The Geography of Health


Where you are and who you are determines how well cared-for you are.


In my last series, I told you the thorny story of how I stumbled my way into adulthood. This series is about healthcare - particularly its trials and tribulations within Western and Indigenous worlds.

I’m really not trying to rehash statistics as just another bored and bland voice in the media.

I’m so tired of hearing the word.

I’m not the media.

I’m just an Onkwehonwe sitting at my computer, telling stories, hoping to show a wider picture of what it’s like to live, and need help, in Canada. I’d like to invite you to consider the geography of health as it relates to First Nations communities in Canada, and join me as I shine a spotlight on the subtle, often overlooked, evils.

This is going to be about healthcare? And geography? You might yawn into your screen just reading this.

Did you?

Then look alive, because I’m writing this especially for you...

A place in the North

For those of you who aren't from a Reserve - let me take the opportunity to tell you that you won’t get beat up if you visit one; yes we have a newspaper; and no there’s no fence keeping us in (at least not in the literal sense). I say this, because I remember the questions I used to get asked in high school. I won’t be offended if you wondered these things too, I just want to make sure we’re all on the same page here.


When we talk about healthcare and geography, there's a lot to cover: Communities are all so unique, and they each deserve their own story. But I’ll start at home, as many story-tellers do. The Reserve I come from is in Southern Ontario. It’s mid-sized, with a population between 1,800 to 2,000. We’re lucky to have a health centre with a few registered nurses - some of whom are even from our Reserve. Sometimes a podiatrist pops in, and a nutritionist. They're mainly there to visit those trying to get a handle on their diabetes. You’ll come to know that diabetes is pretty common amongst Indigenous people in Canada; especially those who live on Reserves.

Growing up, I was lucky that my family had a car. For most of our healthcare needs, including emergencies, we usually had to travel to a small city nearby. Those without access to wheels had a much more difficult time, as our Reserve didn't have public transport and cabs (all exorbitantly expensive) rarely came around. I'll also mention that for the longest time, the roads on my Reserve were either dirt or gravel. If you drive, I'm sure you'll agree that neither option is ideal.

Today, however, I'm happy to report that most of the roads on my Reserve are paved; some are even painted.

That’s me, becoming suspicious that there was a bigger world out there. Cambridge, Massachusetts.

Another aside: one year they painted the roads by hand, leaning out of the back of a truck with a paintbrush. The lines were pretty jagged that season. Which reminds me of another story - the time the garbage truck broke, so they picked up our trash using a front-end loader likely borrowed from a local build site. I never found these anecdotes to be funny until I lived in the city, realizing that these weren't normal occurrences for the kids growing up in wealthier or more urban locations. It's ok to find the humour in creative problem-solving.

Now with a better picture of how life might be on a Reserve, do you wonder how this relates to health geography? It's a relatively new area of study that explores how our health is impacted by where (and therefore how) we live.

For example: How far away is a family's grocery store?  How many parks are within walking distance of a school? What side of the street does a house face? Many things come down to the accumulation of these subtle effects. And therein lies the inherent danger: subtlety is boring - it’s dull. But these are the gentle evils that we live with every day; the evils whose fangs we see so often that we start to ignore them.

Northern airport views, around Iqaluit. They have an acute-care hospital here, with about 35 beds, serving around 16,000 people from the Qikiqtani area.

Spanish and Inuktitut

So now you know where I come from - a relatively small and sleepy Reserve in Southern Ontario. I chose to start there, but rest assured that I’ve traveled far beyond my original stomping grounds and have lots more to say.

Now (perhaps unexpectedly), I want to tell you a little bit about Nicaragua; about a few little villages whose names I don’t remember how to pronounce, if I ever knew them to begin with. That one’s on me, but these places don’t matter any less because my memory for Spanish ends at perdón (“pardon [me]”).

