Access to Sexual and Reproductive Health Care for Indigenous Women in Canada

Academic year. I hope for similar of this academic year, it’s unfortunate that there is indeed a somewhat overlapping event taking place at the same time. There is discussion of
#MeToo in the other, in the other building, which may, certainly have attracted the same crowd. But we’re really happy to have the same core people attending the last seminar of this academic year. So I certainly want for the
last seminar we did that, when we opened the seminar
series, but I would like to acknowledge for the last seminar on this particular topic, the fact that we’re being, we’re using, or we’re welcomed actually, on the sacred land on which the University of Toronto operates. Has been the site of human
activity for 15000 years. It’s the territory of the Huron-Wendaat, and the Petan First Nations, the Seneca, the Mississaugas of the Credit River. It was the subject of
the Dish With One Spoon Wampm Belt Coveneant, an agreement between the
Iroquois Confederacy, and the Confederacy of the Obibwe and Allied Nations, who peacefully shared and cared for the resources
around the Great Lakes. The many indigenous people
in the Toronto area, Susan Stewart, who came
to speak to our class, and who unfortunately isn’t here, that hopes she will still arrive, mentioned that, or put
the emphasis on the fact that we actually have
the biggest community or the biggest population
of indigenous people living in the city. So which, many people
actually often forget to acknowledge or to realize. It’s also a particular
moment in time, actually, that we have this event here. I would say, in a time that there is a lot of trauma, with respect to the Colton
Boushie and Tina Fontaine trials. And then, particularly, again
the decision not to appeal the Tina Fontaine, and the
Tina Fontaine murder case. Which may be legally
rational, but certainly, for the indigenous community, is deeply traumatizing and brings up a lot of emotional moments. It’s also a time when
we have national inquiry into missing and murdered
indigenous women and girls, and ongoing tribulations around that, so all of this makes for a special moment to actually discuss issues around indigenous women and health. And I think it’s maybe
symbolic, hopefully symbolic for a new era in Canada. Also, non-indigenous legal scholars, who are interested in the issues, and are interested in looking particularly at how issues affect indigenous women. So for that reason, with
this long introduction, I want to emphasize that
it’s a special moment, that I really appreciate that Erin Nelson is coming to talk to us today, on the topic of reproductive
healthcare for Canada’s for indigenous women in
the Canadian context. So, Erin will give a presentation, we if Susan too, would arrive, I will introduce her, I
hope she will still arrive. And we will then have another commentary, by Justice Alison Harvison Young. So I introduced the three speakers. They will have a presentation, two commentaries, and then we’ll open it up for questions. So, Professor Erin Nelson is a professor at the faculty of Lloyd University of Alberta since 2000. She teaches Tort Law,
Healthcare Ethics and the Law, and Law and Medicine. She is a fellow of the
Health Law Institute, has served as an associate
doing research in the faculty. Her research interests
include the interface of healthcare law and
ethics, women’s health, issues in reproductive health,
and Feminist legal theory. She’s published many articles and books on a wide variety of
health law related topics, so she’s one of the leading
scholars of health law in general, generally in Canada, but particularly I particularly
want to mention her book, 2013, On Law Policy and
Reproductive Autonomy, which was published by Hart, and which obviously relates
to some of the issues that she will be discussing today. Then, we may have a
presentation, a commentary by Dr. Stewart, who is a member of the Yellowknife Dene First Nation. A registered Psychologist,
she is the Director of the Waakebiness-Bryce Institute for Indigenous Health Sciences, Dalla Lana School of Public Health. And she is actually, her
research focuses on the, you can, you can sit here. Her research focuses on
indigenous mental health, healing, and psychology. homelessness, youth,
mental health, identity, workplace development, paid pedagogies in higher eduction, indigenous ethics and
research methodologies. She’s chair of the Aboriginal Section of the Canadian Psychology Association, and is generally committed to advancing indigenous healing issues through the disciplines
of health and psychology. SUZANNE: Oh do you want
me to put it up there? Yes. And then we will have
Alison Harvison Young providing the commentary. And my entourage is up there, I want to them to fit in here. Thank you. So, Justice Harvison Young is judge of the Superior Court of Justice Ontario, prior to her appointment as a judge, she was a legal academic in Family Law. She was appointed as a judge in 2004. Previously to her additional appointment, she was Dean of the Faculty
of Law of Queens University in Kingston, Ontario. She taught at the Faculty
of Law of McGill University, and University of Pennsylvania Law School. Some of her many contributions
to legal scholarship as an academic were in relation
to reproductive rights, and so she contributed
to, among other things, with papers for the Royal Commission on Reproductive Technologies, and she’s now a Judge in Residence here, at the University of
Toronto, working on access, access to justice issues. So, without further ado,
I will let Erin start. And then we’ll have a
commentary by Suzanne, and Alison will provide
a commentary after that. Then we’ll open it up for questions. Last thing I will
distribute, a present list. So if you could fill that
out, we like to have a sense of who is attending the seminars, and it gives us a sense of who we reach. Thank you. Thanks very much, Trudeau, for that kind introduction, and for the invitation to come
here and speak to all of you. The one topic that I find fascinating and distressing at the same time. I want to note at the
outset, a couple of things. First, that it’s a happy coincidence, when we planned today’s talk, we didn’t, I don’t think either of
us appreciated that it was International Women’s Day,
so it’s a happy coincidence to be speaking about these issues today. And the second thing I want to say, is that my background
and my research focus has been in Health Law. And so I come at this
from a perspective that is sort of based in Health Law, and I just want to note
at the outset, that I want to be, you know I hopefully, am going to use my language
and my words carefully, but if I do slip up, and say things that suggest citizenship or rules in society for indigenous people,
that they don’t agree with, please accept my apologies. I’m not attempting to comment
on that aspect of the issue at all, I’m just kind of trying to make sure that I
continue to refer to the fact that we’re dealing with
the Canadian context, and my own background suggests
to me that I probably will end up saying things
that maybe I don’t intend or appreciate the intent of. So what I want to talk about is access to sexual and reproductive
healthcare in Canada. For women generally, but
focusing in particular on the experiences, as I understand them, and concerns that have been raised, with access for indigenous women. And so I want to start
with an introduction, talking a bit about the healthcare system, and what the system in Canada addresses and what it doesn’t address. And then I will turn to discuss in general
terms access to healthcare for Canadians of indigenous
heritage and background, and then talk about specifically, access to sexual and
reproductive healthcare. So I have, I find, these word clouds, hopefully this shows
up, oh yeah it’s okay, I find these word clouds to be a really interesting exercise, I don’t know if any of
you have ever done them, but there’s this online
platform called Wordle. And you just paste text into it. And you end up with, you know, sometimes a very
interesting perspective on what you thought you were saying, and what your text actually conveys. And I just think it’s
