 Good afternoon everyone. My name is Joanna Erickman and I am the acting assistant director of the Health Law Institute. And it's my pleasure to welcome you to the Health Law and Policy seminar series. This is a series that brings guest speakers to the law school to generate questions and conversations on contemporary issues in health law and policy. And if you're joining us for the first time, this is the second semester of our series. But please check out our winter term schedule. You can find it online or you can find it, post it in the hallways of the school. It looks like this. We have three remaining seminars after this one. We always hold the seminars on Fridays, usually in this room at this time. And if you don't know about it, we also serve a light lunch beforehand and you are always welcome to join us for that. And if you missed past seminars from last semester, also encourage you to visit our website where they are recording. Alright, so this afternoon it's my pleasure to introduce our presenter, Professor Amy Bombay, who's joining us. She is a professor here at Dalhousie University and has been one since 2014 in the Department of Psychiatry and the School of Nursing. Professor Bombay is a researcher who investigates factors related to well-being and mental health among Indigenous people in Canada. With a particular attention to the relationship between historical trauma and contemporary stress or exposure and then stress-related pathology but also resilience. And so in late 2015 she published, I think, quite a powerful piece of advocacy, a kind of call to action on this very subject. And as you can see, posted here on the screen, we have the privilege of engaging with Professor Bombay on a research question and issue of interest, which is historical trauma among Indigenous peoples, implications for improving well-being. So she'll present for approximately 45 minutes and then we will open the floor for a question and discussion. So please join me in welcoming Professor Bombay. Thanks for everybody for coming today. I'm really happy to be here to have a chance to talk about my research. I'll just get right to it because I kind of think I have a bit more slides in here that I have time for because there's a lot of complexities around Indigenous well-being. So I guess I'd first just like to start by kind of going back in time to 1996 when the Royal Commission on Aboriginal Peoples was first published their final report regarding Indigenous issues in Canada. And it was this report that I think really brought attention to the serious health issues facing Indigenous peoples and the serious health disparities that exist and face First Nations, Métis and Inuit communities in Canada. And so what this report, kind of one of their main conclusions was that tinkering with the existing programs and services and the way Canada deals with Indigenous health issues would not be enough to foster substantial improvements in the health of Indigenous peoples and they're really called for new and innovative approaches to tackling these health disparities. Unfortunately, many of these recommendations were not implemented 20 years ago. And so today, about 20 years later, the Truth and Reconciliation Commission just released their final report. And unfortunately, we're looking at the exact same health disparities that we were facing 20 years ago. And we know that what the Royal Commission concluded was that what we're doing now isn't working, it still applies today and so there's still a real need to change the way we approach health issues for Indigenous peoples in Canada. This is just an example. Right now I'm preparing a report to follow up the TRC's final report and to just emphasize the need to really implement these calls to action and the costs of not implementing these calls to action. And so one of the things I was really interested in is looking at, okay, let's look at these health gaps over time and see how they've changed. And what was really surprising to me is that no one actually does this. No one actually keeps track of health disparities among the group, our Indigenous population in Canada who faces the most health problems in our country. And so I was kind of managed to piece together these kind of trends since 1996 until now and we see that when we look at the all Canadians, which is represented by the light blue line and we compare them to First Nations living on reserve, First Nations living off reserve, Métis and Inuit for the most part rates of chronic health conditions are growing and these gaps between these groups and relative to the general population in Canada are not narrowing. So, you know, we need to do something different. If you're wondering about the low rates of Inuit chronic health conditions in that graph, we know that they're actually exposed to a lot higher number of risk factors. So this is actually likely due to the fact that maybe they're kind of dying before they reach these high prevalence levels. So, you know, all of these different Indigenous groups in Canada face very unique health issues. I don't want to spend too much time just going over statistics because we all know that these disparities exist. But just very quickly, mental health is one issue that is really important to me in my research and we actually don't know the number of health disorders faced by Indigenous peoples in Canada. But we know that levels of psychological distress are extremely higher. Just from a national representative surveys, we reported that about half of First Nations living on reserve reported moderate or high levels of distress and this was compared to only one-third in the general Canadian population. And we see this in other Indigenous populations across the world as well. I think one of the real saddest and kind of most devastating manifestations of this psychological distress is in the high suicide rates. Among youth in Canada, it's estimated that these rates are about seven to eight times higher relative to the general population. When we look at the prevalence of suicide ideation and attempts, we found that First Nations adults on reserve just under a quarter reported thinking about committing suicide at one point in their life and about 13% reported actually having an attempt in their life. And when we compare that to the general population, the number of First Nations adults who actually made an attempt is actually more than the proportion in the general Canadian who only considered suicide. So that's a big disparity. And I just included this graph here to note that while these are national general statistics, not all First Nations communities face the same health issues. Some First Nations communities actually had suicide rates that are lower than the general population. So just to keep in mind that there are significant differences between different communities. And so I think one big problem in Canada that has contributed to the kind of status quo and not actually changing the way we address these issues is really misunderstanding these disparities and why they exist. A colleague of mine, we both researched the negative effects of racism on Indigenous peoples in Canada. And he's reported while blatant racism seems to have decreased over the last 20 years, other types of more subtle racism are still very prevalent. And one specific kind of that I think really is relevant to Indigenous peoples in Canada is what we call laissez-faire racism. And this refers to the tendency to blame Aboriginal peoples for their social inequities and to