Josée Gabrielle Lavoie

The 2009 H1N1 pandemic resulted in Indigenous peoples representing 12.6% of confirmed H1N1 cases, 17% of associated hospitalisations, and 14% of ICU admissions [1–4]. At the time, First Nations (FN...

Primary healthcare (PHC) providers working in Manitoba First Nations (FNs) communities have anecdotally reported that the workload they face does not match staffing levels, leaving the care they provide comparable to a walk-in clinic, especially in communities with a population over 2,500. The purpose of this study was to evaluate the capacity of Nursing stations to deliver PHC services in FN communities with populations greater than 2,500, compared to smaller FN communities with populations less than 2,500, by analysing markers of chronic kidney disease (CKD) quality care among individuals living with CKD. We also assessed whether different models of care might reduce disparities in health outcomes. This partnership between researchers from the First Nations Health and Social Secretariat of Manitoba and the University of Manitoba used health administrative data held at the Manitoba Centre for Health Policy (2006-2019), linked to the Manitoba First Nations Research File to identify FNs. Data used included: Diagnostic Services Laboratory Data, Medical Claims, Hospital Discharge Abstracts, Drug Program Information Network Data, Public Canadian Census Files, Manitoba Health Insurance Registry and Physician Resource File. All records were de-identified. PHC visits and hospitalisation rates were higher in larger communities, suggesting a tendency to refer patients more readily to a higher level of care. In contrast, FNs living with CKD in smaller communities are more likely to receive follow up kidney function screening. Premature mortality rates for FNs living with CKD remain lower in larger communities. Our findings show that access to responsive PHC in Manitoba's rural and remote communities remains aspirational and may reflect pragmatic adaptations to workload pressures. There is an urgent need to assess the economic and health impact of these adaptations, to ensure that they result in optimal health results and progress equity for FNs, Manitobans, and those living in rural and remote communities.

Background: End-stage kidney disease continues to disproportionally impact the lives of First Nations peoples. Systemic racism is a key determinant, and manifests as differential access to determinants of health (housing, employment, access to care) and differential care. This paper discusses how different models of primary healthcare operating in rural and remote Manitoba communities results in different outcomes for patients identified as being at risk of kidney disease. Methods: This study is a partnership between researchers from the First Nations Health and Social Secretariat of Manitoba and the University of Manitoba. We used health administrative data held at the Manitoba Centre for Health Policy for the period of 2006-2019, linked to the Manitoba First Nations Research File to identify First Nations. We compared rates of laboratory follow-up tests, nephrology consults, PHC visits, and hospitalizations between different models of care using a negative binomial regression model adjusted for age, sex, eGFR heat-map category, urine ACR heat-map category, and Elixhauser comorbidity index. Results: We identified 12,613 First Nations people with chronic kidney disease (CKD) during the study period. First Nations individuals with CKD who reside in communities served by Nursing Stations (most remote communities) when supplemented by additional Indigenous programs were consistently more likely to receive follow-up serum creatinine (OR 1.37, 95% CI: 1.30-1.45, ppp<0.001) than individuals who lived in communities served by Nursing Stations alone, Health Centres, Health Offices, or Off Reserve. Conclusions: Our results show that addressing the rise in premature mortality experienced by First Nations from kidney diseases require greater investments in First Nations-centric primary healthcare, that is locally managed. Additionally, off-reserve primary healthcare services must be alerted to their need to better address the needs of First Nations at risk of CKD, with more consistent follow up, referrals, and in providing culturally safe care. Finally, First Nations-led research in kidney health and primary healthcare is leading to significant improvements in outcomes, and needs to be better supported and resourced, and imbedded in a context of greater investments to improve access to all determinants of health and counter systemic racism.

Despite decades of Inuit accessing services in Manitoba, Inuit-centric services remain scant and have only begun to emerge. This article reports on Inuit utilisation of mental health services in Manitoba. In this study, we focused on two interrelated cohorts: Inuit living in Manitoba and Inuit from the Kivalliq region who come to Winnipeg to access specialised services. We used administrative data routinely collected by Manitoban agencies. The study was conducted in partnership with the Manitoba Inuit Association, and Inuit Elders from Nunavut and Manitoba. Our results show that mental health-related consults represent between 1 in 5 and 1 in 3 of all consults made by Inuit in Manitoba. Rates of hospitalisation for mental health conditions are considerably lower than those of residents from the Manitoba northern health authority. Given that Nunavut has the highest rate of suicide in the world, our results suggest underserved needs rather than lower needs. Kivalliq and Manitoba Inuit utilise mental health services in Manitoba extensively, yet these services for the most part remain western-centric. Epistemological accommodations in the provision of mental health services have yet to be implemented. This is now the focus of our work.