interesting to kind of consider the interlinked nature of all of these various considerations, of community government, healthcare, the status of women, health status, a lot of kind of interconnected ideas. So I like to show this. To kinda convey that complexity, and intertwined nature of
many of these issues. So as I said, I want to talk briefly about the Canadian healthcare system, I will try to keep it brief. This is an area, you know
it’s not that easy to kind of boil down into basic
principles, but maybe we could get into a bit more detail in
the question period afterward. So Canada is a country that prides itself on having a universal, publicly
funded healthcare system. Care in this system is made
avaiLable on the basis of need, not on the basis of ability to pay. And that’s, you know, a
source of national pride for many Canadians, and
for Canada’s government. There are some important
contextual factors to keep in mind, in
relation to this system, and I, you know, I apologize
if this is old territory for some of you, but I
know that not everybody really has a deep
understanding of these issues. So jurisdiction over health
is not exclusively allocated in our constitution, to one
level of government or another. It’s not explicitly allocated at all. Typically the view is that the provinces have primary responsibility
for healthcare, and that’s how our system
has actually evolved. But it’s not that clear that it is only a provincial responsibility. So that’s the general
view, and what that means is that in Canada we refer to Medicare and the Canadian healthcare system, but what we actually have
are 13 unique systems. Each province and territory
has its own system that shares similar
characteristics and features, but that have their own
sort of different nuances. The Federal government role
in healthcare, in Canada, is largely a financial role. And that’s important for
a whole host of reasons, and some of those reasons are relevant to what we are talking about today. The system also is a
product of its history. So again, I apologize for those of you who know this history well. I just want to take a little
brief detour through it. The Canadian System has
its roots in Saskatchewan, beginning in the 1950s, when the province of Saskatchewan instigated a system whereby
the province was covering or was prepared to cover the costs of hospital and diagnostic services. So that’s the beginning
of our healthcare system. The Canadian government looked at what Saskatchewan
was doing, and thought, well that sounds like a fairly good idea, and offered to cost
share with any province that would agree to create or develop the same kind of system as Saskatchewan had. A decade later, Saskatchewan
again being on the cutting edge of healthcare here, developed a new program to
ensure physician services. And likewise, as they did with the hospital and diagnostic piece, the Canadian government
offered to cost share, with any province that would agree to have a universal and comprehensive
healthcare system, covering physician
services, hospital services, and diagnostic services. The cost sharing proposed
by the federal government at the outset was a 50/50
cost sharing program, and, as you can imagine,
you know, in those days in the 1960s maybe it wasn’t
quite as big of a deal, but 50% of healthcare costs now, certainly is a significant amount of the provincial budget. So all of the provinces
were excited to participate, and agreed to participate. And over the years, these kind of separate pieces of legislation became, they evolved into what’s now our legislation that governs
the healthcare system which is the Canada
Health Act, which kind of bundles everything together. And basically, in very
broad brush strokes, provides federal funding,
not on a 50/50 basis anymore, but provides federal
funding to provinces that have systems, provinces and
territories that have systems that meet the five criteria
outlined in the act. And the criteria are universality, so it’s available to the entire population of the province or territory, comprehensiveness, that it covers all medically necessary services, and we’ll come back to that point shortly. That it is portable, in that a resident of one province can move to another
province and have coverage from the province that they moved from, while they wait to be
covered in the new province. It is publicly administered, meaning that we have a single payer system and that has become a
very important feature of our healthcare system. And that it is accessible, meaning that all Canadians have basically, you know, roughly equal access
to healthcare facilities. So as I said, at the
outset the cost sharing envisioned by the federal
government was a 50/50 basis, and was actually, as I
understand it initially, based on provincial actual expenditures, and the federal government
would pay a portion of those. And over the years, that funding formula and approach to funding changed as well and now what we have is a bundled kind of package of funding that comes to the provinces, that’s called a Health Transfer Payment. It doesn’t address
exactly how the provinces, or what the provinces are paying for, in terms of healthcare costs, and as, over the years,
the federal contribution has become much less than this sort of idealized 50% idea. There’s some dispute and
uncertainty about actually how much of the provincial
healthcare costs are covered by the federal government, but estimates put it
anywhere between 20% and 37%. So 37% is not as far off from 50%, but 20% is a
substantially lower amount. And this has, you know,
as anyone who has any familiarity with Canadian
politics, this is an ongoing tug of war, shall we say? Where the provinces are
repeatedly asking for additional funding, and
the federal government is repeatedly trying to find
ways not to agree to that. So that’s kind of the general picture of our healthcare system. The federal government does
have some specific obligations, in terms of healthcare
in the constitution. One of those is direct
federal delivery of services to First Nations people
and Inuit people in Canada, including primary care,
and emergency services. Particularly on reserve
lands, where there isn’t provincial service nearby. The federal government
is also responsible for community based health programs, and also has a non-insured
health benefits program which provides dental coverage, drug coverage,
and some ancillary services coverage, things that
are not included in Medicare, to people of First
Nations and Inuit descent, wherever they live in Canada. So I want to come back to this point about what is covered by our system. Canada’s system covers
medically necessary services, and so just that phrase
alone gives you a sense that what we are is a system
that provides diagnosis and treatment of medical problems. So, illness and disease. It’s really focused on the
provision of that type of care. It is also focused on hospital services and physician services, and that is a product
of the history, you know the evolution of the system. And so what that means is
that we have some strange inconsistencies in coverage. And in a modern healthcare
system context, we have a lot that is left out, of what
is covered by our system. So, just as an example of
these coverage inconsistencies, if you are an inpatient in
a hospital, and you need prescription medication,
then you don’t pay for it while you’re in hospital. Once you’re discharged, if
you need that medication, that then becomes your responsibility, because that’s no longer
a hospital service. It’s up to you to provide it. And some provinces, do have
developed PharmaCare programs, and it seems that maybe
the federal government is contemplating, certainly they’re going to
look into a PharmaCare program, whether or not that
translates into a real program remains to be seen. But that’s sort of a
broad brushstrokes outline of the system. And, as I said, the system is focused on caring for people’s medical
needs, and medical conditions. And I want to talk now a bit about social determinants of health which are not, you know, something that our
