Ministry of Community Safety and Correctional Services :: Part G: The Social Determinants of Health

Office of the Chief Coroner's logo.

Office of the Chief Coroner

Publications & Reports

The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation

2006 – 2008



Part G. The Social Determinants of Health

“Indigenous peoples” connection to the land not only distinguishes them ecologically and geographically, but a connection to the land also makes them spiritually unique. Aboriginal peoples are tied to the land and it to them. These timeless and imbricated (overlapped) relationships with the land distinguish Indigenous peoples from others around the globe. These relationships are the essence of the individual and collective identities of Indigenous peoples.”1

G1. Introduction

“The importance of recognizing the underlying “root causes” or “causes of causes” in any explanation of the situation or circumstances faced by First Nations in remote communities is fundamental. These underlying factors include first contact and colonialism, the experience of the residential schools and the subsequent demoralization of traditions, language, and culture. The forced erosion of culture and traditional lifestyle led to a psychological disconnection from family, community, and social networks. The predominant outcome as witnessed in Pikangikum is the deterioration of mental health and the high incidence of youth suicide.”2

In 2007, an International Symposium on the Social Determinants of Indigenous Health occurred in Adelaide, Australia. Amongst the key drivers for the meeting was to provide a forum for international exchange on the topic of social determinants of health, as well as to derive “key lessons…to address the social determinants of Indigenous health globally in order to improve the health status of Indigenous Peoples.”3 Canada participated in the Symposium, and was represented by the First Nations and Inuit Health Branch of Health Canada, as well as others.

Amongst those key lessons identified were:

• “The colonization of Indigenous Peoples was seen as a fundamental underlying health determinant.”4 An identified requirement was to reverse colonization by restoring Indigenous Peoples’ control over their lives by ensuring self determination.

• A second was the “…disruption or severance of ties of Indigenous Peoples to their land, weakening or destroying closely associated cultural practices and participation in the traditional economy essential for health and well being.”5

• A third was “…the resolution of Indigenous poverty and economic inequality. Poor health was seen as the corollary of poverty and inequality. Economic redistribution was considered essential for moving towards equality in health outcomes.”6

Colonization is the extension of political and economic control over an area by a state whose nationals have occupied the area and usually possess organizational or technological superiority over the native population.7 This describes the migration of Europeans to the lands traditionally occupied by First Nations. Hans Werner, in writing a book review for the Toronto Star on The Wild Ride: A History of the North West Mounted Police 1873-1904 by Charles Wilkins wrote, “One of the sadder aspects of the story is that the Mounties, having won the trust of Indians such as Crowfoot, then had to turn around and enforce Ottawa’s Indian relocation program to make way for the CPR [Canadian Pacific Railway]. Ethnic cleansing is never very pretty, even when we’re the ones doing it. The Wild Ride’s large double spread photo of a Blackfoot family, refugees in their own land, coming out of nowhere with nowhere to go, sears with haunting eloquence.”8

The view of the International Symposium on the Social Determinants of Indigenous Health was that rather than being an historical fact, colonization was a “contemporary actuality.”9

The Canadian contributions to the Symposium raised a number of observations:

• All Indigenous peoples have a common “…history of colonization and the associated subjugation…”10

• Colonization is a contemporary reality.

• Canadian Aboriginal Peoples have a holistic concept of health including physical, emotional, intellectual and spiritual components.

• An individual’s health can not be understood in the absence of considering the well-being of their community or nation.

• The poor health of Aboriginal Peoples is connected to economic and political marginalization.

• Factors reducing the health status of Aboriginal Peoples in Canada include poverty, violence, poor housing, and deficient physical environments.

• Three quarters of Aboriginal women have been victims of family violence, and they are three times as likely to die from that violence.

These key concepts are fundamental to understanding the illness and health, including mental health and substance abuse in the Pikangikum First Nation. Pikangikum has a fully staffed functioning nursing station open 24/7, access to a physician in the community 25 days of the month, a NNADAP worker, a part-time solvent abuse worker, full time mental health workers, a Health Authority with oversight for delivery of health services to the community, and a variety of other health-related services. Yet, the population could not be described as healthy, by any measure. With up to 300 children and youth abusing solvents, unknown numbers of alcohol and opioid abusers, and the persistent excess mortality associated with suicide, health could best be described as fragile. The question this elicits is, with this level of available service, why isn’t the population healthy?

The answer resides not in access to medical services, but rather, the social determinants which help people to stay healthy. This chapter will explore the social determinants of health as it relates to Pikangikum.

Coercion

“When I was older I learned that during “treaty days,” an official from the Department of Indian Affairs told my parents that I had to go to school “or else.” They said that if I didn’t go to school my parents would not be eligible to receive the family allowance money, or assistance of any source from the government. That was a big “or else” in those days because those kinds of social assistance payments were often the only money that came into the household. No wonder my parents insisted that I go to school. They really had no choice.”11

G2. Definition

Simply stated, the social determinants of health are “…the economic and social conditions under which people live which determine their health.”12 The Public Health Agency of Canada recognizes 12 social determinants of health including:

• Income and social status

• Social support networks

• Education

• Employment/working skills

• Social environments

• Physical environments

• Personal health practices and coping skills

• Health child development

• Biology and genetic endowment

• Health services

• Gender

• Culture13

A conference held in Toronto in 2002 expanded the number to 14 which included Aboriginal status, disability, early life, education, employment and working conditions, food insecurity, health services, gender, housing, income and income disparity, race, social exclusion, social safety network, and unemployment and job security.14

Perhaps the best understanding of Aboriginal social determinants of health arises from the National Collaborating Centre for Aboriginal Health which published in 2009, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health. This document refers to:

  • Proximal determinants of health including health behaviour, physical environments, employment and income, education and food security.
  • Intermediate determinants of health including health care systems, educational systems, community infrastructure, resources and capacities, environmental stewardship and cultural continuity.
  • Distal determinants of health including colonialism, racism and social exclusion, and self-determination.

G3. First Nations Health

First Nations Regional Longitudinal Health Survey (RHS) 2002/03

In attempting to understand how the social determinants of health affect health in Pikangikum, including its mental health, it is essential to begin by understanding what the health of First Nations looks like on a national level. This was achieved by the First Nations Regional Longitudinal Health Survey (RHS) (See Appendix 4) completed and published in March 2005. This survey was conducted by First Nations with the premise that the information arising from the survey will improve the lives of their “…children, adults and elders in our communities.”15 The reader is strongly encouraged to read the report, available at www.rhs-ers.ca.