resist polities that address them. And these types of attitudes are generally accompanied by inaccurate stereotypes like Aboriginal peoples have so many benefits, why do they get all this special treatment, and so on. And this quote that I have on this slide, I pulled off a news article about the Truth and Reconciliation Commission that was talking about the importance of it. And so this person shared in the response section right after these articles, just get the whole thing over with and be done with it. Good Lord, what a farce. What exactly are they trying to prove that there were some bad situations? We all know that and survivors have been paid millions for it. Say your piece, cast your check and get on with life. And so it's really, I found this quote really epitomizes the general attitudes that sometimes we face when we're trying to educate non-Indigenous Canadians about why these disparities exist in Canada. And I think the problem is generally a lack of education and awareness. And so we, in some of my research, wanted to look at this and wanted to see the importance of just knowing about Canada's history and being aware of the discrimination that Indigenous peoples in Canada face. And so directly after the Residential School of Policy and Apology in 2008, we surveyed non-Indigenous Canadians about what degree they still feel that Residential Schools impacts Aboriginal peoples. We asked about their perceptions of the prevalence of discrimination against Aboriginal peoples. We also measured their kind of attitudes regarding, related to modern racism and this laissez-faire racism. And then we also measured their perceived need for further government actions to help improve the health of Indigenous peoples in Canada. And what we found from right when the Apology happened to one year later was that perceptions about the impacts of Residential Schools decreased. There was no change regarding the prevalence of discrimination against Aboriginal peoples. There was no change in modern racism and that perceived need for further action actually decreased. So while we kind of were hoping that that Apology would raise awareness and result in improved intergroup relations and improved support for Indigenous peoples, that didn't really happen. I think now, it was shortly after this time period that the TRC kind of ramped up, so that may have gained more interest in this issue and kind of brought those back up. But again, it just kind of emphasizes the importance of being aware and recognizing these long-term impacts and how it influences peoples' support for Indigenous peoples. And again, just to note, we then kind of carried out these medial analyses and we actually showed that changes in their perceptions of historical trauma and discrimination against Aboriginal peoples leads to changes in these perceptions of modern racism, which in turn leads to changes in their support and perceived need for further government action. And so I think also one of the main conclusions of the recent Truth and Reconciliation Commission report, and this was a quote from Justice Murray Sinclair, who was the chair of the commission. He was quoted saying that Canadians must acknowledge that for generations their public schools have fed them misinformation about Aboriginal people. And so we can't put the blame on Indigenous, non-Indigenous peoples for not knowing about these issues. It was not taught in our public schools, but I think now it's really evident. And now is the time that we all need to take responsibility for learning about this and sharing that with other people. And so right now I'm just going to show a quick video that kind of really, I think epitomizes those attitudes. But for this thing to work, there's five things you're going to have to stop saying about my people. First thing, alcohol. The thing that separates us here isn't the alcohol, it's the poverty. Because when a non-native person passes out, they do it at a curling club or at a nickel background. So when a Native person does, they do it on the street. It's shameful, but also comfortable. Then there's this whole idea of get over it. You know, why don't you guys just get over it? You know what? I am over it. My dad was raised in the residential school by a nun. I'm over it. But it doesn't mean that we should forget it. Then there's the long hair. You know, some aboriginal people do wear their hair long. It's a symbol of cultural pride. Those are the natives with beautiful, long straight hair. Curly hair to jewelry such as myself. And the greatest adventures of the white man. Then, I often hear this question, what are you guys doing with the seven billion dollars? Seven billion dollars we give in a fair is what are you guys doing with it? You know what? That money has to pay for a population the same size as New Bruns. You know what New Bruns expense on their population? Eight billion dollars. And yet, I never hear Canadians ask, hey, New Bruns! Finally, one of your favorites, taxes. Guess what? I'm a status Indian. I pay income tax. I pay sales tax. I wasn't even paid a land transfer tax. I won. It's all part of a much larger stereo cycle. The aboriginal people in Canada are getting a free ride. 140 years after the treaty, we're still waiting for the things that we were promised in those agreements to share the land that I asked you. He's really getting a free ride. So I'm sure you all know that's Wab Kanu. And he just, I think, really drives that point home in that little two-minute clip. And so just to reinforce, you know, it's this lack of awareness of the causes of disparities that reinforces blaming Indigenous peoples and reinforces this non-support for current policies in the status quo. And so what non-Indigenous Canadians often aren't, and also Indigenous Canadians, I myself wasn't taught this growing up in high school. And it wasn't until I started learning about this just through exploring my own personal family that I really became kind of angry and really wanted to do something with my research to address this. And so what a lot of Canadians don't know is about the discriminatory policies enshrined in the Indian Act, the residential school system, the 60s scoop, and that the roots of these disputes that we see on TV, over land resources and cultural rights, including health care rights, often date back for many decades. And, you know, most of us watching this don't really understand the history relating to this. And instead we're exposed to just kind of Indigenous peoples facing off against non-Indigenous peoples without really understanding why. And this is a quote from Phil Fontaine, who is a former national chief, who was the first one to really come out with his own personal experience of abuse at residential schools. And he described that, many non-Aboriginal people see these incidents as tragic but isolated incidents, whereas Aboriginal people in contrast see these incidents in the context of a historical pattern of state behaviour. And so unfortunately we see these same kind of discourses in the health care system and research has shown that encountering discrimination in the health care system actually has the worst effects compared to encountering it in any other context. And just to give you an example, these are quotes from a study that was done in Winnipeg. One health care provider in Winnipeg responded to their questions, saying, it's interesting you're just targeting the native population because my first thought, to be honest with you, was that here we go, we're going to do more for