Saturday, September 28, 2013

Addiction in Aboriginal Peoples

Addiction in the Aboriginal Peoples:
What Went Wrong and What We Are Doing About It?

Sept. 28, 2013

David C. Marsh MD CCSAM
Associate Dean Community Engagement

Lecture given at the Canadian Society of Addiction Medicine, Vancouver, BC Sept 2013.  Dr. Marsh is a superb researcher, educator and a great advocate for his people. These are the rough notes that I have made of this, which I hope are helpful for anyone interested.  

Thank you to the Coast Salish. I introduce myself from an aboriginal perspective.  I’m Micma from NFLD and Eagle Clan.

What do we think we know about aboriginal mental health?
“The sum of the Aboriginal mental health literature is a series of conflicting and contradictory portraits of seriously disturbed individuals living disordered lives......”

“There is increasing recognition we have failed to see others clearly but have instead treated their culture worlds like funhouse mirrors that hold up distorted reflections....’

Why does aboriginal history matter”
Duran 2006
“One of the most important hurdles .....wound of the soul....”

Elder Albert ‘Two Eyed Seeing”
Gift of multiple perspectives treasured and respect by many aboriginal people

First contact
Prior to to contact 0 7 million
90% died as a direct result of contact
Infectious disease, smallpox, measles, bubonic plague
Today, diabetes, obesity
Kirmayer - 2006

Wampum Belt
7 generations
Level of Bond
-White-Purity of Agreement
-Purple - Spirits of all the ancestors
-Three Threads - Peace, Friendship and Respect
-for all time

I was recently at the Indigenous Physicians of Canada meeting
-making committment on tobacco - don’t break unless you attend a funeral
-making committment on eagle’s feather - don’t break unless you participate in funeral
-making committment o medicine pipe - don’t break unless you are convene the funeral

Highest level of committment is talking stick and don’t break unless funeral is yours.

Wampum Belt - treaty of people with white people - boats of aboriginals and europeans, purple and white bead

Indian Act 1876

Federal government “Guardian” of Aboriginal people
Artificial settlements, segregation into groups
Loss of traditional values and practices
Act of parliament to give authority to non-Aboriginals to control the everyday life of Aboriginal people across Canada
Other mechanism-religious instituions
Royal Commission of Aboriginal Peoples - 1996 -Vol. 3 

Aboriginal people in Canada
Most rapidly grown, highest birth rate
over 1 million since 2006
48% under age 24
45% incresae from 1996-2006 (8% for non Aboriginal
Urbanized 54% in cities
Education Gap
  • 41% high  school versus 77% non Aboriginal
  • Heterogeneous
  • -first nations 61%, Metis 34%, Inuit

Determinats of Health
Income and status
Social Support Netwroks,
Employment and working conditions
Physical environments
Biology and genetis

Royal Commission on Aboriginals 1995
 endure ill health etc

over 20, 000 new housing usings need
25% nee marjor structural repairs
lack of safe drinking water
-60% of communities at risk
Child and Family Services
-5% of children in care (8x non-Aboriginal)
Auditor General Report, 2011

(Defended Chief Theresa Spence)

Structural barriers to Service Changes on Reserve
-lack of clarity about service slevesl
-federal funding without targets similiar to provincial and municipal services elsewhere
Lack of Legislative base
-federal programs without legislation
Lack of Appropriate Funding Mechanism
-Annual renewal and heavy reporting requireents

Residential Schools
-in 1987 a social worker who worked with members of the Nl’akapxm First Nation in Bc Canad
took acktion
-Alcoholism and suicide among the Nl’akapxm

Impact of Residential Schools
-Last school closed in 1996
-after Nl’akapxm and thousands of other similar investigations, the Government of Canada acknowledged and apologised for the role they played.
Historical Trauma
-Maria Braveheart - Cumulative Trauma - Lakota people in 1990
Wesley-Esquimaux and Smolewski (2004)  Build on work of Maria Brave Heart (1991) and Judith Herman
Origins - Holocaust survivors and families
-Biological (hereditary predispostions

Historic Trauma Transmission
-Wesley-Esquimaux and SMolewski

Internalized oppression
Duran 2006, Mensies 2009
External oppression is the unjust exercise of authority and power by one group over another.  It includes imposing one groups belief system , values and life ways over another group
External oppression becomes internalized oppression

-In colonization - minority group joined - that group then given power - over the majority - this done routinely - results in internal conflicts - metis against first nations etc.