Canada has an obligation to implement Jordan’s Principle in a way that achieves both substantive equality and self-determination. Both these principles require an approach that centres the full participation of First Nations, supports the development and provision of services tailored to culture and context, and enables differentiation across families and Nations. Canada’s implementation of Jordan’s Principle has relied so heavily on federal employees’ use of administrative discretion that it has side-stepped the resource-intensive requirements of self-determination and substantive equality. Some use of administrative discretion is necessary to accommodate the diverse needs and context addressed by Jordan’s Principle. However, excessive reliance on administrative discretion reproduces pre-existing, colonial power relations. Implementation of Jordan’s Principle in keeping with the principles of self-determination and substantive equality requires: remedying the known gaps in existing policies and funding models that are being addressed through Jordan’s Principle; providing First Nations with timely access to meaningful information about what can be funded through Jordan’s Principle; ensuring that Jordan’s Principle funding is extended on timelines and at levels that allow First Nations to take on responsibilities in tandem with their self-determined priorities; and ensuring First Nations’ involvement in all levels of Jordan’s Principle decision-making. Le Canada a l'obligation de mettre en œuvre le principe de Jordan de manière à réaliser à la fois l'égalité réelle et l'autodétermination. Ces deux principes requièrent une approche qui privilégie la pleine participation des Premières Nations, soutient le développement et la prestation de services adaptés à la culture et au contexte, et permet la différenciation entre les familles et les nations. La mise en œuvre du principe de Jordan par le Canada s'est tellement appuyée sur l'utilisation du pouvoir discrétionnaire des fonctionnaires fédéraux qu'elle a éludé les exigences d'autodétermination et d'égalité réelle, qui nécessitent beaucoup de ressources. Un certain recours au pouvoir discrétionnaire de l'administration est nécessaire pour répondre aux divers besoins et contextes visés par le principe de Jordan. Cependant, un recours excessif au pouvoir discrétionnaire administratif reproduit les relations de pouvoir coloniales préexistantes. La mise en œuvre du principe de Jordan dans le respect des principes d'autodétermination et d'égalité réelle exige de : combler les lacunes connues dans les politiques et les modèles de financement existants qui sont abordés dans le cadre du principe de Jordan ; fournir aux Premières Nations un accès opportun à des informations pertinentes sur ce qui peut être financé dans le cadre du principe de Jordan ; veiller à ce que le financement du principe de Jordan soit étendu dans des délais et à des niveaux qui permettent aux Premières Nations d'assumer des responsabilités en tandem avec leurs priorités autodéterminées ; et assurer la participation des Premières Nations à tous les niveaux de la prise de décision dans le cadre du principe de Jordan.

Background: Differential access to healthcare has contributed to a higher burden of illness and mortality among First Nations compared to other people in Canada. Throughout the Coronavirus Disease 2019 (COVID-19) pandemic, First Nations organizations in Manitoba partnered with public health and Manitoba government officials to ensure First Nations had early, equitable and culturally safe access to COVID-19 diagnostic testing and vaccination. In this study, we examined whether prioritizing First Nations for vaccination was associated with faster uptake of COVID-19 vaccines among First Nations versus All Other Manitobans (AOM). Methods and findings: In this retrospective cohort study, we used linked, whole-population administrative data from the Manitoba healthcare system (February 2020 to December 2021) to determine rates of COVID-19 diagnostic testing, infection, and vaccination, and used adjusted restricted mean survival time (RMST) models to test whether First Nations received their first and second vaccine doses more quickly than other Manitobans. The cohort comprised 114,816 First Nations (50.6% female) and 1,262,760 AOM (50.1% female). First Nations were younger (72.3% were age 0 to 39 years) compared to AOM (51% were age 0 to 39 years) and were overrepresented in the lowest 2 income quintiles (81.6% versus 35.6% for AOM). The 2 groups had a similar burden of comorbidities (65.8% of First Nations had none and 6.3% had 3 or more; 65.9% of AOM had none and 6.0% had 3 or more) and existing mental disorders (36.9% of First Nations were diagnosed with a mood/anxiety disorder, psychosis, personality disorder, or substance use disorder versus 35.2% of AOM). First Nations had crude infection rates of up to 17.20 (95% CI 17.15 to 17.24) COVID-19 infections/1,000 person-months compared with up to 6.24 (95% CI 6.16 to 6.32) infections/1,000 person-months among AOM. First Nations had crude diagnostic testing rates of up to 103.19 (95% CI 103.06 to 103.32) diagnostic COVID-19 tests/1,000 person-months compared with up to 61.52 (95% CI 61.47 to 61.57) tests/1,000 person-months among AOM. Prioritizing First Nations to receive vaccines was associated with faster vaccine uptake among First Nations versus other Manitobans. After adjusting for age, sex, income, region of residence, mental health conditions, and comorbidities, we found that First Nations residents received their first vaccine dose an average of 15.5 (95% CI 14.9 to 16.0) days sooner and their second dose 13.9 (95% CI 13.3 to 14.5) days sooner than other Manitobans in the same age group. The study was limited by the discontinuation of population-based COVID-19 testing and data collection in December 2021. As well, it would have been valuable to have contextual data on potential barriers to COVID-19 testing or vaccination, including, for example, information on social and structural barriers faced by Indigenous and other racialized people, or the distrust Indigenous people may have in governments due to historical harms. Conclusion: In this study, we observed that the partnered COVID-19 response between First Nations and the Manitoba government, which oversaw creation and enactment of policies prioritizing First Nations for vaccines, was associated with vaccine acceptance and quick uptake among First Nations. This approach may serve as a useful framework for future public health efforts in Manitoba and other jurisdictions across Canada.