the Aboriginals again. What about doing it across the board for everyone? Why do we have to target these peoples so much? So that's kind of this notion of egalitarianism. We just treat everybody the same, but what they're not taking into account is the complex history and the effects of historical trauma, which I'm about to get to in a second. Another kind of common discourse that we see in health care contexts is a health care provider saying that it comes down to personal choices. If unfortunately some of them are going to be prone to alcohol abuse and drug addiction because it is in their genetic makeup from birth, at some point there comes a time that they're responsible for where they're at. So as I said, you can provide all the stuff in the world, yet they're not able to access it because they just can't or they do not want to for whatever reason. So obviously encountering these attitudes in the health care system is really not going to encourage Indigenous peoples to come for help. We know that lack of trust and past discrimination does lead to the avoidance of mental health services and health services in general. We know that blatant discrimination does exist in Canada. There's a lot of research showing just reinforcing the main general stereotype about Indigenous peoples as having substance abuse problems. And I think one of the worst case examples of this was in 2014 when Bryan Sinclair was in the Winnipeg Hospital and he was in a wheelchair and it was just assumed that he was drunk and he wasn't and he ended up dying after waiting 34 hours in that hospital. And if you go on this link, which I'm not going to do now, you can actually see this and see their weight and how just terrible it is that we really have to do something to stop this. And so not only do we see this in health care context by health care providers, but people who are making decisions on policies for Indigenous peoples still need to be educated. Just last year, when there was a lot of emphasis on having an inquiry for the missing and murdered Aboriginal women, our Prime Minister, ignoring all of the scientific reports that had been done and showing that this is linked to colonisation, he made the statement that this is actually not a sociological phenomenon, but a criminal phenomenon. So again, this lack of understanding and lack of acknowledging the long-term effects of colonisation. And so that's where, if you're in case you're wondering what historical trauma actually means, it refers to a concept that has been put forward by Indigenous scholars, researchers, and has been really supported by Indigenous communities in North America and worldwide. And it's been defined as the cumulative, emotional, and psychological wounding over the lifespan and across generations, emanating from mass group trauma. And it has been described by Joe Gahn, who is an Indigenous psychologist in the U.S. as a counterbalance to the increasing prevalence of biological explanations for mental health problems. Historical trauma accentuates and implicates the processes of colonisation rather than faulty genes or broken brains as fundamentally causal in the origins of epidemic levels of distress that afflict too many First Nations communities. So it was when I was starting my graduate work that I came across this idea, and it really spoke to me in helping me reflecting on my family's experience of why I see some of the dysfunction and problems in my family that I do. And so it really helped me understand this. But then in the literature, there was also some critique of this concept in showing, well, and a lot of kind of doubting of this concept, showing, well, there's no evidence that there's no, we can't really prove that this exists, so it's not really a useful concept. And so that's where I really wanted to step in and try to provide support for this concept. And specifically, because my family had been affected by residential schools, that's what I really wanted to talk about. So I think most of us here know already, but just to encase the Indian residential school system, ran in Canada from the mid-1800s until the last school closed in 1996. During this time, Indigenous children were forcibly removed from their families and forced to live and attend residential schools, and prisons were, sorry, parents were actually threatened with imprisonment if they tried to keep their children at home. We know now, and if you could read this in the TRC report, many of these students experienced various types of abuse. Neglect was pervasive, and we're still finding about more of the abuses that have happened in that school, in those schools. Research has shown that survivors, so those who attended these schools, are more likely to suffer from various physical and mental health problems compared to those who did not attend. We've reported that those who attended are more likely to report psychological distress compared to Indigenous adults who did not attend, and we've also reported that survivors are more likely to experience various physical health conditions as well. So what I've been really interested in looking at is not only how these schools continue to affect those who attended, but really those who affect the intergenerational survivors, so the children and grandchildren of those who attended. And so first here, this is the proportion of the non-Indigenous population who reported moderate or high psychological distress, and that's from a national sample of Canadians. And then we compare that from another sample of First Nations adults on reserve. So all of these graphs or bars represent First Nations people. And we found that First Nations adults whose families had not been affected by residential schools about 40% reported this moderate or high distress levels, which was significantly higher than the non-Indigenous population, but lower than the First Nations adult population who had been affected by residential schools. We found that survivors about 55% reported high or moderate psychological distress. Those who had at least one parent who attended reported similar levels, and those who had at least one grandparent who attended reported similar levels. So again, really the intergenerational effects seem to be in terms of distress just as strong as compared to having attended themselves. And then this was a paper that we published this finding in just in 2014, and this was the paper that really provided evidence for the cumulative effects of residential schools across generations, so really supporting this notion of historical trauma. We compared First Nations adults whose families had not been affected by residential schools. Again, they had the lowest levels of psychological distress. We compared them to adults who had a parent or a grandparent who attended, so one previous generation. They had significantly greater likelihood of reporting higher levels of psychological distress. And then lastly, we compared them to those who had a parent and a grandparent who attended, so two previous generations. And again, we found this increased risk for psychological distress, so really showing this linear relationship, showing the more generations in your family that have attended the greater the risk. And so then we were also really interested in just kind of looking at the various pathways that were involved in the transmission of trauma across generations. And we were really interested first in looking at adverse childhood experiences because that was one of the most obvious effects of residential schools was that