in Qikiqtarjuaq, a home care nurse in Rankin Inlet, a public health nurse in Iqaluit, and two nurses (one part-time and one full-time) working in the in-patient unit of the QGH.

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144

Notes to pages 79–90

20 The Government of Nunavut received multi-year funding through Health Canada in 2005 to provide support for internationally educated nurses. The supports included orientation sessions, assistance with preparing for the Canadian Registered Nurses Exam, and tutoring and mentoring services. 21 Another critical issue for many younger nurses is the availability of child care services in the community. A lack of affordable and highquality child care or, in the case of a majority of communities, of any child care at all is a deterrent to nurses with young families. 22 The high cost of living in the north, including high food and housing prices, has warranted higher salaries for health care providers and administrators. chapter six

  1 For example, the Hastings Report of 1972 outlined the development of the community health centre model in Canada, which emphasized team-based service delivery, non-fee-for-service payment, and prevention (Hastings 1972). Although the concept faced several challenges in many provinces, including wariness by physicians who already faced several changes to their practice because of Medicare, some provinces like Quebec implemented a system of centres that were communityoriented and provided a wide range of primary and public health services, including mental health, social services, and home care. In 2003, a model of primary health care as the foundation for service delivery came from the commitment by the First Ministers to “provide all Canadians, wherever they live, with access to an appropriate health care provider, 24 hours a day, 7 days a week” (Canadian Intergovernmental Conference Secretariat 2003). In the 2004 10-Year Plan to Strengthen Health Care, the objective of primary care reform is for 50 percent of Canadians to have 24/7 access to multidisciplinary teams by 2011.   2 Many sources discuss the cost-effectiveness, coordination of services, continuity of care, quality of care and comprehensiveness of the CHC model in comparison to other models of delivery (see for instance Shi et al. 2003).   3 One suggestion by Nunavut and Nunavut Tunngavik Incorporated (2006) is to redefine the role and responsibility of the community

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  4

  5

  6

  7

Notes to pages 91–7

145

liaison officer to act as a secretariat to a Community-Wellness Council and/or to coordinate the activities of hamlet committees. They could also serve as a point of communications between the hamlet and frontline workers at the CHC specifically and the Department of Health and Social Services more generally. The Food Mail program has a long history in Canada, beginning in the 1960s, when an Air Stage System was introduced by Canada Post to ensure food delivery to remote communities accessible only by air (Canada 2009b). In 1991, the responsibility for the service was taken over by Indian and Northern Affairs Canada (INAC), and the Food Mail program provided funding to Canada Post to reduce the shipping costs of certain perishable items, such as fresh and frozen fruit and vegetables, milk, cheese, eggs, bread, and meat. Retailers within the communities are then able to sell these food items at a reduced cost to community members. While there have been efficiencies introduced by the INAC, including a uniformity in rates for perishable foods, some concerns have been raised about the effectiveness of the Food Mail Program. Boult (2006), for instance, notes that there are no checks on whether price gouging occurs amongst retailers; nor does the program guarantee food price stability, as is demonstrated in the wide variability in prices across Nunavut. The quality and freshness of perishable items, once delivered, also varies, and food in a state of decomposition is a common occurrence (ITK 2009; Myers et al. 2004). The main goals of the project are a store intervention program that promotes healthy food choices through such activities as taste tests and cooking demonstrations in the stores and an information and health promotion campaign that focuses on physical activity and healthy food choices. Several regulations underscore the testing and inspection by the chief medical officer’s staff. Water safety and the quality of the potable water supply in Nunavut is regulated through the Public Water Supply Regulations. Food inspection in Nunavut is regulated through the Eating or Drinking Places Regulations. Finally, sewage treatment is governed through the Public Sewage Systems Regulations. Other specialist services include otolaryngology, oral surgery, pediatric and adult orthopedics, urology, respirology, and rheumatology (Ottawa Health Services Network Inc. 2009).

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146

Notes to pages 97–103

  8 In 2005, Nunavut residents waited 4.3 weeks on average for selected diagnostic tests, compared to the Canadian average of 3 weeks.   9 While 29.2 percent of Nunavut residents reported waiting over three months for specialist services, (compared to 19.6 percent and 20.7 percent of residents of, respectively, the Northwest Territories and Yukon), 56 percent of Nunavut residents waited less than a month for elective surgery, compared to 40.3 percent of the Canadian population on average. 10 Nurse practitioners working at the Family Practice Clinic can prescribe “all drugs listed in the NIHB Formulary unless there is an exclusion or limitation noted in the schedule A” (RNANTNU 2004). 11 In 2010 dental services for the Kitikmeot region, including services of dentists, denturists, oral surgeons, and orthodontists, were contracted through Jorsyn Dental Services based in Pembroke, Ontario. Dental services for the Kivalliq region, including services of dentists, denturists, oral surgeons, and orthodontists were contracted from Kivalliq Smiles. Dental services for the Qikiqtaaluk region were contracted through Aqsaqniit Dental Services based in Winnipeg. 12 One common issue for many women, however, is a lack of continuity of service because of a reliance on casual and/or agency nurses (Tedford et al. 2007). 13 The Rankin Inlet Birthing Centre began as a three-year project originally funded by the former Keewatin Regional Health Board and a federal government National Health Research and Development Program Grant. In 1996, the project was incorporated into the health system as the Rankin Inlet Birthing Centre (Canadian Association of Midwives 2007). 14 For some communities, such as Grise Fiord or Resolute Bay, expectant mothers may have to wait up to seven hours to get to the QGH in Iqaluit, thereby increasing their risk. 15 NIHB does not cover the travelling expenses for a birthing partner, and some families cannot afford to have someone accompany the expectant mother. As noted by McNiven (2008), the process of medical evacuation has implications for the well-being of the women, their families, and their communities: “It is clear that women suffered during the evacuation. They were separated from their families, surrounded by unknown health professionals who did not speak their language and provided with unfamiliar foods. Substance abuse increased

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16

17

18

19

Notes to pages 105–13

147

and postpartum depression was common. Additionally, the communities suffered the loss of participation in childbirth” (6). More specifically, pediatricians from the Children’s Hospital of Eastern Ontario were contracted to provide 290 service days and pediatric residents 330 days in 2009–10. The pediatrician service days were almost double those of the previous fiscal year (160 service days). The term “ambulance” is loosely applied in Nunavut. In Cambridge Bay, for example, the ambulance is a box van. In other communities, people are transported to the CHC or to the airport for a medevac in trucks and four-wheel drive vehicles. Several community health centres in Nunavut have International Normalized Ratio machines to monitor people on blood thinners. A few community health centres, such as the CHC in Pond Inlet, also has an i-stat machine to perform several tests including tests of electrolytes, gases, urea, glucose, and ionized calcium. However, the regional health centre in Rankin Inlet is equipped with uncrossed blood for use in emergencies and RH Immune Globulin or Rhogam for RH negative mothers. chapter seven

  1 The movement towards a wage economy was bolstered in the 1970s by a burgeoning seal industry. Its collapse in the 1980s because of the European boycott and anti-sealing campaigns further eroded economic stability for the Inuit population (Kral and Idlout 2009).   2 There were 6,877 Inuit student removed from their families to attend residential schools in the Canadian Arctic between 1949 and 1960 (King 2006). Inuit families were forcibly relocated to permanent settlements about the same time, with policies such as the killing of sled dogs and the development of family allowances to encourage relocation (Ford and McKenna 2009).   3 The Health Canada Canadian Alcohol and Drug Use Monitoring Survey does not include Nunavut and thus is not reported here.   4 The Mental Health Services Act outlines the legal protocols and processes for the treatment (both voluntary and involuntary) of people with mental illness in Nunavut including the protocols and procedures for apprehension by peace officers and involuntary admission to an inpatient facility for examination.

