11 Introduction

Lorna Butler and Heather Exner-Pirot

Discussions on health and well-being often focus on health care – medical and pharmaceutical interventions to illness and trauma. Health budgets and policies, in the Circumpolar North as elsewhere, overwhelmingly focus on care provision – hospital and clinic infrastructure, medical supplies, drugs, emergency transportation, and the salaries of health professionals such as nurses and physicians.

Yet, we understand more than ever that health and well-being are rooted in an individual’s

or community’s social context. Educational attainment, economic prosperity and employment, and the food, housing, recreation and status it affords, are far greater predictors of health than the availability of health care. These are known as the social determinants of health.

Historical Perspectives

The concept of social determinants has evolved over the past fifty years with multiple writings on both the conceptualization and the influence on health and well-being of populations. The early writings of the 1980s presented a sociological analyses of structural determinants impacting working class conditions, such as the distribution of economic, social, and political resources; however, these findings were overshadowed by the traditional biomedical interpretations of health (Raphael, 2006). Recognition of a broader understanding of health was later acknowledged in 1984 when the World Health Organization (WHO) convened an international conference “Health for All by Year 2000” (WHO, 1984). Health was defined as “a positive concept emphasizing social and personal resources, as well as physical capacities…with agreed upon “fundamental conditions and resources for health.” (WHO, 1984) Tarlov (1996) has been credited as introducing the term “social determinants of health” to describe how inequalities of living conditions had an effect on disease. Research conducted over the late 1990s and early 2000s provided evidence to support the inclusion of socio-political, economic, biomedical, and behavioural concepts as determinants of health (Health Canada, 1998; Bryant, Raphael, Schrecker & Labonte, 2011). Based on a synthesis of existing research evidence, Raphael (2006) identified eleven constructs as the key social determinants of health (See Table 1).

 

Table 1 Examples of the Evolution of Social Determinants of Health

1984 1998 2006 2011
Ottawa Charter Health Canada Rapheal Cooke & Long
Peace

Shelter

Education*

Food

Income

A Stable Eco-System

Sustainable Resources

Social Justice

Equity

Income/social status

Social Support Network

Education*

Gender

Culture

Employment/Working conditions

Environment: Physical & social

Healthy child development

Health Services

 

Aboriginal status

Early life

Education*

Employment/working conditions

Food security

Health care services

Housing

Income

Social safety net

Social exclusion

Unemployment/ Employment security

Participation in traditional activities

Balance

Life Control

Environmental Education*

Material resources

Social resources

Environmental/cultural connections

The terminology of social determinants of health is understood within academic health sciences, but is less clear for policy makers and public audiences. When the Robert Wood Foundation restructured in 2003, they added a portfolio of vulnerable populations. The challenge became finding ways to translate the meaning of determinants of health at the community level. In developing their messaging, it was identified that social determinants of health consisted of two components: context of health – where people lived, worked, played, and learned – and disparities of health, referring to class, race, and ethnicity (Woods Foundation, 2010). Lessons learned included the use of local language to relate to the people, reflecting the values of a community, and giving some sense of a shared responsibility to achieve a difference resonated with their audiences. Rather than talking about determinants of health, terminology became “Health begins where we live, learn and play.” (p. 7) While some may dismiss this as a corporate example, the purpose is to demonstrate the complexity of layers involved in addressing social determinants of health. Decision making that spans from a company’s mandate to support health-related programs to decisions by governments and policy makers requires an understanding of how social determinants may impact health and health service delivery.

