Introduction

Northern and Indigenous Health and Health Care

Heather Exner-Pirot, Bente Norbye and Lorna Butler, Editors

Welcome to this Open Education Resource on Northern and Indigenous Health and Health Care. With this volume, we hope to address a fundamental gap in nursing and health science education: a lack of textbooks or other resources that are focused on northern and Indigenous health care. Our goal is to respond to the needs of northern health care providers and the unique context in which they practice.

Northern health care is unique. The Circumpolar North is characterized by small communities in sparsely populated regions, separated by large distances and marked by distinct cultures. Weather – cold, snow, ice and wind – influences everything, including the practice of health care. Practitioners, such as paramedics, physicians, dentists, social workers, pharmacists, public health officers, and nurses, are more likely to work in small teams and in isolation from mainstream supports and specialists. They are more likely to take care of a larger range of social, economic and psychological issues. They are more likely to be considered as an important member, partner, and even a leader, of their northern community. Northern practitioners must be resilient, resourceful and collaborative. This volume aspires to help prepare them for those responsibilities.

This Open Education Resource has been led by the University of the Arctic Northern Nursing Education Network (NNEN). The NNEN includes twelve nursing schools in Canada, Finland, Greenland, Iceland, Norway, Sweden, and Russia, who deliver baccalaureate nursing programs in rural and remote northern regions. There are multiple intended audiences for this publication, but foremost amongst them are the NNEN’s own northern nursing students, and other health science students studying in the North. This Open Education Resource aims to reflect what they can expect to see and experience in northern practice, rather than always having to adapt mainstream southern or urban practices to their own contexts. We see and value northern health care practice and seek to centre it here.

An additional intended audience includes health science students studying at large, traditional campuses who may be curious about or would benefit from an orientation to what practice in a different health care setting looks like. Almost every health professional program today seeks to develop cultural competency for their students, and many ‘southern’ health care practitioners working in the eight Arctic states will at some point be required to provide care to a northern client or work as part of a care team with northern practitioners. This volume may be useful in orienting them to the realities of health care in a northern context.

Finally, for the many southern practitioners who may assume roles in northern practice settings, either in locum or contract positions, for a few years of northern experience, or as a permanent settler, it is our hope that this volume may provide a useful introduction to northern clinical care and the unique expectations and responsibilities it entails.

There is a deliberate circumpolar flavour to these writings that reflect the diversity of the North and the ways in which northern health care differs even across similar geographic conditions. Our hope is that this comparative perspective will encourage readers to better understand what makes their own professional contexts unique, as well as be inspired by the things that are possible despite, or in many cases because, they are practicing in northern communities.

The learning objectives of this Open Education Resource include:

  • Understanding the unique healthcare needs and professional responsibilities that result from remoteness and population sparsity;
  • Identifying the social, environmental and cultural aspects of a community that inform and impact care needs;
  • Appreciating traditional and Indigenous medicines and approaches to healing as part of a holistic health care system; and
  • Exploring the similarities and differences in northern health care across the circumpolar region.

Much of this volume is written from a nursing perspective, reflective of the make-up of the health care workforce across the Circumpolar North. Nurses play a key role in providing primary care and services in small, rural communities. At the same time, northern health care is necessarily inter-professional as health care practitioners need to work together to address community health challenges. Collaboration outside of the traditional health care system is imperative: northern community leaders, elders, teachers, police and other community members play essential roles in supporting health and well-being. This Open Education Resource can be and should be relevant to all stakeholders who have a role to play in supporting northern community health and well-being.

Distinguishing Health and Health Care

Northern, or circumpolar, health is sometimes thought of as a niche field, but it has a large following. For example, the latest International Congress on Circumpolar Health, held August 2018 in Copenhagen, featured approximately 750 participants and 400 presentations. Northern health also features prominently in regional decision-shaping fora such as the Arctic Council.

However discussions on circumpolar health too often focus on public and environmental health policy, oftentimes to the detriment of health care practice and policy. Public health approaches to infectious diseases such as tuberculosis, the effect of climate change and Persistent Organic Pollutants (POPs) on Indigenous health, access to traditional foods, and the impacts of colonization such as suicide and substance abuse, feature heavily in northern policy discussions, as they should. But the practice of health care in the North, despite its expenditures accounting for between 5-21% of regional GDP (Ellsworth & O’Keefe, 2013), rarely gets systematic analysis or evaluation. Health care professionals are the core of health care systems: their role must be better understood, defined and revised in order to improve the effectiveness of the systems themselves. This Open Education Resource is the first to be developed by and for northern health care professionals.

At the same time, it is not only about health care, but also health, interpreted broadly. Health care services, after all, are only a means to achieve good health and well-being, and it is far from the only, or even the most important means. We often conceive of health care practitioners operating in a clinical setting, and most do so regularly. But there is also a need and a role for practitioners to promote health generally, especially in the North: empowering people to live their best lives, however they define it, with dignity, self-determination, and choice. Most of this living takes place outside the local nursing station, clinic or community hospital.