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148

Notes to pages 115–19

  5 Brighter Futures began in the early 1990s as a means of developing culturally sensitive and community based programs in First Nations and Inuit communities. While Brighter Futures targets child development, communities can also use the funding to provide services and programs to improve mental health, including wellness coordinator positions. Health Canada’s Building Healthy Communities program funds community-based programs to curtail solvent abuse and manage mental health crises, including suicide prevention and response and mental health education, as well as grief and loss counselling (Kral and Idlout 2009). Short-term funding can have a negative impact on program and personnel continuity.   6 Several activities related to the project include a youth-driven multimedia campaign and an Elder and Youth Cultural Camp in each of the communities in the Kitikmeot region.   7 In Pond Inlet, elders provide counselling two twice a week for survivors of the residential schools through the Aboriginal Healing Foundation. In Clyde River, Cambridge Bay, and a few other communities, mental health counselling is available through wellness counsellors whose positions are funded through federal programs such as Brighter Futures or Building Healthy Communities.   8 Mental health nurses or community social service workers are often available only during regular business hours.   9 Mental health nurses are also known as mental health specialists, psychiatric nurse consultants, and psychiatric nurses. 10 For example, in 2009 one mental health nurse located in Arctic Bay was responsible for the communities of Grise Fiord, Resolute Bay, and Pond Inlet. With some exceptions, most of the mental health nurses in the Qikiqtaaluk region are GN casual or agency nurses. For instance, only the communities of Arctic Bay, Pond Inlet, Grise Fiord, and Pond Inlet had access to an indeterminate psychiatric nurse. 11 Examples of environmental control programs include means-restriction programs aimed at reducing the availability of means for suicide. Kral and Idlout (2009) note, for instance, the removal of bars in closets in the community of Qikiqtarjuaq, since they were the preferred method for suicide in the community. Wraparound programs are offered by a wide variety of providers who focus on the needs of a specific child or family.

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Notes to page 119

149

12 To some extent, community-based programming is supported through federal and territorial funding programs such as Brighter Futures or through contribution agreements. Yet communities need to apply for these programs annually, which creates instability in program availability. Thus the problem may not be simply providing funding for community-based programs but rather moving past short-term planning to long-term solutions through sustainable funding. 13 There are, however, in-patient days at QGH where individuals suffering severe mental illness are stabilized before being sent south for treatment. 14 One of the pressing issues is a general lack of follow-up care once people are sent back to their communities. For people with addictions issues in particular, having access to follow-up counselling and assistance with basic life skills is critical.

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Bibliography

Aboriginal Healing Foundation. 2008. Active Funding Grants, Aboriginal Healing Foundation as of February 2008. Ottawa: AHF. Anderson, M., and J. Smylie. 2009. “Health Systems Performance Measurement Systems in Canada: How Well Do They Perform in First Nations, Inuit, and Métis Contexts?” Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health 7(1): 99–115. Anderson, M., J. Smylie, I. Anderson, R. Sinclair, S. Crengle, and Onemda VicHealth Koori Health Unit. 2006. First Nations, Inuit and Métis Health Indicators in Canada. Discussion Paper no. 18. A background paper for the project Action-oriented Indicators of Health and Health Systems Development for Indigenous Peoples in Australia, Canada and New Zealand. Melbourne: Onemda ­VicHealth Koori Health Unit Centre for Health and Society. Ashton, S. 2006. Development of a Nurse Practitioner (np) – Prior Learning Assessment and Recognition (plar) Process for Community Health Nurses (chn’s) Working in the Northwest Territories and Nunavut. Paper prepared for the Registered Nurses Association of the Northwest Territories and Nunavut. Yellowknife: Registered Nurses Association of the Northwest Territories and Nunavut. Banerji, A., A. Bell, E. Mills, J. McDonald, K. Subbarao, G. Stark, N. Eynon, and V. Loo. 2001. “Lower Respiratory Tract Infections in Inuit Infants on Baffin Island.” Canadian Medical Association Journal 164 (13): 1847–50. Baxter, J.D. 2006. “Historical Overview of the McGill-Baffin Program, 1964–1997.” International Journal of Circumpolar Health 65 (1): 91–5.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    152

152 Bibliography Bjerregaard, P. 2012. “A Comparative Review of Circumpolar Health Systems: Greenland.” Circumpolar Health Supplements 2012 (9): 53–62. Boult, D. 2006. Hunger in the Arctic: Food (In)Security in Arctic Communities. Ottawa: National Aboriginal Health Organization. Bowerman, J. 2006. “Designing the Primary Health Care Centre of the Future: A Community Experience.” International Journal of Health Care Quality Assurance 19 (4): 16–23. Canada. 2009a. Canada Health Act Annual Report, 2007–2008. Ottawa: Health Canada. – 2009b. Food Mail Review: Interim Report. Ottawa: Minister of Public Works and Government Services Canada. – 2008. Canada Health Act – Annual Report 2006–2007. Ottawa: Health Canada. – 2007. Primary Health Care Transition Fund: Information Management and Technology. Ottawa: Health Canada. – 2004. First Ministers’ Meeting on the Future of Health Care: TenYear Plan to Strengthen Health Care. Ottawa: Health Canada. – 2003. First Ministers’ Accord on Health Care Renewal. Ottawa: Health Canada. Canada Health Infoway. 2008. “Infoway Investment to Increase Access to Telehealth in Nunavut.” Accessed 6 May 2011. https://www.infoway-inforoute.ca/lang-en/about-infoway/news/news-releases/186infoway-investment-to-increase-access-to-telehealth-in-nunavut. Canadian Association of Midwives. 2007. Midwifery in Canada: Nunavut. Montreal: Canadian Association of Midwives. Canadian Intergovernmental Conference Secretariat. 2003. First Ministers’ Accord on Health Care Renewal. Ottawa: Canadian Intergovernmental Conference Secretariat (5 February 2003). Canadian Nurse. 2009. “In Conversation with Fred Monpetit.” Canadian Nurse 105 (6): 21–2. Canadian Nursing Coalition on Immunizations. 2004. National Surveys of Provincial and Territorial Immunization Programs. Halifax: Canadian Nursing Coalition on Immunizations. Carroll, B., and D. Dewar. 2002. “Performance Management: Panacea or Fool’s Gold?” In The Handbook of Canadian Public Administration, edited by C. Dunn, 413–29. Toronto: Oxford University Press.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    153

Bibliography 153 Christopher, J., and E. Fast. 2008. The Arctic: Transportation, Infrastructure and Communication. Ottawa: Parliamentary Information and Research Service. CHSRF. 2008. Listening for Direction III: Report on the Northern Dialogues. Ottawa: Canadian Health Services Research Foundation. CIHI. 2010. National Health Expenditure Trends, 1975–2010. Ottawa: Canadian Institute for Health Information. – 2009. National Health Expenditure Trends, 1975–2009. Ottawa: Canadian Institute for Health Information. – 2008a. Hospital Mental Health Services in Canada, 2005–2006. Ottawa: Canadian Centre for Health Information. – 2008b. Supply, Distribution and Migration of Canadian Physicians, 2007. Ottawa: Canadian Institute for Health Information. CMA. 2009. Information Technology and Health Care in Canada. Ottawa: Canadian Medical Association. Couchie, R., and S. Sanderson. 2007. “A Report on Best Practices for Returning Birth to Rural and Remote Aboriginal Communities.” Journal of Obstetrics and Gynaecology Canada 188: 250–4. Creery, D. 2005. “Costs Associated with Infant Bronchiolitus in the Baffin Region of Nunavut.” International Journal of Circumpolar Health 64 (1): 38–45. Damas, D. 2004. Arctic Migrants / Arctic Villagers: The Transformation of Inuit Settlement in the Central Arctic. Montreal and Kingston: McGill-Queen’s University Press. Douglas, V.K. 2007. “Converging Epistemologies: Critical Issues in Canadian Inuit Childbirth and Pregnancy.” Alaska Medicine 49 (2): 209–14. Duffy, R.Q. 1988. The Road to Nunavut: The Progress of the Eastern Arctic Inuit since the Second World War. Montreal: McGill-Queen’s University Press. Dumont, J-C., P. Zurn, J. Church, and C. Thi. 2008. “ International Mobility of Health Professionals and Health Workforce Management in Canada: Myths and Realities.” OECD Health Working Papers No. 40. Paris: Organisation for Economic Co-operation and Development. Embrace Life Council. 2008. “Inuusivut Project Report for the Period January–March 31, 2008.” Accessed 13 June 2012. s3.amazonaws. com/isuma.attachments/InuusivutReportMarch08.doc.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    154

