In the late 1940s, the Canadian federal government began to respond to the epidemic scale of tuberculosis affecting Inuit in the Arctic. The chosen treatment method was to transport Inuit with positive tuberculosis diagnoses by ship, hundreds or thousands of kilometres away from their homes, to sanitoria in southern Canada. Thus began the model of medical transportation as treatment – frequently to the exclusion of all other approaches. That model is still in effect today – with airplanes having replaced ships. But the paradigm remains the same: if you are seriously ill or injured in Inuit Nunangat (the Arctic and sub-Arctic homeland of Inuit in Canada), you will be forced to leave your own community for treatment.
I argue that the entrenched governmental policy and healthcare practice has little to do with good care, or healthcare management, and more to do with what historian Barbara Tuchman described as “wooden-headedness, […] a factor that plays a remarkably large role in government. It consists in assessing a situation in terms of preconceived fixed notions while ignoring or rejecting any contrary signs” (Tuchman 7).
How did we get here? As an Inuk (a person who belongs to the Inuit community) from Labrador, with a long family connection to healthcare establishments; a faculty member in a department of family medicine; a retired federal government healthcare administrator; and most recently, a doctoral student, I have many motivations to try to understand this conundrum – and a variety of lenses through which to view it.
In most of Inuit Nunangat, Western healthcare and its institutions did not begin to appear until the mid-twentieth century. The sole exception to that is Labrador, where hospitals and clinics began to be established by a medical missionary organization, the International Grenfell Association, beginning in 1894. Elsewhere, Inuit provided their own healthcare, based on detailed plant pharmacology and extensive knowledge of treating conditions and wounds, supplemented by care occasionally provided by missionary or mercantile organizations.
Beginning in 1950, a campaign began to forcibly transport Inuit infected with tuberculosis from their home communities to sanitoria in southern Canada. This was directly contrary to medical advice: Dr. R. Millar, a physician advisor working in the federal government, had counselled, “the removal of northern natives to southern institutions is not good practice, but almost invariably the patients […] become lonesome, decline, and sometimes die” (Grygier 62). Other physicians advocated the enlargement and strengthening of the then-miniscule medical infrastructure within Inuit Nunangat (Grygier 62-65), but were ignored. By 1956, approximately one out of every seven Inuit was in a sanitorium (Grygier 71). Baijayanta Mukhopadhyay observes that forced medical transportation “was backed up by brute forces of the Canadian state,” including the Royal Canadian Mounted Police and at times, armed forces aircraft (Mukhopadhyay 173).
There is some suspicion that the continuing reliance on medical transportation contributed to ongoing higher rates of tuberculosis in Inuit Nunangat. Rates are significantly lower in Alaska – a somewhat similar jurisdiction – which “brought care close to home by training local health aides who supervised tuberculosis care in remote communities and establishing state hospitals, whereas Canada relied primarily on nurses sent north and evacuating patients to southern hospitals” (Orr 287).
Skip forward from that often-traumatizing historical experience for Inuit affected by tuberculosis to the modern day to find, if anything, even more reliance on medical transportation than in the past.
Image: Inuit medical transportation routes. Social Determinants of Inuit Health in Canada, Inuit Tapirit Kanatami, 2014.
Prime Minister Justin Trudeau apologized in 2019 for Canada’s treatment of Inuit, including forced medical transportation, describing it as “‘colonial’ and ‘purposeful,’ and saying the government knew it was taking a toll on Inuit” (CBC 2019). However, his government continues to spend heavily on medical transportation; in the 2023 federal budget, it committed to spending “[CAD]810.6 million over five years, beginning in 2023-24, to support medical travel and to maintain medically necessary services” (Budget 2023). The bulk of that funding will inevitably find its way into the coffers of airlines serving northern communities.
