Indigenous Children's Health Report: - Christian Aboriginal ...

Indigenous Children's Health Report:H e a lt h A s s e s s m e n t i n A c t i o nEdited by:Janet Smylie MD MPH CanadaPaul Adomako MSc Canada

Indigenous Children's Health Report:H e a lt h A s s e s s m e n t i n A c t i o nEdited by:Janet Smylie MD MPH CanadaPaul Adomako MSc CanadaContributing Authors:Sue Crengle MD PhD(c) New ZealandJane Freemantle PhD AustraliaGilbert Gallaher PhD CanadaDaniel McAullay PhD(c) AustraliaKelly McShane PhD CanadaMaile Taualii PhD(c) United StatesThis report was funded by First Nations and Inuit Health Branch, Health Canada.Opinions expressed in this publication are those of the editors and othercontributors, and do not necessarily express the official policy of Health Canada.Graphic design: Andrew ScottInformation regarding this publication can be obtained from:Janet Smylie MD MPHResearch ScientistCentre for Research on Inner City HealthThe Keenan Research Centre in the Li Ka Shing Knowledge InstituteSt. Michael’s HospitalAssociate ProfessorDalla Lana School of Public HealthUniversity of TorontoEmail: janet.smylie@utoronto.ca© 2009 Janet Smylie, Some Rights Reserved.Creative Commons Attribution - Noncommercial-No Derivs 2.5 CanadaFor information on Creative Commons license go to http://creativecommons.orgavailable to download at: www.crich.ca

c o n t e n t sAcknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Chapter One Introduction and Report Overview:a Global Perspective on Indigenous Child Health in Canada & Beyond 7Chapter Two Health of First Nations, Inuit, and Métis Children in Canada 112.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.2 Data Sources and Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.3 Demographics of Aboriginal Children in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122.4 Assessing and Responding to the Health Needs of Aboriginal Children in Canada . . . . . . . . . 182.5 Colonization as an Underlying Determinant of Indigenous Children’s Health . . . . . . . . . . . . . . 192.6 Additional Social Determinants of First Nations, Inuit, and Métis Children’s Health . . . . . . . . . 202.7 Children’s Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28I. First Nations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29II. Inuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36III. Métis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41IV. Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43V. Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442.8 Best Practice and Promising Practice Examples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56I. The First Nations Regional Longitudinal Health Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56II. Inuit Health Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56III. Infant Mortality Working Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57IV. Kahnawake School Diabetes Prevention Project (KSDPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . 58V. First Nations Health Plan, British Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58VI. First Nations EpiCentre of Alberta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 592.10 Additional Tables . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612.11 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Chapter Three Health of Aboriginal and Torres Strait Islander Children in Australia 673.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 673.2 The Colonization of Australian and Torres Strait Islander people . . . . . . . . . . . . . . . . . . . . . . . . . . 683.3 Demographics of Aboriginal and Torres Strait Islander Australians . . . . . . . . . . . . . . . . . . . . . . . 693.4 Determinants of Aboriginal and Torres Strait Islander child health . . . . . . . . . . . . . . . . . . . . . . . . 713.5 Specific Health Issues and risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733.6 Other health conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 833.7 Access to health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

3.8 Health Expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873.9 Data limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 873.10 Examples of positive initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 883.11 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 913.12 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92Chapter Four Health of Māori Children in Aotearoa / New Zealand 954.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954.2 Māori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954.3 The Māori Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954.4 Social and Economic Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 964.5 The Health Sector in Aotearoa / New Zealand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 974.6 Ethnicity Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 984.7 Child Health Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 994.8 Use of Ethnicity Data – A Case Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1034.9 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1044.10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105Chapter Five Health of Indigenous Children in the United States 1075.1 Introduction5.2 Indigenous Population of the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1075.3 Social Determinates of Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1085.4 Health of Indigenous children of the USA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1105.5 Critical Areas of Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1135.6 Challenges in Data Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1145.7 Community-Based Strategies and Solutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1155.8 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1155.9 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Chapter SixIndigenous Child Health Stakeholder’s Meeting:discussion and Recommendations 1196.2 Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1196.3 Group Activity1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1206.4 Group Activity 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Chapter Seven Concluding Remarks: Finding Strength in Numbers 127Appendix A: Stakeholder Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129

1 Health of Indigenous Children: Health Assessment in Action Acknowledgements

AcknowledgementsThis report was funded by First Nations and InuitHealth Branch, Health Canada. Opinions expressedin this publication are those of the editors and othercontributors, and do not necessarily express the officialpolicy of Health Canada.We would like to acknowledge all of the participantstakeholders who attended the Indigenous child healthstakeholders meeting in May 2008 for their insightsand contributions. Please see Appendix A for a listof participants.Dr. Janet Smylie was supported during the writingof this report as a Research Scientist at the Centre forResearch on Inner City Health, The Keenan ResearchCentre in the Li Ka Shing Knowledge Institute of St.Michael’s Hospital. Dr. Kelly McShane was supportedby a Social Science and Humanities Research Councilpostdoctoral fellowship. Dr. Gilbert Gallaher wassupported by a Canadian Institutes of Health ResearchStrategic Fellowship and a Peterborough K.M. HunterFellowship at the Centre for Research on Inner CityHealth, St. Michael’s Hospital. Dr. Sue Crengle wassupported by the University of Auckland where she isa member of Te Kupenga Hauora Māori (Departmentof Māori Health), School of Population Health,Faculty of Medicine and Health Sciences. Dr. JaneFreemantle was supported by Onemda VicHealth KooriHealth Unit and by an Australian Research CouncilFellowship. Daniel McAullay was supported by theIndigenous CBG research program Not Just Scholarsbut Leaders, which is funded by the NHMRC andCurtin University of Technology and conducted byCurtin University of Technology, the Telethon Institutefor Child Health Research, combined UniversitiesCentre for Rural Health and the University of WesternAustralia. Maile Taualii would like to acknowledgethe Native Hawaiian Epidemiology Center, Papa OlaLokahi, and the Urban Indian Health Institute, SeattleIndian Health Board. Special thanks to Andrew Scottfor the design of this report.The editors gratefully acknowledge the support ofthe Ontario Ministry of Health and Long-Term Care.The views expressed in this report are the views of theauthors and do not necessarily reflect the views of theOntario Ministry of Health and Long-Term Care.Acknowledgements Health of Indigenous Children: Health Assessment in Action 1

2 Health of Indigenous Children: Health Assessment in Action Executive Summary

Executive SummaryIntroduction: Global Disparities inIndigenous Children’s HealthThis report documents what we know about the healthof Indigenous children (from birth to age twelve) andevaluates the quality of Indigenous child health datacollection in Canada, Australia, New Zealand, and theUnited States.Striking Indigenous/non-Indigenous health disparitieswere identified in all four countries, including:• Infant Mortality Rates that are 1.7 to 4 times higherthan those of non-Indigenous infants• higher rates of sudden infant death syndrome• higher rates of child injury, accidental death,and suicide• higher rates of ear infections• a disproportionate burden of respiratory tract illnessand mortality• a disproportionate burden of dental caries• increased exposure to environmental contaminants,including tobacco smokeOther common themes identified across the fourcountries include:• a need to improve Indigenous child healthethnicity data• the identification of colonization as a shared andunderlying determinant of Indigenous health• disparate numbers of Indigenous children livebelow the poverty line and/or in overcrowdedaccommodation and this directly impacts their health• differential access to healthcare, economic and socialresources for Indigenous children and their familiescompared to non-Indigenous populationsGiven the diverse genetic heritage of these widelydispersed Indigenous groups, we must conclude thatsimilar exclusionary social policies active in all fourcountries are at the root of these profound and unjustdifferences in child health.Indigenous Children’s Health Assessmentin ActionThis report was funded by Health Canada. It wasconducted by a team of international Indigenouschild health researchers, led by Dr. Janet Smylie at theCentre for Research on Inner City Health, St. Michael’sHospital. The report draws upon on a systematic searchof public health data, including scholarly articlesat the national and provincial/territorial level. Thereport first addresses First Nations, Inuit, and Métischildren’s health status and assessment in Canada. Inlater chapters, Indigenous children’s health status andassessment are reported for Australia, New Zealand,and the United StatesSound measurement and reporting of publichealth data are essential steps for overcoming healthdisparities but these are obviously only the first steps.Investment in very strong policies and programmingare required to ensure that Indigenous childrenexperience the same levels of well-being, prosperity,environmental support, and access to health care asnon-Indigenous children. This report documents bestpractices and describes how health assessment data canbe put to action to inform strong policies and programsto improve Indigenous child health.Our report provides a convincing example of thevalue that can be added by forming partnerships andworking across jurisdictions – locally, regionally,nationally, and internationally. In writing this report,our collective intention has been to equip IndigenousExecutive Summary Health of Indigenous Children: Health Assessment in Action 3

Significant deficiencies in current public healthassessment data for Aboriginal children are evident.Foremost is the lack of opportunity for individuals toself-identify as First Nations, Inuit or Métis in mosthealth data systems, including: vital registries, primarycare and hospital records, and surveillance systems.Second, we found substandard data collection sourcesand methods, which result in inaccurate statistics.Finally, there is also a lack of organized linkages of FirstNations, Inuit, and Métis health data to First Nations,Inuit, and Métis health policies, programs and services.A Global Perspective on IndigenousChildren’s HealthEach international chapter provides a rich introductionto the history of colonization and its continuingimpacts on Indigenous health and wellbeing for diverseIndigenous populations including Māori, AmericanIndian, Alaskan & Hawaiian Natives, AboriginalAustralians and Torres Straits Islander children. Thesechapters provide a comprehensive explanation of localIndigenous child health disparities across a range ofphysical and social health indicators including (butby no means limited to) exposure to environmentalcontaminants, access to health care, accidents/injuryrates, infant mortality rates, Sudden Infant DeathSyndrome, asthma and respiratory infection rates.Where possible, national level data has been reportedto facilitate comparative perspectives on disparitiesbetween Indigenous and non-Indigenous children’shealth status. These national data sets also shed light onIndigenous children’s health data collection standardsand practices. We discuss current trends, best practicesand critiques of ethnicity-based child health datacollection methods.Throughout the chapters in this report, multipleexamples of Indigenous resistance and resilience arealso provided, including: the successful transmissionof Indigenous languages to children; improvements inIndigenous educational achievement – often despiteinadequate education systems; the participation ofextended family in parenting; and the participation ofIndigenous communities in specific health assessmentand response activities when opportunities present.Working Together for Policy ActionWe held a key stakeholders consultation meeting inMay 2008, to present our preliminary findings andask for feedback, comments, and recommendations.This event brought together 21 key Indigenousresearchers and policy-makers from Canada, UnitedStates, Australia and Aotearoa. This meeting endorseda cohesive research, practice and policy approach toadvance our ability to improve the health and mortalityof all Aboriginal children in Canada. Improvementsin the availability of comprehensive and accuratechild health data will assist greatly in concertedefforts to improve the health of Indigenous childreninternationally.Indigenous health stakeholders in our homenations have already researched and articulated clearpolicy approaches that would address the ongoingdisadvantages experienced by our children and theirfamilies. In Canada, this includes the recommendationsof the Royal Commission of Aboriginal People and thesubmissions made at the Kelowna Accord discussions.Executive Summary Health of Indigenous Children: Health Assessment in Action 5

16 Health of Indigenous Children: Health Assessment in Action Introduction & Report Overview

Introduction and Report OverviewA Global Perspective on Indigenous Child Health in Canada & BeyondI am extremely pleased to have been able to participatein the production of “The Health of IndigenousChildren: Health Assessment in Action” report. Ithas been an incredible honor to have been supportedin the writing by international Indigenous children’shealth colleagues Jane Freemantle and Daniel McAullay(AUS), Sue Crengle (NZ) and Maile Taualii (US), aswell as postdoctoral fellows Kelly McShane and GilbertGallaher and research co-ordinator Paul Adomako.The international contributors have been generous andastute in their sharing of examples of best practices inboth the collection and the application of Indigenouschild health assessment information.The focus of the report is First Nations, Inuit, andMétis children’s health status and assessment in Canada(from birth to age twelve). There are also chapters onIndigenous children’s health status and assessment forAustralia, New Zealand, and the United States. Notonly does the report include information describingwhat we know about the health of Indigenous childrenand how we know this, but it also includes bestpractices on how health assessment information can beapplied to improve the health of Indigenous children.Critical to the resolution of Indigenous child healthdisparities is both the generation of health informationand the application of this information to healthpolicies, programs, and services.Report objectives include:1. To summarize what we know about the health ofIndigenous children living in Canada, Australia,New Zealand, and the United States.2. To contribute to the translation of healthinformation into evidence-based policies, practices,and services for Aboriginal * children in Canada byhighlighting best practices in the collection and useof health data.3. To identify priority areas for Indigenous children’shealth indicator development.4. To identify key Indigenous children’s health statusinequities in the four countries.Our hope is that this report will be used as areference and advocacy tool by key Indigenouschildren’s health stakeholders in Canada and abroad.With this in mind, we held a key stakeholdersconsultation meeting in May 2008, to present ourpreliminary findings and ask for feedback, comments,and recommendations.While the focus of the report is First Nations, Inuit,and Métis children’s health status and assessment inCanada, the chapters on Indigenous children’s health inAustralia, New Zealand and the United States not onlyprovide insightful country specific overviews, they alsohighlight common problems and successful strategies. Weidentify cross-cutting issues; locate the roots of IndigenousAuthor:Janet Smylie MD MPHResearch ScientistCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt. Michael’s HospitalAssociate ProfessorDalla Lana School of PublicHealthUniversity of Toronto*We have used the term Aboriginalto refer collectively to First Nations,Inuit, and Métis populations inCanada and the term Indigenouswhen we are referring to Indigenouspopulations internationally.Aboriginal is also used in theAustralian chapter to refer to thegroup of Indigenous Australiansalso known as Aboriginal.Introduction & Report Overview Health of Indigenous Children: Health Assessment in Action 7

1International Symposium on theSocial Determinants of IndigenousHealth. Social determinantsand Indigenous health: TheInternational experience and itspolicy implications. In: Reporton specially prepared document,presentations and discussion at theInternational Symposium on theSocial Determinants of IndigenousHealth. Adelaide, Australia:Available at http://www.who.int/social_determinants/resources/indigenous_health_adelaide_report_07.pdf. AccessedJune 6, 2008.child health disparities in colonization; documentdifferential access to healthcare, economic, and socialresources; and share successful strategies for change.There is a need to improve Indigenous child healthethnicity data. Serious deficiencies in the quality andcoverage of Indigenous ethnicity data are describedin all four country specific chapters. Canada is theonly country that does not have systems in place forIndigenous self-identity in the majority of hospital,surveillance, and vital registration (i.e. birth anddeath registration) systems. This results in the notableabsence of disease specific mortality and hospitalizationdata in the Canadian chapter. All authors were clearthat reliable data describing Indigenous child healthis necessary to inform policy; contribute to the designand implementation of effective child health programsand services; and to evaluate policies, programs, andservices. The best practice examples of Indigenoushealth measurement in this report are consistentlyfounded on the central involvement of Indigenouspeople in health data collection, analysis, management,governance, and application.Indigenous children and their families experiencestriking health status disparities compared to non-Indigenous populations regardless of nation. Commonhealth status disparities between Indigenous and non-Indigenous children found in all four countries include:infant mortality rates that are 1.7 to 4 times higherthan those of non-Indigenous infants; higher rates ofsudden infant death syndrome; higher rates of childinjury, accidental death, and suicide; higher rates of earinfections; a disproportionate burden of respiratorytract illness and mortality; a disproportionate burden ofdental caries; and increased exposure to environmentalcontaminants, including tobacco smoke.There is an overwhelming consensus among theauthors and stakeholders that the roots of thesehealth status inequities are found in social rather thanbiologic determinants of health. Colonization has beenidentified as a shared and underlying determinant ofIndigenous health by the contributors to this report aswell as participants at the recently held InternationalSymposium on the Social Determinants of IndigenousHealth. 1 Each country author describes historic andongoing governmental policies that have contributedto and perpetuate the dislocation of Indigenouspeople from their homelands; the disenfranchisementof Indigenous peoples from their rights to selfdetermination;the undermining of economic andsocial development; and the fragmentation of families,communities, and nations. Colonial policies are directlylinked to the current day poverty experienced bymany Indigenous children globally. The shared healthstatus disparities are not surprising when the disparate8 Health of Indigenous Children: Health Assessment in Action Introduction & Report Overview

numbers of Indigenous children living below thepoverty line and/or in overcrowded accommodation inall four countries are taken into consideration.The resolution of Indigenous health inequitiesrequires not only an examination of Indigenous healthstatus and determinants but also an examination ofthe patterns of access to critical societal resources,such as health care among both Indigenous and non-Indigenous populations. This report identifies thatdifferential access to health care services is anothercross-cutting factor that appears to be contributing todisparities in health between Indigenous and non-Indigenous children and their families. In Canada,Australia, New Zealand and the United States therewere absolute and relative reductions in access tocare for Indigenous children. In New Zealand, theseinequities in access to primary care have been linked toincreased numbers of preventable hospitalizations forMāori and Pacific Islander children compared to non-Indigenous children.Although mainstream public health measurementsystems are under developed in the area of strengthbasedassessment, and despite the overwhelmingburden of Indigenous child health inequities, adistinct theme of resilience and resistance emerges.Throughout the chapters in this report there areexamples of: the successful transmission of Indigenouslanguages to children; improvements in Indigenouseducational achievement – often despite inadequateeducation systems; the participation of extended familyin parenting; and the participation of Indigenouscommunities in specific health assessment andresponse activities when opportunities present.Indigenous health stakeholders in our homenations have already researched and articulated clearpolicy approaches that would address the ongoingdisadvantages experienced by our children and theirfamilies. In Canada, this includes the recommendationsof the Royal Commission of Aboriginal People 2 and thesubmissions made at the Kelowna Accord discussions.The collective intention of the authors in the writing ofthis report is that it be used as a reference and advocacytool by these same Indigenous health stakeholders asthey work together to support comprehensive policyactions that will fundamentally address the pressingissues of Indigenous child health disparities that wehave documented within and across our nations.2Royal Commission on AboriginalPeoples. Report of the RoyalCommission on Aboriginal Peoples.Ottawa: Indian and Northern AffairsCanada; 1996.Introduction & Report Overview Health of Indigenous Children: Health Assessment in Action 9

Health of First Nations, Inuit, and Métis Children in Canada2.1 Introduction. This chapter describes the health and health outcomes of Aboriginal children living in Canada. It includesan overview of demographics, a discussion of Aboriginal children’s health measurement systems, a description of socialdeterminants, a detailing of First Nations, Inuit, and Métis child health status and some examples of best or promising practices.The goal of the chapter is to provide First Nations, Inuit, and Métis child health stakeholders with a comprehensive overviewof First Nations, Inuit, and Métis child health in support of their efforts to address ongoing inequities of health determinantsand health status, therefore ensuring that all children in Canada enjoy their right to health. The authors recognize thatimprovements in the assessment of and response to inequities in Aboriginal child health need to be founded on partnershipsbetween First Nations, Inuit, and Métis health stakeholders and health workers with a background in public health assessment.2.2 Data Sources and MethodsThis chapter focuses on First Nations, Inuit, andMétis children’s health data at the national andprovincial/territorial level. Where there are gaps inavailable national or provincial/territorial data, and/or the health determinant or indicator was deemedsignificant, we opted to cite regional or communityspecificrates.Information in this report for First Nations livingon-reserve is drawn primarily from the First NationsRegional Longitudinal Health Survey (RHS) 1 , the 2006Census, 2, 3, 4 and Indian and Northern Affairs Canada’s(INAC) Indian Registry. 5 Information for First Nationsliving off-reserve, Inuit, and Métis are drawn primarilyfrom the 2006 Census, 2, 3, 4, 6 the 2001, 7, 8 and 2006 9Aboriginal Peoples Survey (APS), and 2006 AboriginalChildren’s Survey (ACS). 10In order to identify additional sources of data onthe health of First Nations, Inuit, and Métis children inCanada, a series of searches were conducted for publichealth data, scholarly articles, and published reports.Public health data available for First Nations, Inuit, andMétis at populations at the national and provincial/territorial level had already been systematicallyreviewed by our group in an earlier study. 11 Tosupplement the available public health data, we alsosystematically searched the published literature. Inconsultation with a medical information specialist, aset of key words for population and subject headingswas derived, as well as a list of databases to search.The keywords that were used included the populationkeywords: Native, Indian, Aboriginal, Inuit, Métis,and First Nations. As well, additional populationdescriptors were used to focus on children. Thesewords included: infant and child. For subject headings,the following terms were used in combination with thepopulation keywords: health, health status indicators,health status, health status disparities, health surveys,mental disorders, and suicide. The databases that weresearched were MEDLINE; Bibliography of NativeNorth Americans; and Health Sciences: A SAGE Full-Text Collection. From this initial search, a total of 718articles were identified. This first set of abstracts wasscreened by a Masters-level Research Assistant (PA)using the following criteria: (1) included a populationof children; (2) disease prevalence, incidence presented;and (3) Aboriginal population in Canada. Using thesecriteria, 123 articles were retained. The abstracts werethen independently reviewed by two Aboriginal healthresearchers (JS and KM) and were retained if they metthe following criteria: (1) provided statistics specificallyfor First Nations, Inuit, or Métis (not ‘Aboriginal’broadly defined) and (2) national, provincial, orterritorial level statistics. Articles which pertained toimportant child health issues, not otherwise covered inthe literature were retained even when neither criterionwas met. The final set of articles reviewed for inclusionin this report comprised 27 articles.Based on the two methods detailed above, acomprehensive set of statistical sources of First Nations,Inuit, and Métis children’s health was identified and islisted in Table 1 in the Additional Tables section.We have attempted to be as inclusive as possible inproviding data for all First Nations, Inuit, and Métischildren. At times this has been challenging, as the datasources are not always inclusive and/or consistent intheir terminology or indicators. For example, there aredata quality issues and associated limitations of FirstNations census data. There appears to be a significantundercount of First Nations persons – particularly FirstNations persons living on–reserve. According to the2006 census the total ‘Registered Indian’ populationwas 564,870. 2 This is almost 200,000 less than the763,555 that INAC’s Indian Registry shows for 2006. 5In addition, the 2006 Aboriginal Peoples Survey and2006 Aboriginal Children’s Survey did not include FirstAuthors:Kelly McShane PhDAssistant ProfessorRyerson UniversityAssociate ResearcherCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt. Michael's HospitalJanet Smylie MD MPHResearch ScientistCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt. Michael's HospitalAssociate ProfessorDalla Lana School ofPublic HealthUniversity of TorontoPaul Adomako MScResearch Coordinator IIICentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt. Michael's HospitalHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 11

600,000564,870500,000400,000389,785300,000200,000133,155100,00050,485Figure 1Aboriginal PopulationCompositionSource: Census 20060First Nationswith status or treaty(on/off-reserve)First Nationswithout status or treaty(on/off-reserve)MétisInuitCurrently inCanada, Aboriginalpeople representthemselves politicallyas belonging to oneof several majorgroups: First Nations(Status Indianson-reserve, StatusIndians off-reserve,and non-StatusIndians), Inuit,and Métis.aThis is the census term used toidentify persons of First Nationsancestry. It is in quotation marks,because the word Indian is recognizedas a misnomer for Aboriginal peopleof First Nations ancestry.Nations peoples living on-reserve. Fortunately we areable to draw on the First Nations Regional LongitudinalHealth Survey to address this deficiency and ensurethat First Nations on-reserve information is included.The existing reports for the 2006 Aboriginal PeoplesSurvey and the 2006 Aboriginal Children’s Survey alsouniquely combine those who are ‘Status or RegisteredIndians’ living off-reserve with those who are ‘TreatyIndians’ living off-reserve. For this reason, when weare citing the 2006 Aboriginal Peoples Survey and the2006 Aboriginal Children’s Survey data we use the terms‘First Nations with status or treaty living off-reserve’ and‘First Nations without status or treaty living off-reserve’.In all other cases when referring to First Nations data,if the term First Nations is used without qualifiers, itmeans that the data is inclusive of the total First Nationspopulation (i.e., status and non-status as well as onreserveand off-reserve). Data from the First NationsRegional Longitudinal Health Survey is always for FirstNations persons living on-reserve who participated inthe survey. In all other cases we clarify the First Nationspopulation being described by identifying if it is ‘status’or ‘non-status’ and/or ‘on-reserve’ or ‘off/reserve’. Furtherchallenges were found with locating information forFirst Nations persons without status, Métis people,and Aboriginal people living in urban areas. With theexception of the Aboriginal Peoples Survey and theAboriginal Children’s Survey, health information forthese groups is close to non-existent.2.3 Demographics of Aboriginal Childrenin CanadaCurrently in Canada, Aboriginal people representthemselves politically as belonging to one of severalmajor groups: First Nations (Status Indians on-reserve,Status Indians off-reserve, and non-Status Indians), Inuit,and Métis. These groupings reflect Section 35 of Canada’sConstitution Act as well as the federal Indian Act,which defines the term ‘Status Indian’. From a culturalperspective, Aboriginal people in Canada compriseover 50 distinct and diverse groups, each with its owndistinct language and traditional land base. 12 Further,each of these larger groups represents a complex networkof communities and kinship systems, often with theirown distinct language dialects. ibid According to the 2006census, 2 just under 1.2 million persons in Canada reportAboriginal identity: approximately 60% identified as‘North American Indian’, a 33% identified as Métis, 4%identified as Inuit, and the remaining 3% identified withmore than one Aboriginal group and/or self-reported as‘registered Indians’ or members of First Nations bandsbut didn’t identify as Aboriginal. 2 (See Figure 1) Thesenumbers underestimate the actual Aboriginal population,as there was significant non-participation in the census12 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

350,000300,000273,626284,794250,000200,000150,000100,00050,0000On-ReserveOff-ReserveFigure 2First Nations with Status byPlace of ResidenceSource: Census 2006100%First NationsInuitMétisFigure 3Proportion of TotalPopulation Identifyingas Aboriginal80%Source: Census 200660%40%20%0%N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nvt.1.6% 0.9% 1.7% 1.7% 0.9% 1.3% 8.9% 9.6% 3.0% 3.2% 20.8% 30.8% 0.3%0.2% 0.9% 0.0% 0.0% 0.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.8% 10.1% 84.0%1.3% 0.3% 0.9% 0.6% 0.4% 0.6% 6.3% 5.0% 2.6% 1.5% 2.6% 8.7% 0.4%by a number of First Nations living on-reserve b andpossibly other Aboriginal groups. Additionally, it is likelythat a significant number of individuals chose not to selfidentifyas Aboriginal to government workers. Currently,81% of the First Nations population is considered ‘StatusIndian’. Approximately half of First Nations (51%) liveoff-reserve, with 76% of those living off-reserve living inurban areas. 2 (See Figure 2.) The majority of Métis live inurban areas (69%) and a growing number of Inuit (22%)live outside of Inuit Nunaat c (See Figure 3 for the portionof the population by region that identified as FirstNations, Inuit, and Métis.)bAs discussed earlier INAC figuresindicate that the census undercountof First Nations persons with statusis approximately 200,000 individualscInuit Nunaat comprises four Inuitregions: Nunatsiavut, Nunavik,Nunavut, and Inuvialuit.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 13

40%35%32%34%31%35%30%25%25%20%17%15%10%Figure 4Aboriginal PopulationUnder 14 Years of AgeSource: Census 20065%0%First Nationstotal (on/off-reserve)First Nations(on reserve)First Nations(off-reserve)MétisInuitnon-AboriginalpopulationFigure 5Proportion of AboriginalPopulation that are Childrenaged 14 & under50%Source: Census 200640%30%23%35%26%25% 25%27%33%36%31%28%27%30%38%20%10%0%N.L. P.E.I. N.S. N.B. Que. Ont. Man. Sask. Alta. B.C. Y.T. N.W.T. Nvt.The population of Aboriginal children in Canadarepresents a sizeable portion of the total Aboriginalpopulation (See Figure 4). In Figure 5, there aresome regional differences in the proportion ofAboriginal children (in relation to the total Aboriginalpopulation), with higher proportions observed inNunavut, Saskatchewan and Prince Edward Island.The large and growing populations of First Nations,Inuit, and Métis infants, children, and youth is linkedto a birth rate that is 1.5 times higher than the non-Aboriginal birth rate. 2 Specifically, the fertility rate14 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

etween 1996 and 2001 for First Nations women was2.9 children, 2.2 for Métis women, and 3.4 for Inuitwomen, compared to a rate of 1.5 among all Canadianwomen. 13 As evidenced in Figure 6, in comparisonto the non-Aboriginal population, the First Nations,Inuit, and Métis populations have a larger segmentof young adults (15-24 years) and smaller segment ofolder adults (65 and over). This young and growingpopulation impacts health and education systems, andthe future labour market, particularly in provinces andterritories such as Manitoba, Saskatchewan, Alberta,and Nunavut where there are high concentrations ofAboriginal people.The First Nations, Inuit, and Métis populationsare all much younger than the rest of the Canadianpopulation, with a collective median age of 27years, compared to 40 years in the non-Aboriginalpopulation. Specifically, the median age of the FirstNations population was 25 years, 22 years for the Inuitpopulation and 30 years for the Métis population. 265 yrs +4%5%5%13%non-AboriginalMétisInuitFirst NationsFigure 6Proportion of Population byAge CategorySource: Census 200612%55-64 yrs5%8%6%16%45-54 yrs8%14%11%15%35-44 yrs13%15%14%13%25-34 yrs14%14%14%13%15-24 yrs18%21%18%17%0-14 yrs25%35%32%0% 5% 10% 15% 20% 25% 30% 35%40%Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 15

Aboriginal children often live in families headed bysingle parents (See Figures 7 and 8). According to the2006 Aboriginal Children’s Survey, 2006 Census, andthe First Nations Regional Longitudinal Health Survey,considerably more First Nations, Inuit, and Métischildren live in single parent families, as comparedto non-Aboriginal Children (See Figure 7). 1,2,10 Notethat First Nations children living on-reserve were notincluded in the APS and are therefore not included inthe chart for children aged five and under. They areincluded in Figure 8 which draws on the 2006 Census,as well as the First Nations Regional LongitudinalHealth Survey for older children. 1,2The majority of lone-parent families are led bymothers and many of these mothers are younger whencompared to non-Aboriginal families. According tothe 2006 Aboriginal Children’s Survey, 27% of young(aged five and under) First Nations children livingoff-reserve, 22% of young Métis children, and 26% ofyoung Inuit children, had mothers between the agesof 15 and 24. 10 The rate of young mothers between theages of 15 and 24 for non-Aboriginal families was 8%.Figure 7Percentage of YoungChildren (aged 5 & under)Living in LoneParent Families50%45%40%42%Source: ACS 2006, Census 200635%31%30%28%25%23%20%15%13%10%5%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)InuitMétisnon-AboriginalpopulationFigure 8Percentage of ChildrenLiving in LoneParent FamiliesSource: APS 2006, RHS 2002/3,Census 200650%45%40%35%Census 2006 (aged 14 & under)40%37%33%RHS 2002/3 (aged 11 & under)41%31%30%26%25%20%18%15%10%5%0%First Nations total(on/off reserve)First Nations(on-reserve)First Nations(off-reserve)InuitMétisnon-Aboriginalpopulation16 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

50%45%40%ACS 2006 (aged 14 & under)42%RHS 2002/3 (aged 11 & under)35%30%31%28%25%23%20%17%15%13%10%5%Figure 90%First NationsFirst NationsFirst NationsInuitMétisnon-Aboriginalwith status or treaty without status or treaty (on-reserve)population(off-reserve)(off-reserve)Aboriginal families are more likely to be largefamilies. According to the First Nations RegionalLongitudinal Health Survey, 63% of First Nationschildren living on reserve aged 11 and under lived infamilies with three or more children. 1 According to the2006 Aboriginal Children’s Survey, 17% of young FirstNations children living off-reserve and 28% of youngInuit children, lived in families with four or morechildren, compared to 8% of young non-Aboriginalchildren. For Métis families, 32% of young MétisResults from the Aboriginal Children’s Survey 2006and the First Nations Regional Longitudinal HealthSurvey (see Figure 9) showed that Aboriginal childrenare also twice as likely as non-Aboriginal childrento live in multiple-generation households (children,parents, grandparents). 1,10 Additionally, a number ofchildren lived with their grandparents: 9% of FirstNations children living off-reserve, 8% of Métis, and16% for Inuit children lived with grandparents (eitheras part of a multiple generation household or livingchildren lived in families with three or more children,with grandparents alone). The comparable rate fornon-Aboriginal children aged five and under livingin the same household with their grandparents is 5%.Note that these ACS results again exclude First Nationsfamilies living on-reserve.Percentage of ChildrenLiving in MultipleGeneration HouseholdsSource: ACS 2006, Census 2006Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 17