system really addresses, and that most healthcare
systems actually don’t address. So it’s well known in less wealthy and developing
parts of the world, that there are significant
health inequities among individuals within those
regions of the world. But these inequities are
maybEE, less well known, in a very highly industrialized
and well resourced country, like Canada but they
still exist, and they are an issue that I think we
should be concerned about. You know, and as I said,
Canada’s healthcare system is a source of pride for many Canadians, and for many Canadian governments, as is Canada’s population health status. But if you look a little
bit more deeply into the question of health
status of Canadians, you’ll see some troubling gaps
and troubling disparities. Mostly for Canadians who are marginalized, for one reason or another, either for reasons of
poverty, reasons of gender, reasons of race or ethnicity. All of these factors
play a role in creating and perpetuating health
inequities and health disparities. And one group of Canadians who experience intersecting
disadvantages as the result of some of these factors, are
indigenous women in Canada. And we have, as I said, a universal system that covers people on the
basis of medical need, not on the basis of ability to pay and that should suggest, theoretically, that we would see similar or relatively equivalent levels of health status and access to services. And unfortunately, that
is, generally speaking, an inaccurate picture of the situation. The picture is a lot more
complicated than that. Again, because we focus on medical need, in the provision of medical services, we don’t address many of
these underlying inequities that lead to health disparities. We know now that the
health of a population depends heavily on these
social determinants of health. In terms of indigenous
people in particular, there have been some categories of health determinants
that have been identified. Not on my slide, sorry about that. So proximal determinants is
one category of determinants and these are things that tend to directly affect a person’s health, like health behaviors, the environment, physical environment,
their level of employment, their income level, education, food security,
all those kinds of issues. There also there are intermediate
determinants of health which include primarily
systems oriented concerns. Education systems, healthcare systems, community infrastructure, and cultural continuities,
and other intermediate determined health. And finally, the third category is called distal determinants of
health, and those are issues that are, I guess,
pervade the background of what it means to be an
indigenous person living in Canada and they include colonialism,
racism, social exclusion and some of these broader,
very systemic concerns. What that suggest actually,
is that indigenous status itself is a determinant of health and can itself impact the health status of an indigenous person living in Canada. Canada ranks fourth,
again this is a source of pride for many people in Canada, on the human development index, and that’s a World Health
Organization quality of life index that is based on factors
including life expectancy, standard of living, education level, and gross domestic product in the nation. For rural, aboriginal communities however, the ranking is 68, so it’s a, that I think those numbers
alone give you a sense of the kind of disparity
that we’re dealing with and that we’re concerned about. And as one group of authors,
Canadian authors has noted, there are striking disparities
and health inequities that persist across
Canada and they point out that the health disparities
that stem from these inequities not only cut across almost
every major health outcome, health determinant and measured access, but have also been
exacerbated by institutions such as the Canadian
healthcare system itself. And so I think that’s
something that should give us a bit of pause in terms of how well we’re managing the
health of Canadians in general. So I wanna say a few
introductory remarks about the importance of access to
sexual and reproductive health for women in particular, for
women’s autonomy and equality. Then I’ll kind of get
into the healthcare issues more specifically. I think that probably
I’m not saying anything earth shattering to appreciate
that both women and men have sexual and reproductive
healthcare needs. I am not going to dismiss
the fact that men also have these kinds of healthcare
needs or require access to sexual and reproductive care services, but I do think that there
are uneven implications for men and women of a lack of access to
these kinds of services and so that’s what I am
particularly concerned about. The implications of being unable to access reproductive and sexual
healthcare services for women are far more intense and
play a much bigger role in a woman’s ability to chart the course of their
own life and to participate fully in civic and social society. It’s not the same thing
if a man can’t get access as if a woman can’t, and women’s social and
political circumstances are very intimately
connected to their ability to access sexual and
reproductive healthcare services. I think this is especially
true of women who are marginalized for one reason or another, who are living in
circumstances that make it hard for them to get by as it is. When women can’t access
these services sometimes what that means is that they
can’t exert much control over their own, the
course of their own life and it’s really important
to recognize that reality in this context and to me, as Trudeau said I wrote a book about this so I guess it’s something
that I’ve thought about for a pretty long time, to me the interrelationship
between a woman’s autonomy and her reproductive autonomy or equality, and her ability to access
sexual and reproductive healthcare services is obviously apparent and I think it’s critically important and it’s something that
has been recognized for a long time by advocacy organizations both domestically and internationally, seeking to promote a sexual
and reproductive rights agenda. So I’m not the only one who things that these issues are closely entangled. Canadian women in general are very lucky in that they don’t face access challenges on anything like the scale that many women in developing regions face. Most of the time, women
can fairly readily access these kinds of services
and this type of care. One problem, and I’ll
come back to this sort of closer to my conclusion,
one concern that I think we do have to acknowledge is that we don’t think
that our access problems are very bad and they
may well not be very bad at least for the majority of women, but what we don’t actually
have is a true picture of what our access situation is. We don’t have any data or data tracking. In health generally it’s
not really that terrific, and certainly in the area specifically of sexual and reproductive
healthcare services we don’t know very much
about how accessible or not some of these services are. We do know, in general
terms, that women who live in larger urban centers
and who are educated or relatively well off are
able to access these kinds of services without too much difficulty, but what we don’t know is what happens to women
who are marginalized. Maybe they’re living in
poverty, maybe they’re newcomers to Canada and don’t have
facility with French or English, or maybe they’re indigenous
women who are facing intersecting disadvantages. How well can they, or how
readily can they access sexual and reproductive
healthcare services? And I don’t think that we
have the answers to that and to me, I think that’s the
first step that has to be taken to address the problem. If you don’t know the
magnitude of the problem, or the scale of the
challenge, then we don’t have any way of knowing if
anything we’re doing to try and improve things is
actually doing anything and so I think that is a
critically important issue to keep in mind. Alright, so what about
access to healthcare for indigenous people in Canada? So as I said, there are
significant disparities in health status faced by indigenous people in Canada compared to non indigenous people. They have higher morbidity
