NTI President Aluki Kotierk Opening Remarks – Indigenous Health Conference

Download Speaking Notes: 2018-05 Indigenous Health Conference- Opening Remarks

May 24, 2018Mississauga, Ontario

Introduction
In February 2017, Bernice Clarke in speaking about the death of her mother Annie Kootoo stated that Inuktitut may have been a difference maker for her mother. She had not received health care services in Inuktitut. She was being treated for TB and she died in Ottawa of liver failure.

In March 2017, when Geela Kooneeliusie was asked about her daughter Ileen, who died at the age of 15, what needs to prevent another death like her daughters she responded that the health centres need Inuit staff who speak Inuktitut.

Inuktut as a public health issue
I want to speak to you about Inuktut as a public health issue. Given the many statistics indicating the lower health status of many Inuit compared to the average Canadian and the higher rates of preventable diseases and other medical ailments amongst Inuit this may seem like an unlikely topic to focus on but like Bernice and like Geela, I think it is an important topic that is worth thinking more deeply about.

Our 2007-2008 annual report on Nunavut’s Health System states:

“Inuit are emerging from a period when health care priorities and most aspects of health care practice and delivery were set by non-Inuit. Inuit wish to improve upon the conventional medical system in Nunavut. It does not engage Inuit, does not operate in Inuit language, does not employ Inuit at a representational level, and does not adequately acknowledge Inuit healers or healing practices. Poorly adapted and chronically under-funded health care services and programs based in Southern Canada and delivered primarily in English are no longer acceptable.”

Today, I am addressing you as you attend an Indigenous Health Conference with a theme of, “Walking Together’. It might also be titled: Talking together—since there is no health without communication and understanding. We are and will be unable to walk together unless we have a better understanding of each other.

As quoted from the Commonwealth Fund, and used on the cover of the Systemic Investigation Report into the Qikiqtani General Hospital’s Compliance with the Official Languages Act by the Office of the Languages Commission of Nunavut in October 2015:

“Being able to speak in one’s mother tongue when it concerns health is not asking a favour of health care professionals or organizations. On the contrary, it is a basic issue of accessibility, safety, quality and equality of services.”

Nunavut
Before I delve right into this topic, for those of you who have not had the great fortune to come to Nunavut, I thought I would provide you with a broad context. First, Nunavut, in Inuktut means ‘Our Land’.

As the NTI President, I represent Nunavut Inuit. Nunavut Inuit make up 85% of the population of Nunavut, 70% identify Inuktut as their mother-tongue.

There are 25 communities spread across this vast land that make up one-fifth of Canada’s land mass. These 25 communities receive health services through 22 community health centres, regional health centres in Rankin Inlet, Cambridge Bay and the Qikiqtani General Hospital in Iqaluit.

Depending on a patient’s needs and the types and level of care available in a community, patients may be sent to larger centres for treatment of condition. In 2015-2016 just over $70 million was spent on medical travel (16.7 percent of total departmental expenditures).

Community health centres are typically staffed by a nurse-in-charge and community health nurses. As of March 31, 2016:
 43 of the 69 community health nurse positions were vacant (62%)
 5 of the 25 nurse-in-charge positions were vacant (20%)

Casual and agency nurses are used to fill these vacancies and to replace permanent nurses on leave. During 2015-2016, a little over $30 million was spent on casual and agency nurses.

Inuktut
In Canada, our language, Inuktut, is considered to be one of the stronger Indigenous languages. Yet it is declining at 1% per year. At this rate, by 2051 only 4% of us will be speaking Inuktut at home.

Nunavut is the only jurisdiction in Canada that has a majority language that is not one of the federally recognized official languages – French or English.

Despite this, Inuktut is not the working language of government nor the language used to provide essential services.

This concerns me. It concerns me that some unilingual Inuktut speaking Inuit are not receiving equitable public services similar to those of other Canadians.

Historically, we know that Canada funded buildings and personnel to actively strip Indigenous people of their culture including their language through residential school. In my view, Canada should and has the responsibility to fund buildings and personnel to actively rebuild, strengthen and protect Indigenous languages.

Public Services in Inuktut
I’d like to ask you to take a moment to think about your last trip to the doctor or to the hospital.

