Thank you very much for the invitation. It's a pleasure to be here with you on traditional Algonquin territory.
I think the reason I was invited was that when I was living in Nunavut, I was the government suicide prevention adviser. At that time I had the opportunity to work very closely with Natan Obed, whom I hold in the highest regard, so it's always a pleasure to be presenting with Natan.
I've shown this graph hundreds of times, and every time I look at it, it fills me with sadness and with shame, frankly, as a Canadian. What this shows us is the evolution of the rate of suicide by Inuit living in Nunavut from below the national average in the 1960s and 1970s up to the present day. For the last 15 years the rate has been just under 10 times the national average.
I heard ask about trends. The reason I can do this is that in the territories, death certificates are coded by ethnicity. The reason you don't have something similar to this for first nations in the provinces is that in the provinces, no death certificates are coded by ethnicity. This is a rare example of being able to document a pretty serious epidemiological transition from a low-suicide-rate society to a high-suicide-rate community.
The rate is highly structured by age and sex. The most at-risk population is young men. This is not the structure of most of the society. It's also structured by geography, so the red dots are the communities with the highest rates. You'll see they're overwhelmingly in the Qikiqtani region, plus one community in the west. I think this is explainable based on modern social history.
It's an odd thing to talk about mental health outcomes of individual ethnic groups, I realize, but if we look at the United States, where we do have data broken out by ethnicity, we see, for example—however uncomfortable we might feel about the concept of race as used in the United States—that this official government data shows that black people in the United States die by suicide at a much lower rate than white people do. We can talk about that, but it's a fact.
If we put Canada in for comparison, as a whole, because we don't have this kind of data, we come in between the two. Asians and Hispanics are much closer to blacks than to whites.
If we add in the American Indian and Alaska native population—that's the official coding, American Indian and Alaska native—it's very interesting. At the national level, white people and American Indian and Alaska natives have effectively the same rate of suicide across the United States, but it's structured differently, with much higher rates among younger people, among indigenous Americans, and among older white Americans.
If we look at the state level, we see that there's one state, Alaska, that has a rate of over 40 per 100,000, but there's another state, Texas, with 100,000 indigenous people, that has a rate of under four per 100,000. The rate varies massively in the United States at the state level only among American Indians and Alaska natives, not among other ethnicities.
The logic I take from that is that aboriginality per se is not a risk factor. It's the lived conditions of being aboriginal in different parts of the United States.
If we were to take Alaska out from the rest of the indigenous population, we see that actually a lot of the youth suicide is in Alaska and that in the southern states, youth suicide isn't as big a problem as it is in Alaska. If we take it one step further and put in Nunavut, we see the scale of Inuit youth suicide in Nunavut in comparison to Alaska and the rest of the United States. It's pretty shocking.
As we know, suicide behaviour is complex and multi-causal, but the WHO has said for years that it's a largely preventable public health problem. I think we should focus on both parts of that: largely preventable, and public health.
We need to look in terms of cohorts of people who die by suicide. For example, people whose first suicide attempt, whether it's to completion or not, is later in life have one basket of risk factors. People who attempt as teenagers or in their early twenties have a different pattern of risk factors. In our higher-risk indigenous communities, keeping in mind that the rate is very high among our community, it's the basket of risk factors for young people that we need to be thinking about.
We did do a five-year, CIHR-funded follow-back study in Nunavut, supported by everybody. We looked at all 120 deaths in four years, matched with case controls. The reports are online. We did not find risk factors that were unique to Inuit. We found the usual risk factors, operating at a much higher level in some cases.
The conclusion is that mental health matters. There's a need to focus on families and communities as well as individual-level issues.
As I mentioned, I was part of the team, with Natan, that developed the “Nunavut Suicide Prevention Strategy”, which I think we're very proud of. It was very well received when it came out. There is a link to it. Unfortunately, the initial years of implementation have not gone well. However, as you may know, last year the Nunavut government declared a state of suicide crisis and created the world's first minister responsible for suicide prevention position. We're hoping that things will be taken more seriously in the near future.
I want to show you rates for Inuit and Nunavut, and Inuit and Greenland, and point something out. We have data from Greenland for the period 1900 to 1930 from the first chief medical officer of health, which is a rate of 3 per 100,000. I've gone through RCMP files, and I've calculated a rate of 20 for the period of 1925 to 1945.
