Towards Truth and Reconciliation: Fetal Alcohol Spectrum Disorder in Indigenous Populations

The root causes of health disparities between indigenous and non-indigenous populations with Fetal Alcohol Spectrum Disorder (FASD) must be addressed for increased success of reconciliation efforts. “Health inequalities are the systematic, avoidable and unfair differences in health outcomes that can be observed between populations, between social groups within the same population or as a gradient across a population ranked by social position” (McCartney et al., 2019). Understanding the social determinants of health has been useful in reducing health inequalities and improving population health (McCartney et al., 2019; Raphael et al., 2020). The definition of health has equally evolved over the years beyond "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity" (Huber, 2011). Newer health definitions, like the Population Health Promotion Model, Life Course Model, the Dahlgren and Whitehead Model, and more acknowledge the multilevel influence on health (Government of Canada, 2001; Jones et al., 2019; Raphael et al., 2020). The practicality or operationalism in newer health definitions allows for the innovation and implementation of strategies to maximize health at the individual, community and societal level (Huber, 2011; McCartney et al., 2019). Health inequities worsen health outcomes for indigenous individuals with FASD (McCartney et al., 2019; Richmond & Cook, 2016; Longstaffe et al., 2018). Addressing these inequities is paramount for the promotion and sustainability of health among indigenous people with FASD.

Systemic inequities due to colonial structures like the Indian Act have reinforced the gap between the indigenous population and other non-indigenous populations (Richmond & Cook, 2016). The Indian Act promoted gender bias, when women are prevented from keeping their indigenous status if they marry non-indigenous men (Richmond & Cook, 2016). Male siblings could also lose their indigenous status if their female siblings do not have the status (Richmond & Cook, 2016). The Indian Act was developed on foundations of racism and discrimination, yet the Act has guided decisions on health, education, welfare, justice, and so on for years for the indigenous population (Richmond & Cook, 2016). The discrimination fuelled by the Indian Act has incapacitated many indigenous. Life expectancy is lower in indigenous populations compared to non-indigenous. Life expectancy for indigenous males is 68.9 years while non-indigenous males is 78 years (Richmond & Cook, 2016). Life expectancy for indigenous females is 76.6 years while non-indigenous females is 81 years (Richmond & Cook, 2016). Infant mortality rate is twice as high in indigenous populations compared to non-indigenous populations in specific regions like British Columbia and Manitoba (Richmond & Cook, 2016). Indigenous women are 2-38 times more likely to have a child with FASD than their non-indigenous counterpart (Pei et al., 2019). The prevalence of alcohol consumption in indigenous populations is 3-4 times greater than the non-indigenous populations, which contributes to the higher prevalence of FASD in indigenous communities (Pei et al., 2019). The consequences of systems like the Indian Act, residential schools are deep-rooted in society that one of the social determinants of health is indigenous ancestry (Richmond & Cook, 2016; Raphael et al., 2020). AHS Indigenous Health Program Learning Series is linked below for more exploration of indigenous health.

FASD is a neuropsychological disorder characterized by a range of physical, behavioral, emotional, adaptive and neurocognitive functioning deficits caused by prenatal alcohol exposure (Pei et al., 2017). FASD is the leading cause of developmental disabilities in Canada (Pei et al., 2017). FASD has become a great economic burden for Canada given the consequences of the disorder cuts through multiple systems including the health care system, social services, criminal justice system and more (Pei et al., 2017). In Manitoba, the minimum FASD prevalence is 10% of inmates in a medium-security federal penitentiary (Longstaffe et al., 2018). The statistics on FASD among the indigenous populations have informed policymakers, health workers and so on, on the crises of FASD (Pei et al., 2019). However, the statistics have equally fuelled discrimination towards the indigenous populations especially when these statistics are not used in context of the complexities behind alcohol consumption in indigenous women (Pei et al., 2019). The inequities already existing for indigenous populations will require better policies, more research, increased public awareness and reconciliation strategies for these populations, even though reforms are being implemented to the Indian Act (Richmond & Cook, 2016). Earlier research on FASD in indigenous populations failed to consider the historical and societal factors influencing maternal drug and alcohol exposure (Pei et al., 2019). More recent research evaluates these factors, which promote interventions addressing both women's needs and the fetus' needs. Interventions like the Parent-Child Assistance Program (PCAP) aims at preventing drug- and alcohol-exposed birth by focusing on women's needs (Pei et al., 2019). The suitability of PCAP is continuously assessed and has been associated with increased birth-control awareness and use, fewer pregnancies, fewer drug- and alcohol-exposed births and a greater probability of drug and alcohol abstinence (Pei et al., 2019). Utilizing participatory research approaches which involve the stakeholders in intervention development and implementation, have positive outcomes in reducing the prevalence of FASD in indigenous populations (Pei et al., 2019; Gonzales et al., 2018). The chiefs, council, indigenous women, need to be part of the decision process for the intervention development and implementation. The dream catcher is an example of how indigenous elements are being incorporated in the care of indigenous people with FASD (Vitalité, 2019).

