7 Stories from First Nation Communities in Alberta: Reconciliation Involves All of Us

Lindsay McLaren and Rogelio Velez Mendoza

“In order for [reconciliation] to happen, there has to be awareness of the past, acknowledgement of the harm that has been inflicted, atonement for the causes, and action to change behaviour. We are not there yet.”

— Truth and Reconciliation Commission of Canada¹

Introduction

The Truth and Reconciliation Commission, which documented the truth of survivors, their families, communities, and anyone personally affected by the residential school experience, released its final report and recommendations in 2015. The report includes ninety-four Calls to Action across social and governmental sectors that are essential to realizing a coherent vision of reconciliation that is fundamentally about “establishing and maintaining a mutually respectful relationship between Aboriginal and non-Aboriginal people in this country.”²

Seven Calls to Action are explicitly about health (see Table 7.1), and indeed, the implications of the residential school legacy for health and well-being are immense. As described by Indigenous physician and researcher Janet Smylie in a Canadian Journal of Public Health editorial, the residential school legacy “violated almost every basic principle of public health, sanitation, and healthy child development.”³ Furthermore, the significant and persistent health inequities experienced by Indigenous Peoples in Alberta and Canada stem directly from government policies that legitimated residential schools, appropriated Indigenous lands, enacted forced community re-locations, replaced Indigenous governments, and outlawed spiritual and cultural practices.⁴ The ongoing negative effects of colonial government policies is important for us to acknowledge because colonial governments play a central role in public health, which we consider in some depth throughout this book.

The definition of public health that we embrace in this volume is broad: the science and art of preventing disease and promoting health through organized efforts of society.⁵ We chose that definition deliberately because it represents key features that drew some of us to the field in the first place. These include:

• a holistic view of health that incorporates well-being;
• a collective orientation that values social inclusion;
• emphasis on social, economic, political, and ecological determinants of health and well-being;
• concern with ensuring social justice and health equity;
• use of evidence-informed approaches that embrace different ways of knowing; and
• an upstream approach that prioritizes prevention and health promotion.⁶

We humbly suggest that these features of public health have some alignment with the spirit of the Truth and Reconciliation Commission report and recommendations. For example, the commission’s assertion that “Reconciliation is not an Aboriginal problem — it is a Canadian problem; it involves all of us”⁷ aligns with public health’s collective orientation and emphasis on inclusion and social justice.⁸ A broad view of public health that embraces social and ecological determinants of health, aligns with the sentiment expressed in the “Treaty 6, 7, and 8 Elders Declaration,” and reproduced in the Alberta First Nations Information Governance Centre’s 2018 report titled Indigenous Health Indicators. The report’s authors say, “we understand the 94 Calls to Action [in the Truth and Reconciliation Commission] as a whole, representing not just Calls to Action on Health, but also Calls to Action on Health Determinants.”⁹

Grounded in those points of alignment, the purpose of this chapter is to showcase select examples that illustrate this broad view of public health from Alberta First Nation communities. Following a brief background, the chapter is composed of community-based examples, one each from Treaty 6, Treaty 7, and Treaty 8 territories. We were honoured to speak with and learn from individuals from these communities, and to provide a forum to tell these stories.¹⁰

Background

Putting this volume’s hundred-year historical focus into perspective, Indigenous Peoples, including First Nations, Métis, and Inuit, have inhabited the land that we now call Alberta for over ten thousand years, or five hundred generations.¹¹ Although one could not possibly summarize this rich history concisely,¹² a 2013 Alberta government resource titled Aboriginal Peoples of Alberta: Yesterday, Today, and Tomorrow provides a glimpse of that history.

[Indigenous Peoples] in Alberta are culturally diverse — from the Dene in the subarctic north to the Woodland Cree in the boreal forest and the Blackfoot of the southern plains, and the Métis throughout the province. . . . While the Blackfoot gathered in huge camps on the plains, with their lifestyle centred on the great buffalo hunts that provided vast amounts of food,¹³ the Dene lived in small groups, gathering edible plants, game animals, and fish in the extensive forests and lakes. . . . For all their diversity, First Peoples have much in common. Foremost was a reverence for the natural world, the web of relationships linking every human to every other thing — be it plant or animal, rock or river, invisible spirit or thunderstorm. Living in harmony with their environment, they made little change in their surroundings for thousands of years.¹⁴

In an appalling sequence of events (Table 7.2), European colonization of North America, underpinned by settler entitlement and presumed superiority, instigated a drastic change in way of life for Indigenous Peoples that remains at the root of unacceptable health inequities between Indigenous and non-Indigenous persons that persist today.¹⁵ These historical events, individually and collectively, constitute cultural genocide, described in the Truth and Reconciliation Commission summary report as follows:

Cultural genocide is the destruction of those structures and practices that allow the group to continue as a group. States that engage in cultural genocide set out to destroy the political and social institutions of the targeted group. Land is seized, and populations are forcibly transferred and their movement is restricted. Languages are banned. Spiritual leaders are persecuted, spiritual practices are forbidden, and objects of spiritual value are confiscated and destroyed. And, most significantly to the issue at hand, families are disrupted to prevent the transmission of cultural values and identity from one generation to the next. In its dealing with Aboriginal people, Canada did all these things.¹⁶

One of many important instruments of genocide is the Indian Act, initially passed in 1876, which gave the federal Department of Indian Affairs sweeping powers to intervene in the lives of First Nations Peoples,¹⁷ including to determine who was an Indigenous person; manage Indigenous lands, resources, and moneys; control movement of Indigenous Peoples; outlaw traditional cultural activities; and dictate ways of life — all in the interest of promoting “civilization.” Lest one think that the Indian Act is a distant historical artifact, an important contemporary illustration of its perniciousness is the fact that the otherwise celebrated 1977 Canadian Human Rights Act specifically exempted, under Section 67, decisions or actions made under the Indian Act, meaning that First Nations persons were effectively denied full access to human rights protection. Section 67 was repealed in 2008.¹⁸

The Residential School System was implemented under the Indian Act and the schools were usually administered by churches. There were twenty-five residential schools in Alberta, which is the highest number of any province.²⁰ Importantly, the dire conditions of the residential schools were known, but this knowledge and accompanying recommendations were actively and deliberately quashed. In his position as medical inspector for the federal Departments of the Interior and of Indian Affairs, Dr. Peter Bryce gathered data from First Nation communities across Canada between 1904 and 1914,²¹ including “special inspections” in Alberta and other prairie provinces.²² His findings were unambiguous: his 1907 report revealed that tuberculosis in residential schools was rampant, and 24 percent of students who had attended the schools were known to be dead.²³ He offered several substantive recommendations, including for the government to take responsibility for “the complete maintenance and control of the schools, since it had promised by treaty to insure such.”²⁴ Yet, those recommendations were not published, and despite repeated attempts over several years, Bryce’s efforts to advance “even the simplest effective efforts to deal with the health problem of the Indians” were stymied.²⁵ This reflected active opposition from church officials²⁶ and federal leaders, perhaps most infamously Mr. Duncan Campbell Scott of the federal Department of Indian Affairs.²⁷ Upon his involuntary retirement, Dr. Bryce wrote up his experiences in a highly critical 1922 paper provocatively titled “The Story of a National Crime: An Appeal for Justice to the Indians of Canada,” in which he lamented that “this story should have been written years ago and then given to the public.”²⁸

Between 1871 and 1921, the Canadian government entered into treaties with various First Nations across Canada, of which three pertain to Alberta: Treaty 6, which was signed in 1876 and covers territory in the centre of the province; Treaty 7 (1877) in the south, and Treaty 8 (1899) in the north.²⁹ Under those historic treaties, First Nations who occupied the territories, who were in some cases facing the devastating challenges brought on by colonization, gave up large areas of land in exchange for promised provisions and goods.³⁰ However, different intentions and interpretations of what the treaties meant have led to exceedingly complex relationships between First Nation communities and federal and provincial governments. As stated in the summary report, “the negotiation of Treaties, while seemingly honourable and legal, was often marked by fraud and coercion, and Canada was, and remains, slow to implement their provisions and intent.”³¹ A contemporary map of treaty areas and First Nation communities in Alberta is shown in Figure 7.1 on page 225.

According to the Métis Nation of Alberta, a Métis person is someone “who self-identifies as a Métis, is distinct from other aboriginal peoples, is of historic Métis Nation ancestry, and is accepted by the Métis Nation.”³² Stemming from efforts in the early twentieth century to organize politically, Métis peoples in Alberta have a land base. Briefly, Association des Métis d’Alberta et les Territoires du Nord-Ouest, the precursor of the Métis Association of Alberta and, later, the Métis Nation of Alberta, was formed in 1928 to lobby for improved social and economic conditions and a land base. The lobbying led to land being legally set aside for Métis peoples in Alberta starting in 1938 (Table 7.2), and a governance framework to support local autonomy and self-government was added in the early 1990s. A contemporary map of the eight Métis settlement areas and communities in Alberta is shown in Figure 7.2 on page 226.

Treaty Right to Health

To provide some additional context to the stories that follow, we conclude this background section with a short overview of the colonial structure of health care for Indigenous Peoples in Alberta and Canada (Table 7.2). Importantly, in line with this volume’s broad conceptualization of public health, health care is only one of many policy subsystems that is relevant to health and well-being; yet it is intimately connected to Indigenous social and cultural histories. As described in Alberta Health Services’ Indigenous Health Transformational Roadmap:

Many Indigenous people consider Inherent Rights to Health and Health Care as granted by the Creator. First Nations are born with Inherent Rights and inherit them from generation to generation based on traditions, customs, practices and connections to the land. . . . The oral assurances . . . of medical aid and the provision of medical care during the Treaty negotiations were important to First Nations and form the basis for our understanding of the Treaty Right to Health.³³

The Treaty Right to Health has come to signify the failure of colonial government to uphold obligations related to health care as understood in the Treaties. As stated in the Declaration of Treaty 6, 7 and 8 First Nations – Treaty Right to Health:

As Treaty Indians there is nothing more important than our Treaties, our land and the well-being of our future generations.

All rights are recognized in Treaties between the Crown and Nations or Tribes of Indians in Canada ensuring the wholistic and the spiritual concept of Treaties.

That the medicine chest clause binds the federal government to provide medicines and all that is required to maintain proper health.

Treaty 6, 7 & 8 discussions were based on previous treaties and that all were equally inclusive and applicable.

So long as the sun shines, rivers flow and the grass grows, these words must never be broken.³⁴

Contributing to the failed promise by colonial governments to uphold obligations related to health care is Canada’s complex jurisdictional arrangements, which stem from its federated structure of government. Briefly, nineteenth-century federal legislation assigned authority for all issues pertaining to Indigenous Peoples, including health care, to the federal government.³⁵ Initially situated within the federal Department of Indian Affairs (est. 1880),³⁶ authority for “Indian Health Service” was shifted to the Department of National Health and Welfare upon its establishment in 1945, and in 1962 to the newly created Medical Services Branch within that federal department.³⁷ However, the creation of that new federal department, and the broader post-WWII government expansion of which it was part — while widely celebrated as ushering in Canada’s welfare state — in fact signified intensification of racialized exclusion of Indigenous Peoples. As powerfully described by historian Maureen Lux in her work on Indian hospitals, the use of which are significant in Alberta’s history, the post-war expansion could be characterized as pursuing a vision of national health that was based on white citizenship.³⁸ The Medical Services Branch was renamed the First Nations and Inuit Health Branch in 2000,³⁹ and has historically held responsibility for funding and/or administering various programs and services including some public health and health promotion programs, non-insured health benefits, and primary care services in remote or isolated communities.⁴⁰

Jurisdictional responsibility for health care for non-Indigenous people has a different administrative structure and history. When coupled with ongoing colonial structures, complications are created that are specific to and manifest most acutely for Indigenous Peoples, particularly First Nations and Inuit because the health care benefits in the treaties are directed at them. Briefly, under Canada’s Constitution Act and under parameters enshrined in the Canada Health Act,⁴¹ provincial governments are required to cover insured services, such as hospital and physician services that are deemed medically necessary, for all residents of that province.⁴² Although this includes all Indigenous residents of the province, regardless of whether they live in a First Nation reserve community or not, many pertinent pieces of legislation do not make explicit reference to First Nations Peoples.⁴³ These ambiguities in legislation have created confusion around roles and responsibilities, especially in terms of provincial activities in reserve communities, where there is a common view that the federal government is responsible. These jurisdictional complexities have created significant gaps and problems in health care for Indigenous persons that collectively embody the failed treaty promise of health care.⁴⁴

Following nearly a century of efforts, some slow progress in redressing these colonial-jurisdictional frustrations started to occur in the late 1960s and 1970s.⁴⁵ A 1966 report commissioned by the federal government and led by University of British Columbia anthropologist H.B. Hawkins, identified the significant social and economic disadvantages faced by Indigenous Peoples in Canada, attributed them to failed government policies and problematic public attitudes, and recommended that Indigenous Peoples be considered “citizens plus” with additional rights including opportunities and resources to make their own decisions about issues that affect their lives.⁴⁶ Following that report, the federal government began consulting with First Nation communities across Canada. However, those activities were highly problematic: when the Pierre Elliot Trudeau government released its “Statement of the Government of Canada on Indian Policy, 1969,” colloquially known as the White Paper 1969, First Nations communities across Canada were shocked at the paper’s failure to address the concerns their leaders had expressed.⁴⁷ Lagace and Sinclair said that “the backlash to the 1969 White Paper was monumental” and included a strong and united response from First Nation communities, including a formal rebuttal in the form of Citizens Plus, also known as the Red Paper, which was submitted by the Indian Association of Alberta. This strong and united response led to the withdrawal of the White Paper and empowered a wave of Indigenous leadership and activism that continues to this day.⁴⁸