survivors experienced extreme trauma and neglect. And so we would expect that the ability for them to provide a good environment for their own children would be difficult because they're facing mental health problems, they didn't receive a good education and all of these things. And so that's what we wanted to look at and that's what we found. We found that having a parent who went to residential school, so now none of these people went to residential schools themselves. But having a parent who went to residential school was associated with a greater likelihood of experiencing various types of childhood adversities including not only abuse but various types of neglect like emotional neglect, physical neglect, as well as a greater likelihood of various indices of household dysfunction like having a parent who abuses substances or having a parent with a mental health issue. So in turn we found that the greater risk of these childhood adversities put these same individuals at a greater risk for encountering more stressors in trauma in their adulthood. So we found that parental residential school attendance was linked to greater childhood adversity which in turn put them at risk for more adult traumas and more perceived discrimination in adulthood. In turn those accounted for their increased risk for depressive symptoms compared to those who did not attend. So not only did we find that those whose parents went to residential school were more exposed to a greater number of stressors we also found that they were more vulnerable to the negative effects of these stressors. And so here we showed that among those with at least one parent who went to residential school so that's with the solid line the relationship between childhood adversities and depressive symptoms was much stronger as you can see the slope of that line is much higher. And so those without this family history of residential schools they were less affected by these childhood adversities. And we found the same patterns in relation to adulthood traumas and relation to the negative effects of perceived discrimination. And just to give you an idea of the proportion of the population that has been affected by residential schools so you can get an idea these we just finished doing pulling these statistics from national data sets again of the First Nations population living on reserve. And so we found that from 2002 to 2003 until just last year the proportion of adults reporting to be survivors has remained pretty steady which is surprising because we would expect that survivors would have decreased and that probably is the reality and just probably my guess is that survivors not all said that they went to residential school at that time because at that time there was still a lot of silent surrounding residential schools. But again looking at just the intergenerational survivors with a parent or a grandparent we see that the proportion of these individuals is still remains very high on reserve. So in some communities that have been affected by residential schools you know at least half have been affected by residential schools. And we know and now that we know this increased risk it's not surprising that these disparities exist. So other of my colleagues for example Melissa Walls and Les Whitbeck have shown the intergenerational effects of collective traumas aside from residential schools. So they specifically looked at forced relocation and showed similar intergenerational effects. And one thing, another issue that has been talked about over the years by researchers and many of these researchers have argued that the child welfare system through its large scale removal of Aboriginal children from their families, culture and communities be considered a continuation of the policies of forced assimilation of the residential school system. And so what we're talking about here is following the Indian residential school system as it was kind of widening down the child welfare system was kind of ramping up in their removals of Indigenous children from their home. So it kind of just kind of started doing the same thing with a different mechanism. And so we were really interested in exploring this kind of long-standing hypothesis and we explored whether there's a statistical link between the intergenerational effects of residential schools and the likelihood of spending time in foster care. And so we actually did find support for this and again we looked at the number of generations in one's family affected and that was associated with an increased likelihood of spending time in the child welfare system. We were also interested in looking at what are the factors that are involved in this greater risk. And we looked at both just general childhood stability with the home while growing up and we looked at self-reported childhood economic stability. And what we found was that it was the economic stability in the family that really accounted for this relationship and that it was really this economic stability that would happen first and that it would lead to the lack of ability of parents to provide care for their families. So they're coming out of residential school with a lot of health problems, mental health problems, not a lot of education. Of course they're not going to be able to provide a good economic home for their children and in turn they can't just provide a general stable home and that has contributed to this intergenerational cycle of children being removed from their families and continued childhood adversity over the generations. And this is just to point out that right now there is a human rights tribunal going on about the issue of child welfare. We know right now that approximately 50% of first nations children under the age of... sorry, 50% of children under the age of 14 that are in child welfare are Indigenous, which is a very staggering percentage and it's argued that... and what the Assembly of First Nations argued in this human rights tribunal is that the very point that it's the past historical policies that have led to the continuation of removal of children from their homes. And what our research has really supported them in saying is that despite all of these historical things that have happened and the now current health disparities, the point they're really trying to make is that child welfare is still underfunded. So despite all of these health gaps that currently exist they're not getting funded as much. And that's despite this common myth that we have in Canada that Indigenous peoples get all of these extra benefits when in reality on the reserve a lot of these services are underfunded. And so this is a report prepared by the First Nations and Child and Family Caring Society which is the group that are taking the Canadian government and accusing them of discrimination against Indigenous kids. And so their report has shown that federal funding for First Nations child welfare was 22% less than provincial funding levels. Yet First Nations social workers in many regions have a higher caseload than their provincial counterparts yet are required to do more work with fewer resources. And this also applies to other areas including education and health services. And so this decision of this tribunal might have very big implications for not only child welfare but for education and health services on reserve as well. And so now I'd just like to move on and talk a little bit about the TRC calls to action and about what now, what do we do now to help close these gaps and to reduce these disparities. And