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The community health representative in Alberta : a program evaluation Gerein, Nancy Marian 1977

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THE COMMUNITY HEALTH REPRESENTATIVE IN ALBERTA—A PROGRAM EVALUATION by Nancy Marian Gerein B . S c , Un i v e r s i t y of Alberta, 1974, A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES Department of Health Care and Epidemiology We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA September, 1977 © Nancy Marian Gerein, 1977 In present ing th is thes is in par t ia l fu l f i lment of the requirements for an advanced degree at the Un ivers i ty of B r i t i s h Columbia, I agree that the L ibrary shal l make it f ree ly ava i lab le for reference and study. I fur ther agree that permission for extensive copying of th is thes is for s c h o l a r l y purposes may be granted by the Head of my Department or by h is representa t ives . It is understood that copying or p u b l i c a t i o n of th is thes is fo r f i n a n c i a l gain sha l l not be allowed without my wri t ten permission. Department of H e a l t h Care and Ep i d e m i o l o g y The Un ivers i ty of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date O c t o b e r 11. 1977 i ABSTRACT The Indians of Alberta sustain levels of health and well-being well below that of the average Canadian. Recognizing that the traditional health care system required modification for the special needs of Indians, Medical Services Branch of the Department of National Health and Welfare set up their f i r s t training program i n 1962 to prepare Indian public health auxiliary workers, called Community Health Representatives. The hope was that the program would, among other things, allow Indians to be more involved i n their own health care, extend the coverage of the health services and act as a vehicle to further community development of Indian reserves. To evaluate this program, the general objectives of the program and the job description of the CHR's were used to derive short-term objectives which were examined on v i s i t s to reserves. Quantitative data were not available for assessing the achievement of objectives, but interviews and observations allowed a qualitative assessment of the program's effectiveness. The a c t i v i t i e s of CHR's and Medical Services in this program were examined in the context of their "environment" -the geographic, biological, psychological, sociological and anthropological factors which are both the cause and the effect of the health status of. a people. From this very broad standpoint, a critique of the effectiveness, and the policy and direction of the program was offered. The CHR's were found to be functioning i n varying modes, with varying levels of effectiveness. Most carried out traditional public health nursing, acting mainly as assistants to the nurses. A few had a more p o l i t i c a l bent and were involved with committee work, the Band i i Council and general development on the reserve. Health s e r v i c e s may he extended by t h i s program, but the goals of community development and community involvement i n health care are achieved to a markedly l e s s extent. Several s i t u a t i o n a l and p o l i c y v a r i a b l e s which may account f o r t h i s are put forward. The program i s seen to be too small and too i s o l a t e d from wider events i n the p o l i t i c a l and health spheres to have had any great impact on Indian development and health. The resources a v a i l a b l e to the CHR program from within Medical Services have been scant, and the program has developed few r e l a t i o n s h i p s with outside agencies, e s p e c i a l l y a s i m i l a r p r o v i n c i a l program. The p o l i t i c a l and s o c i a l i s o l a t i o n of Indians i n Canada i s echoed by the i s o l a t i o n of t h i s program within the Department of National Health and Welfare and the province. The program's p o t e n t i a l of improving Indian health, of a c t i n g as a lever to general development, of encouraging Indians to t r a i n and work i n the health f i e l d to eventually have Indians i n c o n t r o l of t h e i r health s e r v i c e , has not nearly been met. The p o l i t i c a l u n c e r t a i n t i e s surrounding Indian a f f a i r s make i t d i f f i c u l t to foresee the r e s u l t s of any decisions. However, i f the Indian health s e r v i c e and t h i s program eventually become the r e s p o n s i b i l i t y of the province, the scope and circumstances under which i t w i l l be operating w i l l broaden. The advantages of having the large p r o v i n c i a l s e r v i c e ' s resources a v a i l a b l e to the program w i l l be great, and the p o s s i b i l i t y of c l o s e r i n t e g r a t i o n with Indian and regional development w i l l a r i s e . The most precious asset of the program, i t s f l e x i b i l i t y , i t s a b i l i t y to adapt to i n d i v i d u a l communities, must be c a r e f u l l y maintained. Thinking about these p o t e n t i a l s and preparation for such changes should s t a r t now. i i i To ray family and f r i e n d s , and to ray s u p e r v i s o r s — without whose help I could not have gotten by. i v CONTENTS PAGE TABLE OF CONTENTS i v LIST OF TABLES v i ^ i MAP OF INDIAN RESERVES VISITED i x ACKNOWLEDGEMENT _x INTRODUCTION 1 A. PURPOSE AND ORIENTATION OF THE THESIS 1 B. BIOLOGICAL AND PSYCHOLOGICAL PERSPECTIVES 2 C. SOCIOLOGICAL PERSPECTIVES 3 D. ANTHROPOLOGICAL PERSPECTIVES 6 E. POLITICAL AND SOCIAL MOVEMENTS 8 CHAPTER I HISTORY OF THE COMMUNITY HEALTH 1 3 REPRESENTATIVE PROGRAM A. THE PLANNING PHASE 1 3 B. THE FIRST TRAINING PROGRAM 1 7 1 . F i r s t Evaluation 1 8 2 . Further Evaluation 2 0 C. CONTINUING DEVELOPMENT OF THE PROGRAM AND 2 1 THE TASK FORCE REPORT D. REGENT DEVELOPMENTS IN ALBERTA 2k CHAPTER I I PROGRAM EVALUATION 2 7 A. EVALUATION: GOALS VERSUS SYSTEMS 2 7 1 . Goals Measurement 2 7 2 . Systems Analysis 3 2 V cont•d PAGE B. A COMBINED APPROACH TO EVALUATION: 35 THE METHODOLOGY CHAPTER I I I HEALTH AND SOCIAL STATUS OF INDIANS ifl A. HEALTH STATUS STATISTICS kl B. SIGNIFICANT ILLNESSES IN THE INDIAN 50 POPULATION 1. Tuberculosis 50 2. Other Communicable Disease 53 3. N u t r i t i o n 55 k. Mental I l l n e s s 56 5- Accidents, Violence and Suicide 57 6. Alcohol Abuse 58 C. SOCIAL STATUS OF INDIANS 60 1. D i f f i c u l t i e s of Measurement 60 2. S o c i a l Indicators 62 i . L i v i n g Standards 63 i i . Housing 66 i i i . Education 66 i v . S o c i a l Deviance 69 CHAPTER IV OBJECTIVES OF THE CHR PROGRAM Ik A. WRITTEN OBJECTIVES ?k B. GENERAL ANALYSIS OF OBJECTIVES 83 C. UNSTATED OBJECTIVES OF THE PROGRAM 90 CHAPTER V CONSUMER INVOLVEMENT IN HEALTH 95 A. OBJECTIVES A1-A12 HEALTH OF THE FAMILY 95 1. Objectives A l and A2 Parental and 95 Immunization C l i n i c s 2. Objective A3 N u t r i t i o n 97 3. Objective A*f Dental Hygiene 99 k. Objective A5 Environmental Safety 99 v i cont'd... PAGE 5. Objective A6 Family Planning 103 6. Objective A7 Exercise 10*+ 7. Objective A8 Alcohol Abuse 105 8. Objective A9 Home Nursing 108 9. Objective A10 Transportation 111 10. Objective A l l Screening 111 11. Objective A12 Water Sampling 112 B. GENERAL ANALYSIS OF OBJECTIVES A1-A12 112 C. OBJECTIVES A13-A20 COMMUNITY AND GROUP 119 FUNCTIONS 1. Objective A13 Health Classes 119 2. Objectives A14-A15 Development and Use of 120 Educational Aides 3. Objectives Al6 and Al8 Band Council Meetings 122 and Health Committees *f. Objective A17 Group Work 124 5. Objective A19 Workshops 125 6. Objective A20 I n t e r d i s c i p l i n a r y Work 125 D. GENERAL ANALYSIS OF OBJECTIVES A13-A20 126 CHAPTER VI CULTURAL LINKING 133 A. OBJECTIVES B21-B2*f THE LIAISON ROLE 133 1. Objectives B21 and B22 C u l t u r a l Bridging 133 2. Objectives B23 Use of Resources 137 3. Objectives B2k S e n s i t i z a t i o n lkO B. GENERAL ANALYSIS - CHR ACTIVITIES IN 1^3 OBJECTIVES B2l-B2k v i i cont'd... PAGE CHAPTER VII CONFLICTS IN THE PROGRAM 152 A. CONFLICTS IN THE OVER-ALL GOAL 152 B. CONFLICTS BETWEEN A-GROUP SUB-OBJECTIVES 153 C. CONFLICTS BETWEEN B-GROUP SUB-OBJECTIVES 158 D. CONFLICTS IN THE THIRD OBJECTIVE: 159 CHAPTER VIII CONCLUSIONS AND RECOMMENDATIONS l 6 l A. ANALYSIS OF OBJECTIVES l 6 l 1. Rating of Achievement of Sub- 162 Objectives A1-A12 2. Rating of Achievement of Sub- 165 Objectives A13-A20 3 . Rating of Achievement of Sub- 168 Objectives B21-B24 k. Discussion 170 B. POLICY CONSIDERATIONS: COORDINATION AND 170 ISOLATION C. FURTHER POLICY CONSIDERATIONS: ROLE CONFLICT 175 D. RECOMMENDATIONS FOR THE CHR PROGRAM l 8 l 1. Go or No-Go? l 8 l 2. What- i s "Responsibility"? 182 3. What Should the CHR be Doing? 185 k. The: T r a i n i n g Required 187 5 . The Place of Evaluation 190 E. THE FUTURE 191 LITERATURE CITED 19^ OTHER LITERATURE CONSULTED 203 APPENDIX I: FIELD VISITS TO CHR'S ON FEDERAL INDIAN 208 RESERVES IN ALBERTA APPENDIX I I : INTERVIEWS CONDUCTED IN THE COURSE OF 209 THE STUDY APPENDIX I I I : JOB DESCRIPTION AND SPECIFICATION REPORT 210 FOR CHR'S v i i i LIST OF TABLES NUMBER TITLE PAGE I SELECTED VITAL STATISTICS I I LEADING CAUSES OF DEATH IN ALBERTA 1965 *+8 I I I LEADING CAUSES OF DEATH IN ALBERTA 1973 ^ IV TUBERCULOSIS RATES IN ALBERTA 53 V COMMUNICABLE DISEASE CASES AND RATIOS 1973 ^ Alberta VI INCOME POSITION OF INDIANS IN CANADA 6*+ VII REVENUE OF THE FIFTEEN INDIAN BANDS IN 65 C. D. 15 1966-67 VIII SERVICES IN INDIAN HOMES CENSUS DIVISION 15, 1968 66 IX GRADE DISTRIBUTION OF INDIAN AND OTHER PUPILS 68 IN ALBERTA SCHOOLS X CHILD MAINTENANCE AND PROTECTION SERVICE - 70 DEPARTMENT CF INDIAN AFFAIRS AND NORTHERN DEVELOPMENT XI PER CENT OF ILLEGITIMATE BIRTHS - OF TOTAL 71 LIVE BIRTHS I Ptisan Banc X ACKNOWLEDGEMENT Many people helped to make this dissertation possible. To Mr. Morton Warner, chairman of my committee, I owe special gratitude for his unfailing helpfulness, good humor and patience throughout the lengthy period of writing and research which this study involved. I thank him and the other member of my committee, Dr. Pauline Morris, for valuable advice and insight, which has helped me to cl a r i f y my thinking and writing and to discern the shape of the forest from a l l the trees I have noted. My greatest debt of gratitude i s owed to the Indian people who patiently shared their knowledge with me and helped me to understand the significance of the events they described. Much thanks i s also extended to the f i e l d personnel of Medical Services for their unfailing hospitality, and willingness to give information and take part i n vigorous discussions, which gave l i f e to sta t i s t i c s and scholarly literature. Many of their names appear i n the citation of sources i n the footnotes or i n the appendix of interviews. I would also lik e to thank the staff of the regional headquarters of Medical Services i n Edmonton for the opportunity to read their records and reports and discuss them with them, especially Dr. Kirkbride and Dr. Shedden. x i Moral and f i n a n c i a l support f o r t h i s t h e s i s i s g r a t e f u l l y [acknowledged from the Canadian Uni v e r s i t y Overseas Service Raya Pearlman Scholarship, and from Mr. Fran Brunelle of the Alberta Department of S o c i a l Services and Community Health. I t remains only to add that I myself am responsible f o r any e r r o r s , omissions, i n c o n s i s t e n c i e s or i d i o s y n c r a s i e s that remain. 1 INTRODUCTION A. PURPOSE AND ORIENTATION OF THE THESIS In 1962 at Norway House i n Manitoba, the f i r s t t r a i n i n g program to prepare native people as public health a u x i l i a r y workers was completed. Eleven native people returned from t h i s program to work on t h e i r reserves. The program, c a l l e d the Community Health Representative Program, has continued and expanded i n A l b e r t a up to the time of t h i s w r i t i n g . The purpose of t h i s t h e s i s i s to examine the written objectives of the program to determine to what extent i t i s meeting i t s manifest objectives and to discuss some of the f a c t o r s behind the d i r e c t i o n of i t s a c t i v i t i e s . From t h i s b a s i s , i m p l i c a t i o n s f o r the future development of the program w i l l be explored. The impetus to choose t h i s subject f o r a t h e s i s arose from the w r i t e r ' s experience as a nurse-educator i n a m u l t i l i n g u a l developing country, where the d e l i v e r y of health services i s implemented to a large extent through a u x i l i a r y health workers . The s i m i l a r i t i e s between t h i s developing country and c e r t a i n areas of Canada, notably those where native people predominate, impressed the writ e r with the f e a s i b i l i t y of using such workers i n the northern and l a r g e l y native areas of Canada, even though she has had l i t t l e d i r e c t experience with providing services to these areas. The wide scope of r e s p o n s i b i l i t i e s and r o l e s which can be taken by a u x i l i a r y workers has c e r t a i n implications for.the administration, supervision, and education of such workers, and open up e x c i t i n g p o s s i b i l i t i e s f o r extensive native involvement i n health care d e l i v e r y . 2 The stated Botive behind the a u x i l i a r y health worker program i n Canada i s that of r a i s i n g the health status of native people to a l e v e l as close as possible to that of the rest of Canadians. Strenuous e f f o r t s to improve the general socioeconomic status of Indians are s a i d to be a basic r e q u i s i t e to t h i s end. An expansion of t r a d i t i o n a l health services i s a l s o necessary. But t r a d i t i o n a l health services are geared to meet the needs and demands of the majority of white, middle-class Canadians, and native peoples are a minority, with d i f f e r e n t c h a r a c t e r i s t i c s . Innovative adaptations to s u i t the needs of natives are also required of the d e l i v e r y system. 1 Weidman and Egeland argue as a b a s i s f o r e s t a b l i s h i n g an e f f e c t i v e health d e l i v e r y system that a t t e n t i o n be paid not only to the usually considered geographic and environmental f a c t o r s , but a l s o to four other perspectives: b i o l o g i c a l (symptoms, disease), psychological ( s t r e s s , p e r s o n a l i t y ) , anthropological ( c u l t u r a l , e t h n i c ) , and s o c i o l o g i c a l ( c l a s s -structure and function). These four perspectives were used i n the context of both h i s t o r i c a l and current p o l i t i c a l and s o c i a l events to provide the basic framework f o r analyzing the functioning of the health a u x i l i a r y program i n Alberta. B. BIOLOGICAL AND PSYCHOLOGICAL PERSPECTIVES Numerous studies document the poor health of native people i n Canada. A quick examination of gross s t a t i s t i c s c o l l e c t e d by Medical Services of the Federal Government comparing Indian with n a t i o n a l health i n d i c a t o r s makes obvious the d i s p a r i t i e s . B r i e f l y , i n f a n t mortality and 3 t u b e r c u l o s i s , considered to be s e n s i t i v e i n d i c a t o r s of health status, and f o r which f i g u r e s are among the more accurate of health s t a t i s t i c s , show rates of two to three times the na t i o n a l rate f o r i n f a n t mortality and ten 2 to f i f t e e n times the rate f o r t u b e r c u l o s i s . A high incidence of i n f e c t i o u s disease, s u i c i d e , congential anomalies and accidents give compelling evidence of the gap which e x i s t s between the health l e v e l s of natives and those of Canadians i n general. E s p e c i a l l y t e l l i n g are the high rates of alcoholism and s u i c i d e , which according to one i n t e r p r e t a t i o n , represent a r e t r e a t from the ' v i c i s s i t u d e s of 1 ; ;life, a f a i l u r e i n h i s mechanisms of 3 adaptation and an escape from r e a l i t y '. C. SOCIOLOGICAL PERSPECTIVES "Socioeconomic status i s a t h e o r e t i c a l concept s t i l l awaiting k c l e a r d e f i n i t i o n " . Many v a r i a b l e s such as occupation, family income, l i v i n g conditions, s o c i a l p r e s t i g e , s o c i a l deprivation, c u l t u r a l d isorganization and combinations of these have been used to describe socioeconomic status. By any of these c r i t e r i a , the native people of Canada occupy the lower s t r a t a of society. In economic terms the present s i t u a t i o n of the Canadian Indian Reserve communities i s comparable to that of underdeveloped countries. Where the average Canadian family of 3*7 persons share 5»3 rooms, the average Indian family i n Canada must f i n d space of 6.4 people i n 3«6 rooms - a complete r e v e r s a l of the n a t i o n a l average. The i n f r a - s t r u c t u r e - the common mechanical ingredients needed f o r both s o c i a l and economic health of a community - r e f l e c t the same d i s p a r i t y with the natio n a l p i c t u r e . For Indian homes across Canada, there are 79% with e l e c t r i c i t y , 31$ with running water, 2k% with indoor t o i l e t s , 19% with indoor baths, and 25$ with telephones. This contrasts with 98% of houses with e l e c t r i c i t y ; 97*^% with running water, 96.1$ with indoor t o i l e t s ; 93-5% with indoor baths and 9^-3% with telephones across Canada. 5 (p. 7 ) . Unemployment l e v e l s are high and chronic dependence on welfare a l l too common. Nearly 50$ of the Indian population i s unemployed g and l i v i n g on r e l i e f ; ten times the natio n a l average, (p. 6) Educational l e v e l s are low, with l e s s than 90$ of Indian ch i l d r e n completing Grade 8; and 6% completing high school, compared with 88% f o r 7 the whole of Canada. (p. 6) A l l these features are both a r e s u l t of and a cause of the l a c k of achievement of good l e v e l s of health and health care. But there i s another aspect to socioeconomic status not measured by these data. Poverty i n i t s truest sense i s more than mere want: i t i s want mixed with a l a c k of a s p i r a t i o n and t h i s i s very d i f f i c u l t to measure i n any quantitative sense. " (p. 6) Oscar Lewis' "culture of poverty" has as i t s core despair, i n a cycle of hopelessness, i l l health and impoverishment, each r e i n f o r c i n g the other. Loss o f ^ s e l f esteem and f e e l i n g s of powerlessness and 5 apathy create dependency on impersonal agencies to make wide-ranging 9 decisions f o r c l i e n t s . At present, rather than being the designers and judges of t h e i r own economic destiny, Indian people have been the root of b i g business employing c i v i l servants, consultants, outside merchants who have been the chief b e n e f i c i a r i e s of large appropriations voted f o r the purpjge of aiding the development of Indian communities. (p. k) The statements of Indian leaders quoted above leave no doubt that the Indian people f e e l themselves that they share i n many of the c h a r a c t e r i s t i c s of poverty variously defined. Strauss,"''"'" i n a recent a r t i c l e , juxtaposes the l i f e - s t y l e of lower-income groups with the l i f e - s t y l e of the middle-class people to which the health d e l i v e r y system i s oriented. He claims that the dichotomy a l t e r s the d e l i v e r y of care to, and u t i l i z a t i o n of services by, people from these groups. To achieve better f i t between these groups, he puts f o r t h s i x proposals: to speed up the i n i t i a l v i s i t made by lower-income groups f o r health care, to improve the experiences which the patient has i n health f a c i l i t i e s , to improve the communication given and received about any necessary regimen, to increase the l i k e l i h o o d that the regimen w i l l be c a r r i e d out at home, to increase the l i k e l i h o o d of necessary r e v i s i t s to health f a c i l i t i e s , and to decrease the time between the necessary r e v i s i t s f o r care. In a l l of h i s recommendations other considerations besides 6 "lower-class" culture are i m p l i c i t : he a l s o c a l l s f o r knowledge of and s e n s i t i v i t y to ethnic groups, t h e i r values and b e l i e f s , and the s o c i a l and c u l t u r a l context i n which they operate. D. ANTHROPOLOGICAL PERSPECTIVES The health care of a people, the phenomena associated with the maintenance of well-being and the coping with i l l n e s s , emphasizes not only the b e l i e f s and p r a c t i c e s of a people, but also the pattern and function i n a c u l t u r e . A s t r i k i n g feature shown by ethnographic studies on health culture i s the u t i l i z a t i o n of several competing health treatment a l t e r n a t i v e s by people, each supported by a d i f f e r e n t 12 value p r o f i l e . T h i s was true f o r very few other s o c i a l i n s t i t u t i o n s studied (economy, education, p o l i c y ) which had clear-cut patterns f o r the l i f e s i t u a t i o n s . The p r a c t i t i o n e r s of "modern medicine" a l s o derive from a health culture with i t s own assumptions, categories and schemata and t h i s i s another source of Strauss' "mismatching". When the "out" group introduces a health program i n t o a community, the members of the community may be expected to a c t i v e l y choose between i t and any a l t e r n a t i v e s . Problems commonly c i t e d by health care d e l i v e r e r such as the non-recognition of the s i g n i f i c a n c e of disease signs, the n o n - u t i l i z a t i o n of resources and the non-acceptance of preventive health p r a c t i c e s , point to a f a r from smooth process of f i t between the two cultures. 7 Elements which characterize P l a i n s Indian culture such as a dependence on nature and a f a t a l i s t i c passive acquiescence to i t , the la c k of developed p o l i t i c a l organization, and the economic independence of f a m i l i e s , engender a sense of emotional i s o l a t i o n , emphasis on the maintenance of the status quo and a reluctance to exercise authority 13 and ascendancy over others outside the nuclear family. T h i s c o n f l i c t s with the bureaucratized, corporate organization of i n d u s t r i a l s o c i e t y which emphasized a c t i v i t y , mastery of the environment, upward mob i l i t y and concern f o r material well-being. The overwhelming d i r e c t i o n of acc u l t u r a t i n g forces have under-mined t r a d i t i o n a l c u l t u r e s , to the extent that the culture which now 14 e x i s t s i s a "reserve" c u l t u r e . Slobodin states that the great changes occuring e s p e c i a l l y since World War Two, the disappearance of almost a l l t r a d i t i o n a l occupations, techniques and a r t i f a c t s , and the weakening of such aspects of culture as language and r i t u a l : , have suggested to some observers that terms as "Indian" are no longer s u i t a b l e as a i d e n t i f i c a t i o n f o r many groupings of t h e i r cultures or subcultures, (p. 2 8 9 ) He a l s o states that there i s l i t t l e comprehensive information about the nature and i d e n t i t y of Canadian Indian groupings today but asserts that Indians l i v i n g away from t h e i r a n c e s t r a l groupings are undergoing more extensive and more intensive a c c u l t u r a t i o n than the land-based 15 groups. S i m i l a r l y , such gross measurements of a c c u l t u r a t i o n as 8 language spoken, educational l e v e l s reached and occupation held suggest that the Indians of A l b e r t a are acculturated to varying 16 degrees. A l l of these considerations point to the advantages of a f l e x i b l e i n d i v i d u a l i z e d approach to Indian communities and progams f o r them. I t i s the l o c a l group, rather than the large taxonomic category "Indians" that has meaning f o r health 17 deliverer..