The RHS, based on data gathered in 2002/03 was completed in 2005. There were 52 geographical sub-regions involved, including 238 communities throughout Canada. This represented 5.9% of the First Nation’s population. In Ontario, 5 territories participated involving 29 communities, including Eabametoong, Grassy Narrows, Lac Seul, Sachigo and Sandy Lake First Nations to name a few. The study sample involved 22,602 surveys, 10,902 adults (>18 years of age), 4,983 youth (12-17 years of age) and 6,657 children (0-11 years of age).

RHS Cultural Framework and a Vision of Wellness

This framework, from a First Nations perspective “…encompasses the total health of the total person within the total environment.”16 It involves physical, mental, emotional and spiritual well-being. First Nations view wellness as a “complex and multilayered philosophy.”17

“We pull out the cultural framework (like an accordion)…to demonstrate from this perspective of First Nations health, human beings are connected to the natural world, and thus to Creation through many different levels, or layers, of understanding. Each level represents only a small portion of the preceding one. All levels are interconnected.

This approach to health and wellness is based on BALANCE…of seeking balance, of achieving balance and of maintaining balance. To visualize this model of health, imagine each level as a wheel, with each of these wheels rotating on a common axis. If one wheel is out of balance, it will affect the balance of the other wheels and also the overall balance of the system. Thus, when we speak of First Nations health, we are referring to the BALANCE of this system. The RHS Cultural Framework encompasses the total health of the total person within the total environment. This is a holistic and rather complex understanding of First Nations Wellness.”18

For First Nations, entrenched in an examination of wellness and health, is the need to address “culture, language, worldview, and spirituality.”19

First Nations Education and the European Model

FN utilized informal education which was integrated into their everyday life activities. Children learned when they participated with their parents, the boys with their fathers and the girls with their mothers. Children also spent time with their grandparents who taught them “…through the use of story-telling, myths and symbols used to represent groups of ideas.”20 Education was the responsibility of the kinship group, which likely represented an extended family.

The European model for education was that it was provided by the state. The residential schools were established by the Canadian government and operated by religious groups, and their purpose was to “…civilize, educate, assimilate and Christianize Aboriginal people.”21

“The changes to the ways in which Cree and Ojibwa people were educated in the residential schools, created a large group of Aboriginal men and women who had neither the education, skills and experience to survive in the bush in a traditional way, nor sufficient education to obtain a job in mainstream, non-Aboriginal society. This group of people got caught between two cultures. They often had a difficult time functioning in either culture, and became marginalized in both cultures. In addition, many of the people lost their pride and felt ashamed of who they were and what they had become. They had lost their identity. In an effort to cope with this situation some individuals resorted to alcohol. And when alcohol was not available, they resorted to drug and solvents to hide their shame and pain and also to forget their experiences.

Unfortunately, the children of these men and women grew up learning exactly what their parents knew, that is, their shame about who they were. They also grew up between two cultures without an identity and some could see no usefulness for their lives. The result of the marginalization is that many aboriginal people have become trapped in a cycle of poverty, neglect, abuse, shame, loss of pride, lack of identity and connectedness.”22

My Poor Little Brother

“My brother and I went to residential school at the same time. I was a couple of years older than him. One day I had to take two trays to the dispensary. The trays only had a glass of water and two pieces of dried bread on them. When I got upstairs I brought one tray to a boy from my community, who was in a locked room and brought the other tray to another room. This room was also locked. When they opened the door, much to my surprise, I saw my brother lying on the bed. He did not have many clothes on and all I could see was his little body covered with bruises. There were bruises all over his body. I asked him what happened. He told me that he and some other boys had tried to run away and he got a real bad licking with a great big heavy black belt. That is how he got the bruises. My poor little brother looked so pitiful lying there in that bed all bruised up with nothing to eat except the dried bread I was bringing him. He was only twelve or thirteen at the time.”23

In Ontario, 16 residential schools were created, 14 were in the north, and 2 in the south. Of these, six were operated by Roman Catholic religious orders, five by the Church of England (Anglican), one each by the Presbyterian and United Church, and three by the Mennonites. The last schools in Ontario to close were the Poplar Hill (1989) and Stirland Lake (1990) schools, both Mennonite schools.

Pikangikum First Nations sent their children to Pelican Lake Indian Residential School in Sioux Lookout, as well as the Mennonite schools at Poplar Hill, Stirland Lake and Cristal Lake.

The Pelican Lake School was operated by the Anglican Church (Church of England) from 1926-1973. It was built on 287 acres of wooded land on Pelican Lake. It had a maximum capacity of 142 students, with a minimum entry age of six. Orphaned children were accepted at any age, even as young as 2.5 years of age. Junior students attended classes from 9 a.m. to 4 p.m. while senior students attended for one half-day, and spent the other half-day learning farming or home making. Organized activities included Girl Guides, Boy Scouts, and Air Cadets, a sewing club, hockey teams, hunting and fishing trips, baseball and soccer.

First Nations Regional Longitudinal Health Survey: The Impacts of Residential Schools on Health

Up until 1980, 20-30% of the First Nations population attended residential schools. Of the adults surveyed, about 20% attended these schools. In 1991, a survey found that 39% of First Nation respondents over 45 years of age had attended a residential school and had stayed an average of six years.

47.3% of survivors of residential schools feel that their health was negatively affected. It appears that the influence of these schools has had enduring negative effects on the health of survivors. Troubling results demonstrate that 69.2% reported being physically abused, and 32.6% reported being sexually abused. The ensuing emotional, mental health and substance abuse issues that arise from these revelations for First Nations provide a contextual framework for understanding the significant impairments and disabilities that have become a prominent reality in certain First Nations.

“Although direct causal links are difficult to demonstrate with quantitative methods, researchers strongly indicate that there is clear and compelling evidence suggesting that the long history of cultural oppression caused by residential schools has contributed to high levels of mental health problems and other negative health effects found in many First Nations communities.”24

Table outlining the negative impacts on the health and well-being of survivors due to attendance at residential schools.
Isolation from family: 81.3 per cent
Verbal or emotional abuse: 79.3 per cent
Harsh discipline: 78 per cent
Loss of cultural identity: 76.8 per cent
Separation from First Nation or Inuit community: 74.3 per cent
Witnessing abuse: 71.5 per cent
Loss of language: 71.1 per cent
Physical abuse: 69.2 per cent
Loss of traditional religion or spirituality: 67.4 per cent
Bullying from other children: 61.5 per cent
Poor education: 45.4 per cent
Harsh living conditions: 43.7 per cent
Lack of food: 43.2 per cent
Lack of proper clothing: 40.5 per cent
Sexual abuse: 32.6 per cent

Source: Regional Longitudinal Health Survey 2002/2003

Many survivors who attended did not attain academic skills beyond a basic level. This is ironic given the very nature of the premise under which education was to be provided to First Nations children.

