From Diversity to a Common Ground: Dissimilarity in a comprehensive approach to health
Our experience in Nunavut.
We left Ushuaia on a Friday afternoon. Several airplanes, airports, and delays later, we arrived at our destination: Nunavut, Canada. Officially we were made up of a ministry of health delegation from the Tierra del Fuego, Antarctic Territory and South Atlantic Islands Province. Our group, which included the Minister of Health, Dr. María Grieco, the Secretary of Community Health, Dr. Nora Guastini, and me, as well as Dr. Andrea Carbone from the Ministry of Health of the Nation, was on a Technical Cooperation among Countries mission organized by the Pan American Health Organization (PAHO). We knew that we carried an enormous responsibility: to continue on a journey that had already begun; an encounter between the opposite ends of the Americas. An encounter between people separated by a vast geographical, historical and cultural distance, yet capable of building a common agenda: a comprehensive approach to health and its determinants, with each party offering a different vision, one that is as different as it is complementary.
We were also bringing “treasured messages,” fraternal greetings prepared with the same care and dedication that our Inuit sisters had put into every gesture, word, and object they had brought with them to share with us in Tierra del Fuego several months before. Governor Fabiana Ríos and María and Mirta Salamanca, on behalf of the Rafaela Ishton Association, had entrusted us with these words, which would traverse the Americas from Ushuaia to the Arctic.
Our work agenda began on a Sunday. Two hours after our arrival at the Ottawa Airport, the Canadian health authorities (Ministry of Health of Canada) were expecting us. We followed an agenda proposed by both parties and a strange alchemy of punctuality, order and organization, and human warmth, simplicity, and respect. They introduced us to the features of the Canadian health system, their national strategy for reducing salt intake, their approach to climate change, and the consequent adaptation of the communities “of the north.” I think the words with which we were introduced to the health system accurately summarize the sense one comes away with: “The Canadian health services, which are publically funded, make up a dynamic system. Reforms have been carried out over the past 40 years and they will continue in response to changes in medicine and in society. The underlying premise, however, has not changed: universal health insurance for medically necessary health services provided based on need rather than the ability to pay.”
On Monday we left “the south”-”western” Canada, globalized Canada. Our destination was Iqaluit, which is the capital of Nunavut (“our land”) and its largest city. We boarded a flight with First Air, the first Inuit airline, and received our first surprise. The explanation was soon forthcoming: there are no roads to Nunavut. The population is scattered and separated by water. One can only travel there by air or by sleigh over frozen waters. Nunavut is the largest and most recently formed autonomous territory of Canada. Somewhere between a national territory and a province, it is an autonomy forged by strong Inuit leadership and resistance to domination. It is not without pain, regrets, and reconciliations. Located in northeastern Canada, it spans 2,093,190 km2-double the surface area of Tierra del Fuego, covering 20% of Canadian territory)-and has 31,000 inhabitants distributed among 26 communities with the lowest population density in the country.
The native language is Inuktitut, essentially a generic term commonly used to refer to the several different languages spoken by the Inuit (meaning “the people”). The population is bi- or trilingual: most speak English and Iuktitut and some people also speak French. Eighty-five percent of the population is of Inuit origin and 60% is under 25 years old. Currently, education is bilingual. The local government consists of a legislative assembly of 19 elected members who choose a head of government (a premier) by consensus from among the members. The premier, in turn, selects a cabinet of ministers. The Assembly meets in the capital in a marvelous round room, where everything is arranged in a circle. No one is in front of anyone else; everyone is equal. Traditional ornaments made of caribou horn, chairs covered with sealskin, and certain rituals straight from the British Parliament, serve as a stark reminder of the colonial reality.
In Nunavut, health, like life, is approached holistically. To speak of health is to speak of the land, of animals, of elders and children, of totems (inukshuk), of death, of school, of history, and of the “white man.”
The current Minister of Health of Canada, Leona Aglukkaq, is of Inuit ancestry. In her own words, the health situation of her people has deteriorated in recent years, a trend which must be reversed. This will never be accomplished without a community health vision, collaborative efforts, unwavering political resolve, and the involvement of the main stakeholders: the communities.
We had the honor of meeting many of the people working for health. They were from a wide range of disciplines, some Inuit some not, some Canadian some not, who were joined by a common theme: to respond to the needs of the community. Feasible solutions, for which they build capacity, skills, and competencies based on what they have, rather than what they lack. If the concept of transculturality applies anywhere, it applies in Nunavut.
We saw very few statistics; they did not generally provide them. They could not, in fact, present a “health situation” in the western sense of the term. It was not necessary. It is astonishing how it is taken for granted these days that the available data reflect an extremely disadvantageous status quo compared to the rest of Canada. And this refers to life expectancy, infant mortality, mortality due to tumors, suicides, violence, smoking, communicable diseases, and the list goes on. A quantitative analysis of all these things would detract from the richness of their stories. Still, these phenomena are worth mentioning if only in an attempt to describe the different manifestations and meanings they produce and reproduce among the various social stakeholders in Nunavut. Their social determinants and conditioning factors transport us to their narrative and leave us with only our capacity to listen and to make of this article a precarious field notebook that strives to capture the “there” from the “here.”