and mortality rates and worse healthcare access. And again, some of the data
don’t speak generally to indigenous people in
Canada but there has been some study in First Nations
and Metis and Inuit people and these have shown,
these studies have shown that there are significant
disparities in health status and morbidity and mortality rates. I think one thing that
we have to keep in mind when we contemplate the
idea of healthcare access is that physical access is
one piece of the puzzle. If you don’t live near a facility, or if there are no providers in your area, then you can’t have ready
access, that’s pretty clear and I don’t think that’s very contentious. But one additional piece of
the puzzle to keep in mind when we’re talking about
indigenous people in Canada in particular is that
access is not just about physically being able to go to the doctor or go the emergency department. There’s a lot involved in how that service is actually delivered at the point of care that can frustrate access or
make access very difficult for people in this
context, and so the fact of bias and stereotyping and racism, these things have not gone away and if you have tried to access care in an emergency department that has staff that ignore you
or treat you without respect you’re not going to feel very welcome, you’re not going to be
terribly excited about going back to seek care
again if you need it and so I think that is
another factor that has to be borne in mind when we think
about access to healthcare. There are also a number
of social realities that face indigenous people living in Canada and these vary significantly
depending on where people live. That can affect their
access to healthcare, so often reserve communities
and individuals living on reserve face a lack of infrastructure and sort of basic sanitation and adequate housing that’s not overcrowded or in need of repair. Often, especially in
rural and remote areas there can be a lack of availability
of healthcare providers. There simply aren’t the people
to deliver the services. Lack of access to safe drinking
water and food insecurity. So all of the risk factors
can play a significant role in one’s ability
to access healthcare. In terms of health status, again we see significant
inequities and disparities and they are multifactorial,
and this is one of the reasons why it’s hard to kind
of come up with an idea, a single idea to address the problem
and to figure out how we might actually solve these
concerns because they’re influenced by so many different factors. Income levels for
indigenous people of Canada are not increasing as
quickly as income levels for non indigenous Canadians. That is also the case with
university degree attainment. It’s increasing in indigenous populations but not as quickly as in the
non indigenous population so the gap in income and the gap in education level is widening. Indigenous people in
Canada have more of their healthcare needs unmet,
they have a heavier burden of illness,
often face younger onset of chronic illness and
chronic disability and the interesting thing, and
again the distressing thing is that it’s not hard to
imagine that when someone lives in a rural or remote part of Canada that it can be very difficult
to access healthcare because the facilities might
not be there or the providers might not be there, but there
is a recent Canadian study that suggests that
indigenous persons living in urban settings in Canada
have even more trouble accessing healthcare than
those who live on reserve land or in a rural setting. Again I think that speaks
the context and the way in which care and services
are provided and delivered. Urban indigenous people
suffer from higher rates of HIV and AIDS, higher rates of diabetes, higher rates of substance abuse and off reserve communities
right now are where half of the indigenous
population lives and these communities are the most quickly growing communities and populations. [Audience Members] Sorry
can I just fix that? It’s actually half of First Nations people that are registered as status Indians and that misses out on the Metis
and non registered indigenous people and Inuit people
we don’t do it so it’s actually about 80%
that live in urban centers. Okay thank you. Thank you for that clarification. Alright, so what about access
to sexual and reproductive healthcare in Canada? And this is again, something that I really
wanna emphasize at the outset and I hope you will bear in mind as I
raise these other sort of issues about access. It’s really important to
note that accessibility of sexual and reproductive
health services has a unique meaning and unique implications
for indigenous women. The experiences of many
indigenous women in Canada involve attempts at being coerced into not reproducing, so coercive
attempts at contraception or sterilization, trying
to prevent reproduction, and also preventing these
women from being able to raise the children that they bear. So there is, as we all
know, an over representation of indigenous children in
all provinces and territories child and welfare group systems. So it’s important to
keep in mind that there are sort of different
pressures depending on the different women’s experiences
that you are considering. So I don’t want to suggest that the reproductive and sexual
health concerns and challenges faced by indigenous women
are the same as those faced by all Canadian
women because I think there are some pretty important differences, but there may be indigenous
women who also do feel that what the issues are
for them are the same as those for non indigenous Canadian women. So it’s important to keep
that in mind and it’s also important to keep in mind that policy has to be approached in an
incredibly thoughtful way because of these unique implications, because of the history,
because of the concerns about how women’s sexual
and reproductive rights have been handled in the past. I’ll talk a bit about abortion services and their access in Canada. I don’t know if I can make
that a little bit bigger. Okay, so this is a map
from statistics Canada, it’s a map of Canada’s
census metropolitan areas which are the red areas and
then census agglomerations which we are not too
terribly concerned about. So if you look where the
red is, you can see that there isn’t, first of all,
very much red on that map and that there are vast
expanses that don’t have any they’re just vast expanses
without a census agglomeration or a census metropolitan area and geographic considerations
can pose a significant barrier, in particular to accessing abortion services in Canada. So Canada is big, and
most of our population is concentrated in the
south part of the country and this, again, I think
this map tells that story quite clearly, and for a long time we didn’t
have a lot of information about where services,
abortion services were located or could be accessed and Wendy Norman at UBC is a
physician, a family physician who’s been, she’s now
a Canada research chair and family planning research
and she’s been doing an enormous amount of work,
she’s only one person, and there’s a lot of work
to be done but she’s making some really important headway in this context with her team. So she did a survey with a
couple of coauthors within the last two or three
years as to where abortion services are available
and the team found that there were 94 facilities
offering abortion services in Canada, nearly half of
which are located in Quebec. So of these 94, 46 are
in Quebec, that’s kind of a staggering piece of
information to contemplate. British Columbia and Quebec
are the only provinces that have paid some
policy attention to where abortion services are
located and so they have services in both urban
settings and in rural locations but they’re the only
provinces that have paid any attention to that, and so most provinces don’t
have that same pattern. So in Quebec, the 46 centers
are distributed roughly equally around urban and rural locations. British Columbia has 16 centers. Eight of them are in rural
centers or rural locations and the other eight are in urban centers. And then the remaining 32 of