There are many compelling results of residential schools that have negatively impacted the health of First Nations. These include:

• The negative impact of health and well-being due to isolation from their families, verbal and emotional abuse, harsh discipline and loss of cultural identity.

• The high incidence of suicide and deaths due to violence or alcohol-related causes.

• 19.4% attempted suicide in their lifetimes.

• 30.3 % of survivors could not speak their FN language fluently.

• The emotional anguish resulting from confused personal identities, alcoholism, and the inability to engage in productive activities.

• Attendees at residential schools were denied role models from whom to learn how to parent.

• Survivors do not appear to have been taught strategies for dealing with interpersonal conflict, leading to family breakdown.

• In addition to the mental health aspects, survivors also appear to suffer with excess incidence of a variety of physical illnesses.

Table listing residential school attendance and corresponding diagnosis of illnesses.

Source: Regional Longitudinal Health Survey 2002/2003

Some of these conditions existing in excess in survivors of residential schools make perfect sense, such as the prevalence of tuberculosis given the crowded sleeping conditions of the dormitory format. Others, such as cataracts are harder to explain.

“In summary, residential schools have adversely affected the overall mental and physical well-being of survivors. The shame, pain and hopelessness resulting from abuses arising from residential schools have lead to internalized oppression, lateral violence and post-traumatic stress disorder, among other things.”25

A Foreign Experience

“With the assistance of a counsellor I came to understand about all the pain and anger I feel about residential school. When I attended the school, I was in a foreign land, at a foreign school, run by foreign people; that I was forced to speak, read and write a different language; and that I was forced to eat different foods. He taught me that when I was strapped for making a mistake; spanked for breaking the rules; teased by the other students because I spoke a different language; and humiliated when I was forced to participate in the sexual activity for the pleasure of someone else that it was not because I was a bad person. The counsellor showed me that these things caused my anger, my hatred for white people and my fear that I was becoming just like them. Once I acknowledged these things I was able to move on and find a way to put these things out of mind in a good way. Now, I seldom think of my residential school experiences. I spend most of my time learning new things and enjoying life.”26

G4. Colonization, Social Structure, Residential Schools and First Nations Health

This is a complex topic which this report can not endeavour to adequately cover. What follows is largely obtained from Suicide Among Aboriginal People in Canada, by the Aboriginal Healing Foundation (2007). The interested reader is referred to this comprehensive document.

Change in Aboriginal society has been driven by a host of external influences at a pace dictated by these interests. Drivers of change have been economic, government, educational, medical and spiritual pressures. Traditional First Nations had unlimited mobility over large expanses of Canadian geography which was sparsely populated. By treaties, these nomadic hunters/trappers were forced onto reserves with overcrowded conditions, and disruption of traditional roles, social networks and identity with the imposition of new political realities as well as foreign bureaucratic institutions.

Acculturation is “the modification of the culture of one group through the influence of the culture of another group.”27 The response of the culture under stress can be integration, assimilation, separation and marginalization. For First Nations, loss of control over their lands, changes in their hunter/trapping subsistence economy, crowded living conditions, and weakening of belief systems, spirituality and social and political institutions resulted in acculturation stress. Highly traditional and highly assimilated cultures appear to be protected from excess suicide.28

John Berry (1980) has suggested that youth suicide in Northern Ontario is related to the youth being caught between two cultures, unable to find satisfaction in either. In essence, these youth lack linkages to the tradition of their elders and culture, and are removed from contemporary mainstream society by “poverty, isolation and educational barriers.”29 The tragic path to excess mortality due to suicide is depicted below demonstrating the effect of colonization on the individual, family, community and society.

An Integrated Model of the Origins of Suicide

Source: Kirmayer, LJ, Suicide Among Aboriginal People in Canada, The Aboriginal Healing Foundation, 2007. p 99

“Thus colonization, and the resulting dislocation from traditional land, isolation, loss of language and culture, loss of identity, political marginalization, forced assimilation, and a severance from the land are all argued to be essential factors in understanding the gross inequities in the status and wellbeing between indigenous and non-indigenous people around the world – it is the underlying fundamental social determinant of health.”30

The greatest effect of colonization was likely demonstrated by the residential school system. Children were taken from their parents at very young ages, as young as six and placed in environments which were foreign to them, resulting in emotional and cultural poverty. There, they were subjected to extreme cultural suppression, and tragically, emotional deprivation and physical and at times sexual abuse. The effect has been catastrophic and as depicted in the chart below, has effected successive generations of First Nations peoples.

Transgenerational Effects of Residential Schools

List of the Transgenerational Effects of Residential Schools

Source: Transgenerational Effects of Residential Schools. Kirmayer, LJ, Suicide Among Aboriginal People in Canada, The Aboriginal Healing Foundation, 2007. p. 72

G5. Social Determinants of Health and Pikangikum

The social determinants of health are “…the economic and social conditions under which people live which determine their health.”31 The National Collaborating Centre for Aboriginal Health published in 2009, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health. This recent publication referred to Aboriginal health in terms of proximal, intermediate and distal determinants.

G6. Proximal Determinants of Health

Health Behaviours

Overuse of alcohol and smoking increases mortality and in addition, when used during pregnancy can lead to poor physical, emotional and intellectual development in children. Although exact figures for Pikangikum are unknown, concerns were expressed about the prevalence of alcoholism in adults, and the presence of Foetal Alcohol Spectrum Disorder in children.

Pikangikum is reported to be a dry reserve, but alcohol is obtained in Red Lake, which is two hours away in winter months by road. However, solvent sniffing in children and in youth is pervasive, with as many as 300 involved.

Physical Environments

Levels of contaminants in air, water, food and soil can cause adverse health effects. For example, homes contaminated with mould may predispose to respiratory ailments, or contaminated water may cause gastrointestinal illness. This issue is related to First Nations through the dispossession of traditional lands, with dislocation to reserves. There are housing shortages on reserves, homes that exist are in need of major repair, and may be contaminated with mould. According to the RHS, 33.6% of houses on reserve need major repairs, and 31.7% need minor repairs.