2.4 Assessing and Responding to theHealth Needs of Aboriginal Childrenin CanadaHealth workers are trained to identify their client’sillness and its cause or source. Public health assessmentsimilarly measures health and its determinants amongpopulations. The assessment of Aboriginal children’shealth challenges public health stakeholders to takeinto account not only illness, but also wellness, usingmethods that build on these children’s rich and diversecultural, linguistic and geographic heritage.Public health assessment data typically relies on fivemain sources: (1) Census data; (2) Vital registration;(3) Acute and chronic disease surveillance; (4) Primaryand tertiary health services utilization records; and (5)Surveys. In Canada, health data exists at the national,provincial/territorial, regional, and community levels.For First Nations, Inuit and Métis peoples, there islimited health assessment data due to problems withdata coverage and quality. Smylie and Anderson 14 havedetailed the significant issues with each of the fivehealth data sources (see Text Box 1 in Additional TablesSection). Broadly speaking, in the health care andvital statistics system, there are few opportunities forindividuals to self-identify themselves or their childrenas First Nations, Inuit or Métis. When opportunities toself-identify do exist, Métis and First Nations personswithout status are almost always excluded. This resultsin the lack of accurate and inclusive First Nations,Inuit, and Métis identifiers or flags in vital registration,acute and chronic disease surveillance, and healthservice utilization data sets. There is an urgent need toremedy this situation and provide more opportunitiesfor First Nations, Inuit, and Métis to self-identify inhealth information systems. In addition, there areinstances of substandard data collection sources andmethods, which have resulted in inaccurate statistics.For example, under reporting of First Nations infantmortality has recently been identified at national andprovincial levels. 14,15Also essential to public health data systems is theirconnection to and integration with health policies,programs, and services. The various sources of healthdata need to be planned and organized so togetherthey form a comprehensive set of health systemperformance measures. These performance measuresshould give an integrated picture of the vitalityand wellbeing of Aboriginal children as well as theenvironments in which they live and grow. Data on itsown, without an organized interface to health policies,programs and services, has little meaning or utility.The organized linkage of First Nations, Inuit, and Métishealth data to First Nations, Inuit, and Métis healthpolicies, programs and services is another area wherethere are significant challenges in Canada. This maybe related to the use of health survey data to address18 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

gaps in vital registration, acute and chronic diseasesurveillance and health service utilization data sets.While we were able to locate a significant amount ofFirst Nations, Inuit, and Métis data using the methodsdescribed below, it was much more difficult to put thesedata sets together to provide a comprehensive overviewof First Nations, Inuit, and Métis children’s health andan assessment of the strengths and limitations of FirstNations, Inuit and Métis children’s health policies,programs, and services.An additional challenge facing First Nations, Inuit,and Métis health information stakeholders is the issueof jurisdictional complexity. Multiple jurisdictions canbe involved in collecting, analyzing, disseminatingand responding to health information, and the levelsof interface vary. For example, in one province, FirstNations infant mortality rates were being calculatedby both the provincial health department as well asthe regional office of Health Canada, First Nationsand Inuit Health Branch (FNIHB). Two slightlydifferent rates were produced. The regional FirstNations governing authority felt that they should shareresponsibility for the governance of this information,but were not yet actively included in data collection,analysis, or dissemination activities.At a national level, the need for data that relates to,and can be applied to specific ethnic and geographiccontexts is not always understood. For example,the recent Maternal Experiences Survey, which wasconducted by Statistics Canada at the request ofCanadian Perinatal Surveillance System, Public HealthAgency of Canada, was not adequately powered toprovide First Nations, Inuit, and Métis specific data.Hence, the experiences of an Inuit women living inNunavut may be compiled with those of a First Nationswomen living in downtown Toronto. Such data willbe of little use to regional policy makers and serviceproviders anxious for data that would help themimprove their local services, which clearly are verydifferent. Ideally, such national level surveys need tobe powered to provide data that is specific to FirstNations (status and non-status), Inuit and Métis withfurther ability to stratify for geography (ie. urban/rural/settlement for Métis; on-reserve/off-reserve forFirst Nations with status; urban/rural for First Nationswithout status; and territorial land claim area/urban forInuit). These are the ethnic and geographic groupingsupon which current health services are structured.2.5 Colonization as an UnderlyingDeterminant of IndigenousChildren’s Health‘Everyone agrees that there is one critical socialdeterminant of health, the effect of colonization.’ 16The colonization of Indigenous peoples globallyhas been increasingly recognized as a fundamentalunderlying determinant of health. Participants atthe first International Symposium on the SocialDeterminants of Indigenous Health documented thelinks between colonial policies and the following:dislocation from traditional lands, cultural suppression,political marginalization, forced assimilation, and theexcess burden of health disparities experienced byIndigenous peoples. 16First Nations, Inuit and Métis peoples in Canadacontinue to endure the effects of European colonizationwith direct impacts on health. Government policieshave supported the disruption of family networks, theforced dislocation of communities from traditionallands, and increased environmental degradationof natural resources due to industrial processes.Historically, First Nations, Inuit, and Métis knowledgeregarding infant, child and family health was sharedverbally and experientially among family and extendedkin. The overt suppression of Aboriginal culturesand languages has caused severe repercussions tothe intergenerational transmission of knowledge andtraditional teachings.Colonial processes in Canada varied according toAboriginal group, time, and geographic location. 12 FirstNations, Inuit, and Métis peoples have all experienceddislocation from and appropriation of their traditionalterritories. ibid For example, the Indian Acts imposeda system for the management of First Nations landswhich legalized removal of First Nations communities(who had signed treaties) from their homelands to‘reserve lands’ controlled by the Government of Canadaon behalf of ‘Indians’ As a result, the livelihoods ofthese communities were undermined as their localeconomies were strongly tied to traditional lands.After Métis homelands were sold by the Hudson BayCompany to the Government of Canada, the ManitobaAct of 1870 reserved 1.4 million acres of Crown landfor the unmarried children of Métis. 17 However,incoming settlers showed disregard for Métis landclaims and the implementation of the land provisionsfor the Métis in the Manitoba Act was plagued byHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 19

dThe unemployment rate particulargroup (age, sex, marital status,geographic area, etc.) is the numberof persons unemployed, expressedas a percentage of the totalpopulation in that particular group(adults aged 15 and over).eThe employment rate for aparticular group (age, sex, maritalstatus, geographic area, etc.) isthe number of persons employedin the week (Sunday to Saturday)prior to Census Day (May 16, 2006),expressed as a percentage of thetotal population in that particulargroup (adults aged 15 and over).delays, speculation, and theft. Consequently, themajority of land set aside for Métis children in theManitoba Act ended up being acquired by speculatorsfor only a fraction of its value and in the end Métisoccupied less than a quarter of the land. ibidBetween 1936 and 1963, federal relocation policies‘encouraged’ Inuit to relocate into permanent villagesin areas selected by the government 17 and requiredchildren to attend schools in these villages in order toreceive family allowance. The hunting conditions of thenew sites were suboptimal, leading to food insecurity,unemployment, and housing issues. Furthermore, themove to permanent settlements was accompanied byoutbreaks of tuberculosis. By 1964, more than 70%of Keewatin Inuit had been in tuberculosis sanatoria.In some cases, children sent to sanatoria were lateradopted by southern families without their parentsbeing informed. 17Federal policies also supported the abduction ofAboriginal children to residential schools, wherelanguage and culture were actively suppressed andchild neglect and abuse were commonplace. Indian Actlegislation in 1920 made school attendance compulsoryfor all First Nations children between the ages of 7 to15 years. Between 1849 and 1983, approximately 100residential schools operated in Canada and includedFirst Nations, Métis and Inuit students. 17 According tothe Aboriginal Peoples Survey in 2006 9 , 16% of Inuitchildren aged 6 to 14 years had a parent who attendeda residential school and 49% of Inuit children aged 6 to14 years had parents with at least one relative (mother,grandfather, etc.) or spouse who attended a residentialschool. According to the RHS 2002–3, 16.5% of FirstNations children (aged 11 and under) living onreserveshad at least one parent and 58.6% had at leastone grandparent who attended residential schools. 1The residential school experience is described in thefollowing excerpt from the 1999 First Nations and InuitRegional Health Survey Report:In some areas as many as five separate generationsof children were removed from their homes, families,culture, and language…many of the children enduredlong years of isolation and loneliness…Scores of childrendied from disease; others were emotionally and spirituallydestroyed by the harsh discipline and living conditions. 18Inuit children also endured the residentialschool experience. Mary Carpenter, an Inuk womansummarizes her experience of residential school:After a lifetime of beating, going hungry, standing ina corridor on one leg, and walking in the snow with noshoes for speaking Inuvialuktun, and having a heavystinging paste rubbed on my face, which they did tostop us from expressing our Eskimo custom of raisingour eyebrows for ‘yes’ and wrinkling our nose for ‘no,’ Isoon lost the ability to speak my mother tongue. When alanguage dies, the world it was generated from is brokendown too. 19Métis children and youth in some parts of the countryalso attended residential schools, and were commonlyexcluded and/or barred from attending communityschools set up for the children of European colonists.The impact of residential schools goes far beyondthe impact on individual survivors; the trauma isevident across generations of families. Dr. CorneliaWieman highlights the enduring aftermath of theresidential schools, asserting that:In addition to the damage caused to the individualsurvivors who endured emotional, physical, and sexualabuse, we must consider the long-term, cumulativeintergenerational effects on First Nations Communities…including dislocation from one’s community, loss of prideand self-respect, loss of identity, language, spirituality,culture, and ability to parent. 20The evidence suggests that health status, healthservice, and/or economic considerations themselvesare not sufficient to describe the excess burdenof health disparities experienced by Indigenouschildren and their families, nor are they adequateto identify appropriate strategies for remediation.Historic and ongoing colonial policies need to beaddressed. Key to the reversal of colonization isthe restitution of the right of Indigenous peoples toself-determination, including the implementation ofthe standards in the UN declaration on the Rights ofIndigenous Peoples. 212.6 Additional Social Determinantsof First Nations, Inuit, and MétisChildren’s HealthEmploymentOverall, rates of unemployment are higher forAboriginal peoples compared to non-AboriginalCanadians. Results from the 2006 Aboriginal PeoplesSurvey found that unemployment rates d for the adultpopulation (15 years and over) were four to five timeshigher for the Aboriginal population compared to thenon-Aboriginal population 7 (See Figure 10). Ratesfor employment e were generally comparable acrossthe First Nations, Inuit, Métis, and Non-Aboriginal20 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

UnemploymentEmployment80%70%60%57%62%58%67%63%50%49% 49% 49%40%34%31%40%33%30%20%10%7%0%First Nations withstatus or treaty(off-reserve15+ years)First Nations withoutstatus or treaty(off-reserve15+ years)First Nations(on-reserve18+ years)Inuit(inside Nunaat15+ years)Inuit(outside Nunaat15+ years)Métis15+ yearsCanadianpopulation15+ yearsFigure 10Rates of Unemployment& EmploymentSource: APS 2006, RHS 2002/3,Census 2006100%FishedTrappedHuntedHunted or TrappedBerry picking or Food gatheringFigure 11Harvesting of CountryFoods for Consumption(in past 12 months)Source: APS 2006, RHS 2002/380%78%72%60%55%40%43%32%37%27%47%36%46%32%43%32%38%20%15%13%13%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)MétisFirst Nations(on-reserve)population. According to the 2006 Census, the rateof employment for the First Nations on-reserve adultpopulation (over 18 years of age) was 49%. 3The harvesting of country food was included as alabor activity on the 2006 Aboriginal Peoples Surveyand the 2002/2003 First Nations Regional LongitudinalHealth Survey. Gathering or harvesting country foodfor personal consumption was an important labouractivity across all groups. Inuit respondents, livinginside Inuit Nunaat, had significantly higher rates ofhunting, fishing and trapping, compared to off-reserveFirst Nations and Métis groups (See Figure 11). 1,9Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 21

TotalAboriginalFirst Nations(on and offreserve)First Nations(on reserveonly)Métis Inuit NonAboriginalTable 2Median EmploymentIncome for Aboriginal andnon-Aboriginal Populationin Canada (based on2005 earnings)Source: 2006 Census.Women(all age groups)Men(all age groups)Total (Men andWomen)16,079 15,489 13,800 17,002 15,387 21,76522,386 19,061 13,607 27,881 19,229 33,21418,962 17,007 13,705 21,498 17,268 27,097fA CMA is an urban area witha population of more than100,000 peoplegThe CCHS excludes on-reserveFirst Nations populations and Inuitpopulations living in the territories.IncomeMedian income for the Aboriginal and non-Aboriginalpopulation is presented in Table 2. 4 Significantdisparities exist for First Nations, Inuit, and Métis,in comparison to the non-Aboriginal population. Themost marked disparities are for First Nations livingon reserve.Further, according to the Aboriginal Children’sSurvey 2006, 41% of young First Nations children(aged five and under) living off-reserve and 32% ofyoung Métis children were from low-income families,compared to 18% of non-Aboriginal young children. 10Differences in frequency of low-income families werealso noted between urban and rural residences. ForFirst Nations families living off-reserve with youngchildren (aged five and under), a higher percentageof urban families were in the low-income category ascompared to families living in rural areas (54% and27% respectively). A similar trend was found for Métis;36% of families with young Métis children in urbanareas were in the low-income category, compared to20% of rural families. Rates for Inuit families withyoung children (aged five and under) were calculateddifferently based on geography. For young Inuitchildren living outside of Inuit Nunaat and living in aCensus Metropolitan Area (CMA), f 45% were livingin low-income families, compared to 21% of youngnon-Aboriginal children living in CMAs. There wereno rates available for First Nations children livingon-reserve or for Inuit children living inside InuitNunaat. 10 For the total Canadian population, 14.5% ofyoung children under 6 years old and 13% of childrenaged six to 14 years old lived in a low income family.Overall, this suggests that young Aboriginal childrenand their families are more often living in poverty, ascompared to non-Aboriginal families.In the Aboriginal Peoples Survey, 17% of status ortreaty First Nations living off-reserve and 11% of nonstatusor non-treaty First Nations living off-reserve,utilized social assistance or welfare as an incomesource. For Inuit living within Inuit Nunaat, rates were24% compared to rates of 13% for Inuit living outsideInuit Nunaat. The rate for Métis respondents was 7%. 9The APS excluded First Nations living on-reserve.These income disparities are all the more alarminggiven the household and demographic characteristicsof Aboriginal families. As mentioned previously,many Aboriginal children live in lone parenthouseholds. Additionally, children and youth accountfor just under half of the Aboriginal population.Therefore, the reduced annual incomes of Aboriginaladults described above will often be providing fora larger group of dependents, compared to non-Aboriginal households.EducationOnly the First Nations Regional Longitudinal HealthSurvey has data on parental education. According toRHS 2002/3, 54% of mothers and 43% of fathers werehigh school graduates. 122 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

100%85%80%75%78%76%69%60%52%40%20%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)Métisnon-AboriginalpopulationFigure 12High School CompletionSource: APS 2006, Census 200680%70%60%58%Figure 13Exposure to AboriginalTeachers or Teacher Aides(elementary orsecondary school)Source: APS 200650%40%30%20%23%11%20%14%10%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)MétisAs there are currently no specific data on parentaleducation for First Nations off-reserve, Inuit,and Metis, we report figures for the general adultpopulation. According to the 2006 Census, rates forhigh school completion are generally somewhat lowerfor Aboriginal populations, as compared to the non-Aboriginal population. In particular, Inuit living insideInuit Nunaat have considerably lower rates of highschool completion (See Figure 12). 6Other data in the 2006 Census examined studentexposure to Aboriginal teachers at the elementary orhigh school level. Evidenced from Figure 13, there weresignificant differences in these rates for First Nations,Inuit, and Métis. 6 These trends could suggest thathaving treaty or status, and living within Inuit Nunaatmay provide increased opportunities for exposure toAboriginal teachers and possibly Aboriginal-basedteachings and philosophies.Food SecurityThere is only sparse and inconsistent informationregarding the rates of food security and insecurityHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 23

40%Moderate and SevereSevere only35%33%30%25%20%15%14%10%9%5%3%Figure 14Food InsecuritySource: CCHS 20040%AboriginalNote: The CCHS excludes on-reserve First Nations populations and Inuit populations living in the territories.non-Aboriginalamong First Nations, Inuit, and Métis populations.Data collection and quality is further complicated bythe use of different measurement instruments, most ofwhich have not been validated in First Nations, Inuit,and Métis contexts. Given the strong links betweenfood security, income, and employment, 22 the paucityof information regarding food security is particularlyconcerning. As we know from the income andemployment statistics detailed above, some Aboriginalpeople will be at risk of food insecurity, possiblyleading to negative health outcomes.Results from the 2004 Canadian Community HealthSurvey (CCHS) g indicated disproportionately high ratesof food insecurity for the Aboriginal population, whencompared to the non-Aboriginal population 22 (SeeFigure 14). Rates of food insecurity for First Nationspopulations living on-reserve vary from 21% to 83% 23According to the 2006 APS, 30% of Inuit children inCanada had at some point experienced hunger as aresult of their family having run out of food or moneyto buy food. Of those who experienced hunger, 24%experienced it regularly at the end of the month and21% had experienced it more than once a month. 9 Itis also important to recognize that the frequency offood insecurity may in fact be higher than observedas a community organizations may be ‘filling the gaps’through community food banks and meal vouchers.Remote and/or northern Aboriginal communitiescan face additional food security challenges, asnutritious food can be difficult and costly to find. For24 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

80%75%70%66%60%59%57%50%47%40%30%25%20%10%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)Métisnon-AboriginalpopulationFigure 15Home OwnershipSource: APS 2006, Census 200650%40%Crowded conditions43%Homes in need of major repairs40%Figure 16Housing ConditionsSource: ACS 2006, RHS 2002/3,Census 200630%20%10%18%16%29%8% 7%22%26%6%14%6% 7% 32%34%0%First Nations(off-reserve)Inuitnon-AboriginalFirst Nations(off-reserve)InuitMétisnon-AboriginalFirst Nations(on-reserve)Children 5 and under Children aged 14 and under Adultexample, a healthy food basket to feed a family of fourfor a week costs between $350-450 in Inuit Nunaat,compared to $200 in the south. 24HousingAccording to the 2006 APS, rates of home ownershipwere lower for Aboriginal populations, comparedto non-Aboriginal population. 9 Furthermore, therewas significant variability among First Nations, Inuitand Métis populations (See Figure 15). Data was notavailable for First Nations living on-reserve.Results from the 2006 Census and ACS 2006 showoverall higher rates of crowding h and homes in needof repairs for families with Aboriginal children, ascompared with non-Aboriginal families (See Figure16). 2,6,10 More specifically, Inuit participants reportedsignificantly higher rates of problems with housing,as well as lower rates of home ownership. ThishCrowded conditions is defined asmore than one person per room.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 25

30%Unsafe waterWater contamination25%21%20%18%17%16%17%15%13%13%11%10%5%Figure 17Water Quality IssuesSource: APS 20060%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)InuitMétisFigure 18Kinship NetworksFirst NationsInuitMétisSource: ACS 2006100%93% 92%94%80%72%77%78%60%44%46%41%47%40%28%21%20%0%Raised by motherRaised by fatherRaised by grandparentsRaised by other(aunts, uncles, cousins, siblings)iSince 99% of the adultsparticipating in the RHS hadchildren living with them, the RHSfigures are comparable to the 2006Census/ACS figures and are includedin Figure 16.could suggest that landlords are not maintaining anacceptable level of safety in their rental units. Datafor First Nations living on-reserve was not includedin this 2006 Census/ACS analysis. According to theRHS 2002/3, 32% of adults reported their homes werecrowded and 34% reported of adults reported theirhomes were in need of major repairs. 1iIn addition, between 10% and 20% of Aboriginalpeople participating in the 2006APS report waterquality issues in their homes (See Figure 17). 9 Thewater quality situation is even more alarming for FirstNations people living on reserve, with only 68% ofparticipants in the RHS 2002/3 reporting that water intheir home was safe to drink. 1 No comparable statisticsfrom the 2006 census have been released for the generalCanadian population.Kinship and Support NetworksMany First Nations, Inuit, and Métis parents andextended family are involved in raising young children(under six years old). The majority of Aboriginal childrenwere raised by their mother and father, and approximatelyhalf were raised by grandparents. (See Figure 18). Nostatistics from the 2006 census have been released for26 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

the general Canadian population or for the First Nationspopulation living on-reserve. The only comparablestatistics for the Canadian population are from theNLSCY 2006/07 for children aged five and under. 25 Whenasked who the child lived with, 86% of children livedwith biological parents, 11% lived with biological motherand did not live with their father, and 0.6% lived withbiological father and did not live with biological mother(although this last statistic was flagged to indicate thatcaution should be used in its interpretation).Communication TechnologyThe 2006 Aboriginal Peoples Survey and StatisticsCanada indicated that most Aboriginal adults hadused a computer and the internet in the past year(See Figure 19). 7,26 Slightly lower rates were found forInuit specifically living inside Inuit Nunaat, whichmight reflect the limited number of internet servicesproviders, the high costs of computer and internetaccess, or computer illiteracy. According to the RHS2002/3, 41% of participant First Nations adults livingon-reserve reported having a home computer and29% reported having access to the internet in theirhome. 1LanguageResults from the 2006 Aboriginal Peoples Surveyshowed considerable variability in language fluencyamong First Nations, Inuit, and Métis adults (SeeFigure 20). 7 Rates of Aboriginal language retentionamong First Nations, Inuit, and Métis children areincluded in the health status sections below. Rates for100%Computer use (past 12 months)Internet use (past 12 months)Personal non-business internet use (past 12 months)Figure 19CommunicationTechnology Use80%79%74%82%78%81%77%84%80%Source: APS 2006, Canadian InternetUse Survey 200567%68%61%60%40%20%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)MétisCanadianpopulationHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 27

accessing care in an Aboriginal language were around20% (See Figure 20). It is unclear if these rates includeuse of an interpreter or simply accessing a health-careprovider who speaks an Aboriginal language. FirstNations living on-reserve were not included in theseanalyses. Increasing the amount of health servicesavailable in an Aboriginal language could significantlycontribute to access and utilization of health servicesfor diverse Aboriginal populations. The discrepancybetween the language capacities of those surveyedand available health services in a primary Aboriginallanguage highlights a critical opportunity for growthand improvement in the delivery of appropriate andinclusive health programs and initiatives.2.7 Children’s Health StatusRefer to the end of this section (v. Figures) forchildren's health status figures. Comparisons in thissection are made to the National Longitudinal Surveyof Children and Youth (NLSCY). 25,27 Ideally, we wouldhave presented comparisons to the non Aboriginalparticipants in the NLSCY however, due to the verysmall sample size of the Aboriginal participantsincluded in the NLSCY, data for the Aboriginal andnon-Aboriginal subsamples has been suppressed toprotect confidentiality. Instead, we therefore makecomparisons with data from the general Canadiansample, which includes a small proportion ofAboriginal children.Figure 20Aboriginal Language Use &Access to Health Services inAboriginal Language100%90%Speak or understand Aboriginal languageAccess to health care in primary Aboriginal language96%Source: APS 200680%70%60%68%53%50%40%37%30%20%22%30%13%27%29%19%10%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Inuit(inside Nunaat)Inuit(outside Nunaat)Métis28 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

First Nations Section Highlights• Infant mortality rates for status First Nations appear to be decreasing but remain approximatelytwice as high as Canadian infant mortality rates. There are no infant mortality rates for non-statusFirst Nations.• In 2002/3, rates of high birth weight (>4.0kg) were significantly higher for First Nations childrenliving on reserve (21%) compared to the non-Aboriginal population (13.1%).• In 2006, rates for breastfeeding initiation, sustained breastfeeding at four months, and sustainedbreastfeeding at six months for status or treaty First Nations living off-reserve were 69%, 56%, and48% respectively. In 2002/3 rates for initiation and sustained breastfeeding at six months for FirstNations on-reserve were 63% and 43% respectively.• According to the RHS, 3.6% of First Nations children living on reserve had bronchitis; more thandouble the rate for the Canadian population (1.4%).• In 2006, 42% of status or treaty First Nations children aged six to 14 years living off-reserve and 45%of non-status or non-treaty First Nations children aged six to 14 years living off-reserve had one oremore severe chronic health conditions.• In 2006, 15% of status or treaty First Nations children aged five years or less living off-reserve hadasthma or used an inhaler/puffer. In 2002/3 14% of First Nations children aged 11 or younger livingon reserve had asthma.• In 2006, 18% of status or treaty First Nations children aged six to 14 years living off reserve and 22%of non-status or non-treaty First Nations children aged six to 14 living off-reserve suffered from oneor more activity limitations; according to the RHS 8.1% of First Nations children(11 and under) livingoff-reserve suffer from an activity limitation.• According to the RHS, 55% of First Nations children (aged 11 and under) living on-reserve reportedalways or almost always eating a nutritious and balanced diet.• In 2006, 25% of status or treaty First Nations children aged five years or less living off-reserve and 9%of status or treaty First Nations children aged five years or less living off-reserve were able to speakor understand an Aboriginal language. In 2002/3, 25% of First Nations children aged 11 or youngerliving on reserve were able to speak or understand an Aboriginal language.• 96% of First Nations children (aged 11 and under) living on-reserve had at least one person helpedthem understand their culture.• In 2006, 12% of status or treaty First Nations children aged five years or less living off-reserve and 8%of non-status or non-treaty First Nations children aged five years or living off-reserve were unable toobtain health care or medication when needed in the past 12 months.• 15.4% of First Nations children (aged 11 and under) living on reserve were reported to have anemotional or behavioural problem.• 29.5% of First Nations children between 12 and 14 years old living on reserve smoked tobacco in 2002/3.I. FIRST NATIONSSelf-rated healthThe measure of ‘self-rated’ health has yet to bevalidated in Aboriginal communities, and in generalis considered problematic in the field of populationhealth. 28 For example, individuals may rate their healthin comparison to others. Thus, their perception of theirown health is a relative comparison, and if the absolutelevel of health of a group is low, the perception will notaccurately reflect a true measure of health. Results fromthe Aboriginal Children’s Survey (2006) found thatnearly all children are described in ‘good,’ ‘very good,’ or‘excellent’ health (See Figure 21), which is comparable tothe rate for the Canadian population. 10,25,27Infant mortality and perinatal health outcomesThis section covers infant mortality, birth weight, pretermbirth, breastfeeding, sudden infant death syndrome (SIDS),and fetal alcohol spectrum disorder (FASD).Infant mortalityThe Joint Working Group of Infant Mortality hasidentified that high quality infant mortality rates areHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 29

The Joint Working Group of InfantMortality has identified that high qualityinfant mortality rates are currently onlyavailable for regional subgroups of theFirst Nations and Inuit populationin Canada and exclude the Métispopulation. Moreover, these ratesdo not exist at a national level.currently only available for regional subgroups of theFirst Nations and Inuit population in Canada andexclude the Métis population. Moreover, these rates donot exist at a national level. 29The averaged infant mortality rate for First Nationsfamilies with status, living both on and off reservefor 1976-1980 was 29 deaths per 1,000 live births. 30This was over two times the infant mortality ratefor Canada during the same time period. ibid Morerecently, First Nations infant mortality rates appear tobe decreasing with respect to absolute numbers butremain approximately twice as high as Canadian infantmortality rates (which have also been decreasing).In British Columbia, using vital statistics data from1981 to 2000, the overall infant death rates were 2.27times higher for status First Nations compared tonon-First Nations living in rural areas, and 2.08 timeshigher for status First Nations compared to non-FirstNations living in urban areas. 31 In Manitoba, using vitalstatistics data from 1991 to 2000, the infant mortalityrate for First Nations persons self-identifying on birthand/or infant death registrations as First Nations withstatus was 10.2 deaths per 1,000 births compared toa non-First Nations rate of 5.4. The rate disparity wasmost marked for post-neonatal death (death between29 days to 364 days of age), for which the First Nationsrate was more than three times the non-First Nationsrate (6.1 per 1,000 compared to 1.7 per 1,000). 32It is important to note that no reliable infantmortality rates exist for First Nations persons living inother parts of the country and for First Nations personswithout status. Additional regional rates are producedby First Nations and Inuit Health Branch and/or theprovinces for the four Western provinces, howeverdue to variations in the calculation methods, as well asquality, they have not been included. 16Birth weightRates of low birth weight for First Nations living onand off-reserve with status were similar to those ofthe Canadian population. Rates of low birthweightfor First Nations without treaty or status livingoff-reserve were higher than those of the Canadianpopulation (see Figure 22a). Rates for high birthweight (>4.0kg) showed some variation, with higherrates observed for First Nations living on-reserveand First Nations with status or treaty living offreserve.1,10,27 (See Figure 22b).In a study examining all births of First Nations infantswith status in British Columbia between 1981 and2000, First Nations infants with status had heavier birthweights, as compared to non-First Nations infants. 31The reasons for the elevated proportions of highbirth weight First Nations babies are unclear and thisissue requires further investigation.Preterm birthThere is no consistent provincial or territorial trackingof preterm birth rates among First Nations. A provincialresearch study of preterm birth among First Nationswith status in British Columbia revealed pretermbirth rates that were consistently over 40% to 70%higher than those of non-First Nations. 31 In Manitoba,published rates of preterm birth for First Nations withstatus are only slightly elevated compared to those ofnon-First Nations, 33,34 with higher rates for First Nationspersons living off-reserve compared to on-reserve.Elevated rates of preterm birth have been linkedto increases in multiple births, increased frequencyof obstetrical interventions, early complicationsduring pregnancy (e.g., vaginal bleeding, gestationalhypertension), inadequate prenatal care and high levelsof perceived stress. 34 Accordingly, the high rates ofpreterm birth may be related to health service deliveryand maternal well-being.BreastfeedingRates of breastfeeding initiation for First Nationswere slightly lower than the rate for the Canadianpopulation (in particular for the on-reservepopulation). 1,27 However, rates of sustainedbreastfeeding (at six months in particular) werehigher than the rate for the Canadian population(See Figures 23, 24, and 25). This suggests thatmothers who decide to breastfeed are adequatelysupported to continue breastfeeding, but that fewer30 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

mothers are deciding to breastfeed. This might berelated to an increased rate of preterm labour that caninterfere with the early interactions and opportunitiesfor breastfeeding. It might also be indicative of thelimited success of breastfeeding promotion efforts.Mothers may be receiving ongoing support fromwithin their family (as evidenced by the strongkinship networks), which would explain the higherrates of sustained breastfeeding.Sudden infant death syndrome (SIDS)In a population-based study in the province of BritishColumbia, which included all First Nations withstatus births between 1981 and 2000, the incidence ofpostneonatal SIDS was higher for both rural and urbanFirst Nations with status, as compared to both ruraland urban non-First Nations. 31In a study of all infants born in Quebec (Nunavikregion) from 1985 to 1997, the incidence of SIDS forIndian (North American Native language base) was2.6 per 1,000, which was higher than among infants ofFrench language background (0.5 per 1,000), Englishbackground (0.4 per 1,000), and other languagebackground infants (0.5 per 1,000). 35 Infant’s ethnicitywas identified using mother’s language. SIDS has beenlinked to certain risk factors including infant sleepposition, poverty and environmental smoke exposure.Fetal alcohol spectrum disorder (FASD)Much controversy surrounds the diagnosis of fetalalcohol spectrum disorder (FASD), particularly forAboriginal communities. The diagnostic categoryis relatively new and diagnostic instruments areonly now being standardized. For the Aboriginalpopulation, the struggle for accurate diagnosis isgreater and complex as access to trained physiciansis often limited. Furthermore, the physical diagnosticfeatures of FASD (e.g., typical facial features,height, head size) were established for Caucasianchildren and their use in Aboriginal settings canlead to misdiagnosis or over-diagnosis of FASD. 36Additionally, standardized testing instruments forcognitive and behavioural features of FASD have yet tobe validated with Aboriginal populations. 37Presently, no population-based estimates for FASDexist for First Nations, Inuit or Métis children inCanada. Furthermore, most studies that are conductedat a provincial or territorial level are criticized for afailure to use blind examiners for maternal alcoholuse. 38 According to parental self-report in the RHS2002/3, 1.8% of participant First Nations children(aged 11 and under) suffer from Fetal Alcohol Effects(considered a broader diagnostic category) 1 .One comprehensive community level study hasbeen conducted to determine prevalence rates ofFASD; between January 1998 and June 1999, theprevalence of FASD was 193 per 1,000 (or 19.25%)for children in grades one to eight in one AtlanticFirst Nations community. 39According to Health Canada, among the generalCanadian population the incidence of FASD is 1 out ofevery 500 to 3,000 live births per year, and the incidenceof FAE is five to 10 times the incidence of FASD. 38NutritionThere is relatively little data regarding the nutritionof First Nations children, despite the evidenceindicating high rates of food insecurity discussedearlier. According to the RHS 2002/3, 55% of FirstNations children (aged 11 and under) living on-reservereported always or almost always eating a nutritiousand balanced diet. 1 According to the APS 2001, 90% ofFirst Nations children (aged six to 14) living off-reserveand 84% of First Nations children living on selectedreserves had breakfast five to seven days a week. 7 In astudy conducted with six of nine Cree villages in theJames Bay region, between January 1995 and October1998, 31.9% of infants had anemia. 40 No national,provincial or territorial rates of anemia in First Nationschildren were identified.Infectious diseasesImmunization and immunizationpreventablediseasesNo national, provincial or territorial rates wereidentified for immunization against preventablechildhood infections (measles, mumps, rubella,haemophilus influenza, diphtheria, polio, tetanus,pertussus, pneumococcus, and varicella zoster).Otitis mediaRates for ear infections or problems are presented inFigure 26. Rates were comparable for status or treaty FirstNations living off-reserve, non-status or non-treaty FirstNations living off-reserve, and First Nations children livingon-reserve. 1,10 At present, we do not have a comparison forthe Canadian or non-Aboriginal population.Respiratory tract infectionRespiratory tract infections constitute a major cause ofchildhood morbidity and mortality. According to theRHS 2002/3, 3.6% of First Nations children living onreserve had bronchitis, which was more than doublethe rate for the Canadian population (1.4%). 1 It shouldbe noted that the statistic for First Nations childrenHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 31

jThe RHS used the internationallyaccepted definition for childhoodobesity, which is based oncalculation of the child’s body massindex and the internationallyaccepted cut-off points to defineobesity for that child’s particularage group. 1living on reserve is flagged and must be interpretedwith caution due to high sampling variability.Inadequate housing conditions, including poorventilation and crowding, directly contribute to theelevated rates of respiratory tract infections. 41With the exception of TB (below) national,provincial and territorial hospitalization and mortalityrates for childhood respiratory tract infection arenoticeably absent.Tuberculosis (TB)According to the RHS 2002/3, 0.5% of First Nationschildren living on reserve (aged 11 and under) hadtuberculosis (although this number should be interpretedwith caution because of high sampling variability. 1Yip et al. (2007) examined cases of pediatrictuberculosis in the province of Alberta, including asample of First Nations with status. 42 It should be notedthat the Canadian ‘other’ category included: non-Status First Nations, Métis, Inuit, and Canadian-bornnon-Aboriginal children of foreign-born or Canadianbornparents. Thus, this statistic on tuberculosis is notrepresentative of the entire population of First Nationschildren in Alberta. The overall rate of pediatrictuberculosis in Alberta between 1990 and 2004 was 1.1per 100,000 person-years. The rate for First Nationswith status was higher in comparison to the Canadianborn‘other’ (First Nations with status rate ratio of29.69) after controlling for gender.Tuberculosis has been linked to health determinantsincluding crowded housing 43 and living in remote areaswhere access to medical professionals is more difficult. 44HepatitisJin and Martin (2003) counted all viral hepatitis Acases (children and adults) on First Nations reservesin British Columbia that were reported to the FirstNations and Inuit Health Branch between January 1991and September 1996. 45 The incidence rate was 31 per100,000 persons per year, which was double the ratefor the general population of British Columbia (15.1per 100,000).Viral hepatitis has been linked to housing conditionsand other determinants of health; higher incidencerates were associated with crowded housing and waterquality problems. 45HIVNo national, provincial or territorial rates identified.Chronic diseaseRates of chronic disease for First Nations childrenare between 28% and 45% (See Figures 27 and 28). 10Such elevated rates suggest that efforts in preventivetreatment are falling short. As well, it indicates thatfrequent medical care and access to specialists isrequired. Unfortunately, there is very limited data onsuch health care accessObesityChildhood obesity has been recognized by policymakersas a significant problem facing Canadian children. Dataregarding obesity prevalence rates are limited for FirstNations children. The only available data is for FirstNations children living on-reserve. j In comparison tothe Canadian population, rates of obesity are over fourtimes higher (See Figure 29). 1Obesity has been linked to a number ofdeterminants of health. In particular, obesity in FirstNations children has been linked to family income,parental education, and physical activity. 1 For FirstNations children, the significant disparities in obesityrates are clear evidence of the impact of determinantsof health. This disparity suggests that preventionmeasures are ineffective. For example, access topreventative healthcare would be able to identifynutritional issues before a weight problemis pronounced.DiabetesThe epidemic of diabetes among First Nations adultscontinues to grow. 46 Elevated rates of diabetes 47,48,49have also been reported among subpopulations ofFirst Nations youth, although nothing has been32 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

eported for children under the age of 12. However,the presence of childhood obesity may be a precursorto diabetes later in life. There is at least one reportof a First Nations youth in Manitoba who died fromdiabetes. Efforts to combat obesity, increase physicalactivity, and improve access to medical care are keyto preventing diabetes.Physical activityAccording to the Aboriginal Children’s Survey 2006,63% of status or treaty First Nations children (aged sixto 14 years) living off-reserve and 69% of non-statusor non-treaty First Nations children (aged six to 14years) living off-reserve played sports one or moretimes a week. 10 The RHS 2002/3, asked 20 questionsabout various types of physical activity, includingmultiple sports; thus, an appropriate comparison wasnot possible. 1 No comparable rate was identified for theCanadian or non-Aboriginal population.AsthmaRates of asthma for First Nations children were between12% and 16% (See Figure 30), and comparable to therate for Canadian children. 1,10,27AllergiesRates of allergies were generally similar for First Nationschildren, as compared to the rate for Canadian children(see Figure 31). 1,10,27CancerNo national, provincial or territorial rates identified.Heart ConditionRates of heart conditions for First Nations childrenwere comparable across First Nations groups (SeeFigure 32). 1,10Child development and disabilityDisabilitiesThe rate of activity limitations for First Nations childrenliving off-reserve was higher than the rate for Canadianchildren. The rate for First Nations children livingon-reserve was comparable to the rate for Canadianchildren (See Figure 33). 1,10,27With respect to specific hearing and visualimpairments, rates of hearing impairments were muchlower than rates of visual impairments (See Figures 34a& 34b). 1,10 It is unclear how many First Nations childrenhave access to proper eye care, which is concerninggiven the high rates of visual impairments. Furthermore,the impact of visual impairments on children’s learningand development remains unclear. Perhaps this is linkedto the higher rates of learning problems.Attention deficit hyperactivity disorder (ADHD)Based on the RHS 2002/3, 2.6% of First Nationschildren living on reserve had ADHD, which isconsistent with the rate for Canadian children. 1 No ratesare available for First Nations children living off-reserve.Learning disordersBased on the RHS 2002/3, 2.9% of First Nationschildren (aged 11 and under) living on reserve hada learning disorder, which was reportedly consistentwith the rate for the Canadian population. 1 Accordingto the APS 2001, it is estimated that 3% of First Nationschildren living on selected reserves and 9% of FirstNations children living off-reserve, suffered from alearning disorder. 7 Note that the statistic for FirstNations children on selected reserves is flagged to beinterpreted with caution.Language and Cultural EngagementRates of language comprehension and ability to speakan Aboriginal language did show some differences;First Nations children without status or treaty hadlower rates when compared to Inuit or Métis children(See Figure 35). 10 Language retention is fundamental toidentity and results suggest that colonization has hada substantial impact on the transmission of languageand culture. Additionally, the relative infrequency ofAboriginal teachers providing instruction suggests thatthe school system is not an effective environment forfostering language development.According to the RHS 2002/3, 96% of First Nationschildren (aged 11 and under) living on-reserve hadat least one person helped them understand theirculture. A variety of different people helped them; 67%reported help from their parents and 62% reported helpfrom their grandparents. 1According to the Aboriginal Children’s Survey(2006), 45% of First Nations children (aged five andunder) living off-reserve had someone who helpedthem understand Aboriginal history and culture. Mostwere helped by their parents (60%) and grandparents(50%). Differences were noted for First Nationschildren with status (54% had someone who helpedthem) and First Nations children without status (32%had someone who helped them). 10InjuriesThis section deals with injuries, accidents andaccidental deaths. It should be noted that some suicidesare classified as accidental deaths.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 33