-E. POLITICAL AND SOCIAL MOVEMENTS The Indians of Canada can be considered a minority group, defined i n Wirth's terms as "a group of people ... s i n g l e d out" from the others i n the society i n which they l i v e f o r d i f f e r e n t i a l 18 and unequal treatment'-. The existence of a minority group by d e f i n i t i o n implies the existence of a p r i v i l e g e d dominant group of high s o c i a l status. 19 Lieberson points out that the subordination of indigenous groups and the d i s s o l u t i o n of t h e i r previous forms of organization are responsible f o r the creation of r a c i a l conscious-ness among the indigenous population. He says considerable c o n f l i c t occurs i n areas where the migrants are not simply superordinate, but have become i n a sense themselves indigenous by maintaining an established population through generations i . e . have become the majority. 9 The 1960's saw a newly awakened world-wide consciousness of people l i v i n g i n s o c i a l , economic and c u l t u r a l misery. In the United Nations, the 1960's were declared the "Development Decade". In North America, the burgeoning p o l i t i c a l movements among the Indians, the statement of Canadian fed e r a l Indian p o l i c y i n 1969* and the i n v e s t -i g a t i o n s by the Senate and other groups i n t o the nature of poverty i n Canada l e d to a movement aimed at allowing the natives a l a r g e r voice i n t h e i r c o l l e c t i v e f a t e . A growing consciousness of the need to be s e n s i t i v e to the wishes off.ethnic groups and to develop adaptations of t r a d i t i o n a l programs fostered new approaches to the "Indian problem". One approach to meeting the needs of depressed areas was to use indigenous non-professionals as workers i n various 20 f i e l d s . As Roberts sta t e s , consumers of services became motiv-ators and providers, r a t i o n a l i z e d by s k i l l based on c u l t u r e , f e e l i n g and communication, rather than t r a i n i n g and knowledge . A service offered by a peer i n language, e t h n i c i t y , background l i f e - s t y l e and i n t e r e s t s could be more e f f e c t i v e , i t was supposed, than that off e r e d by a p r o f e s s i o n a l . At the samel.time, i t was recognized that service occupations could be organized more e f f i c i e n t l y by breaking jobs i n t o hierarchy components which could be provided by people with d i f f e r e n t degrees of t r a i n i n g , and that t r a i n i n g could be provided l a r g e l y by systematic on-the-job experiences. 10 F. A REVIEW OF THE COMMUNITY HEALTH REPRESENTATIVE PROGRAM IN ALBERTA The t r a d i t i o n a l and conventional methods of health care had ra i s e d the health of most people Canada to a high l e v e l , comparable to * other i n d u s t r i a l i z e d countries. However the native people had apparently not b e n e f i t t e d / f u l l y from these approaches, as indic a t e d by the high l e v e l s of i l l - h e a l t h and s o c i a l problems among them. As a r e s u l t of the movement towards greater Indian involve-ment i n t h e i r own a f f a i r s , the fe d e r a l government set up a program i n 1962 to t r a i n and employ t r e a t y Indians as community health represent-a t i v e s . There were 18 employed i n Albe r t a , with another 26 taking t h e i r i n i t i a l t r a i n i n g i n the summer of 1975» An i n i t i a l survey of pro f e s s i o n a l s , organizations and govern-ment officials*knowledge about t h i s program indi c a t e d some confusion over the program objectives, and about the r o l e s , duties and r e s p o n s i b i l i t i e s of such workers. Controversy a l s o e x i s t e d over t h e i r e f fectiveness and e f f i c i e n c y . Uncertainty as to the future need f o r such workers, and trends occuring i n the U.S. e s p e c i a l l y regarding the careers and t r a i n i n g of para-professionals, suggested that a review of the program would be opportune at t h i s time. The review was divided i n t o several steps. The f i c s t step® * There are only three nations i n the world, Sweden, Norway and the Netherlands, which have a greater l i f e expectancy f o r females than Canada, and the difference between Canada and the best nation i s only one year. For male l i f e expectancy, there are s i x countries ... and the gap between Canada and the best nations i s Z\ years 21 11 were to determine i f the needs and concerns which the program was intended to serve had been adequately i d e n t i f i e d , and to determine who had been involved i n d e f i n i n g the needs and s e t t i n g up the program. These needs were presumed to be the basis of the program objectives which were then examined on several counts: t h e i r authors, t h e i r agreement with o v e r - a l l objectives of Medical Services, t h e i r appropriateness to the needs and expressed wishes of Indian communities, and t h e i r measurability and f e a s i b i l i t y of achievement. Next, various c r i t e r i a f o r measuring the achievement of these objectives were proposed as the b a s i s f o r assessment of the e f f e c t s and effectiveness of the program. Both the objectives themselves and the c r i t e r i a f o r measuring achievement of objectives were then analyzed from the context explained e a r l i e r i n t h i s chapter: a health d e l i v e r y system should take account of geographic, environ-mental, b i o l o g i c a l , psychological, anthropological and s o c i o l o g i c a l f a c t o r s i n i t s p o l i c y and implementation. The implications of past actions and present d i r e c t i o n s were explored, with recommend-ations offered f o r the future. I t i s hoped that t h i s sketch of the basic framework used i n the t h e s i s w i l l provide s u f f i c i e n t background f o r understanding the approach taken and the i n t e r p r e t a t i o n placed on the data c o l l e c t e d . Quantitative data f o r assessment of the program were:* not a v a i l a b l e , and examination focussed as much on the program context and the general o r i e n t a t i o n revealed by program a c t i v i t i e s 12 as on the act u a l achievements of the Community Health Representatives. These a c t i v i t i e s and achievements should i d e a l l y be the subject of furthe r research i n more depth than would be managed i n t h i s t h e s i s . 13 CHAPTER 1 HISTORY OF THE COMMUNITY HEALTH REPRESENTATIVE PROGRAM A. THE PLANNING PHASE In the l a t t e r part of the 1950's, both the Indian A f f a i r s Branch of the Department of C i t i z e n s h i p and Immigration, and Medical Services Directorate of the Department of National Health and Welfare were seeking f r e s h approaches to meeting the problems of Indian communities, i n the face of disappointingly slow development up to t h i s date. For various reasons, both departments had been discuss-i n g ways to t r a i n more Indians to, work i n t h e i r own communities i n the f i e l d s of education, health, welfare and general and economic development. I t was hoped that such programs would be an economical means of a l l e v i a t i n g some of the massive problems f a c i n g native communities i n the l i g h t of inadequate f i n a n c i a l resources. Indian workers would form a c u l t u r a l l i a i s o n between white professionals and natives, and help to t a i l o r programs and services to the i n d i v i d u a l communities. Increased i n t e r e s t i n and knowledge about the p r i n c i p l e s of community development l e d to a r e a l i z a t i o n that i d e n t i f i c a t i o n of needs as well as i n i t i a t i v e i n meeting these needs had sprung from l o c a l and indigenous roots, rasbhier than being defined and tackled by outside sources. As a r e s u l t of meetings between the two departments i n 1957 and 1958, i t was decided that the Medical Services Branch of the Department of National Health and Welfare (hereafter r e f e r r e d to as ••MS" or "Medical Services") would carry out a p i l o t project to t r a i n 14 and employ health workers. In i960, a planning group i n Ottawa Head O f f i c e , composed of medical and dental o f f i c e r s , a nurse, a n u t r i t i o n i s t , an accountant, an administrator, a personnel o f f i c e r and a health educator set down the p r i n c i p l e s of the Community Health Worker program. They outlined the c r i t e r i a f o r areas where t r a i n i n g was to be conducted, the number and s e l e c t i o n of candidates, the duties of workers and of t h e i r employment a f t e r t r a i n i n g . The goals of the program were also s p e c i f i e d . Short-term goals were three: 1. to encourage the p a r t i c i p a t i o n of l o c a l people i n the health a c t i v i t i e s of t h e i r communities, by i n v o l v i n g them i n i n i t i a t i n g , planning and carrying out programs; 2. to give p r o f e s s i o n a l health workers an opportunity to become more e f f e c t i v e by providing a person who would l i a i s e with the community; and, 3- to increase the number of a c t i v e health workers i n the f i e l d . The long-term objective was to a s s i s t native people to reach and maintain a standard of health and l i v i n g conditions comparable to that of the remainder of Canada's population. 1 5 A committee was also set up at the Regional l e v e l , i n order to s e l e c t the actual areas where candidates were to be s o l i c i t e d (generally those with large populations with a high incidence of disease!!, to arrange f o r the provision of t r a i n i n g f a c i l i t i e s and to provide administrative support. To t h i s point, although Indians had long talked about employing t h e i r own people i n community work, no mention was made of consult-a t i o n with Indian leaders or communities, at l e a s t i n the published reports and government documents seen by the author. I t remained f o r Medical Services to explain the program to the Indians and to s o l i c i t t h e i r co-operation, as w e l l as that of the other l o c a l communities and Medical Services personnel at Federal, Regional, Zone and nursing s t a t i o n l e v e l . In the communities selected f o r health workers, the program was interpreted by the health educator and planning committee to Medical Services s t a f f , Indian A f f a i r s Superin-tendents, Reserve opinion-leaders and to Chiefs and C o u n c i l l -ors who i n v i t e d views from the community at Band meetings. Care f u l s e l e c t i o n of candidates was recognized as one of the key r e q u i s i t e s of a successful program. The importance of personal and leadership q u a l i t i e s i n the applicants i n pref-erence to academic q u a l i f i c a t i o n s were explained to the Chiefs and C o u n c i l l o r s . People who had the respect and t r u s t of the 16 community, who were s e n s i t i v e to i t s needs and who had already displayed resourcefulness and i n t e l l i g e n c e i n community work, who were seen as 'helping persons', were to be selected and recommended by the Chiefs and C o u n c i l l o r s . They were to be b i l i n g u a l , l i t e r a t e and preferably married and; s e t t l e d i n the community. The f i n a l choice was; .l e f t to the Regional Planning Committee. Eleven candidates were selected, four women whom i t was considered would be a s s i s t a n t s to the f i e l d nurses, and seven men who would focus on basic s a n i t a t i o n . Thair functions were defined as follows: 1. They were to be teacher/motivators, who would acquaint t h e i r people with health concepts and techniques, and teach them the u t i l i t y and function of the l o c a l health s e r v i c e s , e s p e c i a l l y the preventive services. 2. They were to play a l i a i s o n r o l e , helping c l i e n t s to contact and use the appropriate services. 3. They also had an outreach/detection r o l e , as they were to go i n t o homes, and become involved i n group work to determine needs and a s s i s t i n meeting them. 17 k. Their job included helping the community to become more s e l f - r e l i a n t i n health matters. An advocacy/mobilization r o l e was implied, where the worker, basing h i s planning on expressed community needs, was to t r y and ensure that the human service needs of the people were met by a s s i s t i n g community groups or government to develop new f a c i l i t i e s , resources or programs. Trai n i n g and supervision a f t e r s e l e c t i o n were recognized as the other cornerstones f o r the successful u t i l i z a t i o n of such workers. The f i e l d , nurses responsible f o r o r i e n t a t i n g the new workers were prepared by l i t e r a t u r e explaining the program and t h e i r own r o l e , along with a p r a c t i c a l manual f o r the o r i e n t a t i o n period. They were expected to help plan the workers' t r a i n i n g course and to be present during part of i t as w e l l . B. THE FIRST TRAINING PROGRAM In 1961, i n Norway House, Manitoba, the eleven candidates received three months of i n s t r u c t i o n a f t e r a two-month o r i e n t a t i o n on t h e i r own reserves with t h e i r supervising nurses. Orientation was designed to give them a basic grounding i n the 'f a c t s ' of t h e i r communities, to l e a r n the r o l e s of such people as the teachers, RCMP, clergy and so on, what resources were, a v a i l a b l e to meet the d i f f e r e n t needs of people, and about l o c a l health conditions and 18 peoples's a t t i t u d e towards thera. B u i l d i n g on that foundation, the t r a i n i n g course concentrated on techniques «f teaching a i d s , comm-unica t i o n theory, interviewing s k i l l s , and the work of government agencies. The trainees also studied the St. John F i r s t A i d Course and the women weiee given a course i n home nursing. The whole program was designed to provide the candidates with i n f o r -mation, to develop and rei n f o r c e a t t i t u d e s considered appropriate f o r the work e.g. self-confidence, patience, independence, and to develop the s k i l l s regarded as necessary f o r community health work. Aft e r s i x seeks of general health education, the female candidates attended two weeks of discussions on public health nursing, and the males received p r a c t i c a l t r a i n i n g from the eegional s a n i t a r i a n . On graduation, each trainee was presented with a c e r t -i f i c a t e signed by the Ministe r of National Health and Welfare and the Director General of Medical Services. A l l were employed as Public Servants following the course. Another t r a i n i n g program was held i n 1963 and two more i n 1964 and 1965. 1. F i r s t Evaluation An evaluation was c a r r i e d out i n 1964 by a s o c i o l o g i s t from the U n i v e r s i t y of Saskatchewan, i n accordance with a p r i n c i p l e l a i d out by the Planning Committee cof an-going evaluation 19 of the program. The author concluded that the program could be considered successful as a whole, on the ba s i s that the communities had accepted an increase and d i v e r s i f i c a t i o n of the workers' a c t i v i t i e s . L i t t l e s t a t i s t i c a l measurement of the program was poss i b l e , but a c e r t a i n amount of data on garbage p i t and p r i v y construction, and attendance at c l i n i c s was sa i d to point to 1 d e f i n i t e improvements. Attention was drawn to the d i f f i c u l t i e s faced by the workers: the ro l e of acting as a communication l i n k between Medical Services personnel and the native people was constrained by diffe r e n c e s i n c u l t u r a l and educational background and by a lack of fluency i n E n g l i s h . This both r e s t r i c t e d the amount of information a worker could assimilate and affected the smoothness of the s o c i a l r e l a t i o n s between workers and t h e i r supervisors. Furthermore, communication d i f f i c u l t i e s between the workers and t h e i r communities sometimes arose as a r e s u l t of the Indians' t r a d i t i o n a l suspicion of white men's ideas and was augmented by the high turnover of nurses. The fac t that the workers were r e l a t i v e s and f r i e n d s of many people on the reserves, l e d to emotional entanglements complicating t h e i r work. Poor economic conditions made health a low p r i o r i t y on many reserves, and the longstanding l a c k of self-government workedtiagainst the people becoming invdsred i n , and asBuming r e s p o n s i b i l i t y f o r , t h e i r health s e r v i c e s . The author f e l t that without stimulation and 20 encouragement from Zone and Regional l e v e l s of Medical Services, the program would lose i t s c r e a t i v i t y and d r i v e : e x i s t i n g back-up services and v i s i t s from these l e v e l s were sa i d to be sporadic and inadequate. Workers were not always respected by whites outside Medical Services, teachers and Indian A f l a i r s employees experiencing s p e c i a l d i f f i c u l t y i n understanding t h e i r r o l e . The report suggested improved supervision of the workers,^ more communication between the workers themselves, improved working conditions (pay, transportation and teaching a i d s ) , increased p u b l i c i t y about the program on the reserves, improved c o l l e c t i o n and d i s t r i b u t i o n of information on the program and a l t e r a t i o n s i n the course content of the t r a i n i n g program to cover such t o p i c s as alcoholism, school drop-out and family planning. 2. Further Evaluation In 1966, Miss E t h e l Martens, the o r i g i n a l i n s t i g a t o r of the program, studied community development and health education programs f o r the Indian populations i n the United States and Mexico. The broad regional approach taken to community development by the Mexican government was compared^with the Canadian Community Health Worker program, i n the l i g h t of the d i f f e r e n t geographic, economic, demographic and p o l i t i c a l conditions i n the two countries. The author concluded that although the Community 21 Health Worker program by i t s encouragement of s e l f - r e l i a n c e i n the health f i e l d might lead to the spread of such an a t t i t u d e to other f i e l d s such as education and economic development, these e f f e c t s would be of only secondary importance to the health department. The Mexican program involved a l l agencies of government i n a region, i n the b e l i e f that the i n t e g r a t i o n and co-ordination of a l l govern-ment a c t i v i t i e s was necessary i n order to integrate Indian commun-i t i e s i n t o the l i f e of the nation. Questions were thus r a i s e d as to whether the necessary h i g h - l e v e l co-ordination i n p o l i c y -making and execution was developing i n Canada, and whether the Mexican experience i n community development held some lessons f o r Canada. C. CONTINUING DEVELOPMENT OF THE PROGRAM AND THE TASK FORCE REPORT Further t r a i n i n g programs were held i n 1967-68. By that time there were 73 workers trai n e d across Canada, and 63 were s t i l l working with Medical Services. In 1970, a number of changes were introduced i n t o the program. The formal t r a i n i n g was divided i n t o two periods of eight weeks and four weeks, separated by s i x months of on-the-job t r a i n i n g . The number of trainees was increased, so that a l l Regions had Community Health Workers. They were not made Public Servants once graduated, but were put on personal contracts with Medical Services, as an interim step to becoming Band employees ( s t i l l , i n 1975» an infrequent occurrence). By <1973 . 4-7.9% of the male workers and 81.°# of the female workers remained, of a t o t a l of 212 workers trained i n Canada. 22 When programs move from implementation as p i l o t p rojects to i n s t i t u t i o n a l i z a t i o n on a large scale they commonly undergo c e r t a i n modifications. This was true here, where program expansion l e d to re l a x a t i o n of some of the p r i n c i p l e s o r i g i n a l l y l a i d down i n i960. The program had to be adapted to a wider v a r i e t y of geographic, economic and s o c i a l conditions. Greater emphasis on Band s e l e c t i o n of trainees and pressure to obtain candidates meant that s e l e c t i o n c r i t e r i a were modified. S u f f i c i e n t encouragement and support f o r a l l the workers was d i f f i c u l t to ensure, and some communities were not given adequate o r i e n t a t i o n to the program. Even though i t was recognized that a c e r t a i n amount of information had to be provided to communities, community leaders and Medical Services personnel i n order to e l i c i t t h e i r co-operation, e f f o r t s to t h i s end were not alwayB s u c c e s s f u l . Administrative and community enthusiasm fluctuated from very nigh i n some regions to very low i n others. F i e l d nurses were i l l - p r e p a r e d f o r carr y i n g out workers' o r i e n t a t i o n and on-the-job, t r a i n i n g ; refresher courses were infrequent; co-operation between various l e v e l s of Medical Services was sometimes lacking; and Community Health Workers expressed d i s s a t i s f a c t i o n with t h e i r pay and f r i n g e b e n e f i t s . During the 1970*s the numbers of nurses, health educators and Environmental Health O f f i c e r s employed by Medical Services had 23 increased s u b s t a n t i a l l y , as d i d the number of l o c a l , native workers operating on the reserves i n health and other f i e l d s . Indian organizations had become more voc a l , and many Bands had attained more self-government than previo u s l y . In the absence of administrat-i v e c l a r i f i c a t i o n and co-ordination, changes i n the r o l e s of Medical Services personnel r e s u l t i n g from the a l t e r e d environment were confusing and v a r i a b l e . These growing pains of the 12 year-old program and the need f o r "new horizons" f o r Community Health Workers were the subject of a Regional Conference held i n Ottawa i n February, 1972. This l<ed> to the establishment, i n May 1972, o f a Task Force on Community Health A u x i l i a r i e s . I t purpose was to develop new Community Health A u x i l i a r y r o l e s that would a s s i s t Medical Services to achieve i t s ultimate objective of making native standards of health and w e l l -being comparable to those of the r e s t of Canada. By October,of that year i t had recommended Branch p o l i c y f o r the d i r e c t i o n and t r a i n i n g of Community Health A u x i l i a r i e s , and had o u t l i n e d medium and long-range implementation plans. One of the major recommendations was that two Community Health A u x i l i a r y r o l e s be established: a Community Health Represent-a t i v e whose main o r i e n t a t i o n was to the community, and a Family Health Aide whose main function was toward the i n d i v i d u a l and the home. These workers would be employed by Band or Hamlet contract. zk The p r i n c i p l e s of career development and progression were l a i d out, from a f i r s t - l e v e l probationary worker to the fourth l e v e l of Community Health A u x i l i a r y Advisor. A minimum amount of refresher or advanced t r a i n i n g was to be a condition of continued employment. More formal mechanisms to evaluate workers' performance was urged as well as a program to encourage native people to work i n the health professions with Medical S e r v i c e s . ' D. RECENT DEVELOPMENTS IN ALBERTA In the two and a h a l f years since the report was promulgated, a number o f the recommendations have been followed, arid others have been honored more i n the breach than i n the observance. In A l b e r t a , the two d i s t i n c t r o l e s f o r a u x i l i a r y workers e x i s t , and the t r a i n i n g program f o r the two, while having most elements i n common, diverges along c e r t a i n l i n e s e.g. the Family Health Aides receive more i n s t r u c t i o n on the use of many drugs. The workers have r e s i s t e d any move to become Band employees, and the Bands themselves have not evinced any great desire to take over the administrative r e s p o n s i b i l i t y f o r these workers. The idea of career progression has not moved beyond the two stages or probationary and f u l l employee, though i n the summer of 1975, plans were being made i n A l b e r t a Regional Headquarters to have two Community Health Worker Co-ordinators as advisory personnel to Headquarters s t a f f and to nurses working with a u x i l i a r y workers. The hope of providing more continuing education f o r the workers seems to have dimmed with the r e s i g n a t i o n of the A l b e r t a Region Health 25 Educator i n the summer of 1975, with no replacement planned. A d d i t i o n a l l y , ways to finance transportation f o r workers are being sought, but f i n a n c i a l r e s t r i c t i o n s make t h i s u n l i k e l y i n the; near future. Twenty-four new workers, mainly i n the Community Health Representative category, were given a 4-week t r a i n i n g course i n Edmonton i n August 1975 by a f i e l d nurses drawn temporarily from her usual work on a reserve? near Edmonton. A l l the nurses who had orientated these workers f o r the previous two months and who would be supervising them hereafter, were urged to attend the course f o r a few days to f i n d out something of the course content and the r o l e of such workers. However, only three of twenty-four attended. The workers returned to t h e i r reserves f o r a probationary period of s i x months before the second h a l f of t h e i r formal t r a i n i n g course. The nurse-t r a i n e r also returned to her usual duties on her reserve and expected to be able to have l i t t l e or no contact with the new workers or t h e i r nurses u n t i l the next t r a i n i n g period, i n January of 1976. The opportunity f o r the author to look i n t o t h i s program arose when she worked i n 1976 f o r the Al b e r t a health department i n Edmonton, where the p r o v i n c i a l and f e d e r a l governments both have headquarters f o r t h e i r a u x i l i a r y worker programs. This examination of the use of a u x i l i a r y workers for st minority group i n a developed country, comparing i t to previous experiences with such workers i n 26 a developing country, highlighted f or the author the s i m i l a r oppor-t u n i t i e s and d i f f i c u l t i e s experienced by such health workers every-where. The basic p r i n c i p l e s f o r the t r a i n i n g and employment of a u x i l i a r i e s are the same, and useful lessons can be learned by following the progress of these programs i n d i f f e r e n t regions and countries. Such was the c u r i o s i t y that l e d to a program evaluation of the Community Health Representatives i n Alberta. 