Picture 11. House in Pikangikum.32

Acute housing shortages exist in most First Nations

• Overcrowded is defined as more than one person per room

• 17.2% of FN houses are overcrowded

• FN communities have a room density of .76 persons per room

• The national rate is 0.4 persons per room

• Occupant density for FN is increasing while in the general population it is decreasing

In 2003, the Auditor General reported that INAC estimated a shortage of 8,500 houses on reserve, with 44% of the existing housing requiring repairs. About 4,500 new households are being formed each year, yet the current federal funding supported the construction of just 2,600 houses per year.33

Basic Infrastructure and Amenities in Houses

Nearly all FN homes have the following amenities:

• Electricity 99.5%

• Hot running water 96.3%

• Cold running water 96.5%

• Flush toilet 96.5%

• Refrigerator 98.7%

• Cooking stove 99.3%

• Telephone 81.7%

• Computer 40.8%

• Internet connection 29.8% (the more isolated the community, the less the connectivity)

Only 9 % of First Nations homes lack a septic tank or sewage service. Water delivery through a pipe is the source provided to 63.2% of the homes.

In Pikangikum, very few homes have either water or sewage service. The population is severely deprived, even when compared to other First Nations living on reserve.

Picture 12. This house in Pikangikum is currently utilized. The owner raised a family with 14 children in this house (March, 2010).

In Pikangikum, power is provided by a diesel fuel powered generator and is at capacity. There are plans to connect to the hydro grid. In 2000, a contractor had been retained to construct an electric power distribution grid from Red Lake with the intent and purpose being to provide electricity to both Pikangikum and Sandy Lake First Nations. On February 28, 2000, the First Nation informed the contractor for the project that funds were not available to pay him, and it was not completed. Of interest, power generated by the diesel generator is calculated to cost $3,580,650 per year, and with the electric power grid, would be available at a cost of $358,429 per year.34 At the time the project was abandoned, it was 35% complete and 40 kilometres of hydro poles were up.

On November 17, 2000, INAC sent a letter to the Pikangikum First Nation informing them that they were placing them in third party management. This involved a “…third party being appointed by the Crown to administer funds otherwise payable to the Band and to execute the Band’s obligations under the funding arrangement in whole or in part.”35 This was done allegedly because:

• A school fuel oil spill had resulted in clean up costs of $1.6 million and the loss of the school for almost a year.

• Two floods at the water treatment plant resulting in costs of $1 million and the absence of clean water putting the community in crisis.

• Substandard operation of the water treatment plant where plant operators were not monitoring the water quality and distributing unchlorinated water.

• The failed power grid project because the First Nation had not secured financing.

The First Nation refused. Subsequently, it brought an action suing for damages suffered by the FN as a result of alleged malfeasance of public office against Mr. Robert Nault, then Federal Minister of Indian and Northern Affairs (INAC) and the Attorney General of Canada. This appears to have had the effect of halting a long list of community-based projects.

“Thunder Bay staff indicates Minister was very blunt in terms of Pikangikum and holding position. As you know we have briefing note of proceeding with water and sewer project through a third party. I take his remarks to mean he wants no new initiatives or projects in Pikangikum until court action is completed.”36

As Mr. Justice John de Pencier Wright noted in his ruling of December 23, 2010:

“To this day, the power grid has not been completed. Power that could have been supplied at a cost of several hundreds of thousands of dollars continue to be supplied to this Band at a cost of millions of dollars.

To this day, the effluent from the water treatment plant is still directed toward the lake.

To this day sewage facilities continue to be largely dependant upon holding tanks and pump trucks.

To this day potable water must largely be hauled to the consumer from the water treatment plant.”37

There are 450 houses on reserve, 43 of which are connected to the sewage lagoon. 340 homes have no indoor plumbing or running water. The water treatment plant was constructed in 1995, and is not connected to the vast majority of homes. The water source for the water treatment plant is Lake Pikangikum. Water is provided by the existing water treatment system and it is delivered through underwater pipes to eight distribution centres that are not always functioning.38 Water haulage trucks service some of the houses, where water is placed in 100 gallon holding tanks. Residents travel to the water distribution sites to obtain their water in drinking pails or containers.

Picture 13. Residents of Pikangikum obtaining water.39

A small number of the homes have holding tanks for their sewage. These are serviced by truck haulage. The vast majority rely on pit privies for their sewage disposal. These are generally in a state of poor repair and can be full and overflowing with sewage.

Picture 14. Pikangikum home with outdoor pit privy, March 2010.

Some facilities, such as the Nursing Station, have a piped sewage collection system that is pumped to an existing lagoon. The lagoon is located on the northwest edge of the community. It is reported that in the spring, the sewage lagoon overflows into the river upstream from the community and the water intake plant.

In September 2006, the Northwestern Health Unit provided a report of the Pikangikum water and sewage systems. It concluded that the provision of safe drinking and washing water at adequate volumes was necessary for a healthy community. It assessed Pikangikum’s water and sewage disposal systems as “high-risk.” It recommended that:

• The water treatment plant be connected to all the houses in the community by 2010.

• Residents of Pikangikum be provided with information regarding safe in-home water storage and consumption.

• Homes be repaired or replaced to ensure that they support bathroom facilities by 2010.

• All residences be connected to the sewage collection system by 2010.

• A research process be initiated to “…determine the extent of damage done by ongoing neglect of basic health-related infrastructures.”40

In addition, it observed that the inadequate water supply and sewage disposal systems had placed Pikangikum residents at a high risk of illness, and it was probable that residents had suffered illnesses as a result of the unregulated water and sewage systems.41 To this day, these recommendations have not been carried out.

“In First Nations communities, social determinants of health include the direct and indirect effects of colonization as the underlying fundamental factor. Poverty, dislocation from family life and community, extreme stress, trauma, poor health and dependency on government may all be seen as impacts of colonization. All of these factors, including the material deprivation resulting from poverty, have far-reaching effects on a community, on the family, and on children. Stress and trauma may also lead to coping behaviours that have problematic implications. These coping behaviours often include addictions to alcohol and drugs, which can have profound effects on the health of children and families within a community. However, instead of being viewed as a result of history and unbearable life circumstances, these behaviours are most often wrongly viewed as “unhealthy lifestyle choices.” The underlying reasons why people experience severe stress and perhaps engage in maladaptive ways of coping with severe stress are rarely addressed. These underlying reasons are the “causes of the causes.”42

Recommendations

Pikangikum First Nation

  1. The Pikangikum First Nation should develop a housing authority.
  2. The Pikangikum Housing Authority should conduct a study of existing homes and repair needs, as well as a completing a housing status strategic study to understand the community’s projected needs for the future, based on population growth. An external consultant to assist with the study should be retained.