However, in the Arctic, starting in the late sixties and early seventies, the rate takes off everywhere across Inuit societies. Let me point out that it was not the people who were coerced into settled communities by the government as adults who started dying by suicide: it was the first generation of children to grow up in the settlements in those early days, where there was a lot happening in terms of power and people being bossed around.
There is very interesting data from New Zealand, more detailed data than we have for Canada, showing that Maori have transitioned from a society with lower than national norms use of mental health services and lower than national norms of suicide behaviour to higher rates. However, if you do the analysis—and the data from the Christchurch human development study is linked at the bottom—and you control for socio-economic childhood disadvantage, family adversity, and other socio-economic factors, “Maoriness” disappears.
People aren't not well because they're Maori; they're not well because one section of the Maori community is poor, with low educational outcomes and high rates of substance abuse. There are a lot of Maori who don't fit that profile, but the kids of those Maori who are in trouble in their lives grow up in trouble, just like other people's kids in those conditions grow up in trouble. That's changing. It teaches us that when we talk about mental health outcomes among Maori, we know too much to be able to talk about the Maori as if it's one group of people. There are Maori who are doing well and there are Maori who are not doing well, just like everybody else.
In the new Australian indigenous strategy that accompanies the national strategy, we see the focus on the developmental precursors of suicide and suicide behaviour. Understanding that early childhood adversity can put people on a pathway to trouble in life, the end result of which might be suicide behaviour, invest upstream and take a public health approach so that fewer people need services as teenagers and adults.
I watched the video of the meeting on May 31. I heard several references to Quebec. Canada is a backwards country when it comes to suicide prevention. We're one of the few developed countries to not have a national strategy. However, within Canada, we have one of the greatest success stories in the world. That's why the International Association for Suicide Prevention met in Montreal last year to talk about Quebec. It is fantastic to cut a province's rate of youth suicide in half in a decade, and I hope you look into how they did it. I can suggest people you might want to talk to about that.
I've taken the liberty of coming up with six short references for you, which I can deliver in one minute.
Number one, carefully recommend the landmark 2014 WHO report, “Preventing suicide: A global imperative”. Yes, it took the WHO too long to release this report, but it's great. It's weak on indigenous peoples, but it's a great report generally.
Second, when it comes to elevated rates of suicide behaviour in some indigenous communities—because let's be clear that not all indigenous communities have high rates of suicide in this country, and we know that—take a look at the evidence, pay attention to the realities of social disadvantage, unresolved grief, early childhood adversities, and the need for culturally appropriate mental health care.
There's a lot of prejudice, but there's a lot of nonsense spoken in the media about the root causes of suicide in indigenous behaviours. Some of it is pretty unpleasant in its characterization of indigenous peoples. You have to get down to actual results. There is substantial evidence, clear and compelling evidence the size of the Himalayas, on the relationship between poverty and socio-economic inequality with mental health outcomes and suicide behaviour. The world isn't always as complicated as some people make it out to be.
I would urge the federal government to act on the WHO's recommendations and Quebec's success by developing and implementing a national strategy for suicide prevention. Mr. McLeod asked on May 31, “Where is the strategy?” You can make a strategy happen for everybody, not just indigenous peoples.
I would urge you to allow the national indigenous organizations to determine the character of what suicide prevention should consist of in their regions. Nobody has given more thought to suicide prevention in Inuit communities than Inuit themselves.
I would urge the federal government to support ITK's forthcoming national Inuit suicide prevention strategy with the allocation of resources commensurate with the high social burden of suicide behaviour in Inuit communities. If Inuit youth had been dying at this rate from HIV/AIDS, there would have been a coordinated federal intervention, because it's a communicable disease. How do we explain the lack of action on shocking levels of teen suicide for 25 years? Let's get over it; let's do it.
Finally, on a personal level, I am an ASIST trainer. I teach two-day applied suicide intervention skills training workshops. I think it's great. I wouldn't do it if I didn't think it was great. I encourage you as individuals back in your home communities to take ASIST. You won't regret it, and if you'd like to know how you can do that, drop me a line, and I'll make it happen for you.
Thank you for your attention.
My name is Natan Obed. I'm the president of Inuit Tapiriit Kanatami, the national representational organization for Canada's 60,000 Inuit.