27 CHAPTER II PROGRAM EVALUATION A. EVALUATION: GOALS VERSUS SYSTEMS A program i s a set of r e l a t e d a c t i v i t i e s c a r r i e d out by an organization to achieve some purpose or purposes. One type of evaluation study examines the a b i l i t y of the program to achieve i t s objectives - the "goals measurement" evaluation. A set of dimensions are chosen as c r i t e r i a by which to measure the organization's actual performance against the " i d e a l " performance ( i . e . goal achievement) of the program's a c t i v i t -i e s . T h i s i s one measure of e f f e c t i v e n e s s . A second approach i s found i n the 'systems' school of thought, which focusses evaluation attempts on the r e l a t e d a c t i v i t i e s of a program, as well as i t s purposes. Ef f e c t i v e n e s s i n t h i s approach i s defined as the optimal a l l o c a t i o n of resources between achieving the program goals, co-ordinating the organizational sub-units, acquiring and maintaining resources, and adapting to the i n t e r n a l and external environment of the organization, a l l of which are necessary f o r 1 organizational e f f e c t i v e n e s s . 1. Goals Measurement The more commonly used method of evaluation of effectiveness i s the measurement of goal attainment. I t i s supposed to remove the evaluator's b i a s , as he must use "objective" c r i t e r i a to judge the organization i * e . i t s goals. Nevertheless, goals are normative i n the sense that the evaluator reports what the goals are, or should be, 28 as d i c t a t e d by the consistency of h i s personal theory about the 2 r e l a t i o n s h i p among parts of s o c i a l systems. This model also 3 makes, as E t z i o n i points out, two assumptions: that organizations have an ultimate goal which they wish to r e a l i s e , and that the ultimate goal can be i d e n t i f i e d e m p i r i c a l l y and progress towards i t measured. Although goals give a good set of clues as to the organization's primary o r i e n t a t i o n , they may also i d e a l i z e , r a t i o n a l i z e , or omit some aspects of the organization's function-i n g , k Goals may be public or private,-and the organization may be pursuing e i t h e r or both. Organizations may also.seek to perform a number of c o n f l i c t i n g goals, and those working i n the organization may also have varied goals. F i n a l l y , those r e c e i v i n g the services and the wider public may agree or disagree with any of these goals. The evaluator must determine which of a l l of these goals are being r e a l i z e d and indeed, i f they are meant to be r e a l i z e d . He must also determine from observing the organization's a c t i v i t i e s i f there are undeclared or informal goals being pursued, and evaluate effectiveness on that b a s i s as w e l l . This provides an obvious way f o r evaluators to 5 introduce t h e i r own biases. As Yuchtman and Seashore point out, i t i s d i f f i c u l t to separate private goals from e f f e c t , f o r people 29 l e a r n to pursue r e a l i s t i c goals which they r e a l i z e and from which they receive p o s i t i v e reinforcement. For example, i f growth i s d i f f i c u l t , the organization w i l l pursue goals which are non-growth-oriented. These comments are germane to t h i s study, f o r the goals of the program as set out by Medical Services, supplemented by object-i v e s the author i n f e r r e d from the CHR job d e s c r i p t i o n , (see Appendix •Job Description f o r CHR's') have formed the b a s i s of the a n a l y s i s . The author assumed that Medical Services was t r y i n g to achieve the written objectives and then considered the measurement, of progress to these ends As w e l l , the assumption that having such workers requires a c e r t a i n administrative framework f o r t h e i r t r a i n i n g and back-up has l e d the author to analyze the program from that basis as w e l l , even though no written objectives concerning these areas were seen by the author. The goals may be examined as goals-in-themselves; that i s , as regards t h e i r t i e - i n with superordinate program goals, t h e i r b a s i s on s c i e n t i f i c a l l y v a l i d and adequate evidence, t h e i r measureability and t h e i r f e a s i b i l i t y of achievement, c o n f l i c t s inherent i n them and so on. In terms of actual achievement of goals, the long-term end r e s u l t s of such programs as the Community Health Representative program, i . e . the ' e f f e c t s ' on morbidity and 30 m o r t a l i t y , are inconvenient f o r p r a c t i c a l purposes of program evaluation. Even i f such r e s u l t s could e a s i l y be measured, i t i s obvious that many organizations do not reach t h e i r ultimate goals. This i s not to say that organizations should immediately be branded as having 'low e f f e c t i v e n e s s ' . They can be evaluated also i n terms of immediate or intermediate goals, as the former are, i n a well set-up program, the intermediary steps on the way to the ultimate goals. They give an idea of e f f o r t , or the immediate objectives of e s t a b l i s h i n g a s e r v i c e , such assa c e r t a i n number of c l i n i c s . They can also give an idea of performance or accomplishment, such as the number of people with v i s u a l problems detected. Assuming that some of the needs e x i s t i n g i n a community are known, as impression of the appropriateness of the work being done i s possible. In t h i s way, i . e . measuring short-term means rather than long-term ends, the measurement of a program's e f f e c t can be approached. This i s however, one of the important c r i t i c i s m s of functionalism: means tend to become ends, and the provision of services i s assumed to r e s u l t i n b e n e f i t s , not a proven as s o c i a t i o n i n a l l cases. Some cautions must be added. S o c i a l a c t i o n and public health programs may be more concerned with t h e i r impact on a s i t u a t i o n and only secondarily on i n d i v i d u a l s . They do not often produce dramatic impacts, r e q u i r i n g e i t h e r very s e n s i t i v e i n d i c a t o r s or else very large samples.^ Where goals are e x p l i c i t 31 and knowledge about important r e l a t i o n s h i p s i s good, the assumption that an a c t i v i t y leads to an e f f e c t i s reasonably v a l i d . Public health programs and preventive medicine frequently s u f f e r from just t h i s lack. I f a program i s to a l t e r the natural course of a disease, the natural h i s t o r y of the disease must be known, and the points at which intervention w i l l a l t e r i t as w e l l . For many diseases, and c e r t a i n l y f o r various s o c i a l problems such as delinquency, the points 7 of i n t e r v e n t i o n and e f f e c t s are not known. The temptation with the goal model i s to focus too narrowly. I f a number of people are subjected to the same in t e r v e n t i o n with a clear-cut outcome, thei-ffleasurement of goal achievement i s u s e f u l . But the s i t u a t i o n i n which a program takes place i s e s s e n t i a l l y uncontrolled i . e . a community i s openifco a host of influences besides the program, and the program w i l l d i f f e r somewhat i n each community. The outcome of programs i s a f f e c t e d by the s t a f f and s i t e of the a c t i v i t y , as w e l l as the a c t i v i t y i t s e l f . I t i s thus more r e a l i s t i c to speak of an agent as a l t e r i n g the p r o b a b i l i t y of an occurence rather than causing an occurence. As w e l l , using a s t r i c t l y experimental design of planned - output measurement discourages the perception or i n c l u s i o n of unanticipated conseq-uences which may be just as or more important than the a n t i c i p a t e d ones. A l l of these d i f f i c u l t i e s are-reasons f o r the frequent 32 use of service statistics for evaluation purposes, in which the means of a program rather than the ends are emphasized. Means seems to be inherently more quantifiable, and this carries the danger of course that the final goals will be lost in carrying out the 'letter' of the means. But often the lack of knowledge or resources to do a more comprehensive evaluation means that the means; 1 are measured and goal achievement surmised. 2. Systems Analysis Systems analysis starts with a model of a multi-functional social unit which is capable of reaching a goal. The unit is one of a set of units which interrelate and operate together in some sense as a bounded larger unit. That i s , a system consists of subsystems which f u l f i l l the conditions of systems in themselves^ but which are also functional components of a larger system, or the suprasystem. Each 8 subsystem must interact with and adjust to the others. Because each system (or subsystem) must maintain some discontinuity with its environment, i t has boundaries across which i t interfaces with other systems. Matter, energy, information and people pass across these boundaries. Environment, or the surroundings of a system minus its suprasystem, is an important variable since i t interacts with and affects the organizational system, and vice-versa. Different environments call for different strategies and responses i f the 9 organization is to be effective. But there are problems in defining boundaries and environments. Boundaries can be physical, or can be 33 defined i n abstract terms of c l u s t e r i n g s of behaviour or i n t e r a c t i o n s . An environment can be described i n terms of the objective r e a l i t i e s of i t , the system's perception of i t , those elements which are relevant to goal attainment, information which the system uses to function, and i n various other ways. This i s one of the major d i f f i c u l t i e s i n using the systems model. I t requires} that the evaluator set up a working model of a goa l - a t t a i n i n g s o c i a l u n i t and determine what he considers to be the optimal a l l o c a t i o n of means within that u n i t to meet the four a c t i v i t i e s necessary f o r organizational effectiveness as described above. I t requires considerable knowledge of the way i n which an 10 organization of t h i s type functions. Organizational theory, i n i t s present stage of development, often does not provide a model of t h i s type f o r use i n evaluation. The d i f f i c u l t i e s of de f i n i n g boundaries and environments would have to be met by s e t t i n g very a r b i t r a r y c r i t e r i a which would a f f e c t outcomes of the evaluation. For example, with the Community Health Representative program, a l l of the Representatives could be considered as one subsystem, and a l l of the nurses as a separate subsystem, or a l l of the Represent-a t i v e s and t h e i r nurses with whom they work so c l o s e l y could be considered as a subsystem. E i t h e r the various communities i n which the workers function, or Medical Services could be co.. as the environment. The Branch of Medical Services i n the 3k Department of National Health and Welfare i n the fede r a l government could a l l be considered as various subsystems, or as suprasystems, while the provinces i n which the program i s c a r r i e d on would be part of the environment of some of these subsystems, and the p r o v i n c i a l governments part of the environment, or else a suprasystem f o r which elements of the program are subsystems. The nebulous nature of the concepts and the lack of empirical knowledge afforded by organization theory makes t h i s model very demanding and d i f f i c u l t to use. The 'system' i s almost undefinable f o r p r a c t i c a l purposes of evaluation. Systems theory adds some valuable points f o r consideration by noting that effectiveness i s a function of the work to be done, and the resources and techniques a v a i l a b l e to do i t . This i s another reminder of the need to evaluate the f e a s i b i l i t y of goals. The environment must be c a r e f u l l y taken i n t o account, the processes by which an organization copes with i t s environment, solving problems i n adapting to changing conditions. For example, program goals must be considered legitimate by the superordinate organization; they must be evaluated i n terms of t h e i r p r i o r i t y of attainment f o r the superordinate organization. But health programs are also i n the p o s i t i o n of having to motivate the "subordinate" organization i . e . i n order to succeed, the program must be legitimate i n the eyes of the consumers or r e c i p i e n t s of the ser v i c e . Because much of the 35 success of a program such as t h i s depends on behavioural change, Medical Services was anxious to obtain Indian p a r t i c i p a t i o n i n se t t i n g up the program and v a l i d a t i n g i t s goals. The i n t e r n a l environment, such as the r e l a t i o n s h i p s between Medical Services, a u x i l i a r y workers and nurses, the o r g a n i z a t i o n s methods of obtaining and maintaining t h e i r resources e.g. t r a i n e r s and a u x i l i a r y workers, and so on, are also than a necessary part of program evaluation. The systems method could be seen as useful help f o r spotting problems and bottlenecks i f a program does not appear to be meeting i t s objectives. I f these program elements are considered i . e . goals, e f f o r t , performance, process and environment f o r a standardized a c t i v i t y , as well as actual output, the measurement of effectiveness of program a c t i v i t y f a l l s between the systems approach and the goal-attainment-only approach. B. A COMBINED APPROACH TO EVALUATION: THE METHODOLOGY The main focus of the study was on attempting to understand the environment i n whichtthe program operated and the dynamics of the s i t u a t i o n , i n t e r n a l and external, which aff e c t e d i t s outcome. That i s , the emphasis was on process i n the program^ rather than outcome. P o l i c y .and s i t u a t i o n a l v a r i a b l e s were considered as important as outcome v a r i a b l e s . 36 The environmental context of the program was analyzed by reviewing among other things, the h i s t o r y of Pla i n s Indians since contact, and the h i s t o r y of the CHR program, anthropological l i t -erature on Indian culture and s o c i o l o g i c a l l i t e r a t u r e regarding m i n o r i t i e s , c l a s s - c u l t u r e c o n f l i c t s , community development programs, and evaluation methodology. Internal dynamics were examined by using organizational theory re management and work structures, educational theory on para-professional workers and i n s i g h t s from psychology i n t o interpersonal and intrapersonal functioning. These reviews helped to throw l i g h t on p o l i c y and s i t u a t i o n a l Variables a f f e c t i n g the program. The goals of the program were examined more as goals i n themselves - t h e i r f e a s i b i l i t y , appropriateness, inherent c o n f l i c t s -rather than concentrating on t h e i r achievement. They were considered to be revealing of general p o l i c y , and h e l p f u l to under-standing of the processes operating i n the program when studied i n conjunction with the p o l i t i c a l , s o c i a l and c u l t u r a l context of the program. Using the broad goals of the CHR program as written by Medical Services, and the CHR's job d e s c r i p t i o n , the author derived more intermediate and immediate objectives which could be observed and measured, and which were f e l t to be l o g i c a l steps toward the broad, o v e r - a l l goals. I t was noticed:'; that even though objectives 37 were written f o r the program, there appeared to be considerable divergence among the f i e l d nurses and workers as to t h e i r goals, ao that some emphasized one to the exclusion of others, or inter p r e t e d them d i f f e r e n t l y . The workers' performance would then have to be examined i n the l i g h t of these d i f f e r e n t s i t u a t i o n a l contexts. Preliminary interviews at Medical Services revealed that the exact e f f e c t s of the program were not being predicted by e i t h e r the administration of Medical Services or by the f i e l d personnel, since e f f o r t s were Been to vary with the personality of the nurses and workers, the p o l i t i c a l and economic climate on the reserves, the amount of contact between the Indian and white communities, past exper-iences with such workers, and other v a r i a b l e s . These s i t u a t i o n a l v a r i a b l e s were considered to be very important, and were the reason f o r the extensive review of the l i t e r a t u r e . Standardized and separate records are not kept by MS f o r the CHR program, e i t h e r f o r the work done by CHR's or f o r the resources put i n t o the program. Separate f i n a n c i a l accounting records are not kept and personnel concerned with t h e i r t r a i n i n g and supervision have other tasks as w e l l , so that i t i s possible to gain only an impression of tesource input, the ' s p i r i t ' of the e f f o r t . 38 Boos f e e l s that a d e s c r i p t i v e monitoring may be most appropriate i f there i s l i t t l e agreement on objectives, or i f ihere i s l i t t l e understanding on the a f f e c t the program i s l i k e l y to have, where the a n t i c i p a t e d e f f e c t s are so wide-ranging that an a r b i t r a r y focus only i s p o s s i b l e , or where the data wanted i s not obtainable or a v a i l a b l e . As the CHR program f i t t e d reasonably well with t h i s d e s c r i p t i o n , the author elected to pay short v i s i t s of two to three days each to a number of reserves where CHR'S were working. Though a longer time-period f o r observation or even p a r t i c i p a n t observation would have been be t t e r , i t was found necessary to r e l y h e a v i l y on memories and impressions of those who had been associated with the program f o r some time. Their observation about changes on the reserves over the period of time when the CHR's had been functioning, changes i n services given or u t i l i z e d , or a l t e r a t i o n s i n the physical and s o c i a l environment of each reserve, formed the background f o r pla c i n g the work of the CHR i n perspective. As w e l l , the Annual Reports of Medical Services i n A l b e r t a from 1965 to 1975 gave an idea of the services which had been offered by Medical Services over those years. Because of organizational s h i f t s i n administ-r a t i v e r e s p o n s i b i l i t y i n A l b e r t a dad changes i n methods of recording (sometimes reserves were recorded separately; sometimes they were grouped) i t was not possible to use the s t a t i s t i c a l data to follow changes i n such things as morbidity, m o r t a l i t y , or service patterns on any one reserve. Reports on the a c t i v i t i e s of the 39 health educators with regard to CHR's were included irregularly, and no separate mention was made of financial inputs to the program nor of the workers' a c t i v i t i e s themselves. With the assistance of the health educator at Medical Services headquarters, seven reserves were selected for v i s i t s . Four c r i t e r i a were used, to obtain as wide a range of CHR'S and reserves as possible. These c r i t e r i a were population size, distance from major population centres, the state of i t s economy and the evaluation of the resident CHR's work by f i e l d personnel. This last could introduce an element of bias into the author's observation, but since data was gathered mainly on the basis of the nurses' and CHR's impressions of their work, rather than on the author's personal observations, this was not considered to be extremely prejudicial. On this basis, the reserves chosen were the Blood Reserve, Hobbema (Pigeon Lake Reserve), Hay Lakes Reserve, Wabasca-Desmarais, Morley, Lac La Biche and Kehewin Reserve. After sending a letter to the concerned as preparation, the author went to the reserve to observe the CHR i n her work and to talk with her, and other Indian workers on the reserve, the Chief and the supervising nurses. An open-ended interview format was used i n an attempt to reduce as far as possible the 'threat' posed by an outsider. The inter-views attempted to cover a l l the basic areas of work mentioned by the objectives and the CHR's job description, as well as to s o l i c i t ko f e e l i n g s and impressions about the work s i t u a t i o n , as these were also considered to have an e f f e c t on the program output. The goais and objectives of the program, which formed the bas i s f o r the interviews,the data c o l l e c t i o n and the study as a whole are set out i n Chapter IV, as a prelude to t h e i r a n a l y s i s . 