Type 2 diabetes and children in aboriginal communities: the array of factors that shape health and access to health care.(Canada )

Publication: Health Law Journal

Publication Date: 01-JAN-02

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COPYRIGHT 2002 Health Law Institute

The human costs of unrestrained development on our traditional territory, whether in the form of massive hydroelectric development or irresponsible forestry operations, are no surprise for us. Diabetes has followed the destruction of our traditional way of life and the imposition of a welfare economy. Now we see that one in seven pregnant Cree women is sick with this disease, and our children are being born high risk or actually sick. (1)

I. Introduction

The history of Canada's Indigenous (2) peoples would be incomplete without examining and recounting the ravaging toll exacted by illness on their civilization. First contacts between Aboriginal communities and European explorers and settlers were marked by an onslaught of disease and war, resulting in significant population declines among Indigenous communities, and in rare cases, the virtual extinction of Amerindian nations. (3) By the 1870s, European expansion and industrialization resulted in the relocation of Indigenous peoples onto reserve territories where pestilence and famine continued to plague their communities. (4) Through legislation and treaties with Aboriginal leaders, the Canadian government promised to provide for and protect the health of Indigenous peoples, and thereby guarantee the welfare of future generations. Nevertheless, these issues continued to be ignored by the government throughout most of the twentieth century. (5)

In recent years, Canada's federal government has begun to consider Aboriginal claims regarding land, resources, health, social welfare, education, and employment. Although section 88 of the Indian Act (6) provides that general provincial laws are applicable to Aboriginal persons, this is subject to Aboriginal treaty provisions, (7) and to Parliament's overarching constitutional jurisdiction over "Indians, and lands reserved for the Indians". (8) As such, Aboriginal affairs in Canada are governed primarily by Parliament, subject always to Aboriginal rights. At the same time, provincial legislation of general application, that is not inconsistent with Aboriginal rights or federal laws, also extends to Aboriginal peoples. (9)

While Parliament has the jurisdiction to devise policies related to Aboriginal health and social welfare, those which have been developed to date have not been sufficient to overcome the shameful history of neglect toward Indigenous peoples. In the area of health alone, numerous studies reflect the disproportionate burden of illness sustained by Indigenous communities in Canada. In contrast to the non-Indigenous population, Aboriginal peoples have higher mortality rates across all age groups, and their infant mortality rate is twice to three times the national average. (10) Moreover, their propensity for diabetes, cancer, heart disease, hypertension, and arthritis is much higher than that of Canadians. (11)

The impact on the health of Aboriginal adults is not the sole legacy of their historical marginalization. Aboriginal children suffer from excessive rates of meningitis, otitis media, respiratory illnesses and iron deficiency anaemia. (12) The most striking disparity between Aboriginal and non-Aboriginal pediatric health is found in the increased rates of Aboriginal children with type 2 diabetes. Arguably, the psychosocial health of Aboriginal youth is an equal or greater cause for concern: depression, suicide and substance abuse rates among Aboriginal teens are alarming. (13) Like psychosocial illness, diabetes is cyclical, bearing the potential to pass from one generation to the next. Both diseases also have their roots in the effects of colonialism, and both are gravely exacerbated by poverty and social marginalization. Yet, while a study of mental health in Aboriginal communities would lend itself to a similar discussion, the focus here will be on the prevalence of diabetes among Indigenous children and yo uth in Canada.

A move away from a diet based on hunting and gathering food to a sedentary way of life and poor nutrition have contributed to an epidemic of this illness among Canada's Indigenous peoples. (14) Health Canada's First Nations and Inuit Health Branch indicates that the prevalence of type 2 diabetes (15) in Aboriginal communities is three to five times higher than in the non-Aboriginal Canadian population. Complications from this chronic disease are serious, and include kidney disease, cardiovascular illness, blindness, and amputations. (16)

Although type 2 diabetes was previously unknown to children and youth, Canadian researchers have recently found Aboriginal children afflicted with this illness. (17) The rates of pediatric diabetes within some Indigenous communities in Canada have been estimated to be among the highest in the world. (18)

In light of the correlation between diabetes and the social and economic history of Canada's Aboriginal people, this example provides a fertile ground for considering how culture, race and poverty may affect the state of children's health, as well as their ability to access quality medical care. This paper begins with a factual overview of pediatric diabetes among Aboriginal children in Canada. A discussion of the legal rules that structure Canada's health care system, as well as their inability to meet the needs of these children, then is considered. The deficiencies of Canada's health structure for Aboriginal children have resulted in government researchers and Indigenous communities developing special programs designed to promote pediatric health. A series of recommendations aimed at modifying, improving and adding to these programs is presented in the concluding section of this work. These suggestions are intended to protect the health care rights of all children in Canada whose well being has been compr omised by poverty, or racial or cultural discrimination.