Member countries within the United Nations have tried to determine action plans to address health inequalities (WHO, 2008) from an evidence-based perspective. There is strong evidence to demonstrate that, for countries within the OECD, health spending does not translate to improved health outcomes. To give a comparison, between Norway and Canada, health expenditures per capita include: $5,003 (US) and $ 4,078 (US) respectively, life expectancy is the same (80 years), yet infant mortality rates differ significantly with Canada falling to 12th while Norway ranks 6th. How health dollars are spent versus the amount spent is a pressing concern as tertiary care spending competes with the longer term investment in health promotion and disease prevention. Canada must come to grips with the health demands of an aging population that has poor lifestyle behaviours and rising chronic illnesses (CBoC, 2018). Based on an analysis of three core social determinants: income inequality, incidence of poverty, and housing, Canada has made little progress on reducing the health inequities for a country with a great history of universal health insurance (Bryant et al., 2011; Norwood, Ploeg, Markle-Reid & Sherifali, 2017).

Introduction of Indigenous Social Determinants

Simultaneous to the international debates on the social determinants of health, evidence began to emerge on causes associated with the inequities within various populations. Within the Canadian context, early writings by Reading and Wien (2009) considered social determinants of health within the context of Aboriginal people. They presented a model that depicts four dimensions of physical, spiritual, emotional, and mental health across the life span. The goal was to provide a way to consider various pathways of how social determinants influence health at different life stages, such as interventions aimed at the vulnerabilities experienced by Aboriginal children and youth may influence behaviours that could have a lasting impact on adulthood (refer to section on childhood oral health in this chapter). Reflective of the early work by Reading & Wein (2009), incorporating Indigenous values with published documents describing circumpolar values for health systems stewardship found several shared values aligned including: respect, teaching, kinship (family) and nourishment (land) (Chatwood, et, al.  2017).

Introduction to northern social determinants

Residents of the Circumpolar North, especially rural and Indigenous residents, face additional social impacts to their health compared to their southern or urban counterparts. Inequalities arise from boom and bust resource economies and a lack of economic diversification. Limited transportation infrastructure means that basic goods and services such as food and shelter are much more expensive – even unaffordable – for many families. Rural areas of the North have been further marginalized in the 21st century due to poor internet connectivity.

Amongst the greatest social determinant of northern health has been the history of colonization. Northern societies were self-sufficient and autonomous for centuries and millennia before Europeans moved West to North America, East to Siberia and North to the European Arctic. Europeans appropriated vast northern territories and colonized Indigenous peoples in order to support economic activities from fishing to the fur trade to mining, or to conduct Christian missions. The effects of this phenomena include loss of culture and language, disruption of the subsistence economy, forced relocation and settlement, destruction of family and societal values and norms, dependency, and political powerlessness. Although the past four decades have seen a renaissance in northern and Indigenous self-determination and a move towards decolonization, the intergenerational impacts of colonization continue to negatively impact northern health and well-being.

This theme begins with the article Social and Structural Determinants of Indigenous Health from Cindy Jardine and Laurie-Ann Lines who elaborates on this introduction to the social determinants of health and examine how the proximal, intermediate, and distal determinants of health currently affect the health of Indigenous peoples in Canada. Addressing inequities resulting from shortfalls in the social determinants of health is an ongoing problem, and Jardine and Lines underscore the importance of strengths-based approaches and how positive, affirming and health promoting factors provide a positive way of dealing with health issues. This strengths-based approach focuses on celebrating, reinforcing and reaffirming determinants specific to Indigenous peoples’ health, to promote community health in a more holistic way.

Amongst the many impacts of political and economic marginalization, the majority of chapters in this theme focus on one particularly deplorable consequence: family violence. Physical abuse and sexual violence rates are disproportionately high across the Circumpolar North, and are responses to the feelings of powerlessness and the cycles of violence incited by poverty and colonization. In many regions, Indigenous youth are particularly vulnerable. The impacts of violence on its victims are far-reaching, and include low self-esteem, depression, addiction, and vulnerability to physical illness. These, in turn, affect life outcomes, such as educational achievement, employability, healthy family relationships, and overall wellness.

Despite their terrible consequences, family violence and sexual abuse are often hidden or minimized due to shame and a culture of silence, leaving victims with few options to seek health and healing. The following chapters attempt to shed light on this fundamental health challenge.