41 CHAPTER III HEALTH AND SOCIAL STATUS CF INDIANS A. HEALTH STATUS STATISTICS "There are l i e s , damn l i e s , and s t a t i s t i c s " , Disraeli said -a s t i l l - v a l i d commentary on the state of the art. In order to give the most accurate representation of the state of a phenomenon, sta t i s t i c s must be viewed i n the context of how men, resources, policies and strategies of the recording agency cover a given community, assign resources and record happenings. They are not only a record of various phenomena, but are themselves an indication of the norms, values and goals of a society. Data are gathered only when phenomena are considered important and measur-able and effective action can be taken on the basis of the information. They function to provide the basis of planning to future policies, though l i t t l e i s known systematically about the extent to which indicators are actually employed by policy-makers. For many important policies there are no yardsticks by which to ascertain how things are changing in a society. Even i f some st a t i s t i c s are chosen to indicate trends, they may give ambiguous measures of the magnitude and direction of change. For example, changes i n definitions of a category such as mental i l l n e s s can grossly alter the numbers which represent the phenomenon. Administrative procedures may cause startling changes e.g. hospital stat i s t i c s in British Columbia at one time kz recorded a zero incidence of alcoholism, f o r patients could not be admitted to an acute-care h o s p i t a l with a diagnosis of alcoholism. S t a t i s t i c s i s a branch of mathematics which i s concerned with the c o l l e c t i o n and a n a l y s i s of quantitative data. Indian health and s o c i a l status i s measured i n s t a t i s t i c a l s e r i e s which are used f o r other Canadians and f o r many other countries i n the world. This allows f o r a c e r t a i n amount of comparability between groups i n the s o c i e t y , and between countries. These s t a t i s t i c s a lso f i t i n t o the coneepts understood by policy-makers of health and i l l n e s s and q u a l i t y of l i f e by which they carry out programs. In c e r t a i n l e s s c l e a r l y defined e n t i t i e s , such as mental i l l n e s s , where c u l t u r a l variance i s i n f l u e n t i a l , i t i s more d i f f i c u l t to be sure that l i k e u n i t s are being counted together. The i n d i c a t o r s used to measure the chosen e n t i t i e s u sually r e f l e c t the orientations of the most powerful and a r t i c u l a t e groups being a f f e c t e d by the phenomena being measured. The index of health status at the demographic l e v e l i s presently derived e s s e n t i a l l y from mortality data. Attempts to measure health using as the s t a r t i n g point the idea of wellness have foundered on the l a c k of c r i t e r i a , .by which to measure t h i s state of p o s i t i v e health. Thus, the three i n d i c a t o r s of crude death rate, l i f e expectancy and i n f a n t mortality are commonly 43 accepted as gross i n d i c a t o r s of health, and provide reasonably accurate f i g u r e s f o r comparisons within and between nations. More comprehensive measurements of health status, or what Suchman terms " s o c i a l epidemiology", examine the s o c i a l and psychol-o g i c a l dimensions of health, as well as the scale of physical function-ing e.g. measures of s o c i a l d i s a b i l i t y , typologies of i l l n e s s , perceptions of health care needs, motivations to u t i l i z e health s e r v i c e s , and so on. This kind of information has been d i f f i c u l t to c o l l e c t on a broad bas i s . Instead, score - keeping on c e r t a i n diseases deemed to be more s i g n i f i c a n t i s c a r r i e d out on a routine b a s i s . Because morbidity i s l e s s e a s i l y defined than death, s t a t i s t i c s and jargon are l e s s complex than f o r mortality data. Morbidity data are often based on " s p e l l s " of sickness, where each " s p e l l " i s counted, regardless of the patient's i d e n t i t y . Administrative d e f i n i t i o n s may also be used, such as admissions to h o s p i t a l , or absence from school or work. Health surveys may record subjective impressions where a person reports f e e l i n g s of disturbance i n the state of h i s health, but these are not usually as important as other d e f i n i t i o n s of health status. Morbidity data are c o l l e c t e d from a v a r i e t y of sources. Accurate information regarding incidence and prevalence of disease i s obtained when i t s reporting i s compulsory e.g. t u b e r c u l o s i s . However t h i s method does not give a comprehensive view of i l l n e s s since i t i s r e s t r i c t e d to a few diseases, not a l l cases are seen by a physician, and some cases seen may not be reported e.g. streptococcal sore throat. Hospital data are of high q u a l i t y , but r e l a t e only to more serious conditions. Chronic diseases e s p e c i a l l y are under-reported since they may not seem serious enough to warrant a v i s i t to a doctor. Thus the s t a t i s t i c s are g r e a t l y a f f e c t e d by the population's w i l l i n g n e s s to u t i l i z e s e r i i c e s and to comply with advice, as well as the physician's s t y l e of p r a c t i c e . Other sources of morbidity information such as physicians' private records, absentee records i n schools and industry, or s o c i a l insurance programs are also a v a i l a b l e . I t i s more d i f f i c u l t to extract information from these sources, and they are subject to c e r t a i n in a c c u r a c i e s . S p e c i a l morbidity surveys can give comprehensive and d e t a i l e d information on the population studies, but they are expensive and may not be comparable to other surveys, or may be too small to be generalizable. S t a t i s t i c s c o l l e c t e d by Medical Services Branch of the Department of National Health and Welfare are the main source of morbidity and mortality s t a t i s t i c s presented here, supplem-ented by h o s p i t a l s t a t i s t i c s and the tuberculosis r e g i s t r i e s maintained by the p r o v i n c i a l health departments. The count of disease and m o r t a l i t y i n Indian communities i s one of the main 4 5 inputs to Medical Services' planning and programming. L i t t l e systematic knowledge i s available on the more sophisticated aspects of the measurement of health status as outlined above, though attempts are being made by Medical Services to collect information nn Indian communities regarding such matters as housing, nutrition, sanitation, incidence of various types of i l l n e s s and alcoholism, and other social and health problems. Statistics published by Medical Services are based on populations figures issued by the Department of Indian Affairs and Northern Development as of December 31 of each year. Medical services accepts a l l births, deaths etc. reported for registered Indians i n Alberta, though a considerable number liv e off the reserve and do not come under Medical Services* jurisdiction for health workers. They would be included under s t a t i s t i c s for ' A l l Alberta'. As Biderman points out i n his ar t i c l e ^ (p. 9 7 ) , we attempt to observe and comprehend aspects of reality which are important to us, but at the same time, "the aspects&jwe are best able to observe and comprehend seem to be those that become important". Some evidence of this i s seen in the stat i s t i c s 46 which Medical Services compiles, and the programs i t c a r r i e s on, which seem to be mainly against the easily-counted problems. TABLE I. SELECTED VITAL STATISTICS LIVE BIRTHS -Rate per 1000 population 1963 1973 A l l Canada 24 .6 15*5 A l b e r t a Indians 52.3 38.8 A l l A l b e r t a 27 .4 17.4 NATURAL INCREASE 1963 1973 A l l Canada 16.8 8.1 Alberta Indians 45.1 31.0 A l l Alberta 20.7 11.0 INFANT DEATHS Rate per 1000 population 1963 1973 A l l Canada 26.3 15.5 A l b e r t a Indians 56.9 33.3 A l l A l b e r t a 23.6 14.2 CRUDE DEATH RATE Rate per 1000 population 1963 1973 A l l Canada 7.8 7.4 A l b e r t a Indians 7.2 7.7 A l l A l b e r t a 6.7 6.45 47 AVERAGE AGE AT DEATH All Canada Alberta Indians All Alberta 1963  Male Female 6O.5 64.1 28 33 60.0 67.3 1973  Male Female 63.6 69.1 n/a n/a 64.6 69.3 Compiled from Statistics Canada, Vital Statistics Vols. I & III, Ottawa: Information Canada, 1973; from Dept. of National Health & Welfare, Medical Services Branch, Alberta Region, Annual Report, 1973* and personal communication, Dr. A. Shexlden, Zone Director, Medical Services Branch, Edmonton, February 17» 1977. The rate of natural increase of Indians in Alberta of 3.1$ in 1973 indicates the very high birth rates and the skewed age-structure of the native population—fifty-one per cent are under fifteen years of age, in comparison to the national figure of twenty-eight per cent. Over the past twenty-one years, Alberta has seen a 110.7$ increase in its registered Indian population. The high infant mortality rate is reflected in the lower average age of death. Of a total of twenty-five infant deaths in 1973 in Alberta, seven were due to infective and parasitic diseases (usually gastroenteritis), seven were due to respiratory disease, 48 six to suffocation (by bedding or regurgitation), and one to dehydration. The remaining four were related to the circulatory system, or were l i s t e d as "cause unknown". Most of the excess mortality i n the Indian infant population occurs i n the post-neonatal period and i s said to be a result of pathophysiology, geographic isolation, d i f f i c u l t y of communication across cultural 5 barriers, housing, sanitation, diet and parental apathy. TABLE II. LEADING CAUSES OF DEATH IN ALBERTA 1965 Alberta Indians Symptoms, senility and i l l -defined conditions Diseases of the respiratory system * of total deaths 29.8* 14.3* Province of Alberta Diseases of the circulatory system Neoplasms * of total deaths 34.7* 17.6* Accidents, poisonings and violence Diseases of early infancy Diseases of the 14.3* nervous system & sense organs 8.3* Accidents, poison-ings, and violence 12.0* 10.2* H* 9,534 Compiled from Dept. of National Health and Welfare, Medical Services Branch, Alberta Region, Annual Report 1965 and Dominion Bureau of Stat i s t i c s , Causes of Deaths i n Canada, 1965* 49 With 30% of the deaths being i n the category of "symptoms, s e n i l i t y and i l l - d e f i n e d conditions',' i t i s d i f f i c u l t to draw d e f i n i t e conclusions regarding the leading causes of death. Jorty-three of the f i f t y deaths i n t h i s general category were due to "other, unknown and unspecified causes", and of the for t y - t h r e e , f i f t e e n were i n people under twenty years of age. Medical Services expressed t h e i r concern to the Al b e r t a D i v i s i o n of the Canadian Medical A s s o c i a t i o n i n that year, with apparently good r e s u l t s , as can be seen i n the next t a b l e . TABLE I I I . LEADING CAUSES OF DEATH IN ALBERTA 1973 Alberta Indians Accidents, poisonings and violence Infective and p a r a s i t i c diseases 37% Diseases of the c i r c u l a t o r y system 17 5% Diseases of the res p i r a t o r y system 11.2% 5% Certain causes of p e r i n a t a l m o r t a l i t y 5% N=238 Province of A l b e r t a Diseases of the c i r c u l a t o r y system 46.2% Diseases of the respi r a t o r y system Neoplasms Accidents, poisonings and violence 7.0% 18.6% 9.9% N=10,763 Compiled from: S t a t i s t i c s Canada, V i t a l S t a t i s t i c s , V o l . I l l , 1973 and Dept. of National Health and Welfare, Medical Services Branch, Alb e r t a Region, Annual Report 1973. 50 These s t a t i s t i c s r e f l e c t p a r t l y the major r e v i s i o n of the International C l a s s i f i c a t i o n of Disease of 1968, and p a r t l y a change i n reporting of causes of death. In 1973 "symptoms* s e n i l i t y and i l l - d e f i n e d conditions" accounted f o r only 1.7* of A l b e r t a Indian deaths. They must also be read i n the context of the younger age-structure of Indian populations. Accidents, r e s p i r a t o r y diseases, and i n f e c t i v e and p a r a s i t i c diseases heavily a f f e c t the young, while two of the leading causes of death i n the province as a whole, cancer and cardfevascular diseases, are diseases of degeneration, a f f -e cting the e l d e r l y . Nevertheless,the f a c t of excess . mortality f o r a l l age groups of the Indian population remains. B. SIGNIFICANT ILLNESSES IN THE INDIAN POPULATION Several aspects considered to be e s p e c i a l l y s i g n i f i -cant i n the health p r o f i l e of the Indian population have been selected f o r more d e t a i l e d comment. These are the incidence of t u b e r c u l o s i s , communicable and n u t r i t i o n a l disease, mental i l l n e s s e s , ^ a c c i d e n t s and violence, and alcohol abuse. 1. Tuberculosis There has been a general decline i n tuberculosis m o r t a l i t y i n North America and Western Europe f o r the past one hundred years 51 but the reasons f o r t h i s are not c l e a r . The epidemiology of tuberculosis i s of great i n t e r e s t f o r i t appears to be heavily a f f e c t e d by c u l t u r a l c o n f l i c t . Ethnic, r a c i a l and economic minority status, i n d u s t r i a l i s a t i o n and urbanisation are a l l evident f a c t o r s . Poverty, with the associated e v i l s of mal-n u t r i t i o n and poor housing, i s usually involved. Alcoholism and mental i l l n e s s are common problems i n tuberculous patients. L i f e c r i s e s , such as changes i n occupation or residence and marriage break-ups, are frequent i n the two-year period before the onset of the disease. Thus tuberculosis can be considered a rough guide to a whole complex of v a r i a b l e s e x i s t i n g i n the environment and the i n d i v i d u a l which i n d i c a t e low l e v e l s of health and l i v i n g . In the white population, the disease i s more prevalent i n e l d e r l y , d e b i l i t a t e d , " s o c i a l l y marginal" people, and r e a c t i v a t i o n s make up the majority of cases. In marked contrast i s the incidence of tuberculosis amongst Indians. In 1973 i n Al b e r t a Indians, the greatest incidence was i n the age-group one to four years, and i n 1972 i n the group aged f i v e to nine. Even though the percentage of the Indian population i n these age-groups i s greater than i n 52 the white population, the incidence of cases here i s f a r out of proportion to the numbers of c h i l d r e n . About ninety per cent of the cases were new cases, not r e a c t i v a t i o n s . Intensive contact with persons with an active.case of the disease i s the main reason f o r the high incidence i n c h i l d r e n , aided by overcrowded poor housing, poor d i e t , ignorance of the implications of symptoms and process of the disease, fear of being removed to a f a r - d i s t a n t h o s p i t a l and so on. The following table w i l l give an i n d i c a t i o n of the diffe r e n c e s between Indian and white populations. The s t a t i s t i c s * are not s t r i c t l y comparable, since Medical Services reports morbidity rates per 100,000 population (new and reactivated cases found that year) while p r o v i n c i a l s t a t i s t i c s are reported as "patients underttreatment" i . e . cases discovered that year, plus patients s t i l l being treated from previous years. The f i g u r e s are complicated s l i g h t l y by non-Alberta t r e a t y Indians l i v i n g i n A lberta being included and Alberta treaty Indians l i v i n g out-side the province not being represented. The numbers are small and do not a l t e r s i g n i f i c a n t l y the o v e r - a l l p i c t u r e . The Indian rate per 100,000 i s based on the population of a l l A l b e r t a bands. 53 TABLE TSf. TUBERCULOSIS RATES IN ALBERTA 1963 Province of Alb e r t a 1963 Alberta Indians 1973 Province of A l b e r t a 1973 Alberta Indians No. of patients 339 being treated 208 discovered 311 being treated 75 discovered Rate of reported cases per 100,000 population 2571 280.0 18.6 2kk.k Compiled from S t a t i s t i c s Canada, Annual Report of N o t i f i a b l e Diseases, 1963 & 1973: and Alb e r t a Dept. of Public Health, Annual Report, 1963 & 1973. 2. Other Communicable Diseases The amount of communicable disease i s another i n d i c a t o r of the health of a population, and i n d i r e c t l y of i t s s o c i a l status, f o r most communicable diseases are more prevalent i n areas where people have inadequate housing, water supplies, d i e t and education. The following table compares case counts and r a t i o s f o r several important diseases. The r a t i o of the r e g i s t e r e d Indian population to the p r o v i n i c a l population i s 1:53» the Indians making up about 1.9% of the p r o v i n c i a l population. 54 TABLE V COMMUNICABLE DISEASE CASES AND RATIOS 1973 Alberta Disease No. of cases i n No. of cases Ratio of cases Indian population i n province Indians:province Typhoid 1 3 1:3 Salmonella 42 545 1:13 B a c i l l a r y dysentery 40 322 l : l 8 Diphtheria 19 89 1:4.7 Strep throat 16 3624 1:227 Infectious h e p a t i t i s 15 1321 1:88 Measles 33 56l 1:17 Whooping cough 1 34 1:34 Compiled from S t a t i s t i c s Canada, Annual Report of N o t i f i a b l e Diseases, 1973, and Medical Services, Alberta Region, Annual Report, 1973« The Indians are generally over-represented i n a l l the categories except f o r streptococcal sore throat and i n f e c t i o u s h e p a t i t i s . Infectious h e p a t i t i s i s a disease which often has vague, i l l - d e f i n e d symptoms which might not, i n the mind of a person unaware of t h e i r s i g n i f i c a n c e , j u s t i f y a t r i p to a health p r o f e s s i o n a l , e s p e c i a l l y i f the t r i p involved considerable time, trouble and expense. Likewise f o r strep throat, which can e a s i l y be taken f o r "ordinary" sore throat and not deemed to be serious. Other i n f e c t i o u s diseases are highly prevalent, though 55 not serious enough to warrant i n c l u s i o n i n published s t a t i s t i c s . The Annual Report of Medical Services i n Albe r t a i n 1972 noted that The major health problems of the Indian people include i n f e s t a t i o n s with scabies and l i c e , tooth decay, o t i t i s media, tuberculosis and other i n f e c t i o u s d i s e a s e s . 0 (p .15) 3- N u t r i t i o n N u t r i t i o n a l status of persons has been found to be associated with reproductive capacity and prenatal and in f a n t s u r v i v a l , p h y s i c a l growth and development, and rates and 7 e f f e c t s of i n f e c t i o n s . Socioeconomic data and food consump-t i o n patterns show that the average Indian family's d i e t i s now marginally adequate. The Indian d i e t before contact with white men's thought to have been generally n u t r i t i o u s . The high infant m o r t a l i t y and childhood morbidity rates of Indians and t h e i r generally smaller s i z e and weight suggest suboptimal n u t r i t i o n a l states. Severe malnutrition i s not usually seen on reserves, except i n as s o c i a t i o n with h h i l d neglect. The n u t r i t i o n survey c a r r i e d out i n Canada by the Dept. of National Health and Welfare i n 1973 i n d i c a t e d a high prevalence of n u t r i t i o n a l problems among natives, such as low intakes of amany of the vitamins and minerals i n a l l age groups, i n c l u d i n g pregnant women, and too low c a l o r i c 56 intakes among adolescents, the e l d e r l y , and middle-aged women, i n sp i t e of the high incidence of obesity i n the l a t t e r g r o u p — r e s u l t s g considerably poorer than f o r the general population. k. Mental I l l n e s s The 1968 Annual Report of Medical Services i n Albefcta was the l a s t one containing s t a t i s t i c s on mental i l l n e s s among Indians. Detailsi'of the number of patients i n mental i n s t i t u t i o n s , and estimates of the number of mental defectives and mentally i l l persons at home were c a r r i e d , but since then, no mention i s made of t h i s category i n the annual reports. Mental i l l n e s s i s a d i f f i c u l t phenomenon to quantify, and some authors such as Thomas Szasz claim that mental i l l n e s s i s l a r g e l y a "myth", a concept analogous to that of wi t c h c r a f t , j u s t i f y i n g an oppressive method of s o c i a l c o n t r o l . Leighton and Murphy say that p s y c h i a t r i c disorders are patterns of behaviour and f e e l i n g which are out of keeping with c u l t u r a l expectations and which bother the person who acts and f e e l s them, or bother others around him, or both (p. 189).^ D i f f e r e n t c u l t u r e s , by d e f i n i t i o n , have d i f f e r e n t standaaris and expectations, and what may be dis t u r b i n g i n one i s not n e c e s s a r i l y so i n another. However, these authors f e e l that both culture and personality are not i n f i n i t e l y p l a s t i c and v a r i a b l e , but share some 5" 7 common ground, so that the symptoms of mental i l l n e s s are recognized as such i n most cultures, though are ascribed d i f f e r e n t diagnostic categories and theories of causation. Indians would l i k e l y be under-represented i n studies of mental i l l n e s s based on f i g u r e s of patients under the care of p s y c h i a t r i s t s or i n mental i n s t i t u t i o n s . A s e r i e s of recent studies have established a s i g n i f i c a n t r e l a t i o n s h i p between s o c i a l c l a s s 10 and prevalence of treated p s y c h i a t r i c disorders. ' As Medical Services had no f i g u r e s on numbers of Indians r e c e i v i n g p s y c h i a t r i c care i n Alberta other i n d i c a t o r s of mental st r e s s for.which there are f i g u r e s , have been chosen to give a rough idea of the prevalence of mental problems. 5. Accidents, Violence and Suicide In 1965, there were twenty-four Indian deaths due to "accidents, poisonings, and violence", compared to seventy-one i n 1973 — a 300% increase. The Indian population had grown by only 3-f per cent i n these years. Accidental deaths are the leading cause of death i n 1973 f o r a l l age groups between t h i r t e e n months and forty-nine years. In 1969, a l l of the male deaths (17) i n the twenty to twenty-nine year age-group were caused by accident or violence, with a l c o h o l i c i n t o x i c a t i o n a known contributory f a c t o r 58 i n ten of the deaths. This high rate of accidental death could be due mainly to the dangers of the environment i n which many Indians l i v e e.g. the old, unsafe cars many dr i v e , the wood frame houses with f a u l t y heating systems or open f i r e p l a c e s , the prevalence of guns where people hunt and trap f o r a l i v i n g . K arl Menninger adds a further consideration. We know that suicide can be accomplished i n d i r e c t l y , that i s , without the a c t i v e , conscious p a r t i c i p a t i o n of the i n d i v i d u a l . We know of people who seem to have accidental deaths, which, we are convinced from our. knowledge of the case, are unconsciously^etermined.. (they have) unconsciously wished f o r i t . (p. 3^7) The theory f i t s with the high rate of known suicide and s e l f - i n f l i c t e d i n j u r y which accounted f o r approximately fourteen per cent of Alberta deaths i n 1972 among Indians, compared to a national rate of 5.1/100,000 among males and a rate of 1.6/100,000 among females i n 1972. 6. Alcohol Abuse As one man said , " I t ' s the only time I f e e l l i k e a man — when I'm drunk."''"' 