One outcome of those efforts was the 1979 Indian Health Policy. Although only two pages long, the policy was significant in its recognition of the “intolerably low level of health” in many First Nation communities and its identification of three pillars upon which to build efforts to improve health in those communities: i) the importance of socio-economic, cultural, and spiritual development as the underlying determinants of health; ii) recognition of the traditional relationship between Indigenous Peoples and the Canadian government; and iii) the interrelated nature of the Canadian health system, including active participation by First Nation communities.⁴⁹

Although the process continued to be slow and difficult, the 1979 Indian Health Policy provided a foundation for a health transfer program that gives First Nation communities control of their health services; this includes administration and delivery of public health and insured and non-insured health care services, including those otherwise handled by First Nations and Inuit Health Branch.⁵⁰ It also provided a foundation in Alberta for Health Co-Management, which is an agreement signed in 1996 between the First Nation Chiefs of Alberta and the federal government “to work together to make decisions on funding and programs to improve the health of First Nations in Alberta.” However, an important backdrop of the transfer activities nationally was concern about growing costs of health care to First Nation communities, especially non-insured health benefits. This led to efforts to try to contain costs, including the 1986 establishment of a federal Non-Insured Health Benefits Directorate, which issued directives that were to be administered regionally within a certain amount of funding, called an “envelope,” introduced in 1994. The limited envelope for the Alberta region meant that certain services—particularly within the non-insured benefits—would have to be cut, which First Nation communities in Alberta argued was a clear violation of the federal government’s treaty obligations.⁵¹ Thus, while transfer and co-management strategies carry the potential for substantive progress toward health and well-being of Alberta First Nation communities, their success hinges on genuine partnerships, which are one key marker of truth and reconciliation. As illustrated in the stories below, and as per the quote from the Truth and Reconciliation Commission with which we opened this chapter, we are not there yet.

Stories from First Nation Communities in Alberta

In this section, we present three stories that illustrate diverse ways in which these historical events and circumstances have played out in Alberta First Nation communities.⁵² More importantly, they illustrate the communities’ responses, which provide a version of public health where social determinants of health are placed at the forefront of decisions about the public’s health; perhaps more so than anywhere else in this book. Arranged in chronological order, the first story considers a Canada-wide initiative, the Community Health Representative program, from a Treaty 6 perspective. The program is a long-standing, and not uncontroversial, initiative in preventive health services in Indigenous communities in Alberta and beyond. The second story showcases vision and leadership by members of Mistassini Nehewiyuk, commonly called Bigstone Cree Nation in Treaty 8 territory in working toward health transfer, to the considerable social and economic (and thus health) benefit of the community. The third story focuses on a recent and ongoing public health crisis — the opioid epidemic — and the courage shown by the Kainai Nation, commonly called the Blood Tribe in Treaty 7 in generating a community response to a devastating experience. The stories speak for themselves, and we conclude our chapter commentary here.

The Community Health Representative Program, Treaty 6

“We’re all teachers in some way.” — Elder Ella Arcand, Kipohtakaw, Treaty 6 community health representative, retired.⁵³

The Community Health Representatives program has provided for public health service delivery in Indigenous communities in Alberta and beyond since the early 1960s. The program is significant in that it represents efforts to provide preventive public health services in a way that recognizes the unique needs and contexts of Indigenous communities. At the same time, it illustrates the long-standing tensions between Indigenous and non-Indigenous peoples, which are caused and perpetuated by settler colonialism. The perspectives of those who served in these front-line roles is thus highly informative from the point of view of the objective of this chapter, which is to share important stories in the history of public health in First Nation communities in Alberta, including social, colonial, and community determinants of health and well-being.

For this story, we are honoured to draw on the experiences of Elder Ella Arcand, a retired community health representative from kipohtakaw, more commonly known as the Alexander First Nation, who has over thirty years of experience working in the field of First Nations health programming. Although the Community Health Representatives program was not unique to Treaty 6 territory, we situate it here within that perspective.⁵⁴ Treaty 6 was first signed at Fort Carlton in what is now called Saskatchewan on 23 August 1876, and covers a large area that extends from central western Alberta, through central Saskatchewan, and with a 1898 adhesion, into Manitoba.⁵⁵ The territory includes fifty First Nations, of which seventeen are in Alberta (Figure 7.1).

Treaty 6 was negotiated and signed in the context of concerns by Plains Indigenous Peoples over the Canadian government’s colonial-capitalist westward expansion, which threatened Indigenous land, along with bison and other game upon which their societies depended.⁵⁶ As with other treaties, the signing led to land cession by the First Nation communities to the federal government; however, this was not made clear: the Indigenous signatories believed that they were agreeing to share the land and its resources. Ongoing land claims speak to the unresolved nature of these historical tensions rooted in colonization and capitalism.⁵⁷

Of the numbered treaties that pertain to Alberta, Treaty 6 is the only one that explicitly contains a medicine chest clause. The clause says “that a medicine chest shall be kept at the house of each Indian Agent for the use and benefit of the Indians at the direction of such agent.” The Treaty also includes clauses that promise relief in times of famine and pestilence, such as the following:

That in the event hereafter of the Indians comprised within this treaty being overtaken by any pestilence, or by a general famine, the Queen, on being satisfied and certified thereof by Her Indian Agent or Agents, will grant to the Indians assistance of such character and to such extent as Her Chief Superintendent of Indian Affairs shall deem necessary and sufficient to relieve the Indians from the calamity that shall have befallen them.⁵⁸

For many Indigenous Peoples, the medicine chest clause signifies First Nations’ “constitutionally protected, Inherent, and Treaty Rights to Health,” which, as discussed earlier in this chapter, have not been upheld.⁵⁹ The Confederacy of Treaty Six First Nations maintains that “the spirit and intent of the treaties must be respected and honoured as made sacred by traditional Indian laws and ceremonies and the involvement of the Crown.”⁶⁰ The medicine chest clause provides important context for the Community Health Representative program.

Kipohtakaw (Alexander First Nation) is located northwest of Edmonton in Treaty 6 Territory.⁶¹ The Alexander Nation speaks nêhiyawêwin (Cree) and the 2020 population was approximately 2,300, including those living on and off reserve, according to an estimate by Indigenous and Northern Affairs Canada.⁶² In a 2010 Health Canada report of First Nation community profiles in Alberta,⁶³ the Alexander Nation stands out for its high levels of educational attainment (57 percent high school completion rate), labour force participation (70 percent of members 15 to 64 years of age), and income (median after-tax family income of $34,176). Although these statistics compare favourably to other First Nation communities in Alberta and elsewhere, they are well below those for non-Indigenous populations, which, from the same report, were approximately 72 percent, 74 percent, and $65,000. As discussed throughout this chapter, these persistent inequities reflect a constellation of factors including colonization and the residential school legacy, which continue to exert negative effects on Indigenous Peoples’ health and well-being.⁶⁴ Alexander First Nation is a member of the Yellowhead Tribal Council, which was established in 1977 to work collectively to facilitate programs and services for its four member Nations: Alexander, Alexis Nakota Sioux, O’Chiese, and Sunchild.⁶⁵ One of Arcand’s many former roles was as health manager for the Yellowhead Tribal Council.⁶⁶

The origins of the Community Health Representative program in Canada date back to the late 1950s,⁶⁷ when the federal government was “seeking fresh approaches” to what they saw as “the problems of Indian communities.”⁶⁸ It was known that levels of health and well-being in Indigenous communities were persistently and significantly lower than in non-Indigenous communities,⁶⁹ and there was some growing awareness — albeit painfully slow growth — that unacceptable disparities in social and economic circumstances, themselves rooted in colonialism, were the cause.⁷⁰ Within the international context of the so-called Development Decade of the 1960s, there was growing faith in the idea and potential of community development, broadly defined as a process intended to improve social and economic circumstances of a community with their active participation.⁷¹ As applied in Canada, one example was efforts by the federal government to find ways for Indigenous communities to be more involved in their own health care.

In that context, the government decided that they, and in particular the Medical Services Directorate within Canada’s Department of National Health and Welfare, would run a pilot project to train community health workers to work in Indigenous communities.⁷² While the ultimate goal was to “assist native people to reach and maintain a standard of living comparable to that of the remainder of Canada’s population,” the program also articulated short-term goals; namely: i) to encourage the participation of local people in the health activities of their communities; ii) to give professional health workers an opportunity to become more effective by providing a link with the local community; and iii) to increase the number of active health workers in the field.⁷³ However, in her comprehensive study of the program, author Nancy Gerein notes that “although Indians had long talked about employing their own people in community work, no mention was made [in the government planning documents] of consultation with Indian leaders or communities. . . . It remained for Medical Services to explain the program to Indians and to solicit their co-operation.”⁷⁴ As seen below, this partial or perhaps pseudo version of community engagement is an important theme of the Community Health Representative initiative.

The focus of the Community Health Representative program was public health — that is, prevention, promotion, and protection.⁷⁵ In that way, it embodied a broader shift in the federal government’s priorities concerning health services for Indigenous communities. As described by Sheila Rymer of the Medical Service Branch, while the department focus in the mid-1940s through the mid-1950s was building and staffing health care facilities on reserves, the late 1950s saw a shift upstream to public health activities, of which the Community Health Representatives program was an example.⁷⁶ The trainees enrolled in the pilot project, which was held at Norway House, Manitoba, in 1961, were expected to be “teachers, organizers, promoters, and liaisons rather than treatment people” (italics added).⁷⁷ Following the pilot project, the program continued and other training sessions were held across western Canada.⁷⁸ Arcand’s mother was part of that initial wave of training in the mid-1960s.⁷⁹

After attending Olds College and finding limited job prospects, Arcand saw a job advertisement for a community health representative position in Alberta, working for Health Canada.⁸⁰ Not surprisingly, Arcand’s mother — having been through the training herself — encouraged her to apply. Arcand got the job, and she worked in that capacity for several years, recalling growing interest in the Community Health Representative program at the time from Alberta First Nation communities, including isolated ones.⁸¹ Indeed, the number of community health representatives in Alberta increased from “a few” in 1962, to eighteen in 1974, with an additional twenty-four beginning their training in 1975.⁸² In response to the growing interest, Arcand and other community health representative pioneers were involved in efforts to establish a credentialed training program by teaming up with the Alberta Vocational Centre (now called Portage College) at Lac La Biche.⁸³ The Community Health Representatives program in Lac La Biche started in 1973 as part of the centre’s efforts to expand its community-based training programs, and it was the only Community Health Representatives training program in Alberta.⁸⁴

“Less focused on Treaty right to health; more focused on prevention and promotion.” — Ella Arcand

The purview of the community health representatives was broad but consistently focused on prevention and health promotion (Table 7.3).⁸⁵ Arcand recalls that health education activities figured prominently, which aligns with one of the original visions of CHRs as “teachers/motivators” who would provide advice and assistance on health issues.⁸⁶ With a significant focus on children and mothers, health education activities focused on topics like pre- and postnatal care, nutrition, and personal and home hygiene.⁸⁷ It also included family planning, although that could be a “touchy area.” Arcand describes her community health representative peers as “really dynamic” people who came up with creative ideas, such as using crafts as teaching tools.⁸⁸

Beyond health education, community health representatives provided or assisted with preventive clinic-based activities like immunization and health assessments.⁸⁹ Their activities also extended to health protection activities such as collecting and sending water samples for analysis and advising community members based on the results, home inspections, and dealing with “a lot!” of flies.⁹⁰ Providing support to families often involved helping to arrange child care or transportation. Community health representatives like Arcand would often walk between homes within a community and travel between multiple communities, some of which were quite isolated. Overall, these daily activities, which Arcand aptly describes as “24/7,” contributed importantly to health and well-being in many Alberta Indigenous communities.