Background: End-stage kidney disease continues to disproportionally impact the lives of First Nations patients. Systemic racism is a key determinant, and manifests as differential access to determinants of health (housing, employment, access to care) and differential care. This paper discusses how different models of primary healthcare operating in rural and remote Manitoba communities results in different outcomes for patients identified as being at risk of kidney disease. Methods: This study is a partnership between researchers from the First Nations Health and Social Secretariat of Manitoba and the University of Manitoba. We used health administrative data held at the Manitoba Centre for Health Policy for the period of 2006-2019, linked to the Manitoba First Nations Research File to identify First Nations. Data we used included: Diagnostic Services Manitoba Laboratory Data, Medical Claims, Hospital Discharge Abstracts, Drug Program Information Network Data, Public Canadian Census Files, Manitoba Health Insurance Registry, and Physician Resource File. All records were de-identified. Results: We identified 12,613 First Nations people with chronic kidney disease (CKD) during the study period. First Nations individuals with CKD who reside in communities served by Nursing Stations (most remote communities) when supplemented by additional Indigenous programs were consistently more likely to receive follow-up serum creatinine (OR 1.37, 95% CI: 1.30-1.45, p<0.001), urine ACR (OR 1.22, 95% CI: 1.16-1.28, p<0.001), serum potassium (OR 1.40, 95% CI: 1.32-1.49, p<0.001) than individuals who lived in communities' served by Nursing Stations alone, Health Centres, Health Offices, or Off Reserve. Conclusions: In Canada, when primary healthcare is enhanced by health services determined by First Nations remoteness alone is not a risk factor. Addressing the rise in premature mortality experienced by First Nations from kidney diseases require greater investments in First Nations-centric primary healthcare, that is locally managed. Additionally, off-reserve primary care services must be alerted to their need to better address the needs of First Nations at risk of CKD, with more consistent follow up, referrals, and in providing culturally safe care. Finally, First Nations-led research in kidney health and primary healthcare is leading to significant improvements in outcomes, and needs to be better supported and resourced.

The first positive case of COVID-19 (SARS-CoV-2) in the Arctic region was detected in January of 2020 in Saariselkä Outdoor Resort in Finland, precipitating responses across all Arctic countries an...

We document community responses to the COVID-19 pandemic among Inuit living in the province of Manitoba, Canada. This study was conducted by the Manitoba Inuit Association and a Council of Inuit Elders, in partnership with researchers from the University of Manitoba. We present findings from 12 health services providers and decision-makers, collected in 2021.Although Public Health orders led to the closure of the Manitoba Inuit Association's doors to community events and drop-in activities, it also created opportunities for the creation of programming and events delivered virtually and through outreach. The pandemic exacerbated pre-existing health and social system's shortcomings (limited access to safe housing, food insecurity) and trauma-related tensions within the community. The Manitoba Inuit Association achieved unprecedented visibility with the provincial government, receiving bi-weekly reports of COVID-19 testing, results and vaccination rates for Inuit. We conclude that after over a decade of advocacy received with at best tepid enthusiasm by federal and provincial governments, the Manitoba Inuit Association was able effectively advocate for Inuit-centric programming, and respond to Inuit community's needs, bringing visibility to a community that had until then been largely invisible. Still, many programs have been fueled with COVID-19 funding, raising the issue of sustainability.

Across Canada, the COVID-19 pandemic placed considerable stress on territorial and provincial healthcare systems. For Nunavut, the need to continue to provide access to critical care to its citizens meant that medical travel to provincial points of care (Edmonton, Winnipeg and Ottawa) had to continue through the pandemic. This complexity created challenges related to the need to keep Nunavut residents safe while accessing care, and to manage the risk of outbreaks in Nunavut resultant from patients returning home. A number of strategies were adopted to mitigate risk, including the expansion of virtual care, self-isolation requirements before returning from Winnipeg, and a level of cross-jurisdictional coordination previously unprecedented. Structural limitations in Nunavut however limited opportunities to expand virtual care, and to allow providers from Manitoba to access the Nunavut’s electronic medical records of patients requiring follow up. Thus, known and long-standing issues exacerbated vulnerabilities within the Nunavut healthcare system. We conclude that addressing cross-jurisdictional issues would be well served by the development of a more formal Nunavut-Manitoba agreement (with similar agreements with Ontario and Alberta), outlining mutual obligations and accountabilities.