the 94 facilities in Canada are distributed as follows, so partly by population so
Ontario has 16 facilities, there are eight shared among
the three prairie provinces, four in the Atlantic
provinces and another four in the territories. The vast majority of abortion
services in provinces other than Quebec and BC are
located in urban centers, but significant numbers
of people who might need these kinds of services
are not looking in those census metropolitan areas. So, in the prairies as
an example you can see you don’t have a lot of
census metropolitan areas, get closer in to that. Abortion services are
only available in CNAs in the prairies, and 40% of
females of reproductive age, so between 15 and 44, live
somewhere other than a CNA. In Ontario more than a third of women aged 15 to 44 live outside
of an CNA with a facility and there are no abortion
facilities in Ontario that are located in rural areas. This can have, you know, different impacts depending on how far away from
a census metropolitan area you live, but as an example, in Alberta, if you live in Fort
McMurray or Grande Prairie, you probably have a four to
four and a half hour drive in each direction to Edmonton
to be able to access services. I have heard colloquially,
I’ve heard informally that there is one
provider in Grand Prairie but I don’t know if that’s still the case. I don’t know how well known
that is even in Grand Prairie and so these women would face
significant travel instances. In Ontario, one example
is Thunder Bay which is obviously not close to
Toronto, there are limited services available, surgical
abortion services available at a local hospital and
apart from that the nearest clinic far out in Winnipeg,
which is 700 kilometers from Thunder Bay or Toronto
which is 1400 kilometers from Thunder Bay. So women who live half
an hour from Toronto or from Ottawa where
services are available don’t face an enormous challenge, but women who live in
Thunder Bay and can’t get access in a timely
way at the local hospital might face significant access problems. As to how accessible or not abortion services are for
indigenous women in Canada, we don’t really know. There isn’t a lot of
information to suggest whether access is more
difficult, is the same level of difficulty or less so, but there was a recent Canadian survey,
or sorry, Canadian study, that showed that First
Nations and Metis women were almost three times
as likely as other studied participants to report having to travel more than a hundred kilometers
to access abortion services. So that’s a significant distance, and you know a significant barrier to access. Again we don’t have a
huge amount of information to know again how accessible services are. We don’t how many
Canadian hospitals provide abortion services. There was a study done, and I should say study in quotation
marks because there was an attempt at research done in 2006 that suggests that about
16% of Canadian hospitals provide services but it
wasn’t really a rigorous study it was kind of a secret
shopper kind of study where someone phoned
hospitals to ask if services were available so we don’t know if what they received by the
way of answers was a very true or accurate picture. Not all provinces still
fund clinic abortions which are much more readily available than hospital abortions. Only four facilities
provide abortion services for all three territories
combined and I think, I showed you the map,
the territories are vast. That’s maybe not gonna
create ease of access. We do have some hope on the
horizon with the approval of Mifepristone which is the drug
used in medication abortions so theoretically a person
would not have to go to a facility that provides abortion services to be able to access services. It took a long time to
get approved in Canada. Partly it took a long time
because it took a long time for manufacturers to be
willing to apply for approval, but even after the application it took two and a half years for
approval to happen and then I wanna say another year
and a half to two years before the drug became
actually available even after it was approved. Contraceptive services also, you know in general
terms I think most women who are living in an urban
center and have a level of education that permits them to know where they can
access services have fairly ready access, but regulatory barriers
also play a role in what Canadian women are able to access. Far fewer products, variety of products than
are available in general and that are available in other countries, and on important piece of
information to keep in mind is that no long acting
contracptives are available, approved for use in Canada. I think Trudeau’s about to tell
me I’m running out of time. Yes (laughs) okay. Okay, I’m gonna zoom ahead a little bit, and talk about a couple
of other issues and then try to wrap things up so, in terms of access to
prenatal care for women living on reserve this has been described, the level of access has
been described as being a state of crisis by the
Society of Obstetricians and Gynecologists of Canada. I don’t know how much
more bad it could get than a description like that. The other thing that goes
together with that is that women living in rural and
remote areas in particular often have to leave their
community, sometimes for a month or longer in order to give birth
because there are no labor and delivery services
available where they live. What this means is that
women are separated from their families at a very
critical time in their life and this is stressful,
childbirth has become a stressful life event that
sort of isolates women from the community instead
of bringing them together with their community and
there are significant costs to that both financial
and cost to the community. Again here is a situation
where we don’t know, sorry, much about numbers. We have estimates suggesting
that maternal mortality, meaning women who die within pregnancy or within about 42 days after pregnancy is probably or
approximately roughly double for indigenous compared to non
indigenous women in Canada. [Male Audience Member]
Isn’t that recorded? Is aboriginal status not
reported on the death register? [Female Audience Member] No. [Male Audience Member] It’s not? And then we also known that stillbirth and perinatal death rates
are also roughly double, so we know that complications
are much higher. We don’t have good data, we
have estimates that suggest these significant increases. The one last thing I’ll
say about access to reproductive and sexual healthcare is that also in addition to these
other access challenges indigenous women tend to have more reproductive and sexual healthcare needs, higher levels of needs
than other groups do. Mothers tend to be
younger, they often tend to have more children, their
babies often have higher birth weights that can
lead to problems in labor and delivery, they have
higher rates of sexually transmitted infection which
can lead to infertility. So the challenges actually
encompass all of the potential life events that women face. As I said, we don’t have reliable data, but even without that reliable
data it’s very difficult to avoid the conclusion that
indigenous women in Canada confront significantly more
reproductive and sexual healthcare concerns than their
non indigenous counterparts. I just don’t know how, how to reach a conclusion other than that and that they face marked
disparity in access to needed medical care. Alright, so I’m gonna do a
whirlwind conclusion here and we can talk more about
this in the questions. So we need better data collection. Until we know more about
the actual problem, it’s really hard to know how to address the problem or problems. We also need to confront
the systemic issues that face our populations and our indigenous population. That jurisdictional
conflict, so disagreement between the province and
the federal government and who is supposed to
pay for what services needs to be addressed and overcome, and we need to consider
and think about access in rural and remote
parts of Canada and about how the service itself is being provided even when it is available. We need to kind of talk
about the importance of culturally sensitive,