154 Bibliography FNIHB 2011. Non-Insured Health Benefits Program Annual Report 2009/2010. Ottawa: First Nations and Health Inuit Branch, Health Canada. FNU. 2009. Dental Therapy – A Health Career: First Nations University of Canada National School of Dental Therapy. Prince Albert: First Nations University of Canada. Ford, S., and M. McKenna. 2009. “Rosalie’s Story: Putting a Face on Inuit Maternal and Child Health Services.” In Canadian Supplement to the State of the World’s Children, 2009. Aboriginal Children’s Health: Leaving No Child Behind, edited by S. Ford and M. McKenna, 21–9. Toronto: UNICEF Canada. Gearheard, S., and J. Shirley. 2007. “Challenges in CommunityResearch Relationships: Learning from Natural Science in Nunavut.” Arctic 60 (1): 62–74. George, J. 2009. “Kugluktuk’s Alcohol Controls Make for Lower Crime Rate.” Nunatsiaq Online News, Accessed June 13, 2012. http://www.nunatsiaqonline.ca/stories/article/615_kugluktuks_ alcohol_controls_make_for_lower_crime_rate/. Hailey, D., V. Foerster, B. Nakagawaz, T. Wapshall, J. Murtaghz, J. Smitten, J. Stebleci, and G. Wong. 2005. “Achievements and Challenges on Policies for Allied Health Professionals Who Use Telehealth in the Canadian Arctic.” Journal of Telemedicine and Telecare 11 (Suppl. 2): 39–41. Hammond, M., and R. Collins. 2007. Moving Further Down the “Road to Competency”: Final Report of the 2006/07 Core Competencies Project for Wellness & Primary Health Care Providers. Prepared for the National Indian & Inuit Community Health Representatives Organization. Hastings, J.E.F. 1972. The Community Health Centre in Canada. Vol. 1. Report of the Community Health Centre Project to the Conference of Health Ministers. Ottawa: Information Canada. Health Canada. 2009a. Canada Health Act Annual Report, ­2007–2008. Ottawa: Health Canada. – 2009b. Provider Guide for Pharmacy Benefits: Non-insured Health Benefits. Ottawa: Health Canada. Healey, G. 2008. Qaujigiartiit Arctic Health Research Network, ­Nunavut: Final Report. Iqaluit: Arctic Health Research Network.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    155

Bibliography 155 Healey, G., and L. Meadows. 2007. “Inuit Women’s Health in Nunavut, Canada: A Review of the Literature.” International Journal of Circumpolar Health 66 (3): 199–214. Henderson, A. 2009. “Lessons for Social Science in the Study of New Polities: Nunavut at 10.” Journal of Canadian Studies 43 (2): 5–22. Hicks, J. 2007. “The Social Determinants of Elevated Rates of Suicide Among Inuit Youth.” Indigenous Affairs 4:31–7. Ho, K., and S. Jarvis-Selinger. 2006. A Pan-Canadian Environmental Scan of Clinical Telehealth Activity: Evidence Companion. Vancouver: UBC, Division of Continuing Professional Development and Knowledge Translation. IMS Health, Canada. 2009. Retail Pharmacies by Province and Territory, March 2009. Mississauga: IMS Health Canada. ITK. 2009. Social Determinants of Inuit Health in Canada: A Discussion Paper. Ottawa: Inuit Tapiriit Kanatami. – 2008. Inuit Statistical Profile. Ottawa: Inuit Tapiriit Kanatami. – 2007. Inuit-Specific Approaches to Healing from Addiction and Trauma. Ottawa: Inuit Tapiriit Kanatami. – 2002. Negotiating Research Relationships: A Guide for Communities. Ottawa: Inuit Tapiriit Kanatami. ITK and Nunavut Research Institute. 2006. Negotiating Research Relationships with Inuit Communities: A Guide for Researchers. Edited by S. Nickels, J. Shirley, and G. Laidler. Ottawa and Iqaluit: Inuit Tapiriit Kanatami and Nunavut Research Institute. Jeffrey, B., S. Abonyi, C. Hamilton, S. Bird, M. Denechezhe, T. ­Lidguerre, F. Michayluk, L. Thomas, E. Thorassie, and Z. Whitecap. 2006a. Community Health Indicators Toolkit. University of Regina and University of Saskatchewan: Saskatchewan Population Health and Evaluation Research Unit. Jeffrey, B., S. Abonyi, R. Labonte, and K. Duncan. 2006b. “Engaging Numbers: Developing Health Indicators that Matter for First Nations and Inuit People.” Journal of Aboriginal Health 3(1): 44–52. Jenkins, A.L., T.W. Gyorkos, L. Joseph, K.N. Culman, B.J. Ward, G.S. Pekeles, and E.L. Mills. 2004. “Risk Factors for Hospitalization and Infection in Canadian Inuit Infants over the First Year of Life – A Pilot Study.” International Journal of Circumpolar Health 63(1): 61–70.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    156

156 Bibliography King, D. 2006. A Brief Report of the Federal Government of Canada’s Residential School System for Inuit. Ottawa: Aboriginal Healing Foundation. Kirmayer, L., L. Boothroyd, A. Laliberté, and B. Laronde Simpson. 1999. Suicide Prevention and Mental Health Promotion in First Nations and Inuit Communities Report No. 9. Montreal: Culture & Mental Health Research Unit, Institute of Community & Family Psychiatry, Sir Mortimer B. Davis Jewish General Hospital. Kirmayer, L., G. Brass, and C. Tait. 2000. “The Mental Health of Aboriginal Peoples: Transformations of Identity and Community.” Canadian Journal of Psychiatry 45 (7): 607–16. Korhonen, M. 2004. Alcohol Problems and Approaches: Theories, Evidence and Northern Practice. Ottawa: Ajunnginiq Centre, National Aboriginal Health Organization. Kovesi, T., N. Gilbert, C. Stocco, D. Fugler, R. Dales, M. Guay, and J. Miller. 2007. “Indoor Air Quality and the Risk of Lower Respiratory Tract Infections in Young Canadian Inuit Children.” Canadian Medical Association Journal 177 (2): 155–60. Kral, M. 2003. Unikkaartuit: Meanings of Well-Being, Sadness, Suicide, and Change in Two Inuit Communities. Final Report to the National Health Research and Development Programs, Health Canada. Ottawa: Health Canada. Kral, M.J., and L. Idlout. 2009. “Community Wellness and Social Action in the Canadian Arctic: Collective Agency as Subjective Well-being.” In Healing Traditions: The Mental Health of Aboriginal Peoples in Canada, edited by L.J. Kirmayer and G. Valaskakis, ­315–34. Vancouver, BC: University of British Columbia Press. Kral, M.J., P. Wiebe, K. Nisbet, C. Dallas, L. Okalik, N. Enuaruq, and J. Cinotta. 2009. “Canadian Inuit Community Engagement in Suicide Prevention.” International Journal of Circumpolar Health 68 (3): 292–308. Lambden, J., O. Receveur, and H. Kuhnlein. 2007. “Traditional Food Attributes Must Be Included in Studies of Food Security in the Canadian Arctic.” International Journal of Circumpolar Health 66 (4): 308–19. Laugrand, F., J. Oosten, and F. Trudel, eds. 2006. Apostle to the Inuit: The Journals and Ethnographic Notes of Edmund James Peck: The Baffin Years, 1894–1905. Toronto: University of Toronto Press.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    157

Bibliography 157 Laugrand, F., and J. Oosten. 2007. “Reconnecting People and Healing the Land: Inuit Pentecostal and Evangelical Movements in the Canadian Eastern Arctic.” Numen: International Review for the History of Religions 54 (3): 229–69. Law, S., and E. Hutton. 2007. “Community Psychiatry in the Canadian Arctic: Reflections from1-Year Continuous Consultation Series in Iqaluit, Nunavut.” Canadian Journal of Community Mental Health 26 (2): 123–40. Légare, A. 2008. “Canada’s Experiment with Aboriginal Self-­ Determination in Nunavut: From Vision to Illusion.” International Journal on Minority and Group Rights 15:335–67. Levy, S., and E. Fletcher. 1998. “Kamatsiaqtut, Baffin Crisis Line: Community Ownership of Support in a Small Town.” In Suicide in Canada, edited by A. Leenaars, 353–66. Toronto: University of Toronto Press. MacDonald, W. 2009. Nunavut Physician Services: Vision and Strategic Plan. Iqaluit: Department of Health and Social Services. MacLeod, M., A.J. Browne, and B. Leipert. 1998. “Issues for Nurses in Rural and Remote Canada.” Australian Journal of Rural Health 6 (2): 72–8. Marchildon, G.P. 2006. Health Systems in Transition: Canada. Toronto: University of Toronto Press. Marchildon, G.P., and K. O’Fee. 2007. Health Care in Saskatchewan: An Analytical Profile. Regina: CPRC Press. Marchildon, G.P., and S. Chatwood. 2012. “A Comparative Review of Circumpolar Health Systems: Northern Canada.” Circumpolar Health Supplements 2012 (9): 41–52. Marchildon, G.P., and R. Torgerson. 2010. “Memorandum: Inventory of Health Services in Nunavut.” Report prepared for the Government of Nunavut. Marchildon, G.P., and T.K. Young. 2012. “A Comparative Review of Circumpolar Health Systems: Policy Implications and Future Research.” Circumpolar Health Supplements 2012 (9): 99–102. Martin-Misener, R., A. Vukic, and R. May. 1999. “Lessons Learned from the Dalhousie Outpost Nursing Program.” In Health in Rural Settings: Contexts for Action, edited by W. Ramp, J. Kulig, I. Townshend, and V. McGowan, 203–13. Lethbridge: University of Lethbridge.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    158