Another important community health representative role was that of liaison, or cultural bridge between the community and the typically non-Indigenous nurses and other health care personnel and, by extension, the federal government, that served them. In Treaty 6 territory, for example, the Cree language was spoken in all the communities served by community health representatives, which permitted representatives like Arcand to improve upon efforts of the nurses who could not necessarily speak the language of the people they were serving.⁹² This bridging role went beyond language: according to Gerein’s analysis, CHRs in Alberta advised health care personnel on local culture, values, traditions, and politics. Significantly, they would also help the non-Indigenous health care personnel to become aware of their own personal beliefs, feelings, and biases about Indigenous Peoples. Considering the existence of entrenched and widespread colonial attitudes toward Indigenous Peoples, coupled with the fact that the government-employed nurses during the 1970s “receive[d] practically no formal orientation to Indian culture” in their training, these community health representative activities were extremely important.⁹³

As noted above, the context in which the Community Health Representative program was created in the 1960s was one in which problematic ideas of community development were prominent. Accordingly, the community health representative role was envisioned to go beyond delivering health promotion activities and serving as cultural liaison to include advocacy and community mobilization. This role could take various forms.⁹⁴ In general it involved active participation in Band Council or other meetings to advocate for resources, facilities, or programs that, based on the Community Health Representatives program’s understanding of needs, would benefit the community. Gerein’s analysis showed that although some Alberta community health representatives were politically active, such activities were a relatively uncommon part of the community health representative role because the expectation of effective advocacy and community mobilization was fraught, due to the colonial foundations of the program.⁹⁵ This is clearly illustrated by a quote from Rymer who identified that, from the perspective of the federal government, CHRs could be “both a help and a hazard.” That is, “they were a help when they supervised some of the winter works projects such as building privies or digging wells, but they were a hazard when they called public attention to sanitary conditions in reserve schools or insisted that safe water be supplied.”⁹⁶ In other words, so long as it was limited to a certain set of largely depoliticized activities, the Community Health Representative program was viewed positively by the federal government, but if CHRs went beyond those activities and engaged with the social determinants of health, it was threatening and unacceptable. This is despite stated program objectives around improving Indigenous health and well-being, and it clarifies exactly how narrow the federal vision of community development was.

The previous paragraphs are not intended to take away from the significant and valued contributions of community health representatives. Those contributions are corroborated by a 1993 survey of graduates from the Community Health Representative program at Portage College in Lac La Biche, which showed some positive findings: of the 92 percent of graduates who were employed, the overwhelming majority were very or fairly satisfied with their job (86 percent) and reported that their training had been very or fairly related to their job (92 percent).⁹⁷ However, there have since been some important changes. After nearly forty years, the Community Health Representative training program at Portage College was discontinued around 2010.⁹⁸ There have also been changes to public health more generally, upon which Arcand, now retired, is well positioned to reflect, noting, for example, an erosion of public health.

“Public health has sort of disappeared.” — Ella Arcand

Drawing on the three pillars from the 1979 Indian Health Policy — community development; the special relationship between First Nation Peoples and the federal government; and the interrelated nature of the Canadian health care system — Arcand identified changes that signal a disconnect with traditional Indigenous way of life, and a shift toward Western approaches to health and illness.⁹⁹ She gave an example of Elders living in care facilities. An Elder who is feeling cold may wear multiple layers of clothing. A care worker who questions the reason for that behaviour, or asks the individual to remove layers, may fail to recognize that the person is mobilizing collective knowledge and practices accrued through a lifetime of experiences, such as living and working on a trap line. Likewise, giving a pharmaceutical sleep aid to an Elder may be experienced as dismissive of Indigenous knowledge and wisdom for understanding the reasons for poor sleep and traditional methods of healing and wellness to help alleviate it. These issues are further complicated by what Arcand describes as “newer” diseases that accompany an aging population, such as dementia or Parkinson’s disease, which Arcand did not recall ever encountering during her years working in Treaty 6 communities.¹⁰⁰

“Everything is not pills.” — Ella Arcand

Arcand saw her community health representative work was a stepping-stone to an impressive range of other roles and activities. As a few examples, Arcand was founder and president of the First Nations Health Managers Association, health manager for the Yellowhead Tribal Council, and health director for Enoch Cree Nation. She has also served as a member of the board of directors for the Siksika Medicine Lodge Youth Wellness Centre, as a board member for Stoney Health Services, and as a member of the First Nations, Métis, and Inuit Leadership Committee for the Greater St. Albert Catholic School Division.¹⁰¹ One of Arcand’s particularly treasured experiences was her involvement in The Spirit of Healing initiative, which was a partnership of First Nations representatives from Treaty 6, 7, and 8; the First Nations and Inuit Health Branch; the University of Calgary; the College of Physicians and Surgeons of Alberta; and the Alberta College of Pharmacists, that raised awareness about and addressed the issue of prescription drug misuse and abuse within First Nation communities in Alberta.¹⁰²

Through these significant roles and activities, Arcand has served as a strong champion for public health in Alberta and beyond. The contributions of Arcand and her communities provide a strong illustration of public health as we have defined it for this book — that is, as emphasizing collective approaches to supporting social determinants of health and well-being — and we are honoured to share those contributions here.

The Mistassini Nehewiyuk (Bigstone) Experience: For Our Community, in Our Community, by Our Community, Treaty 8

“There is so much to be done and there’s so much opportunity to really make a difference. . . . If they [government] really want to make a difference, if they really want to help reduce costs, if they really want to improve services . . . why can’t we be a real partner? We are Albertans and Canadians too.” — G. Barry Phillips, former CEO, Bigstone Health Commission¹⁰³

In 1992, then-Chief of Bigstone Cree Nation Gordon T. Auger attended a Treaty 8 meeting of Chiefs in Slave Lake, where he learned that his community of Bigstone was the least healthy First Nation in Alberta. By 2010, the community of Bigstone-Desmarais ranked at the top of the First Nations Community Well-Being Index among communities in Alberta, and it scored above the province’s non-First Nations average.¹⁰⁴ The story of how this happened is important and illuminating for public health.

Mistassini Nehewiyuk,¹⁰⁵ commonly known as Bigstone Cree Nation, is a collection of communities in northern Alberta that have been long inhabited by Woodland Cree, an Algonquian people with a history and culture characterized by deep connections to the northern boreal forests and lakes. The region historically spanned a triangular geographic area, with Wapuskaw (more commonly known as Wabasca, which is located approximately 300 km north of Edmonton) and Sandy Lake situated between Calling Lake to the south, Peerless Lake and Trout Lake to the northwest, and Chipewyan Lake to the north.¹⁰⁶ The Bigstone peoples were signatories to Treaty 8 on 21 June 1899 and, as with other First Nation communities, those colonial events and their aftermath caused dramatic disruption in their ways of life. Under the federal Indian Act, for example, there were two residential schools in the Wabasca area,¹⁰⁷ and testimony from those who attended the schools confirm devastating practices such as segregation that divided families and communities by preventing them from talking or interacting.¹⁰⁸

With the signing of Treaty 8, the Crown established five reserves for the Bigstone people: Reserve 166 at Sandy Lake, 166A along the north side of South Wabasca Lake, 166B on the south side of South Wabasca Lake, 166C on the north end of North Wabasca Lake, and 166D on the south side of North Wabasca Lake; they later established Reserve 183 at Calling Lake.¹⁰⁹ Much later, however, in what would become the largest treaty land entitlement claim in Alberta, Bigstone used early population surveys to successfully argue that they were entitled to more land. That claim, initiated in 1981 and finalized in 2010, led to the creation of new reserves, one for Peerless Lake and Trout Lake communities, and one for the Chipewyan Lake community, as well as additional land for the existing reserve at Calling Lake.¹¹⁰ Bigstone Cree Nation, with a current population of approximately 7,200, is geographically remote: “there’s two highways to Wabasca and they both end there,”¹¹¹ and this is a constant theme in the community’s efforts to improve health and well-being.

Through exposure to family friends at a young age, Barry Phillips learned about hospital administration and wanted to become a hospital administrator. By pursuing his interests and being open to opportunities, Phillips worked his way to being named administrator of Ste. Catherine’s Hospital in Lac La Biche in May 1968, making him the first lay administrator of a Catholic hospital in Alberta. However, his passion lay in functional and strategic design of services that met the needs of communities, and following a winter spent on a trapline with his brother-in-law, Phillips sought out opportunities that better aligned with those values. He became involved in emerging economic development opportunities for Métis peoples in Alberta, and he went on to do consulting contract work for Métis Child and Family Services. When the director of Métis Child and Family Services moved to Bigstone, Phillips’s unique set of skills, experiences, and knowledge led to an invitation to follow. In an interview, Phillips told the authors of this book that “perhaps if you are lucky, once in your career you will have a real opportunity to change the way the industry that you work in functions, addresses issues, confronts problems, and meets challenges. Such was my opportunity when I went to work with the Bigstone Cree Nation in northern Alberta.”¹¹²

Phillips’s initial job at Bigstone was connected to the federal government’s efforts related to the health transfer program. When he arrived in Bigstone in 1992, it took Phillips very little time to recommend not pursuing full health transfer. Although it would have provided much-needed flexibility in terms of how the community could allocate funds and services, the limited resources available would have presented major obstacles.¹¹³

Fortunately, however, there was another opportunity. The federal government’s Medical Services Branch, in conjunction with the Assembly of First Nations, was initiating a pilot project for transfer of non-insured health benefits. In the context of concerns about rising costs of non-insured health benefits noted above, the objective of the pilot was to see if First Nation communities could find innovative ways to effectively deliver those programs. In that first round of projects in the mid-1990s, communities could select one or more programs to test, and Bigstone selected medical transportation for its community members. That opportunity was significant in that it allowed the community to identify the needs of its members; for example, what services prompted members to leave the community, and where did they go to access those services? With respect to medical transportation, the foundational work undertaken for the first round of pilot projects set the stage for later successes; for example, Bigstone later won a contract to provide medical transportation services in the Edmonton area, approximately 320 km south, which created twelve jobs for Bigstone community members living in Edmonton. Later, when Greyhound bus lines cut back on regional service, Bigstone was able to expand their transportation activities and provide fee-for-service transportation within the community as well as to and from Edmonton.¹¹⁴

The knowledge, experience, and confidence gained through that medical transfer project positioned the Bigstone community to then pursue transfer of all non-insured health benefits programs, which was the objective of a second round of projects five years later. Phillips explained that, although making improvements to medical transportation was important, Bigstone’s remote location continued to present formidable challenges.

If I live in Edmonton and I have a vision appointment, say it’s going to take me 20 minutes to get there, one hour for the appointment, and 20 minutes to get home. So I only have to make arrangements for two hours. But when, for that vision appointment, [I have to travel from the reserve] I have to get on a medical transportation bus at 7:30 in the morning to get to Slave Lake by 9 a.m. and my appointment isn’t until 11a.m., and the bus doesn’t leave to come back until 4 p.m., I have breakfast, lunch, and supper for my family I have to worry about; I have all those other normal things in life that have to be taken into consideration, so a lot of people just say “it’s not worth it for me so I’ll just walk around like this.” Access to services is not just “is it even possible to access;” it’s, “is it reasonable for me to put in my list of priorities.”¹¹⁵

There was a need to find ways to strengthen service delivery locally.

The community’s efforts were grounded in the social determinants of health. Phillips’s thinking was influenced by the 1974 Lalonde Report,¹¹⁶ along with two other resources — Why are Some People Healthy and Others Not, and Building Communities from the Inside Out¹¹⁷ — which Phillips encouraged all members of Bigstone health leadership to read. Informed by these important perspectives and their own experiences, the Bigstone Health Advisory Council developed a vision for the community’s health transfer that considered issues of access, income, jobs, education, and living environment: “we see a healthy community where our members receive needed services locally, by our own businesses, staffed by our trained membership.”¹¹⁸ Although the need for adequate funding was recognized, it was also clear that simply expanding the non-insured health benefits budget was not going to solve the problems. For example, even if funds were available to hire health professionals to serve the community, how enticing would such an opportunity be if there was no housing, or housing without running water or a sewer connection? Phillips says that challenges were reconceptualized as opportunities:

• We looked at the fact that we had nothing, and therefore, nothing to lose.
• We looked at the fact of our semi-isolation as a positive geographic factor: we had a captive market.
• We looked at the fact that we had a high unemployment rate and members [who were] eager to find meaningful employment and willing to train.¹¹⁹

Mobilizing the resources of the community — including facilities, people, and funds — Phillips and his team developed a capital plan, a human resources plan, and a business plan. Figuring importantly into these plans were the frustrations experienced with current arrangements, in which centralized government decision-making — for example, about what was and was not covered under non-insured health benefits — created rules that felt arbitrary and unfair because they were based on federal resource appropriation rather than on what would meaningfully address needs in the community.

Bigstone’s general approach was to create opportunities for community members to train for careers in health service delivery and to provide ways for those educated community members to return home, earn a fair income, and contribute to their community. According to Phillips, “active, educated, and well-paid community members encourage healthier lifestyles and demand services that improve one’s living environment. The actual provision of jobs reduces stress among a community where unemployment is high and opportunities are few.”¹²⁰

Dental services provide an illustration. The closest available services were 125 kilometres away, presenting the geography-priority trade-off described earlier. The community began by purchasing, for $1, a mobile dental trailer from the provincial government — “this was done even though we were a First Nations organization whose health service was the responsibility of the federal government”¹²¹ — and equipping it with surplus equipment from the University of Alberta’s dental program.¹²² When the dental services expanded and were moved into the newly built professional centre in Wabasca, the mobile trailer was moved to Trout Lake to provide weekly dental services to the Trout and Peerless Lake communities.

Dental services are one of many under the Bigstone Health Commission,¹²³ which is the entity responsible for health services for the Bigstone communities and has administered the non-insured health benefits programs for members of the Nation since 2004.¹²⁴ From essentially no services in the early 1990s, the community now employs nearly 200 people in health and social service sectors.

