Spotlight on Child & Adolescent Health: Indigenous communities

Indigenous children and adolescents, regardless of where in the world they live, have worse health outcomes than other groups of children and adolescents. For our second Spotlight podcast in the Child and Adolescent Health Spotlight, acting Editor-in-chief of The Lancet Healthy Longevity Philippa Harris is joined by Lisa Richardson, Indigenous Health Strategy Lead at Women's College Hospital in Toronto, and Yves Minani, executive director of UPARED in Burundi, to discuss health among children and adolescents in indigenous communities.

Guests on this podcast:

Lisa Richardson - @RicharLisa
Yves Minani - @MinaniYves

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to the Lancet Voice. It's February 2023. I'm Gavin Cleaver, and we're very happy to have you with us. We're focusing at the moment on child and adolescent health as part of our spotlight, some particular areas for this, our 200th year. You can find out more about these spotlights and about our goals for our 200th anniversary year at thelancet.

com slash lancet hyphen 200. For today's episode, I'm very pleased to be joined by the acting editor in chief of The Lancet Healthy Longevity, Philippa Harris. You'll hear Philippa speaking with two guests today about indigenous child and adolescent health. Welcome, Philippa. Why don't you tell us a little bit about how you came up with this particular topic and why it's so important.

Philippa: The Lancet Child and Adolescent Health Spotlight has two asks. And one is that we stop thinking about children as a kind of future resource and we actually focus on their needs now. But the other ask is that we really focus on the health inequalities that you see between different groups of children, both within specific countries and also globally.

And Indigenous children and adolescents. regardless of where in the world they live, have poorer health outcomes compared to the general population. And so we thought this was a really important topic and a great one to dive into in a bit more detail. 

Gavin: Yeah. And why don't you tell us how you came across the first interviewee, who is Lisa Richardson?

Philippa: I think Lisa is someone that has worked with Jessamie before, and she's a really good voice in this, in the area of indigenous health. And there's lots of great work in terms of medical education and with the University of Toronto. And I just thought she'd be such a great person to hear speak. 

Gavin: And the other chat as well is really interesting.

It's Eve Minani, who's talking about the, one of the tribes in Burundi and the children and adolescent health in that tribe in particular, how did that come to your attention? 

Philippa: The Batoa communities? Yeah. Eve is an activist and I knew of him through his work that he's done with the United Nations. And I just thought it would be really interesting to hear a voice from a country where we don't necessarily hear so much about indigenous communities.

I think indigenous communities in Africa often are overlooked in the conversations. 

Gavin: Yeah, definitely. It's really interesting. Well, there are two really great interviews that you're about to hear right now.

Philippa: Hi Lisa. Thanks so much for joining us on this podcast. You know, we're delighted you're here. Could you start just by telling us a little bit about yourself? 

Lisa: Sure. So my name is Dr. Lisa Richardson. I practice general internal medicine in Toronto, Ontario, Canada. My background is mixed Anishinaabe and my community is called Shebanani.

Which is in Northeastern Ontario, about three and a half hours north of Toronto. It's also known as Killarney. And my work is primarily in both clinical practice in internal medicine and also strategic work in education in Indigenous health. 

Philippa: So one of the things that, you know, the Lancet is very interested in is reducing inequities in healthcare, especially in children and adolescents.

And I was wondering if you wanted to start just by talking about. You know, Indigenous children and adolescents and whether they experience equitable health care. 

Lisa: Big sigh because this has been, of course, a focus of for many countries is trying to close the health gaps for Indigenous peoples. And the short answer is that Indigenous children and youth do experience health inequities.

So there are significant gaps and they actually cross a range of areas. So chronic illnesses such as diabetes. The results of infectious illnesses such as rheumatic heart disease are both much higher among indigenous youth. There is data not only in Canada and the US but also in Australia in those areas low birth weight as well as high birth weight is higher among indigenous people.

