Sharing Insights on Pandemic Planning in Aboriginal Communities
Teamwork in Natuashish
October 2010 - When Kathleen Benuen volunteered to be the first to undergo an H1N1 shot in the remote community of Natuashish in northern Labrador last year, the whole population was right behind her. Benuen, community health director, was part of a mass immunization campaign among the Mushuau Innu that, on October 28, 2009, saw 90 per cent of the community get their flu shots – in just one day.
By December 31st, 99% of community members were immunized.
As a result, there was not a single instance of the pandemic H1N1 influenza in Natuashish, said community health nurse Joanne McGee. In fact, there was little incidence of any flu-like illness in the community.
The H1N1 flu pandemic in Canada last year cost $2 billion, lead to 428 deaths and resulted in 8,678 hospitalizations. Aboriginal populations account for less than 5% of the total Canadian population, but represented 17.5% of hospitalized cases of pandemic H1N1 influenza. Manitoba, with a majority Aboriginal population in the north, was more severely affected during the first wave of the pandemic in 2009 than almost any other Canadian province. (See new reports on Canada's response to the pandemic.)
Behind the headlines highlighting the challenges, however, were success stories among communities like Natuashish, the urban Inuit in Ottawa, Cree communities in northern Quebec, and First Nations in Saskatchewan. These are indicating the value of community engagement, partnership, communication and leadership for ongoing and future pandemic planning - while also drawing attention to underlying conditions of poverty, chronic disease, or overcrowding that leave populations vulnerable to such epidemics.
“We knew our population was at high risk for the H1N1 virus and began our work right away,” said McGee. “The community was completely engaged right up front, right from when H1N1 first emerged in May.”
Natuashish, home to the Mushuau Innu who were relocated from Davis Inlet in 2002/2003, is geographically isolated with limited access to health care resources. Its population of 823 experiences high rates of co-morbidity and includes a high percentage of young children and pregnant women.
“The one thing we wanted as our goal in terms of mass immunizations was 100% access to the vaccine," said McGee. "We didn't expect that 100% of those eligible would actually come and get it but we wanted them to at least be informed and have the opportunity to come if they wanted," she said.
Preparing for a Community Immunization Campaign
As H1N1 public health measures evolved in Canada last year, the Natuashish and Mushuau Innu Health Commission kept pace. With government support, the community developed a pandemic plan, including a mass immunization process specific to Natuashish, just before the World Health Organization declared H1N1 a pandemic in June 2009.
A large team of community staff visited the local school, held community meetings, met with Elders, installed hand sanitizers in health buildings, and developed household information kits that were distributed to every home in the community. These provided information and leaflets geared to the community in both English and Innu Aimun (the first language of the Mushuau Innu First Nation).
"Each of the two days prior to mass immunization we met as a group and held briefings. Everyone was well-informed about what they were expected to do, whether it was communicating through the radio or arranging for drivers to pick people up or traffic control by the fire chief and his crew. Everbody had a role to play and everybody understood what their role was,” said McGee.
On the appointed day, the regional Labrador Grenfell health authority chartered an aircraft and brought in a team of nurses to assist in the campaign. Their role was to immunize, and they too were briefed so that everyone could work together to ensure as smooth a campaign as possible. Health director Kathleen Benuen and deputy chief John Nui were the first to get their flu shots, helping reassure others.
Of the total 823 people eligible for shots, 815 were immunized. By the end of December 2009, the team had achieved 99% coverage.
McGee said the factors that contributed to the community's success included teamwork driven by the community and social engagement that ensured everyone was well informed. Good relationships with Labrador Grenfell Health supported effective collaboration, while community leadership from the health sector and elected leaders ensured pandemic planning was a priority.
One of the best indicators of success, however, was "the fact that people told us that we did a good job," said McGee.