“We provide everything to our members.” — former Chief Gordon T. Auger¹²⁵

A foundation of Bigstone’s efforts to provide public services is data and statistics. Recognizing that high-quality information is often a key catalyst for change, the community embraced a partnership with the First Nations Information Governance Centre and their survey work.¹²⁶ Thanks to the efforts of Andy Alook, project coordinator with the Bigstone Health Commission, the community achieved a 92 percent completion rate for First Nations Information Governance Centre’s Regional Health Survey, which is one of the highest for any First Nation in Canada. The community has used data from several surveys to support ongoing planning in health and education, such as a proposal to expand their band-operated school, Oski Pasikoniwew Kamik.¹²⁷ Further, following a 2010 review of the Health Commission, the community also initiated a local report card that embraces a population health approach and is based on a strong commitment to the importance of continually monitoring and working to improve health in the community.¹²⁸

“We measure our status against Alberta not just First Nations” — G. Barry Phillips¹²⁹

Many factors stand out as contributing importantly to Bigstone’s success, including leadership and vision from within the community as well as colleagues from outside the community, including some from the Alberta Region of First Nations and Inuit Health Branch described by Phillips as having “bent over backwards to help us be successful.”¹³⁰ However, some important challenges remain. One example, continuing with the dental services illustration, concerns a clause within Alberta’s Health Professions Act that prohibits dentists from sharing or splitting professional service fees with anyone who is not a dentist registered with the College of Dental Surgeons of Alberta.¹³¹ Because of the significant expense and financial uncertainty associated with setting up a dental practice in a small, remote community like Bigstone, one way to entice a dentist such as a new graduate to set up a practice is for the community to invest financially. For example, the community could invest funds to build and equip a dental facility, and then set up a volume or fee-based long-term lease agreement with the dentist to recoup that investment over time.¹³² This would provide the dentist some financial support and protection to make the venture less risky, and the community would receive a much-needed local service. However, such an arrangement is prohibited under provincial legislation, which leaves the community with no viable choice but to rely on less sustainable arrangements with volunteer dentists.¹³³

As per Call to Action number 23 of the Truth and Reconciliation Commission, which pertains to “increase[ing] the number of Aboriginal professionals working in the health care field; [and] ensur[ing] the retention of Aboriginal health care providers in Aboriginal communities,” it would be ideal to train and recruit dentists from the community.¹³⁴ But until then, as illustrated by the dental example and by health services more generally, the question remains: Why can’t we be real partners?¹³⁵

Mobilizing the Community in a Time of Crisis: Kottakinoona Awaahkapiiyaawa, “Bringing the Spirits Home,” Treaty 7

“The Creator has provided us with the gifts, and it is our responsibility to take care of not only our people, but the land and the animals and the environment.” — Chief Charles Weaselhead¹³⁶

In a time of crisis, characterized by a terrifying increase in opioid overdoses among their people, the Kainai Nation (commonly called the Blood Tribe) of southern Alberta mobilized to build a community response. It is important not to understate what is meant by a community response — the response was fundamentally grounded in Kainayssini, or guiding principles, that were adopted and prepared by Elders from the past. As powerfully described by Chief Charles Weaselhead,¹³⁷ the guiding principles “talk about who we are and what we teach our children, in areas of governance, culture and spirituality, as well as connections and responsibilities to the land, the community, and the spirit of the Creator.”

Grounded in these principles, and by extension the rich stories, collective knowledge, and deep wisdom of the community, Kottakinoona Awaahkapiiyaawa, “Bringing the Spirits Home”: The Blood Tribe Addiction Framework says that “by knowing the past, in the context of seeing today, we can change the path going forward. We can then take stock, tell our story, and pass it along to future generations as a winter count.”¹³⁸ We respectfully use these four components of the community’s approach to structure their story.

Knowing the Past

“The Elders recognize that the Blood Indians have always had control over its lands and over its religious, political, economic and cultural destinies.” — “Kainayssini,” Declaration of the Elders of the Blood Indian Nation¹³⁹

The peoples of the Kainai Nation (“Many Chiefs”), historically known as the Blood Tribe, have a long and rich history in Treaty 7 territory in southern Alberta. Along with the Siksika and two communities of the Piikani (Piegan) people, Aapátohsipikáni in the north and Amskapi Piikani in the south — the Kainai Nation is part of the Siksikaitsitapi (Blackfoot Confederacy), for whom the bison, along with other animals and plants, historically figured prominently for food, housing, clothing, and ceremonial life. The traditional territory of the Niitsitapi (Blackfoot Nation) extends from the North Saskatchewan River in the north to the Yellowstone River in the south, and from the Rocky Mountains in the west to the Eagle Hills in the east. The Kainai Nation, for whom the Siksika language and culture remain strong, inhabits an area of over 1,400 square kilometres located between the Belly and St. Mary’s rivers in the southern part of the province and has a population of approximately 14,000 members who live within and outside of the community.¹⁴⁰

As described by Chief Weaselhead, the Kainai peoples have a very strong connection to Ά pistotooki, the Creator, which is the source of traditional spirituality. Community structures, including societies such as the Horn Society and the role of Elders, help to ensure that traditions and beliefs are passed on through generations.¹⁴¹

Despite these strong foundations, the Kainai Nation has experienced significant loss. As stated in Kottakinoona Awaahkapiiyaawa, “The Blackfoot and Blood Tribe people have been impacted by loss: loss of language, food sources, culture, traditions, land, territory, identity, purpose, and control . . . like ripples in the water [these changes] have far-reaching and continuous effects on every aspect of life, sometimes spanning generations.”¹⁴² Colonialism brought an impossible barrage of assaults that are aptly described as cultural genocide.¹⁴³ Although the introduction of horses, guns, and tools in the eighteenth century seemed to bring some immediate benefits, the arrival of alcohol and diseases eroded communities to such an extent that when the Northwest Mounted Police arrived in Blackfoot territory in the 1870s, it was seen as a relief. It was in those circumstances of desperation that five Nations — Kainai (Blood), Siksika (Blackfoot), Piikani (Piegan), Nakoda (Stoney), and Tsuu T’ina (Sarcee) signed Treaty 7 in 1877 and agreed to share their land in exchange for various provisions. As with many other communities, the ensuing legacy of institutionalized assimilation was, and continues to be, devastating.¹⁴⁴ Today, the Nation faces persistent and unacceptable challenges including poverty, unemployment, and lack of suitable housing, along with mental and physical health issues including addiction,¹⁴⁵ of which colonial acts and their traumatic and enduring negative impacts are the cause.

Seeing Today

The opioid crisis is a comparatively recent phenomenon that has had destructive effects in communities across Alberta and Canada. This complex public health crisis involves both illegal street drugs that have been laced with fentanyl and prescription opioids. Across Canada, between January 2016 and September 2019, there were over 19,400 opioid-related poisoning hospitalizations and over 14,700 apparent opioid-related deaths.¹⁴⁶ Alberta, like much of the rest of Canada, has seen a steady recent increase in opioid-related deaths,¹⁴⁷ and a 2019 surveillance report estimated that on average, just under two individuals died every day in Alberta as a result of an apparent opioid poisoning. Of all confirmed drug and alcohol poisoning deaths in the province in recent years, opioids were involved in approximately 75 percent.¹⁴⁸

Statistics for opioid-related harms among First Nations communities in Alberta are available through a collaboration between the Alberta First Nations Information Governance Centre¹⁴⁹ and the Alberta Ministry of Health, in which Bonnie Healy, Kainai Nation member and former executive director of Alberta First Nations Information Governance Centre, played a significant leadership role.¹⁵⁰ Recent statistics stemming from that collaboration indicate that First Nations Peoples have been disproportionately affected by the crisis; for example, despite representing approximately 6 percent of the Alberta population, they represented 13 percent of all opioid-related poisoning deaths from 2016 to 2018. Across the province, opioid-related harms for First Nations Peoples are highest in the Alberta Health Services South Zone, which includes the City of Lethbridge and the Blood Reserve.¹⁵¹ The contributing factors are a complex mix of the colonial legacy including institutionalized racism and other social determinants of health; one manifestation is that the opioid dispensation rate in Alberta is twice as high for First Nations compared to non-First Nations people.¹⁵²

The Kainai Nation community started to see a considerable number of deaths from opioid overdose around 2014–2015,¹⁵³ which led Chief Charles Weaselhead to take the significant step of declaring a local state of emergency. The worst of the situation, however, was yet to come. According to statistics maintained by the Blood Tribe Department of Health, there were thirty overdose calls from the reserve in 2014, and thirty-five in 2015; a concerning number for any community, let alone a small community. However, these numbers foreshadowed a terrifying increase, to 108 in 2016, 180 in 2017, and 335 in 2018. Kevin Cowan, Chief Executive Officer for the Blood Tribe Department of Health, described the changes in numbers as “pretty much a tenfold increase in a fairly short period of time.” He continued, “by the fall of 2018, we were simply frustrated by the number that we were seeing.”¹⁵⁴ A heartbreaking accompaniment to these statistics is the percentage of babies born exposed to substances: 22 percent in 2014/15, 32 percent in 2015/16, 39 percent in 2016/17, and 51 percent in 2017/18.

An important part of formulating a response to the crisis was recognizing that the existing approach to handling overdoses was not working. If an overdose occurred in the community, first responders would drive the patient thirty kilometres to the nearest medical centre at Cardston or Fort McLeod, or sixty kilometres to the Lethbridge hospital, where they would frequently be released within a few hours. Jacen Abrey, Director-Fire Chief, Blood Tribe Emergency Services, says, “we have seen that in the hospitals: ‘oh, they’re just high again; oh, they’re just drunk again.’”¹⁵⁵ This arrangement was a recipe for disaster. Being alone and away from home, facing racism and discrimination, it is not surprising that some patients relapsed the same day they were admitted.¹⁵⁶ Being in larger towns also provided an opportunity to buy more drugs and bring them back to the reserve.

Since time immemorial, the Blackfoot people have had their healing methods to address mental, spiritual, physical, and emotional ailments.¹⁵⁷ It was time to mobilize those foundations.

Change the Path

In 2018, the work to address the crisis began in earnest. The Blood Tribe Department of Health worked closely with leaders from the Alberta Health Services South Zone, who had been tasked with developing a community-wide, comprehensive, full-continuum of care addiction framework that was based on the Blackfoot culture and context.¹⁵⁸ Lene Jorgensen of Alberta Health Services and Rebecca Many Grey Horses of the Kainai Nation were instrumental in this work. Recognizing the significant strength, wisdom, and resiliency in the community, preparatory work to mobilize those foundations was undertaken between May and November of that year. As stated in Kottakinoona Awaahkapiiyaawa, the process of developing the framework involved the following parameters.

• Looking beyond the problem, to consider the role of culture and spirituality.
• Looking beyond evidence and literature, to explore oral history and Indigenous ways of knowing.
• Looking beyond the data, to adhere to ethical considerations about how the data is collected, used and shared.
• Looking beyond environmental scans, to understand jurisdictions, treaties and peace alliances.
• Looking beyond stakeholder input, to develop the art of truly listening to the stories and wisdom.¹⁵⁹

Kottakinoona Awaahkapiiyaawa was developed through consultations with a wide range of people within and outside the community,¹⁶⁰ and the name signifies two foundations of the framework: i) an invitation to the spirits of those living with addiction, back to the community, and ii) a commitment to bringing back the spirits of those currently living with addiction and those who have lost their lives. The four pillars of the framework — prevention and harm reduction, detoxification, treatment, and aftercare — are grounded in community, healing, wellness, and Blackfoot culture.¹⁶¹ Yet, while the framework clarified what needed to be in place; the question was how to build it? Approaches used elsewhere, such as larger cities of Calgary or Edmonton, were not necessarily going to work in the Kainai Nation’s unique environment.

In late 2018, a meeting was called that brought different departments in the community together. Jacen Abrey, Director-Fire Chief, Blood Tribe Emergency Services, attended that meeting, and had the idea to create a paramedic-run, medically assisted detoxification centre. Paramedic-run was significant: paramedics (and other first responders) have the great advantage of being in the community and closely connected with the people they were helping; there was an important opportunity to strengthen and optimize paramedics’ roles.¹⁶² The novel arrangement, which integrated traditional, non-traditional, clinical, and non-clinical knowledge and disciplines, involved protocols whereby patients could enter a detoxification, treatment, and aftercare process without waiting for a referral. Local physicians, including Dr. Esther Tailfeathers and Dr. Susan Christenson, were supportive, and community leaders, notably Elders, were integrally involved in the centre, providing spiritual and cultural guidance, including connection to the Blackfoot language and adherence to the Kainayssini.¹⁶³ The efforts to put this idea into practice began.¹⁶⁴

“I had done 35 years of front-line paramedic [work]; I’d been in an ambulance, I’d worked for the province in the fire commissioner’s office. I knew the layers of bureaucracy in the provincial government, and I’m thinking, there’s no way [that this idea will materialize].” — Jacen Abrey¹⁶⁵

Despite seemingly insurmountable challenges that came with the urgency of the situation, the work unfolded rapidly. Within one week of the community meeting, they had started renovations on an existing Blood Tribe Department of Health facility to expand and transition its functions toward the paramedic-run, medically assisted approach. Within ten days, they had secured provincial funding. After six weeks, the Bringing the Spirit Home detoxification centre opened its doors.