The extent of contemporary medical transportation is gobsmacking: in 2019-20, 5,000 patients were transported from Nunavik to southern Quebec for healthcare, from a population of approximately 13,000 (CBC.CA 2022/12/22). In 2020-21, the Government of Nunavut projected expenditures of CAD107M on medical travel in (Nunatsiaq News 2020) or CAD2,903 per each of the territory’s 36,858 inhabitants (Statistics Canada 2021).
Jennifer Munick-Watkins, the executive director of the health board for Nunavik in northern Quebec, has discussed the stresses put on Inuit patients forced to relocate to southern Canada for healthcare. “First of all, their first language is Inuktitut, so that means they are already stressed out in ensuring they’re going to have a good translator” (CBC.CA 2022/12/20). Fortunately, a feasibility study is now underway to plan the construction of a new, larger hospital in the Nunavik region.
The costs, financial and human, of medical transportation are only part of the story. What may be more important are the lost opportunities inherent in same old/same old: the denial of health sovereignty to Inuit; a partially closed door to health innovation created by Inuit. Every dollar spent on medical transportation is a dollar not devoted to work to incorporate Inuit health knowledge into medical practice. Inuit realize, and accept, that complex medical procedures usually cannot be performed in very small communities with limited facilities. But putting medical facilities – and professionals – in place to expand the scope of locally-available practice as much as possible, is not inconceivable or inappropriate.
Barbara Tuchman suggested that “Mental standstill or stagnation – the maintenance intact by rulers and policy makers of the ideas they started with – is fertile ground for folly; […] persistence in error is the problem” (Tuchman 383). Her observation rings true to me, as someone who spent thirty years in the Canadian federal public service. While there were many changes in that period, inertia – and doing things the way we always had – remained an underlying principle.
Canadian Inuit seeking to improve the healthcare systems upon which they rely deserve better; we need to be involved in the ongoing development of our healthcare system. Canada, and other states with significant control over healthcare for Indigenous peoples, need to do better than “persistence in error.’
Canada.ca. Budget 2023 A Made-in-Canada Plan: Strong Middle Class, Affordable Economy, Healthy Future, Chapter 4, 4.2. https://www.budget.canada.ca/2023/report-rapport/chap4-en.html#a6. Retrieved April 14, 2023.
CBC.CA. “Trudeau apologizes for ‘colonial,’ ‘purposeful’ mistreatment of Inuit with tuberculosis.” March 8, 2019. Retrieved April 14, 2023. https://www.cbc.ca/news/canada/north/trudeau-apology-tuberculosis-iqaluit-1.5047805
CBC.CA. “A hospital in northern Quebec could cut down on the long journey to Montreal for medical travel.” December 20, 2022. Retrieved April 14, 2023. https://www.cbc.ca/news/canada/montreal/quebec-nunavik-hospital-health-care-1.6690843
Grygier, P. A Long Way from Home : The Tuberculosis Epidemic among the Inuit; McGill-Queen’s University Press, 2014.
Inuit Tapirit Kanatami. Social Determinants of Inuit Health in Canada, 2014.
Mukhopadhyay, B. Country of Poxes: Three Germs and the Taking of Territory. Fernwood Publishing, 2022.
Nunatsiaq News. “Health care sees the biggest boost in Nunavut’s 2020-21 budget.” February 20, 2020. Retrieved April 14, 2023. https://nunatsiaq.com/stories/article/health-care-sees-the-biggest-boost-in-gns-planned-2020-21-budget/
Orr, P. “Tuberculosis in Nunavut: looking back, moving forward.” Canadian Medical Association Journal Mar 5; 185(4): 287–288, 2013.
Statistics Canada. Census Profile, 2021 Census of Population. Retrieved April 14, 2023. https://www12.statcan.gc.ca/census-recensement/2021/dp-pd/prof/details/page.cfm?Lang=E&SearchText=nuna&DGUIDlist=2021A00056204003,2021A000262&GENDERlist=1&STATISTIClist=1&HEADERlist=0
Tuchman, B.W. The March of Folly: From Troy to Vietnam. Alfred A. Knopf, 1984.