Communities in Action
Similar success stories can be highlighted in other communities. The Cree in northern Quebec used social media and Japanese manga comic book storytelling techniques to get their message out among the nine communities of Eeyou Istchee, particularly to youth aged 15-25 who make up the majority of the Cree population in the territory.
"During the H1N1 mass vaccination campaign, social media were used for crisis communications, and demonstrated great potential for health communication generally," said Iain Cook, who helped facilitate communications. In fact, the Cree Health Board recently received kudos for its "world-class vaccination effort," while board chair James Bobbish noted that flexibilty was key to accommodating geographical and cultural differences. (See story).
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The Ottawa Inuit were supported in an H1N1 campaign by a multi-disciplinary team using an Inuit community-based delivery model. The campaign was organized through Tungasuvvingat Inuit, a community counselling and resource centre. Ottawa Inuit experience high rates of hospitalization - seven times higher at the time of the H1N1 outbreak than general Aboriginal rates - and the population is considered high risk given its experience of multiple co-morbidities and chronic disease. As a result, pandemic teams provided cultural interpretation, longer apointment times, heightened follow up and case management. Here too, success was indicated in the fact that more than 800 patients were assessed and 200 vaccines administered, with zero patient hospitalizations or deaths.
In Saskatchewan, on-reserve Saskatchewan First Nations took charge of their pandemic planning and worked cooperatively with various health partners. Health Minister Leona Aglukkaq congratulated Cowassess First Nation as a positive example of pandemic planning that had started long before the H1N1 pandemic, leading to a strong partnership with government and partners and tailor-made plans for the community. Saskatchewan's First Nations coverage for H1N1 immunization was among the highest in Canada, and highlighted the importance of targeted information for clients and health.
Similarly, the Sucker Creek First Nation in Alberta used a holistic approach to pandemic readiness as part of a pilot project conducted by the Assembly of First Nations, incorporating the community medicine wheel and traditional values and teachings.
H1N1 and Pandemic Planning Challenges Continue
Although the World Health Organization declared an end to the pandemic in August 2010, studies, hearings and pandemic planning continues. In Canada, a year after the outbreak, the federal government is working to ensure pandemic flu plans in First Nations communities are up to date. The Senate's Standing Committee on Social Affairs, Science and Technology is currently holding hearings on pandemic preparedness in Canada to assess government response and the socio-economic impacts of the H1N1 pandemic. The World Health Organization's handling of the outbreak is also under study by an independent committee, expected to report back next year.
While the Assembly of First Nations is welcoming the move by the federal government to ensure pandemic flu plans are current, national chief Shawn Atleo is calling on the government to address underlying issues that allowed viruses like H1N1 to spread more quickly. These include overcrowded housing, high rates of type 2 diabetes among First Nations peoples, lack of clean drinking water or easy access to medical facilities, and poverty. He said Aboriginal Canadians will continue to be hit hard by illnesses until living conditions on reserves improve.
Nunavut's chief medical health officer, Dr. Isaac Sobol, said the territory's response to H1N1 was "very positive" but told the Senate committee hearings that delivery of basic health services in Inuit communities is a key concern. He said poor living conditions, with 70 per cent of preschool children living in homes that are food insecure, create a "cauldron for rapid dissemination of communicable disease."
Mary Simon, president of Inuit Tapiriit Kanatami, told the Senate committee that Canada needs a pandemic plan for Inuit and by Inuit, noting that a year and a half after the first cases of H1N1 were diagnosed in Inuit regions, there is nothing in the current national pandemic planning document which is speific to managing a pandemic in Inuit communities. An Inuit-specific plan "must reflect our realities and include what we have learned from our journey with H1N1," she said. [See Sikunews]
As scholars examining learnings from the First Nations and Metis Experiences of H1N1 at the University of Manitoba have found, "public health agencies need to pay more attention to the specific socio-economic and cultural contexts of First Nations and Metis peoples when planning for, managing responses and communicating risks associated with pandemic outbreaks."
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