And there's again, DA data across from a across the globe. For Indigenous peoples that demonstrates that mental illness and suicide are higher among Indigenous peoples. So you're getting a sense, Philippa, of the range of areas, not just physical health, but mental health, and I would say by proxy, emotional health are all areas of concern and gaps for Indigenous peoples and very much connected, which I'm sure we'll talk further about to social determinants of health.

Philippa: So I'm interested, you were saying that, you know, this is an area that some, you know, hopefully all governments are looking at as a sort of something that they want to change. Do you, have you seen progress, do you think? 

Lisa: What I'm seeing are really, really amazing commitments to community based interventions.

Data in specific areas, for example, specific regions or in specific communities are demonstrating progress. I haven't, we haven't yet seen huge sort of systematic reviews that are demonstrating, you know, changes in improvements in ear health across the board for indigenous youth, but we are seeing programs that are, that are working and I think.

Those interventions and examples of that community based work are, are what we need to focus on. 

Philippa: What are the barriers to equitable care? You know, what, why are we seeing these, these big differences? 

Lisa: Yeah, I think as, as is well known by Indigenous peoples in many different countries and jurisdictions, The most significant determinant of health for Indigenous peoples across the globe is definitely colonization and its subsequent effects.

Let's take some of the illnesses that I spoke about. Diabetes. And the fact that, for example, in Canada, Indigenous First Nations youth on reserve have much, much higher rates of youth onset type 2 diabetes than the rest of the population. Type 2 diabetes is related to food security. It's related to obesity.

And if we think about those two areas, both of those examples are disruptions that were caused by colonization. So by moving people into a reserve system where they no longer have access to traditional territory where ways of being and living in a daily basis, such as hunting and gathering foods, are no longer, not even possible due to a land base, but Early in the courses of colonial regimes here, governments, they were actually a band.

And so you're no longer able to be active in the same way, no longer able to have access to healthy food. So there's a preponderance of more processed foods. So that's one example of with a particular condition of diabetes of how colonialism and its downstream effects, including food security and land based activities or lack of ability to practice the usual land based activity has really.

Caused a health gap. So what does that mean? The interventions actually need to not just target diagnosis and treatment of the specific illness, but all of those upstream factors. 

Philippa: So, yeah, I was going to ask what you think are the best ways to overcome these barriers and you know, I can see that it's not a nice easy answer like, Oh, just do this one thing.

What do you think are the best ways that we can address those, those issues? 

Lisa: Yeah, it always becomes a bit. It can seem a bit overwhelming. In Canada, our, our distinct communities, our First Nations, Inuit and Métis, it can seem overwhelming when we say, okay tuberculosis rates, for example, are very high amongst Inuit here both youth and, and adults.

How do we address that? Well, it needs, you need to take a comprehensive approach to any specific illness, which is what is happening right now, and it's being led. By the Inuit organization. I T K here in Canada. They've hired someone specifically to help look at. Okay, well, what did what do we need to do about housing?

How can we address close quarters and inadequate housing and overcrowding? How can we address ventilation? How can we then address early diagnosis and and making sure that the person who is diagnosed is actually able to be cared for away from others? So Mhm. And by the way, I do not mean removed to the south, which is what typically used to happen for Inuit, where they would be come from north, from the north to southern sanatoriums and be disconnected from community.

I just mean where they're no longer, you know, they're able to be convalescing and be cared for in a comprehensive way with comfort. I think that we need to, you know, so you need those comprehensive approaches, but what's most important, Philippa, is The approaches need to be guided by communities and Indigenous health professionals.

So, understanding what is needed specifically, for example, if one community has a high rate of suicide. What are the life affirming approaches that can be adopted? So, I've seen in the northwest of Ontario amazing land based programs where youth are taken out. With elders and with others and go to the goose camp and learn how to hunt.

And in so doing also learned all about traditional knowledge, connection to the land, hear from elders speak the language. So all of those activities that bring a strong sense of identity, pride in self, pride in community, then have these amazing benefits for mental health and wellness. So, so I think I hope that's specific enough.