The first objective in our 2016-2019 strategic plan is to take action to prevent suicide among Inuit. It is a priority of the highest degree for our national organization and for all Inuit in Canada to do something meaningful to prevent suicide.
I want to open by talking about how it affects each and every one of us.
This is a huge difference between the Inuit population, or anyone who lives within an Inuit community, and those who live in southern Canada. Each one of us is personally affected by suicide, and this comes from a very early age. It affects our entire life course, and it is something that is always with us. Imagine a scenario in which you grow up understanding how to die by suicide; you have friends, family members, and loved ones who have died by suicide; and suicide is normalized in your community to the extent that it is used sometimes even as a bargaining tactic, or something that is a threat, rather than a situation that is not normal and one that demands immediate attention and mobilization from communities and from governments.
We all live in this reality, and not one of us wants to see another day that we live in this reality. What you are doing here, and what the House did in its special debate, is being watched by all Inuit. We do hope that it translates into action to prevent suicide for Inuit moving forward.
I also want to recognize all of those people in our communities, from the 1970s to today, who have done amazing work to prevent suicide with absolutely no help or little help. It goes from the faith-based community to those who are champions in our community for people who are at risk. That doesn't necessarily mean there is no mental health system, but for too many years individuals in our communities have had to pick up an enormous burden of caring for the mental wellness and mental health of many of those who are at most at risk in our communities. That is something that will continue to exist, but it should not be the only way that suicide prevention happens, in many cases, in many of our communities.
Over the past two months, there has been a national discussion about suicide prevention and suicide by indigenous peoples. I was at the special debate and I listened to many well-meaning members of Parliament talk about how important this issue is. I would say that I came away frustrated, and have continued to be frustrated, by the way in which the discussion has happened to date. It is as if indigenous suicide and Inuit suicide is something completely outside of a public health context, and somehow the answers only lie with us and us alone.
Many times when we as the national Inuit organization or when individuals who are Inuit are asked by well-meaning Canadians what needs to be done, the response those people are looking for is one that has nothing to do with creating social equity, nothing to do with providing mental health services, and nothing that goes beyond historical or intergenerational trauma. What they're looking for, in many cases, is a particular component of suicide prevention that is indigenous only, that usually has something to do with on-land camps or cultural continuity, that is relatively cheap, and that has nothing to do with the relationship between government services and overarching populations and their overarching health. We need to change that discussion.
For our part, Inuit Tapiriit Kanatami will release a national Inuit suicide prevention strategy on July 27.
In this strategy we talk about why suicide happens the way it does in our communities and also what is necessary to prevent suicide in Inuit communities.
You might find this strange, but our people do not have one common, united narrative about why suicide happens in our communities. Many times the discussions happen about the final step by somebody who was at risk of suicide, who was thinking of suicide, and who then attempts or completes suicide. All the discussion about why it happened is just in that particular moment when we live in an environment of suicide. From the time many of our children are in the womb, they're at risk of suicide in a different way because of the environment in which our children grow up and the environment in which our people live.
The discussion about why suicide is the way it is is as follows.
We have to do a great deal to achieve social equity. Our society has gone through massive historical changes in the last 50 to 60 years. As Jack Hicks mentioned, you can see the suicide rates elevating in the 1970s, corresponding to the first generation of children who grew up in communities. We need to do more to ensure that we have proper education systems, proper mental health systems, and justice systems that reflect our needs; that we address violence and sexual abuse in our communities; and that we end poverty. Social equity is that first societal step that we need to take. It is necessary to improve our mental health and ultimately to prevent suicide.
Then it gets to the community level, where a number of different things happen in normal communities that do not happen in our communities: programs and services, connections between generations, things that allow for coping skills to be created, and things that build resilience.
From the evidence base, we think of risk factors and protective factors. We have societal risk factors and individual risk factors. We do not have the appropriate measures in the protective factors that build resilience in our communities for our society as a whole to come through hard times. Every individual will go through difficult times in their lives. It is a lifetime of experiences and a lifetime of relationships with your family, with you, with your mental health system and health systems in general, and in your communities, that craft the responses to those difficult times. We need to do more to ensure that there are supports at the community level for all our community members to overcome hardship.