“[Unlike other programs], we like to think that our community is the centre, and they can open any door and we will bring them in” — Jacen Abrey¹⁶⁶

A key feature of the program is that it adapts to the individual. For example, in recognition of significant differences in how individuals experience addiction, the duration of the program varies. Another significant example is that babies are welcome and mothers can bring their babies with them. By adapting to circumstances of individuals, including mothers, and working collaboratively with Children’s Services, the program plays a critical role in allowing families to stay together as described by Lene Jorgensen: “when I hear about the babies at the site and how some expectant mothers are entering treatment before the baby is born, returning to the site with the baby after and sometimes supported by the grandmother, I know that the spirits are coming home to the community.”¹⁶⁷

Recognizing the need for a range of integrated services and supports, the program includes opportunities for people to access dental care, optometry, and immunizations while in treatment. A routine blood draw permits early detection of sexually transmitted infections, including Hepatitis C and HIV. In addition to services on the reserve, a mobile medical unit operates in Lethbridge where staff will see anyone who needs the services. As part of the aftercare pillar, there are supports for self-care, education, and life- and job skills development.¹⁶⁸ These are a few examples within a holistic initiative that is grounded in community and culture — that is, the Niitsitapi Ways.¹⁶⁹

A Winter Count

“In my view, I think we have turned a corner” — Chief Charles Weaselhead

For the Blackfoot people, Winter Counts are a mixture of oral history and pictographs, passed on from one person to the next, which are used to record events and track time.¹⁷⁰ We have respectfully borrowed the concept to situate reflections on the story of the opioid crisis in the Kainai Nation from the point of view of a broad version of public health in which the social determinants of health figure prominently.

There are indications that the Kainai Nation’s bold approach is working. The sharp increase in overdose calls has started to level off: following what will hopefully end up being the peak of 335 in 2018, the number of calls went down to 275 in 2019.¹⁷¹ The percentage of babies born exposed to substances decreased from 51 percent in 2017/18 to 39 percent in 2018/19.¹⁷² Although not specifically measured, there is a sense that the number of incidents of petty crime has gone down, which may reflect the program’s success in conveying to clients that the community is there to support them.¹⁷³

“The [solutions] have to come from within” — Kevin Cowan¹⁷⁴

More broadly, there are important signs of an empowered community that can serve and support its members. For example, reliance on external agencies is diminishing: according to Jacen Abrey, who has served the reserve in some capacity for over twenty years, 2019 was the first year in memory that the Kainai Nation did not need to call in any outside community for assistance.¹⁷⁵

This strengthened capacity goes beyond the immediacy of the opioid crisis. For example, under the prevention and harm reduction pillar, activities within Kottakinoona Awaahkapiiyaawa extend into the community’s schools, where paramedics educate students from pre-kindergarten through grade 12 on a range of topics, including opioids and other substances, fire safety, first aid, and driving safety.¹⁷⁶ Moreover, the Kanai Nation is forging partnerships between the local Red Crow College and other post-secondary institutions such as Lethbridge College and Medicine Hat College to create opportunities to train members as nurses and paramedics to serve their community,¹⁷⁷ thus aligning with Truth and Reconciliation Commission Call to Action #23, for “all levels of government to increase the number of Aboriginal professionals working in the health care field.”¹⁷⁸

“As a health [department], we could try to take care of the opioid crisis. . . . But if we don’t take care of those other factors — education, employment, racism, poverty, lack of housing, lack of basic drinking water, all of those, we’re spinning our wheels most of the time” — Chief Charles Weaselhead

The Kainai Nation’s community response to the opioid crisis is a remarkable story of vision, collaboration, and leadership, grounded in culture and tradition. Yet, as per Chief Weaselhead’s words about “spinning our wheels,” much greater attention to the social determinants of health — that is, the root causes of addiction and other health problems on a community-wide basis — is needed. Far-reaching challenges, which cannot be addressed by the health department alone, remain. Unacceptable norms of racism and discrimination and circumstances of poverty persist, for the Kainai Nation and for Indigenous Peoples across Alberta. The loss of culture and identity continues to manifest in levels of incarceration and rates of sickness and premature death that are unacceptably high and far higher than in non-Indigenous populations.¹⁷⁹ These circumstances epitomize the concept of health inequities — that is, differences between population groups that are unfair and avoidable that reflect an unequal distribution of health-damaging experiences, and which are “not in any sense a ‘natural’ phenomenon but [are] the result of a toxic combination of poor social policies and programs, unfair economic arrangements, and bad politics.”¹⁸⁰ Although important work is being done, it is not enough. Respectfully, we give the final words of this chapter to Chief Charles Weaselhead.

In my view, the biggest success factor will be in closing that gap [between Indigenous and non-Indigenous peoples]. . . . Our standard of living is third world conditions. And the government and most of our mainstream Canadians are beginning to realize that the Aboriginal people are right: all they have to do is come into the reserve and look.

In a theme that recurs throughout this chapter, we are not there yet.¹⁸¹

notes

1. 1 Truth and Reconciliation Commission of Canada (TRC), Honouring the Truth, Reconciling for the Future. Summary of the Final Report of the Truth and Reconciliation Commission of Canada (Winnipeg: National Centre for Truth and Reconciliation, 2015), 6–7.

2. 2 TRC, Honouring the Truth, 6.

3. 3 Janet Smylie, “Approaching Reconciliation: Tips from the Field” (Editorial), Canadian Journal of Public Health 106, no. 5 (2015), e261.

4. 4 TRC, Honouring the Truth; Smylie, “Approaching Reconciliation.”

5. 5 John Last, ed., Dictionary of Epidemiology (4th edition) (Oxford: Oxford University Press, 2001), 145.

6. 6 Canadian Public Health Association (CPHA), Public Health: A Conceptual Framework, Canadian Public Health Association Working Paper, Second Edition (Ottawa: CPHA, 2017), https://www.cpha.ca/sites/default/files/uploads/policy/ph-framework/phcf_e.pdf; World Health Organization, Ottawa Charter for Health Promotion (Ottawa: WHO, 1986), https://www.who.int/healthpromotion/conferences/previous/ottawa/en/index1.html.

7. 7 This was expressed by Justice Murray Sinclair, Chair of the TRC. See Chloe Fedio, “Truth and Reconciliation Report Brings Calls for Action, not Words,” CBC News, posted 2 June 2015, https://www.cbc.ca/news/politics/truth-and-reconciliation-report-brings-calls-for-action-not-words-1.3096863.

8. 8 Lindsay McLaren, “In Defense of a Population-level Approach to Prevention: Why Public Health Matters Today,” Canadian Journal of Public Health 110, no. 3 (2019).

9. 9 Paulette Fox, Amelia Crowshoe (editor), and The Alberta First Nations Information Governance Centre, Indigenous Health Indicators: A Participatory Approach to Co-designing Indicators to Monitor and Measure First Nations Health (April 2018), http://afnigc.ca/main/includes/media/pdf/digital%20reports/Indigenous%20Health%20Indicators.pdf.

10. 10 Some of the individuals featured in this chapter, while allies to Indigenous communities, are of non-Indigenous ancestry and lived experience.

11. 11 Alberta Government, Ministry of Indigenous Relations, Aboriginal Peoples of Alberta: Yesterday, Today, and Tomorrow (November 2013), https://open.alberta.ca/dataset/9a704cab-7510-4796-9301-f373cbc27e30/resource/e7e90b67-7308-4f98-a67b-140bf65c7666/download/6429770-2013-aboriginal-peoples-alberta-2013-11-18.pdf. In an interview, Reggie Crowshoe, Piikani cultural teacher in southern Alberta, referred to his father, Joe Crowshoe, who “often said that when the dominant society understands us like we understand the dominant society, then we’ll have a good life.” This Alberta government resource was intended to provide “a starting point for moving toward the kind of understanding Joe Crowshoe talked about.” Alberta Government, Aboriginal Peoples of Alberta, 3.

12. 12 For a much more fulsome treatment of this topic on a national scale, the reader is directed to TRC, Honouring the Truth — one of many reliable sources.

13. 13 To the extent that the large gatherings, including the buffalo hunt, occurred with little indication of disease outbreaks, these events perhaps offer early lessons for public health including communicable disease prevention. We are grateful to Dr. Janet Smylie for this insight.

14. 14 Alberta Government, Aboriginal Peoples of Alberta, 2.

15. 15 Katherine L. Frohlich, Nancy Ross, and Chantelle Richmond, “Health Disparities in Canada Today: Some Evidence and a Theoretical Framework,” Health Policy 79 no. 2/3 (2006):; FNIGC, “First Nations Health Trends-Alberta ‘One-Pagers,’”, accessed 7 August 2020, http://www.afnigc.ca/main/index.php?id=resources&content=FNHTA.

16. 16 TRC, Honouring the Truth.

17. 17 The Indian Act does not pertain to Métis peoples.

18. 18 Indigenous and Northern Affairs Canada, “Canadian Human Rights Act — Repeal of Section 67,”, date modified 15 September 2010, https://www.rcaanc-cirnac.gc.ca/eng/1100100032550/1622036080282.

19. 19 Compiled from various sources including Alberta Government, Aboriginal Peoples of Alberta; Breaker and Smith, “History Prior to Health Co-management”; Government of Canada, Ten Years of Health Transfer First Nation and Inuit Control (Health Canada, First Nations and Inuit Health Branch), https://web.archive.org/web/20190925184528/https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/reports-publications/funding/years-health-transfer-first-nation-inuit-control-health-canada-1999.html; the Métis Nation of Alberta website (http://albertametis.com/about/history/); Government of Canada, “Indigenous health care in Canada”, https://www.sac-isc.gc.ca/eng/1626810177053/1626810219482, date modified 2 May, 2023; Kristin Burnett, “Health of Indigenous Peoples in Canada”, Canadian Encyclopedia, 7 February 2006, https://www.thecanadianencyclopedia.ca/en/article/aboriginal-people-health; personal communications from Bonnie Healey and Eunice Louis.

20. 20 Supreme Court of British Columbia, “List of Residential Schools,” Residential School Settlement, Official Court Notice (27 July 2015), http://www.residentialschoolsettlement.ca/schools.html#Alberta.

21. 21 Dr. Peter Bryce figures prominently in the history of public health in Canada and particularly Ontario. In addition to his roles and efforts noted here, he was also the first secretary of the Provincial Board of Health in Ontario in 1882, in which capacity he led the revision of Ontario’s Public Health Act; he was the chief medical officer of health in Ontario from 1887 until he moved into the federal government in 1904; and he chaired the organizing committee that was appointed at the first meeting of the CPHA in 1919. Christopher Rutty and Sue C. Sullivan, This is Public Health: A Canadian History (Ottawa: CPHA, 2010); Megan Sproule-Jones, “Crusading for the Forgotten: Dr. Peter Bryce, Public Health, and the Prairie Native Residential Schools,” Canadian Bulletin of Medical History 13 (1996).

22. 22 As per the minister’s instruction, this included a “special inspection” of the sanitary conditions and health status of children from thirty-five “Indian schools” in the three prairie provinces in 1907, and an examination of 243 children in eight schools in Alberta in 1909. According to Sproule-Jones, this focus on the prairie provinces was not surprising considering: Bryce’s dual responsibility for Indigenous and immigrant populations; the time frame (namely, the rapid settlement of the prairie region in the early twentieth century); and the fact that much less attention had been devoted to Indigenous Peoples in the prairies than to those in older communities in central and eastern Canada. Megan Sproule-Jones, “Crusading for the Forgotten.” Although the requests from the federal minister to undertake these investigations was prompted in part by health statistics and a need for greater action as expressed by local medical officers, they were also influenced by money: a letter from the minister to Dr. Bryce in 1909 stated, “as it is necessary that these residential schools should be filled with a healthy class of pupils in order that the expenditure on Indian education may not be rendered entirely nugatory, it seems desirable that you should [undertake examinations].” Peter Henderson Bryce, The Story of a National Crime: An Appeal for Justice to the Indians of Canada (Ottawa: James Hope & Sons, Limited, 1922), 5.

23. 23 The 24% death rate was published in Bryce’s 1907 Report on the Indian Schools of Manitoba and the North West Territories. In one school, located on the File Hills reserve in Saskatchewan, over 65% of students who had attended in the sixteen years since the school opened were dead, based on “a complete return” of information from that school. Bryce, The Story of a National Crime; Sproule-Jonesn “Crusading for the Forgotten.”

24. 24 Bryce, The Story of a National Crime, 4; Sproule-Jones, “Crusading for the Forgotten.”

25. 25 According to Sproule-Jones, Bryce’s 1907 report prompted a 1911 federal memorandum titled “Correspondence and Agreement Relating to the Maintenance and Management of Indian Boarding Schools,” which outlined regulations for the construction and maintenance of residential schools; the memorandum did not lead to substantive improvements in the school. Sproule-Jones, “Crusading for the Forgotten.” See also, Bryce, The Story of a National Crime, 4.

26. 26 Church officials who were responsible for managing residential schools in the prairies deflected blame, asserting that the poor health of students reflected the poor conditions of reserve communities from which they came and the inadequate government funding for the schools. In one of many examples of a pervasive theme, the appalling conditions of residential schools were claimed to reflect jurisdictional confusion within the partnership between church and state, which opened the door for inaction and deflection of blame by both parties. Further complicating the situation was the existence of different beliefs about the causes, and thus preventability, of tuberculosis. Despite bacteriological discoveries such as the identification of the tuberculosis bacterium in 1882, some, including residential school principals, continued to believe that tuberculosis represented God’s punishment for the sins of society or that it was genetically determined, and that the high rate of tuberculosis among residential school students reflected the weaker constitution of Indigenous Peoples. Sproule-Jones, “Crusading for the Forgotten.”