culturally competent and culturally safe care for women. The other thing to think about is that many of the problems that
I’m talking about arise out a historical reality,
but these are not only historical problems and three years ago we heard reports from Sasquetoon about indigenous women who
were either induced to have a tubal ligation or actually coerced, or who had tubal ligation
without their knowledge while they were in hospital for
labor and delivery services. So this is not gone,
this problem is not gone, and again that suggests
we need to focus on the provision of culturally safe care. We can’t fix these problems
without cooperative and concerted effort by
all levels of government, indigenous governments included and indigenous communities
and healthcare providers. I think in addition to the
recognition of the need to provide culturally safe healthcare we need to start thinking
about developing culturally safe or culturally competent policy that actually addresses
what the problems are and where they have come from and allows those problems
to be addressed in a manner that is meaningful and
helpful to the people who are experiencing the challenges. Okay, I’ll stop. Okay, very good. (clapping) Sue do you want to comment first, or you want to go after? I can comment first. I feel like there’s so
much information that was presented by Doctor
Nelson and thank you for bringing together such
a succinct presentation of a rather large issue and
trying to educate everyone about context and the
history of colonialism at the same time. What I heard that was
really important as a health researcher and a clinician is that that what was reflected
in Doctor Nelson’s work is further reinforcing the
overarching understanding that the two major issues issues
regarding indigenous health in Canada are around access and racism. I would say those are
intensified for indigenous women and on these issues because
of the double jeopardy. I was a little late, my
apologies because I was giving a talk this morning at
Women’s College Hospital for International Women’s
Day, which is where my youngest daughter, Dinae was born, by an indigenous midwife who’s
sitting right over there, (laughing) and it feels like the
convergence of that understanding that indigenous people’s
health is different not because they’re biologically
from a different race but because of the
systemic policies that have been used to personally
harm a group of people based on their race and gender. And those I think are the
issues that our colleague here is trying to highlight, is how that harm that has been perpetuated through the legal system has become very personal
and has really affected the lives of individual
people and families like myself, like my daughter, and like all of you
because the fact is that all these laws and policies
that have created this situation for indigenous
sexual and reproductive health affect everyone in
Canada because these laws have created the situation
where you’re either negatively impacted and
harmed by these policies or you’re directly benefiting from them. Everyone in this room
falls into one of those two categories, and how we
behave and act as a result of being in one of those two categories determines the future of
what will happen next. Is that a good comment? Okay (laughing) Very good, there will be
questions and more time to intervene, Alison. So I listened with great
interest to Erin’s presentation and the first thing I have to say, well I have to say two
things but first of all, I’ve been out of the loop
as it were, of the academic issues relating to reproductive health really since my appointment
to the bench some 13 years ago and it’s a real pleasure to be back able to think about it. Second, judges of course are
not supposed to have views on these issues and so I’m taking a certain
amount of license in my extra judicial capacity as
a visitor in this faculty to play a role that I probably
wouldn’t normally play. But the, I’ll just make a
few comments on the things that really struck me with this paper. The last thing I would
say is that preliminary comment is that my project during my study week here related to access to justice issues, which of course are quite
parallel to a lot of the issues that Erin has raised,
particularly with respect to what meaningful access
is for indigenous peoples and other marginalized groups in society as well. But my first, more substantively, my first reaction when
I read the paper was how little has changed since the Morgentaler decision in 1988. The Morgentaler, before the
ink was dry on Morgentaler, which of course ended the
criminalization of abortion in this country, the focus shifted to understanding that there were going to be
issues relating to access and there was at the
same time a great deal of optimism that those were kind of minor, mechanical things that
could be dealt with. Well of course, here we are 30 years later and as we hear from Erin and as I think most of us already know, for marginalized populations
across the country access, meaningful access has
not moved along very much. As I will come back to in a second I think the focus has shifted now to meaningful equitable access. The second impression from Erin’s paper that she sort of ended with is the desperate need that we have
in this country for good data. I think that this is
something which Canada, for reasons that I
don’t really understand, is very poor on compared to
other industrialized countries and it’s just not in
this area of healthcare, in fact I think in some
areas healthcare is better than other sectors, but we just do not have
or collect good data and I’m again referring
to the justice system when you start looking at reform. So one of the obvious things
you wanna know is well, what have been the results
from the last set of reforms and it’s very hard to get
any kind of meaningful data and that’s something that
I would hope changes. The other reality of course
that is not going to change, that continues to be a
challenge in this area as in many others is the division of powers in this country, particularly federal and
provincial division of powers. The problem with that
of course is that it has facilitated a lot of finger pointing. Each level of government is
able to say well what can I do really it’s up to the feds to do that, or the feds say well, really
it’s up to the province to do that and or consider that or address
that issue and that has enabled a certain amount
of inertia for a long time. As Erin said this is can be profoundly depressing
but I do think that there is some hope on the horizon because of a convergence of energies, I guess is the best way of expressing it. One of those comes from
what has been happening in the area of end of
life and medical assisted dying and there’s a recent decision of the
divisional court in Ontario called the Christian
Medical and Dental Society of Canada verus the College of Physicians and Surgeons of Ontario. In one sense it’s not
terribly relevant because it’s almost certainly
gonna go all the way to the Supreme Court of Canada
and this is just a first stop but in this case the college
had passed two policies. One applied to doctors
unwilling to provide, quote certain elements of care
for reasons of conscience or religion, generally understood to target abortion services, and the policy provided
that if they weren’t willing to provide those services
they have to make an effective referral
to another physician, and that means good faith to not object an available and accessible physician and the referral has to
be made in a timely way. There was also a similar policy, the second policy,
they dubbed the MAID policy with respect to medical
assistance in dying, same obligation. The applicant doctors
challenged the constitutionality of these policies on the
basis that they violated their freedom of religion mainly. The divisional court
upheld the policies and the constitutionality of these policies and in the course of their
discussion of section one it talked about the
validity of the objectives of protecting the public,
preventing harm to patients and the facilitation of
access to care for patients in our multicultural