59 A combination of psychological need f o r r e l i e f from various stresses and the s o c i a l pressure and support from^a s i m i l a r l y - t h i n k i n g subgroup seems to create a s e l f - r e i n f o r c i n g process entrapping many Indians. The e f f e c t s of alcohol are devastating and reach i n t o every aspect of Indian l i f e . The a s s o c i a t i o n of alcohol with crime, homicide, accident, unemployment and divorce i s well documented i n the white population and Indians are subject to the same e f f e c t s . A study of sudden deaths i n B r i t i s h Columbia i n 1969 showed that a high proportion of them occurred i n Indians who had been drinking. The death rate from suicide was almost three times greater f o r Indians than f o r non-Indians; the accidental death rate almost four times greater, and the death aate from homicide over t h i r t y times greater. Alcohol was a known f a c t o r 14 i n over seventy per cent of the cases. A doctor with long experience with Indian patients stated that the incidence of i n f a n t morbidity and mortality due to malnutrition, exposure, burns, pneumonia, skin i n f e c t i o n s and chronic ear i n f e c t i o n s i s s t r i k i n g l y higher i n f a m i l i e s where a great deal of drinking i s c a r r i e d on. Excessive drinking contributes to reserves often being s p l i t i n t o two f a c t i o n s : the ' 15 drinkers and the non-drinkers. Whatever the dynamics of drinking among Indians, alcohol contributes to a very large percentage of the socio-medical and mental health problems of Indian communities. In fiact, i t s unfortunate presence can be seen i n the background of every s t a t i s t i c quoted i n t h i s chapter. SOCIAL STATUS OF INDIANS 1. D i f f i c u l t i e s of Measurement S o c i a l i n d i c a t o r s serve as i n d i c e s of s o c i a l l y important 16. conditions i n society. However, a key problem i s the d e f i n i t i o n of " s o c i a l " . Roughly, s o c i a l i n d i c a t o r s could be described as the non-economic aspects of a s o c i e t y e.g. education, health, housing and crime and other l e s s obvious aspects: p o l i t i c a l p a r t i c i p a t i o n , s o c i a l m o b i l i t y , status of m i n o r i t i e s , morale etc. They t r y to measure well-being, or the ' q u a l i t y of l i f e ' i n a society, and are c l o s e l y r e l a t e d to the objectives of a society, e s p e c i a l l y those 17 a r t i c u l a t e d as n a t i o n a l p o l i c y . ' They s u f f e r from important d e f i c i e n c i e s though. Even i f a society agrees on the various goals i t wishes to achieve, i t i s d i f f i c u l t to match these goal statements with acceptable i n d i c a t o r s of achievement of these goals. Often the means used to a t t a i n goals are more e a s i l y q u a n t i f i a b l e than the goals themselves and there i s a danger of viewing these means as ends-in-themselves. E s p e c i a l l y f o r s o c i a l , noneconomic fa c t o r s such as p o l i t i c a l and economic organization, psychological a t t i t u d e s and human resources, quantitative measurement i s l a c k i n g to a more serious extent than f o r other v a r i a b l e s . Thus the o b j e c t i v i t y of such data i s l e s s , since o b j e c t i v i t y depends on the character of the symbols used to describe the phenomeaa, and the meaning of numbers between people 61 18 i s more s i m i l a r than i s the meaning of words. These f a c t o r s are measured only i n d i r e c t l y ; surrogates'.that stand i n the place of the v a r i a b l e s of i n t e r e s t are measured. For example, i t i s not possible to measure " e g a l i t a r i a n sentiments" i n a so c i e t y , but i t i s possible to compile s t a t i s t i c s about the d i s t r i b u t i o n of wealth. One t a c t i c used to get around measuring d i f f i c u l t i e s i s that of concept reduction i . e . the s o c i a l concept i s defined as that which i s measured by the operational d e f i n i t i o n , which may d i f f e r considerably from the otherwise-established content of the concept. Much s o c i a l i n d i c a t o r data are i n d i r e c t , having been c o l l e c t e d f o r other purposes, and t h i s makes i t d i f f i c u l t to combine with other data to construct an index, or m u l t i -• 19 d e f i n i t i o n a l i n d i c a t o r of s o c i a l status. The accuracy and v a l i d i t y of the data which i s c o l l e c t e d depends on the competence of the data-gathering agency, the openness of the subject to i n v e s t i g a t i o n and the s u s c e p t i b i l i t y of the subject to measurement. There i s a tendency to ask questions which are more e a s i l y q u a n t i f i e d and questions of q u a l i t y may be downplayed. Other influences a f f e c t i n g what data are gathered are not e n t i r e l y r a t i o n a l i n teams of information a c t u a l l y needed: a v a i l a b i l i t y of resources, p o l i t i c a l issues which push c e r t a i n issues to the fore and downplay others, r e l a t i v e strengths of important o f f i c i a l s i n s t a t i s t i c s -producing agencies and so on. 62 2. S o c i a l Indicators I t has been suggested that a reasonably f u l l d e s c r i p t i o n o f s o c i a l status should include the measurement of incomes - t h e i r l e v e l s , s t a b i l i t y and source (the l a t t e r a f f e c t i n g the s o c i a l 'honor' of i n d i v i d u a l s ) and various measures of comparative income such as share of the n a t i o n a l income. Assets should a l s o be measured - housing, durable goods, savings, insurance. Basic services are important, such as education, t r a i n i n g , health, protection and transportation. A person's p o l i t i c a l p o s i t i o n , h i s i n t e g r a t i o n i n t o the p o l i t i c a l process, and the s e n s i t i v i t y of representatives to c e r t a i n groups, along with h i s s o c i a l m o b i l i t y and f e e l i n g s of s a t i s f a c t i o n as to h i s l i f e would help to round out the measurement of s o c i a l status.^ Indicators, i n the eyes of the National Commission of Technology, Automation and Economic Progress i n the United States, should a l s o include the measurement of s o c i a l costs and net returns to economic innovations, the measurement of s o c i a l i l l s e.g. crime, family d i s r u p t i o n , and 21 the measurement of economic opportunity. Obviously, desirable as a l l t h i s information would be, i t i s not a v a i l a b l e i n a systematic numerical form f o r Indians or the populationaas a whole. Such i n d i c a t o r s as average income, employment patterns, dependence on welfare, educational l e v e l s achieved, housing and c e r t a i n f a c i l i t i e s are q u a n t i f i e d , and are u s e f u l to give a rough idea of the s o c i a l status of Indians. 63 i) Living Standards A major focus for describing the place of Indians in Canada today seems to be not in terms of racial or cultural differences, their separate political identity, geographic distribution, their numbers or many other facets of their existence. They are described in terms of poverty. It i s a term which seems to cast a very wide net, including in i t incomes, houses, jobs, education, community services, goals, attitudes, adaptive behaviours and so on. "Poverty" i s a societal definition, and "lower-class" and "poor" lump together people who may be very heterogeneous in their backgrounds, problems and coping behaviour . The Economic Council of Canada defines poverty not as a sheer lack of essentials to sustain l i f e , but as lack of access to certain goods, services and conditions of l i f e which are available to everyone else and which have come to be accepted as basic to a decent minimum standard of living. It is not only economic insufficiency, but social and political exclusion as well. Poverty i s relative. In terms of the poverty line set by the Council, where $3,500 was needed in 1961 to sustain a four-person family, three-quarters of Indians earned less than 43*000 per year, and supported 22 larger families than four. 64 TABLE VI . INCOME POSITION OF INDIANS IN CANADA Year Per ca p i t a yearly income Indians Canada 1964 4300 $1,400 1973 $500 $5,513 (approx.) Compiled from: S t a t i s t i c s Canada, Canada Year Book, 1974; Economic Council of Canada, F i f t h Annual Review: The Challenge of Growth  and Change, 1968; National Indian Brotherhood, "Statement on Economic Development of Indian Communities," 1973-The d i f f e r e n c e , as Hawthorn explains ^ i s due to the Indian's concentration i n low-paid i n d u s t r i e s , the wide prevalence of unemployment and the lower percentage of the population being i n the productive age-levels of 16-64 years—4 5 % as compared to the Canadian average of 65%. Only 11.5% of Indian reservation households had incomes of $4000 or more i n 1965 (compare t h i s to the poverty l i n e quoted above) and 78.5% received l e s s than $3,000. This takes i n t o account the income derived from farming, trapping and f i s h i n g , 24 a r b i t r a r i l y set at $50 monthly. The national average unemployment f o r employable Indians i e . not disabled, i s 56%, compared to an 25 o v e r a l l national average varying between 6 and 10%. I t should be noted that Indians pay no income tax on earnings made on the reserves. 65 The number of employable Indian adults receiving public welfare 26 was about ten times the national average i n I969. A survey conducted i n 1966-68 i n Alberta Census Division 15, covering fifteen reserves i n northern Alberta, found the same syndrome of low incomes and high dependence on welfare. TABLE VIII REVENUES OF THE FIFTEEN INDIAN BANDS IN C. D. 15 1966-1967 Population 5,511 Leases $10,438 Farming $64,000 Ranching 34,500 Timber 98,558 O i l and Gas 258,498 Trapping 94,900 Fishing 23,500 Wild Hay 300 Welfare 372,408 Total $957,102 Per capita income $173.67 C. A. Sauve, The B-15 Plan—An Outline for Rural Development i n Alberta  Census Division 15, (Edmonton: Research and Planning Division, Human Resources Development Authority, Government of Alberta, 1969) P« 306. Average annual welfare payment per household i n 1968 was S579« No information was available on off-reserve earnings, which would raise the avarage per capita income somewhat. Welfare payments account for about one-third of revenues of the fifteen bands, similar to Hawthorn's survey. 66 i i ) Housing The same study examined housing on the f i f t e e n reserves. Considering that the average family size was s i x , a six-room house having three bedrooms, a kitchen, s i t t i n g room and bathroom would be adequate. Under these c r i t e r i a , only thirty-two of the 688 homes or 27 k.6% were adequate; about 75* were three rooms or l e s s (p. 308). TABLE VIII SERVICES IN INDIAN HOMES CENSUS DIVISION 15, 1968 E l e c t r i c i t y Flush T o i l e t Running Water Telephone C. D. 15 53-3% 2 .8* h.2% 1.6* Canada, 1971 98* 93-1* 96.1* 95-0* Compiled from Sauve, The B-15 Plan, p. 308, and S t a t i s t i c s Canada, Canada Year Book, 197*+, p. 569. Many remote communities i n the north of A l b e r t a are without any dependable form of e l e c t r o n i c communication, even for emergency 28 use. i i i ) Education The r e l a t i o n s h i p between the economic development of a country with the educational l e v e l s achieved therein shows a higher degree of c o r r e l a t i o n than f o r any other v a r i a b l e , according to the 29 UN Report on the World S o c i a l S i t u a t i o n . Although Hawthorn found important exceptions to t h i s among the bands he surveyed, he f e l t that the c o r r e l a t i o n generally held. 67 For those d e s i r i n g i n t e g r a t i o n i n t o the mainstream of Canadian s o c i e t y , education i n i t s i n s t i t u t i o n a l i z e d white middle-c l a s s d e f i n i t i o n i s deemed c r u c i a l . Integration, i n contrast to a s s i m i l a t i o n , encourages the newcomer to a so c i e t y to r e t a i n what he regards as best i n hi6 c u l t u r a l background, to contribute to the richness of s o c i e t y . I t implies f u l l e q u a l i ty i n services and opportunity. A s s i m i l a t i o n on the other hand denotes the l o s s o f c u l t u r a l i d e n t i t y . For some Indians, the educational system i s seen as an organized and continuous method of processing Indians i n t o dark-skinned white men, a process of c u l t u r a l extermination. The dilemma of r e c o n c i l i n g an "Indian i d e n t i t y " with f u l l p a r t i c i p a t i o n i n the educational system and the job market, i s a r e a l one. o^ten, g e t t i n g a higher education means removal from the home community f o r prolonged periods. Once a person i s educated, there are few job opportunities f o r him i n these communities. The prospect may w e l l appear to a young Indian as a "non-choice" between being excluded from b i s home community, yet not ever f i t t i n g i n t o the white man's society e i t h e r . The p o s i t i o n of the Indians i n regards to educational l e v e l s i s revealed by s t a t i s t i c s on numbers attending schools and post-secondary i n s t i t u t i o n s . 68 TABLE IX GRADE DISTRIBUTION OF INDIAN AND OTHER PUPILS IN ALBERTA SCHOOLS 1966-67 Elementary Junior High Senior High P u p i l s i n Indian Schools 83.6* 15.4* 1.0* Indian P u p i l s i n Other Schools 65.5* 26.5* 8 . 0 * T o t a l Indian P u p i l s 72.4* 21.4* 6 .2* Indian Association of A l b e r t a , "Proposals f o r the Future Education of Treaty Indians i n A l b e r t a . " ( B r i e f to the Educational Planning Commission of the Province of A l b e r t a , January, 1971). P. i v - 4. N a t i o n a l l y , 50* of Indian students do not go beyond Grade 30 S i x and 97* f a i l to reach Grade Twelve. About 300 Indians were e n r o l l e d i n post-secondary i n s t i t -utions i n A l b e r t a i n 1973» only t h i r t y - s i x r e c e i v i n g apprenticeship t r a i n i n g i n s k i l l e d trades. This represents . 5 * of a l l Albertans 31 registered i n apprenticeship programs. What emerges i s that the present educational l e v e l s of most natives are f a r below those of most other Canadians, and the gap has not been narrowing appreciably over the years since World War I I , when the nat i o n a l government decided that education was as necessary f o r Indians as f o r other Canadians. 69 A l l these f i g u r e s show one side of the communities i n which the Community Health Representatives l i v e and work. They problems they and Medical Services personnel face are not just those of various p h y s i c a l diseases, but the background from which they arise—unemployment, poor education and housing, low incomes. As well, the material and technological aspects of Indian l i f e are accompanied by a non-material c u l t u r e — t h e values, b e l i e f s , modes of behaviour which a f f e c t the health of the community; the health services must also come to grips with these i f health programs are to be e f f e c t i v e . i v ) S o c i a l Deviance Information c o l l e c t e d on s o c i a l " a c t s " reveals as much about the culture gathering the information as about those people on whom information i s c o l l e c t e d . - E s p e c i a l l y i n the areas defined as "deviant behaviour", the way people come to be l a b e l l e d as suspects or victims, deviant or desirable, i s c u l t u r a l l y determined. O f f i c i a l s t a t i s t i c s are relevant, but i t must be r e a l i z e d that the un i t s i n a given rate of behaviour can be the r e s u l t of quite d i f f e r e n t behaviours i . e . the "objective" manifestation o f the same form of behaviour can lead some i n d i v i d u a l s to be c l a s s i f i e d as deviant, but not others. For example, the c r i t e r i a used to i d e n t i f y a person as a "vandal" or as " i n c o r r i g i b l e " are very vague and include wide ranges of behaviour. 7 0 The following s t a t i s t i c s show aspects of reserve l i f e which have been q u a n t i f i e d and which are both a r e s u l t of and a cause of the health and s o c i a l problems on reserves. TABLE X:. CHILD MAINTENANCE AND PROTECTION SERVICES-DEPARTMENT OF INDIAN AFFAIRS AND NORTHERN DEVELOPMENT F i s c a l Year Number of Children i n T o t a l Costs % Increase Over Care, March 3 1 Previous Year 1 9 6 3 - 64 3 3 6 0 SI, 7 3 2 , 9 4 5 2 3 . 0 1 9 6 4 - 6 5 3642 2 , 0 8 3 , 0 0 0 24.5 1 9 6 5 - 6 6 3 1 9 9 3,464,000 1 8 . 9 1 9 6 6 - 6 7 3 6 3 7 3 , 5 1 1 , 0 0 0 2 0 . 2 1967- 6 8 4 3 1 1 4 , 8 5 1 , 0 0 0 5 3 . 8 1 9 6 8 - 6 9 4541 6 , 8 3 4 , 9 7 4 4 4 . 0 1 9 6 9 - 7 0 5 0 6 2 8 , 0 9 7 , 9 9 5 1 8 . 5 1 9 7 0 - 7 1 5 3 9 5 1 1 , 6 7 9 , 3 3 9 4 4 . 2 Department of Indian A f f a i r s and Northern Development, The Canadian Indian; S t a t i s t i c s (Ottawa: Information Canada, 1 9 7 3 ) , P- 2 8 . The Department of Health and S o c i a l Development i n Alberta i n 1 9 7 3 had 24% of i t s c h i l d care cases coming from l e s s than 2% of the population (i„e. the Indian population), mostly as a r e s u l t 32 of abandonment by parents who had problems with a l c o h o l . 71 I l l e g i t i m a c y i s commonly used as a measure of personal or s o c i a l d isorganization. This i s changing now, e s p e c i a l l y i n middle-c l a s s s o c i e t y , where deliberate choices are being made to have c h i l d r e n outside of l e g a l marriages, and the s o c i a l stigma of so doing i s lessening. I t must be noted a l s o that the i l l e g i t i m a t e o f f s p r i n g of thenunion of a treaty Indian mother and a non-treaty father are considered t r e a t y Indians and receive the benefits s p e c i f i e d under the t r e a t i e s , whereas the legitimate c h i l d r e n do not. To c l a s s i f y i l l e g i t i m a c y as deviance, i t must be assumed that a norm o f legitimacy e x i s t s among Indians. A study o f a reserve i n Quebec c a r r i e d out i n 1964 supported the hypothesis that commitment to the norm of legitimacy existed, but was weak due to a lac k of s o c i a l and c u l t u r a l i n t e g r a t i o n both within the community and between the community and the nation. T h i s l e d to low commitment to both a b o r i g i n a l and European norms and lac k of s o c i a l c o n t r o l of d e v i a n t s . ^ * TABLE XI PER CENT OF ILLEGITIMATE BIRTHS - OF TOTAL LIVE BIRTHS C D . 15 1967 16.9 Province of Albe r t a 1966 11.8 Canada 1966-70 8.7 Compiled from S t a t i s t i c s Canada, V i t a l S t a t i s t i c s , V o l . 1, 1967, and C.A. Sauve, The B-15 Plan, p. 298 . ' I l l e g i t i m a c y r e f e r s to those b i r t h s i n which the parents reported themselves as not having been married at the time of b i r t h or r e g i s t r a t i o n . 72 J a i l s t a t i s t i c s show an undue proportion of native people incarcerated. I n A l b e r t a , where the native population ( i . e . r e g i s t e r e d Indians and Metis) i s 5% of the p r o v i n c i a l population, the 1972 Annual Report f o r the Corrections Branch of the A l b e r t a Attorney-General's Department shows the following percentages o f 34 Indian and Metis prisoners: Lethbridge C o r r e c t i o n a l I n s t i t u t e 61% Fort.Saskatchewan (males) 25% Fort Saskatchewan (females) 62% Nordeg C o r r e c t i o n a l I n s t i t u t e 60% Calgary 12.7% Peace River 5**% The high a r r e s t rates may be p a r t i a l l y a r e s u l t of s o c i a l a t t i t u d e s and l e g a l d i s c r i m i n a t i o n towards natives, but the s i g n i f i c a n c e of the crimes can be given a proper perspective only when the type of crime i s examined: the number of l i q u o r i n f r a c t i o n s and a l c o h o l -r e l a t e d crimes i n every region of Canada i s so great as to almost 35, exclude a l l other kinds of Indian crime. The rates of alcoholism, mental i l l n e s s , accidents and violence quoted above must be very d i s r u p t i v e to family and community l i f e . By t h e i r very existence, they put-: more str e s s on the Indian people, r e q u i r i n g further adaptive e f f o r t s on t h e i r part, and thus tend to^assure the continuance of the pathology. 73 These health and s o c i a l status s t a t i s t i c s are but meagre q u a n t i f i e r s of the state of the Indian communities i n Al b e r t a . Their exact i n t e r r e l a t i o n s h i p s are not known,but they were chosen on the assumption that they are a l l important: the l e s s educated tend to be poor, the poor tend to be s i c k e r , and the s i c k are l e s s able to do anything about t h e i r poverty. Other f a c t o r s , not so e a s i l y q u a n t i f i a b l e , enter i n t o the determinationoof health l e v e l s of people as we l l , and w i l l be d e t a i l e d further on. I t was the evidence o f these f i g u r e s supplemented by knowledge of mostly unquantified s o c i a l , p o l i t i c a l and psychological v a r i a b l e s which formed the background of the Community Health Representative Program, and make up the context i n which i t now operates. 7-f. CHAPTER IV OBJECTIVES OF THE CHR PROGRAM A. WRITTEN OBJECTIVES The o v e r - a l l o bjectives which:vwere written at the program's incep t i o n are intended to give only a broad guide to the d i r e c t i o n of the program, and are not measureable as they stand. The author turned to the CHR job functions (see Appendix 3, Job Description f o r CHR's) r e l a t e d to the f i r s t two objectives from these derived immediate, short-term and intermediate objectives, each intended to incrementally increase the chance of reaching the program objectives and the ultimate goal of Medical Services. The o f f i c i a l program objectives are set out below with the job functions r e l a t e d to each. The immediate objectives derived by the author proved to be operational and could be measured i f data were compiled r e g u l a r l y . They formed the basis f o r the interviews and examination. L r Program Objectives: A. Job Function:': Immediate Objectives To encourage the p a r t i c i p a t i o n of l o c a l people i n the health a c t i v i t i e s of t h e i r t h e i r communities, by involving them i n the i n i t i a t i n g , planning and carrying out of programs. Provides consultation, advice and assistance to individuals and families on health matters and makes appropriate r e f e r r a l s when necessary by making home v i s i t s to prenatals, mothers with infants and young children, k5% of the time.. Intermediate Objectives Long-term Objectives 1. to have a l l pregnant women l a . to detect high-risk pregnancies l a . . t o have a l l pregnant women delivered attend prenatal c l i n i c 2. to have a l l children immunized completely 3« to teach people the elements of a nu t r i t i o u s , economical diet l b . to give good prenatal care 2. to raise the l e v e l of immunity to improve people's eating habits safely of healthy children as far as i s possible with modern technology l b . to reduce perinatal mortality to acceptable l e v e l s 2.