27. 27 Mr. Campbell Scott held leadership positions in the federal Department of Indian Affairs including deputy minister from 1913 to 1932. He has become infamous for his comments about wanting to “get rid of the Indian problem” and “to continue until there is not a single Indian in Canada that has not been absorbed into the body politic.” Robert L. McDougall, Canadian Encyclopedia, “Duncan Campbell Scott,” last edited 18 January 2018, https://www.thecanadianencyclopedia.ca/en/article/duncan-campbell-scott.

28. 28 Mr. Campbell Scott, upon his promotion in 1913 to Deputy Superintendent-General of Indian Affairs, informed Bryce that his statistical reports of conditions of residential schools would no longer be required, and Bryce was passed over for the appointment as Canada’s first deputy minister of health — a position for which, arguably, he was exquisitely well qualified. Bryce, The Story of a National Crime, 15; Sproule-Jones, “Crusading for the Forgotten.”

29. 29 Although these were the original signing dates of Treaties 7 and 8, in some cases there were later signings and/or adhesions where additional Nations joined the agreement. Alberta Regional Professional Development Consortium (ARPDC), Alberta Treaties 6, 7, 8, accessed 10 August 2020, http://empoweringthespirit.ca/wp-content/uploads/2017/05/Alberta-Treaties-678-1.pdf.

30. 30 For example, prior to signing Treaty 7, First Nations in those territories were confronted with smallpox epidemics and the decline of the buffalo, both instigated by non-Indigenous groups. ARPDC, Alberta Treaties 6, 7, 8. On the day Treaty 7 was signed, Blackfoot Chief Crowfoot is widely quoted as saying “Bad men and whiskey were killing us so fast that very few, indeed, of us would have been left to-day” had the police / NWMP not come. Alexander Morris, The Treaties of Canada with the Indians (1880; reprint, Saskatoon: Fifth House, 1991), 295.

31. 31 TRC, Honouring the Truth.

32. 32 The Métis Nation of Alberta (http://albertametis.com/about/) is the Métis Government for Métis Albertans. Their definition of Métis aligns with that of the Métis National Council.

33. 33 Alberta Health Services, Population, Public and Indigenous Health SCN, Indigenous Health Transformational Roadmap, 2018–2020 (2 October 2018), https://www.nccih.ca/634/Indigenous_health_transformational_roadmap,_2018-2020.nccih?id=803&col=3

34. 34 Treaty 6, 7 and 8 First Nations. Declaration of Treaty 6, 7 and 8 First Nations — Treaty Right to Health, 16–17 March 2005. Passed by resolution on 17 March 2005, in Edmonton at an Assembly of Treaty 6, 7, and 8 Chiefs. Provided by Eunice Louis, personal communication, 21 May 2020.

35. 35 Colonial federal authority for issues pertaining to Indigenous Peoples is codified in the Constitution Act (1867) and the Indian Act (1876). Chantelle A.M. Richmond and Catherine Cook, “Creating Conditions for Canadian Aboriginal Health Equity: The Promise of Healthy Public Policy,” Public Health Reviews 37, no. 2 (2016).

36. 36 According to Bryce, medical inspector for the federal Departments of the Interior and Indian Affairs, the first reading in Parliament of the Bill to establish a federal Department of Health, which passed in 1919, contained a provision for including “Indian Medical Service” amongst its services. However, by the second reading that provision was absent. Bryce, The Story of a National Crime.

37. 37 Emblematic of the different perspectives on treaty negotiations, federal authorities claimed that they were providing health care to Indigenous Peoples out of a moral or humanitarian sense of responsibility, rather than out of any promise. Maureen Lux, Canadian Encyclopedia, “Indian Hospitals in Canada,” last edited 31 January 2018, https://www.thecanadianencyclopedia.ca/en/article/indian-hospitals-in-canada.

38. 38 Briefly, there were at least seven racially segregated hospitals established for the treatment of First Nation Peoples in Alberta, including Peigan, Sarcee, Kainai (Blood), Morley/Stoney, Hobbema (now renamed Maskwacis), and Siksika (Blackfoot). Lauren Pelley, “$1.1B Class-action Lawsuit Filed on Behalf of Former ‘Indian Hospital’ Patients,” CBC News, 30 January 2018, https://www.cbc.ca/news/canada/toronto/indian-hospital-class-action-1.4508659. Some of these, such as the Kainai (Blood) and Siksika (Blackfoot) hospitals, had their origins as mission hospitals in the late nineteenth century, were rebuilt in the 1920s, and evolved to practice some medical pluralism, such as combining colonial medicine with local healing practices. However, in a colonial context, those early Indian hospitals faced considerable challenges: they were underfunded, understaffed, and underequipped and could scarcely be expected to offset the dismal conditions that created poor health in the first place. During the post-WWII period, the federal government expanded its program of government-owned Indian hospitals, and the first in the expansion was the five hundred-bed Charles Camsell Indian Hospital in Edmonton where unacceptable practices occurred, including medical experimentation and sexual sterilization without consent. Around this period, the government took efforts to close other hospitals including the Kainai (Blood) and Siksika (Blackfoot) hospitals in Alberta. As noted, those hospitals had managed to exert some local autonomy, which made them a threat to the emerging vision of “national health.” For a much more fulsome consideration of the complex story of the Indian hospitals, the reader is directed to the work of Maureen Lux, including “Care for the ‘Racially Careless:’ Indian Hospitals in the Canadian West, 1920–1950s,” The Canadian Historical Review 91, no. 3 (2010); “We Demand ‘Unconditional Surrender’: Making and Unmaking the Blackfoot Hospital, 1890s to 1950s,” Social History of Medicine 25, no. 3 (2012); Separate Beds: A History of Indian Hospitals in Canada, 1920s–1980s (Toronto: University of Toronto Press, 2016).

39. 39 In 2017, Prime Minister Justice Trudeau announced organizational changes to the federal government that resulted in the First Nations and Inuit Health Branch being moved out of Health Canada and into the newly-created Indigenous Services Canada department.

40. 40 Government of Canada, “Primary Health Care Authority,” Indigenous and Northern Affairs Canada, modified 27 March 2020, https://www.aadnc-aandc.gc.ca/eng/1524852370986/1524852436793.

41. 41 Canada’s original Constitution Act (the British North America Act) identified “The establishment, maintenance, and management of hospitals, asylums, charities, and eleemosynary institutions in and for the province, other than marine hospitals” as one of the “exclusive powers of provincial legislatures.” The Canada Health Act of 1984 sets out the requirements for provincial health insurance plans to qualify for full federal transfer payments. Specifically, those “insured services” must be administered publicly, and they must be comprehensive, universal, portable, and accessible. Government of Canada, “Canada Health Act,” Health Canada, modified 24 February 2020, https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act.html.

42. 42 Government of Canada, “Canada Health Act — Frequently Asked Questions,” Health Canada, modified 20 October 2020, https://www.canada.ca/en/health-canada/services/health-care-system/canada-health-care-system-medicare/canada-health-act-frequently-asked-questions.html#a3; Alberta Health Care Insurance Act, R.S.A. 2000, c. A-20, current as of 5 December 2019.

43. 43 For example, the Canada Health Act (1984) does not contain any mention of First Nations Peoples (https://laws-lois.justice.gc.ca/eng/acts/C-6/). There is likewise no mention of First Nations Peoples in the Alberta Health Care Insurance Act, the Emergency Health Services Act (which includes ambulance service), or the Regional Health Authorities Act. On the other hand, Alberta’s Hospitals Act does stipulate that the provincial health minister may enter into an agreement with the Government of Canada “in respect of the costs incurred . . . in providing insured services to Indians residing in Indian reserves in Alberta.” The Regional Health Authorities Act (and the Public Health Act) explicitly reference Métis peoples by including “Métis settlements” within the definition of “municipality.”

44. 44 The failed treaty promise (i.e., the failure by colonial governments to uphold their obligations related to health care) takes the form of both insufficient and inadequate care. For example, a First Nation community may use its federal funding to hire medical staff. However, if the funding is only sufficient to hire a small number of staff, and those staff have to align with federal human resource policies, it may be impossible to have 24-hour medical service available in the community. With respect to non-insured benefits, if decisions about what is and is not covered are made centrally and seemingly arbitrarily, they are unlikely to fit the needs of each community. AHS, Population, Public, and Indigenous Health.

45. 45 Bonnie Healy, personal communication, 28 November 2019.

46. 46 H. B. Hawthorn (Ed.), A Survey of the Contemporary Indians of Canada. Part 1: Economic, Political, Educational Needs and Policies (Ottawa: Indian Affairs Branch, October 1966), https://publications.gc.ca/site/eng/9.700111/publication.html; Robert Breaker and Gregg Smith, “History Prior to Health Co-management” (PowerPoint presentation), 18 February 2014. Provided by William Wadsworth, personal communication, 20 October 2019.

47. 47 Breaker and Smith, “History Prior to Health Co-management.”

48. 48 Alberta Government, Aboriginal Peoples of Alberta. See also Naithan Lagace and Niigaanwewidam James Sinclair, Canadian Encyclopedia, “The White Paper, 1969,” last edited 10 June 2020, https://www.thecanadianencyclopedia.ca/en/article/the-white-paper-1969.

49. 49 Government of Canada, “Statement on Indian Health Policy,” Health and Welfare Canada (19 September 1979), accessed 14 August 2020, http://publications.gc.ca/collections/collection_2018/sc-hc/H14-296-1979.pdf; T. Kue Young, “Indian Health Services in Canada: A Sociohistorical Perspective,” Social Science & Medicine 18, no. 3 (1984).

50. 50 A policy framework for Health Transfer was approved by federal cabinet in 1988, and the next year the Treasury Board approved the financial resources to support pre-Transfer planning. Government of Canada, Ten Years of Health Transfer. During the 1990s, additional options were advanced to permit communities to take on different levels of transfer activities. For example, in 1994, the federal Treasury Board approved the Integrated Community-Based Health Services Approach, whereby communities could take on a limited or partial version of transfer activities, and in 1995, the federal government announced the Inherent Right to Self-Government Policy, which recognized that First Nation communities have the constitutional right to shape their own forms of government.

51. 51 Breaker and Smith. “History prior to Health Co-Management;” “About Us,” Health Co-Management, accessed 10 August 2020, https://torch7.com/hcom/about-us/

52. 52 While we felt that it was important and valuable to have one story from each Treaty area, we in no way wish to imply that these stories are representative of the diverse communities within Treaty areas or across Alberta.

53. 53 Ella Arcand (Elder, Alexander First Nation), interview by Lindsay McLaren and Rogelio Velez Mendoza, 18 February 2020. All quotations from Ella Arcand are from the interview.

54. 54 The program extended across Canada and the United States. Claudette Lavallée, Catherine A. James, and Elizabeth J. Robinson, “Evaluation of a Community Health Representative program among the Cree of Northern Quebec,” Canadian Journal of Public Health 82, no. 3 (May/June 1991); U.S. Department of Health and Human Services, “Community Health Representative,” Indian Health Service, accessed 10 August 2020, https://www.ihs.gov/chr/.

55. 55 Confederacy of Treaty Six First Nations, “About Us,” accessed 10 August 2020, https://www.treatysix.org/.

56. 56 Michelle Filice, Canadian Encyclopedia, “Treaty 6,” last edited 11 October 2016, https://www.thecanadianencyclopedia.ca/en/article/treaty-6.

57. 57 One Treaty 6 example of an ongoing land claim is the one at Beaver Lake Cree First Nation, which focuses on industrial development related to oil and gas and the impact it has on the Nation’s traditional lands and ways of life. Raven Trust, “Defend the treaties”, accessed 10 August 2020, https://raventrust.com/campaigns/defend-the-treaties/.

58. 58 Copy of Treaty No. 6 between Her Majesty The Queen and the Plain and Wood Cree Indians and Other Tribes of Indians at Fort Carlton, Fort Pitt and Battle River with Adhesions (Ottawa: Roger Duhamel, Queen’s Printer and Controller of Stationery, 1964), http://www.trcm.ca/wp-content/uploads/PDFsTreaties/Treaty%206%20Text%20and%20Adhesions.pdf.

59. 59 Federation of Sovereign Indigenous Nations, “Treaty Right to Health / Medicine Chest Task Force,” Health and Social Development Commission, accessed 10 August 2020, https://fsin.ca/hasd/.

60. 60 Confederacy of Treaty Six First Nations, “Fundamental Treaty Principles,” accessed 10 August 2020, https://www.treatysix.org/treaty-principles.

61. 61 Alexander First Nation, “Alexander First Nation — Kipohtakaw,” accessed 10 August 2020, https://alexanderfn.com.

62. 62 Government of Canada, “Registered Population — Alexander,” Indigenous and Northern Affairs Canada, accessed 10 August 2020, https://fnp-ppn.aadnc-aandc.gc.ca/fnp/Main/Search/FNRegPopulation.aspx?BAND_NUMBER=438&lang=eng.