so one of the calls of the TRC calls to action was to close these health gaps. So how do we do that? Again this is just to reinforce, this is diabetes rates and showing that diabetes is one of those disorders that the gap has actually increased over time. And so that's just to point out that in some of these cases gaps are actually widening. And these gaps are even more important to address because we know that the indigenous population in Canada is growing at a faster rate compared to the non-indigenous population. And we also know that they're younger compared to the non-indigenous population. And so when we consider the differences in the ages and age standardize it, the gaps actually are underestimated. So again these gaps that I've shown in these graphs are actually an underestimate and we don't actually have a clear idea of the prevalence which is something that we also have to start doing. And that was one of the official calls of the Truth and Reconciliation Commission as well. And so to start to decrease these gaps which would result in I think if people aren't convinced by the moral arguments of decreasing health disparities, I think another argument that we could put forth is the economic costs of these disparities. And so to decrease economic costs we know that we have to reduce the number of people developing these health conditions and we know that the health gaps are accounting for a significant proportion of these costs. And so closing these gaps will require, according to the TRC, holistic strategies addressing social and cultural determinants of health and the implementation of the TRC calls to action related to welfare, child welfare, education, language and culture and justice. And we also need more preventative, holistic approaches that really address all of these social and cultural determinants of health which was one of the main suggestions that was put forth 20 years ago in the Royal Commission report. And we would expect that this would actually result in cost savings over time. And this is important because in Canada we know that the costs of our health care system is increasing. This is just the increasing costs of all Canadians over time. This is the estimated, so this is the estimated increase into 2020 of diabetes. So if we just keep going with the status quo it's estimated that these rates are going to keep increasing. Again, just emphasizing the importance. And so again, not surprisingly we know that health Canada spending on First Nations and Inuit health care has also just been continuing to increase as rates of chronic health conditions increase. And so to start some of the other health specific calls to action put forth by the TRC include establishing measurable goals to identify the health gaps and publishing annual progress reports and assessing long-term trends. So that's one thing I'm starting to try to do myself right now. And just the fact that we haven't been doing that up until now is pretty crazy. We know that the lack of comprehensive quality data on the health of Indigenous peoples inhibits the production of research to identify, develop and monitor strategies for addressing the gaps in health outcomes. And it's pretty crazy that there's just no systematic assessment or reporting of these long-term health conditions among Indigenous peoples in Canada. The TRC has also called for the federal, provincial and territorial governments to recognize and implement the health care rights of Aboriginal peoples as identified in international law, constitutional law and under the treaties. And it's also been called to address the jurisdictional disputes concerning Aboriginal people who do not reside on reserves. We call on the federal government to recognize, respect and address the distinct health needs of the Métis, Inuit and off reserve Aboriginal peoples. So this is a bit of a wordy slide and that's because this is not my specialty and a lot of this information I got from Constance McIntosh. But I thought because this is the law seminar that this would be of interest. And so when we're talking about health care rights and international law, we're talking about the United Nations Declaration on the Rights of Indigenous Peoples and just generally numerous articles within this document pertain directly to the health rights and guarantee Indigenous control over health. When we're talking about constitutional law, scholars have argued that healing and health practices were integral to Indigenous society's pre-contact and should thus be protected under constitutional law. And recent cases have found that an Indigenous woman who had a constitutional protected right to treat her daughter according to Indigenous healing practices rather than through the Canadian health care system. And finally, fiduciary law legal scholars suggest that the state's obligation to Indigenous peoples is also a basis for the federal government's responsibility to provide health services. But when we, according to the federal government, they assert that their provision of services is on a humanitarian basis and they kind of deny, continue to deny that there's a constitutional treaty or other legal basis for the provision of such services. The federal government maintains that provinces and territories have an obligation to provide health services mandated in the Canada Health Act, both on and off reserve. And in general, First Nations agree and this is the kind of the treaty rights that they're really fighting to get recognized. And I think there is a little bit hope with our new government and some of the steps that they've already taken. But just to give you some updates, previous course decisions in Saskatchewan have denied that treaty rights include an obligation to provide health care. But current legal principles for treaty interpretation have found that those earlier cases were not correct and suggest that new challenges would be decided in favor of the existence of treaty rights to health care. So I think in general these kind of arguments are moving in the right direction, I think. Regarding jurisdictional disputes, we know that this is part of the reason that has led to the significant underfunding of some services on reserve. And ambiguities over provincial responsibilities remain. And most provinces and territorial health ministries interpret their obligation to provide services to First Nations in different ways. And so one of the very kind of simple conclusion of one of the working groups that have been working specifically on these jurisdictional issues is by clarifying jurisdictional responsibilities and eliminating the underfunding identified in individual cases, governments can prevent denials, delays, and disruptions in services. So some very, I think, evident things need to happen to stop these jurisdictional issues from continuing. And this is just a list of some of the gaps or disparities in the access to health services on reserve that are associated with these jurisdictional disputes. And there's just a whole bunch that I won't go over. And so these jurisdictional disputes, they also affect First Nations people's living off reserve. It's very complicated to know as a First Nations person if you're status, if you're non-status what special services is available to you. And generally off reserve, there's huge gaps in Indigenous-specific and culturally relevant programming that we know are needed to address these health issues. Right now I'm working at the Friendship Centre in Halifax and they've identified mental health issues