Rates for injuries were higher for First Nationschildren living on reserve, as compared to rates for theCanadian population (See Figure 36). 1,27Some injuries may have occurred at home andperhaps could be linked to substandard and/orcrowded housing. Other injuries may have been theresult of a lack of safety equipment (e.g., car seats,helmets), failed prevention efforts, lack of availability ofsafety equipment and/or financial constraints.Harrop et al (2007) examined injury mortality ratesfor First Nations children (aged 19 years and under) inAlberta. 50 Over a 10-year period (1985 to 1994), annualinjury mortality rate decreased from 129 per 100,000to 68 per 100,000, representing a 47% decline. Thisdecline was comparable to the rate decrease for non-First Nations children. However, injury mortality rateswere consistently higher for non-First Nations children.It is unclear how access to quality medical carefactors into the increased rates of injury mortality.Remote and isolated areas present challenges fortravelling to tertiary care centres.Smoking, alcohol, and drug useThere is very little information on alcohol and drug usefor children less than 14 years old. According to the RHS2002/3, the rate for smoking tobacco was 29.5% for FirstNations children between 12 and 14 years old living onreserve. 1 The average age of smoking initiation was 12.7years old and some respondents started as young as fouryears old. For First Nations children between 12 and14 years old living on reserve, 22.3% reported havinghad alcohol in the past 12 months and 14.9% reportedhaving used marijuana in the past 12 months. 1Mental healthThis section covers socioemotional problems,depression, and suicide. There is no data onaccess to medical care for mental health concernsspecifically, and similarly no data on access to mentalhealth professionals, such as psychiatrists, clinicalpsychologists, or social workers.Socioemotional problemsAccording to the RHS 2002/3, 15.4% of First Nationschildren (aged 11 and under) living on reserve werereported to have an emotional or behavioural problem. 1This rate was considered comparable to the rate forthe Canadian population according to the NLSCY,however it should be noted that items from the NLSCY2000/2001 were worded differently. 2734 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

DepressionAccording to the RHS 2002/3, 28% of First Nationsgirls aged 11 to 14 years living on reserve, reportedfeeling sad or depressed. This rate was two-times higherthan the rate for First Nations boys aged 11 to 14 yearsalso living on reserve (13.3%). 1SuicideSuicide data sets that did not include children underthe age of 12 were excluded. According to the RHS2002/3, among First Nations girls aged 12 to 14 yearsliving on reserve, 6.7% reported suicidal thoughtsand 2.6% reported a suicide attempt. 1 In comparison,among First Nations boys aged 12 to 14 years old livingon reserve, 1.8% reported suicidal thoughts and nonereported a suicide attempt. 1In a population based study of First Nationschildren with status living in Alberta (from 1985-1994),suicide ranked second as the leading cause of injuryfor children aged 10 to 14 years. 50 The suicide rate forFirst Nations children was 12.8 per 100,000 per year,considerable higher than the rate for non-Aboriginalchildren (at 2.4 per 100,000 per year).Suicide is the result of a variety of pre-existingfactors, including hopelessness, depression, andsubstance misuse. Links have been established betweenthe experience of trauma during residential schoolingand mental health, substance abuse problems, andsuicide for adult survivors of residential schooling. Aswell, there is emerging evidence and recognition ofthe intergenerational effects of residential schooling.It is likely that the effects of residential schooling andsubsequent family disruption are evidenced in themental health of children.Dental healthRates of dental problems varied for First Nationschildren, with fewer problems noted for non-status ornon-treaty children (See Figure 37). 10 However, youngchildren without status or treaty also had low rates ofaccessing dental services, making it possible that dentalproblems were not diagnosed (See Figure 38). 1,10,25,27Rates of access to dental care were comparable to thoseof the Canadian population. Rates for access to dentalcare were lower for older First Nations children livingon-reserve, compared to those living off-reserve.Environmental exposuresThe rate of prenatal environmental tobacco exposure(smoking in the home of a pregnant First Nationsmother) reported by participants in the RHS 2002/3,was about one out of every two families living onreserve (48.2%). 1 No national, provincial or territorialrates were identified for environmental exposuressuch as mold in houses, crowding in homes, andenvironmental contaminants (e.g., PCBs). Also, recallthat the housing condition and water quality of someFirst Nations children and their families is substandard(see Additional social determinants section).Access to health careRates for accessing a family doctor, general practitioneror pediatrician were comparable for young FirstNations children, although status or treaty FirstNations children off-reserve were more likely to havebeen unable to obtain health care or medication. Thereasons for this are unclear. Rates of access to care forthe Canadian population were comparable (See Figure39) 10,25 Perceptions of health care facilities were equalfor both status or treaty and non-status or non-treatyFirst Nations children living off-reserve (See Figure40). 10 Rates of access to medical care for older childrenshowed a similar pattern (See Figure 41). 10The RHS 2002/3 asked different questions regardingaccess to health care. The focus was on barriers foradults in accessing health services. The followingbarriers were identified by participants: Doctor or nursenot available (18.5% of adult participants); service notavailable (14.7% of adult participants); not being able toafford childcare costs (7.1% of adult participants). 1Additional data on interactions, proximity to healthcare facilities, and quality of health care are necessaryto understand the health care experience of FirstNations children and their families.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 35

Inuit Section Highlights• Over a three year period from 1999 to 2001, the infant mortality rate for Canada was 4.4 per 1,000births compared to a rate 13.9 per 1,000 births for Nunavut.• In Quebec (Nunavik region) from 1985 to 1997, the incidence of SIDS for Inuit was 6.0 per 1,000,which was higher than rates among infants of French language background (0.5/1,000) or Indian(North American Native language base) background (2.6/1,000).• 33% of Inuit children aged six to 14 years were diagnosed with one or more severe chronic healthconditions in 2006• Between 1998 and 2000 18.2% of births in the Baffin Island region were preterm.• In 2006, 66% of Inuit women initiated breastfeeding and 54% maintained breastfeeding aftersix months.• In 2006, 15% of Inuit children aged six to 14 years old had an ear infection or ear problem.• According to a 2006 follow up study in Nunavik, 97% of children had one or more episodes of upperrespiratory tract infection and 83% had one or more episodes of lower respiratory tract infectionbefore the age of five.• In 2006, 48% of Inuit children aged five years or less could speak or understand an Aboriginallanguage compared to 72% of Inuit children aged six to 14 years.• In 2001, 56% of smokers in Nunavut were children and youth aged 12 to 19 years.• In 2006, 53% of Inuit children aged five years or less and 35% of Inuit children aged six to 14 yearshad seen a family doctor, general practitioner or pediatrician in the past 12 months.II. InuitRefer to the end of this section (v. Figures) forchildren's health status figures.Self-rated healthThe measure of ‘self-rated’ health has yet to bevalidated in Aboriginal communities, and in generalis considered problematic in the field of populationhealth. 28 For example, individuals may rate their healthin comparison to others. Thus, their perception of theirown health is a relative comparison, and if the absolutelevel of health of a group is low, the perception willnot accurately reflect a true measure of health. Resultsfrom the Aboriginal Children’s Survey (2006) foundthat nearly all Inuit children described being in ‘good,’‘very good,’ or ‘excellent’ health (See Figure 21),which is comparable to the rates for the Canadianpopulation. 10,25,27Infant mortality and perinatal health outcomesThis section covers infant mortality, birth weight, pretermbirth, breastfeeding, sudden infant death syndrome (SIDS),and fetal alcohol spectrum disorder (FASD).Infant mortalityAt present, IMR for Inuit are inferred using populationbased statistics in territories. This is due to the lack ofAboriginal identifiers on death registrations. Authorsof a recent study generated abridged life tables usingcensus and vital statistics data for residents of censussubdivisions in which 33% or more of the populationwas Inuit – this included all communities in the fourInuit land claim settlement territories. The infantmortality rate for Inuit inhabited areas decreased from25.6 deaths per 1,000 births for 1989-1993 to 21.9deaths per 1,000 births for 1994-1998 to 18.5 deaths per1,000 live births for 1999-2003. These rates persisted tobe four times the general Canadian rate, which also fellduring the period of the study. 51The rate for infant mortality in 2001 in Nunavut was15.6 per 1,000 births, which is almost four times greaterthan the rate for Canada (4.4 per 1,000 births). Overa three year period, from 1999 to 2001, the rate forCanada was 4.4 and the rate for Nunavut was 13.9 per1,000 births. 52Birth weightThe rate of low birthweight for Inuit was slightly highercompared to the Canadian population. The rate ofhigh birthweight was slightly lower than that of theCanadian population (see Figure 22). 10For Nunavut, high birth weight was 8.7% and 9.2%and for Canada it was 5.2% and 5.8%, for males andfemales, respectively. Over a three year period from1999 to 2001, the rate for low birth weight was 7.6% forNunavut and 5.5 for Canada. 5236 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

Preterm birthThere is no consistent provincial or territorial trackingof preterm birth rates among Inuit. Muggah et al (2003)collected information on all live births in the BaffinRegion between 1998 and 2000. 53 A sample of 835 Inuitbirths and 45 non-Inuit births was identified. AmongInuit women, 18.2% of births were preterm (before37 weeks) and 2.4% of births were extremely preterm(before 32 weeks). These rates are much higher thanreported rates of preterm births in other regions ofCanada for the same time period. 54Elevated rates of preterm birth have been linkedto increases in multiple births, increased frequencyof obstetrical interventions, early complicationsduring pregnancy (e.g., vaginal bleeding, gestationalhypertension), inadequate prenatal care and high levelsof perceived stress. 33 In a study of risk factors for Inuitpreterm birth in Baffin Region, 53 preterm birth wasassociated with fewer prenatal visits, previous pretermdelivery, and previous births.BreastfeedingRates of breastfeeding initiation for Inuit werelower than the rates for the Canadian population. 1,27However, rates of sustained breastfeeding (at sixmonths in particular) were higher than the rate forthe Canadian population (See Figures 23, 24, and25). 10,27 Additionally, according to the APS 2001,the average duration for breastfeeding for Inuitchildren was 15 months. 7 The relatively high ratesof sustained breastfeeding may reflect a supportivefamily environment and/or cultural norms. Theoverall lower rates of breastfeeding initiation for Inuitmay be attributable to concern about environmentaltoxins contained in breastmilk (see discussion inEnvironmental Exposures). Furthermore, rates ofbreastfeeding for Inuit might also be lower becauseadoption is common, which might preclude thepossibility of breastfeeding.Sudden Infant Death Syndrome (SIDS)In a study of all infants born in Quebec (Nunavikregion) from 1985 to 1997, the incidence of SIDSfor Inuit was 6.0 per 1,000, which was higher thanamong infants of French language background (0.5per 1,000), Indian (North American Native languagebase; 2.6 per 1,000), English background (0.4 per1,000), and other language background infants (0.5per 1,000) 35 . Infants’ ethnicity was identified usingmother’s language. SIDS has been linked to certainrisk factors including infant sleep position, povertyand environmental smoke exposure.Fetal alcohol spectrum disorder (FASD)No national, provincial or territorial rates wereidentified for Inuit.Nutrition and traditional foodsAccording to the APS 2001, 49% of Inuit children (agedsix to 14) ate wild meat at least three times a week. 8Infectious diseasesImmunization and immunizationpreventable IllnessNo national, provincial or territorial rates wereidentified for immunization against preventablechildhood infections (measles, mumps, rubella,haemophilus influenza, diphtheria, polio, tetanus,pertussus, pneumococcus, and varicella zoster).According to the Nunavut Comparable HealthIndicators Report (2004), there were no reported casesof measles in 2002. 52 There was one new case of invasivemeningococcal disease and two cases of invasiveHaemophilus influenzae B reported in 2002, whichresulted in rates of 7.6 per 100,000 and 57.8 per 100,000respectively. ibid However, these rates are for the generalpopulation, not children specifically.Otitis mediaRates for ear infections or problems are elevated forInuit 10 (See Figure 26).Dallaire et al. (2004) recruited a sample of Inuitinfants in Nunavik to participate in a prospectivecohort study. 55 All Inuit infants born in Nunavikbetween November 1995 and March 2001 were eligibleto participate. The researchers reported that there were417 pregnancies in the identified communities duringthe study period. They reported that 96% of infants hadat least one episode of otitis media.In a follow-up study completed by Dallaire et al.(2006), they reported on the sample group of infantswho were now preschoolers. 56 The recruited samplerepresented 75% of infants born in Nunavik duringthe study period. Medical charts were reviewed fordiagnoses of infection over the first 5 years of theinfants’ lives. The cumulative incidence, which is thepercentage of children with one or more episodesbefore age five, was 95% for acute otitis media.Environmental contaminants remain a significanthealth risk for Inuit living in the north (see below).Researchers have also identified an association betweenotitis media in infants and exposure to PolychlorinatedBiphenyls (PCB). In one study, infants who hadexperienced one or more acute otitis media infectionsHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 37

Environmental contaminants remaina significant health risk for Inuitliving in the northHeart conditionThe rate of heart conditions for Inuit children washigher than the rates for First Nations and Métischildren (See Figure 32). 10Child development and disability.DisabilitiesRates for activity limitations for Inuit children were higherthan rates for the Canadian population (see Figure 33). 10,27Rates of hearing impairment are higher for Inuit, ascompared to other Aboriginal children (See Figure 34). 10As mentioned previously, this might be the consequenceof elevated rates of chronic otitis media or ear infectionsamongst Inuit children. As noted for First Nationschildren, the impact of visual and hearing impairmentson learning for Inuit children remains unclear.Attention deficit hyperactivity disorder (ADHD)No national, provincial or territorial rates identified.Learning disordersAccording to the APS 2001, it is estimated that 4% of Inuitchildren have a learning disability. Note that this statisticis flagged and should be interpreted with caution. 8Language and Cultural EngagementRates of Aboriginal language comprehension and abilityto speak were generally high for Inuit (See Figure 35). 10This is likely linked to high fluency rates among Inuitadults, as well as high rates of student exposure toAboriginal teachers.According to the Aboriginal Children’s Survey(2006), 65% Inuit children (aged five and under) hadsomeone help them understand Aboriginal cultureand history. 10 No rates were reported on who helpedthem understand.InjuriesRates of injury for Inuit were comparable to those ofCanadian children (See Figure 36). 10Smoking, alcohol, and drug useThere is very little information on alcohol and drug usefor children less than 14 years old. According to theNunavut Comparable Health Indicators Report (2004),in 2001, 56% of current smokers were children and youthaged 12 to 19 years. 52 This is substantially higher than therate for the general Canadian population (14.8%).Mental healthNo national, provincial or territorial rates forsocioemotional problems, depression, and suicide wereidentified for Inuit children. Suicide data sets, that didnot include children under the age of 12, were excluded.Dental healthRates of dental problems were elevated for Inuitcompared to other Aboriginal children. The rates ofdental treatment were somewhat lower (for older Inuit)compared to other Aboriginal children and the Canadianpopulation (See Figures 37 and 38). 10,25,27 This suggestsdeficiencies in the delivery of dental care services.Environmental exposuresMultiple small studies have been conducted thatexamine prenatal exposures to environmentalcontaminants such as lead, environmentalcontaminants such as organochlorines including DDT,HCB, and PCBs, DDE. These studies have examinedcord blood measures among Inuit living in Nunavikand Nunavut. 55,61,62 Elevated levels of mercury werefound in the cord blood of infants from Nunavikand Nunavut. Elevated levels of lead were found inNunavik and Nunavut. Elevated levels of cadmiumwere found in cord blood in all regions. Infantsexposed to the highest levels of PCBs and DDE inNunavik had the most infections, as compared toinfants exposed to the lowest levels of PCBs and DDE.Elevated levels of organochlorines were associated withhigher rate of infections during the first six months ofinfants’ lives. Studies in the 1980s and 1990s conductedin villages in northern Quebec found that InuitHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 39

mothers’ breast milk had five to six times the amountof PCBs, PCDDs, and PCDFs, when compared tobreast milk of mothers living in southern Quebec. 63,64The authors suggested that the increased levels of PCBswere the result of high consumption of fish and seamammals among Inuit women.In a small community-based study in Nunavut,Kovesi et al. (2006) found that exposure to second handsmoke and reduced air exchange, as a result of the smallsize of the dwellings, were linked to lower respiratorytract infection. 65 They found that 90% of householdshad smokers present.Also, recall that housing conditions and water qualityfor some Inuit children and their families is substandard(see Additional social determinants section).Access to health careRates for accessing a family doctor, general practitioneror pediatrician were considerably lower for Inuit, ascompared to other Aboriginal children (See Figure 39 and41). 10 Rates of access to care for the Canadian populationwere considerably higher. Despite this fact, perceptionsof health care facilities among Inuit were consistent withother Aboriginal populations (See Figure 40). 10The reasons for this are unclear. Additional dataon interactions, proximity to health care facilities, andquality of health care are necessary to understand thehealth care experience of Inuit children and their families.The discrepancy between access to health careproviders and perceptions of health care facilities isinteresting. It may be related to the fact that nursesare providing care to Inuit children at local nursingstations, where there are no resident doctors.40 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

Métis Section Highlights• Despite accounting for 33% of the Aboriginal population there is currently no information availableon infant mortality rates for Métis populations.• In 2006, rates for breastfeeding initiation and sustained breastfeeding at six months were 74% and51% respectively for Métis children aged five years or less.• 42% of Métis children aged six to 14 years had one or more severed chronic health conditions in 2006.• 28% of Métis children aged five years or less had a long-term health condition diagnosed by a healthprofessional in 2006.• In 2006, 9% of Métis children aged six to 14 years were diagnosed with an ear infection or ear problem.• In 2006,13% of Métis children aged five years or less were diagnosed with asthma or used apuffer/inhaler.• In 2006, 19% of Métis children aged six to 14 years were diagnosed with allergies.• In 2006, 10% of Métis children aged five years or less could speak or understand an Aboriginallanguage; the rate was 7% for Métis children aged six to 14 years.• In 2006, 18% of Métis children aged six to 14 years suffered from one or more activity limitations.• In 2006, 12% of Métis children aged six to 14 years experienced an injury in the past 12 months.• 81% of Métis children aged five years or less and 54% of children aged six to 14 years had seen afamily doctor, general practitioner or pediatrician in 2006.III. MétisRefer to the end of this section (v. Figures) forchildren's health status figures.Self-rated healthThe measure of ‘self-rated’ health has yet to bevalidated in Aboriginal communities, and in generalis considered problematic in the field of populationhealth. 28 For example, individuals may rate theirhealth in comparison to others. Thus, their perceptionof their own health is a relative comparison, andif the absolute level of health of a group is low, theperception will not accurately reflect a true measureof health. Results from the Aboriginal Children’sSurvey (2006) found that nearly all Métis children aredescribed as having ‘good,’ ‘very good,’ or ‘excellent’health (See Figure 21), which is comparable to the ratefor the Canadian population. 10,25,27Infant mortality and perinatal health outcomesThis section covers infant mortality, birth weight,preterm birth, breastfeeding, sudden infant deathsyndrome (SIDS), and fetal alcohol spectrumdisorder (FASD).Infant mortality rateThere is currently no information on infant mortalityrates for Métis populations in Canada. Métis currentlyaccount for 33% of the total Aboriginal population inCanada and number just under 400,000 persons. 2 Thecensus socio-demographic profile of this populationindicates that this is a population that would be at riskfor a disproportionate burden of infant mortality andmorbidity. 4,6,9Birth weightThe rate of low birth weight was slightly higher forMétis infants compared to the Canadian population,as was the rate of high birthweight (see Figure 22). 10,27Preterm birthNo national, provincial or territorial rates identifiedfor Métis.BreastfeedingRates of breastfeeding initiation for Métis werecomparable to the rate for the Canadian population.However, rates of sustained breastfeeding (at sixmonths in particular) were higher than the rate forthe Canadian population (See Figures 23, 24, and25). 10,27 As mentioned in both the First Nations andInuit sections, this suggests that mothers may bereceiving ongoing support from within their familywhich explains higher rates of sustained breastfeeding.Sudden infant death syndrome (SIDS)No national, provincial or territorial rates identifiedfor Métis.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 41

Fetal alcohol spectrum disorder (FASD)No national, provincial or territorial rates identifiedfor Métis.NutritionAccording to the APS 2001, 87% of Métis children(aged six to 14) had breakfast five to seven days a week. 7Infectious diseasesImmunization and immunizationpreventable diseasesNo national, provincial or territorial rates wereidentified for immunization against preventablechildhood infections (measles, mumps, rubella,haemophilus influenza, diphtheria, polio, tetanus,pertussus, pneumococcus, varicella zoster).Otitis mediaRates for ear infections were comparable to otherAboriginal populations (See Figure 26). 10,27 At present,we do not have a comparison for the Canadian or non-Aboriginal population.Other infectious diseasesNo national, provincial or territorial rates forbronchitis, respiratory tract infection, tuberculosis orHIV were identified for Métis children.Chronic diseaseRates for chronic disease for Métis children arecomparable to those of First Nations and Inuit (SeeFigures 27 and 28). 10Physical activityAccording to the Aboriginal Children’s Survey 2006,70% of Métis children (aged six to 14 years) playedsports one or more times a week. 10 No comparablerate was identified for the Canadian or non-Aboriginal population.AsthmaRates of asthma for Métis children were comparable toother Aboriginal populations (See Figure 30), 10,27 andcomparable to the rate for Canadian children.AllergiesRates of allergies were generally comparable for Métischildren, as compared to the rate for Canadian children(see Figure 31). 10,27Heart conditionThe rate of heart conditions for Métis children wassimilar to that of First Nations children and lower thanthat of Inuit children (See Figure 32). 10Other chronic conditionsNo national, provincial or territorial rates wereidentified for obesity, diabetes, or cancer.Child development and disabilityDisabilitiesRates of activity limitations for Métis children werehigher than the rate for the Canadian children (seeFigure 33). 10Rates for hearing impairments were much lower thanrates for visual impairments (See Figure 32). 8 As notedin the First Nations section, it is unclear how manyMétis children have access to proper eye care, which isconcerning given the high rates of visual impairments.Additionally, the impact of visual impairments onchildren’s learning and development remains unclear.Attention deficit hyperactivity disorderNo national, provincial or territorial rates identified.Learning disordersAccording to the APS 2001, it is estimated that 8% ofMétis children have a learning disability. Note that thisstatistic is to be interpreted with caution. 7Language and Cultural EngagementRates of Aboriginal language comprehension andability to speak were low for Métis children (see Figure35). 10 This may reflect the distinct multilingual (Michif,French, English) language heritage of the Métis.According to the Aboriginal Children’s Survey(2006), 31% of Métis children (aged five and under)had someone who helped them understand Aboriginalculture and history. Most were helped by their parents(56%) and their grandparents (46%). 10InjuriesRates of injuries were similar for Métis as compared tothe Canadian population (See Figure 36). 10Smoking, alcohol, and drug useIn general, there is very little information on smoking,alcohol, and drug use for children less than 14 years old.No national, provincial or territorial rates were identified.42 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

Mental healthNo national, provincial or territorial rates of socioemotionalproblems, depression, and suicide were identified.Dental healthRates of dental problems were lower for young Métischildren and comparable for older Métis children,as compared to other Aboriginal populations andthe Canadian population (See Figure 37). 10 Access todental care was also comparable to other Aboriginalpopulations (See Figure 38). 10Environmental exposuresIn a comprehensive review of environmentalcontaminants, van Oostdam et al. (2005) foundthat Métis in the north had elevated levels of lead inmaternal cord blood. 61Also, recall that housing conditions and waterquality for some Métis children and their families issubstandard (see Additional social determinants section).Access to health careRates for accessing a family doctor, generalpractitioner or pediatrician were similar for Métischildren, as compared to other Aboriginal children(See Figures 39 and 41). 10 Rates of access to care forthe Canadian population were comparable. Rates foraccessing a traditional Aboriginal healer were lowfor Métis (See Figure 41). 10 Ratings of health carefacilities as excellent or very good were comparableto those of other Aboriginal children (See Figure40). 10 As mentioned in the First Nations section,additional data on interactions, proximity to healthcare facilities, and quality of health care are necessaryto understand the heath care experience of Métischildren and their famlies.IV. Information GapsThere are large gaps in the health information availablefor First Nations, Inuit, and Métis children livingin Canada. Most notably, there is very little vitalregistration (infant mortality and disease specificmortality) and health care utilization data (includinghospitalization data) at all levels of aggregation. Thereis very little data for Métis and non-status First Nationschildren, as well as Aboriginal children living in urbanareas. There is almost no data regarding the prevalenceof immunization preventable childhood diseases,immunization rates, obesity, diabetes, cancer, and mostmental health indices. Progress continues to be madein the collection of survey data. For example, the FirstNations Regional Longitudinal Health Survey 08–09is collecting immunization data. However, surveydata is a complement to, not a replacement of, vitalregistration and health care utilization data.Health care access data is limited to medicaland dental health care professionals, little is knownabout accessing specialists for eye sight and hearing,particularly important given the high rates ofvision and hearing impairment. In addition, littleinformation exists on accessing mental healthprofessionals, including clinical psychologists,psychiatrists, and social workers. Furthermore, noinformation exists on the quality of interactions withhealth care professionals, and experiences with thehealthcare system.Other challenges include existing data sets thatfocus on disease and illness outcomes rather thanpreventative and wellness measures; a paucity ofculturally relevant Indigenous specific measures; andthe need for validation of many existing measures andscales (such as self-rated health and developmental/psychological indices) in Aboriginal cultural contexts.Again, the First Nations Regional LongitudinalHealth Survey is exemplary and unique in it focus onpreventative and wellness measure and application of acultural framework.Canada’s child health measurement gaps areparticularly evident when Canada’s Aboriginal childhealth surveillance is compared to the systems inAustralia, New Zealand and the United States. All threeof these countries have superior systems, particularlywith respect to core measures such as mortality andhealth care utilization. These deficiencies in Canada’sAboriginal child health assessment system representa missed opportunity to address the health statusinequities experienced by Aboriginal children inCanada, compared to the rest of Canadian children.Over the past several years the First Nations RegionalLongitudinal Health Survey has been the onlycomprehensive source of First Nations on-reservechildren’s health survey data. Recent federal initiativesto improve the availability of Aboriginal children’shealth information include the initiation of theAboriginal Children’s Survey, which released its firstdataset in December 2008.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 43

V. FiguresChildren

25%Children

70%60%56%61%63%60%50%40%30%20%10%Figure 24Sustained Breastfeeding(at 4 months)Source: ACS 20060%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)InuitMétisFigure 25Sustained Breastfeeding(at 6 months)Source: ACS 2006, RHS 2002/3,NLSCY 2000/160%50%Children

Children 6-14yrs old (ACS 2006)Children

50%45%42%42%40%33%30%20%10%Figure 28Any Chronic Disease forChildren (aged 6 to 14)Source: ACS 20060%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)Note: The ACS asked about one more severe chronic conditions diagnosed by a health professional.InuitMétisFigure 29Overweight & Obesity40%First Nations children

20%Children

3.5%Children 6-14yrs old (ACS 2006)Children

8%Children 6-14yrs old (ACS 2006)Children

80%Children

35%30%Preschool Children (RHS 2002/3) Children

100%Seen family doctor, general practitioner, or pediatrician80%83%Unable to obtain health care or mediation81%88%80%60%53%40%20%12%8%8%7%Figure 39Access to Medical Care forChildren Under 6 years oldSource: ACS 2006, NLSCY 2006/70%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)InuitMétisCanadian population(NLSCY 2006/7)Figure 40Perceptions ofHealth Care Facilities60%Excellent or Very GoodGoodFair or PoorSource: ACS 200650%45%47%45%48%40%30%32%30%32%20%20%19%20%10%0%First Nationswith status or treaty(off-reserve)First Nationswithout status or treaty(off-reserve)InuitMétisNote: The ACS Métis section is pending, thus there is missing data.54 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

70%Seen family doctor, general practitioner, or pediatricianSeen traditional Aboriginal healer60%55%59%54%50%40%35%30%20%10%0%8%First Nationswith status or treaty(off-reserve)4%First Nationswithout status or treaty(off-reserve)Note: Statistics for traditional Aboriginal healer for Inuit is flagged (should be interpreted with caution).Inuit1%Métis2%Figure 41Access to Medical Care forChildren 6 to 14 years old(ACS 2006)Source: ACS 2006Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 55

2.8 Best Practice and PromisingPractice ExamplesI. The First Nations Regional LongitudinalHealth SurveyThe First Nations Regional Longitudinal Health Surveyis the only First Nations governed national healthsurvey in Canada. 66 It is also the only national surveydata for the First Nation on-reserve populations.The report of the First Nations RegionalLongitudinal Health Survey (RHS) 2002/2003 wasreleased in Fall 2005 and contains information fromover 30 topic areas, including demographics, language,housing, health status, culture, and communitydevelopment. It builds on the 1997 First Nations andInuit Regional Health Survey, which included fiveLabrador Inuit communities and 181 First Nationscommunities. The RHS 2002/3 collected 22,602 surveysfrom 238 First Nations communities across the country.Data collection is currently underway for RHS Phase 2(2008/2009).The purpose of the RHS is to obtain longitudinal,comparable data that is centered around FirstNations conceptualizations of health, is controlled byFirst Nations, reflects the priorities of First Nationscommunities, and respects the principles of OCAP (theright of Indigenous people to Own, Control, Accessand Possess Indigenous health information). TheRHS collects information based on both Western andtraditional understandings of health and wellbeing. TheRHS survey fills a gap left by large national populationbased surveys which exclude sampling from reserves.Furthermore, in contrast to the RHS, the majorityof national population based surveys do not providerespondents an opportunity to self-identify theirAboriginal ethnicity, thereby failing to generate anyIndigenous-specific health information.In addition to its progressive First Nationscontrolled governance structure, and its broad scopeof both Western and traditional health measures, theRHS is an excellent example of health measurementwith respect to community engagement and capacitybuilding. See the RHS website for more info:http://www.rhs-ers.ca/english/II. Inuit Health Survey‘Qanuippitali?’ represents the first comprehensive examinationof the health of Inuit residing in Nunavut, theInuvialuit settlement region, and Nuntsiavut. ThisInuit Health Survey is based on a collaboration ofpartners from the north and the south, including56 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

academic researchers, communities and healthdepartments. The survey has been developed througha participatory partnership and is co-owned, with theultimate plan for the survey to be owned in the longtermby Inuit and community representatives. Themission is to improve health care planning, personalhealth, and community wellness for Inuit. The projectis funded by the Government of Canada, FederalProgram for International Polar Year, CanadianInstitutes of Health Research, Health Canada, Indianand Northern Affairs, the Government of Nunavutand ArcticNet.The Inuit Health Survey for children ages three tofive relies on interviews, questionnaires, and a clinicalappointment with health care professionals. Children andtheir caregivers will be seen in their home communities.The child health survey data collection started in 2007and concluded in fall 2008 (after 15 months of datacollection). Health data will be collected on:• Nutritional health: levels of vitamin D and iron;exposure to mercury and bacteria (H. pylon whichcauses iron deficiency); traditional food use andgeneral eating habits (including early infant feeding)• Healthy growth and bones: heel ultrasound for bonedensity, height, weight, vitamin and supplements,medication usage• Vision testing• Medical HistoryIn total, approximately 12% of Inuit fromcommunities in the three regions will be randomlyselected to participate. Following data collection, allchild participants will receive their personal results inthe mail. Communities will receive information on thehealth of their residents, as well as the areas of focus forhealth promotion.III. Infant Mortality Working GroupThe Canadian Perinatal Surveillance System, HealthInformation Analysis Division – First Nations andInuit Health Branch, Inuit Tapiriit Kanatami, andMétis National Council Joint Working Group onFirst Nations, Inuit, and Métis Infant Mortality Data(also known as the Joint Working Group on InfantMortality) was formed in 2005 in response to problemsin the accuracy of publically released First Nationsinfant mortality data, as well as major deficits inthe coverage and quality of infant mortality data forAboriginal populations in Canada. Infant mortalityrates are only available for subgroups of the FirstNations and Inuit population in Canada. No rates areavailable for Métis. The infant mortality data that isavailable is often of substandard quality. For example,problems with the accuracy of several publicly releasedinfant mortality rates for First Nations populationshave been identified by members of our group. Thesedeficits of coverage and quality interfere with the effortsof public health workers to identify and respond toconditions leading to infant death and are unacceptablein a developed country such as Canada. As a workinggroup, the primary goal is to improve the accuracy,reliability, coverage, and appropriateness of FirstNations, Inuit, and Métis infant mortality data.The Joint Working Group approach is premised onthe understanding that improvement to First Nations,Inuit, and Métis infant mortality data can only bedone through partnerships with First Nations, Inuitand Métis governing and representative organizations.Members include representatives from nationalAboriginal governance groups, including the Congressof Aboriginal Peoples, Inuit Tapiriit Kanatami, MétisNational Council, and the Native Women’s Associationof Canada, as well as representatives from the CanadianPerinatal Surveillance System - Public Health Agencyof Canada, First Nations and Inuit Health Branch– Health Canada, Statistics Canada, and the VitalStatistics Council of Canada. The Joint WorkingGroup also maintains regular communication with theAssembly of First Nations.This initiative has a multi-pronged approach to theimprovement of First Nations, Inuit, and Métis infantmortality data. This includes: supporting the liaisonbetween provincial and territorial vital registrars andFirst Nations, Inuit, and Métis stakeholders groupsin their region, to develop joint data governance andmanagement agreements, if these do not already exist;support for the First Nations client registry pilots;and discussion of an improved and formulationof a standardized question regarding Aboriginalethnicity that would accurately identify First Nations,Inuit, and Métis infants and their parents on vitalregistration forms.Key achievements to data include: annualpresentations to the provincial and territorial vitalregistrars; a review of First Nations, Inuit, and Métisinfant mortality data practices in all provinces andterritories; agreement on a draft Aboriginal ethnicityquestion that could be used by provincial/territorialregistrars on the birth registration; funding of tworegional pilot projects to support regional planning,consultation, and liaison process and to improveregional First Nations, Inuit and/or Métis infantmortality rates; briefings regarding IMR data toregional and national level First Nations, Inuit, andMétis stakeholders; and the preparation of a nationalstatement on First Nations, Inuit, and Métis InfantMortality Rates.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 57