158 Bibliography McCallum, J. 2006. “History of Aboriginal Nursing in Canada.” Presented at the Aboriginal Nursing Association of Canada Annual Conference, Sudbury, Ontario, 19–20 October. McGregor, H.E. 2010. Inuit Education and Schools in the Eastern ­Arctic. Vancouver: UBC Press. McKinnon, T. 2008. E-health and the iiu Telehealth Network. Iqaluit: Department of Health and Social Services. McNiven, P. 2008. “Iqaluit Midwifery Gathering: Promoting, Supporting and Strengthening Inuit Midwifery.” Accessed 13 June 2012. http://69.27.97.110/inuit-midwifery/english/documents/2008–10_ IqaluitMidwiferyReport.pdf. Mignone, J., and J. O’Neil. 2005. “Social Capital and Youth Suicide Risk Factors in First Nations Communities.” Canadian Journal of Public Health 96 (S1): S51–S55. Miller, J.R. 1996. Shingwauk’s Vision: A History of Native Residential Schools. Toronto: University of Toronto Press. Milloy, J.S. 1999. A National Crime: The Canadian Government and the Residential School System. Winnipeg: University of Manitoba Press. Minore, B., M. Boone, M. Katt, P. Kinch, S. Birch, and C. Mushquash. 2005. “The Effects of Nursing Turnover on Continuity of Care in First Nation Communities.” Canadian Journal of Nursing Research 37 (1): 86–100. Moloughney, B.W. 2007. Defining and Strengthening the Public Health System in Nunavut: Final Report. Iqaluit: Department of Health and Social Services. Muttitt, S., R. Vigneault, and L. Loewen. 2004. “Integrating Telehealth into Aboriginal Healthcare: The Canadian Experience.” International Journal of Circumpolar Health 63 (4): 401–13. Myers, H., S. Powell, and G. Duhaime. 2004. “Setting the Table for Food Security: Policy Impacts in Nunavut.” Canadian Journal of Native Studies 24 (2): 425–45. NAHO. 2008. First Nations, Inuit & Métis Education History from a Health Human Resources Perspective. Ottawa: National Aboriginal Health Organization. – 2006. Exploring Models for Quality Maternity Care in First Nations and Inuit Communities: A Preliminary Needs Assessment. Final Report of Inuit Women’s Needs Assessment. Ottawa: National Aboriginal Health Organization.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    159

Bibliography 159 – 2004. What Sculpture Is to Soapstone, Education Is to the Soul: Building the Capacity of Inuit in the Health Field. Ottawa: National Aboriginal Health Organization. – 2003. The Profession of Dental Therapy: Discussion Paper. Ottawa: National Aboriginal Health Organization. – 2002. “Who’s Doing What”: An Environmental Scan of Select Provincial, National, and International Health-Related Organizations/ Initiatives that May Influence Aboriginal Health Policy. Ottawa: National Aboriginal Health Organization. Niclasen, B., and G. Mulvad. 2010. “Health Care and Health Care Delivery in Greenland.” International Journal of Circumpolar Health 69 (5): 437–47. NIHB. 2009. Non-Insured Health Benefits Program Annual Report, 2007/2008. Ottawa: First Nations and Inuit Health Branch, Health Canada. Nunavut. 2010. Business Plan 2011–14. Iqaluit: Government of Nunavut. – 2009a. Government of Nunavut Budget, 2009–2010: Budget Address and Fiscal and Economic Outlook. Iqaluit: Department of Finance. – 2009b. Collective Agreement between the Nunavut Employees Union and the Minister Responsible for the Public Service Act. Iqaluit: Department of Health and Social Services. – 2009c. Towards a Representative Public Service: Statistics as of March 31st, 2009. Iqaluit: Government of Nunavut. – 2009d. Summary of Nursing Statistics by Community as of January 31st, 2009. Iqaluit: Department of Health and Social Services. – 2009e. 2009–2010 Government of Nunavut Business Plan. Iqaluit: Government of Nunavut. – 2009f. Nunavut Maternal and Newborn Health Care Strategy, 2009–2014. Iqaluit: Department of Health and Social Services. – 2009g. Summary of Doctor Days. Iqaluit: Department of Health and Social Services. – 2009h. Terms of Reference Developed as Guidelines for the Community Health Committees. Iqaluit: Department of Health and Social Services. – 2009i. Facilities Plan, 2009. Iqaluit: Department of Health and Social Services.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    160

160 Bibliography – 2009j. Overview of the Department of Health and Social Services’ Involvement in Suicide Prevention. Iqaluit: Department of Health and Social Services. – 2009k. Interim Evaluation of the Nunavut Nursing Recruitment and Retention Strategy, 2007–2012. Iqaluit: Department of Health and Social Services. – 2008a. Update on Financial Support hss Provides to Nursing Students. Iqaluit: Department of Health and Social Services. – 2008b. Nunavut Nursing Recruitment and Retention Strategy: Implementation of the Strategy. Iqaluit: Department of Health and Social Services. – 2008c. Supply of Staff Housing across Nunavut May Not Be Able to Accommodate hss Future Staffing Needs. Iqaluit: Department of Health and Social Services. – 2008d. Developing Healthy Communities: A Public Health Strategy for Nunavut. Iqaluit: Department of Health and Social Services. – 2008e. Memorandum of Understanding between Stanton Territorial Health Authority and the Government of Nunavut. Iqaluit: Department of Health and Social Services. – 2008f. Community Health Visits by Diagnostic Group. Iqaluit: Department of Health and Social Services. – 2007a. Terms of Reference Developed as Guidelines for the Community Health Committees. Iqaluit: Department of Health and Social Services. – 2007b. Revised Nunavut Addictions and Mental Health Strategy. Iqaluit: Department of Health and Social Services. – 2007c. Annirusuktugut: A Suicide Intervention and Prevention Strategy for the Government of Nunavut. Iqaluit: Department of Health and Social Services. – 2007d. Nunavut Nursing Recruitment and Retention Strategy. ­Iqaluit: Department of Health and Social Services. – 2005a. Health Human Resources (hhr): An Education, Training and Development Plan. Iqaluit: Department of Health and Social Services. – Nunavut. 2005b. Health Services Utilization in Nunavut’s Community Health Centres: Primary Care and Public Health Clinics. Iqaluit: Department of Health and Social Services.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    161

Bibliography 161 – 2004a. Nunavut Report on Comparable Indicators. Iqaluit: Department of Health and Social Services. – 2004b. Closer to Home: Executive Summary. Iqaluit: Department of Health and Social Services. – 2002. Building Nunavut through Decentralization: Evaluation Report. Iqaluit: Department of Executive and Intergovernmental Affairs. – 2001. Towards a Representative Public Service: Statistics as of December 31st, 2001. Iqaluit: Government of Nunavut. Nunavut and Nunavut Tunngavik Inc. (NTI). 2006. Piliriqatigiinngniq: Working Together for the Common Good. Iqaluit: Government of Nunavut. Nunavut Broadband Development Corporation. 2008. Infrastructure Phase II. Iqaluit: Nunavut Broadband Development Corporation. Nunavut Economic Forum. 2008. 2008 Nunavut Economic Outlook: Our Future to Choose. Rankin Inlet: Nunavut Tunngavik Incorporated. Nunavut, NTI, and Isaksimagit Inuusirmi Katujjiqatigiit (Embrace Life Council). 2009. ‘Qaujijausimajuni Tunngaviqarniq’ Using Knowledge and Experience as a Foundation for Action: A Discussion Paper on Suicide Prevention in Nunavut. Iqaluit: Department of Health and Social Services. NunaWorks and Harbour Front Health Group. 2009. Operational Review for Baffin Region of Special Services, Medical Travel and Telehealth: Final Report, January 12, 2009. Iqaluit: NunaWorks Inc. NTI. Working Group for a Suicide Prevention Strategy for Nunavut. 2009a. “Appendix 2: Overview of Suicide Prevention and Intervention Training Courses Delivered in Nunavut 1994–2009.” In Using Knowledge and Experience as a Foundation for Action: A Discussion Paper on Suicide Prevention in Nunavut, 1–33. Nunavut: Nunavut Tunngavik Inc. – 2009b. Qauma Mobile Treatment Project Schedule Announced. Iqaluit: Nunavut Tunngavik Inc. – 2008. Nunavut’s Health System: Annual Report on the State of Inuit Culture and Society, 2007–08. Iqaluit: Nunavut Tunngavik Inc. O’Neil, J.D. 1990. “The Impact of Devolution on Health Services in the Baffin Region, NWT: A Case Study.” In Devolution and