^  to reduce the amount of communicable disease i n the community 3a. to reduce the amount of obesity, hypertension and diet-related disease 3b. to raise people's resistance to disease to the highest possible l e v e l s 3c. to provide optimal conditions for children's growth and development k. to teach people good k.. to increase the use of dental hygiene toothbrushes and dental services k. to reduce dental pathology and related diseases Immediate Objectives 5» to teach the community and parents aspects of a safe and hygienic environment 6. to teach people the value and techniques of family planning 7. to teach people the necessity f o r adequate exercise 8. to make people aware of the dangers of alcohol abuse Intermediate Objectives 5a. to remove domestic and environmental hazards 5b. to improve the l e v e l of personal and domestic hygiene 6a. to allow people to space t h e i r c h i l d r e n adequately 6b. to reduce the incidence of i l l e g i t i m a c y 7a. to help people obtain r e c r e a t i o n a l and exercise f a c i l i t i e s 7b. to increase the amount of exercise taken by those needing i t 8a. to reduce the amount of drinking and alcohol abuse 8b. to provide a l t e r n a t i v e a c t i v i t i e s to drinking 8c. to help people control t h e i r own and others' drinking Long-term Objectives 5a. to reduce the incidence of accidents of a l l types and the resultant d i s a b i l i t y and death 5b. to reduce the incidence of disease r e l a t e d to poor hygiene 6a. to help ensure c h i l d r e n are are welcome and adequately cared f o r 6b. to reduce p e r i n a t a l morbidity and mortality 6c. to reduce s t r e s s on f a m i l i e s and consequent pathology 7a. to provide an a l t e r n a t i v e to health-destroying behaviours 7b. to reduce the amount of disease., r e l a t e d to lac k of exercise eg. obesity, heart disease 8. to reduce the amount of al c o h o l - r e l a t e d disease, accidents and deaths 9 . to give elementary home nursing 9 a . care to the e l d e r l y , s i c k or i n f i r m and/or to teach others to do so. 9b. 10. to help arrange f o r trans- 10a. p o r t a t i o n , b a b y s i t t i n g or other forms of support 10b. 11. to perform basic screening and 11a. p h y s i c a l examinations 11b. 12. to take and record water samples 12a. f o r a n a l y s i s 12b. to maintain the health of people at current l e v e l s or to improve i t . to reduce the extent of i n s t i t -u t i o n a l i z a t i o n f o r health care 9 a . to help f a m i l i e s support each other 9b. to reduce family break-up 9 c . to provide cheap." -& apprppriate care to enable people to use resources 10. to ameliorate some of & services the people's problems within the scope of services a v a i l a b l e to increase the appropriate u t i l i z a t i o n of resources and services to detect abnormalities needing further care to provide a basic data base on people to advise people of the need to p u r i f y t h e i r water 11. to see that people receive further necessary care 11b. to f a c i l i t a t e the planning • ... programs & services 12. to reduce the amount of water-borne disease to advise l o c a l a u t h o r i t i e s of any need for safe water supplies Program Objective: as before Job Function: A s s i s t s the community and groups within the conimunity to improve t h e i r health status 40% o f the time. 13. to teach health classes i n fe d e r a l schools at l e a s t once a month 13a. to arouse i n t e r e s t among teachers and students i n health matters 13a. to help i n c u l c a t e habits of h e a l t h f u l l i v i n g at a young age ( i n the c h i l d r e n ' case) 14. to develop and posters and dis p l a y s , use f i l m s , s l i d e s e t c . i n health education programs 15. to u t i l i z e a v a i l a b l e mass media to disseminate health information 13b. to give teachers and chi l d r e n an 13b. understanding o f some of the elements of h e a l t h f u l l i v i n g 14a;. to arouse i n t e r e s t among:the 14a. community & inform them about health matters & services 14b. to r e i n f o r c e retention of information & understanding of health matters by using a v a r i e t y of media 14c. to present information i n a way which i s more understandable & acceptable to l o c a l people 15a. to reach a wide number of people 15» with health information to prevent or to reduce d i s a b i l i t y and morbidity to help change un-h e a l t h f u l ways of l i v i n g to more b e n e f i c i a l ones to help people change unhealthful ways of l i v i n g to more b e n e f i c i a l ones 15b. to complement & supplement other modes of teahhihg public about health 16. to r e g u l a r l y attend Band and Council l 6 a . meetings 16b. I6c. 17. to organize new groups or work with 17a. e x i s t i n g groups to improve the community's health 17b. 17c. 17d. to keep health workers informed about l o c a l current s i t u a t i o n s of importance to t h e i r work l 6 a . to create Indian leaders who are w e l l -informed about and able to administrate health programs to i n t e r e s t l o c a l Indian ad-administrators i n health matters l 6 b . to arouse appropriate l o c a l demand f o r ser v i c e s and programs to allow workers to give advice when asked f o r , and recommend needed l o c a l improvements to increase resources i n the community a v a i l a b l e to health workers 17a. to improve the chances of acceptance and success of health programs to arouse widespread i n t e r e s t i n and knowledge about health matters 17b. to meet demands and needs which the community defines as important to support e x i s t i n g attempts to meet problems i n the community to create a well-informed group who are able to administer health and other programs o oo l 8 . to take an active r o l e on health committees eg. draw up budgets, secure funding, supervise garbage c o l l e c t o r s and water-suppliers, etc. 19. to organize, plan, secure funds f o r and conduct workshops, short courses, continuing health education programs, youth summer camps, etc. l 8 a . to a s s i s t groups to be successful i n t h e i r chosen tasks l 8 b . to widen the scope of l o c a l committees 19* to help rpovide i n f o r -mation and services i n areas defined by the community as needing programs and services 18., 19a. 19b. to improve s k i l l s i n leadership and adminis-t r a t i o n i n l o c a l people to engender b e l i e f s and a t t i t u d e s conducive to greater a c t i v e control of themselves and t h e i r environment to reduce problems created by lack of employment and r e c r e a t i o n f a c i l i t i e s 20. to work with community leaders and ZQi workers, and with government o f f i c i a l s ,3 to resolve problems a f f e c t i n g the health of a community (This could a l s o be placed with the Program ^Objective following) to f o s t e r i n t e r e s t i n >,s-and habits of cooperation between workers 20. to achieve the greatest possible return to input by combining resources Program Objectives; B. To give p r o f e s s i o n a l health workers an opportunity to become more e f f e c t i v e by providing a l i n k with the l o c a l community. Job Functions: As before 21. to i n t e r p r e t between non-bilingual care-givers and consumers 21a. to enable care-givers to understand c l i e n t s * problems and provide appropriate care 21a. to help ensure safe and appropriate c^ Jjv-care i s given when needed 21b. to encourage and:mable c l i e n t s to use services 22. to advise health care personnel on the l o c a l c u l t u r e , values, t r a d i t i o n s , p o l i t i c s , e t c . 21c. to help l o c a l people understand the ways of a bureaucracy and white professionals 22a. to help health care personnel 22a. understand the people- behaviour 22b. to help personnel change people' i 22b. behaviour b e n e f i c i a l l y 22c. to allow personnel to adapt t h e i r 22c. services to l o c a l customs and needs 22d. to increase the s a t i s f a c t i o n f o r personnel of working with Indians to avoid destruction of b e n e f i c i a l habits to replace unhealthy habits with healthy ones to make services more acceptable to - people and thus more l i k e l y to be used 22d. to decrease turn-over among personnel 22e. to help make health personnel aware of t h e i r personal b e l i e f s , biases, and fee l i n g s about Indian people to advise people of and a s s i s t them to use the resources and services a v a i l a b l e to them eg. nurses, RCMP, Dept. of Indian (Affairs and Northern Development to make health care personnel aware of t h e i r personal b e l i e f s , biases and f e e l i n g s about Indian people to increase the use of available 23. to reduce the services appropriately incidence and s e v e r i t y of problems within the scope of the ser v i c e s Zk, to allow personnel to d e l i v e r a service which i s as sympathetic as as possible to the needs of the c l i e n t 8} B. GENERAL ANALYSIS OF OBJECTIVES The goal of the Indian Health Services Branch of Medical Services (hereafter r e f e r r e d to as Medical Services) i s to help the Indian and Eskimo population of Canada to a t t a i n the standards of health and l i v i n g conditions which are comparable to the rest of the population. It i s a statement of the general purpose of Medical Services and as such, i s quite vague and ambiguous, providing an idea as to the primary d i r e c t i o n f o r a l l a c t i v i t i e s of the Service, and at the same time allowing f o r the manoeuverability necessary to functioning under changing conditions. For example, the i n c l u s i o n of " l i v i n g conditions" i n t h i s goal suggests a very wide f i e l d of a c t i v i t y i s possible f o r Medical Services, implying involvement i n a c t i v i t i e s which might be more rigorously defined as belonging to economic, p o l i t i c a l or s o c i a l spheres. The phrase "comparable to the rest of the population" also allows f o r wide i n t e r p r e t a t i o n . Comparability does not mean equality, but implies a not-too-great d i s p a r i t y between Indians and other Canadians. Since Indians are mainly r u r a l , i t might more r e a l i s t i c a l l y r e f e r to r u r a l Canadians, rather than to the whole rest of the population, r u r a l and urban. One of the means to t h i s o v e r - a l l goal i s the t r a i n i n g and employment of Indians as Community Health Representatives. When the program was i n i t i a t e d , three shorter-term goals were 8k set out f o r i t . These objectives, or fundamental s t r a t e g i e s , as Drucker uses the term, must be viewed within t h i s framework of the existence o f a "health gap" i . e . d e f i c i e n c i e s i n the health status and health care of Indians i n comparison to most Canadians. The program could also be viewed as a part of a package of programs with broader s o c i a l o b j e c t i v e s , such as the a l l e v i a t i o n o f poverty or the improvement of education. In f a c t , i n a number of monographs and papers on the program, the main i n i t i a t o r of the program mentioned community development as the wider context within which the workers were to pursue the goal of improved health. They were to be "observers, diagnosticians, s t r a t e g i s t s and stimulators" i n helping to promote growth and development leading to improved 2* health i n t h e i r communities. However, since that purpose i s not mentioned d i r e c t l y i n the o f f i c i a l program objectives, nor d i d i t seem strongly evident i n the a c t i v i t i e s being c a r r i e d on i n the name of the program, the evaluation i s approached from the view-point of the health status of the native people, i . e . are the objectives appropriate to health needs and the resources a v a i l -able. I t would be i n t e r e s t i n g to examine the legitimacy of the goal of community development i n the o v e r a l l context of govern-ment dealings with Indians, and to speculate on some o f the •See also £. Martens "T r a i n i n g A u x i l i a r y Health Workers i n Community Development", paper prepared f o r Community Development Seminar, by the Department of Health Education, School of Public Health, U n i v e r s i t y of North Car o l i n a , Hhapel H i l l , May 5-9, 1963. 85 f a c t o r s which l e d to the seeming disappearance of t h i s goal, but t h i s i s beyond the scope of t h i s study. The a n a l y s i s of program objectives cannot stop at the l e v e l of the o f f i c i a l o b j e c t i v e s . These r e f l e c t values which the administration believes w i l l be accepted as le g i t i m a t e , but they do not i n d i c a t e p r i o r i t i e s among the several objectives, nor do they i n d i c a t e a l l the objectives being pursued by the members of an organization. These "operative" or u n o f f i c i a l goals can be i n f e r r e d from observing the a c t u a l a c t i v i t i e s and operating p o l i c i e s i o f an organization. They are i m p l i c i t i n the way 3 things are done, rather than e x p l i c i t l y recognized. Another important feature to note i s that s p e c i f i c targets and assignments can be derived from objectives which are operational i . e . objectives should give some i n d i c a t i o n of possible courses o f a c t i o n , and whether and to what extent an objective w i l l be r e a l i z e d by a sequence of act i o n s . They must be c l e a r , formulated i n concrete terms and understood by a l l employees. Another necessity i s that objectives be r e a l -i s t i c . There must be a reasonable congruity between the cap-a b i l i t i e s of the organization and the objectives to be reached -s u f f i c i e n t l y challenging to be motivating but not so f r u s t r a t i n g i f as to be demoralizing. The l a s t f a c t o r i s that objectives should be i n a l o g i c a l hierarchy with shorter-term subordinate objectives c o n t r i b u t i n g no longer-term and h i g h e r - l e v e l ones. 86 The objectives of the program w i l l be o u t l i n e d and -discussed according to the c r i t e r i a given above f o r " i d e a l " objectives, both the o f f i c i a l o b jectives, and those i n f e r r e d by the author from the job d e s c r i p t i o n of the Community Health Representative i n A l b e r t a as l a i d out by Medical Services. The assumption being made, of course, i s that the job functions determined f o r these workers are considered by Medical Services to be techniques of reaching subordinate goals, which are a means to the h i g h e r - l e v e l o f f i c i a l program ob j e c t i v e s . The three o f f i c i a l o bjectives set out f o r the program are: A. To encourage the p a r t i c i p a t i o n of l o c a l people i n the health a c t i v i t i e s of t h e i r communities by i n v o l v i n g them i n the i n i t i a t i n g , planning and c a r r y i n g out of programs. B. To give p r o f e s s i o n a l health workers an opportunity to become more e f f e c t i v e by providing a l i n k with the l o c a l community. C. To increase the number of a c t i v e health workers i n the f i e l d . The f i r s t objective i s d i f f i c u l t to quantify, suggesting l i t t l e i n the way of concrete tasks and functions which w i l l involve the l o c a l people, and what i s the extent 8> o f hoped-for involvement. "Local people" i s an unclear term -i t may mean l o c a l people i n terms of the workers themselves or may mean whole l o c a l communities. A reading of the o r i g i n a l philosophy behind the program seems to imply both, as does the workers* job d e s c r i p t i o n . I t ' s r e a l i z a t i o n i s subject to a c l a r i f i c a t i o n of what extent of "involvement" would be con-sidered a "success" f o r the program. S p e c i f i c parameters, such as the number of people attending planning meetings or using the health services could be used, i f data were a v a i l a b l e . These values of 'consumer"involvement" and "linkage^ don't provide s u f f i c i e n t l y concrete c r i t e r i a to be applied to s p e c i f i c d e c i s i o n a l problems. How much i s enough 'consumer involvement? How i s the CHR to be a l i n k - by working c l o s e l y with the nurse at c l i n i c s ? By working out i n the community or with the t r i b a l council? How much energy i s to be expended to obtain consumer involvement i f the Chief and Band di s p l a y l i t t l e i n t e r e s t i n health problems? I t would l i k e l y be subject also to the nature of the l o c a l s i t u a t i o n . Some communities may be already quite highly-organized and administering most aspects of t h e i r community l i f e , which would conceivably give a worker more resources to draw upon and more chances of obtaining l o c a l involvement i n health matters. 'Involvement'- would, i n one other sense, mean that more health-care givers are Indians, and a hoped-for s p i n - o f f from the program i s that i t w i l l 88 encourage more native people to educate themselves f o r careers i n the health f i e l d , and to work with t h e i r own people follow-i n g . "Involvement" also can mean that the Band take charge o f administration of the l o c a l worker - s e l e c t i o n , h i r i n g , f i r i n g and payment. The second objective i s again o p e r a t i o n a l l y quite vague. Providing a CHR as a 'link'' i s supposed to increase e f f e c t i v e n e s s 5 . How? By making health personnel more understanding of the consumers or devising more appropriate s o l u t i o n s to t h e i r problems, by making consumers more favorably i n c l i n e d to heed advice or use s e r v i c e s , by having a Medical Services representative i n the community at a l l times even when nurses are absent? I t does suggest that there should be good two-way communication between a u x i l i a r i e s and p r o f e s s i o n a l s and that a u x i l i a r i e s w i l l promote the a c t i v i t i e s of the p r o f e s s i o n a l health workers by some sort of teaching and p u b l i c r e l a t i o n s work. But c l a r i f i c a t i o n i s again only found i n the job d e s c r i p t i o n . T h i s objective i s more d i r e c t l y r e l a t e d to the o v e r - a l l goal o f r a i s i n g health status, but unfortunately c a r r i e s a suggestion as to the r e l a t i v e importances of a u x i l i a r y and p r o f e s s i o n a l work. The r e s p o n s i b i l i t y to 89 d e l i v e r e f f e c t i v e health care i s l a i d at the profe s s i o n a l ' s door, and the a u x i l i a r y ' s work i s to make that more probable, ignoring the r e a l p o s s i b i l i t y that the a u x i l i a r y worker may d i r e c t l y give good health care, rather than just f a c i l i t a t e another person's s e r v i c e s . Not mentioned d i r e c t l y here, but also pertinent to t h i s o bjective, i s the idea of having stable, long-term health workers i n the community i n the face of high nurse turn-over. This would hopefully encourage c o n t i n u i t y of carB-:and ser v i c e s and concomitant t r u s t i n the health s e r v i c e . As we l l , the a u x i l i a r y workers allow f o r the more appropriate use of various l e v e l s of manpower, i n p r i n c i p l e , at l e a s t , encour-aging each person to concentrate on those functions he does best. The t h i r d objective i s simply a service objective, e a s i l y measured, very operational, more c l e a r and r e a l i s t i c than the f i r s t two. Unfortunately, i t s s i g n i f i c a n c e i s correspondingly l e s s , f o r just having more 'bodies' on the p a y r o l l does not mean improved health care. However, the obvious i m p l i c a t i o n i s that the more workers a c t i v e l y supplying safe, good-quality, appropriate s e r v i c e , the more people w i l l u t i l i z e the se r v i c e with a resultant improvement i n health status. I t i s e s p e c i a l l y important i n smaller and more i s o l a t e d communities, where a p r o f e s s i o n a l could not be employed f u l l - t i m e or might not always be able to get i n t o the communities. The a u x i l i a r i e s are sometimes employed half-time. 90 In Alberta, the program has moved from a few workers t r a i n e d i n 1962 to 18 on s t a f f by 1974, with a further 24 r e c e i v i n g the f i r s t part of t h e i r t r a i n i n g i n the summer of 1975* These plus the eight Family Health Aides i n more i s o l a t e d reserves were the t o t a l Indian a u x i l i a r y health workers. C. UNSTATED OBJECTIVES OF THE PROGRAM. In a d d i t i o n to the formal written goals of the program, there were, as predicted by functionalism theory, unwritten goals of the program and of the i n d i v i d u a l s involved i n i t . Some of these emerged a f t e r interviews with people involved i n the program and some a f t e r observing CHR's working on the reserves. L i k e l y , many more would be discovered i f the program could be observed more c l o s e l y . One long-term goal which the f e d e r a l government was attempting to reach through t h i s program was to avoid p o l i t i c a l embarrassment: both over the poor health l e v e l s of Indians, and the small numbers of Indian people employed by Medical Services e s p e c i a l l y at the l e v e l s where they would have input i n t o policy-making and program-planning. Whether t h i s program was intended as a means to move toward r e a l power-sharing between government and Indian communities or a "token" to appease the growing Indian discontent, i s not c l e a r . The i n i t i a t o r , E t h e l Martens, d i d state that the program was intended as means to f o s t e r i n g community development a c t i v i t i e s on Indian reserves. I t was conceived and implemented i n the 1960*s by 91 Medical Services, Indian advice being asked f o r only l a t e r on, and the i n i t i a t i v e and power seems to remain f i r m l y i n the hands of Medical Services. Willingness to ask greater p a r t i c i p a t i o n of the A l b e r t a Indian Association i n the program was expressed, along with doubts as to t h e i r i n t e r e s t i n so doing.^ Another hoped-for e f f e c t of the program was that the l e v e l s o f health and l i v i n g condition o f the Indians would be r a i s e d to the point where such workers were neither necessary nor appropriate. I t was not determined whether t h i s meant that a l l Indian health workers would i d e a l l y be professionals eventually, or whether the l e v e l of s k i l l of the a u x i l i a r i e s would need to be r a i s e d to deal with more sophisticated 7 communities. This program i s also seen as an economical way of providing health s e r v i c e s , and a means of allowing personnel at various s k i l l l e v e l s to employ t h e i r s k i l l s most appropriately. Administrative objectives to produce e f f e c t i v e health workers are i n operation. They are concerned with the s e l e c t i o n , t r a i n i n g , supervision and support of the workers, and although they are not l i s t e d as program ob-j e c t i v e s , they do e x i s t . Structures have been set up concerned with these functions, and by examining some of the a c t i v i t i e s i n these areas c a r r i e d out by Medical Services, i t i s possible to i n f e r the existence of 92 such objectives and t h e i r r e l a t i v e importance i n the organ-i z a t i o n . Although no written personal objectives f o r the Community Health Representatives were seen by the author, one can i n f e r that each has her own reason f o r taking on t h i s job e.g.to earn money, to challenge h e r s e l f with i n t e r e s t i n g work. In c e r t a i n communities, there i s p r e s t i g e attached to having a steady job which i s a l l the greater i f i t i s a government job, or one which i n -volves working c l o s e l y with white people. In other communities there i s d e f i n i t e opprobrium attached to government work, and t h i s d i d create problems f o r some CHR's. Each worker would l i k e l y to be anxious to es-t a b l i s h her own legitimacy i n the eyes of f i e l d personn-e l and her own community - indeed, such a concern was expressed by three workers although i n i n d i r e c t words. Nurses mentioned that evaluation was a source of great concern to the workers, not because of any gross e.ffect such a l o s s of s a l a r y or the p o s i t i o n , but because the workers wished to do a "good job". Another objective mentioned by most a u x i l i a r y workers interviewed was to increase t h e i r resources - education, s k i l l s , transportation, and support of t h e i r nurses, i n order to carry out t h e i r job more e f f e c t i v e l y . Two mentioned a desire to take further 93. education as a prelude to p r o f e s s i o n a l nurse-training, though whether t h i s objective arose because of experience i n t h i s program, or was a p r e - e x i s t i n g d e s i r e which l e d them to take the CHR course, was not c l e a r . This i s one e f f e c t of the program which some of the administrators hoped f o r : to encourage Indians to study i n the health professions and work i n Medical Services at a l e v e l higher than that of a CHR. I t does appear to p o t e n t i a l l y c o n f l i c t with the objective of having Indians working on the reserve, * c l o s e l y a l l i e d to t h e i r people. Two workers mention-ed a wish to belong to an a s s o c i a t i o n of a u x i l i a r y wor-kers, maintaining frequent communication and contact, so as to support and l e a r n from each other. None mention-ed the a s s o c i a t i o n as a "union-ty:pe" organization concern-ed with workers' benefits or improving t h e i r educational and f i n a n c i a l s tatus. There are c e r t a i n l y many more unwritten object-i v e s which are held by personnel involved i n the program, but time d i d not permit them a l l to be searched out. * There i s controversy i n the literature:, as to whether fur t h e r , p r o f e s s i o n a l t r a i n i n g strengthens tendencies to middle-class biases i n the indigenous workers, or whether he can maintain h i s indigenous " q u a l i t i e s " ( s p e c i a l personal knowledge and understanding of h i s c l i e n t s and t h e i r problems, greater a c c e p t a b i l i t y o f h i s s e r v i c e by c l i e n t s ) even a f t e r such education. See Arthur Pearl and Frank Riessman, New Careers f o r the Poor (London: C o l i e r - MacMillan, 1965) pp. 155-w r . — 94 Those d e t a i l e d above formed part of the basis f o r the a n a l y s i s of c o n f l i c t s which a f f e c t ^ t h e program, and f o r making the concluding evaluatory comments on the program as a whole. 