IV. Kahnawake School DiabetesPrevention Project (KSDPP)Kahnawake is a Mohawk territory near Montreal,Quebec, with a population of 7000. In the 1980s,physicians documented high rates of Type 2 diabetesand the community responded by requesting help toprevent future generations from developing diabetes.The community took action in partnership withacademic researchers and developed a preventionprogram focused on elementary school children,their families, and the community. KSDPP began in1994 and continues to date. The goal is to decreasethe onset of Type 2 diabetes in Kahnawake, throughthe promotion of health eating, physical activity and apositive attitude.Most recently, community workers weredisheartened to see that obesity rates were elevatedin children starting nursery school and kindergarten.Discussions at the Community Advisory Boardmeetings lead to focus activities geared towardsyoung mothers. This resulted in the refinement of ayearly calendar of eating habits according to the foodson a seasonal level and cooking workshops whichfocus on young mothers making meals for the family,as well as foods which can be put into a blender tobe made into baby food, put in ice cube trays, andfrozen for future use. Parents are also provided withinformation about how the intestines function tobreak down the foods.KSDPP has developed a traditional approach tocombating diabetes through programs such as ‘HealthyMind in a Healthy Body’ workshops which link therelationship between Mind, Body and Spirit andHaudenosaunee Foods Cooking Workshops geared toteach young mothers how to cook economical healthymeals using native cultural and seasonal foods toenhance cultural pride.V. First Nations Health Plan, British ColumbiaIn 2007, a Tripartite First Nations Health Plan wassigned by the First Nations Leadership Council(representing the BC Assembly of First Nations), theFirst Nations Summit and the Union of BC IndianChiefs; and the Government of Canada; and theGovernment of British Columbia. The goals of theFirst Nations Health Plan is to improve the health andwell-being of First Nations in British Columbia, closethe gaps in health between First Nations people andother British Columbians, and ensure First Nations arefully involved in decision-making regarding the healthof their peoples. In this 10-year trilateral agreement,all three parties have committed to action in fourpriority areas:• Governance, relationships and accountability• Health promotion and disease and injury prevention• Health services• Performance trackingA new First Nations Health Council was establishedto provide leadership in the implementation of the FirstNations Health Plan.In the area of performance tracking the partiesagreed to work together to develop the data andinformation necessary to improve health services,and to monitor and report on health status and healthcare information for First Nations in B.C. Specifically,the parties committed to tracking progress for thefollowing indicators: life expectancy at birth; mortalityrates (deaths due to all causes); infant mortality rates;diabetes rates; status Indian youth suicide rates;childhood obesity; and practising, certified First Nationhealth care professionals. A Tripartitie Data Qualityand Sharing Agreement between the Governmentof British Columbia, Health Canada’s First Nationsand Inuit Health Branch and the First Nations HealthCouncil is being developed and will facilitate datalinkages and define how federally and provincially heldinformation on First Nations is to be used and shared.Through this agreement, OCAP principals will governthe collection, analysis and sharing of BC First Nationshealth information.VI. First Nations EpiCentre of AlbertaThe name ‘EpiCentre’ comes from the EpidemiologyCenters established by the US Indian Health Servicesin 1996. These US Tribal Epicentres are described inthe US chapter of this report. The recently establishedFirst Nations EpiCentre of Alberta is the first suchorganization in Canada. The EpiCentre brings togetherspecialists in public health, epidemiology and otherdisciplines to develop the intelligence needed toimprove public health programs for First Nations inAlberta and beyond. The EpiCentre was establishedin partnership with First Nations communities andfederal/provincial governments in Alberta. Themission of the First Nations EpiCentre of Alberta is toimprove the quality and use of information requiredto take action on health, health programs and healthdeterminants while respecting the Treaty rights tohealth and the cultural diversity of First Nations.Core business of the EpiCentre includes:• improving the quality of information available tocommunities• developing the capacity of communities to collect,manage, and use health data• fostering strategic health information partnershipsand policies to support public health programs58 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

First Nations, Inuit and Métis childrenface striking disparities in the socialdeterminants of health, including familyincome, parental employment, parentaleducation, food security, and housing,compared to non-Aboriginal children.The EpiCentre has programs in environmentalhealth, diabetes, prescription drugs, communityhealth, planning, and homecare. Staff includes fourepidemiologists, a medical geographer, a healtheconomist, a pharmacist, a statistician, and a dataanalyst. More information can be found on theEpicentre’s website:http://www.fnepicentre.org/2.9 ConclusionThe human right to health is internationallyrecognized. For example, Article 12.1 of the UnitedNations’ International Covenant on Economic, Socialand Cultural Rights identifies the ‘the right of everyoneto the enjoyment of the highest attainable standardof physical and mental health’. 67 The next article ofthe covenant highlights the importance of child andreproductive health, with a provision ‘for the reductionof the stillbirth rate and of infant mortality and forthe healthy development of the child’ (art. 12.2 -a). 67Despite international agreement that substandardhealth is unacceptable, First Nations, Inuit, and Métischildren in Canada continue to experience inequitiesin health status and health determinants comparedto non-Aboriginal Canadians. The persistence ofthese inequities and substandard health outcomes isparticularly bothersome in Canada, one of the world’srichest nations.First Nations, Inuit and Métis children face strikingdisparities in the social determinants of health,including family income, parental employment,parental education, food security, and housing,compared to non-Aboriginal children. For example, theCanadian Community Health Survey revealed rates ofsevere food insecurity that were over five times higherfor Aboriginal households compared to non-Aboriginalhouseholds and the Aboriginal Peoples Survey 2006revealed that 30% of Inuit children experience hungeras a result of their family having run out of foodor money to buy food. The First Nations RegionalLongitudinal Health Survey reveals that only 68% ofFirst Nations participants living on-reserve consideredtheir water safe to drink.Underlying these classic health determinants is theexperience of colonization, which disrupted familynetworks, dislocated communities from traditionallands, and interfered with the intergenerationaltransmission of knowledge and culture. Colonialprocesses continue to have direct and indirect impactson the health of First Nations, Inuit, and Métis childrenand their families. The reversal of colonial policiesand the restitution of the rights of Indigenous peoples,including the implementation of the standards in theUN declaration on the Rights of Indigenous Peoples, isa necessary prerequisite to fundamental improvementsin the health determinants and health status ofAboriginal children.Despite the knowledge that Aboriginal children inCanada are at risk of adverse health outcomes, giventhese disparities in social determinants of health,there are large gaps in available health information.When it comes to health surveillance in Canada,many First Nations, Inuit, and Métis children remaininvisible or uncounted. For example, currently thereis no information regarding the infant mortality ofMétis in Canada, despite the fact that Métis accountfor approximately one third of Canada’s Aboriginalpopulation. There is are similar gaps in information forFirst Nations children without status and Aboriginalchildren living in urban areas. One of the major healthinformation challenges is the lack of standardizedFirst Nations, Inuit, and Métis identifiers in vitalregistration, surveillance, and health care utilizationdatabases. Another major challenge is the lack ofHealth of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 59

The long term goal with respect toAboriginal children’s health assessmentand health performance measurementinformation is clearly better evidencefor decision making, resulting in betterhealth outcomes and a reductionin health disparitiesintegration of First Nations, Inuit, and Métis healthinformation with health care programs and services.In the end, this review was able to identify quite abit of health determinant and health status data forAboriginal children living in Canada, however, verylittle of this data was already linked to the ongoingevaluation the health services and programs that areserving Aboriginal children.This is not the first time that an Indigenous grouphas faced a challenge in exercising the ‘right to becounted’. It wasn’t until 1967 that Aboriginal Australianswere recognized as having the right to be counted inthe national census and 40% of infants born worldwidestill do not have reliable access to birth registration. 68,69Being recognized in a census and/or through birthregistration are essential steps in ensuring that otherhuman rights, including the right to health are achieved.Public health programs designed to safeguard the healthof children are founded on health information systemsthat count or survey health determinants and outcomesdrawing on the census, birth and death registrations,health care utilization records, disease reporting,and health surveys. As stated earlier, these shortfallsin Aboriginal child health assessment and healthsystem performance measurement represent a missedopportunity to address the health status inequitiesexperienced by Aboriginal children in Canada,compared to the rest of Canadian children.The best practice examples at the end of thischapter demonstrate the way forward with respectto the enhancement of Aboriginal children’s healthinformation systems in Canada. Notably, all sixexamples are founded on partnerships betweenAboriginal stakeholders and health workers with abackground in public health assessment. These modelsallow for a balance between the desires of First Nations,Inuit, and Métis health stakeholders to play a rolein the governance and management of their healthinformation and the pressing need to better healthinformation to address and prevent unnecessary childillness and death.At a policy level, the long term goal with respectto Aboriginal children’s health assessment and healthperformance measurement information is clearlybetter evidence for decision making, resulting in betterhealth outcomes and a reduction in health disparities.The current gaps in health information, whileundesirable, do not provide an excuse for inaction.This chapter has clearly detailed pressing inequities inhealth determinants and health status outcomes forFirst Nations, Inuit, and Métis children compared tonon-Aboriginal children in Canada. These disparitiesare not new and are not just. Over a decade ago, theRoyal Commission on Aboriginal Peoples (RCAP)examined the health of Aboriginal people, includinginfant, child and maternal health. While some gainswere identified, clear disadvantages persisted. Inaddition, the roots of the disproportionate burdenof ill health were linked ‘outside the boundaries ofordinary medicine’ to ‘social, emotional and economicconditions that in turn lead back to the complex,destabilizing and demoralizing legacy of colonialism’.Recommendations of the RCAP were aimed ataddressing these underlying causes of health statusdisparities and included: a significant restructuringof relationships between the federal government andAboriginal nations; a substantial federal investmentin Aboriginal institutions and communities; and aredistribution of lands. Unfortunately, to date very fewof these (and other RCAP) recommendations havebeen implemented. There appears to be an ongoingdisconnect between the undeniable evidence regardingthe unacceptable disparities in Aboriginal children’shealth in Canada and the implementation of federalpolicies that would rectify these disparities. It is ourhope that the information in this chapter can be usedas an advocacy tool and resource for those working tobridge this disconnect.60 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

2.10 Additional TablesCensus dataData produced when participants identify themselves as First Nations (registered and nonregistered),Métis or Inuit• Nonparticipation is common• On many reserves, enumeration is incomplete• Mobility and overrepresentation of homeless people contributes to undercounting of Aboriginal groups• The ethnicity question appears on only about 20% of forms• Aboriginal people may choose not to self-identify to government employees• Ethnic mobility contributes to inaccuracy of dataVital registration dataINAC’s Indian Register: First Nations–specific rates generated from cross-linkage of data from four provinces• Lack of prospectively collected data on ethnicity by voluntary self-identification excludes generationof rates for nonregistered First Nations, Métis and Inuit peopleQuestions about Aboriginal ethnicity on the registration forms of some provinces and territories• Privacy concerns about transfer of the INAC registry• Lack of standardization of ethnicity questions on formsData from health surveysNational health surveys (none to very limited)• Most national surveys done by Statistics Canada exclude sampling from reserves, don’t ask aboutAboriginal ethnicity, or use a sample too small to generate anything other than national pan-Aboriginal dataAboriginal Peoples Survey: nonregistered First Nations, Métis and Inuit people• Sampling frames are derived from the census data from self-identified Aboriginal people, socoverage issues are the same as for the census• Done only every 10 yearsFirst Nations Regional Longitudinal Health Survey: First Nationspeople living on-reserve• Comprehensive coverage of First Nations reserve communities in most regions of the country• In some regions not all First Nations reserve communities participate• Questions reflect health issues and measures that are important to participant First Nationscommunities• Content is not entirely comparable to other national surveysHealth services utilization dataCompiled by Canadian Institute of Health Information (CIHI)*• Compiled by geographic region: no ethnic-specific data• In some regions where the proportion of Aboriginal people is very high (e.g., NorthernSaskatchewan and Nunavut), geography can serve as proxy measureData from surveillance systems• Registered First Nations people only, by data linkage in National Diabetes Surveillance System andsome surveillance systems for notifiable diseases• Lack of standardized, inclusive means to permit self identification of Aboriginal ethnicityNote: INAC = Indian and Northern Affairs Canada.*Reports have been published in which provincial health systems linked their databases with the IndianRegister or Band Membership lists to generate health-service utilization data specific to Aboriginal people.Text Box 1Concern with statisticalsources for First Nation,Inuit and Métis healthadapted from Smylie &Anderson, 2006Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 61

Table 1 Major Statistical Sources for First Nations, Inuit & Métis Children's HealthSource Population Comments Access/LocationFirst Nations Longitudinal RegionalHealth Survey 2002/3 (RHS)First Nations children (0-11 years) living onreserve in CanadaNot all First Nations reserves participated http://www.rhs-ers.ca/english/Canadian Census 2006 Children aged 0 to 14 years See Table 3 for concerns http://www12.statcan.ca/english/census06/analysis/aboriginal/index.cfmAboriginal Children’s Survey, 2006 Children aged 0 to 14 yearsIncludes Inuit, Métis, and off-reserve FirstNations living in urban, rural and northernlocations in CanadaIncludes only those respondents whocompleted 2006 census and indicated someform of First Nations, Inuit or Métis identityhttp://www.statcan.gc.ca/aboriginal/acs/5801793-eng.htmAboriginal Peoples Survey, 2006 Includes Inuit, Métis and off-reserve FirstNations living in urban, rural and northernlocations in CanadaIncludes only those respondents whocompleted 2006 census and indicated someform of First Nations, Inuit or Métis identityhttp://www.statcan.gc.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=3250&lang=en&db=imdb&adm=8&dis=2Maternal Experiences Survey Census based sampling frame, 6000 +total respondents411 self-identified First Nations, Inuit,and Métis mothersReserves excludedFirst Canadian survey devoted topregnancy, labour, birth and postpartumAboriginal report pendinghttp://www.statcan.gc.ca/cgi-bin/imdb/p2SV.pl?Function=getSurvey&SDDS=5019&lang=en&db=imdb&adm=8&dis=2First Nations ComparableHealth IndicatorsFirst Nations with statusSome figures are for First Nationson-reserve onlyUses a variety of data sourcesTechnical issues with vital registration rates,as coverage (on/off-reserve) and source ofdata (death certificate vs. nursing stationreport) is not consistent across provincesand territorieshttp://www.hc-sc.gc.ca/fnih-spni/pubs/gen/stats_profil_e.htmlInuit Health Survey Inuit children age 3-5 years living inNunavut, the Inuvialuit Settlement Regionand Nunatsiavut.Data collection 2007-2008.No results at time of publication. http://www.inuithealthsurvey.ca/?nav=childrensProvincial/territorial ministries of healthFour western provinces produce vitalregistration and some health care utilizationdata for First Nations persons with statusand/or living on reserve, using birthregistration identifier, linkage to INACregistration lists, and/or on-reserve postalcodesQuebec has a ‘mother tongue’ birthregistration identifierNunavut vital registration, utilization,and surveillance data includes very smallproportion of non-InuitInconsistencies in ethnic identifiers andrate calculation methods result in data ofvariable quality for western provinces.Métis and Inuit specific rates are notavailable. Comprehensiveness of datarelease varies.Mother tongue identifier in Quebecsensitive and specific for Inuit but much lesssensitive for other Aboriginal groups.Capacity issues in Nunavut prohibit regularand comprehensive health data release.http://www.health.gov.bc.ca/aboriginal/pho.htmlhttp://www.fnepicentre.org/http://www.gov.nu.ca/health/hir.shtmlNunavut Report on Comparable HealthIndicators 2004http://www.gov.nu.ca/health/PIRCenglishlow.pdf62 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

2.11 References1. First Nations Information Governance Committee. First NationsRegional Longitudinal Health Survey (RHS) 2002/03: Results forAdults, Youth and Children Living in First Nations Communities,Second Edition. Ottawa: Assembly of First Nations; 2007.Availableat: http://www.rhs-ers.ca/english/pdf/rhs2002-03reports/rhs2002-03-technicalreport-afn.pdf. Accessed February 28th, 2009.2. Statistics Canada. Aboriginal Peoples in Canada in 2006: Inuit, Métis,and First Nations, 2006 Census. Ottawa: Ministry of Industry; 2008.Catalogue number 7-558-XIE.3. Statistics Canada. Labour, 2006 Census. Ottawa: Ministry ofIndustry; 2008. Catalogue Number 97-559 XIE4. Statistics Canada. Income and Earnings, 2006 Census. Ottawa:Ministry of Industry; 2008. Catalogue Number 97-563 XIE5. First Nations and Northern Statistics Section Strategic Researchand Analysis Directorate Research, International and GenderEquality Branch Department of Indian Affairs and NorthernDevelopment. 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St. Regis, Quebec: First Nations and Inuit RegionalHealth Survey Steering Committee; 1999.19. Royal Commission on Aboriginal Peoples. Report of the RoyalCommission on Aboriginal Peoples. Ottawa: Indian and NorthernAffairs Canada; 1996.20. Wieman CA. Return to Native Roots: Aboriginal Health BuildingInformed Partnerships. Paper presented at: The Society ofObstetricians and Gynaecologists of Canada 55th Annual ClinicalMeeting; June 25-29, Montreal, QC; 1999.21. United Nations General Assembly. United Nations Declaration onthe Rights of Indigenous Peoples. Geneva: United Nations. Availableat: http://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf. Accessed September 9, 2008.22. Health Canada. Canadian Community Health Survey Cycle 2.2(2004). Nutrition: Income-Related Household Food Security inCanada. Ottawa: Office of Nutrition Policy and Promotion; 2007.Catalogue Number. H164-42/2007E.23. Power E. Food security for First Nations and Inuit in Canada-Background Paper. 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24. Northern Food Security, Strategic Policy and Devolution Branch,Indian and Northern Affairs Canada. The Revised Northern FoodBasket. Ottawa: Ministry of Public Works and Government ServicesCanada; 2007. Available at: http://www.ainc-inac.gc.ca/nth/fon/fc/pubs/nfb/nfb-eng.pdf. Accessed March 1, 200925. Statistics Canada. National Longitudinal Survey of Children andYouth (NLSCY) cycle 7, 2006-2007. Ottawa: Statistics Canada; 2009.26. Underhill C, McKeown L. Getting a Second Opinion: HealthInformation and the Internet. Ottawa: Statistics Canada; 2008.Available at: http://www.statcan.gc.ca/pub/82-003-x/2008001/article/10515-eng.pdf. Accessed February 15, 2009.27. Statistics Canada. National Longitudinal Survey of Children andYouth (NLSCY) cycle 4 , 2000-2001. Ottawa: Statistics Canada;2003.28. Kawachi L, Kennedy B, Glass R. Social capital and self-rated health:A contextual analysis. American Journal of Public Health. 1999; 89:1187-1193.29. Smylie J, Fell D, Pennock J, and the Joint Working Group onFirst Nations, Inuit, and MétisInfant Mortality. Statement on FirstNations, Inuit, and Métis infant mortality rates in Canada. Underreview.30. Health and Welfare Canada, Indian and Northern Health Services,Medical Services Branch. Health Status of Canadian Indians andInuit, update 1987. Ottawa: Health and Welfare Canada; 1988.31. Luo ZC, Kierans WJ, Wilkins R, Liston RM, Uh S, Kramer M. Infantmortality among First Nations versus non-First Nations in BritishColumbia: Temporal trends in rural versus urban areas, 1981–2000.International Journal of Epidemiology. 2004; 33(6):1252–59.32. Zhong-Cheng Luo and Manitoba Assembly of First Nations.Community Report: Community Characteristics and Birth Outcomesamong First Nations and non-First Nations in Manitoba, 1991–2000.Available by contacting the author or Manitoba Assembly of FirstNations.33. Heaman MI, Blanchard JF, Gupton AL, Moffatt MK, Currie RF.Original articles: Risk factors for spontaneous preterm birthamong Aboriginal and non-Aboriginal women in Manitoba.Paediatric and Perinatal Epidemiology. 2005; 19(3): 181–193.34. Luo ZC, Heaman M, Wilkins R, Smylie J, Martens P, Fraser WD,for the CIHR Community and Aboriginal Birth Outcomes studygroup. Community Report: Community characteristics and birthoutcomes among First Nations and non-First Nations in Manitoba,1991-2000. Released 2007. Available by contacting the firstauthor or Assembly of Manitoba Chiefs – Health Information andResearch Governance Committee.35. Luo ZC, Wilkins R, Platt R, Kramer S. Risk of adverse pregnancyoutcomes among Inuit and North American Indian women inQuebec, 1985–97. Paediatric & Perinatal Epidemiology. 2004; 18(1):40–50.36. Tait CL. (2003). Fetal Alcohol Syndrome among Aboriginal peoplein Canada: Review and analysis of the intergenerational links toresidential schools. Ottawa: Aboriginal Health Foundation; 2003.37. Burd L, Moffat ME. Epidemiology of fetal alcohol syndrome inAmerican Indians, Alaska Natives, and Canadian AboriginalPeoples: A review of the literature. Pub Health Rep. 1994; 109(5):688-693.38. Health Canada. Fetal Alcohol Syndrome/Fetal Alcohol Effects –First Nations, Inuit and Aboriginal Health. Health Canada websitehttp://www.hc-sc.gc.ca/fniah-spnia/famil/preg-gros/intro-eng.php. Accessed February 10, 2009.39. Cox LV, Dickenson M. The prevalence of Fetal Alcohol SpectrumDisorder in a Maritime First Nation Community. Int JFAS. (In press).40. Willows ND, Morel J, Gray-Donal K (2000). Prevalence of anemiaamong James Bay Cree infants of northern Quebec. CMAJ. 2000;162(3): 323–6.41. Kovesi T, N Gilbert, C Stocco, D Fugler, R Dales, M Guay, JD Miller.Indoor air quality and the risk of lower respiratory tract infectionsin young Canadian Inuit children. Canadian Medical AssociationJournal 2007; 177 (2).42. Yip D, Bhargava R, Yao Y, Sutherland K, Manfreda J, Long R.Pediatric tuberculosis in Alberta: epidemiology and casecharacteristics (1990–2004). Canadian journal of public health.2007; 98(4): 276–80.43. Clark M, Riben P, Nowgesic, E. The association of housing density,isolation and tuberculosis in Canadian First Nations communities.Int J Epidemiol. 2002; 31:940–43.44. Health Canada. Tuberculosis-First Nations, Inuit and AboriginalHealth. Health Canada website http://www.hc-sc.gc.ca/fniahspnia/diseases-maladies/tuberculos/index-eng.php.AccessedFebruary 10, 2009.45. Jin A, Martin D. Hepatitis A among residents of First NationsReserves in British Columbia, 1991-1996. Canadian journal of publichealth. 2003; 94(3):176-9.46. Kue Young T, Reading J, Elias B, O’Neil J. Type 2 diabetes mellitusin Canada's First Nations: status of an epidemic in progress. CMAJ.2000; 163 (5):561-6.64 Health of Indigenous Children: Health Assessment in Action Health of First Nations, Inuit, and Métis Children in Canada

47. Dean HJ, Mundy RL, Moffatt M. Non-insulin-dependent diabetesmellitus in Indian children in Manitoba. CMAJ. 1992;147(1):52-7.48. Harris SB, Perkins BA, Whalen-Brough E. Non-insulin-dependentdiabetes mellitus among First Nations children. A new entityamong First Nations people of north western Ontario. Can FamPhysician. 1996; 42:869-76.49. Dean HJ. NIDDM-Y in First Nations children in Canada. Clin Pediat.r1998; 37: 898-96.50. Harrop AR, Brant RF, Ghali WA, Macarthur C. Injury mortality ratesin Native and non-Native children: A population-based study.Public Health Reports. 2007; 22: 339-346.51. Wilkins R, Uppal S, Finès P, Senécal S, Guimond E, Dion R. Lifeexpectancy in the Inuit-inhabited areas of Canada, 1989 to 2003.Ottawa: Statistics Canada. Available at http://www.statcan.ca/english/freepub/82-003-XIE/2008001/article/10463-en.htmAccessed June 18, 2008.52. Government of Nunavut. Nunavut Report on Comparable HealthIndicators. Nunavt: Government of Nunavut-Department of Healthand Social Services; 2004.53. Muggah E, Way D, Muirhead M, Baskerville B. Preterm deliveryamong Inuit women in the Baffin Region of the Canadian Arctic.Circumpolar Health. 2003; 63(Suppl 2): 242-247.54. Public Health Agency of Canada. Canadian Perinatal Health Report2008 Edition. Ottawa: Public Health Agency of Canada; 2008.55. Dallaire F, Dewailly E, Muckle G, Vezina C, Jacobson SW, JacobsonJL, Ayotte P. Acute Infections and Environmental Exposure toOrganochlorines in Inuit Infants from Nunavik. Environ. HealthPerspect. 2004; 112(14): 1359-1364.56. Dallaire F, Dewailly E, Vezina C, Bruneau S, Ayotte P. Portrait ofoutpatient visits and hospitalizations for acute infections inNunavik preschool children. Canadian Journal of Public Health.2006; 97(5): 362-8.57. Banerji A, Bell A, Mills EL, et al. Lower respiratory tract infections inInuit infants on Baffin Island. CMAJ 2001; 164:1847-50.58. Nguyen D, Proulx JF, Westley J, Thibert L, Dery S, Behr MA.Tuberculosis in the Inuit community of Quebec, Canada. AmericanJournal of Respiratory and Critical Care Medicine. 2003; 168(11):1353-1357.59. Public Health Agency of Canada. Tuberculosis in Canada-2002.Ottawa: Public Health Agency of Canada. Cat. H39-1/6-2002E.60. Charbonneau-Roberts G, Saudny-Unterberger H, Kuhnlein HV,Egeland GM. Body mass index may overestimate the prevalence ofoverweight and obesity among the Inuit. International Journal ofCircumpolar Health. 2005; 64(2):163-9.61. Van Oostdam J, Donaldson SG, Feeley M, Arnold D, Ayotte P, BondyG, Chan L, Dewaily E, Furgal CM, Kuhnlein H, Loring E, MuckleG, Myles E, Receveur O, Tracy B, Gill U, Kalhok S. Human healthimplications of environmental contaminants in Arctic Canada: Areview. The Science of the total environment 2005; 351-352:165-246.62. Levesque B, Duchesne JF, Gariepy C, Rhainds M, Dumas P,Scheuhammer AM, Proulx JF, Dery S, Muckle G, Dallaire F, DewaillyE. Monitoring of umbilical cord blood lead levels and sourcesassessment among the Inuit. Occupational and environmentalmedicine 2003; 60(9):693-5.63. Dewailly, E., Nantel, A, Weber J-P, Meyer, F. High levels of PCBsin breast milk of Inuit women from Arctic. Bull. Environ. Contam,Toxicol. 1989; 43: 641-646.64. Dewailly E, Nantel A., Bruneau S., Laliberte C, Ferron L, & GingrasS. Breast milk contamination by PCDDs, PCDFs, and PCBs in ArcticQuebec: A preliminary assessment. Chemosphere. 1992; 25(7-10):1245-1279.65. Kovesi T, Creery D, Gilbert NL, Dales R, Fugler D, Thompson B,Randhawa N, Miller JD. Indoor air quality risk factors for severelower respiratory tract infections in Inuit infants in Baffin Region,Nunavut: a pilot study. Indoor Air. 2006; 16(4): 266-75.66. First Nations Information Governance Committee. RHS backgroundand governance. First Nations Regional Longitudinal Health Surveywebsite http://rhs-ers.ca/english/background-governance.asp..Accessed Oct 1, 2008.67. United Nations Economic and Social Council. The right to thehighest attainable standard of health.11/08/2000. (GeneralComments). United Nations Human Rights-Treaty Databasewebsite http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En. Accessed November 15, 2008.68. Screen Australia Digital Learning. Indigenous Rights- Repatriation-Indigenous Studies, History. Screen Australia website http://dl.screenaustralia.gov.au/module/1354/. Accessed on Oct 1, 2008.69. Todres J. Birth Registration: An Essential First Step toward Ensuringthe Rights of All Children. Human Rights Brief. 2003; 10(3): 32-35.70. Royal Commission on Aboriginal Peoples. People to People, nationto nation: Highlights from the Report of the Royal Commissionon Aboriginal Peoples. Ottawa: Ministry of Supply and ServicesCanada; 1996.Health of First Nations, Inuit, and Métis Children in Canada Health of Indigenous Children: Health Assessment in Action 65

366 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Health of Aboriginal and Torres Strait Islander Children in Australia“Ampe Akelyernemane Meke Mekarle – Little Children are Sacred – In our Law children are very sacred because they carry thetwo spring wells of water from our country within them” (traditional Aboriginal law of the Yolngu people of Arnhem Land inthe Northern Territory). 1‘Compared with their non-Aboriginal and Torres Strait Islander Australian counterparts, Aboriginal andTorres Strait Islander children are:• more likely to be stillborn, to be born pre-term, to have low birth weight, or to die in the first monthof life;• 2 to 3 times more likely to die in the first twelve months of life, and 11 times more likely to die fromrespiratory causes;• at a much higher risk of suffering from infectious and parasitic diseases, diseases of the respiratoryand circulatory system, hearing loss, rheumatic fever, dental caries, injuries, and clinically significantemotional and behavioural difficulties;• nearly 30 times more likely to suffer from nutritional anaemia and malnutrition up to 4 years of age;• cared for by significantly fewer adults, who are also at higher risk of premature death, serious illness,substance abuse, imprisonment, major social and emotional stress, lower household income, lowereducational attainment, lower employment, and lower access to appropriate sanitary and householdconditions, than other Australian adults.’ Australian Medical Association Report Card, 2008Source: Australian MedicalAssociation 63.1 IntroductionThe United Nations International Children’sEmergency Fund (UNICEF), better known as theUnited Nations Children’s Fund, suggests that:the true measure of a nation’s standing is how well itattends to its children – their health and safety, theirmaterial security, their education and socialization, andtheir sense of being loved, valued, and included in thefamilies and societies into which they are born. 7Indeed, Aboriginal and Torres Strait Islanders viewhealth from a holistic perspective. They believe that:Aboriginal health is not just the physical wellbeing ofan individual but is the social, emotional and culturalwellbeing of the whole community in which eachindividual is able to achieve their full potential therebybringing the total well being of their community. It is awhole-of-life view and includes the cyclical concept of lifedeath-life.National Aboriginal Health Strategy WorkingParty 8 available: http://www.health.gov.au/oatsih/pubs/An analysis of national health information gives apowerful insight into the ongoing legacy of colonizationon the Indigenous people of Australia, New Zealand,Canada and the United States of America. While thesefirst-world nations boast first class health systems, thekey health indicators clearly show that the traditionalcustodians of the land do not share equally in thebenefits of these systems. There is a pressing socialjustice issue in the wide disparity in outcomes thatresults in Indigenous people suffering a far greaterhealth burden than non-Indigenous people. Of greatconcern is that despite widespread acknowledgmentof the gap and actions to address it, progress in itsreduction appears to be minimal for many indicators.Indigenous populations in Australia, New Zealand,Canada and the United States of America share manycommonalities of cultures that extend for thousandsof years: deeply held spiritual beliefs and practices;prolonged experiences of exploitation, prejudiceand discrimination; attempts at forced segregationfollowed by forced assimilation; large-scale neglectof human rights; inequalities in health status; andan increasing, if at times ignored, effort to achieveinternational recognition and protection for theirpeoples and cultures.It is a human right to be counted in populationstatistics and Indigenous people should not beinvisible in national health statistics. Currently, themeasurement of the health of Indigenous peopleAuthors:Dr. Jane Freemantle PhDAssociate ProfessorCentre for Health and SocietyMelbourne School ofPopulation HealthThe University of MelbournePrincipal Research FellowOnemda VicHealth KooriHealth UnitDaniel McAullay PhD(c)Senior Research OfficerPhD CandidateTelethon Institute forChild Health ResearchHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 67

Pictured:Hiarnz & Darheioworld-wide is complicated by deficiencies in the datadescribing Indigenous people. These deficienciesare in part due to inconsistencies in the collection,the sources, completeness, classifications, analysisinterpretation and ownership of the data in eachjurisdiction. This chapter, while providing an insightinto the state of the health of Aboriginal and TorresStrait Islander children, and at times linking theirhealth outcomes to the health outcomes of Indigenouschildren in other countries, does not attempt to directlycompare outcomes between the contributing countries 5 .3.2 The colonization of Australian andTorres Strait Islander peopleThe colonization of Australia by Great Britainbegan in 1788 with the arrival of the First Fleet.The original ‘protectorate’ system of the 19thand early 20th Century resulted in wide-spreaddisplacement of Aboriginal and Torres Strait Islanderpeople. ‘Protectionism’ was replaced by a policyof ‘assimilation’ after a 1937 national conference,at which the assimilation policy was adopted.From this date all States began adopting policiesdesigned to ‘assimilate’ Indigenous people of mixeddescent. Assimilation was ‘a highly intensive processnecessitating constant surveillance of people’s lives’.New legislation was introduced almost everywhereby 1940. The policy of assimilation was replaced by apolicy of ‘self-determination’ in the 1970s.68 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