So the idea is that we do need to have targeted and distinct approaches, not only for indigenous peoples, but even more distinct within communities and within nations so that our community specific with that share general principles, but that are also guided by the leaders in those communities and by indigenous health professionals.

who understand and can work with communities in trusting and thoughtful ways. 

Philippa: And do you think the communities, I mean, I appreciate you'll be talking sort of from a North American perspective, but do you think the communities that have the power, you know, do the systems allow the communities to really, truly drive the change?

I mean, I can see how these interventions will never work unless they're community led, like you said, but, you know, You're talking about, you know, systems that have kind of oppressed indigenous people for ages. Do you feel the systems are changing? Do you feel like the communities, you know, now have the 

Lisa: power?

I do. I mean, indigenous peoples across the globe have their rights protected by the UN Declaration on the Rights for Indigenous Peoples, which upholds the right to self determination. You know, one of the amazing places where really cool community based initiatives are happening are both in New Zealand and Australia.

So for example, to target the high rates of rheumatic fever, which lead to rheumatic heart disease, which is a preventable infection with an antibiotic. I, I met a, an amazing young Maori doctor who was working in her own community actually on a program to train community health professionals. And there's a similar program that's been written about in in Northern Australia.

So I think governments are understanding that they need to actually uphold these rights, which means in many cases, a transfer of of responsibility for health care or co management of health care. Prior to the transfer, and I think so. We are moving that way. There are numerous examples, even looking at some of the changes in in the land back movement across the globe are really, really important.

Philippa: And I wonder if we could just sort of backtrack, because you were talking, obviously, about, you know, mental health of indigenous youth being an area of particular inequities. And I wanted to talk about, you know, the last couple of years. Do you think COVID 19 has had a big impact on that and what, what has that impact been?

As we know, COVID, 

Lisa: not only from the literature, but from those of us who are parents, or guardians, or aunties, uncles, we've seen the effects of this pandemic on, on the mental health and well being of our youth, and not just Indigenous youth. And so. Absolutely, this has strained that, but I think what is remarkable is how Indigenous youth have responded to COVID.

It's an example of resilience and the importance of culture. The desire to care for and protect elders and community, the engagement in activities like food delivery and You know, facetiming or regularly with elders is something that's been talked about here and written about as well by Indigenous youth.

The desire to actually share what they're doing related to public health practices through TikTok and all their social media has been a really cool example of how youth have actually, I think, demonstrated resilience despite the isolation. Absolutely, it has been an issue. And we have had communities in Canada where there have been particularly bad outcomes related to mental health.

But what has been amazing is then to see the community response, not just within community, but surrounding communities to actually help and, and intervene. I think the other piece to note is that because of the move to online learning has also created significant inequities for Indigenous peoples. You know, particularly for schooling, because there is not always the same infrastructure for online school.

And there are examples of places here where youth actually just were not able to engage in, in the online school that they had to pick up textbooks and, and learn independently and then do check ins because they didn't have the wifi access on their reserve. 

Philippa: That's something we certainly saw in the UK as well.

I mean, not specifically with indigenous youth, but people that didn't have the technology really, really suffered. And it, it's something that I think certainly in the UK, I don't think enough has been done to try and sort of address that gap and, and catch up. I don't know if there's been any efforts in, in the Toronto area or, or wider that where you've seen, Efforts to try and bridge that gap.

I think the 

Lisa: major piece here is that we need to see the, the infrastructure commitment and some governments have made that commitment. It just will take a while, a while to do that. In terms of the gaps that will emerge with respect to education. I haven't necessarily seen a cohesive strategy yet, and I think that's, it is a real problem.

Why this is relevant to health, of course, when we're talking about youth and, and children and adolescents school is a huge component of, and, and education is a big part of of future health. There are also tons of opportunities that I like to think about in terms of community based healthcare within schools.

I mean, I grew up in the era of a school nurse and what an incredible opportunity to have touch points with you and to, to level the access and care issue, which often occurs, hearing screening, eye screening, et cetera. We used to have all of those exams. So, so schools as a, as a touch point for community health for vaccine strategies.