95 CHAPTER V CONSUMER INVOLVEMENT IN HEALTH The f i r s t objective of the CHR program i s to encourage l o c a l people to p a r t i c i p a t e i n the h e a l t h a c t i v i t i e s i n t h e i r communities. The general job functions f o r the CHR o u t l i n e d under t h i s objective include providing consultation, advice and assistance to i n d i v i d u a l s and groups i n the community, and making appropriate r e f e r r a l s when necessary. More s p e c i f i c job functions under t h i s objective were used by the author to derive immediate objectives f o r the CHR's and these are given below as the basis f o r examining the CHR's a c t i v i t i e s . Immediate objectives one to seven are b a s i c a l l y concerned with healthy family functioning. Although incom-p l e t e l y described by these a c t i v i t i e s , teaching parentcraft i s an important part of the CHR's work. By having CHR's car r y i n g out these functions and by encouraging parents to follow c e r t a i n p r a c t i c e s and make use o f health resources i n the community, i t i s hoped to reach the o v e r - a l l object-i v e s of improved health status. A. OBJECTIVES A1 - A12 - HEALTH OF THE FAMILY i . Objectives A1 & A2 - Prenatal and Immunization C l i n i c s . When prenatal or w e l l baby c l i n i c s are to be held, most of the CHR's t r y to remind a day or two beforehand those who are due to attend, and make sure that arrangements 96 f o r transportation or b a b y s i t t i n g can be made. The greatest d i f f i c u l t y i s i n the prenatal area, none of the workers or nurses being s a t i s f i e d with the c l i n i c turn-out. Women 'resent' prenatal care, according to Florence Youngchief, and do not see any necessity f o r i t except f o r the l a s t months of pregnancy ( F i e l d Notes, J u l y 24-25). On Morley reserve, thev<:nurse men-tioned that s e v e r a l older women who used to act as midwives wei?e s t i l l consulted by younger women regarding pregnancy. She also expressed great f r u s t r a t i o n a t the lack of response to the nurses' prenatal c l i n i c s , but she d i d not have any contact with these older 'midwives* and d i d not wish to work with them i n t h i s area ( F i e l d Notes, J u l y 19, 1975). At Athabaska and Blood Reserves^ prenatal classes had been held a few times, although the small numbers of women preg-nant at any one time and the even smaller numbers attending made t h i s a c t i v i t y a s u b s t a n t i a l input of the nurses' time and energy f o r l i m i t e d returns. Immunization c l i n i c s met with greater success, though there i s d i f f i c u l t y persuading women to bri n g very young babies, f o r the immunizations do cause some fever and upset i n the c h i l d r e n . Mrs. Samson the CHR of Hobbema Reserve advised the nurses to hold immunization c l i n i c s i n grandmothers* houses and the grandmother would see that a l l her grandchildren were brought. By choosing d i f f e r e n t grandmothers over the months, a f a i r l y good immunization 97 record was obtained ( F i e l d Notes, May *\k & 15). On Kehewin reserve, immunization i s done by the nurse on home v i s i t s , so that 100% coverage i s obtained, while at Athabasca, immunizations are done when ;people a r r i v e during treatment c l i n i c hours. T h i s combines a curative function with preventive health work, which nurses and CHR's f e e l makes t h e i r presence more acceptable. This l a t t e r reserve i s r e l a t i v e l y remote, so that the nurses carry out curative work as well as preventive. (On a l l the other l e s s remote reserves v i s i t e d , most of the nursing i s pu b l i c health nursing, with minor treatments such as f o r l i c e and scabies a l s o a c a r r i e d out). None of the a u x i l i a r y workers di d immunizations, though several expressed a desire to l e a r n to do so. Although nurses, expressed the idea that the CHR's could take on much wider r e s p o n s i b i l i t i e s - s u c h as ear and eye screening, only one f e l t they should be able to do immuniz-at i o n s . T h i s seems to be a function the nurses keep f o r themselves, perhaps from a need to keep i n t a c t t h e i r job domain, or a need to keep t h i s as a mode of entry to Indian f a m i l i e s f o r other purposes besides immunization. Most nurses were unsure about the l e g a l i t y of allowing CHR's to give i n j e c t i o n s . 2. Objectives A3 - N u t r i t i o n The a u x i l i a r y workers o b v i o u s l y i f e l t comfortable teachingnutrition, mainly to the e l d e r l y and to mothers. 98 Regina Pastion of Athabaska f e l t that teaching n u t r i t i o n and budget-i n g was one of the most important areas of her work, and expressed an i n t e r e s t i n l e a r n i n g to conduct cooking c l a s s e s . She f e l t that her experience of feeding a large family on a small income supp-lemented by hunting and f i s h i n g enabled her to give more approp-r i a t e advice than could the nurses. The author does not know i f she had mentioned her wish to l e a r n and do more i n t h i s area to the nurses, but to t h i s point, she had taken no i n i t i a t i v e s about t h i s . ( F i e l d Notes, June 10-13). Several workers mentioned that while shopping, they noted those f a m i l i e s buying what they considered to be non-nutritious food, such as snack items and expensive convenience foods, and would remember t h i s on t h e i r home v i s i t s to those f a m i l i e s . Infant n u t r i t i o n i s a matter of great i n t e r e s t to a l l the CHR's and they say they encourage breast-feeding, though some f i n d i t hard going - Carolya Noskiye of Bigstone Reserve says that a common re a c t i o n i s "what's the use?" when the babies go away to h o s p i t a l so frequently ( F i e l d Notes, June 3 -6) . Regina Pastion o f Athabasca has another problem - mothers breast-feed c h i l d r e n f o r over a year g i v i n g few supplements, and she i s concerned with a l t e r i n g t h i s habit, with she says, considerable success ( F i e l d Notes, June 10-13). I n a l l these areas, the workers mentioned the need f o r persistence and patience. 99 3. Objective Ak - Dental Hygiene Teaching dental hygiene was an a c t i v i t y the workers c a r r i e d out i n schools u s u a l l y under the supervision of a dental h y g i e n i s t . More i n t e r e s t was expressed i n the reserves where running water was a v a i l a b l e to most people and the l e v e l of income and education reasonably high, (Kehewin, Blood) whereas i t was not an a c t i v i t y of high p r i o r i t y on other, poorer reserves. Other problems were more pressing, and i t was f e l t , probably r e a l i s t i c a l l y , that supervised "brush-ins" i n school were the only time the c h i l d r e n would follow the regime, since there would be l i t t l e encouragement at home ( F i e l d Notes, June 3-6). A study by Stolpe and h i s colleagues found i n a program taught to Indian school c h i l d r e n that o r a l hygiene improved during the school year with i n s t r u c t i o n i n o r a l health, but t h i s improvement was not maintained. k. Objective A3 - Environmental Safety A l l workers were concerned with t h i s o b j e c t i v e , a safe and hygienic environment. Skin conditions, mainly l i c e , scabies and i n f e c t i o n s , are common i n conditions of poor hygiene, and the workers r e g u l a r l y v i s i t e d schools and homes to both t r e a t c h i l d r e n and i n s t r u c t parents i n the prevention and treatment of the problems. Th i s i s another area where repeated v i s i t s and patience are required, f o r the burdens are great of keeping a house and large numbers of c h i l d r e n clean, e s p e c i a l l y when running water i s not a v a i l a b l e . The CHR's seem to manage t h i s area almost e n t i r e l y 100 by themselves, i t being relatively uncomplicated, and, i t should be added, rather unattractive. Lice do not appear to hold any horrors for the workers. Domestic and environmental cleanliness and safety i s an area where the CHR's feel themselves quite effective. Several mentioned their efforts, exhaustive i n a few cases, to get privies built by the Band, arrange for garbage pits or drums or a regular garbage collection, arrange for regular water service (a truck i s used on some reserves to haul water to household cisterns) and to have at least annual clean-ups on the reserve to remove hazardous and unsightly l i t t e r . On Kehewin and Heart Lake Reserves, the CHR's did a survey to see which houses needed repairs and renovations, and recommended to the Chief those needing the greatest amount of work to be done. On Kehewin the nurse also noted that several houses were uninhabitable, and their word was used by the Chief to press Indian Affairs to provide funds for:-:new housing. Florence Youngchief noted that the people lik e the house-to-house safety inspection they carried out - "nobody ever told them about loose chimney pipes, etc." (Field Notes, July 2V-25). The area where the CHR's could most easily point our tangible accomplishments was i n the area of hygiene, and their effectiveness depended very much on the avail a b i l i t y 101 of resources to put these needed improvements onto the reserves. Teaching people, persuading them to change t h e i r p r a c t i c e s , e s p e c i a l l y i f the new p r a c t i c e s required more e f f o r t on the part of the people was much more d i f f i c u l t , and produced much slower, l e s s noticeable r e s u l t s . However, just putting i n running water d i d not automatically produce cleaner houses and people, and the CHR's s t i l l had to teach and encourage e s p e c i a l l y mothers to be more hygienic. Mrs. Youngchief follows up every case of g a s t r o e n t e r i t i s seen by h e r s e l f and the nurses to determine the cause i f p o s s i b l e , and t o l d the author that most cases were due to unclean food and houses ( F i e l d Notes, J u l y 24-25). The accident prevention work i s confined to removing unsightly and hazardous l i t t e r from the reserve, and inspecting houses f o r obvious dangers e.g. f a u l t y e l e c t r i c a l o u t l e t s or heating systems. Even though i n d u s t r i a l accidents are common due to the nature of most people's employment, and car accidents are common p a r t l y due to the vintage of the cars and people 1s drinking habits, the CHR's di d not appear to ihave conducted any educational programs on safety. I t was-the author's impression that alcoholism workers or the Department of Indian A f f a i r s had occasionally held safe d r i v i n g courses sometime i n the past, but CHR's were not involved i n t h i s themselves. Perhaps they 102< were doubtful of the effectiveness of safety campaigns or t h e i r a b i l i t y to conduct such campaigns themselves. The work c a r r i e d on i n t h i s area of c h i l d - r e a r i n g i s at a simple, p h y s i c a l l e v e l — feeding, keeping clean, avoiding domestic accidents, obtaining immunizations. These seem to be appropriate and important l e a r n i n g needs f o r many mothers, f o r the problems here are frequent and e a s i l y detected. Other concerns, such as a c h i l d ' s normal growth and development, d i s c i p l i n i n g and behaviour problems, the need f o r i n t e l l e c t u a l stimulation f o r c h i l d r e n , were not mentioned by CHR's - perhaps as a r e s u l t of t h e i r l a c k of t r a i n i n g i n these areas, because they are not common worries to parents, or perhaps because the majority culture's thoughts on c h i l d - r e a r i n g are not completely appropriate to Indian c u l t u r e . These problems are not so apparent as the phys i c a l ones and are more d i f f i c u l t to rec-ognize and t r e a t , as well as not being a relevant area to tackle i n many cases — asking a mother with l i t t l e education and many small c h i l d r e n to think about t h e i r " i n t e l l e c t u a l growth" i s probably not r e a l i s t i c . However, even where parents would be receptive to such knowledge i t i s doubtful that the CHR's could give very sophisticated information. 103, 5. Objective A - Family Planning Family planning i s a touchy area on several reserves. Carolya Noskiye of Bigstone Reserve mentioned that family sizes were changing, that younger women were having three or four children "only", though community approval was generally for large fa m i l i e s . She f e l t that the r e l i g i o n of the area (Roman Catholic) was not a potent force against family planning, but that the men especially were ag a i n s t . i t . Why, she did not know. She put much ef f o r t into working with several families where the women, with up to ten children each, were i n very poor health. She spent much time reminding the husbands of the work-load that children?meant f o r the wife and how she was "t i e d down", while i t did not mean that for the men. These women were persuaded to have tubal l i g a t i o n s , but most women, she said, say nothing, only giving a blank face, when she brings up the topic of family planning ( F i e l d Notes, June 3 - 6 ) . On the Athabasca Reserve, the CHR also mentioned the objections of the husbands and found i t a d i f f i c u l t subject to broach, while on the Blood and Kehewin Reserves, the CHR's f e l t able to t a l k e a s i l y on the subject to women. What t h e i r effect was, they did not know. Teaching sexual hygiene.in schools was mainly done by the nurses, i f at a l l , though the CHR's advice was asked about the appropriateness of certain films and lessons by some nurses. 104 CHR's mentioned that the problems of illegitimate pregnancies and young marriages was substantial, but felt unsure of how to prevent them. They connected these with the problem of child neglect usually, although Florence Youngchief said emphatically that the apprehension of one's children by child care workers was considered to be a great disgrace. She also added that the white people got "too excited" about situations, and she did not think that apprehension was necessary as often as the child-care workers did (Field Notes, July 24-25)• The author felt a certain ambivalence and shyness in the CHR's about the subject of birth control. Most of the CHR's are women with large families themselves; several are Catholics. They expressed the idea that spacing of children was 'health-ier" for the mother, referring mainly to physical health, and did not place much emphasis on economic constraints, the opportunities for development of the children, family dynamics and so on. It was not an area they wished to discuss to any extent and the author was able to get only a vague impression of how much time they spent in this area, or how effective they thought they were. 6. Objective A7 - Exercise This objective of teaching the need for regular exercise was not mentioned by any CHR's except Mrs. Samson at 105 Hobbema, where a weight-watchers group had been set up, and was slowly d e c l i n i n g to the point where a l l but two women had dropped out. Obesity does seem to be a common_problem on reserves, mostly i n women and mainly due to poor d i e t s over-abundant i n carbohy-drates. The idea of 'regular exercise' has a white middle-class r i n g to i t (as do many of these objectives) f o r people employed i n non-physical occupations and leading sedentary l i v e s . The Indian men often work at physi c a l labouring jobs, and i f not employed, are probably as act i v e as most middle-class Canadians anyway. Recreational and exercise f a c i l i t i e s are la c k i n g on many reserves, and i f present, are used mostly f o r school-c h i l d r e n and youths. 7. Objective A8 - Alcohol Abuse In the area of alcohol abuse, the CHR's a l l mentioned that excess drinking was a major problem on t h e i r reserve. However only one mentioned she would l i k e to take a course to study alcohol treatment, although.all were involved i n dealing with the e f f e c t s of i t - t r e a t i n g i n j u r i e s , ensuring that c h i l d r e n were fed and looked a f t e r and so on. They expressed t h e i r f e e l i n g s of i n a b i l -i t y to^ handle a l c o h o l i c s or to reduce the incidence of 'binge' drinking, p r e f e r r i n g to leave t h i s work to s p e c i a l i s t s . Thus t h e i r p a r t i c i p a t i o n consisted of co-operating with e i t h e r Band employees acting as counsellors, helping p r o v i n c i a l or Indian 106 Affairs alcohol workers to start alcohol treatment on the reserve, or sitti n g on the Board of a Detoxification Centre, whichever approach i s used on the reserve to handle alcohol problems. Carolyn Noskiye of Bigstone mentioned that she did attempt to get the Band to help her set up an alcohol program when she f i r s t started work as a GHH, but they were not interested u n t i l a wave of vandalism started a few years ago. She now i s helping a provincial alcohol worker start his work on the reserve^and has persuaded the Council to use the Band bus to pick up clients for the alcohol-treatment programs (Field Notes, June 3-6) . A l l CHR's knew which families had problems with alcohol and^made direct referrals between alcohol workers and patients. The CHR on Hobbema, which has a Band-run DeTox Centre, feels that the centre has been very successful i n reducing alcohol-related marriage break-up, child neglect, car accidents, fights and so on. She was instrumental i n setting up the Centre and now s i t s on i t s Board (Field Notes, May 14-15). The worker on Kehewin noted that economic development on her reserve has been very great over the past three years; this and the two alcohol counsellors, she f e l t , reduced alcohol problems, such as car accidents and marriage problems (Field Notes*! July 24-25). It should be noted that the objective as set out by the job function "to make people aware of the dangers of alcohol abuse" i s probably largely superfluous, since everyone i n the communities has had contact with drinking 107 and seen the a c t i v i t i e s surrounding alcohol use from a very young age. There i s some evidence that alcoholism as c l a s s -i c a l l y defined from studies on Europeans does not e x i s t among Indians to a great extent. Lone drinkers are quite rare and i n d i v i d u a l addicted drinkers are l e s s common amongst Indians than i n other groups, while 'binge' drinking presents a large 2 problem i n terms of crime rates and community d i s r u p t i o n . The r e s u l t s of binge drinking are obvious, whereas the dangers of c l a s s i c a l alcoholism are not so apparent and perhaps not so r e a l . I t i s probably a r e a l i s t i c a t t i t u d e on part of the CBS's to avoid d i r e c t involvement i n alcoholism treatment, f o r several reasons. I f a community was not ready to ack-nowledge t h i s as a problem area, attempts on the part of the CHR to force acknowledgement or a c t i o n might only cause resentment and al i e n a t e her from the people. Several CHR's expressed a b e l i e f that excess drinking was due to lack of employment and r e c r e a t i o n a l opportunities, and they knew t h e i r a b i l i t y to change such large s o c i a l circumstance was l i m i t e d . Even i f b e l i e f s are not o b j e c t i v e l y true, they are true i n t h e i r consequences, and i n the l i g h t of such b e l i e f s , < these workers might not be very e f f e c t i v e i n treatment and preventive attempts. Their supervising nurses do not work 108, i n the f i e l d of alcoholism prevention and treatment, so that effective support or advice from them would be lacking. In effect they are not different from most health professionals who find complex social problems such as alcoholism d i f f i c u l t and unrewarding to work with, as results are often long-term and 'cures' less frequent than i n biological diseases. In this same l i n e , i t i s noticeable that there i s no mention made of ac t i v i t i e s i n the mental health area. Mrs. Samson of Hobbema said that she would counsel people on marriage or child-management problems i f they asked. She had had no specific education i n this area, but drew on her years of experience and "folk-wisdom". None of the other CHR's attempted to deal with severe mental health problems - they knew what mental health resources were available and ref-erred people to them. It was not a problem area which loomed large for them, for no-one mentioned i t except Nora Brewer of Blood Reserve, who put suicide as the major health problem. She said she f e l t no-one was dealing with the mentally i l l and she herself was not capable (Field Notes, Aug. 21-22). 8. Objective A9 - Home Nursing This objective, giving and teaching home nursing care seems to depend on the ava i l a b i l i t y of other resources. If a hospital i s nearby, the CHR's prefer to take people 109 there, e s p e c i a l l y c h i l d r e n . Most workers expressed concern f o r the e l d e r l y , but t h e i r v i s i t s were mainly f o r the purpose of seeing i f they were " a l l r i g h t " , or i f they were taking t h e i r drugs. I t seems that people were not discharged from h o s p i t a l generally u n t i l they were quite completely recovered and would not need extensive home nursing, a prac t i c e r e s u l t i n g from h o s p i t a l personnel's b e l i e f that recovery would not be enhanced by the i s o l a t i o n of and conditions on many reserves. The r o l e of the k i n group i n sickness i s not c l e a r l y defined f o r P l a i n s Indians, as i t i s , f o r example, f o r Navaho Indians. Presumably they, as i n a l l s o c i e t i e s , take notice of the i l l n e s s , take some care of and comfort the s i c k person. However, somewhat paradoxically, t h i s support i s considerably reduced by t h i s very p r a c t i c e ofumodern medicine of removing people to f a r - d i s t a n t h o s p i t a l s , as well as others such as examining and t r e a t i n g patients p r i v a t e l y , and r e s t r i c t i n g v i s i t i n g hours and numbers of v i s i t o r s i n i n s t i t u t i o n s . The CHR's say they encourage f a m i l i e s , i f they can t r u s t them, to carry out simple home nursing procedures e.g. bathing a f e v e r i s h c h i l d , or helping an e l d e r l y person to take exercise ( F i e l d Notes, J u l y 30). Tuberculosis follow-up i s an area where CHR's f e e l e f f e c t i v e as w e l l . Emily Wesley of Morley manages follow-up 110 quite independently, doing the drug dispensing and paper-work by h e r s e l f ( F i e l d Notes, J u l y 19). Others go around with the nurse and encourage people to take t h e i r p i l l s and teach them about the disease - i t s signs, symptoms, prevention, trans-mission - often i n the l o c a l language. Studies of the e f f e c t s of b e l i e f s on health behaviour have i n d i c a t e d that fear, instead of inducing a person to take therapeutic or preventive a c t i o n , may instead act as a deterrent. A patient, ignorant of the meaning of signs and symptoms, and f e a r f u l of t h e i r consequences, may delay seeking care and information. For example, a b e l i e f i s s t i l l current on many reserves that a p o s i t i v e diagnosis of tuberculosis means being taken o f f to a c i t y h o s p i t a l f o r several years, or perhaps being taken o f f to die i n the h o s p i t a l , with the r e s u l t that tuberculosis screening programs are shunned. On one reserve the wr i t e r v i s i t e d , many of the middle-aged multiparous women believed that contraceptives caused cancer, with predictable r e s u l t s . On the Blood Keserve, diabetes i s a common chronic complaint, e s p e c i a l l y i n the e l d e r l y , and the GHB's are i n -volved i n day-to-day treatment and teaching, as well as f o r arranging a yearly seminar to which resource people and the community are i n v i t e d ( F i e l d Notes, Aug. 21-22). 