Indian and Northern Affairs Canada (INAC)

  1. INAC and the Pikangikum First Nation should complete its earlier project to connect the First Nation to the hydro grid. Funding for this initiative should be provided by INAC.
  2. INAC and the Pikangikum First Nation should review the current water treatment system and identify the need for any upgrades to ensure that Pikangikum has access to safe healthy potable water, immediately and in the future. Funding for the projected improvements to the water treatment system should be provided by INAC.
  3. INAC should be a stakeholder in the housing status strategic study (see recommendation #89) and plan for the building and upgrading of sufficient housing units to address the critical housing shortage and overcrowding that exists in the Pikangikum First Nation. It is the belief of the current Chief and Council that to effectively alleviate overcrowding, 50 new homes are required.
  4. INAC and the Pikangikum First Nation should review the sewage disposal system and identify the need for any upgrades to ensure that Pikangikum has a safe healthy sewage disposal system in the future; one which will not compromise the First Nations drinking water supply. Funding for the projected improvements to the sewage disposal system should be provided by INAC.
  5. INAC and the Pikangikum Housing Authority should ensure that all homes built in the future are connected to water for indoor plumbing, and the sewage disposal lagoon. In addition, the Pikangikum Housing Authority should study and determine which homes could be retrofitted to allow for indoor plumbing and sewage. Funding for the projected improvements to the homes which could be retrofitted for indoor plumbing and sewage disposal should be provided by INAC.

Employment and Income

Health improves with each increment in income. Low income Canadians die earlier and have more illness. With higher income comes better housing and better and sufficient food supply. There has been research that suggests that higher income allows a person discretion and some degree of control over stressful life situations.43 51% of First Nations are not employed across Canada. Women are more likely to be working part-time. Also, approximately 60% of young people aged 18 to 29 are unemployed. Education clearly shows a trend toward greater employment, with completion of a high school education, almost doubling the probability of employment.

The median personal income in 2001 of RHS adults in First Nations communities was $15,667. The median household income was $29,897. Men and women had essentially the same income levels.44

In Pikangikum, there are 170 jobs with 50 held by “outsiders” such as nurses and teachers. There are 542 heads of households receiving social assistance. Based on the North South Partnership for Children study, this translates into employment income of $8 million (one third to outsiders) and $8 million of social assistance annually.45 Low-income Canadians are more likely to die earlier and to be sicker than high income Canadians, and this is regardless of age, sex, race or place of residence.46 A family of four living in Pikangikum would receive about $862/month, or about $10,000/year. Each family can also receive a shelter allowance of $400/month, which is paid directly to the Band, to cover power, water and firewood.47

There is no doubt that employment provides people with a sense of identity and purpose, socialization and opportunities for growth. This leads to an income and better health. However, in First Nations remote fly-in communities, the opportunities to create an economic base are limited.

Federal Government

  1. The Federal Government, Indian and Northern Affairs Canada should develop an antipoverty strategy for Aboriginal people, particularly focusing on those living in remote and isolated First Nations reserves such as Pikangikum. This strategy could be modelled after provincial strategies such as Ontario’s Poverty Reduction Act, 2009 or Nova Scotia’s Poverty Reduction Strategy.

Statistics Canada produces a figure called the Low Income Cut-off (LICO). It is the level at which an individual or family will struggle as it spends a large amount of its income on the necessities of life. The figure for 2006 was $11,492 for an individual and $24,742 for a family of five living in a rural area. Although not determined for individual families in Pikangikum, the figures provided above suggest a large number of the families residing in Pikangikum fall below the LICO.

The principles of Ontario’s Poverty Reduction plan resonate with the challenges of First Nations communities. It seeks to eliminate barriers to participate in the economy and society based on race, ancestry, colour or ethnic origin. It recognizes the importance of healthy communities, the heightened risks of Aboriginal and racialized peoples, seeks to support families, and insists that those living in poverty are treated with dignity and respect. Importantly, it targets a 25% reduction in children living in poverty in 5 years.

The Nova Scotia Poverty Reduction Plan enables and rewards work by removing disincentives to work, improves support for those in need, focuses on children and families to break the cycle of poverty, and collaborates and coordinates to increase capacity and integration.

  1. The Government of Canada, Indian and Northern Affairs Canada should support the Pikangikum First Nation’s Whitefeather Forestry Project.

Pikangikum is currently limited in terms of economic development and there are limited employment opportunities. There is promise in the Whitefeather Forestry Project which is a project in the boreal forest involving Pikangikum’s traditional lands. The provincial government has agreed, “subject to conditions” to grant Pikangikum a sustainable forestry license.48

The Whitefeather Forest Management Corp. is Pikangikum owned and has been working in close co-operation with the Ontario Ministry of Natural Resources (MNR) to meet the terms and conditions for acquiring the Sustainable Forest License (SFL). A conditional SFL based on the work that has been completed to date included an approval for an Environmental Assessment coverage for Forest Management Planning. The sole work to be completed is the Forest Management Plan (FMP), which is on schedule for completion in early 2012.

Pikangikum has also begun to deliver a major training program in support of this initiative, which has included construction of a training facility in Pikangikum consisting of three classrooms and an instructors’ residence. These were scheduled to be completed by the spring of 2011. The Whitefeather Forest ASEP partnership includes Pikangikum, HRSDC, Confederation College, OMNR, and Goldcorp, amongst others. Training for a variety of careers including resource technicians, woodlands and heavy equipment operators amongst others are ongoing.

Once the Forest Management Plan (FMP) is completed, projected for the spring of 2012, Pikangikum will have management control over approximately 1.3 million hectares of crown lands (traditional ancestral lands of the people of Pikangikum known as the Whitefeather Forest), and will have approval to commence commercial forestry operations. It is estimated that approximately 350 jobs, on a sustainable, permanent basis, will be generated, both in the woodlands operations and in the opportunities that will be created in the sawmill and plants that will produce value-added products.

The Whitefeather Forest represents the hope and future for its current youth and future generations. The First Nation is requiring a concerted and co-ordinated commitment to provide financial resources to enable the work to be completed for securing and sustaining the SFL. This includes support for the purchase of LKGH, a market logging business in Red Lake. This interim opportunity includes putting to work Pikangikum’s youth who are presently being trained for the numerous and varied jobs that will be filled once Pikangikum has secured the SFL for the Whitefeather Forest Project and has purchased LKGH.