as one of their main issues, and they have no mental health workers. That's one of the main things that they need, and there's just no support in the city for them to do that. So some of the last TRC calls to action that I just want to go over is the requirement of improved and equitable access to preferred and culturally safe and effective health care and health promotion. And these are going to need a number of things that have been called for including addressing the distinct health needs of Métis Inuit and off reserve populations and recognizing the value of Aboriginal healing practices and using them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and elders. And I think there are a lot of good examples across Canada where this is actually happening, but it's all too few and far between and this needs to become more of a regular practice. There's a call for all levels of government to increase the number of Aboriginal health professionals working in the health care field and ensure their retention in the health care field as well to provide cultural competency for all health care professionals and for medical schools and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues. And again, this is something I think institutions have started, but we have a long way to go including here at Dalhousie and in the Atlantic region. So one of the last health related calls to action was calling on the federal government to provide sustainable funding for existing and new Aboriginal healing centers to address the physical, mental, emotional and spiritual harms caused by residential schools. And again, I guess I haven't even mentioned this yet. I have this similar recommendation that was recommended 20 years ago and so in all of these instances the exact same recommendations had been put forward in the ARCAP report. And so just emphasizing the importance of healing and healing from historical trauma, the term healing in health and Indigenous peoples kind of grew as this notion of historical trauma has grown. And so healing is really often described as a journey and an ongoing process for Indigenous peoples. We know that approaches to wellness that draw upon Indigenous healing practice are often more effective in responding to the health needs of communities. And research undertaken by the Aboriginal Healing Foundation which is one of the organizations that really provided funding for all of these community based healing projects that happened from about 2002 to about 2013. And so they did an analysis and an evaluation of all of these projects and concluded that the services that were being most asked for and that were most in demand were those looking to work with elders do traditional ceremonies and that they found those services to be most critical to their health. And so this is just a graph that we've done showing the number of these healing centers over time. So I mentioned it was in about 2000 when they provided funding for these healing centers and in about 2007 and 2008 when the healing was cut. And so now there's only about five or six of these healing centers in Canada. And when we look at the proportion of adults who have been affected by residential schools and we see that that hasn't decreased in the same way. We see that it doesn't really make sense that this funding has come and gone because these problems still exist and still need to be addressed. So just to emphasize this continued need for these healing centers, one of the main points from their evaluation that they did was at the height of the Healing Foundation when they had the most projects running only 11% of their service providers reported feeling confident that they were reaching individuals in their community who had the greatest need for these programs. So at the height when most of these programs were actually running, they were only really getting to a small proportion who needed the help. The Healing Foundation found that approximately 36% of funded healing initiatives had waiting lists and program staff stated that many of those affected were not able to receive care. And so I think there's no reason to think that this extensive need for care has decreased. But we do know that the funding for these supports have decreased. And so just to emphasize, kind of ending on a good note and emphasizing the power of learning about historical trauma and learning about history not only for non-Indigenous peoples, but for Aboriginal people as well. And a lot of our research, we asked people about when did you find out about your family history and a lot of them report only having learned about residential schools and their parents and families experience in the last five to ten years. And this is just an example of one of the quotes from our participants. I found out when I was 27 that my father attended residential school. My sister told me, my father has never spoken to me about it. I read his court statements without his knowledge and this is where I learned about the sexual, physical, emotional and cultural abuse he endured. I was deeply saddened because it gave me an understanding of why my father behaves the way he does. It helped me understand the cycle of abuse because in turn he abused my mother and I. He learned these behaviors in residential school and could not cope so he turned to alcohol and so did I. But at the moment I'm in treatment and I'm dealing with these issues, I can break the cycle. And so we found that learning about historical trauma really fosters this sense of empowerment and it really is kind of that aha moment for some Indigenous peoples whose families have still not healed and have still not found a way to openly talk about these issues. Another thing I just like to end on is, you know, a lot of my presentations I focused on the trauma but I'd also like to emphasize that despite all of the things that have happened to Indigenous peoples, the fact that they're still, we're still here and are I think on turning a corner right now really speaks to the resilience of Indigenous peoples. This is another quote shared by one of our participants. I was ashamed growing up but I've since reclaimed my identity. Now that I'm on my own I have more pride and I'm learning to love my identity. I gave my son a traditional Ojibwe name and I vowed to raise him to be proud of who he is. And our quantitative research really supports these ideas of the importance of cultural identity, the importance of cultural pride and the importance of learning about history and culture. We found that First Nations adults found a strong relationship between perceived discrimination and depressive symptoms but we looked at what we call in-group affect which is really just cultural pride. We found that those who were high in cultural pride were really protected against the negative effects of discrimination and that those who were lacking in this cultural pride were the ones who were really negatively affected by perceived discrimination showing that cultural pride can act as a buffer. And so just to emphasize that I think we need to recognize and raise awareness about the long-term impacts of historical trauma but also raise awareness about the resilience, the importance of cultural pride and reconciliation and for non-Indigenous and Indigenous peoples to both come together to create Indigenous peoples in Canada. So thank you and I'm happy to take any questions and feel free to email me if you have any questions as well. Thank you. It is difficult to follow all the texts but your presentation was