63. 63 N. Lachance et al., Health Determinants for First Nations in Alberta — 2010 (Health Canada; 2010), http://publications.gc.ca/collections/collection_2011/sc-hc/H34-217-2010-eng.pdf.

64. 64 Naomi Adelson, “The Embodiment of Inequity: Health Disparities in Aboriginal Canada,” Canadian Journal of Public Health 96, (Suppl. 2) (2005); Kristen M. Jacklin et al., “Health Care Experiences of Indigenous People Living with Type 2 Diabetes in Canada,” Canadian Medical Association Journal 189, no.3 (2017).

65. 65 Yellowhead Tribal Council, “About,” accessed 10 August 2020, https://yellowheadtribalcouncil.ca/about/.

66. 66 Ella Arcand, interview.

67. 67 The program initially referred to both Community Health Workers, to denote working in the community rather than in institutions, and auxiliary health workers, which included community health representatives, who took a community public health approach, and other workers such as Family Health Aides, who took a family approach and may have engaged in some treatment activities depending on location and circumstances. Sheila Rymer, “Community Health Representative Program,” Health Education 7 (Nov/Dec 1976). For ease, we refer to “community health representative” throughout the section.

68. 68 Initial meetings were held in 1957 and 1958 between the Indian Affairs Branch of the federal Department of Citizenship and Immigration and the Medical Services Directorate of the Department of National Health and Welfare. Nancy Marian Gerein, “The Community Health Representative in Alberta — A Program Evaluation” (M.Sc. thesis, University of British Columbia, 1977), 13. The Medical Services Branch within the Department of National Health and Welfare, upon its establishment in 1962, assumed responsibility for the Indian Health Service.

69. 69 As noted by Gerein, writing in the mid-1970s, “Numerous studies document the poor health of native people in Canada. A quick examination of gross statistics collected by Medical Services of the Federal Government comparing Indian with national health indicators makes obvious the disparities.” Gerein, “The Community Health Representative in Alberta,” 2.

70. 70 Hawthorn’s report, noted earlier in this chapter, laid bare the significant disadvantages faced by Indigenous Peoples in Canada and concluded that those disadvantages were caused by failed government policies. Hawthorn, Survey of the Contemporary Indians of Canada.

71. 71 In 1961, the UN declared the 1960s the First Development Decade. Recognizing that economic and social development in “less developed” countries is critical to the well-being of those countries as well as to international peace, security, and prosperity, the designation called on Member States to “intensity their efforts to mobilize and sustain support,” primarily to strengthen the economies of those countries. United Nations, “United Nations Development Decade. A Programme for International Economic Co-operation (I),” accessed 10 August 2020, https://undocs.org/en/A/RES/1710%20(XVI). We acknowledge Nancy Gerein’s 1977 work for providing this international contextualization. Gerein, “The Community Health Representative in Alberta,” 2.

72. 72 The federal Department of National Health and Welfare had, upon its creation in the mid-1940s, assumed responsibility for Indian Health Services.

73. 73 Gerein, “The Community Health Representative in Alberta,” 14.

74. 74 Gerein, “The Community Health Representative in Alberta,” 15.

75. 75 As described by Lavallée, James, and Robinson, although community health representatives were involved in primary care in some jurisdictions in Canada, the intention was that those ‘curative activities’ would be the responsibility of physicians and nurses while the community health representatives would be responsible for prevention and health education. Claudette Lavallée, Catherine A. James, and Elizabeth J. Robinson, “Evaluation of a Community Health Representative Program among the Cree of Northern Quebec,” Canadian Journal of Public Health 82, no. 3 (May/June 1991).

76. 76 Rymer, “Community Health Representative Program.”

77. 77 The pilot project at Norway House included four women and seven men from ten reserves in Manitoba that had medical care available, either at a Medical Services Nursing Station or from nearby private physicians. The trainees had been selected by a joint Medical Services – Indian Affairs Branch committee based on the recommendation of the band councils. Rymer, “Community Health Representative Program,”; Gerein, “The Community Health Representative in Alberta.”

78. 78 Writing in 1976, Rymer stated that between 140 and 150 CHRs had been trained in British Columbia since 1963. Rymer, “Community Health Representative Program,” 19.

79. 79 Ella Arcand, interview.

80. 80 While community health representatives were initially hired by Health Canada (Medical Services Branch of the Department of National Health and Welfare), over time a growing number were employed by their Band or district council. Rymer, “Community Health Representative Program,” 18; Gerein, “The Community Health Representative in Alberta.”

81. 81 Ella Arcand, interview.

82. 82 Gerein, “The Community Health Representative in Alberta.”

83. 83 Portage College (as it is now called) has an interesting history. According to its website, the college first opened in 1968 as “Alberta NewStart,” which was part of federal government efforts to invest in adult education, but it closed without notice in December of 1970 (“they actually used chains to lock the doors, so no one could get in,” Corianne Morin, Granddaughter of founder Veronica Morin. Portage College, A People’s Success [video], available in “History,” Portage College, accessed 10 August 2020, http://www.portagecollege.ca/About/History). Students affected by the closure organized a successful demonstration (a twenty-six-day sit-in), and the federal government provided an additional two-year grant. The community re-named the school “Pe-Ta-Pun” (“New Dawn”). When the federal funding ran out, the provincial government took over the funding and re-opened the school in 1973 as a campus of the Alberta Vocational Centre (AVC) (one of five campuses in the province). During the remainder of the 1970s the institution expanded its programs to include community-based programs; this is the period when the CHR training program began. A new facility was announced (by the provincial government) in 1980 and opened in 1985. In 1999 the institution was re-named Portage College, and the Lac La Biche campus is one of seven across Alberta. “History,” Portage College.

84. 84 As described by Akin Bob Adebayo, the CHR training program at the Alberta Vocational Centre was a thirty-week certificate program, including sixteen weeks of instruction and fourteen weeks of practicum work. The courses focused on communication and well-being, environmental health and communicable diseases, health promotion, networking, practical skills, and anatomy and physiology. There were approximately twenty students per year, of whom over 90% were Indigenous. Akin Bob Adebayo, “Characteristics, Employment Status, and Scope of Duties of Community Health Representatives: A Survey of Graduates,” Canadian Journal of Public Health 86, no. 1 (Jan–Feb 1995).

85. 85 Ella Arcand, interview; Gerein, “The Community Health Representative in Alberta;” Adebayo, “Characteristics, Employment Status, and Scope of Duties.”

86. 86 Gerein, “The Community Health Representative in Alberta,” 16.

87. 87 CHRs rarely interacted with men in the communities. Gerein, “The Community Health Representative in Alberta,” 113.

88. 88 Ella Arcand, interview

89. 89 Ella Arcand, interview; Gerein, “The Community Health Representative in Alberta;” Adebayo, “Characteristics, Employment Status, and Scope of Duties.”

90. 90 Ella Arcand, interview.

91. 91 Compiled from several sources. Ella Arcand, personal communication; Gerein, “The Community Health Representative in Alberta – A Program Evaluation,” 18; Adebayo, “Characteristics, Employment Status, and Scope of Duties of Community Health Representatives,” 16–19. Of course, the breadth and proportionate time spent on different activities depended on various factors, such as the geographic location of the community (CHRs in more isolated communities may have performed a greater breadth of activities) as well as the needs or desires of the (typically non-Indigenous) nurse.

92. 92 Ella Arcand, interview.

93. 93 Gerein, “The Community Health Representative in Alberta.”

94. 94 The CHR role also depended on unique local circumstances, such as whether there was an active Band Council. Gerein, “The Community Health Representative in Alberta.”

95. 95 Gerein, “The Community Health Representative in Alberta.”

96. 96 Rymer, “Community Health Representative Program,” 18. This quotation was in reference to the initial set of trainees in the Norway House pilot project in the early 1960s.

97. 97 A questionnaire was distributed via mail to all graduates of the program from 1980 to 1992, and 67% were returned. This high response rate was thought to reflect that “many of the respondents were very enthusiastic about the study and felt that this type of study was long overdue.” Adebayo, “Characteristics, Employment Status, and Scope of Duties,” 17.

98. 98 Dr. Trent Keough, President and CEO, and Nancy Broadbent, Executive Vice President Academic, Portage College, “Community Information Night” (Power Point presentation), 2 November 2017.

99. 99 Palmer, Tepper and Nolan, “Indigenous Health Services Often Hampered.”

100. 100 Ella Arcand, interview.

101. 101 Ella Arcand, interview; For example, see Siksika Medicine Lodge, Youth Wellness Centre, “Our Board of Directors”, http://www.siksikamedicinelodge.com/board.html.

102. 102 “Spirit of Healing, Alberta First Nations Conquering Prescription Drug Misuse,” accessed 10 August 2020, http://www.abfnspiritofhealing.com.

103. 103 G. Barry Phillips, interview by Lindsay McLaren and Rogelio Velez Mendoza, 22 January 2020.

104. 104 AFNIGC, “The Power of Data,” http://www.afnigc.ca/main/includes/media/pdf/news/FNIGC_PoD_Series-Bigstone_FINAL_SCREEN.pdf; Lachance et al., Health determinants.

105. 105 Thanks to Chief Silas Yellowknee for confirming the correct name in Cree.

106. 106 G. Barry Phillips, interview.

107. 107 These were the St. John’s Anglican / Church of England Indian Residential School (Wabasca Residential School), which ran from 1895 to 1966, and the St. Martin’s Wabasca Roman Catholic Boarding School, which ran from 1901 to 1973. Supreme Court of British Columbia, “List of Residential Schools.”

108. 108 TRC, Honouring the Truth, 41.

109. 109 G. Barry Phillips, “The Bigstone Experience: 20 Years to a Healthier Community” (Unpublished manuscript), 4.

110. 110 G. Barry Phillips, interview; Phillips, “The Bigstone Experience”; G. Barry Phillips, personal communication, 18 April 2020; Alberta Government, Aboriginal Peoples of Alberta.

111. 111 G. Barry Phillips, interview.

112. 112 G. Barry Phillips, interview.

113. 113 G. Barry Phillips, interview. Phillips, “The Bigstone Experience.”

114. 114 Phillips, “The Bigstone Experience”; Bigstone Health Commission, “Medical Transportation / Referral,” accessed 10 August 2020, https://www.bigstonehealth.ca/medical-transportation-referral/.

115. 115 G. Barry Phillips, interview.

116. 116 Marc Lalonde, A New Perspective on the Health of Canadians: A Working Document (Ottawa: Department of National Health and Welfare, 1974), https://www.phac-aspc.gc.ca/ph-sp/pdf/perspect-eng.pdf. Among other things, this report introduced the health field concept, whereby health is influenced by multiple factors including human biology and health care and lifestyle and environment.

117. 117 Robert G. Evans, Morris L. Barer, and Theodore R. Marmor, Why are Some People Healthy and Others Not? The Determinants of Health of Populations (New York: Aldine de Gruyter, 1994); John P. Kretzmann and John L. McKnight, Building Communities from the Inside Out: A Path Toward Finding and Mobilizing a Community’s Assets, (Evanston, IL: Institute for Policy Research, 1993). Barry was also influenced by the 1974 Lalonde Report.

118. 118 Phillips, “The Bigstone Experience,” 21.

119. 119 Phillips, “The Bigstone Experience,” 21-22.

120. 120 Phillips, “The Bigstone Experience,” 27.

121. 121 Phillips, “The Bigstone Experience,” 38.

122. 122 For these initial steps, which were the first toward providing dental services right in Wabasca, the community is grateful to Dr. Keith Ellis, a retired dentist from Westlock in central Alberta who also helped recruit dental professionals to work in the community. One example was Dr. Joanne Wendell, whose “local presence and personality” in the early years of the dental service inspired members of the Bigstone community to take Dental Assistant training, some of whom became registered to practice in both dental and orthodontic settings. Such double-registration — unusual amongst dental assistants — provided “a reason to hold their head high, a reason to say, ‘I can contribute to my community.’ ” G. Barry Phillips, interview.

123. 123 G. Barry Phillips, interview; Bigstone Health Commission, “About Us,” accessed 10 August 2020, https://www.bigstonehealth.ca.

124. 124 Cora Voyageur, Angeline Letendre, and Bonnie Healey, Alberta Baseline Assessment Report (AFNIGC, 2015), 23; Bigstone Health Commission, “About Us.”

125. 125 Former Chief Gordon T. Auger, as quoted in AFNIGC, “The Power of Data.”

126. 126 The First Nations Information Governance Centre has been collecting data about First Nation reserves and northern communities since 1997 through surveys, including the First Nations Regional Health Survey and the First Nations Regional Early Childhood, Education and Employment Survey. The FNIGC, including regional partners, of which AFNIGC is one, is a non-profit organization that “envisions that every First Nation will achieve data sovereignty in alignment with its distinct world view.” First Nations Information Governance Centre, “Vision,” accessed 10 August 2020, https://fnigc.ca/about-fnigc/vision.html.

127. 127 FNIGC, “The Power of Data.”

128. 128 Lorraine Muskwa and Janice Willier, “Bigstone Health Commission Report Card,” presentation at FNHMA National Conference, 25 September 2014, https://www.fnhma.ca/archive/conference/2014/Files/Workshop%20N.pdf.