The 1967 Referendum afforded the CommonwealthGovernment legislative authority for Aboriginal andTorres Strait Islander people (formally the powerrested with the States). 5 Prior to the referendum,Aboriginal and Torres Strait Islander Australians wereincluded in Census data under the section ‘flora andfauna’. Following the referendum, people were ableto self identify as an Aboriginal and or Torres StraitIslander. Since the inclusion of Aboriginal and TorresStrait Islander Australians in the Census, Australia hassought only information about ‘general ancestry’ asdefined by the Census question. The Census definitionof an Aboriginal and Torres Strait Islander is “a personof Aboriginal or Torres Strait Islander descent whoidentifies as an Aboriginal or Torres Strait Islanderand is accepted as such by the community in which heor she lives”. 15 The 1986 Census did include a questionto identify Aboriginal and Torres Strait Islanderorigin and a question to determine the ancestry orforebears of all people including Indigenous people.However, these questions were cross-edited 9 and thusno distinction can be drawn between the historicalancestry and the current identity of the population.In Australia, since 1981, all Censuses have used thesame question to identify Aboriginal and Torres StraitIslander people. 9-10Following the Referendum, the Office ofAboriginal Affairs was set up to establish Aboriginalhealth units. 11 The Aboriginal and Torres StraitIslander Commission was established in 1990 anddisbanded in 2005. A number of regional IndigenousCoordination Centres were then convened to advisethe Federal Government on funding priorities andprocess. However, with the change in the FederalGovernment in 2007, these Centres are beingreviewed and the current Aboriginal and Torres StraitIslander Social Justice Commissioner Tom Calmahas been appointed to oversee the establishment of anew body that will advise the Federal Government onIndigenous affairs. Historically and currently, thereare no Treaties between the Australian Governmentand the Aboriginal and Torres Strait Islander people.By the late 1800s there were systematicremoval practices being implemented through arange of assimilation and ‘protection policies’. Aseminal report, the Bringing Them Home report,acknowledged that ‘Indigenous children hadindeed been forcibly separated from their familiesand communities since the very first days of theEuropean occupation of Australia’ by governmentsand missionaries. These children who were removedcame to be known as the Stolen Generations. Thepublic and political debate about the removal ofchildren was marked by intense political activityfrom the mid-to-late 1980s. 12 In 1992 PrimeMinister Keating acknowledged that ‘we took thechildren from their mothers’, at a speech in Redfern.In 1994, legal action was commenced in theSupreme Court of New South Wales by members ofthe Stolen Generation. 13On the 13th of February 2008, more than tenyears after the Bringing Them Home report wasaccepted, the Prime Minister, Kevin Rudd, tableda motion in parliament apologizing to Australia’sIndigenous peoples, particularly the StolenGenerations and their families and communities, forlaws and policies which had ‘inflicted profound grief,suffering and loss on these our fellow Australians’ .This motion was passed with acclamation.The apology included a proposal for a policycommission to be convened and to be responsiblefor advising the government on how to ‘close the gap’between Indigenous and non-Indigenous Australiansin ‘life expectancy, educational achievement andeconomic opportunity’. 143.3 Demographics of Aboriginal andTorres Strait Islander AustraliansAboriginal and Torres Strait Islander people havea wide range of lifestyles and social, cultural,educational and family backgrounds. What is trueof one Indigenous person or group is not necessarilytrue of another’s values and life style. 16 Currently,there are at least 250 documented Aboriginal andTorres Strait Islander language groups.In June 2006, the estimated Aboriginal and TorresStrait Islander population was 517, 200 or 2.5% ofthe total Australian population. 17 The Indigenouspopulation is estimated to have increased by 58,700(13%) between 2001 and 2006. People identifyingas Aboriginal made up 90% of the Aboriginal andTorres Strait Islander population, 6% identified asTorres Strait Islander and 4% as Aboriginal and TorresStrait Islanders. 18Torres Strait Islanders are the Indigenous peopleof the Torres Strait Islands, part of the State ofQueensland, and are culturally akin to the coastalpeoples of Papua New Guinea. They are regardedas being distinct from other Aboriginal peoples inAustralia, and are generally referred to separately. TheIndigenous people of the Torres Strait have a distinctculture, with slight variants between the differentislands. They are a seafaring people and engaged intrade with people of Papua New Guinea. 19 In 2006,there were 6,958 Torres Strait Islander people livingin the Torres Strait Indigenous Region (15% of theHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 69

Size of green circles is indicative ofrelative size of the Aboriginal and TorresStrait Islander population for example :Large green circles:29,000 personsMedium green circles: 14,500 personsSmall green circles: 2,900 personsFigure 1Distribution and relativesize of AustralianIndigenous population inIndigenous locations, ruraltowns and urban centres.Source: Department of theEnvironment and Heritage 22The continuingdisparities in healthoutcomes amongIndigenous peoplein Australia, NewZealand, Canadaand the United Statesof America is in greatpart the legacy ofthe colonization oftheir landstotal count of Torres Strait Islander people), andaround 42,000 others living outside this area, mostlyin the north of Queensland, particularly in Townsvilleand Cairns. 20Geographical distributionIn 2006, the largest population of Aboriginal andTorres Strait Islander people in Australia lived in majorcities (31%). The remaining population was evenlydistributed across areas categorised by the AustralianBureau of Statistics as Inner Regional (22%), OuterRegional (23%) and Remote/Very Remote Australia(24%) (See Figure 1).States with relatively high proportions of Aboriginaland Torres Strait Islander people living in majorcities included South Australia (48%), Victoria (48%)and New South Wales (42%). In contrast, 81% of theAboriginal and Torres Strait Islander population in theNorthern Territory lived in Remote/Very Remote areas.Similarly, in Western Australia 41% of the Aboriginaland Torres Strait Islander population lived in Remote/Very Remote areas. 23Age structureThe Aboriginal and Torres Strait Islander populationat 30 June 2006 had a younger age structure than thenon-Aboriginal and Torres Strait Islander population,with large proportions of young people and smallproportions of older people (See Figure 2). The medianage of the Aboriginal and Torres Strait Islanderpopulation at 30 June 2006 was 21.0 years, comparedto 37.0 years for the non-Aboriginal and Torres StraitIslander population.Based on estimates for 2003, there were 179,128Aboriginal and Torres Strait Islander children livingin Australia. All Australian children aged from zeroto fourteen years accounted for 20% of the totalpopulation. Aboriginal and Torres Strait Islanderchildren aged from zero to fourteen years accountedfor 39% of the total Aboriginal and Torres StraitIslander Australian population. Australia is a vastcountry and the numbers of Aboriginal and TorresStrait Islander children living in the various statesand territories of Australia vary significantly. In theNorthern Territory, 40% of the child population agedless than fourteen years is Aboriginal and TorresStrait Islander which compares with Victoria, wherethis percentage is 1%. Further, 30% of Australia’sAboriginal and Torres Strait Islander children agedless than fourteen years live in New South Wales, 28%live in Queensland, 14% in Western Australia, 11%in the Northern Territory, 6% in Victoria and South70 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Australia, 4% in Tasmania and 0.8% in the AustralianCapital Territory. 17Indigenous familiesThe 2006 national Census reported that Aboriginaland Torres Strait Islander families are more likely tobe larger, with an average of 3.4 people compared withother Australian households (2.6 people). Aboriginaland Torres Strait Islander families are three timesmore likely than other single family households tobe one-parent families with dependent children orstudents (30% compared with 10%) but are less likely tobe families without dependents. (33% compared with54%). 17 The characteristics of Aboriginal and TorresStrait Islander families differ from the majority of otherAustralian families. They tend to be larger, non-nuclearand more fluid in composition. Aboriginal and TorresStrait Islander families have overlapping and extensivekinship, with both adults and children moving betweendifferent households. 24 These extensive and fluid familystructures are more common in remote communities,but are also found in more settled areas of Australia. 253.4 Determinants of Aboriginal andTorres Strait Islander child healthEmploymentBeing employed leads to improved income for familiesand communities, which in turn has a positiveinfluence on the health and education of children. Italso enhances self-esteem, increases opportunities forself-development, influences interaction at the familyand community level, and decreases social alienation. 26In 2004–2005, after adjusting for the age difference, theunemployment rate for Aboriginal and Torres StraitIslander people (12.9%) was about three times higherthan for non-Aboriginal and Torres Strait Islanderpeople (4.4%) 26. Aboriginal and Torres Strait Islanderchildren were also less likely to have a parent in paidemployment and, in 2006, 42% of Aboriginal and TorresStrait Islander children lived in families where there wasno parent working, which was three times higher thannon-Aboriginal and Torres Strait Islander children. 17IncomeThe incomes of Aboriginal and Torres Strait Islanderpeople are generally below those of non-Aboriginaland Torres Strait Islander people, and there tends tobe a relatively higher proportion of Aboriginal andTorres Strait Islander people with lower incomes anda lower proportion with higher incomes. 26 People whohave lower incomes or are socially disadvantaged inother ways tend to live shorter lives and suffer moreillnesses than those who are well off. It is widelyacknowledged that health status is affected by theavailability of material resources and the income tobuy them. Higher incomes can enable the purchaseof health-related goods and services, such as betterfood, housing, recreation and health care, and mayprovide psychological benefits such as a greater senseof security and control. 27Adverse health outcomes and higher mortalityrates are important examples of the effect that lowincome has on people, and the link between reducedfamily income and associated poor child healthoutcomes is compelling. For the period 2002 and2004–05, after adjusting for inflation, median grossweekly equivilised household income for Aboriginaland Torres Strait Islander people rose by 10% from$AU 308 to$AU 340. This compare to $AU 618 forAge group (years)Age group (years)85+ 85+80-84 80-8475-79 Male Female 75-79Male Female70-74 70-7465-69 65-6960-64 60-6455-59 55-5950-54 50-5445-49 45-4940-44 40-4435-39 35-3930-34 30-3425-29 25-2920-24 20-2415-19 15-1910-14 10-145-9 5-90-4 0-47 6 5 4 3 2 1 0 1 2 3 4 5 6 7 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7PercentPercentINDIGENOUSnon-INDIGENOUSFigure 2Aboriginal and Torres StraitIslander and non-Aboriginaland Torres Strait Islanderpopulation at30 June 2006Source: Australian Bureau ofStatistics 23Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 71

100Year 3 students100Year 7 students9090808070706060Percent504050403030Figure 3Proportion of studentswho achieve the numeracybenchmark20100Indigenous students All Students2001 2002 2003 2004 2005201002001 2002 2003 2004 2005non-Aboriginal and Torres Strait Islander householdsin 2004–05. 26HousingA poor living environment, with for example, low orno access to clean water, functional sewerage systemsor appropriate housing conditions, has been associatedwith tuberculosis, rheumatic heart disease, respiratorydiseases, urinary tract diseases, intestinal worms,trachoma and intestinal infections. 28 Many rural andremote Indigenous communities still do not have accessto the basic level of environmental health experiencedby the rest of the population. Overcrowded housing,in particular, still remains a significant problem. In2006, an estimated 25% of Aboriginal and Torres StraitIslander people lived in overcrowded accommodation. 17EducationInternational research has clearly established thathigher levels of educational attainment are associatedwith improved health outcomes. 29 There is alsopersistent evidence regarding the importance ofcompleting Year 12 at school. 30 Positive relationshipshave been observed between levels of educationalattainment and positive health outcomes. 31 Youngpeople who do not complete Year 12 are less likelyto be fully engaged in study or work compared withthose who do complete Year 12, and the fewer years ofschooling competed, the less likelihood of engagementin study or work. 32 Aboriginal and Torres Strait Islanderchildren are more likely to have parents who left schoolearly (57% of children in Aboriginal and Torres StraitIslander households are living with parents who hadnot completed Year 10, compared with 25% of childrenin other households).Between 2001 and 2005, 78% of Year 3 Aboriginaland Torres Strait Islander students met the readingbenchmark and 80% met the numeracy benchmark.However, at Year 7 in the same period, 65% ofAboriginal and Torres Strait Islander students metthe reading benchmark and 50% met the numeracybenchmark. Between Year 3 in 2001 and Year 7 in 2005,the rate of attainment of the numeracy benchmarkalmost halved among Aboriginal and Torres StraitIslander students, from 80.2% to 48.8% (See Figure 3).Rates of attainment of the reading benchmark droppedfrom 72% to 65% among these students. 26Food securityThe hunter–gatherer lifestyle of Aboriginal and TorresStrait Islander people changed after the arrival ofEuropeans. 33 Many Aboriginal and Torres Strait Islanderpeople became dependent on Europeans for food, aswell as for many other resources. Indigenous populationnumbers decreased after initial contact with Europeansdue to violence, introduced diseases and malnutrition.A rapid change in the diet of many Indigenous peoplefrom a fibre-rich, high-protein, low-fat traditional dietto one high in refined carbohydrates and saturated fatsincreased the risk of diet-related disease. Vulnerabilityto obesity and non-insulin-dependent diabetes mellitushas been common among other groups that havebeen subjected to similar rapid lifestyle changes—forexample, Pima Indians and Native Americans. 34Food security has been largely unreported andcould be a major factor contributing to poor childhoodgrowth and nutrition. Good nutrition is necessary forgrowth and physical and mental health. The effects ofdiet and nutrition in pregnancy and during a child’searly life may have lifelong consequences. 35 Poorfetal growth (or stunting in the first two years of life )leads to irreversible damage, including shorter adultstature, lower attained schooling and reduced adultincome. Healthy nutrition in pregnancy is crucial forthe mother, as it influences both her health and thatof her baby. Low dietary-energy intake, malnutrition,72 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Aboriginal and Torres Strait Islanderpeople have a wide range of diverse lifestylesand social, cultural, educational andfamily backgrounds. What is true of oneIndigenous person or group is not necessarilytrue of another person’s values and life style.inadequate weight gain during pregnancy and lowpre-pregnancy weight can lead to intra-uterine growthretardation, which in turn can reduce birth weight. Formany Aboriginal and Torres Strait Islander Australians,whether living in urban, rural or remote settings, theavailability and cost of healthy nutritious food is a basicpublic health issue. In 2004–05, among Indigenouschildren aged twelve to fourteen years in non-remoteareas, only 24% met the recommended daily fruit intakeof three or more serves, and 59% met the recommendeddaily vegetable intake of three or more serves. Amongteenagers fifteen to seventeen years of age, 20% met thedaily fruit consumption guidelines and 61% met thedaily vegetable consumption guidelines. 173.5 Specific Health Issues and risk factorsTobacco smokingSmoking during pregnancy is associated with poorperinatal outcomes such as low birth weight, pretermbirth and perinatal death. For the period 2001–04,51% of all Aboriginal and Torres Strait Islander womenreported smoking during pregnancy. Aboriginal andTorres Strait Islander mothers were about three timesmore likely to smoke in pregnancy compared withnon-Aboriginal and Torres Strait Islander mothers. 29 Incontrast, only about 20% of all other Australian womenwere reported to smoke during pregnancy and thisfigure appears to be declining. 20Aboriginal and Torres Strait Islander children wereexposed to nearly twice the amount of environmentaltobacco smoke compared with non-Aboriginal andTorres Strait Islander children and were significantlymore likely to live in a household with smokers (68.4%compared with 36.3% of non-Aboriginal and TorresStrait Islander children). Between 2004–05, 30.5% ofAboriginal and Torres Strait Islander children wereexposed to regular indoor smokers compared with 10%of non-Aboriginal and Torres Strait Islander children(See Table 1).Alcohol useAlcohol use in pregnancy is associated with anincreased risk of fetal alcohol syndrome and perinatalIndigenous children Non-Indigenous childrenaged 0–18 aged 0–18% %Does the regular smoker in your household smoke at home indoors? (a)No 37.6 26.1Yes 30.5 10.2Regular smoker in household 68.4 36.3No regular smoker 31.6 63.7Total 100.0 100.0Total number of children 217,815 4,802,303Table 1Children aged zero toeighteen years: smokingstatus in households,2004–05Source: Adapted from ABS andAIHW Analysis of 2004–05 NATSIHSand 2004–05 National HealthSurvey.(a)Excludes not applicable, not asked (single-person household), not stated and not known.Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 73

Table 2Self-assessed health statusof people aged fifteen toeighteen years 2004–05Source: AIHW analyses of 2004-05National Aboriginal and Torres StraitIslander Health SurveyProportionIndigenous Non-IndigenousExcellent 30.0 40.3Very good 34.4 38.3Excellent/very good 64.5 78.6Good 26.8 16.6Fair 7.6 4.0Poor 1.1 0.8Fair/poor 8.7 4.8Total 100.0 100.0Note: Excludes persons for whom self-assessed health status was not stated.death. The Western Australian Aboriginal Child HealthSurvey reported that the mothers of an estimated 23%of Aboriginal children reported that they drank alcoholduring their pregnancies. 36 Risky alcohol consumptionhas not abated for men and has increased for women.Excessive alcohol consumption also accounted for thegreatest proportion of the burden of disease and injuryfor young Aboriginal and Torres Strait Islander males(fifteen to thirty-four years) and the second highestproportion for young Aboriginal and Torres StraitIslander females (after intimate partner violence). 36Self-rated healthSelf-rated health status provides an overall measure ofa population’s health based on an individual’s personalperception of his or her own health. Health is recognisedas having physical, mental, social and spiritualcomponents, and measures of them go beyond moreobjective measures such as morbidity and mortality.Aboriginal and Torres Strait Islander teenagers agedbetween fifteen and eighteen years rated their healthas consistently poorer than their non-Aboriginal andTorres Strait Islander counterparts (See Table 2).Perinatal health outcomesBirthsThe recording of Indigenous births is likely to be anunderestimate because the Aboriginal and Torres StraitIslander status of the parent is not always recorded orcorrectly recorded. In 2006, there were about 12,300live births registered in Australia for which at least oneparent was of Aboriginal and Torres Strait Islanderorigin; these accounted for about 5% of total births. 37About one-third of these babies had both an Aboriginaland/or Torres Strait Islander mother and father, 41% hadan Aboriginal and/orTorres Strait Islander mother andnon-Indigenous father, and 29% had a non-Indigenousmother and Indigenous father. 17 These percentagesvaried by state/territory (also reflecting ascertainment)between 39% of all babies in the Northern Territory, and0.7% of all babies in Victoria. In 2006, the total fertilityrate for Aboriginal and Torres Strait Islander motherswas 2.1 babies compared with 1.8 babies for non-Aboriginal and Torres Strait Islander mothers. 17In the period 2001–04, approximately 23% ofAboriginal and Torres Strait Islander females whogave birth were aged less than 20 years comparedwith about 4% of non-Aboriginal and Torres StraitIslander females.The life expectancy at birth for Aboriginal andTorres Strait Islander babies born in the period1996–2001 was estimated to be 59.4 years for males and64.8 years for females compared with 76.6 years for allmales and 82.0 years for all females. This represents anestimated difference of approximately seventeen yearsfor both males and females. 17Preterm birthsA baby born at a gestational age or length of pregnancyless than thirty-seven completed weeks is preterm.Preterm birth is associated with early health problemsthat cause considerable illness and a higher risk ofdeath in newborn babies. In the period 2001–04,14% of all babies born to Aboriginal and Torres StraitIslander women were born preterm, compared with8% of babies born to non-Aboriginal and Torres StraitIslander women. 37Birth weightBabies born with a birth weight of less than 2500 gramsare classified as low birth weight. Low birth weightmay result from being born preterm or from poor fetal74 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Since the most powerfuldeterminants of infant mortality aresocial and economic, death in infancy isa good indicator of the social progress ofa society, country or group of peoplegrowth during pregnancy. Being born low birth weightincreases an infant’s chances of dying in the first year oflife and of poor health outcomes throughout life.During 2003–05, there were 3,601 low birth weightbabies born to Aboriginal and Torres Strait Islandermothers, which represented 13% of all Aboriginal andTorres Strait Islander births. This was more than doublethe proportion of low birth weight babies born to non-Aboriginal and Torres Strait Islander mothers (6.1%). 17Data from 1991–2004 show a significant increase in therate of low birth weight babies born to Aboriginal andTorres Strait Islander mothers, from 11.2 to 12.1 per 100live births (See Figure 4).Breast feedingBreast feeding has many positive effects on survival,growth, development and the health of infants. Thereis strong evidence to support the protective effect ofSource: CRCAH-CooperativeResearch Centre for AboriginalHealth, Darwin1411Indigenous OtherFigure 4Rate of low birth weightbabies by Indigenous statusof mother 1991-2004Percent86Source: AIHW National PerinatalData Collection3019911992199319941995199619971998199920002001200220032004(a) Excludes data for Tasmania and the Australian Capital Territory(b) Rates have been directly age standardized using all Australian mothers who gave birth in 2001 as the standard population.(c) Comprises non-Indigenous mothers and mothers for whom Indigenous status was not stated.YearHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 75

Source: CRCAH-CooperativeResearch Centre for AboriginalHealth, Darwinbreast feeding against conditions such as diarrhoeaand respiratory infections. Breast feeding has alsobeen shown to benefit children’s growth, cognitivedevelopment and immunological functioning, 38 andalso to offer a protective effect against Sudden InfantDeath Syndrome (SIDS), asthma and other allergicdiseases. 39 The National Aboriginal and Torres StraitIslander Health Survey in 2004–05 reported thatapproximately 79% of Aboriginal and Torres StraitIslander children living in non-remote areas had beenbreastfed compared with 88% of non-Aboriginal andTorres Strait Islander children. A higher proportionof non-Aboriginal and Torres Strait Islander thanAboriginal and Torres Strait Islander children (agedzero to three years) had been fed for longer than twelvemonths (14% compared with 11%). 27 85% of Aboriginaland Torres Strait Islander children aged between zeroand three years living in remote areas and 75% livingin non-remote areas were currently being or had beenbreastfed in 2004–05. The proportion of Aboriginaland Torres Strait Islander infants less than twelvemonths old living in remote areas who were beingbreastfed in 2004–05 was particularly high (85% ofbabies less than six months and 82% aged betweensix and twelve months). 27Table 3Breastfeeding status,Indigenous infants aged 0to less than 6 months and6 months to less than 12months 2004–05Source: ABS and AIHW analysis of2004–05 NATSIHSBreastfeeding status Age 0–

Perinatal and infant mortalitySince the most powerful determinants of infantmortality are social and economic, death in infancyis a good indicator of the social progress of a society,country or group of people. Many of the causesof infant death, such as infections, are potentiallypreventable; others, such as low birthweight or pretermbirth can be treated with good health care and services.Perinatal deathsNeonatal deaths are deaths of live-born babies inthe first 28 days of life. Perinatal death includesstillbirths and neonatal deaths. These deaths typicallyresult from factors arising during pregnancy andchildbirth. In 2006, Aboriginal and Torres StraitIslander babies were over two and a half times morelikely to die in the neonatal period and nearly twiceas likely to die in the perinatal period compared withnon-Aboriginal and Torres Strait Islander babies(See Table 4).Infant deathsInfant deaths are deaths of live-born children beforethey reach their first birthday. For the period 2001–05,Aboriginal and Torres Strait Islander infants inQueensland, Western Australia, South Australia andthe Northern Territory were two to three times morelikely to die in infancy than non-Aboriginal andTorres Strait Islander infants. 17 However, between1998 (15.2 per 1000 live births) and 2006 (11.6 per1000 live births), there have been significant decreasesin the rates of Aboriginal and Torres Strait Islanderinfant deaths in Queensland, Western Australia, SouthAustralia and the Northern Territory. These ratescompared with rates of 5.1 per 1000 live births in 1998and 4.2 per 1000 live births in 2006 for non-Aboriginaland Torres Strait Islander infants. The disparitybetween these two populations has also decreasedover these years from a rate ration of 3.0 to 2.7, whichrepresents a 30% decrease (See Table 5) (source AIHWanalysis of the National Mortality Database, 2008).Postneonatal death occurs after 28 days andbefore the first birthday. Data from Western Australiaindicates that the post-neonatal death rate is higherthan the neonatal death rate for Aboriginal and TorresStrait Islander infants, and the disparity betweenAboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander post-neonatalmortality rates is increasing. This is a pattern found inless-developed countries. 2Between 1998–2006, an Aboriginal and Torres StraitIslander boy was 2½ times more likely to die in the199819992000200120022003200420052006Indigenous deaths per 1,000 live birthsAnnualchange (b)% change overperiod (c)15.2 14.7 14.9 13.0 14.0 11.6 11.8 12.6 11.6 -0.5* -24.9*Non-Indigenous deaths per 1,000 live births5.1 4.7 4.7 4.8 4.8 3.8 4.0 4.4 4.2 -0.1* -17.8*Table 5Infant mortality rates, rateratios and rate differences,Qld, WA, SA and NT,1998–2006 (a)Source: AIHW analysis of NationalMortality DatabaseRate ratio (d)3.0 3.2 3.1 2.7 3.0 3.1 3.0 2.9 2.7 0.0 -8.4Rate difference (e)10.2 10.1 10.1 8.2 9.3 7.8 7.8 8.2 7.4 -0.4* -28.5** Represents results with statistically significant increases or decreases at the p < 0.05 level over the period1998–2006.(a)Data exclude 90 registered infant deaths where Indigenous status was not stated over the period1998–2006 in Queensland, Western Australia, South Australia and the Northern Territory combined.(b)Average annual change in rates, rate ratios and rate differences determined using linear regressionanalysis.(c)% change between 1998 and 2006 based on the average annual change over the period.(d)Mortality rate for Indigenous infants divided by the mortality rate for non-Indigenous infants.(e)Mortality rate for Indigenous infants minus the mortality rate for non-Indigenous infants.Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 77

first year of his life than a non-Aboriginal and TorresStrait Islander boy, and an Aboriginal and Torres StraitIslander girl was 3½ times more likely to die than anon-Aboriginal and Torres Strait Islander girl. 17Cause of DeathBetween 2002–2006, the major causes of death forAboriginal and Torres Strait Islander infants wereconditions originating in the perinatal period (44%),SIDS (22%), congenital malformations (12%),respiratory diseases (8%), external causes (mainlyaccidents) (4%), and infectious and parasitic diseases(such as septicaemia, meningococcal infection andcongenital syphilis) (4%) (See Table 6). The rate ofdeaths due to respiratory diseases and infectious andparasitic diseases was particularly high for Aboriginaland Torres Strait Islander infants, and was between fivetimes higher (for infectious and parasitic diseases) andeleven times higher (for respiratory diseases) than non-Aboriginal and Torres Strait Islander infants.Table 6Causes of infant death byAboriginal and Torres StraitIslander status, Queensland,Western Australia, SouthAustralia and the NorthernTerritory, 2002–06Source: AIHW analysis of NationalMortality DatabaseCause of death Indigenous Non-Indigenous Rate ratioDeaths per 1,000 live birthsCertain conditions originating in the perinatalperiod (P00–P96)Symptoms, signs, and abnormal clinical findingsn.e.c. (R00-R99)5.7 2.1 2.7*2.7 0.5 5.7*SIDS (R95) 1.1 0.2 5.4*Congenital malformations, deformations andchromosomal abnormalities (Q00–Q99)1.5 1.0 1.5*Diseases of the respiratory system (J00–J99) 0.9 0.1 8.6*External causes (injury & poisoning) (V01–Y99) 0.5 0.1 3.8*Certain infectious and parasitic diseases (A00–B99) 0.3 0.1 4.2*Diseases of the circulatory system (I00–I99) 0.2 0.1 3.1*Other conditions(a) 0.5 0.3 1.8*Total 12.3 4.2 2.9** Represents results with statistically significant differences in the Indigenous/non-Indigenouscomparisons at the p < 0.05 level.Other conditions include: neoplasms (C00–D48); diseases of blood and blood-forming organs (D50–D89);endocrine, nutritional and metabolic diseases (E00–E89); mental and behavioural disorders (F00–F99);diseases of the nervous system (G00–G99); diseases of the eye and adnexa (H00–H59); diseases ofthe ear and mastoid process (H60–H95); diseases of the digestive system (K00–K93); diseases of themusculoskeletal system and connective tissues M00–M99); diseases of the genitourinary system N00–N99); and diseases of the skin and subcutaneous tissue (L00–L99).Note: Data are reported for Queensland, Western Australia, South Australia and the Northern Territoryonly. These four states and territories are considered to have adequate levels of Indigenous identificationin mortality data. They do not represent a quasi-Australian figure.78 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Sudden Infant Death Syndrome (SIDS)The rate of SIDS among the total Australian infantpopulation has decreased significantly over the past twodecades from 17.9 per 10,000 live births in the period1980–90 to 11.5 per 10,000 live births in the period1997–2002. However, these decreases have not beenobserved among the Indigenous population. Giventhe inaccuracies and lack of inclusion of Indigenousspecificinformation in statutory and administrativedata-sets, there is no available national informationdescribing the rates of Indigenous SIDS. However, atotal population study that included all deaths that hadoccurred in Western Australia between 1980 and 2002,reported that the rate of SIDS among non-Aboriginaland Torres Strait Islander infants had decreasedsignificantly over this period, from 1.3/1000 live birthsto 0.6/1000 live births. However, a similar decreasewas not observed among Aboriginal and Torres StraitIslander infants: 4.9/1000 live births to 4.7/1000 livebirths over the same time period. This slower decreaseamong Aboriginal and Torres Strait Islander infantsrelative to non-Aboriginal and Torres Strait Islanderinfants resulted in an increase relative risk (RR= 7.9). 3There are a number of factors that are associatedwith an increased risk of SIDS, including sharingsleep surfaces, maternal smoking, infant exposureto environmental smoke, overcrowding in homes,prematurity and lack of breast feeding. These factors areproportionately more prevalent among the Indigenouspopulation. It is therefore critical that well-resourcededucation campaigns led by Indigenous people areinstigated in order to reduce these unexpectedly highrates of SIDS.Childhood deathsChild mortality rates should be interpreted withcaution due to the small number of deaths each yearof Aboriginal and Torres Strait Islander and otherAustralian children. The quality of death data is onlyacceptable in Western Australia, South Australia, theNorthern Territory and Queensland (after 1998) (SeeTable 7). Available data report that Aboriginal andTorres Strait Islander children are three times morelikely to die in the first eighteen years of life comparedwith non-Aboriginal and Torres Strait Islanderchildren. The disparities varied according to the agegroup: one to four years, rate ratio 2.8; five to twelveyears, rate ratio 2.3; thirteen to eighteen years, rateratio 2.8.Deaths among children aged 1–4 yearsFor the period 2002–06, an Aboriginal and Torres StraitIslander boy aged one to four years was 2.6 times morelikely to die than a non-Aboriginal and Torres StraitIslander boy. An Aboriginal and Torres Strait Islandergirl was 2.9 times more likely to die thana non-Aboriginal and Torres Strait Islander girl. 17There has been a statistically significant reduction inall-cause mortality rates, particularly in children agedless than five years in the Northern Territory andWestern Australia 2, 40 .Deaths among children aged 5–12 yearsFor the period 2002-06, an Aboriginal and Torres StraitIslander boy was 2.2 times more likely to die than anon-Aboriginal and Torres Strait Islander boy. For thesame period an Aboriginal and Torres Strait Islandergirl was 2.1 times more likely to die than a non-Aboriginal and Torres Strait Islander girl.Deaths among children aged 13–18 yearsFor the period 2002–06, an Aboriginal and Torres StraitIslander boy was 2.7 times more likely to die than anon-Aboriginal and Torres Strait Islander boy. For thesame period an Aboriginal and Torres Strait Islandergirl was three times more likely to die than a non-Aboriginal and Torres Strait Islander girl.Causes of deaths among childrenFor the period 2002–06, the death rate from externalcauses (such as transport accidents, accidentaldrowning, assault and intentional self-harm) wasIndigenousNon-IndigenousMales Females All Males Females AllDeaths per 100,0000 1,452.8 1,028.9 1,246.3 447.7 390.4 419.91–4 70.9 62.2 66.6 26.9 21.3 24.25–12 27.5 19.1 23.4 11.4 9.0 10.213–18 44.8 26.6 35.9 16.5 8.6 12.7Total 97.1 67.9 82.8 31.2 23.5 27.5Table 7Deaths of children, agegroup and Indigenousstatus, Queensland, WesternAustralia, South Australiaand the Northern Territory,2002–06Source: AIHW analyses of AIHWNational Mortality DatabaseHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 79

Source: CRCAH-CooperativeResearch Centre for AboriginalHealth, Darwinaround three times higher for Aboriginal and TorresStrait Islander children (between six and eleven per10,000 population) than for non-Aboriginal and TorresStrait Islander children (between one and three per10,000 population) in Queensland, Western Australia,South Australia and the Northern Territory. Deathsdue to accidental drowning continued to be prevalentamong Aboriginal and Torres Strait Islander children.Aboriginal and Torres Strait Islander children also diedfrom infectious and parasitic diseases and diseasesof the respiratory and circulatory system at three tosix times the rate of non-Aboriginal and Torres StraitIslander children. Tables 8 and 9 show the main causesof death according to the International Classification ofDiseases version 10 for children aged between zero andfour (See Table 8) and for children aged between fiveand eighteen (See Table 9), highlighting the differencesbetween the rates of death for Aboriginal and TorresStrait Islander children compared with non-Aboriginaland Torres Strait Islander children.Table 8Deaths of children aged0-4 years, by main causeof death and Indigenousstatus, Queensland, WesternAustralia, South Australiaand the Northern Territory,2002–06Source: AIHW analyses of AIHWNational Mortality DatabaseCertain conditions originating in thePerinatal period (P00–P99)Symptoms, signs and abnormal findingsn.e.c. (R00–R99)Congenital malformations, deformationsand chromosomal abnormalities (Q00–Q99)IndigenousNon-IndigenousMales Females All Males Females AllDeaths per 100,000134.7 96.1 115.8 43.5 39.4 41.571.7 48.6 60.4 12.6 9.2 11.035.8 31.6 33.8 22.5 19.3 20.9External causes (injury & poisoning)(V01–Y98)40.2 24.9 32.7 12.0 10.0 11.0Diseases of the respiratory system (J00–J99) 26.1 17.0 21.6 3.1 2.9 3.0Diseases of the nervous system (G00–G99) 10.9 11.3 11.1 3.9 3.5 3.7Certain infectious and parasitic diseases(A00–B99)8.7 10.2 9.4 2.5 2.0 2.2Diseases of the circulatory system (I00–I99) 8.7 5.7 7.2 2.3 1.5 1.9Other causes (a) 15.2 11.3 13.3 7.8 6.3 7.1Total 351.9 256.5 305.2 110.1 94.1 102.3(a)Other causes includes: neoplasms (COO–D48); diseases of the blood and blood-forming organs andcertain disorders involving the immune mechanism (D50–D89); endocrine, nutritional and metabolicdiseases (E00–E89); mental and behavioural disorders (F00–F99); diseases of the eye and adnexa (H00–H59); diseases of the ear and mastoid process (H60–H95); diseases of the digestive system (K00–K93);diseases of the skin and subcutaneous tissue (L00–L99); diseases of the musculoskeletal system andconnective tissue (M00–M99); and diseases of the genitourinary system (N00–N99).80 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