To position its youth to secure the Whitefeather Forest Project employment opportunities, Pikangikum has committed to the strategic purchasing of LKGH. This will provide immediate employment opportunities in the forest area adjacent to the projected Whitefeather Forest lands. In addition to the acquisition of an annual timber harvest, the purchase includes woodlands harvesting equipment and an option for a lease-to-purchase of the sawmill owned by LKGH in Red Lake.

In summary, the youth of Pikangikum need hope and promise for their future. Health is intimately linked to economic prosperity. If successful, the Whitefeather Forest Project has the potential to be transformative for the youth and future generations of Pikangikum. Significant and sustainable employment for the youth and community of Pikangikum is integral for the success of the many health-related recommendations to prevent youth suicide.

Education

Education is tied to socioeconomic status and health. Persons with low literacy skills are less likely to be employed, more likely to be poor and die early. Education contributes to health and prosperity by providing people with the knowledge and skills to control their life circumstances and problem solve.49

As educational levels are related to income, prosperity and health, it is not surprising that First Nations suffer poorer health when compared with other Canadians.

The future of Pikangikum, including its health is largely contingent on the education of its children. Outcomes will need to vastly improve. There are 520 children enrolled in the school for 2010-2011, with estimates of 300-500 other children and youth eligible, but not attending school. None of the graduates from high school in the previous year attended post-secondary education. Ultimately, the health, well-being and hope for the children, youth, and community must rely upon its education system which should aggressively seek to educate a critical mass of youth above the high school level to the college or university level and to come back to the community and become its leadership. This singular issue, more than any other, is the driver to health and wellness and diminishing the suicide rate in Pikangikum (Refer to “Part D: Education” of this report).

Food Insecurity

Food insecurity means that there will not be enough to eat because of lack of money. Food insecurity is related to health outcomes that include multiple chronic conditions including obesity, distress and depression (major depressive illness).50 58% of residents relying on social assistance experienced reported suffering from food insecurity in the previous 12 months.51

According to the North South Partnership’s Report, virtually all of Pikangikum’s resources come from the federal government. The community is heavily reliant on social assistance for income. Of interest is the association of food insecurity and depression, likewise linked to suicide.

Picture 15. Food costs are extremely high in Pikangikum,

particularly for fresh fruit, vegetables, and fuel (March 2010).

.

G7. Intermediate Determinants of Health

Health Care Systems

Health care systems should ideally be designed to promote and maintain health, and prevent disease. Health care is delivered to First Nations on reserve by a collage of programs, at times fragmented, where jurisdictional ambiguity sometimes arises between federal and provincial responsibilities, and with limited accountability.52

In Pikangikum, physicians are in-community 25 days a month and access to primary care is not an issue. Access to mental health services, with four full time in-community counsellors is also present. Addiction and solvent abuse services are limited. Where the system of delivery fails is with respect to integration, jurisdictional boundaries and accountability. Access to tertiary care mental health professionals such as psychiatrists can be limited. Also, care for Pikangikum residents transferred out of the community can be difficult to arrange when trying to find a receiving physician. Lastly, some programs are deemed to be present, but their actual benefit to the community is unknown as accountability arrangements appear limited. (Refer to “Part C: Health In Pikangikum” of this report).

Educational Systems

Well educated parents earn higher incomes, and pass the value of education and learning on to their children. Pre-school programs, such as early childhood education, have a maximal benefit. Importantly, culturally competent curricula can keep children engaged.

Pikangikum would greatly benefit from a day nursery which does not currently exist. The Eenchchokay Birchstick School is classified as an English as a Second Language School. There are cultural and language programs which include cultural teachers which consist of members of the community teaching traditional methods of living off the land such as hunting, trapping and ice fishing. Language retention upon school entry approaches 100%. Cultural teachers teach native art, language and music.

Community Infrastructure, Resources and Capacities

The community in which an individual resides can influence their health. Where a community has limited infrastructure and economic development, the community may become marginalized and its members deprived. Not surprisingly, a community requires a critical mass of qualified individuals to assist with the development of strategic direction and future planning.

With respect to qualified individuals, neither the Pikangikum Education Authority nor the Pikangikum Health Authority have the qualified expertise developed in the community and educated at the university level to assist them with executing their important portfolios.

Leadership has also been an issue in Pikangikum. The Indian Act provides that a Chief and Councillors hold office for two years under section 78. Sustainable traction on initiatives can be challenging in this environment. This is further compounded by the First Nations choice of control over elected officials. As noted by Mr. Justice John de Pencier Wright in describing the stability of the Pikangikum Band Council:

“The political expertise and stability of the Band council has been a problem. The Pikangikum Band functions under a “customary system.” This means that the chief and members of council can be replaced summarily by what people in the south would call a “recall vote” at a general meeting of Band members. This makes it difficult to maintain continuity of policy and experience.”53

Pikangikum First Nation

  1. The Pikangikum First Nation should undertake a review of its electoral policy and practices and consider adopting an electoral process whereby elected officials retain office for a sustained period of time to allow for the growth of political expertise, stability, and to allow for momentum to be obtained with respect to projects directed toward enhancing community infrastructure. The First Nation might benefit from formalizing, in writing, and communicating its electoral process to its constituents. The First Nation could retain expertise for assistance from political organizations such as the Nishnawbe Aski Nation who would be aware of “best practices” with respect to First Nations’ governance. Consultation and assistance from the National Centre For First Nations Governance Institute should be obtained.

Environmental Stewardship

First Nations have enjoyed a healthy environment. Increasingly, their traditional lands have been subject to environmental stress.

Pikangikum has encountered difficulties in this regard. The useable land on the reserve is less than 2.5 square kilometres and can not adequately house the community.

  1. The Pikangikum Housing Authority should clearly identify its future land needs as a product of its study (see recommendation #89) and with the assistance of Indian and Northern Affairs Canada, obtain reserve lands to allow for sustained population growth in its membership.

Pikangikum has approximately 70-90 infants born each year and has grown beyond its current useable reserve lands.

Cultural Continuity

Chandler and Lalonde in 1998, as referenced in the below publication, described the notion of cultural continuity. It is the degree of “social and cultural cohesion within the community.”54 In British Columbia, they found low rates of suicide amongst First Nations in which the reserve had control over such areas as land title, self-government (particularly where women were involved in government), control of education, policing, health and where cultural facilities were available. It is the “intergenerational connectedness….maintained through intact families and the engagement of elders, who pass traditions on to subsequent generations.”55

Pikangikum speaks Ojibwa, and most of the community can speak English. The North South Partnership found a “gap in knowledge transmission between the generations.” The Report states that elders talked about changes to lifestyle such as diet and technology, and the reluctance of the youth to learn traditional ways. Clearly, there was a reported lack of intergenerational connectedness, and proponents of cultural continuity theories would suggest that the excess mortality in Pikangikum has resulted from this.