So, how did I end up in Nicaragua? I was volunteering. I arrived in the South after I signed up to work with a medical brigade that toured Central America. This wasn’t an ecotourism trip; this group offered vital and sorely needed healthcare services to those most in need, and I was there to help. After petitioning a dozen organizations for donations to help me pay the price of my plane tickets (shout-out to the Native Women’s Association for their support), I successfully gathered enough funds to get on a plane and head out alone.

Through this program, five other university students and I made it to a hotel in Managua with a doctor, a dentist, a medical aid, and about a hundred tiny green lizards.

Walking to the first day in triage.

I was looking to dare myself out of my shell. I needed to see the world beyond my Reserve and my university, which I'd begun to suspect were only a tiny glimpse of life.

Each day in Nicaragua, we’d pile into a van and drive hours to reach rural surroundings. It was a shock to see the sports cars and iPhones turn into unpaved underbrush and homes with packed dirt floors where people cared for livestock in their yards. This contrast vaguely reminded me of the difference between Reserve and city.

With the professionals, we’d meet with locals seeking medical attention. The days would blend together as we saw hundreds of faces, old and young, all warm-eyed. There were no real medical facilities in these places, so we’d set up our clinics in churches.

Translators facilitated our initial interactions with the patients. Sometimes this was harder than we'd thought it would be; people can be guarded around strangers, and I’m sure it’s difficult to tell a bunch of foreign students that you haven’t gone to the bathroom in three days, or that your husband hits you. The latter is perhaps unsurprising; violence against women, like the epidemic in Canada, is also a considerable issue in Central America. Machismo, our doctor told us, is the biggest contributor for this. I think it might have something to do with poverty, too, and loss of traditional practices. After all, which population do we know in Canada that suffers from unfairly low socioeconomic status, cultural extinction, and an unprecedented climate of violence around women? These issues coincide too often for there to be no true relationship between them; and slowly, I think, the rest of Canada is beginning to take some notice.

Back to Nicaragua: Because we were only a small clinic, we’d usually just end up dispensing vitamins and giving referrals; telling people to drink more water, and distributing anti-parasite pills. Our doctor told us that travelling brigades like ours were often the only way that rural patients were able to obtain this important anti-parasite treatment. Many of these patients, we were told, lived with the parasite long before help came. Sometimes, they said, you could feel it wriggle around in your stomach after a meal.

Children were at the greatest risk for many ailments in Nicaragua. But don’t worry, this little guy was only sleeping.

This wasn’t my only run-in with treatable diseases left untreated. While at university, I attended several seminars given by doctors working in Northern Canada, and the reality is that many Indigenous people have no choice but to live with uncomfortable, painful, or otherwise incapacitating diseases, too. Tuberculosis, for example, is still a real threat in both North and Central America, coincidentally (or not).

The good news, at least, is that the incidence of active (non-latent) tuberculosis in the overall Canadian population has been declining, and is among the lowest rates in the world. But were you aware that tuberculosis, in Canada, is still more common among Aboriginal peoples than non-Aboriginal peoples? And unsurprisingly, high rates still persist in Indigenous communities, as many such regions have not experienced the same decrease in annual cases.

To put that into perspective, some of the latest available numbers (released in 2012) reveal that Aboriginal peoples, who account for only 4% of Canadians, reported 23% of all active tuberculosis cases in Canada. And for First Nations people, both those living on and off Reserve, the rate was 32 times higher. Lastly, and most awfully, compared to the non-Aboriginal population, the incidence rate of active tuberculosis for Inuit in particular was almost 400 times higher. Four-hundred times. How can that be?

It’s the un-drama of it all rearing its dull head again. Diseases fester because they're provoked by too many underwhelming factors. Coincidentally, the combination of these factors often overwhelms us. With so many little problems, where does one begin?

Too many people forced to live in a single space; Homes poorly built, insulated, and ventilated; malnutrition; unemployment; addiction; debt; diabetes and/or HIV. All of these factors make it more likely that someone (especially in a rural community) will be a prime, fatal candidate for tuberculosis. Both in Canada and Nicaragua, there are too many communities who fit this profile.