Et cetera. I think that's very important. Schools are also virtual infrastructure or digital infrastructure is really important to health because of all the virtual care that's exploded during COVID. And so if we don't have that infrastructure, then actually those gaps, and we haven't talked at all about access, particularly for those in.

In remote communities or in areas where they're not close to, they don't have easy access to hospitals and clinics and have care delivered by nursing on nursing stations. That digital health is a really important component that we need to be attentive to as we try to ramp it up. 

Philippa: Yeah, it certainly seemed to me that there's sort of such tremendous opportunities there if the infrastructure was in place and, you know, communities.

that, that do suffer because of rural locations. There's, there's so much going on now that, that could really kind of make a difference if they can tap into it. I know medical education is a, is an area that you're very passionate about and you've done a lot of work in. Talking about kind of representation with healthcare practitioners, how important is it for, for children and adolescents to, to see themselves represented in the, the healthcare practitioners they're interacting with?

It's 

Lisa: hugely important. I mean, the literature around this, so it's primarily from the, from the U. S. when we look at. That I, that I'm familiar with, particularly amongst black youth and black patients and their providers. Demonstrating how cultural congruence, so being of the same background as your provider actually leads to better health outcomes.

Not really surprising, right? You can relate to the person, you see yourself, but, but also other more granular factors like more time being listened to, opportunity to ask more questions. It's actually fascinating. We see this anecdotally in terms of how Indigenous youth. Respond and are inspired by Indigenous care practitioners and the ability to connect with your practitioner, particularly as an adolescent, I think, is so important.

So it is key, not only for the actual care received by Indigenous children. But actually to strive and aspire to consider a career in healthcare and to be able to, to give back to your community, if that's what you choose to do. The literature also shows that those from underrepresented groups in medicine are more likely to care for underrepresented population.

So it's yet another reason why this is so important. I think the, the other piece about Indigenous care providers is not just understanding the context, specific context. The barriers that may be faced by an Indigenous client who they're seeing, but also bringing that breadth of knowledge from an Anishinaabe perspective for, you know, mental, physical, emotional well being.

And spiritual well being, the four directions of care, which are typically not not addressed in the usual biomedical system. It's just you know, mental health and physical health. And by the way, they're quite separate. They're not seen as intertwined very often, although they should be. So considering those cultural dimensions of care, their spiritual dimensions of well being which are so, and emotional.

Health, which is about connection to family connection to community connection to your land base. So how indigenous providers can bring that multi dimensional perspective into the care they provide. is amazing, not just for indigenous youth, but for, I would argue for all people who are seeking health care.

Philippa: No, I find that really interesting. The kind of the much more holistic view of, of kind of health and wellbeing that seems to come out and it seems like something that's really not captured very well in the medical literature. Is that something you think is changing as we see more research led by indigenous peoples, you know, do you think that kind of that more holistic view is coming out more?

Lisa: Absolutely. I think the line there that is critical is research that is being led by Indigenous peoples and often now it's the most relevant and important research on Indigenous health. There are knowledge keepers present, there are community members present, there are, as well as Indigenous researchers.

I don't want to give the impression, though, from my, our conversation, that there is no role for non Indigenous providers. Absolutely not. I, I just there is a huge role that non Indigenous providers We don't have nearly enough Indigenous providers and strong allyship and learning to understand your local community and the context where you work and building relationships with with the leaders, with the families, with the children is so critical.

And I've seen amazing examples. of non Indigenous researchers and providers who've done incredible work in Indigenous communities. So I, I don't, I don't want to suggest that this can only be done by Indigenous peoples, but the key is it must be led by Indigenous peoples and that it must be conceptualized by.

The heavy lifting doesn't all need to be done by. By the Indigenous care providers, in fact, we're seeing a lot of burnout among Indigenous providers because there's so much strain and so much, the expectations are so high or the workload is so high. So it really has to be a shared initiative. 