Centring the “Indigenous” in Northern and Indigenous Health and Health Care

This volume is entitled “northern and Indigenous health and health care” for good reason. We have consciously ensured Indigenous perspectives, authors, and issues are integrated in to this volume as a reflection of the fact that northern health care in many parts of the Circumpolar North cannot be assessed separately from the Indigenous context in which it is practiced. There is a long and discomfiting history of non-resident health professionals coming in to communities and problematizing or outright prohibiting traditional healing practices and beliefs. It is widely acknowledged that the imposition of Western-style health care has had damaging effects on patient, family and community agency. Many Indigenous residents avoid the health care system due to prior traumatic experiences, lack of trust and not being met with the knowledge required to understand their health issues in the relevant cultural context.

At the same time, advances in Western medical practice have contributed to a marked increase in life expectancy across the Circumpolar North compared to pre-colonial times, and many northern Indigenous residents want, expect, and deserve equitable access to such care. Most Indigenous northerners seek an integration of Western and Indigenous practices in the delivery of health care. This volume seeks to provide some examples on these efforts, with the hope that the next generation of northern health care professionals will better embrace the contributions of both Western and Indigenous perspectives.

Themes of this Volume

An open call for contributions from northern and Indigenous health care researchers and practitioners produced five distinct themes around which the publication is organized:

  • Community Health in Northern and Indigenous Communities
  • Social Determinants and Structural Impacts on Northern and Indigenous Health
  • Culture and Health
  • Innovations in Northern Health Care
  • Professional Practice in Northern and Indigenous Communities

These themes represent the most salient issues and opportunities in northern health care in the early 21st century, as articulated in 38 peer-reviewed chapters written by 51 different experts, practitioners and researchers. Many different subjects are broached, and if not necessarily divergent from mainstream health education, there is certainly a uniquely rural and northern perspective to the chapters. One common theme emerges: northern health care cannot be practiced separately or in isolation from the community in which it is practiced.

This Open Education Resource is meant to be easily accessible, both in content and in format. Many readers may speak English only as a second or third language. As such, we have chosen to compose this volume with themes manifested by short chapters, and written at an academic level aimed at third year baccalaureate students. This publication reads differently than a traditional textbook or course material. But it is well placed to be shared, scanned, and read piecemeal or as a whole, serving different purposes for different audiences and contexts.

What is an ‘Open Education Resource’?

We have chosen to publish this collection as an ‘Open Education Resource’. This means that the volume is free and as accessible as possible. The contemporary Open Education movement grew largely as reaction to the growing unaffordability of textbooks. At the same time, the rise in internet access has made it possible to share knowledge in new and exciting ways. David Wiley (2014) defines Openness as:

  • Retain – the right to make, own, and control copies of the content
  • Reuse – the right to use the content in a wide range of ways (e.g., in a class, in a study group, on a website, in a video)
  • Revise – the right to adapt, adjust, modify, or alter the content itself (e.g., translate the content into another language)
  • Remix – the right to combine the original or revised content with other open content to create something new (e.g., incorporate the content into a mashup); and
  • Redistribute – the right to share copies of the original content, your revisions, or your remixes with others (e.g., give a copy of the content to a friend)

Because we intend for this volume to be used by different post-secondary institutions, in different programs, countries and disciplines, as well as for different health care systems, it is essential that users could draw from the volume in ways that make the most sense for them. We are grateful to our authors for sharing their knowledge in this comprehensive way.

In addition, the Open Education Resource format will allow us to add and update this content as desired.  If you would like to add your knowledge to this volume, please get in touch.

Because some northern communities don’t have affordable or easily accessible internet connections, we can also print this volume on a cost recovery basis upon request.

Acknowledgments

An Open Education Resource with the diversity of authors and disciplines as this one entails requires the contributions of many people. In particular we would like to acknowledge:

  • Stan Yu, the Project Manager for this volume, without whom the project would not have been realized.
  • The Norwegian Centre for International Cooperation in Higher Education (SIU) and the University of the Arctic for their generous funding of this project.
  • The Rebus Foundation, especially Zoe Wake Hyde, for their technical advice and support for the Open Education concept.
  • The original participants of the international meeting in April 2017 to outline the concept behind this volume, including Lorna Butler, Heather Exner-Pirot, and Rachel Johnson (University of Saskatchewan); Jennifer Wakegijig (Northern Ontario School of Medicine); Bente Norbye and Sisko Honkala (UiT the Arctic University of Norway); Nadine Crossland (Nunavut Arctic College); Nikolai Diachovskai (North Eastern Federal University); Brenda Dawyduk (University College of the North); Gert Mulvad (University of Greenland); and Arja Rautio (University of Oulu).
  • All of our authors and anonymous reviewers, whose expertise and knowledge are truly the core of this project.

License

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

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