wonderful. There was one thing that is a contradiction to me. You said that among the human rights there is a right to to use Indigenous healing services. And on the next page you say that Indigenous people have the right to expect the federal government to look after them according to their health care. So these two things don't always go very well together because either you have the right to do it according to Aboriginal practices but then if things don't improve then you go back to the federal and do the Canadian or use the Canadian health system and there might be an argument on the Canadian system that you did your work so I did not live with it because it might have aggravated this situation. You say this is what it's not going to be. Okay. Yeah, it's a tough one. Is there an explanation why they want both? I think the ultimate goal according to treaties is for Indigenous people to take control of their own health services. Is that kind of what you're wondering about is their own control? We want to use their Indigenous healing services. That's one argument or one request and the other one is the right to use or to enjoy the Canadian health system. So what we're arguing is that Indigenous people should be able to seek out and acquire their cultural healing services within the mainstream system and that's what we're hoping for is that mainstream practitioners can become more aware of the needs of Indigenous Indigenous peoples and at least be aware of where they can send them to schools and start to bring that into the mainstream systems. Does healing centre sound wonderful and I wish they existed for everybody not the only four. Absolutely, yeah. Thank you. Yes. Have you come across any work that in voluntary psychiatric commitment amongst Aboriginal populations where is there no data on that? That's a really good question. I have not come across any literature that has looked at that but if you're thinking about it it would probably be good something to look into. Sorry, I don't wear a helmet. Yes. Thanks Amy, that was an excellent presentation. I'm with the Aboriginal Children's Church of Healing Initiative a research initiative of the United Kingdom and we're certainly learning about Aboriginal children where could you just speak up a little? We can't quite hear you on this side of the room. Sure. We're learning that Aboriginal kids today are certainly affected by the residential school experience because they learn how to express their pain from their grandparents who sort of learn from cultural perspective to be what they felt and so I'm just wondering in your 2011 study you said about the adverse childhood experiences what did they have been who described those? We measured 10 specific adverse childhood experiences and that score was cumulative whenever they were exposed to a different one they got a point so the more adversities they're exposed to the higher the score but physical abuse sexual abuse, emotional abuse physical neglect and emotional neglect having a parent growing up in a household where there is domestic violence growing up in a household where parent abuse substances growing up in a household where there is someone who was involved in the criminal justice system and there were two others that I can't recall but that's really interesting and makes a lot of sense it's kind of related to some of the work we've done looking at the intergenerational effects of just communication in general we find those whose parents went to residential school those families don't have a good sense of communication within the family and I think it kind of is related to that don't express yourself, don't express your feelings don't express how you're feeling just be good type of thing yes I'm a social work student and I've just been thinking a lot about the child welfare system and the shocking rates of the children being taken out of the company saying that there are more kids being removed by child welfare now than in schools so in a way it's like a lot of people think it's a historical trauma but it's an ongoing current trauma and I'm wondering what I don't know, it feels to me like social work would be put in an awful position to kind of enforce this situation and also deal with kids that really are in distress and maybe do need to be removed from situations that are not safe but at a rate that just can't be something is wrong that's bapping our solution it seems to me, I'm wondering if like I always imagine like there could be a solution involving like care for the whole family instead of a child being removed from a situation that's unhealthy and I'm wondering if that's something that is recognized within indigenous medicine or within like healing centers, some kind of sense of like the family being what needs to have a care worker helping them versus the kid needs to be removed yeah, exactly and that speaks to the nature of intergenerational trauma taking them out at each generation is not going to address the problems and so that's exactly what Cindy Blackstock talks about is these kind of holistic approaches that attack these issues at all different slides and so I'd recommend reading some of her stuff specifically related to the child welfare system yes yeah, so the decision is expected within the next two weeks before the end of January the decision is supposed to be expected so that's something that everybody's kind of really listening for closely yeah, yes I don't know if there's a question or a comment but so there are three generations of first nations who have been in residential schools so that must mean that for a lot of the reserves not only are the families dysfunctional but the reserves must be dysfunctional is there any way that people are talking about or thinking about going back to your social work where you're trying to have your family but you need to help the reserves because there must not be that many elders left anymore that know the traditional method and how they get off the land yeah, absolutely and that is an issue and that's going to vary a lot between different communities and vary according to their histories some communities absolutely have thriving elders but then others, that is a major problem that a lot of communities are facing not only with traditional knowledge but with language and all of these other things and so a lot of communities are right now doing all sorts of different unique community-based interventions to address that specific issue but it's a really hard one you know, with culture change and the youth having different experiences and different there's no real easy answer it also differs a lot across different communities and some communities that I go to there's a real kind of change to go back to traditional ways but then some other communities I work in they're very a religious Christian community the answer is not just it's a bit more complicated and I think that's why there's not just a one answer statement for all communities and it's complicated I must also say that I know I've lived in Vancouver for a while so a lot of the BC reservations are quite well off whereas some of the northern ones in Manitoba or Ontario do that or not so the housing and all of the water and all of those issues yeah and that's I think why it makes it so people would just like, well what's the answer but there's not a one blanket answer and it's really complicated yes I'm curious to hear you talk about what's going on with just our data our access to data and you've obviously been very instrumental in developing