Individuals with FASD often experience secondary disabilities due to neglect, abuse, school failure with early dropout rates, addictions, limited employment, homelessness and increased crime involvement (Longstaffe et al., 2018). These secondary disabilities tend to be exacerbated when FASD is not detected early or therapy or interventions are not accessed early (Longstaffe et al., 2018). FASD has become a great economic burden for Canada given the consequences of the disorder cuts through multiple systems including the health care system, social services, criminal justice system and more (Pei et al., 2017). Indigenous peoples have experienced years of systemic inequities arising from several factors linked to colonialism (Richmond & Cook, 2016). Fetal Alcohol Spectrum Disorder worsens the outcomes for indigenous peoples, who are already at high risk of being criminally involved with the justice system (Pei et al., 2019; Samaroden, 2018). Many health professionals are exposed to both indigenous and non-indigenous individuals with developmental disabilities, including FASD, in the line of duty (Gonzales et al., 2018). The dynamics of supporting individuals of indigenous descent tends to be different from non-indigenous. Certain services are accessible to indigenous individuals that are not typically accessed by non-indigenous individuals, in efforts of reconciling the traumatic history and experiences of indigenous populations due to colonialism (Alberta Courts, 2021; CLEO, 2021). An example of such difference is with the justice system. An adult indigenous individual navigating the justice system can access the indigenous court services where the individual is tried in the indigenous way in the presence of elders and chiefs.

A round-table design of Calgary Indigenous Court

Indigenous courts are being established in other provinces Canada-wide as a movement towards truth and reconciliation (Alberta Courts, 2021; CLEO, 2021). Ontario has the largest population of indigenous peoples in Canada, while Alberta has the third highest (Statistics Canada, 2020). According to the 2016 census, Ontario accounts for 22% of indigenous population, while Alberta accounts for 15% (Statistics Canada, 2020). Ontario accounts for 29% of indigenous adults admitted to correctional services in Canada in 2018/2019, while Alberta accounts for 17% (Statistics Canada, 2021). Elements of indigenous culture are being integrated into rehabilitation programs, addictions services, and the justice system Canada-wide as a pathway to reconciliation of colonialism and healing (Samaroden, 2018). The indigenous court in Ontario incorporates indigenous cultural practices while applying Canadian law (CLEO, 2021). These indigenous courts are typically used for sentencing hearings, where alternatives to jail are considered first. When a jail sentence is given, the length of the sentence is considered with respect to the indigenous courts’ principles (CLEO, 2021). The practices of different indigenous courts may vary and individuals are expected to consult with their lawyers or duty counsel to be familiar with court practices (CLEO, 2021). In Aberta, Calgary established the Calgary Indigenous Court in September 2019 to provide indigenous individuals with a restorative, holistic and culturally relevant approach to justice (Alberta Courts, 2021). This initiative is a step towards truth and reconciliation for indigenous people, which aims to address issues of overrepresentation of indigenous people in the justice system. Community services exist to connect and guide indigenous people with the processes of the indigenous courts in Calgary Alberta like the Elizabeth Fry Society of Calgary, Calgary Legal Guidance, Native Counselling services and other support agencies. A focus on rehabilitation of indigenous individuals with FASD in Alberta has reduced the overall recidivism and incarceration rates (Samaroden, 2018).

Cartoon illustrating the cycle between FASD and justice system

In moving towards truth and reconciliation in indigenous populations with FASD, the root causes of higher prevalence of FASD in indigenous populations must be addressed.The impact of FASD on health is multifaceted, affecting both individuals and systems like the health care system, social services, criminal justice system and more (Pei et al., 2017). More evidence on FASD association with crime has come to light in recent times and initiatives are being developed to support individuals with FASD in leading meaningful life in society (Longstaffe et al., 2018). More comprehensive research is however still needed to compare and evaluate the prevalence and impact of FASD in indigenous populations in Canada (Flannings et al., 2018).