G8. Distal Determinants of Health

Colonialism, Racism and Social Exclusion and Self-Determination

Colonialism impacted First Nations by dispossessing them of their traditional lands and displacing them onto reserves. The political agenda of 20th century Canada saw the creation of residential schools, which had the effect of destroying culture, language and family ties. The result was that children became disengaged from their ancestry, and did not learn for themselves how to parent.

Of First Nations peoples living on reserve, 37.9% stated that they had experienced racism in the prior 12 months.56 Those that are perceived to be at the bottom of the social hierarchy may experience social exclusion and not experience the same opportunities with respect to education and income. The result may have a negative impact on their health. Self-determination ensures First Nations have “a say” in their futures. The work of Chandler and Lalonde, as referenced in the aforementioned referenced publication, suggested an inverse relationship between self-determination and suicide.

  1. A Committee should be struck called the Pikangikum Steering Committee:

• Joint chairs should be named from a Provincial Ministry and the Federal Health Canada, First Nations and Inuit Health Branch.

• The Province of Ontario should have inter-ministerial representation at the Assistant Deputy Minister level from the Ministries of Health and Long-Term Care, Aboriginal Affairs, Children and Youth Services, Community Safety and Correctional Service, Health Promotion and Sport, and Education.

• The Pikangikum First Nation should be represented on the Committee by the Chief, Deputy Chief, a youth leader and an Elder.

• Federal Government representatives on the Committee should include Indian and Northern Affairs Canada, and Health Canada, First Nations and Inuit Health Branch.

• Invited members might include the North West Local Health Integration Network, the Sioux Lookout and First Nations Health Authority, the Nishnawbe Aski Nation, the Sioux Lookout Meno-Ya-Win Health Centre, Nodin Child and Family Intervention Services, Tikinagan Child and Family Services, the Ontario Provincial Police, the Ontario Child and Youth Telepsychiatry Program, and a paediatric and adolescent psychiatrist providing services in the North West of Ontario.

The purpose of the Pikangikum Steering Committee would be to advance the recommendations included in this report.

The deaths under review at Pikangikum were those of youths who lost their lives due to suicide. This mental health issue is a Federal responsibility on-reserve. Provincially, the Ministry of Children and Youth Services has primacy over mental health of children and youth, with the Ministry of Health and Long-Term Care taking a smaller role.

  1. The context for change in Pikangikum should include:

• A dialogue with Elders, Chief and Band Council members, and selected community members about any recommendations stemming from the Report.

• Elders, Chief and Band Council members and selected community members should lead any initiative to encourage and facilitate change in Pikangikum First Nation.

• Mechanisms to support and bolster leadership in the change initiative need to be put in place.

Given the historical and current context, the Pikangikum community, government, and all other involved parties should anticipate a long-standing change process. The duration of the intervention, in order to maximize outcomes, needs to span a decade.

“The strength of the community and its ability to make fundamental and incremental change rests with the leadership. In turn, the success of the leadership is dependent on the involvement of Elders and other community members to take ownership of the change process”.57

There are many recommendations in this report. The causes of youth suicide are complex and traverse many boundaries locally, regionally, provincially and federally. To be successful, astute and skilled administrators are needed from a variety of stakeholder interests, who have sufficient knowledge of the intricacies of government and are experienced in collaboration and integration to generate a persistent and successful effort on behalf of the citizens of Pikangikum. This need is the genesis for the creation of the Pikangikum Steering Committee.

G9. Concluding Remarks

The social determinants of health are the economic and social conditions under which people live which determine their health. A contemporary Aboriginal view of the social determinants of health considers proximal, intermediate and distal social determinants of health.

The most important social determinant of health is education. There is no greater barrier to improving the health, mental health and suicide rate in Pikangikum than through its education system. Many of the children do not go to school. Many of these children sniff solvents. Those that do go to school are not being given the quality of education which prepares them for the contemporary world outside of Pikangikum. Almost none of the students seek post-secondary education.

Pikangikum must educate a critical mass of its young children and youth and adequately prepare them to face the world and lead Pikangikum to a better and brighter future. As education increases, so does income and health. Education enables capacities and resiliencies to withstand life’s stressors. Education will contribute to the health and prosperity of Pikangikum’s people by giving them the knowledge and skills to control their life circumstances and problem solve. Education will lead to sustainable and rewarding employment, possibly in the Whitefeather Forestry Project. When this happens, the unfathomable deprivation they face through poverty, lack of running water, overcrowded inadequate housing, lack of a sewage system, and the death of their youth through suicide, will finally abate.

“Overall, it is argued that the social determinants of health or “causes of the causes” provide the context for understanding the collective well-being of Aboriginal peoples in remote Ontario First Nations. A layered approach to community healing is therefore necessary to achieve sustainable change, and the goals of intervention must include improving the material and social conditions within which people live, in addition to the provision of culturally appropriate mental health services. It is apparent that there is currently no equitable distribution of power and resources, as evidenced by the impoverished conditions in remote First Nations communities. Consideration of the social determinants of health described herein and their root causes are critical when developing interventions that will work to reduce or eliminate youth suicides in Pikangikum. This being understood, it is clear that youth suicide in Pikangikum is the outcome of an historical progression that began with colonialism and its demoralizing impact on the retention of culture and tradition. This was followed by the residential school experience and then the resulting intergenerational collective trauma and its effects on parenting and subsequent well-being. Running parallel to this pathway is dependency on government by means of a reserve system, which led to extreme poverty and an insecure economic base for families and community…

Like other northern communities, Pikangikum aspires to break this cycle and interrupt the damaging life trajectories. Self-governance is viewed as a potential vehicle for emancipation. In the process of exploring self-governance, it is necessary for the promotion of a graduated transition that allows for capacity-building in a measured way. A meaningful partnership that is dedicated to supporting this type of transition must exist between Aboriginal and non-Aboriginal peoples. This includes a movement towards economic security, the building of a solid community infrastructure, development of sustainable housing which is appropriate to culture and environment, the settlement of land claims and the provision of health and education services. The preservation of tradition and culture is fundamental to each. An extreme example of a dysfunctional partnership is the lack of resolution to unsafe drinking water in Pikangikum. For over a decade, community outcry and government risk assessment each conclude that the water is dangerously unsafe…