and multi faith society and it talked about the essential purpose of these policies being
the facilitation of equitable access. My point is that there seems
to be much more political will and momentum these days around
medically assisted dying than there has been with respect to reproductive autonomy. Some might suspect that the
fact that the reproductive autonomy affects women
more than men may have something to do with it, but the point I’m making
is that I think, perhaps, the climate is right and there’s a potential for the access
to reproductive services can kind of piggyback and
help use some of the momentum that is out there on these other areas to move forward. This is also a period, and
I’ve been struck by this while I’ve been here at the university, it’s a period of great,
increased awareness of the challenges facing indigenous people in Canada and around the world and
in Canada in particular and the need for us all to contribute to a better world for indigenous
people in this country. I think that those
things may be converging so that access and
meaningful, equitable access can now become more of a reality for all communities and
for indigenous women, and those are my comments, thank you. Very good, on that note we’ll open it up for questions, I have first two students. Jennifer. Okay. JENNIFER: I know I’m gonna
pronounce names wrong but my question was regarding Mifegymiso Mifegymiso, I don’t know how you say it, I know what you’re on about. JENNIFER: So you mention
in your paper the high cost and how it doesn’t bode well for access to abortion for Canadian women, but I wanted to clarify, does Medicare cover that because it’s administered by physicians,
and if that’s the case if the law changed to
permit non physicians to prescribe it then would
that bring it down in price? So it’s not covered by Medicare in general except that many provinces
have agreed to cover the cost of it, not all provinces have agreed to cover the cost of it, but it wouldn’t be an ordinary
or typical thing that’s included because it would be
an outpatient prescription. You’re very perceptive
though to raise the issue of what happens then if it gets, if prescription authority gets broadened, and this is something that Wendy Norman, that doctor I referred to earlier has been working on. She’s seeking to have this
open practice of midwives, for example, so that they
would be able to provide and prescribe this drug and
also nurse practitioners I think are in the offing, potentially as being
allowed to prescribe it. And that, if it were a
typical Medicare service, that would potentially
take it out of the scope of what’s covered. But it is being covered as kind of a extraordinary expense or
I don’t know how they’re exactly framing it, by some provinces. [Male Audience Member] But
not all provinces presumably? Not all provinces. [Male Audience Member] Does Ontario do it? I think Ontario does. JENNIFER: Yes Ontario does it as a provider that is
able to prescribe as it’s possible for not abortion
services but for post natal and pregnancy but it’s
actually a really stable drug that’s very easily
transportable and it’s like in a pill form so it’s
something that could be used very easily across anywhere in Canada and having increased
access for some provinces so it’s being looked
at to expand the scope which would increase access
for people to those services. Any other comments from
our two commentators, no? Jacob. JACOB: My question is
actually different to what I sent you actually. Thank you very much also for being here and also to Dinae for being here as well. My question is for Justice Harvison Young, thus far action seven of
the charter has no allowed for a positive rights (chair dragging) but the majority in the Gosselin case suggest that there might be
some special circumstances under which one could make a
successful section seven claim. Do you think given the
special position the indigenous communities
occupy in Canada that access to reproductive
services could plausibly form the basis of a positive
rights interpretation of section seven? That is a really tough question. I don’t have a crystal ball. I would say, we’re closer to that now with some of the decisions
that have been made than I would have said that
we were 15 or 20 years ago and I see Erin nodding her head. I think with the emphasis
on equitable access I don’t think it’s a huge
leap to find positive right in a situation
where there’s any argument that such rights are available elsewhere in other parts of the
country but of course that starts to look
like a section 15 right rather than a section seven right. So it’s much easier if you’re
talking about deprivation of a right but I think we may be getting
there in some respects but that’s about as much as I can say. I think this decision will be interesting to see when it goes further up, the Christian doctors
case to which I referred. I think it will be
particularly interesting in the Supreme Court to
see what they have to say because it could well be
something that could form the basis for positive
rights in the future. [Male Audience Member]
Okay I’m an economist so I’m gonna focus slightly differently. First off a comment on the data. One problem that we have
with that original data is that in many cases the
aboriginals have refused to fill out the surveys, so for example I have decent survey
data from the last census up north of 50, but Six
Nations refused to fill out the census so that makes
it very difficult to do comparative analysis
because everything we do in government funding is
relative because we are allocating on the basis of equitable need. So I’m working on projects now to discuss equitable need to child
welfare and family services. One of the characteristics
of that, and this is where my question comes, and it really gets down to a legal, I’m gonna frame it in a
legal question because if you take a look at the
distribution of population what you see is, for example, for NAN, the Nishnawbe whatever up out of Thunder Bay, Thunder Bay’s a big city, and I think about 49
communities that range down to something about 56 people, okay that are geographically
quite difficult to access. We now have some standardized
measure of access and we actually have some
standardized measures of service that StatCan has been working on and I’m actually going home to do some mapping to play around with
when I get back to the hole. But the point is what is the right to
access in a physical sense? I’m asking you people as
lawyers what you can expect, I was very excited to
see about that they’re making medical solutions
in terms of drugs and stuff because then it becomes
a much more effective thing but when you can’t
even get to a doctor to get prescribed, and when
doctors want to see you to get paid, okay and when they are a long way away, cause as I said I’m writing right now on
the remoteness concept and all sorts of blah blah about that, so I’m asking the legal question. How do you define a right to any service that is spatially delivered in the context of Canada? One characteristic of other
countries is they have enormous density of population, a much different geographic density. If you look at the maps I’m
playing with in the north, you get the point I’m
spending all my time on that. So that’s the question. Well. I don’t know that I
have an answer for that. [Male Audience Member]
But you understand that it’s a legitimate question. It is a legitimate
question, I just think that we haven’t turned our attention and creativity sufficiently
to how we might address it and I think maybe, what would
be very interesting is if improved access to abortion services because of Mifepristone being able to be more widely available and widely prescribed, if that maybe makes people look at
some other access problems a little bit differently. Some of the access problems are, they range in the cause, right? So the reason why women
have to leave their home to give birth is because
in the 1970s the decision was made that it is better,
all things considered, to have especially a first delivery, to give birth in a
hospital where you could access high tech facilities