Well, those Indians, why don’t they just move South to the city to get help?

It seems that a lot of the blame for these health inequalities is put on the shoulders of those already suffering. And I don’t think that’s fair. Reserves - no matter how rural they are - aren't out of sight out of mind. At this point in history, we all need to realize that we live in a web, with life and history truly more tangled than colonial society wants to recognize.

We can’t get away from each other. And we can’t ignore our tangled problems.

Helicopter Care

I'm now taking you back to the place that first introduced me to a world beyond myself: Nicaragua. It was here, among the avocado trees and the Caribbean pines, that I began to feel the true weight of healthcare inequalities. Recognizing it first among the Nicaraguans, and then, slowly realizing the parallels between this place and home, was what ultimately pushed me toward a keen interest in rural and remote healthcare.

This is rural healthcare in Nicaragua.

One of the many inequities that both worlds share is poor health education. At the clinics in Nicaragua, for example, we repeatedly explained to parents that children needed to drink more water than soda, and that fruit alone was not an ideal diet. Later, in a northern First Nations community, I worked with youth who didn't know that cigarette smoke is bad for your lungs. Too many people take 'obvious' knowledge for granted. Based on statistics, it certainly isn't obvious to the majority of people, and we need to wonder why.

North / South

I’ve got one last story for you, about our parallels in Central America.

Multipurpose church, clinic, and town hall.

One day, our team met with a grandmother and her grandson. Sitting on a plastic lawn chair on the dirt floor of a local church, she told us how difficult of a time she'd had trying to see a traveling doctor over the last few weeks. She hadn't been able to visit the hospital because she had no vehicle, and because she was unable to walk the long distance with a bad knee. Does that sound like a familiar problem?

Nausea, blurred vision, lightheadedness, abdominal pain, and extreme fatigue were the forerunners of an earlier episode where she had blacked out in her kitchen, falling and hitting her head on a table. As she spoke, blinking slowly, my stomach tightened. I was immediately worried that it was a worst case scenario: a heart attack or stroke, or a lead-up to one.

I began waving my clipboard to bring our doctor to us and to review our notes first, in case immediate medical attention was necessary. Satisfied that help was imminent, I turned back to the woman. She had her eyes closed. I waited, but she didn’t open them. Her grandson, grabbing her arm, became confused when she didn’t stir. My heart was now beating like a wartime telegraph. He shook her hand. It was too cliché to be real. I could see a prickly fear begin to crawl over him as the doctor arrived.

There was a flurry of concerned Spanish between the professionals as I handed over my notes. Everything seemed so slow, my hands so heavy as I passed my clipboard.

The air felt like it was closing in on our circle. It was growing oppressive. By now, my partner was crying, and so was the woman’s grandson.

Nobody else had a vehicle, so the aid and a few men from the village whisked the woman up and carried her to the back of our van, and sat her in the back with the plastic chair. They flew down the road, tires kicking up dirt plumes as they sped off to the distant hospital.

The whole thing felt like a walking nightmare. Had this poor old woman just died, or was she going to die before getting to see a doctor? I started to silently berate myself for not being better. No doubt my partner felt these things, too. She sat crumpled in her plastic chair, wet-faced.

Coming back into my body, everything focused around me again, and I realized how alarming we must have seemed. My partner and I gathered our nerves; we had a job to do and people to help. And so we finished the day wrapped in forced bravery, with no news of the woman’s condition. This was difficult, to say the very least, especially for all of us so young with so few experiences to put it in perspective.

Our van returned much later in the evening to take us to our beds; we were at least assured that the woman had reached the hospital’s emergency room.

But that was the last we ever heard of her. She'd made it to the emergency room, but that's all we knew.

Sound familiar?


Beautiful memories.

Marcy is originally from a Mohawk reserve in southern Ontario. She's moved around a lot, and has traveled even more. She recently received her BSc from a Quebec university and now lives in Toronto where she is pursuing a second degree in multimedia design.

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