References

Alberta Courts. (2021). Area of law: Calgary indigenous court. https://albertacourts.ca/pc/areas-of-law/criminal/calgary-indigenous-court

CLEO. (2021). Steps to justice: What is a Gladue or indigenous peoples court? https://stepstojustice.ca/questions/criminal-law/what-gladue-or-indigenous-peoples-court

Flannigan, K.,Unsworth, K., & Harding, K. (2018). FASD prevalence in special populations. Canada FASD Research Network. https://canfasd.ca/wp-content/uploads/2018/08/Prevalence-2-Issue-Paper-FINAL.pdf

Gonzales, K. L., Jacob, M. M., Mercier, A., Heater, H., Nall Goes Behind, L., Joseph, J., & Kuerschner, S. (2018). An Indigenous framework of the cycle of fetal alcohol spectrum disorder risk and prevention across the generations: historical trauma, harm and healing. Ethnicity & health, 1-19. https://doi.org/10.1080/13557858.2018.1495320

Government of Canada. (2001). Population Health Promotion: An Integrated Model of Population Health and Health Promotion. Canada. https://www.canada.ca/en/public-health/services/health-promotion/population-health/population-health-promotion-integrated-model-population-health-health-promotion/developing-population-health-promotion-model.html

Jones, N. L., Gilman, S. E., Cheng, T. L., Drury, S. S., Hill, C. V., & Geronimus, A. T. (2019). Life course approaches to the causes of health disparities. American journal of public health, 109(S1), S48–S55. https://doi.org/10.2105/AJPH.2018.304738

Huber, M. (2011). Health: How should we define it? British Medical Journal, 343,(7817), 235-237. https://doi.org/10.1136/bmj.d4163

Longstaffe, S., Chudley, AE, Harvie, MK, Markesteyn, T., Neault, D., & Brown, T. (2018). The Manitoba Youth Justice Program: empowering and supporting youth with FASD in conflict with the law. Biochemistry and Cell Biology , 96 (2), 260-266. http://dx.doi.org/10.1139/bcb-2017-0078

McCartney, G., Popham, F., McMaster, R., & Cumbers, A. (2019). Defining health and health inequalities. Public health, 172, 22–30. https://doi.org/10.1016/j.puhe.2019.03.023

Pei, J., Tremblay, M., McNeil, A., Poole, N., & McFarlane, A. (2017). Neuropsychological aspects of prevention and intervention for FASD in Canada. Journal of Pediatric Neuropsychology, 3(1), 25-37. https://doi.org/10.1007/s40817-016-0020-1

Pei, J., Carlson, E., Tremblay, M., & Poth, C. (2019). Exploring the contributions and suitability of relational and community‐centered fetal alcohol spectrum disorder (FASD) prevention work in First Nation communities. Birth defects research, 111(12), 835-847. https://doi.org/10.1002/bdr2.1480

Raphael, D., Bryant, T., Mikkonen, J. and Raphael, A. (2020). Social Determinants of Health: The Canadian Facts. Oshawa: Ontario Tech University Faculty of Health Sciences and Toronto: York University School of Health Policy and Management. https://www.thecanadianfacts.org/The_Canadian_Facts-2nd_ed.pdf

Richmond, C., & Cook, C. (2016). Creating conditions for Canadian aboriginal health equity: the promise of healthy public policy. Public health reviews, 37, 2. https://doi.org/10.1186/s40985-016-0016-5

Samaroden, M. (2018). Challenges and resiliency in aboriginal adults with fetal alcohol spectrum disorder. First Peoples Child & Family Review, 13(1), 8-19. Retrieved from https://fpcfr.journals.publicknowledgeproject.org/index.php/FPCFR/article/view/335

Statistics Canada. (2020, October 02). Aboriginal Peoples Highlight Tables, 2016 Census. https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/hlt-fst/abo-aut/Table.cfm?Lang=Eng&T=101&S=99&O=A

Statistics Canada. (2021, March 20). Table 35-10-0016-01 Adult custody admissions to correctional services by aboriginal identity. https://doi.org/10.25318/3510001601-eng

Vitalité. (2019, April 4). FASD - Dream catcher [Video]. Youtube.https://youtu.be/pmSKvaZ6Pxc