and I think that thinking has really started to shift and the recognition
that you have to balance benefits and disadvantages
and from the standpoint of what benefits a woman and
the child and her family and the community, maybe
access to a hospital isn’t [Male Audience Member] My
guess is technologies have changed in terms of like obviously being a male I don’t even wanna comment about birth but the obvious problem is that you need some facilities which can be flown in and the rest of it. The other characteristic
is the federal government and your tax dollars are paid
for extraordinary amounts of money so that in a lot of communities they have far better
internet access than I do, quite seriously, paid for at extraordinary cost. So the things that we could do remotely are at least that is a, I can’t even comment whether
that’s useful for sexual or reproductive health. But I think the issue is that there are probably technologies
and technical solutions that are feasible if you’re
prepared to spend the money. And the last simple comment is the biggest problem when
you talk about jurisdictions the fighting between when
something is partially funded by the feds, partially
funded by the provinces or not even funded, that creates a problem and until we solve and
that may be a legal problem and constitutional problem. I think that’s going to
come up in PharmaCare. I was having a debate with friends at the Department of Finance
last week about that. And I think those are what
you’re gonna have to do. Just to follow up on that, I think these are more
political problems than they are legal problems. I think that you mentioned the issue about the distance to a doctor and physical distance
to a doctor for example. I think there is change, there are people who
know a lot more than I do about the increasing roles
that nurse practitioners, midwives, other people in
communities are playing in various aspects of healthcare. But also, technology, Skype and so on, is putting
pressure on some of the sort of absolute necessity that a doctor cannot bill unless you’re
right physically there. So I think there are solutions there and we may be pressured
partly because people are increasingly ordering drugs online, not necessarily legally, which of course has health risks but that puts pressure
on the legal regime. So all this to say is that I think some of the potential
solutions are coming from other social developments
that may be, hopefully, used to generate some change. Any other questions? If I could just speak for a moment to the concern about data regarding indigenous people. You brought that up a few times, and our colleague over
there brought that up and he brought up a point that indigenous communities refuse
to fill out census data. [Male Audience Member] Not all of them Well you say in Six Nations
Six Nations specifically What might be some of the reasons that indigenous people may not want to fill out government documents? Does anyone here have
any ideas about that? Not you Juan (laughing) Juan works in my office. AUDIENCE MEMBER: Just
another way of stigmatizing. Stigmatizing, that’s true, what else? AUDIENCE MEMBER: Fear of being identified and have their children taken away. Absolutely, every time
there’s a knock at the door I still think that someone’s
showing up to take away my status Indian children. There’s a lot of policies
that have been used, that have been based on
data that’s been collected on indigenous people that
have been used to harm them, so there’s a lot of reasons, so really the onus is on the
government and the systems in society to change their relationship with indigenous people in order to make indigenous people feel safe
in those culturally safe ways that you talked about to participate in our healthcare systems, in our data collection
systems, in all of our systems. And that’s gonna take a lot of what the government is calling
reconciliation which is really just a crock anyways but
that’s a different topic. [Female Audience Member] If
I could just add on to that. I think that one of the
things that you spoke to is the urban myth of health outcomes don’t actually improve when
we move into urban centers and I just participated in
a study in Toronto recently where we were able to demonstrate
that the health outcomes are definitely not better
for indigenous people in particularly the sexual
and reproductive health outcomes for indigenous people in Toronto, and the population size
is Toronto is at least 75000 indigenous people
living just in the city of Toronto properly, which is the size of the
whole Sioux Lookout region, including all of the First Nations, and so if 80% of the
population in non reserve communities and non isolated
communities are actually living in urban regional centers and our health outcomes are not improving. It’s not purely a geographic issue, it’s actually much, much
bigger and it’s much more related to the systemic issues of racism and discrimination
and those are the things that we need to fix, not the geography. AUDIENCE MEMBER: Thank you. Just wanted to add some legal
perspective of this issue. So how we are going to
balance self determination by indigenous people to work versus the right
to intervene or the right to protect or the right
to act in a situation. For example, knowing that
sterilization of women in indigenous communities
with fallopian tool that was used to stop the growing
of indigenous community in the, between 70s and
74, more than 415 cases were documented. In a way the structural system
that we are just promoting and in our society, put in a
very, very difficult position a young, indigenous woman who’s pregnant because the future of
the baby is going to be very difficult in terms of constraints of economic constraints,
social, political, education. So how we are going to manage that and how from the perspective of
law we are going to balance these two rights? Perhaps the obligations
that the federal government and provinces (mumbles). Well I think as Alison said, the problems are more
political than they are legal problems but that doesn’t mean that they sometimes don’t
manifest as legal problems. I don’t have a crystal
ball either, and I think it will be very interesting
to see what happens when a rights contest like that develops and is actually faced by
the courts because I don’t know what to anticipate. The closest example that
comes to mind of what you’re talking about reminds me of the DH and Hamilton Health
Sciences case that happened, every year that I get older I forget how many years ago things
were but a few years ago, recently, where there was this decision that the
mother’s aboriginal rights were such that she was entitled to pursue traditional indigenous medical
approaches for her daughter and take her out of chemotherapy and the sort of significant
concern raised after that decision was made
was that that leaves children who are indigenous unprotected if their parents are making
a decision that puts them in harms way and isn’t in
keeping with their best interest. I think what happened
after that case was a negotiation process whereby
the parties came to a negotiated agreement and
everybody was able to participate and agree that both
traditional western medicine and traditional indigenous
kind of medical approaches could be used at the same time. I think that’s maybe an
example of how to approach this problem from our
cultural safety standpoint. I also think the issues
arise less when there is cultural sensitivity and
cultural safety in place. It’s my understanding that
the DH case in many ways came about because
there was a comment by a member of the nursing staff that was perceived as racist and
hurtful to the family. I think that’s why the
family became afraid of keeping their child in
medical care and if we can alleviate those kinds of systemic concerns the rights contests won’t
materialize to the same degree. We have to stop, please join
me in thanking the speakers. (clapping) So we’re nearly over time
but there is one more question that you can ask in
person now for the speakers. So thank you very much. (panelists talking amongst themselves)

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