The history of the Inuit is not so different from that of other native peoples. The Arctic has been their territory for over 10,000 years. They were nomads until a little more than 50 years ago, when they were forced to abandon their camps and lands and move into the cities to settle in communities. The values of the “south,” – western values – were imposed on them: salaried employment, compulsory schooling, Canadian justice instead of traditional Inuit justice, housing (precarious and substandard), a government not made up of their ethnic group. All of these are cited as the historical context for the traumatic acculturation process that explains the health problems that concern the Inuit today-and that they are tackling in such an exemplary manner-as well as the resistance that led them down the long road to territorial autonomy, which they achieved in 1999.
This mix of past and present was reflected in every face, in the very rhythm of this city of 5,000 people, Iqaluit, or “place of many fish,” which lies on the banks of Frobisher Bay. The landscapes are reminiscent of the northern part of our Island; the colors too. It was early fall and even the temperature was similar to ours. In some ways, we felt at home. It was a new city with structures of no more than two or three stories with houses of many hues, all dry construction, with building projects underway everywhere, set against a blue backdrop, very blue, very marine, with birds zigzagging across the sky. Inuit faces are unmistakable, marked by the indelible imprint of climate and time. Toothless smiles that are also ageless. There are many children, as well as faces from all over: people from the south, from other countries, even from other continents. Nunavut promises work and prosperity to the migrant. It also asks for tolerance for diversity and for isolation, for openness and respect, a great deal of respect for a culture that wanted, knew how, and was able to resist.
We covered a very broad agenda with the health authorities of Nunavut. In our first exchange we presented the main features of the three health systems represented (Nunavut, Argentina and Tierra del Fuego) and our provincial health situation. We shared the greetings we had brought with us. It was very moving. The auditorium was spacious and included the Minister of Health, also Inuit, and his team of collaborators that was as multidisciplinary as it was multiethnic.
After the initial formalities, we plunged into the work agenda, which had been carefully crafted to cover topics of mutual interest, shared health problems, and different strategies for approaching them. We discussed Vitamin D deficiencies in extreme latitudes, breastfeeding, childhood nutrition, food security, well-being programs, healthy communities, nursing training programs and general policies on human resources in health. We learned about the territorial mental health strategy, approaches to vulnerable children and adolescents, the profound concern over high suicide rates, and poverty reduction strategies. These exchanges were rich beyond measure, making the task of capturing them on paper difficult indeed. I know that these people at the other extreme of the hemisphere embody, in their everyday work, the concept of health as a social phenomenon. Each one of the complex problems mentioned earlier was described and explained from an historical and cultural perspective that transcends the strictly biomedical, and each is addressed accordingly. I must confess that it was sometimes uncomfortable to see the disadvantages that the Inuit minority faced-and still face in some instances by the dominant western majority presented in such an explicit manner. And these disadvantages are plain to see in the health indicators. What never ceased to amaze us, however, was the way they approach their situation. The problems are shared by everyone and therefore everyone is committed and involved in addressing them. Although the health services are part of this, the circle is completed by forging healthy partnerships with the community and in communion with the environment. We also visited the hospital, where we were impressed with the emphasis on respect.
After a three day stay in Iqaluit, we again boarded a First Air flight. The “milkman” (which seems to be a Pan American concept) made every stop except for one-where the pilot felt landing would be too dangerous-en route to our destination: Rankin Inlet. All the landing strips were gravel. Tiny airports served free hot coffee to travelers.
Rankin Inlet is on the western bank of the Hudson Bay. Nunavut’s second largest community in terms of population, it prospered from the nickel mines. It is currently home to a vibrant midwifery training program. The midwives there have shouldered the difficult task of recovering the traditional knowledge of the elders, which is blended with modern medicine to create an ideal syncretism. They encourage giving birth in a squatting position, as many cultures have done since the beginning of time (after all, the Earth does have gravity) and they also provide referrals for caesarean sections. Here again, training programs are tailored to current circumstances and already include Inuit graduates from the Arctic College. This program follows the logic of not reinventing the wheel, so that other communities can rely on their own maternity services.
The community honored us with a party at the health center on the day of the fall equinox. We shared their traditional dishes, saw dances performed to the beat of drums, and listened to their “throat singing,” a competition of sorts between two women, who clutch each other by the arms and make guttural noises, imitating each other at top speed. This practice is handed down from mothers to daughters and between sisters. Once again we were able to witness the joy in these people and transcultural living.
The next morning, the same health center became our meeting place, which included another exhaustive agenda and presentations on the many programs being implemented. As I leaf through my papers to write this article, I find among the vast amount of materials so generously provided to us, the concept of public health espoused by the Rankin Inlet team: “the science and art of improving community health through the organized efforts of society, using techniques to prevent disease, and promote and protect health.” Certainly the science and art, the effort, organization, and social participation would be hard to miss.
Any effort to convey this experience is going to fall short. The experience was so rich that words cannot do it justice.
Our mission was more than a simple exchange visit or to identify “good practices.” The more I think about it, the more of them I am able to identify and relate to our own setting. Living in a complex society, I place a premium on respect for diversity, tolerance, and responsible participation in the search for creative solutions to the problems we all share.
Yours forever, Nunavut, it was an honor to tread your soil.
Dr. Virna Almeida
Director of Epidemiology and Health Information
Ministry of Health
Tierra del Fuego, Antarctica and the South Atlantic Islands Province