Struggle and resilience: advancing culturally competent healthcare in Nunavik
Page talks with Dr Tcholakov, who offers insights into the healthcare challenges Inuit communities of Nunavik face, and the importance of supporting community-centred care in the region.
We recently had the privilege of speaking with Dr Yassen Tcholakov, Clinical Lead in Infectious Disease at the Nunavik Department of Public Health in Quebec, Canada. Dr Tcholakov began working in Nunavik during his medical residency, when he was involved in a community Tuberculosis (TB) screening programme. He is passionate about global medical education, and chairs the Junior Doctors’ Network of the World Medical Association in addition to his role as a public health doctor in Nunavik. In conversation with the Keppel Health Review, Dr Tcholakov offered insights into current challenges the communities of Nunavik face, as well as the successes and importance of community-centred care in the region.
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Current challenges
“for much of the year these villages are only accessible by plane; this remoteness and distance makes day to day healthcare delivery a challenge”
From a public health standpoint, the geographic characteristics of Nunavik present unique challenges and strengths. Nunavik is a large, sparsely populated region with a population of 15,000 and the home of the Inuit of Quebec. The majority of Nunavik residents, called Nunavimmiut, reside across 14 small coastal villages, some that are occupied by only a few hundred people. Healthcare is available in the region through 12 health centres, two hospitals, and access to referral hospitals in Montreal. However, for much of the year these villages are only accessible by plane; this remoteness and distance makes day to day healthcare delivery a challenge.
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The health challenges that Nunavimmiut currently face are shaped by complex historical and social factors that continue to have devastating effects on health in the region. While Nunavik has coped well with COVID-19 overall, mistrust remains a barrier to vaccination uptake for some communities. This mistrust stems from a history of violence against Inuit communities in Canada, including community relocation, separation of children from families in residential schools, and the destruction of land and the natural environment. Colonial violence has caused great damage to Inuit culture and community prosperity, with effects on infectious diseases, mental health, and challenges in sustaining traditional and culturally important ways of life.
Along with these deep rooted health implications, Dr Tcholakov highlighted the particular threat that the climate crisis poses to communities in Nunavik. For example, some traditional methods of food preparation rely on sufficiently cold temperatures, and herds of caribou—an important food source—are declining. As caribou numbers dwindle, Inuit communities lose not only a source of sustenance, but a cultural keystone which cannot be replaced. Climate change is already damaging communities’ self-sufficiency and ability to pass their traditions on to the next generation, leading to a great sense of cultural loss which is not adequately addressed by biomedical mental health interventions.
“Colonial violence has caused great damage to Inuit culture and community prosperity, with effects on infectious diseases, mental health, and challenges in sustaining traditional and culturally important ways of life”
A third major challenge is a shortage of housing in Nunavik which causes overcrowding. Dr Tcholakov explains that overcrowding leads to increased interpersonal conflict, and probably contributes to other health and social problems such as substance abuse and suicide, as well as rates of infectious diseases such as TB. Dr Tcholakov estimates that TB incidence in Nunavik is over 100 times higher than in other parts of Canada. Although drugs for TB treatment are accessible in Nunavik, he explains that antibiotics alone fail to address the complex socio-economic and historical roots of this infectious disease. Dr Tcholakov believes that improving the housing situation in Nunavik should be a priority, as it would have many positive effects on both physical and mental health.
Culturally competent care: successes and goals
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In healthcare, cultural competency refers to the capacity of healthcare systems to deliver care that meets patients’ social, cultural, and linguistic needs in order to reduce disparities that perpetuate unequal health outcomes. For example, nearly all Nunavimmiut speak Inuktitut—the majority as their primary language. Dr Tcholakov explains this is an impressive achievement demonstrating local commitment to preserving their culture, as speakers of many non-dominant languages are globally on the decline. However, the majority of healthcare workers in Nunavik come from elsewhere in Canada and do not speak Inuktitut. This results in a language barrier between patient and provider, impeding the patient-provider relationship and potentially reducing the quality of care received.
In addition to language, Dr Tcholakov notes that there can also be a divide between what community members and outside providers perceive as top priorities for intervention due to different perspectives and ideas about health. Dr Tcholakov emphasises that training more Nunavimmiut to enter the healthcare workforce should be a key priority for the future of the region. However, there are barriers to development of a local health workforce. Namely, the communities are too small to support a university, so those seeking advanced training have to go elsewhere—at minimum a few hours away by plane. There is also the issue of poor internet access in parts of Nunavik, although this is set to be improved soon, spurred in part by COVID-19.
“Although drugs for TB treatment are accessible in Nunavik, he explains that antibiotics alone fail to address the complex socio-economic and historical roots of this infectious disease.”
Despite these challenges, however, the community has already achieved major success in implementing culturally competent care in the form of its groundbreaking midwifery programme—the Inuultisvik Midwifery Service—which was founded in 1986. Prior to the programme’s initiation, pregnant women were flown some 500 miles by the Canadian national health service in order to give birth in an area with specialised care. However, this was difficult and isolating for women, and required families to be separated during their children’s first weeks or months of life. In response, services were brought to Nunavik—initially led by midwives trained in southern Canada, but later expanding to train locals in the vocation. Now, a dozen Nunavimmiut in three communities are helping to train the next generation of midwives, providing contraceptive and nutrition services and allowing the majority of women with low-risk pregnancies to deliver their babies safely in Nunavik, alongside their families and with the support of local midwives. The programme has been so successful that it has been used to model similar programmes in other countries such as Australia.
Looking ahead
“....research conducted in Nunavik needs to be actionable, appropriate, and to the benefit of local people”
We asked Dr Tcholakov if there were any areas where he thought academic research could benefit the communities of Nunavik. “I think that research has a role to play,” he said. “There are many efforts into having collaborative research, where the beneficiaries of the research are involved in the process of planning what needs to be done, how priorities are set, how the research is conducted and so on.” He emphasised that research conducted in Nunavik needs to be actionable, appropriate, and to the benefit of local people.
Despite the many obstacles the communities of Nunavik continue to face, Dr Tcholakov emphasises that what defines the region is its resilience. The communities’ commitment to protecting their traditions is one of the things that Dr Tcholakov enjoys the most about working in Nunavik: “It's very nice to see and live the determination of people to preserve their culture and their way of life despite the challenges that they have faced,” he says. He also admires the determination of the health system as a whole to consistently forward culturally appropriate, high-quality care, as exemplified by the success of the Nunavik midwifery programme. The Nunavik health system faces heavy challenges, but also possesses unique strengths in the commitment of its workers and residents to safeguarding the cultural practices that hold its communities together.