The Social Determinants of Health

Poor health is not something that just happens. There are many reasons why certain groups in every country have an increased risk of mortality and illness than others. The social determinants of health examine the factors responsible for a person’s overall physical, mental and social well-being (Marmot & Wilkinson, 2003). Therefore, it comes as no surprise that those living in a lower socioeconomic status situation face the greatest health related issues than those with higher income (Marmot & Wilkinson, 2003). Other areas include but are not limited to, inadequate healthcare and education, toxic social and family relationships, racism and social exclusion. For many Indigenous peoples, the effects of historical trauma can adversely affect the health and wellness of the individual, their family and on a macro level within communities. Without the correct interventions and support, these experiences can result in recurring multigenerational cycles of abuse. This paper will touch upon some of the distal, intermediate and proximal social determinants of health that affect Indigenous communities within our country (Reading & Wien, 2009).
In Canada, there are various culture groups/nations that include six hundred and thirty distinct communities known as the “Assembly of First Nations” (2013). According to the National Household Survey conducted in 2011, it was estimated that 851, 560 First Nations people were living within Canada at that time. Of those, forty-nine percent were living on a reserve and fifty-one percent lived off. Statistics Canada data revealed that approximately seventy-five percent of First Nations people that did not live on a reserve were in an urban area (2013). For years prior to colonization, the Indigenous people practiced traditional healthcare and healing and what was once an effective system became obliterated. As a result, the Indigenous populations were quick to diminish from increased disease and/or conflict (2013). Fast forward decades later and the Indigenous peoples are still facing several but important inequities including food shortages, income inequality, unsafe bathing/drinking water, addiction issues and chronic health conditions such as diabetes (Greenwood, 2017). A consequence of this was the Indigenous people have an increased risk of developing undesirable physical, emotional, and mental health related issues over that of non-Indigenous (Greenwood, 2017). The Indigenous social determinants of health are a key factor in the overall physical, mental, emotional and spiritual health and healing to all ages of Indigenous peoples (Reading & Wien, 2009). The following classification headings have been identified that best categorizes the determinants, they are distal, intermediate and proximal. Identified as having the most profound negative impact on Indigenous health is the distal category. Examples include economic, political and social factors. These aspects set the foundation for intermediate and proximal social determinants. “Research clearly indicates a link between the social inequalities created by colonialism and the disease, disability, violence and early death experienced by Aboriginal peoples in Canada (Reading & Wien, 2009)”. Socioeconomic, political and social inequality are a direct result of historical colonization (Reading & Wien, 2009).
Distal determinants have been identified as having the greatest impact to Indigenous health, with the most influential being the ongoing effects from colonization including the Residential School experience and the Indian Act of 1876 (Miller, 2012). From 1831-1996 there were approximately one hundred and thirty residential schools in Canada, sadly the last school did not close their doors until 1997 (Miller, 2012). The initial premise behind Residential Schools were to educate Indigenous children and move them into Canadian society.

The Christian churches and the Canadian government were responsible for the creation of Residential schools where Aboriginal children were stripped of their heritage, identity and way of life (Miller, 2012). These children were taken away from their families and separated from other Residential School family members. As well, alterations were made to their physical appearance such as male students having their hair cut and children had to have their names changed to a more “whiteman” sounding name (Miller, 2012). Residential School children were forbidden to speak in their native language or participate in cultural practices. Unfortunately, many children suffered years of physical, emotional and sexual abuse while attending these schools. Students had little to no contact with family and few where able to leave the schools for visits. Thousands of children did not survive the Residential School experience, though an accurate number of deaths is unlikely to be known due to insufficient record keeping (Miller, 2012). The Indian Act of 1876 gave control of Aboriginal lands, wills, status and education to name a few to the Canadian government (Montpetit, 2011). “The Indian Act came to be developed over time through separate pieces of colonial legislation regarding Aboriginal peoples across Canada such as the ‘Gradual Civilization Act of 1857. In 1876 these acts were consolidated as the Indian Act” (Hanson, 2011). Over time, there have been amendments to the act, though for the most part it remains in its original form (Hanson, 2011). Another distal social determinant of health for Indigenous is self determination, where there is a direct connection between to other equally important social determinants of health; Examples of this include healthcare and education (Redding & Wein, 2009).