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    162

162 Bibliography ­ onstitutional Development in the Canadian North, edited by G. C Dacks, 157–93. Ottawa: Carleton University Press. – 1979. “Health Care Delivery in an Inuit Settlement: A Study of Conflict and Congruence in Inuit Adaptation to the Cosmopolitan Medical System.” Master’s thesis, University of Saskatchewan. Orr, P. 2007. “Respiratory Tract Infections in Inuit Children.” Canadian Medical Association Journal 177 (2): 167–8. Orr, P., and R. Brown. 1998. “Incidence of Ectopic Pregnancy and Sexually Transmitted Disease in the Canadian Central Arctic.” ­International Journal of Circumpolar Health 57 (Suppl. 1): 127–34. Ottawa Health Services Network Inc. 2009. Annual Report, ­2008–2009. Ottawa: Ottawa Health Services Network Inc. Owen M.J., C.D. Baldwin, P.R. Swank, A.K. Pannu, D.L. Johnson, V.M. Howie. 1993. “Relation of Infant Feeding Practices, Cigarette Smoke Exposure, and Group Child Care to the Onset and Duration of Otitismedia with Effusion in the First Two Years of Life.” Journal of Pediatrics 123 (5): 702–11. Pauktuutit Inuit Women of Canada. 2007. Sivumuapallianiq-Journey Forward: National Inuit Residential Schools Healing Strategy. Ottawa: Pauktuutit Inuit Women of Canada. – No date. A Proposed Inuit Plan of Action on hiv/aids. Ottawa: Pauktuutit Inuit Women of Canada. Peters, P.A. 2010. “Causes and Contributions to Differences in Life Expectancy for Inuit Nunangat and Canada, 1994–2003.” International Journal of Circumpolar Health 69 (1): 38–49. PHAC. 2009. What Mothers Say: The Canadian Maternity Experiences Survey. Ottawa: Public Health Agency of Canada. – 2008a. Publicly Funded Immunization Programs in Canada: Routine Schedule for Infants and Children. Ottawa: Public Health Association of Canada. – 2008b. Canadian Prenatal Health Report: 2008 Edition. Ottawa: Public Health Association of Canada. – 2006. Brief Report on Sexually Transmitted Diseases in Canada, 2006. Ottawa: Public Health Agency of Canada. Priest, A. 2006. “Nunavut’s ‘Drop the Pop’ Campaign.” Canadian Nurse 102 (4): 12.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    163

Bibliography 163 Promed Associates. 2009. “Medical Imaging in Northern Canada: A Snapshot in Time.” Presented to the Canadian Radiological Association, Coquitlam, British Columbia, April 19. Quality End of Life Care Coalition of Canada. 2008. Hospice Palliative Home Care in Canada: A Progress Report. Ottawa: Quality End-of-Life Care Coalition of Canada. Quiñonez, C.R. 2006. “A Political Economic History of Medical and Dental Care in Nunavut, Canada.” International Journal of Circumpolar Health 65 (2): 101–16. Quiñonez, C.R., D. Locker, L. Sherret, P. Grootendorst, A. Azarpazhooh, and R. Figueiredo. 2005. An Environmental Scan of Public Dental Programs in Canada. Toronto: Community Dental Health Services Research Unit, Dental Research Institute, Faculty of Dentistry, and the University of Toronto. Raphael, D. 2009. “Social Determinants of Health: An Overview of Key Issues and Themes.” In Social Determinants of Health: Canadian Perspectives. 2d ed., edited by D. Raphael, 2–19. Toronto: Scholar’s Press. RNANTNU. 2006. Nurse Recruitment and Retention Survey 2005: Nunavut Survey Results Report. Yellowknife: Registered Nurses Association of the Northwest Territories and Nunavut. – 2004. Prescriptive Authority for nwt Primary Health Care Nurse Practitioners. Yellowknife: Registered Nurses Association of the Northwest Territories and Nunavut. Royal Commission on Aboriginal People. 1995. Choosing Life: Special Report on Suicide among Aboriginal People. Ottawa: Canada Communication Group. Schroth, R. 2006. “The State of Dental Health in the North.” International Journal of Circumpolar Health 65 (2): 98. Sevean, P., S. Dampier, M. Spadoni, S. Strickland, and S. Pilatzke. 2008. “Patients and Families Experiences with Video Telehealth in Rural/ Remote Communities in Northern Canada.” Journal of Clinical Nursing 18:2573–9. Sharma, S., X. Cao, C. Roache, A. Buchan, R. Reid, and J. Gittelsohn. 2009. “Assessing Dietary Intake in a Population Undergoing a Rapid Transition in Diet and Lifestyle: The Arctic Inuit in Nunavut, Canada.” British Journal of Nutrition 135 (5): 749–59.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    164

164 Bibliography Shi, L., B. Starfield, J. Xu, R. Politzer, and J. Regan. 2003. “Primary Care Quality: Community Health Center and Health Maintenance Organization.” Southern Medical Journal 96 (8): 787–94. Silvekin, A., and S. Kvernmo. 2008. “Mental Health and Suicide.” In Health Transitions in Arctic Populations, edited by K. Young and P. Bjerregaard, 359–78. Toronto: University of Toronto Press. Smylie, J., I. Anderson, M. Ratima, S. Crengle, and M. Anderson. 2006. “Indigenous Health Performance Measurement Systems in Canada, Australia, and New Zealand.” Lancet 367 (17 June): 2029–31 Sobol, I. 2006. “Public Health Challenges and Opportunities for Aboriginal Communities.” Presentation for the Canadian Conference on the Public’s Health and the Law, Toronto, Ontario, November 5–7. Spien, A.R. 2008. “Smoking, Alcohol and Substance Abuse.” In Health Transitions in Arctic Populations, edited by K. Young and P. Bjerregaard, 205–8. Toronto: University of Toronto Press. Statistics Canada. 2010. Health Trends. Catalogue No. 82-213-XWE. Ottawa: Statistics Canada. – 2008. Aboriginal Peoples Survey, 2006: Inuit Health and Social Conditions. Ottawa: Statistics Canada. – 2007. Canadian Community Health Survey, 2007. Ottawa: Statistics Canada. – 2006. Aboriginal Population Profile, Nunavut. Ottawa: Statistics Canada. – 2005. Canadian Community Health Survey, 2005. Ottawa: Statistics Canada. – 2003. Aboriginal Peoples Survey 2001 – Initial Findings: WellBeing of the Non-Reserve Aboriginal Population. Ottawa: Statistics Canada. Statistics Canada and CIHI. 2012. Health Indicators 2012. Ottawa: Canadian Institute for Health Information. Steenbeek, A., M. Tyndall, R. Rothenberg, and S. Sheps. 2006. ­“Determinants of Sexually Transmitted Infections among Canadian Inuit Adolescent Populations.” Public Health Nursing 23 (6): 531–4. Tait, H. 2008. Aboriginal Peoples Survey, 2006: Inuit Health and Social Conditions. Ottawa: Statistics Canada.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    165

Bibliography 165 Tan, J., A. Maranzan, M. Boone, J. Vander Velde, and S. Levy. 2004. Usage of the Nunavut Kamatsiaktut Help Line: An Analysis of 11 Years of Database. Iqaluit: Government of Nunavut. Tarlier, D., J. Johnson, and N. Whyte. 2003. “Voices from the Wilderness: An Interpretive Study Describing the Role and Practice of Outpost Nurses.” Canadian Journal of Public Health 94 (3): 180–4. Tedford, S., J. Gold, J. O’Neil, and V. van Wagner. 2007. “The Community as Provider: Collaboration and Community Ownership in Northern Maternity Care.” Canadian Journal of Midwifery Research and Practice 6 (2): 5–17. Tester, F.J. 2002. “The Evolution of Health and Social Services for Nunavut: Ethnicity and Public Versus Private Provision.” Canadian Review of Social Policy 49–50: 199–225. Tester, F.J., and P. Kulchyski. 2004. Tammarniit (Mistakes): Inuit Relocation in the Eastern Arctic, 1939–63. Vancouver: University of British Columbia Press. Tester, F., and P. McNicoll. 2004. “Isumagijaksaq: Mindful of the State: Social Constructions of Inuit Suicide.” Social Science & Medicine 58 (12): 2625–36. Uswak, G. 2007. Pan -Territorial Oral Health Initiative: Final Report. Saskatoon: University of Saskatchewan. Uswak, G., N. Jamal, and C. de Jong. 2009. “The Impact of Private Practice Employment of Dental Therapy Graduates in Saskatchewan on Pan-Territorial Dental Therapy Programs.” Paper presented at Canadian Association of Public Health Dentistry Conference, ­Vancouver, British Columbia, March 4. van Oosterbos, H. 2006. “The Future of Integrated Primary Care: Community Health Centres at the Heart of the Neighbourhood.” International Journal of Integrated Care 6 (2): 1–2. Vukic, A., and A. Keddy. 2002. “Northern Nursing Practice in a ­Primary Health Care Setting.” Journal of Advanced Nursing 40(5), 542–48. White, G. 2009. “Governance in Nunavut: Capacity v. Culture?” Journal of Canadian Studies 43 (2): 57–81. – 2006. “Traditional Aboriginal Values in a Westminster Parliament: The Legislative Assembly of Nunavut.”Journal of Legislative Studies 12 (1): 8–31.