the picture we have on health disparities we might assume we live in a data-driven world where you push back because it doesn't where are we at and what structural changes have happened to make that data more available looking at problems it's a complicated one I was just saying at the beginning so I just started working on a report for the TRC to present on disparities over the years and I was just blown away that no one tracks that and no one does that and so there's definitely major problems I had to go to different there's a national surveys for First Nations on reserve that are run by a First Nations organization but then other than that all the Statistics Canada stuff doesn't cover on reserve so they don't have as much data other issues is that for the national data off reserve they have a lot of data coverage issues and issues related to self-identification and all of this and so it's the accuracy of the data related to indigenous peoples is also we're not really sure because what we do know is the amount of indigenous peoples who have started identifying in national data sets has increased significantly over the past 20 years greater than even possible population growth so more people are self identifying and we don't so there's all those issues that are going to play into it too and it's so data coverage and quality is something we need to improve and then also just tracking it yeah so you noted that communities have different rates of health disparities and you noted at the end that there were things that seem to be correlated with resilience so I'm wondering if in your work working with different communities if there are other things other than a greater sense of cultural pride and identity that have been correlated with greater resilience in those communities where health disparities are lesser or even better than national averages on certain things I would say we really focus on on cultural identity in our research but you know there's other research that was done specifically in First Nations communities in BC and they looked at suicide rates in youth and they found that they used the term cultural continuity and I'm not sure if that accurately describes what they were measuring they were measuring they looked at the number of self run organizations and kind of things that they were able to offer in their community like their own fire department their own I think one of the measures was the number of women in their chief and council and so they had all these measures of just community community real resilience measures and that seemed to be related to youth suicide and so those were I know I'm not giving you specific examples because I can't remember them but they were like systemic issues that the community would provide good services cultural services and all of these culturally based things so I think a lot of the focus has been on culture and how that acts as a resilience factor but I mean of course all of the other factors that are relevant to non-indigenous populations are just going to be as just as important like addressing the childhood adversity addressing all of those things so I think we still have a lot of research to do to find out to find what are the the solutions and how that varies across different communities Yes I'm a First Nations social worker and I'm doing my master's right now I'm trying to focus as much of my degree on indigenous senior health and I'm having a hard time finding energy surgery data that kind of speaks to the long-term care units that are available on reserve I think it might be less than one percent so I'm just wondering if you'd be able to point me in the right direction or if there's any resources that you are aware of that may help me I'm not aware of any long I think there's a lot of issues that there's just a lack of information out there so that's a good thing for you to keep going on I guess Just related to that I'm aware of one in northwestern BC in Hazelton so you might be able to it's part of their local hospital but it is on reserve Okay Thank you Okay I have a comment about a couple of comments actually that relates to some of our health issues that we're looking at I'm John and I do a lot of health policy and research and I work with Mark when we're looking at any of the health determinants of health for example and any of the social determinants that relate to health I think a lot of the movement is going towards not the dysfunctional side of what the Aboriginal policies are not or the lack of for developing I think what we're trying to do now is to move towards building those partnerships and research of course to look at how we're going to put that information back up there so this whole IRS thing I know for a lot of people here it's very new and a lot of people that live there's more than three generations for generations just for the next few generations it's something not new at all but frustrating there's been your wheels in these communities trying to develop policies with very little funding and very little outward policy support for example from province or from federal government I think one of the big things that in the Atlantic region we're trying to look at from the First Nations perspective or the New York perspective here in Scotia is to make sure that we go towards legal matters and jurisdictions and responsibilities and it's not about who is responsible for that particular jurisdiction legally it's a responsibility that we all have to assume but we don't have those resources and we have to reach out for those resources or build those resources there are communities in this province that are really well off and others that are despairing the opposite so we have to look at balancing that out some time and the big challenge is the public the public can not know the educational system the post-secondary education system the trying to put content out there that's more aboriginal focused or anything that has to do with humanity so that allows you to go over eight years that I've seen building this content has done tremendous effort that's why we're here five years that we've seen the topics are ten years so there's a lot more public support now because of education and legal matters and that's the only way we could carve out this process it's a longer process somebody mentioned social work for example there's health there's education all of these areas we have to scrape at every single area you can't just go at the education and the health you have to go at the policy people there's somebody here from one of our communities that is a leadership then we have to look at for example anything that has to do with trees we have to revisit every single document out there and a lot of it is it's plain scrapped it's trying to make pieces work for everybody very challenging but for a positive person and positive people here it's changing quite a bit and this whole government thing about recognition for example IRS and the recommendations and then looking at the UN declaration of indigenous rights public policy and public people are the ones that voted for it so we're moving forward with that change of tide and people like yourself being in the activity but it's a long process still that we won't see making it better or improving for another three generations so it's a long, long road but there's hope out there at least and there's a lot of research and that's the only way we can build that partnership out there otherwise we'll be still fitting our rules and what's what happens great thank you