There is evidence that improved access toprimary healthcare can impede increasingpreventable mortality rates. Such programsmust be supported by well-constructed andwell-resourced secondary prevention andhealth promotion programsInjuriesRates of injury mortality and hospital admissiondue to injury are substantially higher for Aboriginaland Torres Strait Islander Australians than for theAustralian population as a whole. 11 Children agedzero to fourteen years are known to be particularlyvulnerable to injury, but very little is known about thenature and extent of injury to Indigenous children.Injury issues that confront children in Aboriginal andTorres Strait Islander communities are more complexExternal causes (injury and poisoning)(V01–Y98)Symptoms, signs and abnormal findingsn.e.c. (R00–R99)IndigenousNon-IndigenousMales Females All Males Females AllDeaths per 100,00042.4 23.6 33.3 14.7 6.7 10.84.8 1.7. 3.3 0.6 0.6 0.6Diseases of the circulatory system (I00–I99) 3.6 2.5 3.1 0.8 0.4 0.6Neoplasms (C00–D48) 3.2 2.5 2.9 2.8 2.8 2.8Diseases of the nervous system (G00–G99) 2.4 2.1 2.3 1.5 0.9 1.2Other causes (a) 4.8 5.5 5.1 2.6 2.2 2.4Total 61.2 38.0 49.9 22.9 13.7 18.4(a)Other causes includes: infectious and parasitic diseases (A00–B99); diseases of the blood and bloodformingorgans and certain disorders involving the immune mechanism (D50–D89); endocrine,nutritional and metabolic diseases (E00–E89); mental and behavioural disorders (F00–F99); diseasesof the eye and adnexa (H00–H59); diseases of the ear and mastoid process (H60–H95); diseases of therespiratory system; diseases of the digestive system (K00–K93); diseases of the skin and subcutaneoustissue (L00–L99); diseases of the musculoskeletal system and connective tissue (M00–M99); diseasesof the genitourinary system (N00–N99); pregnancy, childbirth and the puerperium (O00–O99); certainconditions originating in the perinatal period (P00–P96); and congenital malformations, deformationsad chromosomal abnormalities (Q00–Q99).Table 9Deaths of children aged5–18 years, by main causeof death and Indigenousstatus, Queensland, WesternAustralia, South Australiaand the Northern Territory,2002–06Source: AIHW analyses of AIHWNational Mortality DatabaseHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 81

Pictured: Darheiothan those commonly experienced within the generalpopulation, and are related to Aboriginal and TorresStrait Islander social disadvantage, poverty and generalill health. Aboriginal and Torres Strait Islander childrenmay be put at risk through living in an overcrowdedhome environment, economic deprivation, high stresslevels and recurring domestic violence. 26Between 2001 and 2003, Aboriginal and TorresStrait Islander children aged zero to fourteen yearsexperienced a 2.5 times higher average injury mortalityrate compared with non-Aboriginal and Torres StraitIslander children. 41 In 2004–05, Aboriginal and TorresStrait Islander children under four years were nearly1.5 times more likely to be hospitalised as a result ofinjuries, poisoning and other external causes thannon-Aboriginal and Torres Strait Islander children(See Figure 6). 26 Aboriginal and Torres Strait Islanderchildren had a higher hospitalization rate for injuriesfrom burns and scalds (approximately 2.3 times higher),assault and traffic-related pedestrian injury (two timeshigher) compared with other Australian children. 41Suicide and self-harmSuicide is influenced by a complex set of factors asindicated by the significant differences that existin suicidal behaviour not only between Aboriginaland Torres Strait Islander and non-Aboriginal andTorres Strait Islander populations, but also betweendifferent Indigenous communities. 42 These factorsinclude the history of disposition, removal fromfamily, discrimination, resilience, social capital andsocioeconomic factors. 26 Evidence suggests that82 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Aboriginal and Torres Strait Islander suicide is mostcommon among young men, while suicide attempts arereported to be more common among women. 43,44Mental and behavioural disorders are oftenassociated with an increased risk of self-harm, as isalcohol and substance abuse. 45 Environmental riskfactors have also been associated with a higher rate ofsuicide. Relevant family factors have included parentswho are substance dependent, have been imprisonedor have violent tendencies, particularly if this translatesinto family violence. 26In the period 2001 to 2005, after taking into accountthe different age structures in the Aboriginal and TorresStrait Islander and non-Aboriginal and Torres StraitIslander populations, data from Queensland, WesternAustralia, South Australia and the Northern Territoryreported that suicide rates among all Aboriginaland Torres Strait Islander males were significantlyhigher (between 32.3 and 84.9/100,000) than fornon-Aboriginal and Torres Strait Islander males(between 17.0 and 25.8/100,000) and also higher for allAboriginal and Torres Strait Islander females (between6.2 and 21.0/100,000) compared with non-Aboriginaland Torres Strait Islander females (between 4.3 and5.1/100,000). 26For Indigenous males aged 0–24 years, the agespecificrates were three times the corresponding agespecificrates for non-Indigenous males. The suiciderate for Indigenous females aged 0–24 years was fivetimes the corresponding age-specific rates for non-Indigenous females. 17In 2005, suicide was the second leading cause ofdeath (after transport accidents) for people aged15–24 years, accounting for 22.2% of deaths in thisage group. 26Hospital admissionsIn 2005-06, Aboriginal and Torres Strait Islanderinfants were 1.4 times more likely to be admittedto hospital compared with non-Aboriginal andTorres Strait Islander infants. For skin diseases,respiratory conditions, and infectious and parasiticdiseases Aboriginal and Torres Strait Islander infantswere around three to four times more likely to beadmitted to hospital than other infants. In 2005-06,Aboriginal and Torres Strait Islander children agedone to fourteen years were 1.3 times more likelyto be admitted to hospital than other Australianchildren. Diseases of the respiratory system were themajor cause of hospitalization for these Aboriginaland Torres Strait Islander children. 17 Most of theconditions resulting in Aboriginal and Torres StraitIslander infants and young children being admittedto hospital are related to poverty, housing andenvironmental conditions. 263.6 Other health conditionsLong term health conditions in childhoodSimilar proportions of Aboriginal and Torres StraitIslander and non-Aboriginal and Torres Strait Islanderchildren had long-term health conditions, the mainbeing diseases of the respiratory, ear and mastoid,eye and adnexa, skin and subcutaneous tissue andthe nervous systems. There were similar percentagesof respiratory morbidity in both populations in theyears 2004-05. However, Aboriginal and Torres StraitIslander children were more likely to suffer fromasthma (14% compared with 11%) and/or bronchitis(2% compared with 1%) and more likely to have ear/hearing problems especially partial deafness (5%Indigenous OtherFigure 6Rates of childrenhospitalized for injuries,2004-05Source: SCRGSP 20070 50 100 150 200 250 300Children Aged < 4 yearsRate / 1000Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 83

3025Prevalence of current asthma (%)Indigenous Non-indigenous Males201510500-14 15-34 35-54 55 & over3025Prevalence of current asthma (%)Indigenous Non-indigenous Females201510500-14 15-34 35-54 55 & overNote: Age-standardized to the Australian population as at June 2001.Source: Australian Centre for Asthma Monitoring (ACAM) analysis of the Australian Bureau of Statistics (ABS) National Aboriginal and Torres StraitIslander Health Survey (NATSIHS) and National Health Survey (NHS) 2004-05, expanded confidentialised unit record files, Remote Access DataLaboratory.Figure 8Prevalence of currentasthma by age, sex andIndigenous status, 2004–05Source: Asthma in Australia 46smoke in the home (and not attending organisedchildcare) and an increased risk of otitis media. 51Eye healthTrachoma is a disease of early childhood and ifuntreated leads to significant vision impairment andblindness. Trachoma is the most common cause ofinfectious blindness, with Australia being the onlydeveloped country to still have blinding endemictrachoma. A review of the National Aboriginal andTorres Strait Islander Eye Health Program in northernand western Australia in 2003 found prevalence ofactive trachoma (>20%) similar to those of thirtyyears ago. 52 Studies have identified a maximumage-specific infection in pre-school Aboriginal andTorres Strait Islander children, but there are alsoconsiderable rates of active trachoma into the teenageyears. Studies have also identified that between 20%and 30% of Indigenous children in rural and remoteAustralia have active trachoma. Trachoma can betreated by antibiotics and can be prevented throughhealth promotion and education that highlights theimportance of face washing and facial cleanliness andimproved environments and health hardware. 53ImmunizationThere are varying estimates of the level ofimmunization coverage among Aboriginal and TorresStrait Islander children. Coverage varies from beingmuch lower to being the same as non-Aboriginal andTorres Strait Islander children. In general, vaccinationcoverage tends to be higher among Aboriginal andTorres Strait Islander children living in remote areascompared with those living in non-remote areas.However, there are concerns as to the adequacies indata collection because estimates are drawn from aHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 85

Pictured:Hiarnz & Darheionumber of sources and different methods can be usedto ascertain the level of coverage among Aboriginaland Torres Strait Islander children. Data suggests thatAboriginal and Torres Strait Islander at twelve monthsof age had lower vaccine coverage compared withnon-Aboriginal and Torres Strait Islander children atthe same age (82% compared with 91%), whereas attwenty-four months of age they had the same level ofcoverage as other Australian children (90.9% comparedwith 91.3%). 54Mental healthThere is a paucity of data to describe the mental healthand wellbeing of Aboriginal and Torres Strait Islanderchildren. The Western Australian Aboriginal ChildHealth Survey (WAACHS), conducted in 2001 and2002, found that:• 24% of Aboriginal and Torres Strait Islander childrenwere at high risk of clinically significant emotional orbehavioural difficulties compared with 15% of non-Aboriginal and Torres Strait Islander children. 36• more than one in five (22%) Aboriginal and TorresStrait Islander children aged zero to seventeen yearswere living in families where between seven andfourteen major life stress events had occurred in thetwelve months prior to the survey. 55• the proportion of children at high risk of clinicallysignificant emotional or behavioural problems waslowest in areas of extreme isolation. 55• stronger adherence to traditional culture and waysof life in extremely isolated areas may be a protectivefactor. 55• of the Aboriginal and Torres Strait Islander youngpeople aged twelve to seventeen years who weresurveyed, 9.0% of females and 4.1% of males hadattempted suicide in the past twelve months. 56• the children of Aboriginal and Torres Strait Islandercarers who had been forcibly separated from theirnatural families by a mission, the government orwelfare were more than twice as likely to be at highrisk of clinically significant emotional or behaviouraldifficulties. 55Child abuse and neglectThe relationship between child abuse and neglect andchild health and wellbeing is complex and related tothe type, severity and duration of the abuse and neglectand to the context in which it occurs. As in non-Aboriginal and Torres Strait Islander communities,it is commonly believed that child abuse and neglectin Aboriginal and Torres Strait Islander communitiesare caused by a multitude of factors However, theIndigenous perspective usually places considerablymore emphasis on the impact of the wider communityand societal causal factors. 57 Memmot suggests thesefactors include: precipitating causes (one or moreevents triggering a violent episode); underlying factors(historical circumstances); and situational factors (such86 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

as the combination of alcohol abuse, unemployment,and welfare dependency).A number of prominent Indigenous spokespersonsbelieve that present dysfunctional behaviour in someIndigenous communities, including the abuse andneglect of children, is grounded in unresolved griefassociated with multiple layers of trauma that hasspanned many generations. 58-60The report, Bringing Them Home drew attentionto the fact that violence may also be transmitted byomission. The past forced separation of Indigenouschildren from their families and communities hasresulted in a loss of parenting skills and abilities 12 , thusincreasing the likelihood of the involvement of childprotection services in Aboriginal families. 61It is clear that Aboriginal and Torres StraitIslander children are significantly over-representedin most statutory child protection systems. Basedon notifications (or reports) to child protectiondepartments in Australia in 2001–02, 3,254 Aboriginaland Torres Strait Islander children under seventeenyears had some form of abuse substantiated—that is,the statutory protection authority believed that abuseor neglect had occurred. 62 This rate of substantiationwas on average 4.3 times higher (for all types of abuse)in the Aboriginal and Torres Strait Islander populationthan in the non-Aboriginal and Torres Strait Islanderpopulation. The rate varied widely between states, withVictoria and Western Australia having a substantiationrate nearly eight times higher for Aboriginal and TorresStrait Islander children than non-Aboriginal and TorresStrait Islander children.Aboriginal and Torres Strait Islander children aresix times more likely to be removed from their familiesthan other Australian children 63 , a situation that haschanged little since this problem was identified in1979 at the First Aboriginal Child Survival Seminar. 64Aboriginal and Torres Strait Islander children comprise2.7% of children in Australia, yet constitute 20% ofthose placed in out-of-home care. 613.7 Access to health careThere is very little information detailing issues ofAboriginal and Torres Strait Islander children’saccess to health care at a national level. The mostcomprehensive information available is at the WesternAustralian state level from the WAACHS.The WAACHS survey found that Aboriginalchildren had fewer contacts with doctors whencompared with non-Aboriginal and Torres StraitIslander children. This difference becomes greater themore isolated children are. The more isolated childrenwere, the less likely they were to see a doctor and morelikely to see a nurse or Aboriginal Health Worker. 65 Thesurvey also found that:• Aboriginal and Torres Strait Islander children have avery low attendance for dental care• Aboriginal and Torres Strait Islander childrenattended accident and emergency health care atsimilar rates to non-Aboriginal and Torres StraitIslander children, regardless of location• Aboriginal and Torres Strait Islander children hada higher overall hospitalization rate compared tonon-Aboriginal and Torres Strait Islander children.However, the reasons for admission were similar,with the most common causes of hospitalizationfor all children being respiratory illnesses, otherinfections and injuries• the hospitalization rate for people who live in veryremote areas of Australia is almost 50% higher thanthat for people living in major cities. 653.8 Health ExpenditureOver one-quarter of Aboriginal and Torres StraitIslander peoples live in remote and very remote areasin Australia. 66 As such, and in order to experience thesame level and quality of care as their Aboriginal andTorres Strait Islander and non-Aboriginal and TorresStrait Islander urban counterparts, an increase in healthcare expenditure per capita must occur.In 2004–05, $1.17 per person was spent onAboriginal and Torres Strait Islander healthcare forevery $1.00 spent on the health of non-Aboriginaland Torres Strait Islander health. Average total healthexpenditure per Aboriginal and Torres Strait Islanderperson was $4,718 compared with $4,019 per personestimated for non-Aboriginal and Torres Strait Islanderpeople. It was also estimated that $2,304 million wasexpended on health care in 2004–05 for Aboriginaland Torres Strait Islander people. This was 2.8% of thetotal national expenditure on health services. Further,when compared to non-Aboriginal and Torres StraitIslander people, Aboriginal and Torres Strait Islanderpeople used public hospital and community healthservices more, and used less medical, pharmaceutical,dental and other health services. However, accurateand consistent Aboriginal and Torres Strait Islanderidentification continues to be a major barrier to preciseestimates of Aboriginal and Torres Strait Islander use ofhealth care. 663.9 Data limitationsCurrently, Indigenous people are relatively invisible inglobal health statistics due to major deficiencies in thehealth data describing them. Such deficiencies havebeen acknowledged in New Zealand, 67-69 Canada andHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 87

(1)Statutory data are data that areregulated or imposed by or inconformity with laws passed. Theyinclude vital statistics data.(2)Administrative data aredata collected as part of theadministrative process generallyfor audit purposes.the United States and in a number of Australian statesand territories. These deficiencies are in part due tomisclassification of Indigenous people; inconsistencies inthe collection, sources, completeness and classificationsin statutory (1) and administrative (2) data collections; andinconsistencies in analysis, interpretation and ownershipof the data in each jurisdiction.Prior to 1976, no Australian jurisdiction separatelyidentified Aboriginal and Torres Strait Islander peoplein vital statistics or hospital-based collections. In 1984,the Australian Government initiated moves to identifyall Aboriginal and Torres Strait Islander Australians inbirths and deaths data collections. By the end of 1997all major vital statistics and hospital-based collectionsincluded the Aboriginal and Torres Strait Islanderstatus of people who are born, die or are admitted tohospital in every state and territory. However, there isan acknowledged under-identification of Aboriginaland Torres Strait Islander people in statutory andadministrative data collections due to a general lack ofrecognition of the importance of collecting accuratedata, ineffective processes for the collection of dataand the absence of mandates to ensure that accuratedata are collected. Thus, the complete ascertainmentof Aboriginal and Torres Strait Islander people isquestionable. Those states where the ascertainment is ofconcern are Victoria, New South Wales, the AustralianCapital Territory, Tasmania and Queensland (before1998), which makes it impossible to provide a completeand accurate profile of the mortality of Australia’sAboriginal and Torres Strait Islander people. 5Mortality statistics are important indicators of apopulation’s health, as they provide vital informationon the prevalence of serious diseases and injuries.Studies of the trends in mortality and related statisticsalso demonstrate how the health status of a populationis changing, and enable the effect of health policies,services and interventions to be monitored andevaluated. The lack of ascertainment and accuracy inthese collections is of great concern because mortalitydata is one of the most important ways of measuringcommunity health. Important information aboutthe patterns of illness and deaths for the communityas a whole become available when details about thedeaths in the community are disaggregated. The excessburden of mortality borne by young Aboriginal andTorres Strait Islander Australians, and the disparity inthe rates of infant and childhood mortality that existsbetween Aboriginal and Torres Strait Islander and non-Aboriginal and Torres Strait Islander Australians, hasbeen reported in the Northern Territory and in the twostates (South Australia and Western Australia) that haveaccurate mortality data.Notwithstanding these limitations, the magnitude ofhealth disparities in Aboriginal and Torres Strait Islanderchild populations is concerning. Perhaps equallyworrying is that these disparities have not reduced inrecent years and, in many cases, are increasing.3.10 Examples of positive initiativesThe health status of Aboriginal and Torres StraitIslander people is significantly poorer than forAustralians as a whole. However, there have beensome improvements. Data indicates that theincrease in death rates for many chronic diseases isslowing and that deaths due to infectious diseaseshave significantly declined. Improvements havebeen identified across all age groups, but are mostdramatic in the under-five age group. These resultsshow evidence of health gain and that interventionscan make a difference. They demonstrate clearlythat improved access to primary healthcare canimpede increasing preventable mortality rates. Suchprograms must be supported by well-constructedAn Aboriginal and Torres Strait Islanderboy was two-and-a-half times more likely todie in the first year of his life than a non-Aboriginal and Torres Strait Islander boy,and an Aboriginal and Torres Strait Islandergirl was three-and-a-half times more likelyto die than a non-Aboriginal and TorresStrait Islander girl.88 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

Healthy for Life is an Australian Government initiative that commenced during the 2005–06budget cycle.The four year program, with an allocated budget of A$102.4 million, aims to improve the health ofAboriginal and Torres Strait Islander mothers, babies and children, improve the quality of life for peoplewith a chronic condition, and over time, reduce the incidence of adult chronic disease .The program is based strongly around the use of quality improvement principles, processes and toolsto deliver primary maternal, infant and child health care. The first phase of the program has seenparticipating services analyze collected information about the child and maternal health and chronicdisease service activity with the purpose of establishing baseline information.This baseline information has been used to monitor progress in achieving objectives for improvementin maternal, infant and child health.The objectives of Healthy for Life are to improve the:• availability of child and maternal health care• prevention, early detection and management of chronic disease• long term health outcomes for Aboriginal and Torres Strait Islander Australians• Aboriginal and Torres Strait Islander health workforce.The expected short, medium and long term outcomes include:Short to medium term outcomes (1–4 years)• increase in first attendance for antenatal care in first trimester• 10% increase per year of adult and child health checks, with associated plans for follow-up• 30% improvement in best practice service delivery for people with chronic conditions.Longer term outcomes (5–10 years)• increase in mean birth weight to within 200g of the non-Indigenous population• decrease in incidence of low birth weight by 10%• reduction in selected behavioural risk factors (eg smoking, harmful alcohol intake among others)in pregnancy by 10%• 30% reduction in hospital admissions for chronic disease complications• 30% improvement in numbers of patients with intermediate health outcomes within acceptable range.Text Box 1Healthy for Life programand well-resourced secondary prevention and healthpromotion programs.Reliable total population data in some Australianstates and territories provide an excellent resourcein determining the patterns and trends of morbidityand mortality among Aboriginal and Torres StraitIslander people.The authors of this paper have identified a couple ofinitiatives that have demonstrated that well-resourced,community-controlled and culturally appropriateand accessible programs can, and do, have a positiveimpact, and result in significant and sustainedimprovement in the health outcomes of Aboriginalpeople. An important component of any healthimprovement program will be the ability to measureaccurately the disparities and to track the impact thatpolicies, strategies and interventions have on healthoutcomes and the reduction of health disparities.Collection of dataText Box 1 provides a description of the programHealthy for Life. Importantly, this program willcontribute not only to an improvement in Aboriginaland Torres Strait Islander health in the perinatal periodand the early years, but also to the more accurate andcomplete collection of vital statistics data describingHealth of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 89

Text Box 2The Western AustralianMortality Database, Infants,Children and Young People• The primary source of data was the WA Maternal and Child Health Research Database which is acomprehensive linked total population data base including comprehensible information describingbirth, death, hospitalizations and the health status for every child born in Western Australia.• The other data sources include: The Registry of Births, Deaths and Marriages; autopsy case reports;reports of Coronial enquiries; forensic pathology reports; the Birth Defects Registry.• The forensic and coronial documents for every death are reviewed and the information informs theclassification of the death and coding of the cause of death.• A rigorous validation process is undertaken to ensure objectivity and every classification and code isreviewed by three independent experts to ensure internal validity of the classifications.• The databases is managed at the Telethon Institute for Child health research, Centre for Child HealthResearch, the University of Western Australia.• The continuing collection, review and analysis of these data has been funded by the WesternAustralia government – initially the Department for Community Development and more recently theDepartment of Child Protection.Pictured: HiarnzAboriginal and Torres Strait Islander, maternal, infantand child health.The Western Australian Mortality Database,Infants, Children and Young PeopleThis database includes comprehensive informationdescribing the death and the context in which the deathhas occurred for every child born in Western Australiabetween 1980 and 2006. The data from this databasehave been rigorously analyzed, and the patterns andtrends of mortality among Western Australian borninfants, children and young people that have occurredin the last quarter of a century have been widelyreported. The following information describes thestructure and content of this database.Particular focus has been on describing the change inthe disparities existing among the Indigenous populationwhen compared with the non-Indigenous population.These data have informed evidence-based policy, practiceand health information and education initiatives,particularly the prevention of SIDS and the change inlegislation to allow the fortification of flour with folateto assist in the prevention of Neural Tube Defects.‘Closing the Gap on Aboriginal and Torres StraitIslander disadvantage’In 2007, the new Federal Government made acommitment to Close the Gap in Aboriginal and TorresStrait Islander disadvantage including disparities90 Health of Indigenous Children: Health Assessment in Action Health of Aboriginal and Torres Strait Islander Children in Australia

• To close the life-expectancy gap between Aboriginal and Torres Strait Islander people and otherAustralians within a generation;• To halve the mortality gap between Aboriginal and Torres Strait Islander children and other childrenunder age five within a decade;• To halve the gap in literacy and numeracy achievement between Aboriginal and Torres StraitIslander students and other students within a decade;• To halve the gap in employment outcomes for Aboriginal and Torres Strait Islander people within adecade;• To at least halve the gap in attainment at Year 12 schooling (or equivalent level) by 2020; and• To provide all Aboriginal and Torres Strait Islander four year olds in remote communities with accessto a quality preschool program within five years.• Commonwealth of Australia, 2008 Statement by the honourable Jenny Macklin MP Minister forFamilies, Housing, Community Services and Indigenous Affairs. Closing the gap between Indigenousand non-Indigenous Australians.Text Box 2The Western AustralianMortality Database, Infants,Children and Young Peoplethat exist between the Aboriginal and Torres StraitIslander populations and other Australians in allthe social determinants of health. The Close the Gapcampaign, launched in 2007 was centred on two goals.The first being to drive existing Australian, state andterritory government commitments targeted at endingAboriginal and Torres Strait Islander health inequalitywith added accountable timeframes. The second beingthe development of a set of ‘Close the Gap IndigenousHealth Equality Targets’. In 2008, the AustralianGovernment allocated $AU 425.3 million in new fundsin the 2008-09 Budget specifically addressing the Closingthe Gap targets. The Australian Government has alsoagreed to an annual regimen of reporting the progresson reducing the gap of inequality. The threat to beingable to measure the success or failure of the campaignlies with the ability to accurately measure progress to thetargets set. Text Box 3 identifies the specific targets.3.11 Conclusion‘[T]he time is right for a global response to improve thehealth and well-being of Indigenous peoples’ (Assemblyof First Nations, Discussion Paper, p.40) 70Significant efforts and resources have been devotedto improving the health of Indigenous infants, childrenand young people in Australia, Canada, New Zealandand the United States of America over the past decade.There have been improvements in some educationaland health outcomes for Indigenous children. However,even in the face of these improvements, Indigenouschildren continue to fare worse than their non-Indigenous counterparts and disparities continue toexist among Indigenous populations. Many of thesedisparities reflect the historic, economic and socialcircumstances of Indigenous communities. Thesecontinuing and in some cases widening disparities,should challenge us all to do whatever is necessaryand to commit whatever resources at whatever cost, toremedy the causes of Indigenous disadvantage.Too often Indigenous people and their socialconditions are invisible. Much better data and qualityresearch on Indigenous health needs to be generated, butthis must be with the specific agreement of Indigenouscommunities. This includes the need to take account ofthe Indigenous communities’ holistic approaches to, andunderstandings of, health and well-being. Indigenouscommunities must be been actively involved in decidinghow or what should be studied about them, and for whatpurpose. This is particularly important, considering thatmany political decisions are made on the basis of thisresearch and often simplistic interpretations of data. 70Good health, education and social connectednessin childhood are fundamental to the developmentof human potential and to full participation in ademocratic society. Improving the health and wellbeing across all social determinants and reducing thedisparities that currently exist for Indigenous childrenin our society is not an option, it is an imperative.Improvements havebeen identified acrossall age groups amongAboriginal andTorres Strait Islanderchildren, but aremost dramatic in theunder-five age group.Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 91

3.12 REFERENCES1. Wild R, Anderson P. Report of the Northern Territory Board of Inquiryinto the Protection of Aboriginal Children from Sexual Abuse. Darwin:Northern Territory Government; 2007.2. Freemantle C.J., Read AW, de Klerk NH, McAullay D, AndersonI ., Stanley FJ. Patterns, trends and increasing disparities inmortality for Aboriginal and non-Aboriginal infants born inWestern Australia, 1980–2001: population database study. Lancet.2006;367:1758–1766.3. Freemantle C.J., Read AW, de Klerk NH, McAullay D, Anderson I .,Stanley FJ. Sudden Infant Death Syndrome – Aboriginal and non-Aboriginal disparities among infants born in Western Australiafrom 1980–2001 inclusive. Journal of Paediatrics and Child Health.2006;42:445–451.4. Freemantle CJ, Stanley FJ, Read AW, de Klerk NH. The First ResearchReport: patterns and trends in mortality of Western Australian infants,children and young people 1980–2002. 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37. Australian Bureau of Statistics. Births Australia, 2006. Canberra:ABS; 2007. Cat. no. 3301.0.38. Oddy WH, Sly PD, de Klerk N. H., et al. Breast feeding andrespiratory morbidity in infancy: a birth cohort study Archives ofDisease in Childhood 2003;88:224-228.39. Oddy WH, Holt PG, Sly PD, et al. Association of breastfeeding andasthma in 12 year-old children: findings of a prospective cohortstudy. British Medical Journal. 1999;319(7213):815-819.40. Thomas DP, Condon JR, Anderson AP, et al. Long-term Trends inIndigenous deaths from chronic diseases in the Northern Territory:a foot on the brake, a foot on the accelerator. Medical Journal ofAustralia. 2006;185(3):145–149.41. Australian Institute of Health and Welfare. A picture of Australia’schildren. Canberra: Australian Institute of Health and Welfare; 2005.AIHW cat. no. PHE 58.42. Hunter E, Harvey D. Indigenous suicide in Australia, New Zealand,Canada, and the United States. Emergency Medicine (Fremantle,WA). Mar 2002;14(1):14–23.43. Elliot-Farrelly T. Indigenous suicide in the United States of America,Canada and New Zealand: part 1. Aboriginal and Islander HealthWorker Journal. Jul 2004;28(4):21–25.44. Elliot-Farrelly T. Australian Aboriginal suicide: the need for anAboriginal suicidology? Australian e-journal for the Advancement ofMental Health. Vol 3; 2004.45. Vicary D, Westerman T. That’s just the way he is: some implicationsfor Aboriginal mental health beliefs. Australian e-journal for theAdvancement of Mental Health. Vol 3; 2004.46. Australian Centre for Asthma Monitoring. Asthma in Australia 2008.Canberra: AIHW; 2008. Asthma Series no. 3. Cat. no. ACM 14.47. Australian Institute of Health and Welfare. Rheumatic fever andrheumatic heart disease. www.aihw.gov.au/cvd/majordiseases/rheumatic.cfm. Accessed 28 January 2009.48. Currie BJ, Brewster DR. [Editorial] Rheumatic fever in Aboriginalchildren. Journal of Paediatrics and Child Health. 2002;38:223–225.49. Jamieson LM, Armfield JM, Roberts-Thomson KF. 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East Melbourne: Centre for Eye Health Research; 2008.54. Australian Institute of Health and Welfare., Australian Bureau ofStatistics. The health and welfare of Australia’s Aboriginal and TorresStraight Islander Peoples. Canberra: AIHW &ABS; 2005. AIHW cat.no. IHW 14; ABS cat. no. 4704.0.55. Silburn SR, Zubrick SR, de Maio JA, et al. The Western AustralianAboriginal Child Health Survey: Strengthening the Capacity ofAboriginal Children, Families and Communities. Curtin Universityof Technology and Telethon Institute for Child Health Research,Perth; 2006.56. Blair EM, Zubrick SR, Cox A. The Western Australian Aborignal Childhealth Survey: findings to date on adolescents. Medical Journal ofAustralia. 2005;183(8):433-435.57. Memmott P, Stacy R, Chambers C, Keys C. Violence in IndigenousCommunities. Canberra: Commonwealth of Australia; 2001.58. Pearson N. Our Right to Take Responsibility. Cairns: Noel Pearsonand Associates Pty Ltd.; 2000.59. Tomison AM. 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If Everyone Cared: Report arising from an InternationalSeminar on Aboriginal family life and the welfare of Aboriginalchildren. Melbourne: Victorian Aboriginal Child Care Agency inassociation with the Federal Office of Child Care; 1979.65. Zubrick SR, Lawrence DM, Silburn SR, et al. The Western AustralianAboriginal Child Health Survey: The Health of Aboriginal Children andYoung People. Perth: Telethon Institute for Child Health Research;2004.66. Australian Institute of Health and Welfare. Expenditures on healthfor Aboriginal and Torres Strait Islander peoples 2004-05. Canberra:AIHW; 2008. Health and welfare expenditure series no. 32.67. Blakely T, Ajwani S, Robson B, Tobias M, Bonne M. Decades ofdisparity: widening ethnic mortality gaps from 1980 to 1999. NewZealand Medical Journal. 2004;995(38).68. Blakely T, Kiro C, Woodward A. Unlocking the numeratordenominatorbias. II: Adjustments to mortality rates byethnicity and deprivation during 1991-94. The New ZealandCensus-Mortality Study.[erratum appears in N Z Med J 2002Feb 22;115(1148):87]. New Zealand Medical Journal. Feb 82002;115(1147):43–48.69. Blakely T, Tobias M, Robson B, Ajwani S, Bonne M, Woodward A.Widening ethnic mortality disparities in New Zealand 1981-99.Social Science & Medicine. 2005;61(10):2233-2251.70. Commission on Social Determinants of Health (CSDH). Socialdeterminants and Indigenous health: The International experienceand its policy implications. Paper presented at: InternationalSymposium on the Social Determinants of Indigenous Health,2007; Adelaide, South Australia: quote p.4.Health of Aboriginal and Torres Strait Islander Children in Australia Health of Indigenous Children: Health Assessment in Action 93

494 Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand

Health of Māori Children in Aotearoa / New Zealand4.1 Introduction. This report is a background document that outlines Māori child health outcomes in Aotearoa / New Zealand.It contains an overview of the Māori population, a brief description of the health system in Aotearoa / New Zealand, adescription of the collection and use of ethnicity data, an account of Māori children’s health status, and an outline of the useof ethnicity data using sudden infant death syndrome as an example.4.2 MĀoriMāori are the Indigenous peoples of Aotearoa / NewZealand. Prior to colonization Māori society wasstructured around kinship groups – whānau (families),hapū (sub-tribes) and iwi (tribes). The colonizationof Aotearoa / New Zealand commenced in the late1700’s and progressed at a more rapid rate after thesigning of the Treaty of Waitangi (the Treaty). TheTreaty formalized the relationship between Māori andthe British monarch and is sometimes referred to asthe ‘founding document’ of New Zealand. It forms thebasis of the relationship between Māori (the collectivegroup) and the government of New Zealand (as therepresentative of the Monarch). There has been, andcontinues to be, considerable debate about the Treaty,its implementation, and its relevance to contemporaryAotearoa / New Zealand. Historical and contemporaryclaims regarding breaches of the Treaty are heard bythe Waitangi Tribunal, which is able to make findingsabout alleged breaches and, where claims are upheld,recommend actions to address the breaches. Therecommendations it makes to government are nonbinding,and the government and the group who madethe claim then enter into negotiations in order to settlethe grievance. Further detailed information about thecolonization of Aotearoa / New Zealand, the Treaty,and the Waitangi Tribunal may be found in Orange1and Walker².Each tribe occupies specific regions in Aotearoa.Post-colonial settlements (rural, towns, and cities) arecontained within traditional tribal areas. For example,the greater Auckland region, which includes AucklandCity and contains about one-third of the populationof Aotearoa / New Zealand, is located within the tribalareas of the Ngāti Whātua and Tainui tribes. There areno reserves or reservations of the type found in Canadaand the USA.4.3 The Māori populationIn the 2006 census 15% of the population reportedMāori ethnicity – a total of 565,329 people. Just overhalf (52.8%) only identified Māori as their ethnicgroup, with the remainder identifying Māori and atleast one other ethnic group.³The Māori population is younger than the non-Māori population with a median age of 23 years forMāori and 36 years for the total population in 2006. In2006, 35% of the Māori population were under 5 yearsof age, and 53% were less than 25 years of age.⁴ Figure 1presents the population pyramids for Māori and non-Māori, illustrating the younger age structure of Māoricompared to the non-Māori population.AuthorSue Crengle PhD(c)Senior LecturerTe Kupenga Hauora MāoriDirectorTōmaiora Māori HealthResearch CentreFaculty of Medical &Health SciencesUniversity of AucklandAge group (years)Age group (years)85+ 85+80-84 80-8475-79 Male Female 75-79Male Female70-74 70-7465-69 65-6960-64 60-6455-59 55-5950-54 50-5445-49 45-4940-44 40-4435-39 35-3930-34 30-3425-29 25-2920-24 20-2415-19 15-1910-14 10-145-9 5-90-4 0-415 10 5 0 5 10 15 10 8 6 4 2 0 2 4 6 8 10PercentPercentMāorinon-MāoriFigure 1Age distributions of theMāori and non-Māoripopulations 2006Source: Hauora: Māori Standardsof Health IVHealth of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 95