C:\Users\Public\MQUP\Marchildon\Marchildon-Ch11-Biblio.indd, 5/6/2013 9:31 AM    166

166 Bibliography Wilkinson, R., and K. Pickett. 2009. The Spirit Level: Why More Equal Societies Almost Always Do Better. London: Allen Lane. Young, T.K. 2012. “A Circumpolar Review of Circumpolar Health Systems: Background and Overview.” Circumpolar Health Supplements 2012 (9): 7–30. – 2010. “Health Expenditures [2010: 2].” International Journal of Circumpolar Health 69 (5): 417–23. – 2008. “Circumpolar Health Indicators: Sources, Data, and Maps.” Circumpolar Health Supplements 2008 (3): 1–128. – 2003. “Contributions to Chronic Disease Prevention and Control: Studies among the Kivalliq Inuit Since 1990.” International Journal of Circumpolar Health 64 (2): 323–30. Young, T.K., and P. Bjerregaard, eds. 2008. Health Transitions in Arctic Populations. Toronto: University of Toronto Press. Young, T.K., and T.M. Mäkinen. 2009. “The Health of Arctic Populations: Does Cold Matter?” American Journal of Human Biology 22 (1): 129–33. Zamparo, J., and S. Spraggon. 2004. “Echoes and Reflections: A Discussion of Best Practices in Mental Health Promotion.” Paper prepared for Health Canada’s Centre of Excellence for Children and Adolescents with Special Needs and the Government of Nunavut Task Force on Mental Health. Thunder Bay: Lakehead University.

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Index

Aboriginal Diabetes Initiative and Injury Prevention Program, 35 Aboriginal Head Start Program, 104 Aboriginal Healing Foundation, 115, 118, 137, 148n7 Aboriginal Health Transition Fund, 114 acute care, 37, 45, 47, 61, 63, 88, 96–7, 140n2 Access to Information and Protection of Privacy Act, 53 Accord on Health Care Renewal, 54 Accreditation Canada, 27 acellular pertussis, 94 Akausisarvik Centre, 100 Akausisarvik Mental Health Treatment Centre, 117 Alaska, 43, 139n2 Alberta, 33, 51, 66–7 alcohol, drinking, 11, 15, 21, 35, 49, 69, 70, 89, 111–13, ­117–18, 147n3; banning sale and consumption, 118; binge

drinking, 112, 117; fetal alcohol syndrome, 105 American bases, 22–3 American Registry for Diagnostic Medical Sonography, 71 Andy Aukatjut Elders Centre, 49 Anglican bishop, 24 Anglican mission hospital, 22 Aqsaqniit Dental Services, 73, 146n11 Arctic Bay, 12, 66, 74, 148n10 Arctic Circle, 23, 43 Arctic Circle Dental Services, 73 Arctic Cooperatives Ltd, 91 Arctic Health Research Network (AHRN), xiii, 56 arthritis, 18–19 Arviat, 12, 49, 67–8, 78, 102, 108, 122 asthma, 13, 18–19 Avatittinnik Kamatsiarniq, 17 Baffin Island, 24–5, 43, 139n1 Baffin Regional Health and Social Services Board, 25

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168 Index Baffin Regional Hospital, 47 Baker Lake, 12, 49, 63, 141n5, 142n6 blood services, 108–9 Brighter Futures Program, 35 British Columbia, 66 bronchus, 19 Building Healthy Communities, 35, 115, 136, 148n5, 148n7 Calder v. British Columbia, 7, 139n3 Cambridge Bay, 12, 25, 29, 32, 37, 39, 46–7, 49, 53, 60–1, 63, 66–8, 70, 81, 83, 88–9, 91, 93, 96, 98, 106–8, 113, 126, 137, 147n17, 148n7; ­Cambridge Bay Wellness C ­ entre, 89 Canada, government of, 7, 10, 24, 29–31, 43, 53–4, 124; exercising sovereignty over Arctic, 23, 124; federal grant programs, xiv, 10, 35, 39, 51, 88–9, 91, 104, 115, 146n13, 148n7, 149n12; federal nursing stations, 5, 24, 28–9, 86, 142n7; federal transfers, xv, 10, 38, 69, 97, 124 Canada Health Act, 32, 36, 38, 131 Canada Health Infoway, 52 Canadian Agency for Drugs and Technologies in Health (CADTH), xiii, 54 Canadian Arctic, 3, 7, 108, 147n2 Canadian Armed Forces, 105

Canadian Association of Medical Radiation Technologists (CAMRT), xiii, 71 Canadian Association of Occupational Therapy, 72 Canadian Association of SpeechLanguage Pathologists and Audiologists (CASLPA), xiii, 72 Canadian Community Health Survey (CCHS), xiii, 18, 92, 96 Canadian Council on Health Services Accreditation. See Accreditation Canada Canadian Health Services Research Foundation (CHSRF), 55 Canadian Institute of Public Health Inspectors, 69 Canadian Prenatal Nutrition Program, 35, 89, 91, 104, 136 Canadian Rangers, 119 Canadian Registry of Diagnostic Medical Sonographers, 71 Canadian Society of Medical Laboratory Science, 71 Canadian Society of Respiratory Therapists, 72 Cape Dorset, 12, 22, 93, 137, 141n7 Catholicism, 108 certified nursing assistant (CNA), xiii, 66, 131 Chesterfield Inlet, 22, 49, 52, 66, 105, 137 child health services, 104–5 Children’s Hospital of Eastern Ontario, 21, 51, 105, 147n16

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Index 169

Churchill, 29, 36, 43, 96 Closer to Home strategic plan, Department of Health and Social Services, 126 Clyde River, 12, 89, 148n7 Cold War, 23, 111 colon cancer, 18 Common Drug Review, 54 communicable disease, 28–9, 50, 52, 69, 85, 88, 90, 92–3, 135 community health centre (CHC), xiii, 24–5, 27–9, 32, 37–9, 45–8, 50–8, 60, 63, 64, 74–6, 80–1, 86–90, 93, 95, 98, 100, 102–3, 105–8, 120, 123, 126, 140n1–2, 141n9, 143n9, 144nn1,2, 145n3, 147n1, 17, 18 community health nurse (CHN). See nursing Community Health Nurses Association of Canada, 64 community health representative (CHR), xiii, 29, 32, 58, 75–6, 88–9, 91–3, 104, 116, 123, 135, 138, 143nn15–16 Coral Harbour, 12, 100 coverage, publicly funded health benefits, 32–5, 93 Curley, Tagak, 30 Denmark, 24, 121 Dental Auxiliaries Act, 73, 131 dental care, 33, 86 Dental Mechanics Act, 135 Dental Profession Act, 131

Department of Education, Nunavut, 48, 119 Department of Health and Social Services (DHSS), Nunavut, xiii, 17–18, 25–7, 29–30, 37–9, 48, 52–5, 58, 60–2, 65, 67, 69, 73, 78, 80–1, 83, 86, 91–2, 98, 100–3, 106, 108, 113, 121–3, 125–6, 136, 140n3, 145n3 Department of Indian and Northern Affairs, 55, 75 Department of National Health and Welfare, 22–4 diabetes, 16, 18–19, 69, 124 Diagnostic Imaging Consultants Inc., 106 diagnostics, 45, 106–8, 133 Dieticians of Canada, 69 diphtheria, 94 Distant Early Warning (DEW) Line, xiii, 23–4, 111 drug use and abuse, illicit, 11, 21, 35, 49, 69–70, 111, 113, 118; drug-induced psychosis, 113 DynaLife Diagnostic Laboratory Services, 107 Eastern Arctic, 22, 24–5, 111; Eastern Arctic Patrol, 22–4 Eastern Arctic Marine Sciences Project, 55 economy, Nunavut, 14–17, 38, 124, 147n1 Edmonton, 29, 43, 96, 107 education. See social determinants of health e-Health, 50–3