Geoffrey Maina, in his chapter on Sexual Violence and its Impact on Physical, Mental, and Psychological Health, addresses the many impacts of sexual violence. Sexual violence can happen to both men and women of any age; however, in Canada victims tend to be women, young, Aboriginal, single, homosexual, or bisexual. Aboriginal women are more than three times more likely to be victims of sexual violence due to the objectification of Aboriginal women, which is engrained in racism, sexism, and colonialism. Community-focused solutions which involve men are more likely to be sustainable in the long term.

Siv Kvernmo looks at the Scandinavian comparative context in her chapter Sexual Abuse in Indigenous and Arctic Children and Adolescents in Scandinavia. While Arctic residents have higher rates of sexual abuse than non-Arctic ones, she finds little evidence to support the assumption that Sami, like other Indigenous groups across the North, have more experience with sexual violence than their non-Indigenous peers. The recent literature on the subject, in fact, finds similar rates among Sami and non-Sami youth in Norway. Kvernmo attributes the lower Sami rates of sexual abuse, as compared to other Arctic Indigenous groups, to lower incidence of substance use among parents, lack of parental involvement or broken families, as well as the strong socio-economic benefits enjoyed in the Nordic states.

Following on this theme, Sigrun Sigurdardottir and Sigridur Halldorsdottir examine sexual violence from an Icelandic perspective in their chapter Childhood Sexual Abuse (CSA):  Consequences and Holistic Intervention. Comparing gender similarities and differences, they find that women have a greater tendency to internalize their emotional suffering, resulting in behavioral and emotional suppression; whereas men have a greater tendency to externalize their emotional suffering, making them more prone to rage, aggressiveness, antisocial behavior, and other behavioral problems. All survivors demonstrated poor health and lack of well-being, both in childhood and adulthood, as well as difficulties in relationships and in relating to their children. A holistic intervention of a Wellness Program, which provided person-centered, holistic, traditional and complementary therapy for female CSA survivors, proved effective in addressing trauma.

Pertice Moffitt and Heather Fikowski look at two sides of the same issue in two separate but complementary chapters. In Addressing Intimate Partner Violence in the Northwest Territories, Canada: Findings and Implications from a Study on Northern Community Response, they find that in the Canadian territories, intimate partner violence (IPV) rates are seven times the national average. Factors that keep IPV rates at crisis levels include the normalization of violence, depleted resources, a revolving frontline service, and historical trauma. The Northwest Territories government has made addressing family violence a top priority, with an action plan that consists of seven strategies: knowledge mobilization, education and awareness, stable and adequate funding, a coordinated response strategy, assessment and screening, social supports, and community healing.

In their second chapter, A Culture of Violence and Silence in Remote Canada: Impacts on Service Delivery to Address Intimate Partner Violence, Fikowski and Moffitt describe the Canadian North’s social construct of violence and silence based on powerful anecdotes from over fifty interviews with frontline service providers, including police officers, shelter workers, victim services workers, nurses, counsellors and social workers. Contributors to the high incidence of violence include historical trauma, normalization, gossip as a tool for silence, community retribution, family and community values, and self-preservation. This “culture of violence and silence” imposes barriers to service provision in northern areas of Canada requiring new and innovative strategies. Front line workers must also guard against vicarious trauma and compassion fatigue.

Gert Mulvad examines Family Health and Local Capacity Building in a Developing Community in Greenland, Seen from a Health Promotion Perspective. Mulvad makes the case that family values, and the health of children and youth must be prioritized to address the effects of disparities between settlements and cities, and their impact on family values and social norms, and ensure the healthy development of future generations. Increased investment in children’s education; social services; resources and increased training for new families; language; public health; and social research on mental health can help to achieve this goal.

Together these chapters provide a compelling narrative on the widespread impacts of colonization and poor social determinants of health. Health care professionals must be mindful of these contexts in order to effectively promote community and individual health and well-being.

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Northern and Indigenous Health and Healthcare by Lorna Butler and Heather Exner-Pirot is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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