II. An Overview of Pediatric Type 2 Diabetes in First Nations Communities in Canada

1. Historical and Current Presence of Type 2 Diabetes in Indigenous Communities

Prior to Canada's colonization by Europeans, the country's Indigenous population was organized into groups of hunting and gathering communities. Within these societies, inactivity and obesity were uncommon. Aboriginal people's genetic make-up had evolved over time to cope with alternating periods of abundant and reduced food intake by producing increased insulin and by developing excessive insulin resistance. However, colonial expansion, industrialization and urbanization produced a ready and continuous food supply within Indigenous communities. (19) As a result, obesity rates rose dramatically and quickly. Diabetes, an illness linked to obesity, began to appear within Aboriginal communities in North America in the 1940s, and in Canada over the last two decades. (20) Moreover, a rapid transition from hunting and gathering to sedentary, reserve-based lifestyles, as well as a switch from a high-fibre, low-fat diet to one based on low-fibre, high-calorie foods, exacerbated the prevalence of obesity and diabetes among Canada's Indigenous peoples. (21)

Type 2 diabetes traditionally is related to obesity with associated insulin resistance, and decreased uptake of glucose by the cells, leading to excess glucose in the bloodstream. Although the scope of this paper does not allow a full analysis of diabetic illness, the primary distinctions between type 1 and type 2 diabetes should be highlighted. In type 1 diabetes (which mainly affects children) the pancreas stops producing insulin. Injections of insulin are thus required to secure the survival of the person with diabetes. In contrast, type 2 diabetes is an illness that usually starts in adulthood and, until ten years ago, did not affect children. It occurs where the insulin produced by the pancreas is not properly used at the cell level, resulting in excessive insulin within the body. This in turn leads to decreased use of glucose by the cell, and increased levels of circulating glucose. At an initial level, type 2 diabetes is treated through lifestyle modifications; an elimination of foods high in sugar an d fat, an increase in physical activity and reduction in weight. Oral medications and insulin injections may also be administered. (22)

Although type 2 diabetes was previously known as "adult-onset" diabetes, recent research indicates that this form of the illness now affects an increasing number of children and adolescents. (23) This is particularly true for Aboriginal youth in Canada, who suffer from type 2 diabetes at seven times the rate that Caucasian Canadian children are afflicted with type 1 diabetes. (24) Although the specific causes of type 2 diabetes among Aboriginal children are uncertain, research has shown that youth who sustain this illness typically have family histories of type 2 diabetes, particularly in the form of maternal diabetes or gestational diabetes. (25) Most of these children also struggle with their weight, with keeping active and maintaining a healthy diet. (26)

Given that pediatric type 2 diabetes is a relatively new illness, researchers have had difficulty predicting its consequences for Indigenous communities. Nevertheless, in adults, long-term complications include neuropathy, cardiovascular disease, renal failure and blindness. (27) Affliction with type 2 diabetes during childhood might suggest an even longer list of complications, or their earlier onset. Moreover, the fact that most youths with this illness are female is alarming, as the onset of diabetes before or during pregnancy bears a potential impact on the health of a developing fetus. (28) The cycle of poor health in Aboriginal communities is therefore likely to be perpetuated.

2. Potential Barriers to Prevention, Management and Treatment

The health implications presented by pediatric type 2 diabetes necessitate the development of strategies for preventing, managing and treating the illness among Aboriginal children and youth. As such, several researchers have undertaken studies in Indigenous communities to further assess the impact of type 2 diabetes, and develop programs that help children, families and communities understand and cope with the illness. These initiatives have combined suggestions related to healthier and more active lifestyle modifications, diabetes screening programs, and pharmacological treatment programs within Aboriginal...

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