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170 Index elder care, 27, 35–6, 49, 89, 94, 141nn4, 5 elders, planning and delivering health services, 17, 48, 70, 81, 85, 105, 115, 117, 148n67 electronic health records, 52–3 Embrace Life Council, 113–15 emergency services, 60, 105 emphysema, 13 Environmental Health and Communicable Disease Programs and Services, 92 Environmental Health Officer (EHO), Nunavut, xiii, 29, 68–9, 84, 88, 92 Extended Health Benefits Program, Nunavut, 33 eye care, 33, 47, 57, 73–4, 101 family physician (FP). See physicians Family Practice Clinic (FPC), Iqualuit, Nunavut, xiii, 48, 65–6, 95, 102, 140n1, 146n10 Family Practice Unit, 50 Faroe Islands, 42–3 Federation of Nunavut Teachers, 114 Fetal Alcohol Spectrum Disorder Program, 35 Finland, 42 First Ministers’ meeting, 97, 144n1 First Ministers’ Ten Year Plan, 121 First Nations, 30, 33, 73, 141n12, 148n5

First Nations and Inuit Health and Community Care Program, 35 First Nations and Inuit Health Branch (FNIHB), Health ­Canada, xiii, 33, 39, 64, 115 First Nations and Inuit Home and Community Care Program (FNIHCC); Health Canada, xiii, 35 First Nations University of ­Canada, 73 Frobisher Bay General Hospital, 24. See also Qikiqtani General Hospital Gjoa Haven, 12, 24, 48, 81, 118, 137 Government of Nunavut (GN), xiv, 4, 10, 17, 25–7, 30, 32–3, 36, 38–40, 43, 45, 49, 54–5, 59–63, 68, 77–9, 80–4, 90–4, 96, 99, 100, 104, 107, 113–14, 116–19, 121–2, 136, 140nn1, 3, 141n5, 142n1, 144n20, 148n10 Greenland, 6, 24, 42–3, 112, 121–2, 139n1 Greenlander, 6, 122 Grise Fiord, 12, 23, 66, 80, 137, 143n10, 146n14, 148n10 haemophilus influenza type B, 94 Hall Beach, 12 Health and Social Services Administration Act, 32, 131

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Index 171

Health Canada, 10, 18, 30, 33, 35, 39, 119, 144n20; Wait Time Fund, Health Canada, 52; Health Committees of Council, 89 health human resources, 26, 46–7, 55, 57–84, 123, 125–6, 138; scope of practice, 61, 64–6, 86, 116, 133–5 Health Protection Unit, Nunavut, 92 health research, 46, 55–6, 126, 138, 142n15 health services, Nunavut, 4, 27–9, 85–119 health spending, Nunavut, 38–44 health status, Nunavut, 4, 6, 11, 18–21, 54–5, 58, 124 health technology assessment (HTA), xiv, 54 Healthy Foods North Initiative, 86, 91 hepatitis B, 94 high blood pressure, 13, 16, 18–19 High Arctic, 23 history, Nunavut health system, 22–6 home care, 27, 35, 39, 52, 55, 61, 63, 74, 99–100, 106, 142n1, 143n19, 144n1 hospital care. See acute care Hospital Insurance and Health and Social Services Administration Act, Canada, 32, 131 Hudson Bay, 3, 25, 43 Hudson’s Bay Company, 22

Igloolik, 12, 48, 81, 100, 108 Ikjuruti Inungnik Ungasiktumi Telehealth Network (IIU), Nunavut, xiv, 37, 50–1, 53, 87, 123, 140n3, 141nn7–8 Ilisaqsivik Society Family Resource Centre, 89 Illagiittugut Group Home, 49 Indigent Health Benefits, 33 influenza, 94 information and communications technology (ICT), xiv, 50–4, 123 Information and Privacy Commissioner, Nunavut, 53 infrastructure, health, 45–50 Innuvialuit, 5 Interdepartmental Continuing Care Task Force, Nunavut, 48 Inuinnaqtun, 4, 29, 58, 139n1 Inuit, 55–6, 58, 60, 63, 73, 77–9, 81–2, 85–6, 99–100, 103–4, 106, 110–12, 115, 117–19, 122–4, 126, 139n1, 139n4, 140n1, 141nn6, 11, 142nn8, 12, 143nn15, 18, 19, ­147nn1–2, 148n5; culture, 17–18, 26, 75, 77–9, 85, 87, 111, 118, 124, 140n2, 141n6 Inuit Nunaat, 5, 6, 10, 13 Inuit Employment Plan, Nunavut, 77 Inuit Qaujimajatuqangit (IQ), xiv, 17 Inuit Tapiriit Kanatami, 117, 126, 137 Inukjuak, 23

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172 Index Inuit Taparit Kanatami, xiv Inuktitut, 4, 13, 29, 58, 77, 118, 139n1, 141n6 Inupiat, 6 Inuuqatigiitsiarniq, 17 Iqaluit, 12, 21, 25–7, 29, 36–7, 39, 43, 46–50, 53, 56, 60–1, 63, 65–6, 68, 70, 72–3, 78, 80–1, 86, 88, 92–3, 95–109, 117, 137, 140n1, 141n7, 143n19, 146n14 Iqaluit Dental Services, 73 Isaccie Group Home, 48 Isuarsivik Treatment Centre, 118 J.A. Hildes Northern Medical Unit, University of Manitoba. See University of Manitoba, Northern Medical Unit (NMU) Jorsyn Dental Services, 73, 146n11 Kalaalit, 6 Kamatsiaqtut Helpline, 116 Kimmirut, 12, 22, 137 Kitikmeot Region, 25, 29, 37, 43, 52, 60–1, 64, 66, 68, 72–3, 82, 95–8, 105, 106–7, 117, 146n11, 148n6; Kitikmeot Inuit Association, 91; Kitikmeot Regional Health Centre, 47, 63, 66, 68, 70–1, 100–3, 106–7, 140n3 Kivalliq Region, 25, 29, 37, 43, 52, 60–1, 64, 68–9, 72–3, 82, 95–8, 103, 105, 107, 117, 140n3, 142n4, 146n11; ­Kivalliq Regional Health

­ entre, 47, 63, 71, 100, 102–3, C 106–7; Kivalliq Smiles, 73, 146n11 Kugaaruk (Pelly Bay), 12 Kugluktuk, 12, 26, 137 Kuujjuaq, 118 Labrador, 5, 10, 11, 55 Lake Harbour, 22 Laurentian University, 67 legislation, health laws, and regulations in Nunavut, 131–2 licensed practical nurse (LPN). See nursing LivingWorks Education, 114 limiting injuries, 19 long-term care, 27, 48–9, 99–100 low birth weight, 18–19, 103 lung cancer, 18–19, 85, 91, 142n13 Manitoba, 33, 36, 43, 51–2, 66, 96 marijuana, 11, 113 Martha Taliruq Centre, 49, 141n5, 142n6 Maternal and Newborn Health Care Strategy, Nunavut, 67 maternity services, 102–4 maternity care worker. See Nunavut Arctic College MBTelehealth Network, 52 McGill-Baffin program, 25 measles, 94 Medical Care Act, Canada, 32, 131 Medical Registration Committee, Nunavut, 59

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Index 173

medical travel, 26, 33, 36–9, 43–5, 140nn1, 8 meningococcal conjugate, 94 mental health, 18, 27, 35, 39, 56, 61, 66, 69–70, 76, 81, 86–7, 104, 110–19, 125, 132, 142n1, 144n1, 147n4, 148nn5, 7–10; addictions 110–11, 117–19, 149n14 Midwifery Profession Act, 67, 104, 132 Minister of Health and Social Services, 30, 104 Mohawk College-McMaster University,74 Moms and Tots program, 105 Montreal, 43, 97; Montreal Children’s Hospital, 24 mumps, 94 Naja Isabelle Home, 49, 52, 66, 105 National Aboriginal Health Organization (NAHO), xiv, 77, 79, 137 National Indian and Inuit Community Health Representative Organization (NIICHRO), xiv, 76, 138, 143n15 National Inuit Youth Council, 115 National Native Alcohol and Drug Abuse Program, 35 National School of Dental ­Therapy, 73. See also First Nations University of Canada NIHB Formulary, 54, 65, 146n10