Aboriginal peoples are reticent to collaborate with non-Aboriginal peoples, particularly when it relates to their own community well-being. This lack of trust is an outgrowth of the long history of government imposition and dependency and overt attempts at assimilation…Partnerships between First Nations and non-Aboriginal peoples require relationships that are meaningful, transparent, productive and enduring. As indicated earlier, agencies and institutions need to be reconfigured in order to embrace these types of partnerships, which are necessarily built on First Nations’ values of mutual trust, respect, reciprocity and mutuality. These partnerships go beyond mere collaboration and compel the sharing of control over governance and management in order to equalize the power base. They may entail deference to traditional wisdom and approaches. Whereas outcomes are unpredictable and cannot be foreseen, new ways of working together emerge. Relationships are active, built over time, and are not abandoned when differences or difficulties arise. This type of partnership requires continual maintenance, the expenditure of personal and economic resources, and the ability to pursue new and innovative approaches that go beyond conventional boundaries. These partnerships are indeed the vehicle required to change perceptions and facilitate resolution.

History cannot be undone. However, strategies can be put in place to alleviate its impact. The circumstances and conditions in Pikangikum are widely known and are now legendary. The legend of Pikangikum focuses on tragedy and needs to be reframed to consider the potential for change. The immediate challenge is individual and collective healing. Simultaneously, a viable economic base to address the poverty and deprivation and their deleterious effects on the community needs to be established. However, how this takes place is the most critical question facing the Pikangikum community and its partners? Successful outcomes that interrupt the negative pathway can only occur through a meaningful partnership between members of Pikangikum First Nation and those who are genuinely interested in their well-being. Movement from a position of dependency to self-governance is required by way of a graduated transition period that allows for capacity-building in a measured way.58

1 Social determinants and Indigenous health: The International experience and its policy implications. Report on the International Symposium on Social Determinants of Indigenous Health Adelaide, 29-30 April 2007 for the Commission on the Social Determinants of Health (CSDH), p. 25.

2 Finlay, J, and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January 17, 2011, p.3, in publication.

3 Social determinants and Indigenous health: The International experience and its policy implications. Report on the International Symposium on Social Determinants of Indigenous Health Adelaide, 29-30 April 2007 for the Commission on the Social Determinants of Health (CSDH), p.5.

4 Ibid., p. 2.

5 Ibid.

6 Ibid.

7 See Glossary of Terms

8 Werner, Hans, Canadian History, The Great March West, Toronto Star, p. E15, Sunday December 26, 2010.

9 Ibid., p. 30.

10 Ibid., p. 24.

11 Auger, DJ., Stories from the Residential School, Nishnawbe-Aski Nation and the Aboriginal Healing Foundation, 2005, p.9.

12 http://en.wikipedia.org/wiki/Social_determinants_of_health.

13 http://www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php

14 Raphael, D., Social Determinants of Health: Canadian Perspectives, 2nd edition, Canadian Scholars Press, 2009.

15 First Nations Regional Longitudinal Health Survey (RHS) 2002/03, Results for Adults, Youth and Children Living in First Nations Communities, Assembly of First Nations/First Nations Information Governance Committee, second edition, March 2007.

16 Ibid. p. 1.

17 Ibid. p. 2.

18 Ibid. p. 3.

19 Ibid. p. 5.

20 Auger, DJ, Indian Residential Schools in Ontario, Nishnawbe Aski Nation, copyright 2005, p. 3.

21 Ibid. p 3.

22 Ibid. p 4.

23 Auger, DJ., Stories from the Residential School, Nishnawbe Aski Nation and the Aboriginal Healing Foundation, 2005, p.57.

24 DJ, Indian Residential Schools in Ontario, Nishnawbe Aski Nation, copyright 2005, p. 3.

25 First Nations Regional Longitudinal Health Survey (RHS) 2002/03, Results for Adults, Youth and Children Living in First Nations Communities, Assembly of First Nations/First Nations Information Governance Committee, second edition, March 2007, p. 137.

26 Auger, DJ, Indian Residential Schools in Ontario, Nishnawbe Aski Nation, copyright 2005, p. 71.

27 Gage Canadian Dictionary.

28 Kirmayer, LJ, Suicide Among Aboriginal People in Canada, The Aboriginal Healing Foundation, 2007. p 63.

29 Ibid. p. 64.

30 Finlay, J, and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January 17, 2011, p.8, in publication.

31 http://en.wikipedia.org/wiki/Social_determinants_of_health.

32 Provided by the Ministry of Aboriginal Affairs.

33 Ibid., p. 45.

34 Pikangikum v. Nault, 2010 ONSC5122, p. 13.

35 Ibid., p. 19.

36 Ibid., p. 53.

37 Ibid.

38 Information based on North South Partnership for Children Participatory Assessment of Pikangikum, February 2008.

39 Provided by the Ministry of Aboriginal Affairs.

40 Northwestern Health Unit, Inspection Report on the Pikangikum Water and Sewage Systems, September 2006, p. 15.

41 Ibid., p. 16.

42 Finlay, J, and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January 17, 2011, p.4-5, in publication.

43 www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php.

44 First Nations Regional Longitudinal Health Survey (RHS) 2002/03, Results for Adults, Youth and Children Living in First Nations Communities, Assembly of First Nations/First Nations Information Governance Committee, second edition, March 2007, p. 28.

45 Information based on North South Partnership for Children Participatory Assessment of Pikangikum, February 2008, p. 14.

46 www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php.

47 Information based on North South Partnership for Children Participatory Assessment of Pikangikum, February 2008, p. 14.

48 Information based on North South Partnership for Children Participatory Assessment of Pikangikum, February 2008, p. 13.

49 www.phac-aspc.gc.ca/ph-sp/determinants/determinants-eng.php

50 Loppie, C and Wien, F, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health, National Collaborating Centre for Aboriginal Health, 2009, p. 14.

51 Ibid. p. 14.

52 Ibid., p. 15.

53 Pikangikum v. Nault, 2010 ONSC5122, p. 10.

54 Loppie, C and Wien, F, Health Inequalities and Social Determinants of Aboriginal Peoples’ Health, National Collaborating Centre for Aboriginal Health, 2009, p. 18.

55 Ibid., p.18.

56 Ibid., p. 23.

57 Finlay, J and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January, 2011, p. 26, in publication.

58 Finlay, J, and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January 17, 2011, p.23,24 & 27, in publication.