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As health care staff working in Psychiatric Emergency Rooms, we see patients from Quebec’s remote north who are transferred to receive care in Montreal. A striking difference between these patients and the rest of the Quebec population is the dearth of health services in their home communities.
This was the case of one man in his late twenties who initially presented inebriated to a Nunavik hospital, with thoughts of suicide and homicide. In order to receive the necessary and appropriate psychiatric care, he then had to travel 1100 km to a Montreal hospital.
Access to care can save lives
When interviewed by our psychiatric emergency team, he was reluctant to speak to us, and maintained that he only had these ideas because of his intoxication. He expressed a desire to stop drinking, but the necessary resources were not available in his home community. He refused the help that was available, due to concern for confidentiality – a common concern, as it is nearly inevitable that therapists and patients know each other socially in such small communities.
After several days in the emergency room and then in a Montreal crisis center, he was discharged to his home in Nunavik. A few weeks later, he killed a man and committed suicide. This was an immense shock to the entire medical team involved in his care. Many of us were left with a similar thought: "This probably would not have happened if he had been from another region of Quebec, with more access to care."
There are many reasons for lack of access to health care among remote populations, including issues involving logistics, resources, political will and history.
Lack of resources for remote, First Nations communities
One important reason linked to all of this is money. Notably, spending for Aboriginals under the Non-Insured Health Benefits (NIHB) program is $1215 per capita, compared to per capita spending for other Canadians, $5614, and $5096 for residents of Quebec. The NIHB covers First Nations and Inuit people in Canada who have status, which by no means includes all Aboriginal persons. The largest areas covered under the NIHB are pharmacy (42.9 per cent; including medical supplies and equipment), dentistry (21 per cent), and medical transportation (30.3 per cent). The "Other Health Care" category is comprised mainly of short-term crisis intervention mental health counseling, which suffered a funding decrease of 3.5 per cent over the last fiscal year.
Some communities receive additional treaty money for healthcare which is used to cover the costs of running a hospital. Many community-based health projects, including counseling for public health, detoxification centers, and suicide prevention, are funded by grants or other agencies such as the National Aboriginal Health Organization, which has had its funding cut completely and will close down this summer. The Assembly of First Nations, which provides support to other organizations for health care provision, received a budget cut of 40% by Health Canada this year.
There is no easy solution when it comes to delivering appropriate mental health care in remote communities. Nonetheless, examples of successful interventions exist, and guidelines can also be borrowed from the humanitarian sector. For example, the World Health Organization suggests an intervention pyramid with a broad base of basic security and social services, followed by strengthening community and social networks, non-specialized supports, and a peak of specialized services. This model can be followed in remote areas with programs starting from and involving the community as actors.
Successful examples, viable solutions
A successful example is the Australian New South Wales training program for Aboriginal mental health care workers: a rigorous three-year program which trains and subsequently guarantees employment for members of the community as care providers. In a parallel vein, today's communications technology could be used for the development of tele-mental health programs, where clients and care providers would be linked across distances, and support and specialized care be made affordable and accessible.
Tele-health may be one viable solution to the problem of health care access in Quebec's remote North and also to the difficulties with confidentiality that are frequently found in small communities, while not interfering with actual community supports. Multiple projects already exist in Canada: for example the Health Services Integration Fund is a 5-year, $80 million initiative funding Aboriginal health projects across Canada, a portion of which concern mental health care.
While this is a good start, the truth is that the existent funding is far from enough to found and sustain the necessary rigorous programs, and more needs to be invested into federal and provincial rural and remote community mental health programs. There also needs to be security in funding, as often funds are available for limited periods of time and remain subject to political interests.
Lack of access to health care is a human rights issue
In the meantime, Northern communities continue to have lower life expectancies, and higher than average rates of suicide and addiction. Our patient's story was, sadly, not unique. Lack of access to health care in general and mental health care in particular is a health and human rights issue.
The brand new Canadian Mental Health Strategy emphasizes the importance of both responding to the diverse mental health needs of all people in Canada, and that people have “equitable and timely access” to programs and services that are based around their needs. Immediate action is needed around all aspects of mental health care provision to those in remote communities, vital to prevent the kinds of tragedies that evolve when access is not available.
Julia Dornik, Nisrine Masrouha, Katerina Nikolitch, Melissa Pickles, Lorin J Young are members of Physicians for Human Rights, Montreal Chapter.
A version of this article was originally published in the Montreal Gazette and is republished here with permission.
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