129. 129 Phillips, “The Bigstone Experience,” 33.

130. 130 G. Barry Phillips, interview.

131. 131 Health Professions Act, R.S.A. 2000, c. H-7, current as of 5 December 2019. Health Professions Act, R.S.A. 2000, 79–80.

132. 132 The parameters of the lease could be modeled on those used in other circumstances but adapted for the unique First Nation and non-insured health benefits context. For example, a new dental graduate who sets up a practice within an established practice (working for another dentist) in an urban setting may enter into a 60%–40% (approximate) arrangement where 60% of the amount billed goes to the established dentist to help pay for the space, equipment, etc., and 40% goes to the new dentist as earnings. Adapting this for a First Nation context would take into account the fact that NIHB fees for dental services are lower than Alberta Blue Cross fees. G. Barry Phillips, interview.

133. 133 G. Barry Phillips, interview.

134. 134 TRC, Honouring the Truth.

135. 135 G. Barry Phillips, interview.

136. 136 Chief Charles Weaselhead, interview by Lindsay McLaren and Rogelio Velez Mendoza, Standoff, AB, 28 January 2020. All quotations from Chief Charles Weaselhead are from the interview.

137. 137 Charles Weaselhead Jr. served as Chief of the Blood Tribe from 2004 to 2016. During that time he was appointed as the Treaty 7 Grand Chief, and also held the health and education portfolio for the Treaty 7 Chiefs. Amongst numerous other leadership roles, Chief Weaselhead served as the Director of the Blood Indian Hospital in the early 1990s, and as Chief Executive Officer for the Blood Tribe Department of Health until his 2004 election to Chief of the Blood Tribe. “Chancellor Charles Weaselhead,” University Secretariat (Governance), University of Calgary, accessed 10 August 2020, https://www.uleth.ca/governance/chancellor-charles-weaselhead.

138. 138 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa, “Bringing the Spirits Home”: The Blood Tribe Addiction Framework, November 2019, https://btdh.ca/wp-content/uploads/2019/11/Blood-Tribe-Bringing-the-Spirits-Home-Addiction-Framework_November-2019.pdf. Kottakinoona Awaahkapiiyaawa can be translated as “Bringing the Spirits Home,” “Telling Our Spirits to Come Home” or “Calling the Spirits Home.” Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa

139. 139 Kainaysinni, or Guiding Principles, as described in the Declaration of the Elders of the Blood Indian Nation, available at https://crystalgoodrider.weebly.com/blackfoot-values--elders-declarations.html.

140. 140 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa; Kevin Cowan (CEO, Blood Tribe Department of Health), personal communication, 28 January 2020.

141. 141 The Horn Society, for example, is a group of spiritual leaders in the community who “come together annually to pray for the protection, for the safety, for the nourishment . . . for our people.” Chief Charles Weaselhead, interview; Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

142. 142 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

143. 143 TRC, Honouring the Truth.

144. 144 These include (but are not limited to) the residential schools, of which there were two in the Cardston area, and as the Blood Indian Hospital, which despite evolving to serve the community, was badly affected by a later wave of federal government assimilationist policy, during their post-WWII welfare state expansion. The two residential schools in the area were St. Paul’s Anglican school, which opened in 1891 and closed in 1975, and St. Mary’s Immaculate Conception Roman Catholic school, which opened in 1898 and closed in 1988. There were several other schools throughout Treaty 7, including St. Joseph’s, Ste. Trinité in Cluny (Siksika); Morley (Stony) school in Morley; Old Sun School in Gleichen; Sacred Heart school and St. Cyprian’s (Queen Victoria’s Jubilee Home), both in Brocket; St. Joseph’s school in High River; and St. Barnabas school at T’suu Tina. Supreme Court of British Columbia, “List of Residential Schools.” Interestingly, the TRC identified that it was not unusual for parents of an entire community to refuse to take their children to school, and one instance of this resistance was noted in the Blood Reserve: “In October 1927, seventy-five school-aged children from the Blood Reserve in Alberta either had not returned to school or had not been enrolled in school.” Although it is not entirely clear, one could speculate that this was an example of strength and resilience in those dire circumstances. TRC, Honouring the Truth, 116. For scholarship on the Indian hospitals in general and the Blood Indian Hospital in particular, the reader is directed to the work of Maureen Lux, “Care for the ‘Racially Careless,’ 407–434; Separate Beds.

145. 145 Kevin Cowan, personal communication, 28 January 2020.

146. 146 For current statistics see: Federal, provincial, and territorial Special Advisory Committee on the Epidemic of Opioid Overdoses. Opioid- and Stimulant-related Harms in Canada. Ottawa: Public Health Agency of Canada; https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/

147. 147 For example, the number of apparent accidental drug poisoning deaths related to fentanyl, a type of opioid, in Alberta was six in 2011, twenty-nine in 2012, sixty-six in 2013, 116 in 2014, 256 in 2015, 347 in 2016, 566 in 2017, and 673 in 2018. “Opioid Surveillance Quarterly Reports,” Opioid Reports, Government of Alberta, accessed 11 August 2020, https://www.alberta.ca/opioid-reports.aspx.

148. 148 Government of Alberta, Analytics and Performance Reporting, Alberta Health, Alberta Opioid Response Surveillance Report, Q3 2019 (December 2019), https://open.alberta.ca/dataset/f4b74c38-88cb-41ed-aa6f-32db93c7c391/resource/c9e430f9-0951-436a-9b36-f372ee476498/download/health-alberta-opioid-response-surveillance-report-2019-q3.pdf.

149. 149 It is essential that data and statistics for First Nation communities reflect First Nations’ knowledge and leadership, and this is enshrined in the First Nations’ OCAP^® (Ownership, Control, Access and Possession) principles. OCAP^® is a registered trademark of the First Nations Information Governance Centre (FNIGC), https://fnigc.ca/ocap-training/; Alberta First Nations Information Governance Centre (AFNIGC), accessed 11 August 2020, http://www.afnigc.ca/main/index.php?id=home.

150. 150 In response to a request by Chief Weaselhead, Blood Tribe member Aapooyakii (Bonnie Healy) a, trauma-trained registered nurse with three decades of nursing experience, and executive director of AFNIGC at the time, honoured her ancestral obligation to her people by leading efforts to achieve the AFNIGC mandate from the Alberta Chiefs. The mandate was to create First Nations identifiable data and a First Nations Health Information Governance Agreement with the Alberta Ministry of Health’s surveillance unit, which were respectful of OCAP^® principles. The Alberta First Nations Opioid Report is significant: it is the first in the world to recode the data in a way that provides more detail including, importantly, separating the prescribed opioids from the illicit drugs (fentanyl). AFNIGC and Government of Alberta, Alberta Opioid Response Surveillance Report – First Nations People in Alberta, (December 2019), https://www.alberta.ca/assets/documents/health-first-nations-opioid-surveillance.pdf; Bonnie Healy, personal communication, 25 May 2020.

151. 151 AFNIGC and Government of Alberta, Alberta Opioid Response First Nations

152. 152 The discrepancy was three-fold for those aged twenty-five to forty-nine years. AFNIGC and Alberta Government, “Opioid Dispensations to First Nations people in Alberta,” 30 August 2016, http://www.afnigc.ca/main/includes/media/pdf/fnhta/HTAFN-2016-08-30-Opioid.pdf.

153. 153 Although our focus here is the opioid crisis, the Blood Tribe people and community have battled other types of addiction as well. Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

154. 154 Kevin Cowan, personal communication, 28 January 28, 2020; Kevin Cowan, interview by Lindsay McLaren and Rogelio Velez Mendoza, Standoff, AB, 28 January 2020.

155. 155 Jacen Abrey, interview by Lindsay McLaren and Rogelio Velez Mendoza, Standoff, AB, 28 January 2020.

156. 156 The racism and discrimination Cardston is deeply rooted. When the federal government stepped up their assimilationist policies in the post-WWII period, including efforts to force the closure of the Blood Indian Hospital in Cardston, they recommended that the local First Nation people instead attend the municipal hospital in Cardston. Members of the Blood Tribe resisted, citing the discrimination against the Indigenous Peoples by the people of Cardston. Maureen K. Lux, Separate Beds.

157. 157 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

158. 158 The task was initially to develop an opioid response plan, which included detoxification, treatment, and aftercare. However, because opioids are merely the major drug of choice, it was determined that it would be more appropriate to create a broader addiction framework that included dimensions of prevention and harm reduction. Lene Jorgensen, personal communication.

159. 159 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa, 7.

160. 160 Including those on the front line of the crisis, within and outside the community; those providing other programs and services to members; Elders and Knowledge Keepers; those living with addiction; those in recovery; those who have recovered; and family members. Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

161. 161 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

162. 162 Lene Jorgensen, personal communication.

163. 163 Lene Jorgensen, personal communication.

164. 164 Dr. Tailfeathers had advocated for a safe withdrawal site in the community as early as 2015, which provided an important foundation for the 2018 efforts. Personal communication, Lene Jorgensen, March 29 2020.

165. 165 Jacen Abrey, interview.

166. 166 Jacen Abrey, interview.

167. 167 Lene Jorgensen, personal communication, 2 April 2020.

168. 168 Jacen Abrey, interview.

169. 169 Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa

170. 170 Details of the evaluation, of the activities that we have partially described here, have not been fully worked out; however, they will involve quantitative service data as well as Blackfoot ways of knowing, including the Winter Count. In the Winter Count, symbols illustrate the most significant events, and are painted – often on buffalo hides – starting in the centre and spiraling outward. The importance of the information captured in the Winter Count is more about the story contained within, than about the chronological order. Blood Tribe Department of Health, Kottakinoona Awaahkapiiyaawa.

171. 171 Kevin Cowan, personal communication, 28 January 2020.

172. 172 Lene Jorgensen, personal communication.

173. 173 Jacen Abrey, interview.

174. 174 Kevin Cowan, interview.

175. 175 Kevin Cowan, interview.

176. 176 Jacen Abrey, interview.

177. 177 Jacen Abrey, interview.

178. 178 TRC, Honouring the Truth.

179. 179 Charlotte Reading and Fred Wien, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health (Prince George, BC, National Collaborating Centre for Aboriginal Health, 2009), https://www.ccnsa-nccah.ca/docs/determinants/RPT-HealthInequalities-Reading-Wien-EN.pdf; AFNIGC and Government of Alberta, “Mortality Rates in First Nations in Alberta” (23 February 2016), https://www.afnigc.ca/main/includes/media/pdf/fnhta/HTAFN-2016-02-23-AllCauseMortality.pdf

180. 180 National Collaborating Centre for Determinants of Health, “Let’s Talk: Health Equity” (Antigonish, NS: NCCDH, St. Francis Xavier University, 2013), http://nccdh.ca/images/uploads/Lets_Talk_Health_Equity_English.pdf; Commission on Social Determinants of Health (CSDH), Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Final report of the Commission on Social Determinants of Health (Geneva: World Health Organization, 2008), https://www.who.int/social_determinants/thecommission/finalreport/en/.

181. 181 TRC, Honouring the Truth.

182. 182 Alberta Health Services, Population, Public and Indigenous Health Strategic Clinical Network, Esther Tailfeathers, Indigenous Health in Alberta: A Primer 101 (May 31, 2018), 4.

183. 183 Alberta, Legislative Assembly, MLA Committee on the First Nations, Metis and Inuit Workforce Planning Initiative, Connecting the Dots: Aboriginal Workforce and Economic Development in Alberta (Edmonton: Government of Alberta, 2010), 12-13, https://open.alberta.ca/publications/9780778559726. Contains information licensed under the Open Government Licence – Alberta.

notes to Table 7.2

1. 1 “History of Providing Health Services to First Nations people and Inuit,” First Nations and Inuit Branch, Government of Canada, accessed 14 August 2020, https://web.archive.org/web/20191012164923/https://www.canada.ca/en/indigenous-services-canada/corporate/first-nations-inuit-health-branch/history-providing-health-services-first-nations-people-inuit.html.

2. 2 Health Canada, First Nations and Inuit Health Branch, Ten Years of Health Transfer First Nation and Inuit Control (1999), https://web.archive.org/web/20190925184528/https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/reports-publications/funding/years-health-transfer-first-nation-inuit-control-health-canada-1999.html.

3. 3 Government of Canada, Indian Health Policy (1979), accessed 14 August 2020, http://publications.gc.ca/collections/collection_2018/sc-hc/H14-296-1979.pdf

4. 4 Breaker and Smith, “History Prior to Health Co-management.”

5. 5 Metis Settlement Act, R.S.A. 2000, c. M-14, 132, current as of 1 September 2019.

6. 6 Bill C-3 (2010) amended the federal Indian Act to entitle individuals in the following circumstances to register: those whose mother lost Indian status upon marrying a non-Indian man; those whose father is a non-Indian; those who were born after the mother lost Indian status (with date restrictions); those who had a child with a non-Indian (with date restrictions. Alberta Government, Ministry of Indigenous Relations, Aboriginal Peoples of Alberta: Yesterday, Today, and Tomorrow. The amendment was in response to a British Columbia Court of Appeal decision that section 6 of the Indian Act contained gender discrimination.

7. 7 Truth and Reconciliation Commission of Canada, Honouring the Truth, Reconciling for the Future.