30Percentage2520Māori non-Māori15105Figure 2Distribution of deprivationby ethnicity 2006Source: Ministry of Health01 2 3 4 5 6 7 8 9 10NZ Index of Deprivation decile 2001Decile 1 = least deprived; decile 10 = most deprivedMāori womenexperience boththe ethnic and thegender income gaps. 5This is particularlyimportant in relationto Māori children,as a substantialproportion of Māorichildren are livingin householdsheaded by a solefemale adult.The Māori population continues to grow and ispredicted to account for 17% of the total populationby 2021. The number of Māori children is expected tocontinue to increase, but will do so at a slower rate thanseen in previous years. Predictions suggest that by 2021the proportion of children in the Māori population willbe smaller than it is currently.⁴Māori are highly urbanized, and many live outsidetheir tribal areas. In 2006, 84% of Māori lived in urbanareas. The majority of Māori live in the North Island(87%) and about 25% of the Māori population live inthe greater Auckland region.³Just over 23% of Māori reported speaking morethan one language in the 2006 population census. Thispercentage is consistent with the proportion of Māoriadults who reported speaking Māori with some degreeof proficiency in the 2006 Māori language survey.An estimated 9,500 children attended Kohangareo (Māori language immersion pre-schools) andover 26,000 Māori children attended Māori languagemedium schools in 2006.4.4 Social and economic indicatorsThis section provides a brief overview of Māorisocio-economic status, experience of the widerdeterminants of health, and an overview of the livingstandards experienced by Māori. These factors arevitally important in determining the health statusof individuals and families, and are also importantdeterminants of access to care and health outcomes.Māori are over-represented in indictors of deprivationand have poorer access to the social and economicfactors that are important determinants of health.IncomeThere is a persistent disparity between the incomesof Māori and non-Māori. The median annual incomefor Māori 15 years of age and over was $NZ 20,900 in2006 while that of non-Māori was $NZ 24,400. Theethnic income gap is greater than the gender incomegap. Māori women experience both the ethnic and thegender income gaps.⁵ This is particularly important inrelation to Māori children, as a substantial proportionof Māori children are living in households headed by asole female adult.27% of Māori children live in poverty (definedas a household income below 60% of the medianhousehold income), as compared to 16% of NZEuropean children.⁵DeprivationThe New Zealand Index of Deprivation is a smallarea (neighbourhood) measure of deprivation.Small area deprivation is associated with bothmortality and morbidity in Aotearoa / New Zealand.Using nine variables from the population census,the index assigns each census mesh block to adeprivation decile.The least deprived decile is decile 1, and the mostdeprived is decile 10. Theoretically, ten percent ofthe population should reside in areas associatedwith each decile. However deprivation is not equallydistributed across the population. In 2001 over halfthe Māori population lived in areas associated withthe three most deprived deciles. However, less thanone third of non-Māori lived in areas associated withthose deciles. (See Figure 2)96 Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand

EducationEvidence suggests that the education system continuesto provide Māori students with lower quality educationthan that provided to non-Māori students. Māorichildren are more likely to leave school without aNational Certificate of Educational Achievement(NCEA) qualification. Half (49%) of Māori studentsleft school without this qualification in 2005, comparedwith 22% of non-Māori students. In tertiary educationsettings Māori are more likely to be studying forcertificate level qualifications than for degrees.⁵EmploymentA higher proportion of the Māori population isunemployed with 7.6% of Māori and 2.6% of NZEuropean people aged 15 years of age or overunemployed in June 2007.Māori who are employed are more likely to workin service industries and as machine operators andassemblers. Furthermore, there is evidence that Māoriexperience discrimination in getting a job, the type ofjobs they are able to obtain, and the wages paid for aspecific job.⁵HousingQuality of housing is an important determinant ofhealth. Māori are more likely to live in temporary orrental accommodation and to live in crowded houses.⁵Living StandardsThe living standards experienced by children aresignificant determinants of a child’s opportunities forhealthy development. The Economic Living StandardIndex (ELSI) incorporates data from a range ofindicators and measures the living standards of familyunits across Aotearoa / New Zealand. In 2000 and 2004the living standards for Māori were significantly lowerthan those of the total population. In 2004, 40% ofMāori families were living in hardship, compared with19% of European families.DiscriminationThe 2002/03 New Zealand Health Survey askedparticipants about their experience of ethnicallymotivated discrimination. Māori reported the highestprevalence of having ‘ever’ experienced discriminationin the health sector, work environment or whenbuying or renting housing. Overall, one third of Māorireported experiencing discrimination in any one ofthese settings. Furthermore, Māori were nearly tentimes as likely to report experiencing discriminationin all three setting (4.5% compared with 0.5% ofEuropean participants). The reported experienceof discrimination was significantly associated withadverse health outcomes in relation to self-rated health,physical functioning, mental health, being a currentsmoker, and reporting cardiovascular disease. 6,74.5 The health sector in Aotearoa /New ZealandThe NZ Public Health and Disability Act (2000)provides for the public funding and provision ofpersonal health services, public health services,and disability support services. The first two statedobjectives of the Act are:(a) to achieve for New Zealanders –(i) the improvement, promotion, and protectionof their health:(ii) the promotion of the inclusion andparticipation in society and independence ofpeople with disabilities:(iii) the best care or support for those in need ofservices.(b) to reduce health disparities by improving the healthoutcomes of Māori and other population groups.The majority of health services in Aotearoa / NewZealand are publically funded, with private insuranceaccounting for a small part of health sector activity.Services in secondary and tertiary care are free.Primary care funding includes a contribution fromthe government but patients also contribute towardsMāori – the indigenous people of Aotearoa / New Zealand• In 2006 about 15% of the population were Māori• The Māori population is younger than the non-Māori population• In 2006 35% of the Māori population was under 5 years of age and 53% were under 25 years of age• The Māori population is growing and is predicted to account for 17% of the population by 2021Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 97

Social and environmental determinants of health• Māori children are more likely to experience adverse social and environmental determinants of health• 40% of Māori families live in hardship compared with 19% of European (White)• 27% of Māori children live in poverty compared to 16% of European children• Māori are more likely to live in crowded homes• The education system fails to provide Māori children with the same quality of education as non-Māori• Māori are more likely to report experiencing discrimination that other population groups inNew Zealandthe cost of seeing a primary care doctor (user partcharges).Following the implementation of primaryhealth care reforms in 2001 the level of governmentsubsidy for primary care has increased, and the userpart-charges have been reduced for a substantialproportion of the population. Health care to childrenunder six years of age is typically free if the childattends the General Practitioner who usually providestheir care. Routine childhood immunizations arefree. Prescriptions attract a small charge – rangingfrom three to fifteen dollars per item if the drug isfully subsidized by the government. Prescriptionsfor medications that are not fully subsidized by thegovernment have higher charges.Māori health service providers (Māori providers)deliver primary health care and community healthprogrammes to Māori who choose to access theseservices. The number of Māori providers increasedsubstantially after the implementation of health sectorreforms in 1991 – 1992, and there are now over 200Māori providers. However, the majority of theseservices do not deliver primary medical care services.The majority of Māori receive care from ‘mainstream’health services (i.e. not from Māori providers). About14% of Māori participants in the 2002/03 New ZealandHealth Survey reported using a Māori health providerin the twelve months prior to their interview⁸. Moredetailed accounts of Māori providers may be foundin Crengle⁹; Crengle, Crampton & Woodward 10 andCrengle, Lay-Yee & Davis 11 .Specific strategies have been developed andimplemented to assist the health sector to achievethe objectives of the NZ Public Health and DisabilityAct. He Korowai Oranga: Māori Health Strategy waspublished by the Ministry of Health in 2002. Thestrategy contains four pathways:• Pathway 1 – development of whānau, hapu, iwi andMāori communities• Pathway 2 – Māori participation in the health anddisability sector• Pathway 3 – effective health and disability services• Pathway 4 – working across sectors.Increasing Māori provider capacity and capabilityand developing the Māori health and disabilityworkforces are included within Pathway 2. Pathway3 includes addressing health inequalities for Māori;improving the effectiveness of ‘mainstream’ servicesin relation to Māori health; providing highest qualityservices; and improving Māori health information.4.6 Ethnicity dataImproving Māori health status and reducinginequalities in health outcomes between Māori andnon-Māori are key objectives for the New Zealandhealth sector. 12, 13 In order to achieve these objectiveswe must able to describe and monitor Māori healthoutcomes. This requires complete, accurate, reliable,and valid ethnicity data.Prior to the 1986 census, for statistical purposesmembership of the Māori population was based ona biological definition (‘persons greater than halfMāori blood’, ‘persons of half or more Māori blood’).In 1986 the biological definition of ethnicity used inthe national census was replaced by a definition thatwas based on a social construct of ethnicity. However,ethnicity data relating to births and deaths continuedto use the biological definition until 1995 when thiswas also replaced by the social definition.The definition of ethnic group developed in 1988 bythe Department of Statistics is still in use. Accordingto this definition (Ministry of Health, 2004 pg.5) anethnic group is:A social group whose members:• share a sense of common origin• claim a common and distinctive history and destiny• possess one or more dimensions of collectivecultural individuality• feel a sense of unique collective solidarity.Each individual is able to nominate their ethnicaffiliation(s) – the ethnic group or groups which98 Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand

they (or their child) belong to. That is, an individual’sethnic affiliation is self-identified, and is not limitedto one ethnic group. Furthermore, an individual’sethnic affiliation may vary according to the situation,circumstances, or manner in which they are beingasked their ethnicity, and may vary over time.Although the definition of ethnicity has not beenchanged for twenty years there have been significantvariations in the manner in which ethnicity datahave been collected and used over those twenty years.These variations have adversely affected the accuracy,completeness, reliability and validity of (particularlyMāori) ethnicity data. The utility of the data forcomparison and time series analyses has also beencompromised by regular changes to the ethnicityquestion and changes to methods used for classifyingand using ethnicity data. 15-23In recent years strategies such as workforce trainingand the development of ethnicity data protocols havebeen implemented in order to improve the collectionand use of ethnicity data across the health sector.Recent evidence suggests that for the period 2001–04differences in ethnicity counts between the census andmortality datasets are minimal but hospitalization andcancer registration datasets continue to undercountthe Māori ethnic group. 24 The completeness andaccuracy of ethnicity data in primary care is poor andthe differential misclassification of ethnicity in thesedatabases results in under-enumeration of Māori andPacific people. 25-274.7 Child health statusThis section contains a brief overview of Māorichild health outcomes. With few exceptions the datademonstrates significant disparities in health outcomeswith Māori children experiencing worse outcomesthan non-Māori children.There are significant ethnic (and gender)differences in life expectancy at birth. A Māori maleborn in 2006 has a life expectancy of 71.2 years (78.8years for non-Māori males) and Māori females canexpect to live for 75.8 years (82.8 years for non-Māorifemales). 28Table 1 presents all-cause mortality rates by agegroup for children and young people aged 0–14 years.In each age group Māori experience higher mortalityrates with the greatest disparity occurring in infants(under one year).Age group Māori rate Non-Māori rate Rate ratio95% CI 95% CI 95% CI< 1 year 840.2 501.3 1.68777.7 – 907.6 471.4 – 533.1 1.52 – 1.85Table 1All-cause mortality ratesper 100,000, by age group2000 – 2004Source Hauora: Māori Standardsof Health IV1 – 4 years 40.9 30.1 1.3634.2 – 48.8 26.6 – 34.1 1.09 – 1.695 – 14 years 22.7 15.4 1.4719.4 – 26.4 13.9 – 17.1 1.22 – 1.77Māori children face significant challengesto their opportunities to develop and realisetheir potential. Many of these challenges,such as socioeconomic disadvantage, poverty,and poorer outcomes from health services,are located within the structures, institutions,services, and the power relationships inherentin New Zealand society. The disparitiesin health and social outcomes that areexperienced by Māori children are breachesof the rights and protections afforded themby the United Nations Declaration of theRights of the Child, Declaration on theRights of Indigenous Peoples, UniversalDeclaration of Human Rights and theTreaty of Waitangi.Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 99

were significantly higher than non-Māori for prematurebirth, unknown causes, SIDS, accidents, accidentalsuffocation in bed, and respiratory diseases.In the two older age groups accidents are thecommonest cause of death for both Māori and non-Māori although Māori rates are significantly higherthan non-Māori. In the one to four year age groupsMāori also have significantly higher mortality ratesfrom meningococcal disease and homicide. Mortalityrates from accidents (especially motor vehicle accidentsand drowning) and suicide are significantly higheramong Māori children aged five to fourteen yearscompared with their non-Māori peers.Table 3 presents the leading causes of hospitalizationfor infants under one year, and children aged one tofour years, and five to fourteen years. The all-causehospitalization rate for Māori infants was significantlylower than that of non-Māori infants, while the allcauserates were significantly higher for Māori childrenaged one to four and five to fifteen years compared withtheir non-Māori peers.The leading causes of hospitalization were the samein the two ethnic groups. In both ethnic groups livebirths was the most common reason for admissionof infants under one year. However, Māori infanthospitalization rates for perinatal conditions (includingpremature birth) and congenital anomalies weresignificantly lower than those of non-Māori, whilethe hospitalization rate for respiratory disease wassignificantly higher for Māori infants.Cause of Hospitalization Māori Non-Māori Rate ratioRate Rank Rate RankInfants under 1 year (rate per 100,000)Total: all causes 130764.6 161434.5 0.81*Liveborn infants ** 58338.0 1 71092.7 1 0.82*Perinatal conditions 21958.5 2 36003.6 2 0.61*– Premature birth 6393.9 7892.3 0.81*Respiratory diseases 18853.6 3 9213.8 3 2.05*Congenital anomalies 5203.2 4 7010.0 4 0.74*Infectious diseases 4956.0 5 4778.7 5 1.04Children ages 1 – 4 yearsTotal: all causes 17634.5 16793.2 1.05*Respiratory diseases 5094.3 1 4266.7 1 1.19*Injury and poisoning 2227.6 2 2022.3 3 1.10*Digestive system diseases 2003.1 3 1478.4 5 1.35*Ear disease 1874.5 4 1748.7 4 1.07*Infectious diseases 1666.9 5 2096.6 2 0.80*Children ages 5 – 14 yearsTotal: all causes 8189.8 7587.4 1.08*Injury and poisoning 1850.3 1 1687.6 1 1.10*Digestive system diseases 1079.8 2 959.3 2 1.13*Respiratory diseases 1022.0 3 944.8 3 1.08*Ear disease 950.5 4 523.7 5 1.81*Symptoms and signs (unknowncause)466.2 5 593.6 4 0.79*Table 3Leading causes of publichospitalizations by agegroup 2000-04Source Hauora: Māori Standards ofHealth IV* Rate ratios are statistically significant at the 5% level** Liveborn infants do not include all live births. They are discharges with live birth recorded as theprinciple diagnosis. These rates use babies born in hospital as the numerator and intercensual estimatesof the number of Māori and non-Māori babies as the denominator. They do not reflect the higher birthrates among Māori, where the rate is based on numbers of women giving birth.Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 101

The leading cause of hospitalizations for childrenaged one to four years, and for those aged five tofourteen were the same for the Māori and non-Māoriethnic groups, although the ranking varied.Among children aged one to four yearshospitalization rates for respiratory diseases, injury andpoisoning, digestive system diseases, and ear diseaseswere all significantly higher for Māori than for non-Māori. However the Māori hospitalization rate forinfectious diseases was significantly lower than thatof non-Māori.Among children aged five to fifteen yearshospitalization rates for injury and poisoning,digestive system diseases, respiratory diseases, and eardiseases were all significantly higher for Māori thanfor non-Māori. However the Māori hospitalizationrate for ‘symptoms and signs (unknown cause)’ wassignificantly lower than that of non-Māori.Māori children are less likely to experience thebenefits of preventive strategies such as routinechildhood immunization. National data indicate that, inthe 12 months to September 2008, fewer Māori children(68% of 24 month olds) had received their routineimmunizations compared with 82% of NZ Europeanchildren. 29 Disparities in access to immunization havebeen documented for many years and reflect barriers toaccessing these services. It is possible for health servicesto deliver effective immunization services to theircommunities and achieve near complete immunizationcoverage (Rachel Thomson personal communication).However, effective delivery such as this is the exceptionrather than the rule.Other data suggests that Māori children are notserved as well by primary care services. ‘The Top 10Report’ on the health and wellbeing of children andyoung people aged 0 to 24 years in the Auckland andWaikato regions found that regional rates of potentiallyavoidable hospitalizations in 1999 were higher for theMāori and Pacific ethnic groups 30 .Disparities in mortality and hospitalization rates arenot simply due to differences in socioeconomic statusbetween the Māori and non-Māori populations. Withineach decile of the New Zealand Index of Deprivationage-standardized all-cause mortality rates are higher inthe Māori than in the non-Māori population.This pattern is evident in SIDS mortality. As seen inFigure 3 Māori mortality rates from SIDS in deciles twothrough ten exceed that of non-Māori indicating thatthe differences in mortality are not due to differencesin socioeconomic status alone.Figure 3Māori and non-Māori SIDSmortality rates by NZ Indexof Deprivation decile2000-2004Source Hauora: Māori Standardsof Health IV1086Age-sex-standardized rate per 100,000Māori non-Māori4201 2 3 4 5 6 7 8 9 10NZ Index of Deprivation decile 2000 – 2004Decile 1 = least deprived; decile 10 = most deprived102 Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand

1210Māori Pacific Other8Rate64201968197019721974197619781980198219841986198819901992199419961998200020022004Figure 4 SIDS rates per 1000live births, by ethnicity1968-2005YearSource: New Zealand HealthInformation Service, 20084.8 Use of ethnicity data – a case studyThis section briefly describes the use of ethnicity datafor the monitoring of Māori SIDS.Figure 4 presents SIDS mortality rates by ethnicityfor the years 1968 – 2005. Pacific ethnic group data isonly available from 1998 onwards. Direct comparisonsbetween the years before 1995 and those after 1995 aredifficult as the method for classifying ethnicity changedfrom the biological definition to the social definitionin 1995. The effects of this change are most evident inthe Māori ethnic group, which substantially increasedin size. That is, there was a marked increase in thedenominator for Māori and the apparent reductionin Māori SIDS rates between 1994 and 1996 is largelydue to the increase in denominator rather than a ‘true’reduction. Nevertheless, some general observationscan be made. Māori SIDS rates have exceeded those ofthe ‘Other’ and Pacific ethnic groups in all years. From1968 both the Māori and Other ethnic groups SIDSrates increased. The rate for Other ethnic group infantspeaked at about 4 per 1000 live births in the years 1980– 1988. The Māori SIDS rate peaked at 8 – 10 per 1000live births in 1983 – 1993. As the SIDS rates increased,the Māori rate increased more rapidly resulting in amarked widening of the disparities between Māori andnon-Māori infants.The initial results of a major national studyto identify the factors associated with SIDS werepublished in 1991 31 . The study identified fourmodifiable risk factors: prone sleeping positionof baby, maternal smoking, absence of breastfeeding,and bed sharing. A major health promotionprogramme to reduce these risk factors was designedand implemented in 1991 – 1992. Although Māorimortality was greater than non-Māori, the interventionwas universally targeted and did not include Māorispecific messages or mechanisms for implementing theprogramme in Māori communities. The Other ethnicgroup SIDS rate fell steadily over the years 1990 – 1994,while the Māori rate fluctuated between about 7 and8 per 1000 live births, suggesting that the programmewas more effective for the non-Māori community.Furthermore, as the non-Māori SIDS rate fell muchfaster than the Māori rate, the disparity betweenMāori and non-Māori increased markedly. Specificcritique of the universal programme included that: theprogramme did not include appropriate and effectivemessages for Māori, did not consider appropriatemechanisms for disseminating the messages amongthe Māori community, and did not provide culturallyacceptable alternatives for bed sharing – a commonpractice in the Māori community.In 1994 a Māori SIDS prevention team wasestablished and subsequently implemented a specificMāori SIDS prevention programme across the country.Māori SIDS rates have steadily fallen since 1995. Itshould be noted that while the data suggests that theMāori SIDS programme was more effective than theuniversal programme, we are unable to draw absoluteconclusions that this was the case as the mortalitydata is ecologically derived rather than obtained froma specific outcome evaluation of the programme. Itshould also be noted that there is a yet to be answeredquestion about whether the reduction in Māori SIDSis a ‘real’ reduction or is an apparent one arising fromchanges in the classification of the cause of death. Theuse of ‘accidental suffocation in bed’ as the cause ofdeath has increased in recent years and is significantlyHealth of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 103

Improving Māori health status and reducinginequalities in health outcomes betweenMāori and non-Māori are key objectivesfor the New Zealand health sector. In orderto achieve these objectives we must able todescribe and monitor Māori health outcomes.This requires complete, accurate, reliable,and valid ethnicity data.Māori children’s health• The delivery of childhood immunizations is less effective for Māori children who have lower levels ofimmunisation coverage than European children• Data about potentially avoidable hospitalizations suggest that provision of primary care services toMāori children could be improved• All-cause mortality rates for Māori children under 1 year of age, aged 1-4 years and aged 5-14 yearsare significantly higher than those of non-Māori children• For many conditions Māori hospitalization rates exceed those of non-Māori childrenmore common for Māori infants (see Table 2). Whetherthe use of ‘accidental suffocation’ instead of ‘SIDS’accounts for all the apparent reduction in the MāoriSIDS rate is yet to be determined. The final point tonote is that although SIDS mortality rates for Māoriand non-Māori have dropped, the disparity betweenMāori and non-Māori persists, and in the years 2000-2004 Māori were more than five times likely to die fromSIDS than non-Māori 32 .4.9 ConclusionThis paper has provided a brief overview of indigenous(Māori) child health in Aotearoa / New Zealand.Māori children face significant challenges to theiropportunities to develop and realize their potential.Many of these challenges, such as socioeconomicdisadvantage, poverty, and poorer outcomes fromhealth services, are located within the structures,institutions, services, and the power relationshipsinherent in New Zealand society. The disparitiesin health and social outcomes that are experiencedby Māori children are breaches of the rights andprotections afforded them by the United NationsDeclaration of the Rights of the Child, Declaration onthe Rights of Indigenous Peoples, Universal Declarationof Human Rights and the Treaty of Waitangi.Improving health and social outcomes for Māorichildren requires us to collect accurate, complete,reliable, and valid ethnicity data. In addition toreporting these outcomes for Māori children, we mustalso compare them with the most advantaged childrenin our society.104 Health of Indigenous Children: Health Assessment in Action Health of Māori Children in Aotearoa / New Zealand

4.10 References1. Orange C. The Treaty of Waitangi. First ed. Wellington, NewZealand: Allen and Unwin in association with Port Nicholson Press;1987.2. Walker R. Ka Whawhai Tonu Matou: Struggle Without End: PenguinBooks; 1990.3. Statistics New Zealand. QuickStats About Māori. Census 2006.Wellington: Statistics New Zealand; 2007.4. Cormack D. The Māori Population In: Robson B, Harris R, eds.Hauora: Māori Standards of Health IV. Wellington: Te RōpūRangahau Hauora a Eru Pōmare; 2007.5. Robson B, Cormack D, Cram F. Social and Economic Indicators.Hauora: Māori Standards of Health IV. Wellington: Te RōpūRangahau Hauora a Eru Pōmare; 2007.6. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, NazrooJ. Racism and health: the relationship between experience ofracial discrimination and health in New Zealand. Social Science &Medicine. Sep 2006;63(6):1428-1441.7. 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Ministry of Health. He Korowai Oranga: Māori Health Strategy.Wellington: Ministry of Health; 2002.14. Ministry of Health. Ethnicity Data Protocols for the Health andDisability Sector. Wellington: Ministry of Health; 2004.15. Robson B, Harris R. Hauora: Māori Standards of Health IV. A study ofthe years 2000-2005. Wellington: Te Rōpū Rangahau a Eru Pōmare;2007.16. Ajwani S, Blakely T, Robson B, Atkinson J, Kiro C. Unlocking thenumerator-denominator bias III: adjustment ratios by ethnicityfor 1981-1999 mortality data. The New Zealand Census-MortalityStudy. New Zealand Medical Journal. Jun 6 2003;116(1175):U456.17. Blakely T, Kiro C, Woodward A. Unlocking the numeratordenominatorbias. II: Adjustments to mortality rates byethnicity and deprivation during 1991-94. The New ZealandCensus-Mortality Study.[erratum appears in N Z Med J 2002Feb 22;115(1148):87]. New Zealand Medical Journal. Feb 82002;115(1147):43-48.18. Blakely T, Robson B, Atkinson J, Sporle A, Kiro C. Unlocking thenumerator-denominator bias. I: Adjustments ratios by ethnicity for1991-94 mortality data. The New Zealand Census-Mortality Study.New Zealand Medical Journal. Feb 8 2002;115(1147):39-43.19. Pōmare E, Keefe-Ormsby V, Ormsby C, et al. Hauora: MaoriStandards of Health III; 1995.20. Robson B, Reid P. Ethnicity Matters: Māori Perspectives. Wellington:Statistics New Zealand; Sept 2001 2001.21. Smartt P, Marshall RJ, Kjellstrom T, Dyall L. Reporting comparisonsbetween Maori and non-Maori populations.[see comment]. NewZealand Medical Journal. Apr 12 2002;115(1151):167-169.22. Te Rōpū Rangahau a Eru Pōmare. Counting for Nothing:Understanding the issues in monitoring disparities in health.Social Policy Journal of New Zealand. July 2000 2000(14):1-16.23. Thomas DR. Assessing ethnicity in New Zealand health research.New Zealand Medical Journal. Mar 9 2001;114(1127):86-88.24. Harris R, Purdie G, Robson B, Wright C, Zhang J, Baker M. Appendix3: Estimating Māori Hospitalizations and Cancer Registrations.Wellington: Te Rōpū Rangahau Hauora a Eru Pōmare; 2007.25. Bramley D, Latimer S. The accuracy of ethnicity data in primarycare. New Zealand Medical Journal. 2007;120(1264):U2779.26. Health Utilisation Research A. Ethnicity data and primary care inNew Zealand: lessons from the Health Utilisation Research Alliance(HURA) study. New Zealand Medical Journal. 2006;119(1231):U1917.27. Marshall RJ, Zhang Z, Broad JB, Wells S. Agreement betweenethnicity recorded in two New Zealand health databases: effectsof discordance on cardiovascular outcome measures (PREDICTCVD3). Australian & New Zealand Journal of Public Health. Jun2007;31(3):211-216.28. Ministry of Health, Minister of Health. Health and IndependenceReport 2008. Wellington: Ministry of Health; 2008.29. Ministry of Health. Immunisation Coverage National and DHBData. http://www.moh.govt.nz/moh.nsf/indexmh/immunisationcoverage-data.Accessed 21 November 2008.30. Graham D, Leversha A, Vogel A. The Top 10 Report: Top 10 issuesaffecting the health and wellbeing of children and young people inAuckland and Waikato. Hamilton: Waikato District Health Board;December 2001 2001.31. Mitchell EA, Scragg R, Stewart AW, et al. Results from the first yearof the New Zealand cot death study. New Zealand Medical Journal.Feb 27 1991;104(906):71-76.32. Robson B, Purdie G. Mortality. In: Robson B, Harris R, eds. Hauora:Māori Standards of Health IV. Wellington: Te Rōpū RangahauHauora a Eru Pōmare; 2007.Health of Māori Children in Aotearoa / New Zealand Health of Indigenous Children: Health Assessment in Action 105

5106 Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States

Health of Indigenous Children in the United States5.1 Introduction. The United States population spends more on health care than any other country in the world. 1-3 And yet, asa whole, the health status of the United States’ population lags behind citizens of other industrial nations who spend less onhealth care. As of 2006, the US was 30th in life expectancy of 30 developed counties. 4 Research shows that not all Americanshave equivalent life expectancy. Some studies report that the gap between the highest and lowest life expectancies for a raceand geographic combination in the United States is over 35 years. 5, 6Indigenous people in the United States are among those in the US with the lowest life expectancy. 7 One contributor to thepoor health status of Indigenous people in the US is infant mortality. Infant mortality is regarded as an important indicator ofa nation’s health and social well-being. Some Indigenous groups in the US experience the highest infant mortality ratesin the country.This chapter discusses briefly a number of key issues, including infant mortality, which affects the health of Indigenouschildren in the United States. In addition, this chapter provides a brief overview of the Indigenous people of the United Statesand their health status, highlights some lesser known social determinates of health, presents available data on the health ofIndigenous children, and describes some major difficulties with the data collected on and for Indigenous people in the country.Finally, this chapter presents a successful strategy to address a number of key challenges; Indigenous epidemiology centers.5.2 Indigenous Population of the USAIn this publication, the Indigenous people of the UnitedStates are defined as populations who:• Have Pre-Invasion/Pre-Colonial HistoricalContinuity on Territory• Are Considered Distinct from those Now Prevailingin Territories• Are in Their Present Form, Non-Dominant Sectorsof Society• Are Determined to Preserve, Develop and TransmitAncestral Territories and Ethnic Identity to FutureGenerationsAlthough many members of these Indigenouscommunities refer to themselves using traditionalnames, the United States refers to members of thesegroups as American Indians, Alaska Natives and NativeHawaiians (AIANNH). There are over 562 federallyrecognized American Indian and Alaska Native Tribesand many more petitioning and working towards forFederal Recognition or Sovereignty, including NativeHawaiians. The Indigenous peoples of the United Stateshave diverse histories and rich cultures.According to the most recent US Census in 2000,4.3 million people, or 1.5% of the total US population,reported that they were American Indian or AlaskaNative. 8 Native Hawaiians makes up approximately0.1% of the US population, and currently numbers401,000 people. Residing on traditional home lands oron reservations/homesteads is an important measurefor Indigenous communities in the US because many ofthe resources and services provided to these populationsare available only in these areas. While having access tosuch lands may be equated with greater access to targetedservices, for various reasons, both by force and by choice,many Indigenous people have relocated to urban areasor relocated completely off island. An example of such aDiaspora is revealed in the fact that over 67% of AmericanIndians/Alaska Natives (AIAN) and 43% of NativeHawaiians (NH) reside off reservation or off island. 8Similar to other nations, the Indigenous people ofthe USA suffer grave health concerns.• AI/AN/NH have lower educational levels and higherunemployment rates AI/AN/NH population is ayounger population. Median age AIAN 28.0 years,NH 32 years, compared to 35.3 years for the US AllRaces.• Life expectancy for AI/AN 74.5 years (compared toUS Population 77.8)• Diseases of the heart, malignant neoplasm,unintentional injuries, diabetes mellitus, andcerebrovascular disease are the five leading causes ofIndian deaths (2002–04).• Native Hawaiians also have a higher rate of deathand disability due to stroke and cerebrovascularconditions than other populations (mortality rateof 58 per 100,000).Author:Maile Taualii MPH PhD(c)DirectorNative HawaiianEpidemiology CenterPapa Ola LokahiHealth of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action 107

Table1SocioeconomicCharacteristics AmongAmerican Indians/AlaskaNatives/Native Hawaiians,2000Source: 2000 US CensusNationwide PopulationsAIAN NH GeneralSocioeconomic Characteristics % % %Income in 1999 below poverty level 22.0 14.6 12.4Children (age

examined and applied the effects of historical traumaon Indigenous people. Contemporary symptoms ofdepression, posttraumatic stress disorder (PTSD) andgrief have been attributed to historical trauma.Loss of Traditional DietOne of the most crucial, yet still insufficientlyemphasized social determinate of health is the lossof traditional foods. In many cultures food is heldsacred. Often times, there are many direct links to foodand the creation beliefs. An example of this spiritualrelationship can be seen in the Hawaiian creation story:The taro, or kalo plant originated when the son ofWakea (Sky Father) and his daughter Ho’ohokukalaniwas born lifeless and deformed like the gnarled rootof a plant. The grieving parents buried the baby, but thenext day a taro plant sprouted from the grave, whichWakea named Haloa-naka. When the second son ofWakea and Ho’ohokukalani was born, they named himHaloa, because he was the younger brother of taro,from whom all Hawaiians descended. Haloa, first-bornman, was to respect and to look after his older brotherforever more. In return, the elder Haloa-naka, wouldalways sustain and nourish him and his descendants.The spiritual connection between food and manin many societies is not a coincidence. For survivalpurposes, societies were completely dependent on thefood they were able to grow and harvest. They chosefood products that would ensure their ability to surviveand thrive. In the example of the Hawaiian diet, thetaro plant, mentioned above, was the major staple ofthe diet. They considered the plant akin to a god, andbelieved they ingested his power when they consumedthe plant. In addition to strong cultural and spiritualties to the food source, taro is a nutritional food source.It is rich in calcium, riboflavin, iron and thiamine, hasno cholesterol and almost no fat, and is also used as amedicinal preparation for many ailments.The social costs resulting from a loss of traditionaldiet present themselves at both the individual andsocietal level. Initial costs to the individual beginwith the shift from consumption of healthier,traditional foods to the consumption of foods oflower nutritional value. It has been observed globallythat when changes in dietary consumption such asthese occur, there is a profound increase in dietrelatedchronic diseases such as obesity, coronaryheart disease, diabetes, high blood cholesterol levels,stroke, etc. These poor health outcomes have thepotential of limiting employment opportunities forthose individuals where the disease state resultsin a reduced capacity for work or left the personwith physical limitations at performing work.Consequently, reduced employability has an obviousnegative consequence on income and social status.In addition to these individual impacts, there arealso a number of societal consequences whenever thereis a loss of access to a traditional diet. For example,nutrition transition, especially among Indigenouspeoples, has been noted to result in a grave loss ofcultural and spiritual connection to traditional food.The very food that has for centuries served as thespiritual, cultural, and physical lifeblood of Indigenouspeople the world around has suddenly becomeunavailable or ‘unsafe’ to consume. This, in turn, lendsto the potential demise of those customs and traditionsassociated with traditional foods. Other challengesto society include rising health care costs due todiet-related diseases. This is especially pronouncedwhen the abandoning of native diets with its inherentAmerican Indian/Alaska Native1.91%Native Hawaiian0.21%Figure 1US Children – Ages 0–14Source: 2000 US CensusNon-Indigenous97.89%Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action 109

protective benefits is substituted for foods with highfatand high-sugar content which can lead to thosepredictable poor health outcomes. While this is a globalphenomenon, government agencies of many countriesare ill-equipped and poorly educated to effectivelyaddress the resultant increase in costs in health care.In addition, national productivity (i.e. industrial)decreases when work days and school days are misseddue to diet-related chronic diseases.5.4 Health of Indigenous children ofthe USAIn the United States there are approximately 1,274,000American Indian/Alaska Native/Native Hawaiianchildren between the ages of 0–14. These Indigenouschildren comprise roughly 2.1% of the total 0–14 agegroup and more than 25% of the Indigenous population.The health status of these children mirrors that oftheir preceding generations, in that there are gravehealth disparities. A number of key areas of disparitiesare highlighted within this report.Infant MortalityInfant mortality is one of the most reliable indicatorsof a nation’s health and social well-being. The UnitedStates ranked 26th among thirty developed countriesin terms of infant mortality rate in 2000 and recentdata suggest that the rate of decline in the nationalinfant mortality rate has stabilized. 11 However, for someIndigenous communities in the US, disparities in infantmortality persist and in some instances have evenworsened. All of this while proportional risk factorsto infant mortality (e.g., rates of low-birth weight)continued to increase. 12-15Among Indigenous populations in the US,Native Hawaiians experience the highest infant andneonatal mortality rates. 15, 16 American Indians/AlaskaNatives also experience high infant mortality rates. 14Table 2Mortality rate per 1,000 livebirthsSource: CDC, National Center forHealth Statistics (NCHS).Race of mother Infant Neonatal PostneonatalAll races 7.0 4.7 2.3White 5.8 3.9 1.9American Indian/Alaska Native 8.6 4.6 4.0Native Hawaiian 9.6 5.6 4.0110 Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States