“How important is communication to you? How important is language to communicating with your doctor or nurse?” (Inuktut and English)

Think about your doctor’s visit: How big a role does accurate communication and understanding play in what type of health treatment you receive? Pretty big, right?

So imagine living here in Mississauga where the majority public language is English; now imagine that almost none of the health professionals speak or understand that majority language. How would you feel going into that system?

This is our reality.

And, I did not even ask you to imagine the next step, where you needed the expertise of a doctor or services only a hospital could deliver and you had to fly, often unaccompanied, down to Mexico.

Some of the findings of the systemic investigation included:
 Language barriers have a negative impact on quality of care, patient safety and access to health care services
 Patient-provider communication problems may result in a misdiagnosis and relevant follow-up treatment
 Patient confidentiality rights and informed consent may not be protected.

In speaking about interpretation services, one of the contributors stated,

“The worst case I saw is that we had to use other patients as interpreters. Obviously it is a breach of confidentiality, but I also feel that if I use a patient to translate for another patient it transgresses medical rights. You are here to get better and you are being used as staff. Sometimes the patient has to give it a try, but it is the best solution we can come up with.”

Public Safety Issue
In Nunavut, we Inuit live under a public government, just like Ontario or Quebec. We pay income tax. We expect to receive public services just like other Canadians. We
want to feel safe when we enter the health system, the school system or the justice system. Do we feel safe? No.

What’s the difference? The difference is, our majority public language is Inuktut.

What happens when a government does not deliver public services in the language of the public? Canadians die. Canadians are hurt. This happens in Nunavut. Would this be allowed to happen in Mississauga, or in Montreal?

This is a public safety issue.

Inuktut as working language
2018 marks 25 years since Nunavut Inuit achieved a land claims agreement with the crown. It is a good time to reflect on where we are. Is this what Inuit envisioned when they tirelessly negotiated the land claims agreement? Where would we like to see ourselves in the next 25 years? How can we make life better for our children and their children?

When the Government of Canada and the Government of Northwest Territories met 20 years ago to design how to fund the Nunavut’s public government and public services, they decided not to fund Inuktut as the language of our government. This was a decision; it was not an accident or an oversight.

Inuit experience the results of this decision. The results are that we have a health system that does not function in the majority public language, a justice system that does not function in the majority public language, and an education system that does not function in the majority public language.

Inuit are resilient, adaptable and pragmatic. So we cope, we cooperate and we communicate. We do what the public services have chosen not to do. We keep our language alive at home, we interpret for our relatives in the health system. Everyday in hundreds of interactions with public services we help our relatives and community members communicate. I do this. My relatives do this. This is our reality as Inuktut speaking residents of Nunavut.

Medical Interpreters
Often, informal interpretation services is provided on top of one’s own employment or community responsibilities. Recently, I was trying to check in at the Iqaluit airport for my own flight and an employee of an airline at the counter gestured me over to help them speak to an unilingual Inuktut-speaking passenger. This is in Nunavut. On Inuit homelands. Where the majority public language is Inuktut.

Providing informal interpretations is an additional burden of being an Inuktut-speaking Inuk living in Nunavut, that is hardly ever acknowledged and recognized but is very readily expected and undeniably necessary. Just because an Inuk is fluent in Inuktut, the assumption is made that an Inuk will be able to effectively and accurately interpret any discussion even if it has complex technical vocabulary that one has never spoken about in their personal life.

I often wonder what it would have been like if there had been a decision made to fund Inuktut as the working language of our government.

I want to take a second to dwell on how it is expected. Imagine for instance, if in the airport scenario, although being gestured over, by a person that I do not work with, by a person I do not associate with, I had said no. I was not willing to help the airline employee communicate with the passenger.

 The airline employee would probably be offended and think that I have an attitude and that I was being difficult
 The unilingual Inuktut-speaking person would probably wonder what kind of an Inuk I was. As Inuit we are brought up to be helpful contributing members of society.
 I would be left feeling guilty and thinking that I was a bad Inuk for not helping out a fellow Inuk

This is another way of maintaining the power imbalance and accepting things that are unacceptable! Imagine if French, an official language of this nation, had been expected to thrive through the goodness of peoples’ hearts?