On the individual level, we have a number of different things we can do to provide mental health services and support for those at risk of suicide. That means improving some of our mental health acts, improving mental health services at the community level, and incorporating Inuit-specific healing practices within the mental health continuum. We need a mental health continuum to overcome the challenges that people face on a day-to-day basis. When people are experiencing acute stress—and this gets to the individual level, where a lot of the discussion about suicide takes place in suicide prevention—we need people who can help, and we need interventions for those who are at risk.
There are usually three ways to break down suicide prevention: prevention, interventions, and post-interventions.
At the intervention stage, when people are at the most risk, programs like ASIST, which arm community members with the ability to identify those at risk and link them to care, are great examples of how we can prevent suicide in a way that we have not done previously. Our strategy will present actions that will create meaningful change in our community and will prevent suicide.
I'd like to leave with an association between what has happened in relation to lung cancer over the past 50 to 60 years with what must happen with Inuit suicide prevention in the coming 50 to 60 years.
In the beginning, there was not even a recognition of the causes of lung cancer, especially in relation to smoking, but over the course of generations and upstream investments in public health measures to ensure that people knew the risks and took mitigative actions so that they would not develop lung cancer, we have arrived at a very different place. Those who do have lung cancer, we treat. We treat through radiation and medication, and we also have palliative care for those who are beyond that stage of treatment.
It is as if today, with Inuit suicide prevention, we allow only for very small, palliative care-type interventions for our people. We do not have the requisite upstream investments in social equity. We do not have the requisite interventions, mental health facilities, and mental health continuum of care for Inuit that would allow people to get through difficult times and to have positive mental health. We certainly don't have enough to ensure that our communities can be healthy, happy, and productive in the way we believe we were before we moved the communities and before all this colonization happened.
I look forward to working with each and every one of you to make the meaningful changes necessary to prevent suicide of Inuit.
Thank you for the question.
If you look at the map that I have, you'll see there are many isolated communities in Nunavut with not very elevated rates compared to other parts of Nunavut, so I don't think it's isolation in and of itself. There's a general pattern that northern first nations people have lower rates than Inuit. Dene in the Northwest Territories have a lower rate than Inuvialuit. In northern Quebec, the Cree have a lower rate than the Inuit, and they share a land claim.
There are larger factors at work. I can't claim to have come up with an explanation for all of them, but I don't think there's any evidence that isolation, per se, is a factor. However, across the north, for Inuit, we are seeing that the rates for suicide of young men are falling in the cities and that it's in some of the more traditional—which is a strange term—communities where they are the highest, which is kind of the reverse of the way some people might think it would be. From a cultural continuity perspective, Inuit, generally speaking, have very high levels of cultural continuity, as do Dene, but if it's only about cultural continuity, then how come some of these smaller communities have higher rates than Iqaluit? In Greenland and in Alaska, it's very much the case.
I think a lot of it has to do with the realities of being a young man in today's world and how you see the future—how you've grown up, whether your family was happy, what your peers are like, whether you can see a future that makes sense for you. Can you see a path to being happy and healthy? Can you see graduating from high school, getting a job, getting an apartment, getting a girlfriend, getting a boat? You're still an Inuk and you still speak Inuktitut. You still go hunting.
There are communities where there is just a lot less hope, and I think in part it's because of weaker services and more trauma from the past, but isolation, in and of itself.... I'm not sure how we would wrap our heads around that.
Thank you, Natan and Jack, for being here. I appreciated your presentation today. It's been informative.
I don't have a lot of questions for you today. I think your presentations have been amazing. I've been reading this piece of paper right here, particularly on the risk factors. That's probably the number one thing, if we can mitigate the risk factors.
We've worked really hard on the protective factors for a while, specifically mental health. Every time there is a suicide crisis, there's a call for mental health workers. That's entirely a Band-Aid solution. We need to get past that. There is a culture of suicide, and we have to work to change that culture a little bit.
Natan, can you just explain or broaden that out a little bit for me? Is that the correct terminology to be used, “culture” of suicide? I have no experience with what you're talking about. It's foreign to me. Perhaps you could just broaden that out a little in terms of communities suffering from suicide.
I read here about family strength, and to me that seems obvious, but when you write it on a piece of paper, it's suddenly, “Oh yes, we have to worry about family strength.” How does that work, and how does community cohesion play into it? When I look at my own life, those things exist in my own life, and I can't see a reality without them.
Could you speak to that a little bit?