Non-Insured Health Benefits (NIHB), xiv, 10, 30, 33–4, 36, 39, 54, 65, 106, 121, 136, 140n1, 146nn10, 15 North Pole, 3 North West Company, 91 Northwest Territories (NWT), 4–5, 7, 10–13, 15, 18–19, 20, 24, 25, 33–4, 36, 40–1, 43, 51, 55, 57, 62–3, 91, 94, 96, 101–2, 111–12, 124, 146n9 Norwegian Sami, 112 Nunatsiavut, 5, 10–11, 13 Nunavik, 5, 10–11, 13 Nunavut: Nunavut Act, 7; Nunavut Association of Municipalities, 90; Nunavut Broadband Development Corporation (NBDC), xiv, 53, 141n11; Nunavut Economic Forum, 11, 16; Nunavut Employees Union, 80; Nunavut Health Care Plan, 39; Nunavut Housing Corporation, 48; Nunavut Implementation Commission, 25; Nunavut Land Claims Agreement (NLCA), xiv, 7, 17, 77, 78; Nunavut Legislative Assembly, 114; Nunavut Nurses, 83, 138; Nunavut Nursing and Recruitment Strategy, 61; Nunavut Physicians, 83, 138; Nunavut Public Health Act, 69; Nunavut Research Institute, 55–6, 138 Nunavut Settlement Area, 77; Nunavut Telehealth Expansion and Change Management

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174 Index ­ roject, 52; Nunavut TunngaP vik Inc. (NTI), xiv, 7, 26, 30, 113–15, 137, 144n3 Nunavut Arctic College (NAC), xiv, 56, 63, 67, 70, 72, 74, 76, 81, 104, 138; Maternity Care Worker Program, 67–8, 102, 104, 142n1; Midwifery Program, 67 nurse practitioner (NP), xiv, 48, 63–5, 95, 98, 102, 132–3, 143n9, 146n10 nursing: community health nurse (CHN), xiii, 23, 25, 29, 46, 51, 57–8, 60–1, 63–6, 68, 70, 74–6, 78–80, 86–8, 91–3, 95, 98, 100, 102, 104–8, 115–16, 118, 122–3, 133–4, 143n10; licensed practical nurse (LPN), xiv, 49, 66; Nursing Profession Act of the Northwest Territories, 63, 65, 143n11; Nursing Recruitment and Retention Strategy, 82–3 nutritional programs, 90–1 obesity, 18–19, 124 Old Health Centre, Ranklin Inlet, 50, 102–3 Ontario, 33, 51 Ottawa, Ontario, 21, 29, 43, 96–7, 106, 118 Ottawa Health Services Network, Inc., 60, 97, 121, 137 Pairijait Tigumivik Elders’ Society, 117 palliative care, 47, 99–100

Pangnirtung, 12, 22, 93, 101, 105, 108, 113 Pan-Territorial Oral Health Initiative, 101 Pembroke, Ontario, 146n11 performance measuring and monitoring, 46, 54–5, 84, 120, 125–7, 141n12 Personal Information Protection and Electronic Documents Act (PIPEDA), xiv, 53 pharmaceuticals, 33, 52, 54, 65, 68, 98, 134 Pharmacy Act, 68, 132 Philippines, 79 physicians, 46, 48, 53, 57–60, 65, 75–6, 78, 80, 82–4, 86–7, 93, 95, 102, 113, 116, 120–1, 123, 131, 138, 140n2, 144n1; family physician (FP), xiv, 48, 60, 95, 102, 116, 120–1 Pijitsirniq, 17 Pilimmaksarniq/Pijariuqsarniq, 17 Piliriqatigiinniq/Ikajuqtigiinniq, 17 Pimakslirvik Corporation, 49 planning, health system, 125–7 pneumococcal conjugate, 94 Polar Vision Centre, 73, 101 polio, 94 Pond Inlet, 12, 23, 66, 78, 108, 137, 141nn18, 148nn7, 10 population health, 10, 30, 35, 39, 54, 87–8, 143n16 Port Harrison. See Inukjuak prescription drugs. See pharmaceuticals

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Index 175

primary health care, 32, 67, 76, 86, 95–6, 120, 144n1 Professional Practice Unit, Department of Health and Social Services, 71 Protestantism, 108 Psychologist Act, Nunavut, 70 Public Health Agency of Canada, 10, 30, 35, 39, 136 Public Health Clinic of Iqaluit, 88, 92 public health, 10, 28–30, 35, 38–40, 45–6, 50, 61, 63–4, 68–9, 75–6, 83, 88, 90, 92–3, 104, 120, 125, 132, 134, 136, 143nn16, 19, 144n1; public health clinic, 134 Pulaarvik Kablu Friendship ­Centre, Ranklin Inlet, 89 Qanuqtuurniq,17 Qaujigiartiit Arctic Health Research Network, 56 Qikiqtaaluk Region, 25, 29, 37, 48, 60, 64, 68–70, 72, 73, 82, 91, 93, 96–7, 99, 101, 105, 107, 115, 117, 140n3, 142n1, 146n11, 148n10; Qikiqtani General Hospital (QGH), ­Iqaluit, Nunavut, xiv, 29, 47–8, 53, 60–1, 63, 68, 70–2, 93, 96–100, 102–3, 106–9, 117, 143n19, 146n14, 149n13; Qikiqtani Inuit Association, 114 Qikiqtarjuaq, 12, 78, 93, 137, 143n19, 148n11 Quebec, 5, 10, 11, 23, 55, 118, 144n1; Quebec City, 23

Rankin Inlet, 12, 25, 29, 32, 37, 39, 46–50, 53, 60–1, 63, 67–8, 70–2, 78, 81, 83, 88–9, 93, 97–8, 102, 105–8, 113, 126, 137, 143n19, 147n19; R ­ ankin Inlet Birthing Centre, 103, 146n13; Rankin Inlet Group Home, 48 registered nurse (RN), xiv, 63, 64, 78, 83, 86, 116, 132–3; Registered Nurses Association of the Northwest Territories and Nunavut (RNANTNU), xiv,62–5, 138 registered psychiatric nurse (RPN), xiv, 66, 69, 116 rehabilitation services, 50–1, 72, 98–9 Repulse Bay, 12 Resolute, 12, 23, 66, 146n14, 148n10 Roman Catholic mission hospital, 22 Royal Canadian Mounted Police (RCMP), 66, 114 rubella, 94 Sami, 6, 112 Sanikiluaq, 12, 25, 118, 140n3 Saskatchewan, 33, 66, 73, 141n12 scope of practice. See health human resources Second World War, 22–3, 29, 86 Selkirk Mental Health Centre, 117 smoking. See tobacco

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176 Index social (non-medical) determinants of health, 11, 15, 124–5; education as social determinant of health, 4, 11, 13, 15, 58, 75, 88, 101, 113, 119, 124 spiritual care, 108 Stanton Hospital, NWT, 60, 68, 72–3, 96–8, 105–6, 117, 121, 137; Stanton Hospital Mental Health Clinic, 117; Stanton Territorial Hospital, 96 suicide: Applied Suicide Interventions Skills Training (ASIST), xiii, 114; Annirusuktugut Suicide Intervention and Prevention Strategy, 113; Inuusivut, Our Way of Life, 115; National Aboriginal Youth ­Suicide Prevention Strategy, 35; Office for Suicide Prevention, 113; Uqaqatigiiluk! Talk About It! Program, 114; Working Group for a Suicide Prevention Strategy for Nunavut, 113 Taloyoak, 12, 91 Territorial Formula Financing (TTF), Government of Canada, xiv, 38 Territorial Health Access Fund, 69 tetanus, 94 Timimut Ikajuqsivik Centre, 50, 72 tobacco (smoking), 11, 15, 20, 58, 75, 86, 90–2, 125, 132

Training Ladders initiative, 77 Tungasuvvingat Inuit Mamisarvik Healing Centre, 118, 137 Tunnganarniq, 17 United States, 22 University of Alberta, 67 University of Manitoba, Northern Medical Unit (NMU), xiv, 61, 68, 72, 96–8, 105, 117, 121, 137, 142n4 University of Ottawa Clinic, 73 University of Ottawa Eye Institute, 101 University of Toronto Psychiatric Outreach Program, 117 varicella, 94 websites, 136–8 Westminster parliamentary model, 10 Whale Cove, 12, 118 Winnipeg, 29, 43, 52, 71, 96, 106, 117, 146n11 youth health services. See child health services Yukon, 4, 10–11, 13, 15, 18–20, 33, 34, 40–1, 43, 94, 102, 112, 124, 143n13, 146n9; Yellowknife, 29, 36, 43, 61, 68, 72–3, 96, 98, 101, 105–6, 117, 121, 137