Philippa: And talking about increasing participation for kind of future generations, what cultural shifts would you like to see to you know, encourage more Indigenous youth to consider or access careers in healthcare and, and be that next generation of, of leaders?

We need to have dedicated access 

Lisa: programs into the health professions, but here's the caveat. The programs should not just be at the undergrad level, because of course, some of the programs that I'm talking about well, medicine specifically is in, in Canada anyway, it's a, it's a post secondary, you have to have an undergraduate degree first, I know in the UK it's different, but we need to go back, not just into high schools, we need to go into elementary schools.

We need Indigenous youths and children to actually see role models who are Indigenous and have summer mentorship programs and summer camps and exposure to science. and understand the beauty and fun and creativity of science. And, you know, let alone melding that with Indigenous knowledge and Indigenous science.

It's exciting. And so those programs need to actually extend back. And so that's what we have been doing at the University of Toronto. We realized, okay, we've got a great high school mentorship program where students get a credit. And our data shows that many of the youth who participate in that one month program, and then there's a longitudinal follow up over the years, actually go on into careers.

In the medical in the health care professions, and that's for both black and indigenous youth. We have developed a separate program that is for even younger people for, for children in early high school and in late elementary school. And my goal is to actually go even further back and have like a cool summer camp for grades, kids in, in primary school.

So I think those are the sorts of things that we need to be doing to encourage folks into, in these exciting careers. 

Philippa: No, that sounds fantastic. And I have young kids and it's amazing how even really young kids respond so positively to kind of science and, and, and health and, and they find it so fun.

And yeah, I think if you can tap into that early, it's great.

So thank you so much for joining us, you know, we're delighted you're here to speak to us. Yeah, could you start just by telling us a bit about yourself, and then we'll get the conversation started. 

Yves: Okay Ivo Minani Founder and Executive Director of Indigenous organization called Inyo de Peplu Otoktonepulo Khenre Odeverukuma.

Also, I am Regional Coordinator of Indigenous Network called Initiative for Equality. We cover the country, Burundi, DRC, and Rwanda. Also, I am Africa Regional Focal Point of Indigenous Youth, Global Indigenous Youth Caucus. 

Philippa: Brilliant. Well, thank you so much for joining us. So we're talking about health inequities and healthcare for Indigenous children and adolescents.

So I was wondering if you could just start by Talking about, you know, your experience of inequities and, you know, whether you think Indigenous children and adolescents experience equitable health care. 

Yves: Before talking about, about health care of Indigenous children and adolescents, let's tell you, tell you in small words about, about my community.

In my country, Burundi, Batwa estimate about a hundred people. So around 1 percent of the, the national people. It's difficult to find exactly the statistic of Batwa in Burundi because investigation of some group is not allowed. So Batwa are dispersed everywhere in small communities, often at the periphery of mixed areas.

They live in a discrimination, extreme poverty, lack of access to health service. lack of means and the lack of land. So lead off sharp and a quick decrease of this community about the the equitable health care is difficult to get to get good health for for adolescent and the and the youth because of malnourishment.

So they don't have access to insurance health care because of lack of means. Yeah, that, that I can say about about equitable health care of adolescents and the youth in general. 

Philippa: And you talk about the difficulties the community face. What do you think the main reasons for these difficulties are? 

Yves: So the, the main reasons of this, this difficult in our country, we have, we, we have two ethnic in, in Burundi to get a job.

Our constitution refer to theism. So they said that 50% of Utu and the 50% of Tutsi to get job. Also, to get any opportunity, it mentioned in, in constitution. So for Batwa to get, to get a job, to get any opportunity in Burundi is very difficult because nowhere is mentioned the, the, the, the opportunity for, for the Batwa.

Philippa: And do you see any appetite for change? You know, do you think the government is doing enough to try and improve the situation for the Batwa? Do you think the government is doing enough to try and improve the situation for the 

Yves: Yeah. Yeah. Actually, we see even with we, we, we, we don't have any place in the constitution.