“In order to ensure the most favorable intermediate determinants of health, Aboriginal peoples must participate equally in political decision-making, as well as possess control over their lands, economies, education systems and social/health services”.
Unfortunately, this does not usually happen as the they must deal with little access or control over their lands, financial assets or healthcare services (Redding & Wein. 2009).
Intermediate determinants of health include community and/or household infrastructure such as inadequate economic conditions which hinders their ability to provide safe community or household infrastructure. An ongoing example of this would be the unsafe drinking and bathing water Indigenous people live with daily (Novak et al., 2018). Regional systems infrastructure such water, power, communication and transportation. Many of the remote areas are vulnerable to damages and power outages that can cause interruptions to homes and businesses and are expensive to repair. There is a lack of essential services such as law enforcement, healthcare services and disaster response in many Indigenous communities as they are reliant on solid infrastructure. Harsh climate conditions place more of a burden on an already weak system (Novak et al., 2018). In 2016, The Canadian government announced a long-term infrastructure plan allocating approximately four-billion dollars to help in the much-needed improvements in water quality, waste management, education infrastructure, on reserve housing, the First Nation Infrastructure Fund and cultural and recreational infrastructure needed on reserves. In 2017, an additional four-billion dollars over a ten-year period was proposed to improve water treatment systems, healthcare facilities, housing and community infrastructure in a partnership with Indigenous peoples through the ‘Investing in Canada Plan’ this was to commence 2018-2019 (2019).

Some of the proximal determinants of health include housing, mobility, poverty and unemployment, which can impact the physical, mental, emotional and spiritual health. These determinants affect Indigenous of all ages but have a profound effect on the early life of children (Redding & Wein, 2009). Many Indigenous families that live on the reserves occupy inadequate housing that is overcrowded or in dire need of major repairs such as the need to correct faulty plumbing and electrical issues. Additional major repairs include a large amount of structural housing issues including flooring, inside and outside walls, and ceilings. Most of the major repairs required were significantly higher than those needing only minor fixes (2019). Other proximal determinants include a decline in overall health especially in relation to mobility. Aboriginal children are particularly vulnerable to ill health effects in families that had frequent moves. The odds of not having a regular physician in a family with more than one move increases to eighty percent, up from sixty percent to those who did not move at all or only changed residences one time (2019). Research has long demonstrated a person’s education level is directly correlated to poor health and negative social relationships (Zimmerman & Woolf, 2014). Those that did not obtain a high school diploma were more likely to have at least one chronic issue such as Diabetes, cardiovascular disease and unsatisfactory overall general health (2019). Income and unemployment are also a crucial factor in the Social Determinants of Health, with those in a lower socioeconomic status facing the greatest risks of obtaining adequate housing, food shortages or the resource to access only lower quality foods. The ramifications of low income can also directly affect one’s mental health, this can lead to depression, addiction, poor social relationship and family violence (Marmot & Wilkinson, 2003).
This paper has briefly touched upon some of the crucial social determinants of health and the vast array of issues that face the Indigenous peoples in our country daily. Distal determinants such as the historical trauma caused by colonization including Residential Schools and the Indian Act of 1876, continue to generate a multitude of damaging physical, emotional and mental effects in the lives of the Indigenous peoples and their communities. There are no words that can be said that will undo the decades of emotional, physical and sexual trauma that was forced upon them. For those that live on reserves in Canada, many are trying to survive in substandard living conditions that include deteriorating infrastructure, poor water filtration systems, inaccessible healthcare services, and insufficient education and early life programs for children. It is important for the Canadian government and policy makers to understand the relationship between key social issues such as poverty, unemployment, housing, and food insecurities to one’s overall health and that of their family.

While it appears some levels of the Canadian government have taken a step in the right direction focusing on continued reconciliation efforts and the allocation of finances to aid in improving worsening reserve infrastructures, increasing healthcare and addiction service accessibility, as well as quality educational resources. Canadians need to recognize the importance of the social determinants of health to everyone’s well-being. Instead of treating symptoms, work to identify the problems that are to blame. This is crucial, for those most vulnerable in our communities and beyond. The health and well-being of Canada’s Indigenous population should be a top priority for all Canadians including the government, policy creators and service providers. Who is going to benefit from merely temporarily treating the Indigenous people’s individual symptoms of illnesses, addiction and depression when in the end they are being returned to the exact substandard living conditions that made them unwell in the first place? The time to make a difference for everyone is long overdue and now.

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