Anecdotally, to bring it back to the health field, I have heard that Inuktut-speaking nursing students are expected to step up without the additional supports of Inuktut medical terminology when they are doing their practicum at the hospital. Think about the additional stress! The additional stress that is not placed on non-Inuktut-speaking mostly non-Inuit students. . . and then the system wonders why Inuit are sometimes less successful.

The March 2017 OAG report on Health Services in Nunavut found that there is a non-mandatory course on medical terminology available for clerk interpreters. Yet the clerk interpreters that they had met had not received such training, had not received it in a timely manner or had not taken training in many years. It states,

“Having interpreters with knowledge of medical terminology and vocabulary is important because it helps Inuit patients who do not speak English and their health care providers better understand each other about, for example, the patient’s condition.”

One of the recommendations coming out of the systemic investigation was,

“The Department of Health, in collaboration with Inuit Uqausinginnik Taiguusiliuqtiit (IUT), should develop competency tools to evaluate language proficiency of medical interpreters.”

Too often, when an Inuktut-speaking patient walks into a health care centre in Nunavut they must revert to speaking in English to receive essential health services – even if they are more comfortable in speaking Inuktut.

Again, from the systemic investigation, it states,

‘What medical providers must understand is that when one is placed in a situation of vulnerability, it is often difficult to understand medical jargon and to clearly express one’s needs, fears, pain, etc. It is even more difficult to express these concepts in a language that is not our own.”

This is recognized and most recently expressed in the Coroner’s report surrounding the circumstances of the death of Annie Kootoo. The report had two recommendations that highight to the need to use Inuktut interpreters when providing health teaching as well as the need to provide written instructions in Inuktut.

Approach to health service delivery – trauma-informed – culturally appropriate
I have spent much of my talk on language and culturally appropriate health service delivery. I think I also need to speak to the importance of having a trauma informed approach to health services. It is important for any health worker going into our communities to have a general understanding of the types of lived experiences, social history and intergenerational trauma that Inuit carry.

In Nunavut, it is in living history that our family members were living out on the land. It is quite recent that the 25 communities were established. Before that, Inuit lived, as masters of their own destiny, in family groupings in a nomadic lifestyle.

When communities were being established, Qallunaat (non-Inuit) would come to our lands in authoritative positions. Life was disrupted and changed forever.

During this period there was an increase in tuberculosis, As documented in the Qikiqtani Truth Commission report on health care, “By 1955, almost one thousand Inuit had been evacuated to Southern santoria. Treatment generally averaged twenty months. This meant that in 1956, one in seven Inuit were in hospitals in the South.”

This has an impact on Inuit living today who still carry pain and heartaches about this era. Some Inuit still do not know where their family members were sent and where their remains may be. An Inuk TB patient at a southern sanatorium wrote,

“I really do want to go home. I do want to stay outside. I cannot tell you about my health, as I am not able to understand English. . . I am obeying the medical staff. I take aspirins. . . It is hard to tell. . .Also, I cannot cure myself. . . I very, very much want to speak English. I am trying to obey the directions of the medical people. I want to go home too. Sometimes, I appear not to be listening. . . I want to follow the wishes of the medical people. I, however, do not understand.”

It is important that health care professionals understand the context and the reasons behind some of the stigma that exists for instance in the circumstances of tuberculosis.

Building an Inuktut health care system
In my view, the health care system can play an important role in reconciliation with Indigenous peoples across this nation. In my view, the Nunavut health care system can play a significant leadership role in achieving reconciliation with Inuit. For me, reconciliation includes bringing back dignity to a people.

NTI’s 2009 annual report on the Recruitment and Retention of Inuit Nurses in Nunavut states,

“Linguistic and cultural barriers separate health care providers from patients. These barriers can lead to incomplete or incorrect diagnosis and treatment of health problems due to health care providers’ limited understanding of what a patient says. One informant noted that southern public health strategies tend to rely upon printed materials and provision of readings, resources, and web-based information. In Northern communities, the most effective communication is verbal and one-on-one. This approach, however, requires both fluency in the patient’s language and familiarity with culturally relevant communication styles.

Many Inuit have little faith in the current health service delivery model and, to a certain degree, in the staff of health care centres. There is a sense that their needs are not well understood at the community level, and that the communication gap is even greater when they are forced to travel to regional centres for care.