There is some, some advantage for us because in this, in this period the Batwa are integrated in some, in some areas, for example, from 2020, we, we have a minister and some, some staff in the government. In French they say, they add, even they don't have access to some services, they try to add, to integrate Batwa in some areas.

Philippa: And how do you think the best way to overcome these barriers are? And are there any initiatives you're aware of that have helped? 

Yves: We, we continue the advocacy for, for us, for example, to, to integrate in every way the, the, the Batwa, about, about health. For example, nowadays, Batwa live in misery, in poverty.

We see some, some, many Batuas are dying by hunger because of lack of, lack of land. But we are trying to, to convince the government to, to give, to give land to, to Batuas is one of the, the solution to, to overcome that problem because we, we, we can't live without it. Without eating, we can't live, we can't get access to, to, to good health without eating.

Philippa: One thing that really unites indigenous communities across the world is this right to land and, and, and right to exist in, in the way they used to. I wondered just talking about, you know, food security and land, if you wanted to talk about climate change and whether you're seeing that having an impact.

Yves: Yeah, about climate change. Also, we get many problems about that. For example, before we, we are the owner of, of, of the forest of everything and we safeguard our forest. But today, no, no, no, but are the forest because of protecting our forest and be. Become the protected area and some, some but was lived in the mountain where they can't get easily water and everything to feed to feed our families.

So. For example, when the rain come, it's difficult to resist. All that, if that there is any, any climate change is very difficult to resist because we live in the, in the mountain where we can't, we can't get anything. 

Philippa: You talked that there's been a bit of progress recently, sort of government is, is starting to perhaps integrate the Batoa communities into their initiatives and things.

Does it feel on the ground like progress is being made? 

Yves: What we do that that progress is not it's not enough. It's not enough because there are so we are trying to convince the government to give the land of the land to the battle also to to to to elaborate some specific policies of battle because we don't have a specific police of battle.

For example, today, this, this actual president. He understands the problem of battle, but. The future president, he could, he could say that. No, no, no, no. I forget about that one. Reason why we, we continue our advocacy. To be mentioned in the constitution, also some specific laws. Which could protect us.

Philippa: Obviously you're working for an organisation that's really involved in this group. Have you been able to work kind of across countries with other organisations working with Bacto communities to work together or has that been a challenge? 

Yves: Yeah, for example, today we are working with the other indigenous organisation in Rwanda, also in Congo.

Sometimes we make advocates together in order to convince our government. Even Burundi, even Rwanda, in general, in East Africa, we, we live the same, the same situation. This is why we, we are trying to To make, to, to put our force together with other, other organizations in different countries. 

Philippa: Looking to the future, if you could make one change to improve the health of indigenous children and adolescents, would it be to have recognition in the constitution?

Or is there, if you can sort of, if you had a magic wand and you could make one, one change? 

Yves: Is when we see, when you see our future, we don't see where we go because it is if is very difficult to change the Constitution. So it is very, very difficult to see our future, but we continue the advocate. Perhaps, perhaps it'll goes well.

But what we see is very, very difficult to, to, to change the, the Constitution. Only the, the, the some they, they give us some opportunities. That opportunity, we are trying to convince the government to elaborate the specific policies and the laws which could protect us. If not, we don't see, if they don't elaborate or write those policies, those opportunities, the constitution, or everywhere.

We don't see the future of RYU. What I want to talk about also is about women. So, We, we amplify for change. We, we are trying to, to, to, to help our, our our Batwa women to, because the, the, the, the, there's some, some violence against, against a woman, for example, rape so we are trying to work, to work hard, to work hard with, with that issue, because it's very, very, very, we have many, many case about rape, yeah, is what I could add.

Philippa: So women's rights are sort of a big area of advocacy work for you at the moment. 

Yves: Yeah, so I thank you very much for this time you give me to tell you about children and adolescents in my country, also about health in my country.

Gavin: Thanks so much for joining us for this episode of the Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlight with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.