Intergenerational Trauma - Dr. Maria Yellow Horse Brave Heart - bring back the strengths to prevent trauma continuing
Mensies - 2009
Importance of our kids seeing healing love

What is culture?
Culture is more than beliefs, practices and values.  Culture has commonly been defined as the worldview, lifestyle, learned and shared beliefs and values, knowledge, symbols and rules that guide behaviour....

World Views
-philosophical lenses that are entrenched ways of perceiving the world - Hart 2010, 
Worldviews are cognitive, perceptual, and affective maps that people continuously use to make sense of the social landscape and to find their ways to whatever goals they seek
-A lifetime process of development and occurs through socialization and social interactions 
-Worldview is also describd as the fundamental cognitive orientation of an individual or society encompassing the entirety of the individual or society’s knowledge and point of view

Indigenous worldviews
-all things exist according to the principle of survival
-the act of survival pulse with the natural energy and cycles of earth
-the energy is part of the grand design
-all things have a role to perform to ensure balance and harmony and overall well-being of life
-highlight strong focus on people and entities coming together to help and soup
-relational and relational accountability
-spirit and spirituality are key

Political Systems and Governance
-European - versus - Indigenous

Cultural Safety
-recognition that we are all bearers of culture and we need to be aware of and challenge unequal power relations at the indvvidual, family, communit yand societal levels
-cultural awareness
-cultural sensitivity
Cultural competence - ‘skills, knowledge, and attitudes’

Cultural continuity
Chandler and Lalonde, 2008
-Suicide rates lower or absent in BC communities with high cultural continuity
Continuity factors - self government, settled land claims, women in community government
community control of 

Vancouver Withdrawal Management Continuum
-Publicly intoxicated - Sobering Unity
Level 1 - Home detox
Level II - Daytox
Level III Non medical social residential
Level IV Medically management

Medical WM Evaluation Results
Occupancy rate 83%
Wait time 1 day
Lengthy of Stat 2 groups 22 % AMA, and 78% completed
Seasonality effect -difference in summer and winter
Welfare check issuance effect (Tue Thus)
-when checks came more likely to leave

Risk factors for Non aboriginals
Drop out more about substance and younger

Risk factors for aboriginal drop out
  • homeless
  • women with children to care for at home
  • HCV
  • discharge on weeken and welfare check
  • more social factors

Diacetylmorphine versus Methadone for treatment of opioid addiction - NEJM Aug 20 2009

Patient profile for Naomi - E.Oviedo-Joekes et al J Urban Health 
Years injecting drugs 17 years mean, mean failure of treatment 11 years
Overdoses in life 3 to 6

Being aboriginal in downtown eastside correlated with being more marginalized
15 to 20% injection aboriginal

Systemic racism factors impact on aboriginal people

  1. Oviedo-Joekes et al NEJM 2009

Aboriginal retention - Injection site 83.5% versus methadone 57.1%
Response 68.8% injection versus 53.4 % methadone
Non aboriginal people retention injection 90.7% versus 50 % methadone

Northern Ontario School of Medicine 
  • what I am doing now as dean of medical school
Global Health
an area for study, research
-social accountability - WHO 1995 
NOSM Charter Class - do very well on Medical Council of Canada
-completed examination above the mean

Physician Role from CMA and grandfather teachings
-wisdom.medical expert
-love/health advocate
-bravery /manager
Seven Grandfathers - Humilty, Love, Respect, Bravery, Wisdom, Honesty, Truth

Advancing Aboriginal Health
-What do physicians need to learn
-become involved in Anishnawbe Culture- promote understanding and better care
-understand Anishnawbe perceptions of health
-understand the use of traditional medciines, teachings and ceremonies in promoting health
-when to refer to tradtional healers
-leaver more about non-insured health benefits

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