Disease patterns and health disparities among thisheterogeneous population have been associated withpoverty, limited access to health care services, andcultural dislocation. Much of the research on infantmortality among American Indians/Alaska Natives hasfocused on Sudden Infant Death Syndrome (SIDS). 14Although little is known and documented related tothe direct causes of infant mortality, one surveillanceproject, the Pregnancy Risk Assessment MonitoringSystem (PRAMS), conducted by the US Centers forDisease Control and Prevention (CDC) as well as statehealth departments, aim to collect population-baseddata on maternal attitudes and experiences before,during, and shortly after pregnancy. Table 3 showsa number of key factors associated with poor healthand infant mortality for American Indians and AlaskaNatives. Comparable data on Native Hawaiians is notavailable at this time.Table 4 shows the mortality rate for AIAN childrenby age group. Data for Native Hawaiian children is notyet available.HospitalizationHospitalization data specific to AIANNH populationsis very limited. Many of the complexities related to datainterpretation results from the non-uniformity of healthservice delivery in the US The US is the only westernindustrialized nation that relies on for-profit privateinsurance agencies to fund the cost of health care for amajority of the US population. 17 This has lead to a crisislevellack of adequate access to health care in the UnitedStates for some 45 million people. 18Although limited, some hospitalization datais available for American Indians/Alaska Natives.Hospitalization rates for injury among AI/ANs havebeen published for the Indian Health Service (IHS)service population, but these analyses have notspecifically focused on children (IHS). Furthermore,these analyses have used IHS hospital discharge dataand may miss AI/AN patients who receive hospitalcare outside of the IHS system, especially if thepayer is other than the IHS. State hospital dischargeregistries represent another potential source of datafor surveillance of hospitalizations, but many do notcontain racial or ethnic identification data. If they do,the potential also exists for racial misclassification. 13The most widely used source of information onhospitalization is National Hospital Discharge Survey(NHDS). Conducted annually by the National Centerfor Health Statistics, NHDS collects medical andNationwide PopulationsAIANGeneral% 95% CI % 95% CIPoor Birth Outcomes/Risk Factors (1991-2000)Low birth weight (

Table 4American Indians/AlaskaNatives Children MortalityAIANAll Races CombinedRate per 100,000 95% CI Rate per 100,000 95% CILess than 1 YearAll Causes 782.17 (753.49, 811.7) 715.11 (712.15,718.08)Congen malfrm/defrm/chrm abn 147.72 (135.41, 160.87) 140.85 (139.54, 142.17)Accidents and external causes 41.24 (34.87, 48.46) 22.84 (22.31, 23.37)Influenza and pneumonia 22.95 (18.27, 28.47) 7.57 (7.26, 7.88)Diseases of heart 19.46 (15.17, 24.59) 13 (12.6, 13.4)Assault (homicide) 16.2 (12.31, 20.92) 8.3 (7.98, 8.62)Age 1-4All Causes 47.53 (44.19, 51.07) 32.79 (32.47, 33.11)Accidents and external causes 19.25 (17.15, 21.55) 11.62 (11.43, 11.81)Assault (homicide) 4.07 (3.14, 5.2) 2.49 (2.40, 2.58)Congen malfrm/defrm/chrm abn 3.96 (3.04, 5.07) 3.4 (3.30, 3.50)Age 5-9All Causes 47.53 (44.19, 51.07) 32.79 (32.47, 33.11)Malignant neoplasm (MNP) 19.25 (17.15, 21.55) 11.62 (11.43, 11.81)Assault (homicide) 4.07 (3.14, 5.2) 2.49 (2.4, 2.58)Accidents and external causes 3.96 (3.04, 5.07) 3.4 (3.3, 3.5)Age 10-14All Causes 24.11 (22.16, 26.19) 20.11 (19.89, 20.32)Accidents and external causes 12.44 (11.05, 13.95) 7.9 (7.76, 8.04)Intent self-harm (suicide) 2.4 (1.82, 3.12) 1.35 (1.29, 1.41)Assault (homicide) 1.2 (0.8, 1.74) 1.13 (1.08, 1.18)CI=confidence intervaldemographic information from a sample of inpatientdischarge records selected from a national probabilitysample of non-Federal, short-stay hospitals. The dataserve as a basis for calculating statistics on hospitalinpatient utilization in the United States.Race is not reported in about 18% of NHDSrecords since data on race are not reported by manyhospitals due to the omission of a race field onhospital discharge reporting forms. 19 More hospitalshave automated their discharge systems in recent yearsand are currently using a form which does not requirerace reporting.Because population based, hospitalization data forUS Indigenous children is not available at this time, aspecial focus highlighting areas of concern is includedfor this report.InjuryInjuries are a leading cause of childhood morbidityand mortality throughout the world. Although therehave been substantial declines in the rates of deathfrom injuries among children in developed nations,it still remains the principal threat to the health andwelfare of children and adolescents. American Indiansand Alaska Natives (AI/ANs) have higher rates ofinjury morbidity and mortality than all other races. 20In addition, AI/AN children experience higher rates ofmorbidity and mortality from unintentional injuriesthan do other US children. The 881 injury deaths to AIchildren between 1992 and 1994 translate to an overallrate of 52.3 deaths per 100,000 children per year. Thisrate is nearly twice the US rate of 28.3 per 100,00021, 22children for all races (1993).Limitations in the health population datamake it nearly impossible for communitiesto advocate for resources to createculturally appropriate care112 Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States

A particularly revealing study which examinedhospitalizations for AIAN youth provides an analysishighlighting one area of health disparities existing inthe US 23 In this analysis, a total of 694 hospitalizationsfor injury were identified for AI/AN youth and29,048 were identified for all races. Table 5 presentsfindings from this study. In summary, AI/AN childrenexperience a disproportional rate of hospitalizationsdue to injury and therefore more efforts to reduceinjury are critical for this population.DiarrheaFor 2000–04, diarrhea-associated hospitalization rateswere similar for AI/AN children versus US children

Aberdeen area found that binge drinking (five or moredrinks at a time) during the mother’s first trimesterof pregnancy made it eight times more likely that herinfant would die of SIDS. 36 Any maternal alcohol useduring the periconceptional period (three monthsbefore pregnancy or during the first trimester) wasassociated with a six-fold increased risk of SIDS. Thestudy also found that infants were more likely to die ofSIDS if they wore two or more layers of clothing whilethey slept. 365.6 Challenges in Data CollectionLocal, state and federal public health institutionsroutinely develop, coordinate, and maintainsurveillance systems for the US populations; however,major gaps exist for Indigenous communities.Although various departments of health collect datawhich might include Indigenous populations, it isatypical for the surveillance data to be disaggregated orseparately analyzed for the population. The occurrenceof sub-analysis and/or the availability of this data varybetween the different health departments. Federalpublic health institutions may conduct national surveys(through state agencies) which provide national andstate data for monitoring various health indices.However, small population numbers, low responserates, and the lack of dis-aggregation for analyses aresome examples of why such analyses have failed to beforthcoming. This continues to be one of the ongoingchallenges faced.One solution to this data survey discrepancy is toperform sub-population oversampling. Unfortunately,this requires additional financing and consequentlymay not be frequently considered or incorporated.Until recently, no national data was available on thehealth of Native Hawaiians. Data was only collected forthe aggregate population group, Asian/Pacific Islanders(Asian/PI). Asian/PI encompasses many distinctcultures and as a consequence, the disparities affectingNH become invisible under this system. Currentefforts to describe the health of NH are challengeddue to sample size limitations and under counting. As114 Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States

An example of successful strategies employedin the U.S. Indigenous communities are thecreation and establishment of the TribalEpidemiology Centers.more government agencies adopt and implement thenew Federal data collection guidelines on race whichspecifically identifies NH separately from the largerAsian category, more data will be available and thehealth status of the now identifiable sub-population canbe measured and monitored with greater accuracy.Recent literature provides strong evidence of howessential accurate health information is in effectivelyidentifying and eliminating current health disparities.Limited or inaccurate population health data is acore problem for Indigenous communities. Datais needed to create culturally appropriate healthprograms, identify areas of need, and for advocatingon behalf of the community. Such efforts could redressthe health disparities and would result in improvedaccess and affordability of health care. Inaccuraciesand deficiencies in the health population data dueto misclassification and aggregation make it nearlyimpossible for subpopulation groups to advocate forresources to create culturally appropriate care essentialto address health needs.5.7 Community-Based Strategiesand SolutionsIn recent years, the Indigenous communities ofthe US have expressed interest in increasing theirunderstanding, capacity in effective use, and controlover health data for the purposes of developingprograms and in forming policy. Indigenouscommunities express a clear understanding of the valueof data, and especially of high quality data, as a toolfor making better program and funding decisions thatwill have demonstrated benefits for their communitymembers. This insight and strategy is tremendouslyimportant for any program wishing to strengthen andexpand its use of health data.An example of successful strategies employed byIndigenous communities within the US is seen in thecreation and establishment of the Tribal EpidemiologyCenters. Funded by the Indian Health Service, TribalEpidemiology Centers are community or Tribal-basedorganizations that plan, coordinate, and performessential public health services necessary to addressthe health deficiencies specific to AIAN. In 2009, theNative Hawaiian health organization, Papa Ola Lokahi,announced the establishment of its own Indigenousepidemiology center.Effectively addressing the health and wellness ofthe US Indigenous populations demands a greateraccountability with sound planning and development.Central to this effort is consistent, specific, andstandardized data collection and the utilization ofthat information which addresses all factors affectingIndigenous health. Indigenous epidemiology centersmanage public health information systems, investigatediseases of concern, manage disease preventionprograms, and coordinate activities with other publichealth authorities. The Indigenous epidemiologycenters focus on collaboration with existing publichealth entities and filling gaps in the public healthsystem where Indigenous populations’ needs mightotherwise go unnoticed.5.8 ConclusionIn reviewing data for this chapter, a number ofchallenges were raised, particularly since no priorreport has detailed health issues facing AmericanIndians, Alaska Natives, and Native Hawaiian childrencollectively. A key challenge was the availability ofquality data for all Indigenous children in the UnitedStates. Thus, data which highlighted or reported thehealth of the United States Indigenous people waslimited; only subsections of the people were highlighted,data was regional, or the data excluded a substantialproportion of the population (e.g. off-reservepopulations and non-federally recognized people).Unfortunately, the special and unique relationshipformalized between the US government and the nation’sfirst and original people does not ensure systematic,standardized, and comprehensive monitoring of health.This negligence, whether intended or unintended, hasserious deleterious effects on the Indigenous childrenin the US, as many health issues may go unmonitoredand unmeasured. Without careful attention andprioritization of Indigenous children in the US, manywill continue to suffer grave disparities.Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action 115

Indigenous epidemiology centersmanage public health information systems,investigate diseases of concern, managedisease prevention programs, and coordinateactivities with other public health authoritiesDespite the limitations of low quality data, findingsshow that Indigenous children of the US carry adisproportionate weight of the burden of poor healthin the country and efforts must be made to improvetheir health status. In a nation as wealthy as the UnitedStates, children should always have access to healthcare. Timely access to culturally sensitive and highquality health care is central to improving the health ofIndigenous children.In addition to the health challenges which couldbe resolved by access to quality health care, a numberof health issues faced by Indigenous children could beaddressed through support services to families. Socialdeterminants of health such as poverty, employment,and education can have a greater impact on health thenaccess to health care.Most importantly, efforts must be made to supportthe resurgence of Indigenous culture, language, andtraditions. Resiliency of traditional practices, accessto traditional foods, and the resurgence of Nativelanguages help to address the effects of colonization.Local community based solutions which supporttraditional practises, coupled with community basedsolutions to monitor progress towards improvinghealth (i.e. Indigenous epidemiology centers) willenrich the lives of Indigenous people in the UnitedStates, resulting in improved quality of life forIndigenous children.116 Health of Indigenous Children: Health Assessment in Action Health of Indigenous Children in the United States

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NewYork: Oxford University Press; 1992.Health of Indigenous Children in the United States Health of Indigenous Children: Health Assessment in Action 117

6118 Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations

Indigenous Child Health Stakeholder’s Meeting –Discussion and Recommendations6.1 Introduction.. The chapter presents a summary of findings from discussion groups held with key First Nations, Inuit,and Métis child health stakeholders in Canada and the international authors. The summary is derived from The Health ofIndigenous Children: Health Assessment in Action Meeting held at St. Michael’s Hospital, Toronto, Canada, on May 30th, 2008.This important meeting brought together a diverse mix of twenty-one health professionals, policy makers, communityrepresentatives, analysts and researchers working in the field of Indigenous children’s health from Canada, New Zealand,Australia, and the United States. (Participants are listed in Appendix A). Discussion topics included: identification of keyhealth issues; best practice ideas; and policy approaches. This summary is a reflection of the stakeholders enthusiasm andpassion for improving Indigenous children’s health in both a Canadian and international context.6.2 PROCESSPresentationsAt the meeting, Canadian and international authorsshared their knowledge with stakeholders on currentIndigenous child health assessment information andbest practices from each presenter’s home country.Presentations focused on commonly used children’shealth measures as well as Indigenous-specificmeasures where available. Please refer to previouschapters for more in-depth accounts of Indigenouschildren’s health assessment in individual countries.Group Activities and FeedbackFollowing the presentations, those at the meetingparticipated in two discussion group activities. The firstactivity involved small group discussions. The secondactivity was a large group discussion involving everyonein attendance. Following the meeting, all the prioritiesand recommendations identified and discussed weresummarized and provided to participants via emailfor review and clarification. This final report summaryincorporates that additional feedback.Group Activity 1Participants were organized into three groups: FirstNations, Inuit, and Métis. Each group brainstormedideas, provided insights and developed a list of:(a) key health status inequities and / or issues facingIndigenous children (First Nations, Inuit andMétis respectively)(b) priority areas for Indigenous children’s healthassessment and responseThe groups then presented the lists they hadgenerated to the larger group. These lists were laterarranged by the chapter authors into the followingbroad theme groups: Social Concerns; HealthConcerns; and Health Service Delivery Concerns.Group Activity 2Following the first group activity, a larger groupdiscussion took place to identify:(a) Indigenous child health assessment and responseissues that cut across First Nations, Inuit, andMétis groups(b) best practice ideas for Indigenous children’s healthassessment and response(c) policy approaches to Indigenous children’s healthassessment and response (i.e. balancing the rightto be counted, OCAP (ownership, control, accessand possession of information), Indigenous rightto participate in governance and management ofhealth data, and the rights of children)Authors:Dr Gilbert Gallaher PhDResearch FellowCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt Michael’s HospitalPaul Adomako MScResearch Coordinator IIICentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt Michael’s HospitalJanet Smylie MD MPHResearch ScientistCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt Michael’s HospitalAssociate ProfessorDalla Lana School ofPublic HealthUniversity of TorontoCommunity autonomy and selfdeterminationdo not necessarily need tobe incompatible with using other westerntools for accurate data collectionIndigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action 119

6.3 GROUP ACTIVITY 1Table 1Inequities / PrioritiesSmall Group One – First NationsSocial ConcernsAdditional comments from flipcharts /mini-group presentations1. Poverty2. Housing3. Education −−Lack of access to quality on-reserve education−−Difficulty accessing off-reserve education−−Post and secondary retention rates−−Sustainable costs4. Food security5. Child welfare −−Family violence; foster care; abuse6. Environmentally related impacts −−Environmental contamination and some cancerslinked to child health7. Experiences of racism −−Interpersonal & institutional (systemic) racismaffecting accessibility to servicesHealth Concerns1. Oral health −−Access to fluoridation in water; access to receivetreatment (anesthetic waiting lists)2. Obesity −−Links to other chronic conditions includingdiabetes / hypertension3. Cervical Cancer Screening* (see below) −−Implications of HPV vaccinations4. Special needs:• Autism• Fetal Alcohol Syndrome5. Hearing (Otitis Media)1. Lack of coordinated care• Multiple visits with different care providers /specialists−−Stereotypes and stigma associated with labelingand the potential for this to impact serviceaccessibilityHealth Service Delivery Concerns−−Need for a harmonization of servicesOther1. * Scope of the proposed Report − − * Clarification required re: ‘just’ Child health –or Child and Maternal Health?Need to note linkages between these.120 Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations

Inequities / Priorities1. Schooling• Quality of education/curriculum• Workforce• Historical family experiences• Pre-school and Day Care needs (especially witheconomic development drive)Small Group Two – InuitSocial ConcernsAdditional comments from flipcharts /mini-group presentations−−Workforce/Human Resources (across sectors;Inuit capacity; retention)−−Increase Aboriginal Head Start programs.Making the system work better for Inuit children –improving retention in Education−−Second languages and bilingualism−−Balancing women in the workforce and the needsof their children2. Housing• Quality of housing• Overcrowded housing• Health impacts of poor housing−−Respiratory illnesses and infectious diseases−−Reduced schooling−−Social impacts−−How do Inuit access quality housing?3. Food Security• Multifaceted4. Exposure to violence1. Mental Health−−Traditional economy: hunter / gathering / fishingand how to preserve this− − Implications of foods and their links to oral health− − Links between workforce and being able to accessoral healthHealth Concerns2. Suicide −−Suicide awarenessHealth Service Delivery Concerns1. Lack of child-centered care Limited access to healthcare/doctors2. Lack of data• ‘Next to nothing’• Limited mortality information• Data use and accessibility−−Establish data protocols with researcheraccountability; researchers need to returninformation back to the community−−Include statistics on resilience outcomes from‘on the land’ programs etc.−−Data to reflect regions and communities as well as‘national’ (total Inuit) populationNurturing intra-cultural resilience and wellbeingOther−−Inuit traditional values:On the Land & ‘Country Food’Table 2Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action 121

Inequities / PrioritiesSmall Group Three – MétisAdditional comments from flipcharts /mini-group presentations1. Health Status Inequities are unclear because of:• lack of ability to measure• lack of consistent terminology• Data is required to provide reasons as to whythese events occur−−Currently no baseline data records / measurementsfor infant health exist – so difficult to paint anaccurate & ongoing picture of Métis health or toplan more appropriate health service delivery−−Cross-jurisdictional challenges−−Communities to identify the health and wellbeingindicators that are relevant to them:• interpreted in context (community norms &mores could be reflected within these indicators)• Community to be involved as a Data WorkingGroup & provide input on a ‘Data Dictionary’Social ConcernsTable 31. Racial discrimination −−Lateral violence is an issue that is often articulatedby Métis and can be more common and destructivethan within First Nation Communities−−Discrimination exists within families, betweencommunities as well as from other Aboriginalcommunities2. Kinship / Family −−Acceptance of heritage or lack of recognition,generational effects of abuse may be present dueto a number of factors not excluding residentialschool experience−−Domestic violence, ‘parenting’ knowledge& strategies3. Food security4. Housing securityHealth Concerns1. Infant mortality – reproductive health −−Pre-conception and pre-natal2. Mental wellbeing3. Mobility −−Highly mobile population intra andintergenerational mobility thus difficult to identifyactual numbers, and deliver programs whenpopulation is often in flux1. Pre-natal careHealth Service Delivery Concerns122 Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations

6.4 Group Activity 2A) Cross-Cutting Indigenous Children’s Health andHealth Assessment Issues and PrioritiesAs evident from Group Activity 1, many of theissues affecting the health of Indigenous childrenare cross-cutting for First Nations, Inuit and Métispopulations. Some similarities / commonalitieswere also identified and shared with the Canadianstakeholders by international guest speakers fromNew Zealand, Australia and the USA. Although thefollowing cross-cutting areas of concern were identifiedas priority areas, they are not listed in any hierarchy. Itis also acknowledged that these issues are not seen asoccurring in isolation from one another, but rather areundoubtedly inter-related.Social Concerns• Poverty• Housing• Education / Schooling• Food Security• Child Welfare / Exposure to Violence• Racial discrimination as a determinant of healthaffecting access to services and quality of carein servicesHealth Concerns• Oral health• Hearing health• Diabetes, Obesity & other chronic diseases• Respiratory & other infectious diseases• Mental healthHealth Service Delivery Concerns• Lack of child-centered care• Lack of coordinated careHealth Status Inequities and IMR• Health status inequities for Indigenous childrenare currently unclear because of the inability toaccurately measure them• Need for the development and/or improvement ofboth data collection and data sharing protocols in amanner that is respectful and ensures cultural safetyfor Aboriginal groupsB) Best practice ideasBest practice ideas generated from discussions at themeeting reflected the concept of ‘Practice Partnerships’.This included more consultation, engagement andinvolvement amongst researchers, public healthpractitioners and Aboriginal communities. This wouldprovide communities with the time and space toidentify, utilize and then apply health data productsto benefit their children. Most importantly, practicepartnerships would foster increased opportunitiesfor engaging with and drawing on the expertise ofAboriginal community leaders. This was seen as afundamental and necessary for establishing trustand negotiating ownership of data for Aboriginalcommunities.In the spirit of best practice partnerships and inlight of Canada’s colonial history, it was identified thatcommunity autonomy and self-determination do notnecessarily need to be incompatible with using other‘western’ tools for accurate data collection. Participantsrecognized that attempts to achieve a balance in thissense must account for the differences in historicalperspectives and experiences of First Nations, Inuit andMétis. Understanding these differences when informingbest practice and policy initiatives is important, forit avoids the mentality of ‘a one size fits all’ approachto Aboriginal issues. As such, it reduces the socialfallacy of Aboriginal essentialism and promotes a spacefor recognizing and celebrating the diversity of FirstNations, Inuit, and Métis in Canada.Participants highlighted that action was requiredto strengthen and increase the capacity for Indigenouscommunities to identify issues and address inequitiesin relation to data collection (or lack thereof) whichcontinue to have huge impacts on the health ofAboriginal children. This action is important becausecurrent data sets are skewing (underestimating /misrepresenting) infant and child morbidity andmortality rates for our children. Again, the notion ofbest practice and sustainable partnerships was raisedas one way for reducing the chance of data misuseor misinterpretation. This would be seen in practiceas advocating for community representatives, publichealth data practitioners, and other stakeholdersto work together. One example of this discussedat the meeting came from the SOGC (Society ofObstetricians and Gynecologists of Canada). TheSOGC stated their strong interest in collaboratingwith Aboriginal groups, noting that addressingIndigenous maternal and child health data problemsand discrepancies could greatly contribute to theimprovement of Indigenous children’s health.Some Aboriginal community representatives alsoidentified that there was a mismatch between whatacademic institutions recognized as ‘research’ andwhat Aboriginal communities ‘need’ as ‘action’ and‘deliverables’. As a result, best practice would need totake account of research and data collection approachesthat incorporate the timely needs and desires of theIndigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action 123

There is currently a mismatch between whatacademic institutions recognize as researchand what Aboriginal communities need asaction and deliverablescommunity, so that research and data collectiontranslates into tangible outcomes and benefits forAboriginal communities. Part of this best practiceprocess would involve increasing the capacity forAboriginal communities and researchers to have theircommunity based health research approaches (as CIHRguidelines for research involving Aboriginal peoplesadvocate) recognized and funded accordingly forongoing sustainability.C) Policy ApproachesA central theme to the meeting discussions wasthe development of balanced policy and practiceapproaches to the collection of Indigenous childinfant mortality and morbidity data in Canada. Theseapproaches call for the need to balance the right to becounted, with OCAP Indigenous right to participate ingovernance and management of health data, and theoverarching rights of children.Policy and practice considerations discussed at themeeting reflected the complexities associated withorchestrating and implementing initiatives aimed atimproving Indigenous children’s health. Having nostandardized data collection methods, little statisticaldata readily available to accurately identify health statusinequalities (or even where they stem from in relationto Indigenous infant and child morbidity and mortalityrates), is in itself a major public health issue; arguablyone that speaks to colonization and many of its ongoingguises. As Aboriginal people we can not, nor should we,ignore the power dynamics inherent at a functioningsocial systems level between non-Aboriginal andAboriginal Canada - for it is these power relationshipsthat shape and determine what is socially ‘significant’and worth ‘measuring’ in terms of health statusinequities. One thing we can say with certainty isthat our meeting and the discussions generateddemonstrated the shared commitment to improvingthe health of Aboriginal children in Canada – for theyare our future. Having established our dedication toimproving the health of Aboriginal children, the nextobstacle to overcome is how we work together withdiverse Aboriginal communities to achieve improvedhealth outcomes for our children.As any good healer knows, before you can begin totreat it helps if you can first identify the poisons. Onemajor concern at the moment is that we do not have anaccurate picture of Indigenous child health status. Thus,we are unaware of the specific ‘poisons’ we are dealingwith. Any policy or best practice designed to changethis lack of knowledge will therefore need to be wellinformed and be able to engage community support.124 Health of Indigenous Children: Health Assessment in Action Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations

Any policy and practice initiatives formulated thatconsider the rights of children, the right to be counted,and the rights of Aboriginal communities to participatein the governance and management of their healthdata will have a host of complex questions that must beaddressed. Due to the social, political, economic, andhealth ramifications we should ask ourselves: ‘What arethe costs associated with opting out of census in termsof political repercussions and funding? What will bethe repercussions of this on smaller Aboriginal groupsbeing able to run their own data systems independently?How does this sit with vital statistical information?’To help navigate our way through some of thesecomplex questions in relation to our approaches topolicy and practice in the area of Indigenous childhealth data collection, participants at our meetingshared their ideas in relation to both policy concepts /ideas, as well as actual policy strategies.Policy Concepts / IdeasPolicy concepts that emerged from our meetingwere heavily focused on establishing policies andpractices that support the preservation and protectionof Indigenous OCAP (Ownership, Control, Access,Possession) principles. This would include reservingthe right for Aboriginal groups to collect data forthemselves and operationalize this for themselves– without necessarily having to share this data withother Aboriginal groups. This reflects that someAboriginal groups may prefer not to share datawith other Aboriginal groups in an ‘overarching’macro-Aboriginal health agenda and this shouldbe respected. This raises an important implicationfor policy formulation in terms of avoiding a ‘onesize fits all’ approach. Flexibility and scope formaneuverability in relation to tailoring policyapproaches that are applicable to specific Aboriginalgroups will therefore be necessary. This does notmean that individual Aboriginal communities andgroups are not interested in the collection of data forimproving child and maternal health. It also doesn’tmean that all Aboriginal groups/communities agreewith OCAP principles.Flexibility in policy and practice approaches is alsonecessary in light of some Aboriginal groups’ strongbelief that if an issue within their community needsto be ‘studied’ then they themselves should be theones initiating this study first. Help would be soughtfrom outside the community only if it is required.This stands in stark contrast to historical policy andpractice initiatives that view Aboriginal communityhealth issues through a western frame, dictating fromthe ‘outside’, ‘What is needed’. In this instance, theseAboriginal groups follow the concept of initiating,controlling, and having ownership over research dataand research practice.Different experiences for different Aboriginalgroups however, may not necessarily mean thatdifferent truths and perspectives are incompatible.For instance, Métis people have been completelyignored in the collection of health status data, andthis in itself is a major health status inequity. Somecommunities, including Métis, have not been fundedfor infrastructure around health or other sociallyrelated data collection. In a practical sense, the notionof integrating Indigenous and Western knowledgewhen developing policies aimed at working withAboriginal communities would need to involveAboriginal communities taking a pro-active approachin the research/data collection process. This will helpto identify the health and wellbeing indicators thatare relevant to each communities needs. In so doing,community norms and mores would be reflectedin those indicators. Our strength and creativity asAboriginal people affords us the ability to identify thescope and potential opportunities for us to exploreavenues for improving our children’s health, whilstat the same time respecting diversity between andwithin Aboriginal groups and our sovereign right toparticipate in the implementation and sharing of ourchildren’s health data.Policy StrategiesOne key policy strategy that emerged through ourdiscussions included being respectful of the ownershipand use of data. Developing partnerships and protocolsfor the sharing of information between Aboriginalgroups and data collection agencies is therefore amajor priority. So too is respecting that data frommultiple sources may be conflicting or contradictory.Again, this is where knowledge sharing betweenAboriginal groups and researchers can help to clarifydata and what data means.Additionally, the meeting discussions addressed theneed for communities and researchers to work togetherin lobbying as advocates for improvements in children’shealth and to use community lobbying platforms todrive and inform policy on the issue of data collection,ownership and sharing agreements. Appropriate policywas identified as a critical and crucial step in thedevelopment of data collection. The use of culturallymeaningful marketing strategies was identified as animportant policy strategy to give communities a betterunderstanding of how data collection initiatives canhelp us to provide better services and improve thehealth of children in Aboriginal communities.Indigenous Child Health Stakeholder’s Meeting – Discussion & Recommendations Health of Indigenous Children: Health Assessment in Action 125

126 Health of Indigenous Children: Health Assessment in Action Concluding Remarks – Finding Strength in Numbers

Concluding RemarksFinding Strength in NumbersEighteen months ago Health Canada approached me towrite this report. Although enthusiastic about the taskat the time, I did not anticipate the broad scope andnew depths of knowledge about Indigenous children’shealth that this project has generated. The quality andcomprehensiveness of this final product is rooted ina fundamental commitment by all of the writers andparticipant stakeholders to the health and wellbeingof Indigenous children not only in this generation,but for many generations to come. Action to ensurethat Indigenous children begin to experience thesame levels of prosperity, environmental nurturance,access to health services and wellbeing that most non-Indigenous children take for granted in our relativelyaffluent countries is long overdue.In Canada, jurisdictional complexities are oftenused as an excuse for double standards in Indigenous/non-Indigenous health assessment and response.Commonly, the argument is between the provinces/territories and the federal government as to who holdsthe responsibility for Indigenous health and publichealth assessment and service. Unfortunately, moreoften than not, the argument is not clearly resolved andthere is a resultant lack of action. It is First Nations,Inuit, and Métis children who end up experiencingavoidable suffering as a result of these stalemates. It isone of the causes of the deficiencies in Indigenous childhealth assessment data in Canada, and also results insignificant challenges in access to care. For example,in 2005 a chronically ill and disabled First Nationschild by the name of Jordan River Anderson died ina Winnipeg hospital, far away from his family andhome community in northern Manitoba, because thefederal and provincial government argued for over twoyears over which government would be responsible forthe cost of his home health care. In response to thissituation, Jordan’s Principle, a child first approach toresolving jurisdictional disputes within and betweenthe federal and provincial/territorial governments 1 wasdeveloped as a private members bill and unanimouslyapproved by federal parliament. Jordan’s Principlerequires that the government of first contact pays forthe service to the child without delay or disruption.Although it is now legislated, Jordan’s Principle has yetto be implemented.This report provides a convincing example ofthe value that can be added by forming partnershipsand working across jurisdictions – locally, regionally,nationally, and internationally. Collaboratinginternationally in the production of this report hasprovided an opportunity for the authors to highlightthe Indigenous child health disparities that exist in eachof our countries and also identify a number of crosscuttingissues. The report is crafted as a reference andadvocacy tool for Indigenous child health stakeholderscommitted to ensuring the prosperity, environmentalnurturance and well being of Indigenous childrenaround the world. Hopefully these stakeholders willsimilarly find “strength in numbers” both throughmutual collaboration and the figures shared in thepreceding chapters and with this renewed energycontinue to press for the policy actions required toaddress Indigenous children’s health disparities at homeand abroad.Author:Janet Smylie MD MPHResearch ScientistCentre for Research onInner City HealthThe Keenan Research Centrein the Li Ka Shing KnowledgeInstituteSt. Michael’s HospitalAssociate ProfessorDalla Lana School of PublicHealthUniversity of Toronto1http://www.fncfcs.com/docs/JordansPrincipleFactSheet.pdfConcluding Remarks – Finding Strength in Numbers Health of Indigenous Children: Health Assessment in Action 127

128 Health of Indigenous Children: Health Assessment in Action Appendix A – Stakeholder Meeting Participants

Appendix AStakeholder Meeting ParticipantsIndigenous Children’s Health ReportStakeholder MeetingFriday May 30th , 2008St. Michael’s HospitalPlease note that attendants’ participation atthe stakeholder meeting does not indicate anendorsement from their respective organizationsfor the information contained in this report.We acknowledge with thanks their time andcontributions to the engaging discussions thattook place.Heather McCormackChildren and Youth DivisionCommunity Programs DirectorateFirst Nations and Inuit Health BranchHealth CanadaJennifer Pennock MScManager, Surveillance and Data CollectionHealth Information Analysis and Research DivisionFirst Nations and Inuit Health BranchHealth CanadaJanet Smylie MD MPHResearch ScientistCentre for Research on Inner City HealthThe Keenan Research Centre in theLi Ka Shing Knowledge InstituteSt. Michael’s HospitalAssociate ProfessorDalla Lana School of Public HealthUniversity of TorontoKelly McShane PhDAssistant ProfessorRyerson UniversityAssociate ResearcherCentre for Research on Inner City HealthThe Keenan Research Centre in theLi Ka Shing Knowledge InstituteSt. Michael’s HospitalGilbert Gallaher PhDResearch FellowCentre for Research on Inner City HealthThe Keenan Research Centre in theLi Ka Shing Knowledge InstituteSt. Michael’s HospitalPaul Adomako MScResearch Coordinator IIICentre for Research on Inner City HealthThe Keenan Research Centre in theLi Ka Shing Knowledge InstituteSt. Michael’s HospitalJane Freemantle PhDAssociate ProfessorCentre for Health and SocietyMelbourne School of Population HealthThe University of MelbournePrincipal Research FellowOnemda VicHealth Koori Health UnitDaniel McAullay PhD(c)Senior Research OfficerPhD CandidateTelethon Institute for Child Health ResearchAppendix A – Stakeholder Meeting Participants Health of Indigenous Children: Health Assessment in Action 129

Sue Crengle PhD(c)Senior LecturerTe Kupenga Hauora MāoriDirectorTōmaiora Māori Health Research CentreFaculty of Medical & Health SciencesUniversity of AucklandMaile Taualii MPH PhD(c)DirectorNative Hawaiian Epidemiology CenterPapa Ola LokahiJessica DemeriaResearch OfficerMetis CentreNational Aboriginal Health OrganizationWinona Polson-LahacheResearch OfficerFirst Nations CentreNational Aboriginal Health OrganizationKatherine MinichChair, Governing CommitteeInuit Tuttarvingat (formerly Ajunnginiq Centre)National Aboriginal Health OrganizationMishael GordonEarly Childhood Development CoordinatorDept. of Socio-Economic DevelopmentInuit Tapiriit KanatamHeather TaitData CoordinatorInuit Tapiriit KanatamAlastair MacPheeCongress of Aboriginal PeoplesMelanie MorningstarSenior Policy AnalystAssembly of First NationsMargo GreenwoodScientific DirectorNational Collaborating Centre for Aboriginal HealthAssistant ProfessorUniversity of Northern British ColumbiaKent Saylor MDConsultant PediatricianMontreal Children’s HospitalCanadian Paediatric SocietyLisa SterlingSpecial Advisor/Director of Aboriginal AffairsOffice of the Vice-President, AcademicAnd Assistant ProfessorSimon Fraser UniversityDr. Suzanne ToughScientific DirectorAlberta Centre for Child, Family and CommunityResearchVyta Senikas BSc MDCM FRCSC FSOGC CSPQAssociate Executive Vice-PresidentThe Society of Obstetricians and Gynaecologistsof Canada (SOGC)130 Health of Indigenous Children: Health Assessment in Action Appendix A – Stakeholder Meeting Participants