For communities such as Rankin Inlet, with a relatively high proportion of Inuit nurses (five out of a total of seven), informants reported a very positive impact on the impressions of Inuit patients who have been able to access health care in their own language. Several informants noted that the presence of Inuit nurses on staff reduces much of the stress experienced by non-Inui full-time nurses.”

I know that the Truth and Reconciliation Commission will be discussed later this afternoon. Under the heading of health there are 7 Calls to Action. I am particularly interested in Call to Action 23.

We call upon all levels of government to:
i) Increase the number of Aboriginal professionals working in the health-care field.
ii) Ensure the retention of Aboriginal health-care providers in Aboriginal communities.
iii) Provide cultural competency training for all health-care professionals.

This is so crucially important that at NTI’s AGM in 2006, the membership put forward a resolution calling on the Government of Nunavut to:
1) To implement robust and creative measures to increase the number of Inuit primary health care professionals in Nunavut Tunngavik Inc.
2) To actively encourage and adequately support the successful completion of Inuit students attending the Nursing Program offered by Nunavut Arctic College
3) To evaluate the Department of Health’s efforts to increase recruitment and retention of Inuit nurses.

The theme of this Indigenous Health Conference is “Walking Together’.

How can we better walk together so that an Inuktut-speaking, culturally competent, trauma-informed health system can be built in Nunavut? So that, Nunavut Inuit can to expect and feel reassured that the health system that serves our health needs recognizes our understanding of the world and delivers it in a language that we understand?

Within Nunavut, the Nunavut Arctic College has a Nursing Program with the intentions of being a space in which home-grown Inuktut-speaking nurses can attain their accreditation.

In February, through the Northern Ontario School of Medicine, the first Health Careers Camp was held in Iqaluit for Inuit High School students. This was a week long camp that allowed students the opportunity to: hear first hand from individuals (including Inuit) in the health care field; try hands on activities such as setting a cast, going to the laboratory; speaking with an Elder about traditional medical treatments, going to the hospital etc. The hope is that camps such as these would pique the interest of young Inuit to pursue health careers.

I would be remiss in not taking this opportunity to express how extremely proud I am with the Nunavut Inuit who have successfully completed medical school.

Elaine Kilabuk was the first Inuk physician to graduate from McGill University. She was inspired to take up medicine after she watched what her grandmother had to go through when she had a respiratory illness and she had to be moved from Pangnirtung to Iqaluit to Ottawa, without culturally sensitive health care. I am very pleased that her intentions are to provide health services in Iqaluit.

Donna May Kimmaliardjuk who is the first Inuk heart surgeon. She is currently in her fourth year of residency at the University of Ottawa and is also a 2018 Indspire Award recipient.

These are some successes and positive initiatives but certainly, there is much work that still needs to be done in areas of student support for success, medical terminology development, filling vacancies, Inuit nurse supports and medical clerk interpreter supports etc. I would also add that as Inuktut-speakers, we also have a responsibility to request services in Inuktut rather than continually reverting to speaking English. The more we demand services in Inuktut, surely government systems will get the message that we need and expect services in Inuktut.

I invite each of you – in whatever capacity you are attending this conference – to think about how you can walk with us. How can we make the health care system better for Nunavut Inuit?

Looking to the future
In walking with you and with talking with you, I look forward to the day in which an Inuktut-speaking Inuk, living in Nunavut can walk into a health centre or the Qikiqtani General Hospital with the self-assuredness that they will be able to receive their health care service in Inuktut. I look forward to the day in which I see more Inuit walking within Nunavut, in our homelands with their heads held up high – proud to be Inuit, with dignity and without shame, knowing that they can receive services in Inuktut.

Conclusion
Finally, I wanted to leave the most important for last. I know people most often begin with this but I wanted it to remain fresh in your minds as I concluded my remarks. I want to acknowledge and show appreciation for the people of that land on which we meet today – the Missisaugas of the New Credit First Nations.

If you will indulge me, I would like to take a few minutes to show particular gratitude to the Mississaugas of the New Credit First Nations.

Qujannamiik! Through your financial support you have supported and allowed for Inuit to pursue a higher formal education. Qujannamiik!