111 9. Objective A1Q - Transportation I f the CHR has her own car she w i l l do much home v i s i t i n g on her own and also bring people i n to c l i n i c s , f o r treatment and so on. I t depends a great deal on the l o c a l s i t u a t i o n - what transportation f a c i l i t i e s are a v a i l a b l e on the reserve, i f the CHR has her own transport, what the nurses' b e l i e f s are regarding the extent of support people should receive. Some nurses f e e l people should take more "respon-s i b i l i t y " f o r t h e i r health care and do not believe that immunizations should be c a r r i e d out i n the home, nor people f e r r i e d about to various s e r v i c e s , e s p e c i a l l y i f they have a car i n the family. Whatever p o l i c y the nurse set seemed to be the one c a r r i e d out, and the author was unable to determine i f the CHR's wished or t r i e d to change the trans-portation p o l i c y . Several mentioned that they would do more home v i s i t i n g i f a car was a v a i l a b l e f o r t h e i r use and Medical Services headquarters i n Edmonton are seeking ways to provide cars f o r CHR's. 10. Objective A11 - Screening Another area where CHR's are able to demonstrate tangible a c t i v i t i e s i s i n basic screening and ph y s i c a l exam-in a t i o n s e.g. taking temperatures, measuring children's height and weight and so on. A l l CHR's helped at the nurse's c l i n i c andiseveral expressed t h e i r pleasure at learning how to carry 112 out more sophisticated techniques such as Denver developmental t e s t s f o r c h i l d r e n and audiology screening. The^jaurses seemed to vary a great deal i n what they taught the CHR's to do i n this::area, probably because of the a b i l i t y and i n t e r e s t shown or not by the CHR, and the nurse's own p r o c l i v i t i e s and need f o r the CHR's help e.g. i f she i s s h o r t - s t a f f e d , or a large number of people on the reserve do not speak -English. 11. Objective A12 - Water Sampling A l l CHR'sulook a f t e r water a n a l y s i s , taking samples, sending them o f f f o r t e s t i n g and recording r e s u l t s , as well as advising f a m i l i e s and Band of actions to take i n the l i g h t of r e s u l t s . N aturally, the importance of t h i s function v a r i e s , depending on the water-supply of the area. B. GENERAL ANALYSIS OF OBJECTIVES A1 - A12 Most workers spend most of t h e i r time with mothers and c h i l d r e n , i n the b e l i e f that t h i s i s where the greatest changes can most e a s i l y be wrought, and returns to e f f o r t are greatest. Educating a mother who i s r a i s i n g a family i s claimed to give the c h i l d r e n a h e a l t h i e r s t a r t i n l i f e , i n c u l c a t e s healthy a t t i t u d e s and p r a c t i c e s when people are young, and c a r r i e s the promise of passing such habits on to t h e i r future f a m i l i e s . In t h i s respect the CHR's are following the examples of the t r a d -i t i o n a l public health nursing, and the nurses, and the emphasis 113 l a i d by Medical Services on maternal and i n f a n t care, c h i l d immunization and hygienic environments. In f a c t , very l i t t l e p a t i ent-therapist contact occurs between men and CHR's. I t could be a function of t r a d i t i o n a l male stoicism and the place of women - a man might be reluctant to admit weakness to a woman. I t could be an e f f e c t of the b e l i e f that most of men's 'non-medical' problems such as drinking are due to s o c i a l conditions, which the CHR's are i n no p o s i t i o n to a f f e c t e.g. the lack of formal employment, the usurping of the male r o l e by welfare, schools, government, and the s o c i a l rewards f o r deviant behaviour. The CHR's are mostly women who have r a i s e d or are r a i s i n g t h e i r own f a m i l i e s and can add years of p r a c t i c a l experience to t h e i r short t r a i n -ing course to give them a f e e l i n g of confidence when working i n t h i s area. I t i s very s a t i s f y i n g to concentrate work here, f o r r e s u l t s can be seen quite quickly andsdramatically e.g. cleaning up skin i n f e c t i o n s , preventing water-borne disease by teaching a mother hygienic infant feeding. In t h e i r emphasis on contact with mothers and c h i l d -ren, the CHR's are i n agreement with a study by Lewin,' i n which he concluded from attempts to change wartime food habits that housewives stood i n the important "gatekeeper p o s i t i o n " . I t was 114 t h e i r system of values and b e l i e f s that determined what would eventually be the type of food consumed. S i m i l a r l y , T y roler and i f h i s colleagues, studying l e v e l s of tooth salvage f o r i n d i v i d u a l s within f a m i l i e s suggest that maternal influence i s maximal i n the area of family preventive health behaviour. The emphasis ou these obvious ph y s i c a l problems of mothers and c h i l d r e n may be due to another pressure. S c o t t ' suggests that a subtle di s p l a c e -ment of goals can occur i n service organizations. I d e a l l y , the form and content of agency programs are determined by the c l i e n t , changing with h i s needs. However various pressures a l t e r o r i g i n a l goals and p o l i c i e s , such as theaneed to preserve the organization or the absence of c l e a r c r i t e r i a by which to determine i f the agency i s or i s not implementing i t s goals. Service agencies must demonstrate that they are successful i n meeting t h e i r goals i , e . they are e f f e c t i v e i n helping solve the problems of t h e i r c l i e n t s . Thus a process of s e l e c t i o n f o r those c l i e n t s with the most e a s i l y - s o l v e d problems operates, while the most handicapped, who present the greatest challenge to the organ-i z a t i o n ' s e f f e c t i v e n e s s , may be comparatively ignored. The agency workers may simply not have the knowledge and s k i l l s required to deal with the most d i f f i c u l t problems, a f r u s t r a t -ing experience which leads to mutual withdrawal.^ As w e l l , those i n greatest need of assistance are often those l e a s t 115 knowledgeable of the complex organizational r u l e s of the game and can take the l e a s t advantage of s e r v i c e s . They f i n d i t d i f f i c u l t to i n t e r a c t with personnel who deal with them i n an impersonal, segmented r a t i o n a l i s t i c way, f o r t h e i r customary mi l i e u i s personal, l o c a l , n o n - i n t e l l e c t u a l and non-segmented. The concentration on mothers and c h i l d r e n may be also a help to l e g i t i m i z i n g the program or p u b l i c health a c t i v i t i e s i n general, f o r the Indian society seems to be quite c h i l d -centred and the communities take great i n t e r e s t i n the welfare of c h i l d r e n . For chronic problems such as t u b e r c u l o s i s , diabetes and those a f f e c t i n g the e l d e r l y e s p e c i a l l y , the CHR's seem very valuable. Although s c i e n t i f i c medicine may not be able to always improve a person's health status or cure him, the CHR can provide the continuous monitoring and support which can prevent or r e t a r d d e t e r i o r a t i o n . These are areas which are t r a d i t i o n a l l y " l e t go" by public health nurse, when acute problems a r i s e , e s p e c i a l l y i n c h i l d r e n , which they often do on the reserves. They also require much educational and motivational work, perhaps more than parentcraft teaching does. The^educational work has two important e f f e c t s : to give correct information and to i n s t i l a b e l i e f that e f f e c t i v e 116 a c t i o n i s p o s s i b l e . Combining the preventive work with curative work, i . e . having v i s i b l e , tangible evidence that the worker r e a l l y i s "working" has important be n e f i t s too. "Just t a l k i n g " , f o r most people and perhaps more so f o r the l e s s educated who do not h a b i t u a l l y deal with abstract concepts, i s not v a l i d "work". One of the major motivational o r i e n t a t i o n s found i n Indian society i s that of " u t i l i t a r i a n i s m " or the a b i l i t y to grapple with problems 7 i n a resourceful manner with a minimum of abstract speculation. This has implications f o r the teaching of both Indian c l i e n t s and health workers. Almost a l l of the CHR program's objectives, and thus the job functions of the CHR's, share two c h a r a c t e r i s t i c s of public health and preventive work. The r e s u l t s of many public health a c t i v i t i e s are characterized by t h e i r "non-appearance". Their value i s thus not apparent - a woman who has never:seen a case of diphtheria does not n e c e s s a r i l y see the importance of diphtheria immunization. I f the i n d i v i d u a l does not see h i s s u s c e p t i b i l i t y or the seriousness of the threat, and the s i t u a t i o n a l f a c t o r s a f f e c t i n g personal convenience or e f f o r t required are such that much energy i s required on the c l i e n t ' s part, the l i k e l i h o o d of p a r t i c i p a t i o n i s low. As w e l l , most public health a c t i v i t i e s have no r e s u l t s which are immediately tangible - e f f e c t s are long-term, which 117. again reduces the " s e l l i n g " value of preventive a c t i v i t i e s . This i s e s p e c i a l l y important i n l i g h t of the t r a d i t i o n a l Indian a t t i t u d e to time, as well as the modern a t t i t u d e s . Native people, l a c k i n g a written h i s t o r y , had a concentric rather than l i n e a r conception of time, wherein important events were remembered whether they happen-ed i n the immediate or f a r - d i s t a n t past. The future was l a r g e l y unknowable and uncontrollable. Foresight and planning were of l i t t l e b e nefit i n most areas. Orientation was thus mainly to the present. To the extent that t h i s a t t i t u d e s t i l l e x i s t s , i t has an obvious e f f e c t on planning and saving a c t i v i t i e s , ami on the day-to-day round of l i v i n g which i s f a i r l y unscheduled and not co-8 ordinated by clocks. This has implic a t i o n s f o r those teaching CHR's, f o r the workers w i l l experience only f r u s t r a t i o n and dismay at t h e i r own l a c k l o f e f f e c t i f they a n t i c i p a t e great or obvious changes due to t h e i r e f f o r t s . The workers d i d t a l k about the fa c t that only continual, slow prodding and much patience could achieve changes i n some areas, and a l l had f a m i l i e s whom they s a i d heeded l i t t l e of what the worker taught them, but whom they continued to "bother t h e i r conscience, anyway" ( F i e l d Notes, May I*f-15). They learned to content themselves with small changes. A study by Kelman and Houland showed that changes were greater when the source of the changes presented h i s i n f l u e n c i n g e f f e c t s more than once. Family and neighbourhood networks are important f o r t h i s reason - that contact between members i s renewed at frequent i n t e r v a l s and the 118 c r e d i b i l i t y of the change-source i s reconstituted. The CHR's f e l t that the more contact people had with people outside the reserve, and the more contact with mass media, the easier i t was to persuade them to adopt new h a b i t s . In t h i s they wereaconcurring with some research 10 done on the health behaviour of groups of people, such as Suchman's study of people who had recently undergone some form of serious i l l n e s s . He divided them i n t o two groups: " p a r o c h i a l " and "cosmo-p o l i t a n " . The parochial group exhibited higher ethnic e x c l u s i v i t y , family o r i e n t a t i o n to t r a d i t i o n and authority, and friendship-group s o l i d a r i t y . The cosmopolitan group were more open, instrumental, i n d i v i d u a l i s t i c , and had a higher l e v e l of s c i e n t i f i c knowledge about disease. I t was found that the parochial group tended to underestimate the seriousness of t h e i r signs and symptoms, and were concerned about the interference with t h e i r s o c i a l functioning. They conferred about the i l l n e s s with t h e i r l a y reference group and delayed seeking professional care more than d i d the s c i e n t i f i c group. S o c i a l i s o l a t i o n bred "medical" i s o l a t i o n , and the l a c k of s c i e n t i f i c information about disease, the narrow outlook and lower expectations i n general r e s u l t e d i n lower health horizons. The s o c i a l l y i s o l a t e d tended to c o n f l i c t more with the medical and public health p r o f e s s i o n a l s , being l e s s i n agreement f o r example, with the purposes and p r a c t i c e s of w e l l - c h i l d supervision, and not putting the same value on health care as the health profession-a l s . 119 Public health programs have t r a d i t i o n a l l y been conceived and implemented by middle-class people and di r e c t e d at the lower c l a s s . They embody the Protestant e t h i c of activism and are con-cerned with i n c u l c a t i n g i n the i n d i v i d u a l a strong sense of personal r e s p o n s i b i l i t y f o r one's own health. T h i s contrasts with the t r a d i t i o n a l Indian b e l i e f that much that happens i s due to external forces and i f something unfortunate does happen,ithe=kin w i l l see one through. The middle-class emphasis on c l e a n l i n e s s , and on patterns of c h i l d - r e a r i n g which feature a good deal of con t r o l and supervision by the mother contrast with the more casual a t t i t u d e of the poor and the Indians. These are a l l p o t e n t i a l sources of 12 clash and f r u s t r a t i o n between health workers and Indians. This l a s t point re middle-class e t h i c s , i s a fundament-a l basis f o r the whole program, and one Qf i t s fundamental weaknesses. I t w i l l be returned to l a t e r on i n the f i n a l chapter. C. OBJECTIVES A1J - A20 COMMUNITY AND GROUP FUNCTIONS 1. Objective A13 - Health Classes Under the same o v e r - a l l objective of encouraging l o c a l people to p a r t i c i p a t e i n health programs, the CHR's have functions r e l a t i n g to groups rather than i n d i v i d u a l s i n the community. The f i r s t immediate objective here i s to teach health classes i n the feder a l schools. A l l the CHR's v i s i t e d mentioned t h i s as a usef u l a c t i v i t y , though i t was confined to teaching c h i l d r e n i n 120 the f i r s t grades, i n t h e i r own language usually, about hygiene and n u t r i t i o n . More sophisticated teaching f o r the older grades e.g. about matters of se x u a l i t y , was done by the nurses. Mrs. Samson of Hobbema added an i n t e r e s t i n g twist - she used to go around with a minister to surrounding white schools and t a l k about the reserves and Indian people to the c h i l d r e n ( F i e l d Notes, May 14-15). The CHR's d i d not mention that they had much contact with teachers, most of the i n t e r a c t i o n occurring between the teachers and nurses, which seemed to be a f a i r l y t y p i c a l pattern i . e . CHR's confined much of t h e i r work i n t e r -a c t i o n and r e f e r r a l s to nurses or other Indian personnel. They&seemed to f e e l uneasy with the idea of d i r e c t l y r e f e r r i n g c l i e n t s to other white professionals. White people working i n ca p a c i t i e s other than health d i d not know the functions of CHR's and preferred to work with known e n t i t i e s , such as a nurse ( F i e l d Notes, J u l y 24-25). 2. Objectives A14-A15 - Development and Use of Educational Aides The next objectives concerning health education to groups and the use of f i l m s , posters and mass media produced varied r e s u l t s . The older CHR's with seven to ten years exper-ience a l l mentioned that they used to do more group teaching, bringing i n f i l m s and holding teaching sessions. Mrs. Samson from Hobbema now r e s t r i c t s t h i s to a health 'display' at home 121 and school meetings. They f e l t i t was a great deal of work f o r u s u a l l y poor-turn-outs e.g. two to four people, and f e l t i n d i v i d -ua l teaching was more s a t i s f y i n g and e f f e c t i v e . The more recent CHR graduates mentioned t r y i n g one or two projects but evinced l i t t l e enthusiasm f o r them. For example, on Athabasca, a night-time meeting was held f o r e l d e r l y people, to which a large number came. The CHR and nurses checked t h e i r height, weight, eyes, blood and talked about health problems of the e l d e r l y . To the next session they advertised, no-one came, and they had given up the idea. The author d i d not say that t h i s was probably not anyone's idea of an entertaining night out, and Mrs. T a i l f e a t h e r s on the Blcod Reserve has had much more success with a recreational/program f o r the e l d e r l y - bingo, dances, music -where health teaching can be c a r r i e d out very in f o r m a l l y , i f at a l i i the main emphasis simply being on healthy r e c r e a t i o n ( F i e l d Notes, Aug. 21-22). Nora Brewer u t i l i z e d a l o c a l Indian news-paper to write a r t i c l e s on health and to advertise the< community clean-ups, healthy baby contests, garden contests e t c . she organized. She i s a very a r t i c u l a t e young woman who was leaving work to take r e g i s t e r e d nurse t r a i n i n g i n the autumn of 1975» and was one of the few CHR's who f e l t confident with E n g l i s h , and had a l o c a l newspaper and radio a v a i l a b l e to p u b l i c i z e a r t i c l e s on health ( F i e l d Notes, Aug. 21-22). 122 I t i s l i k e l y that CHR's would use mass media more, or printed media at l e a s t , i f they f e l t i t u s e f u l and i f they them-selves were receptive to t h i s mode of information. I t i s i n t e r e s t -ing to note that most r e l i e d on the nurse's i n s t r u c t i o n s or answers to s p e c i f i c questions f o r t h e i r information. Nursing books were generally beyond t h e i r comprehension and none evinced much i n t e r e s t i n newspapers or magazines, i n c l u d i n g a former CHR news magazine, now defunct. Theyvare being r e a l i s t i c i n t h e i r l a c k of use of printed material i f most of t h e i r c l i e n t s read E n g l i s h poorly. A study of low-income groups r e c e i v i n g public assistance by Brightman 13 and h i s colleagues found that t h i s group r e l i e d very l i t t l e on mass media f o r health information, but made heavy use of t h e i r physicians, nurses and caseworkers, even though the l a t t e r had no formal t r a i n i n g i n health matters. 3. Objectives A16-A18 - Band Council Meetings and Health Committees The objective to attend Band Council meetings was f u l f i l l e d by a l l but a few CHR's. The exceptions occurred where the Council was " t r a d i t i o n a l and do-nothing" according to the nurses and CHR, and through which l i t t l e could be accomplished anyway. In these reserves, the Chief and Council would not give notice when meetings were being held, so that attendance by the community and CHR was rather occas-i o n a l ( F i e l d Notes, June 3-6, June 10-13). This objective seemed to f i t hand-in-glove with the organization of a health committee, who 123 presented, along with the CHR, the health concerns of the community to the Chief-Council. A l l f e l t that health committees and Band meetings were a most important means to arousing community i n t e r e s t i n health. Not everyone had a health committee to work with, though i t was the author's impression that those who d i d not work with a committee pre-f e r r e d home-visiting and one-to-one type of work and d i d not have the self-confidence or p o l i t i c a l connections that others d i d . One nurse explained the importance,of health committees by saying that everyone i s ascribed t h e i r 'place' i n an Indian reserve by b i r t h and can reach only some people from that status and p o s i t i o n , and never other people. A health committee enables the CHR to reach a wider spectrum 14 of the community through i t s members . T h i s i s very much i n agree-1 5 ment with Sanders, who states that p a r t i c i p a t i o n i n the d e c i s i o n -making process should occur at a l l l e v e l s of the power g r i d , f o r the ordinary c i t i z e n has power to withhold support simply by not being a c l i e n t , and key people i n power cl i q u e s have l i m i t e d time f o r part-i c i p a t i o n and much competition f o r t h e i r sponsorship. As well the pressures f o r economic development on most reserves would occupy the time and i n t e r e s t of the Band Council, and leave l i t t l e energy f o r health matters without a health committee. Several CHR's proved t h e i r usefulness to the Chief and Council by doing housing surveys and recommending to the Chief which!families were most urgently i n need of housing help. The support of the nurse and health committee helped to get funding f o r 124 new houses. Most had gone through the Band administration to get some sanitary f a c i l i t i e s and services on the reserve. Some seemed to have come to a h a l t a f t e r accomplishing that. E s p e c i a l l y i f the members of the health committee or the CHR were r e l a t e d to Band administrators, and the Chief and Council were i n t e r e s t e d i n health matters, there was regular attendance at Band meetings and c o l l a b o r a t i o n on a v a r i e t y of projects between the Council and committees. Several CHR's s a i d that t h i s was a d i f f i c u l t thing f o r them to do, to stand up at meetings and badger, complain or whatever to the Council, e s p e c i a l l y since many reserves are " c h a u v i n i s t i c " places, and p o l i t i c s i s the preserve of the men. The urging and support of the nurses helped them a great deal they f e l t . Carolyn Noskiye would e i t h e r speak f o r people at Band meetings who had complaints or problems, or else went along with them to the meetings, supporting them v e r b a l l y and morally ( F i e l d Notes, June 3^6). 4. Objective A17 - Group Work The next objective, to form or support groups i n the community to improve health seems to have f a i r l y l i m i t e d success on most of the reserves the author v i s i t e d . A few have homemakers clubs and one has a weight-watchers' group, a l l of which are rather f a l t e r i n g at best. On the more organized and sophisticated reserves, such as Hobbema and Blood, the concerns regarding a l c o h o l , housing, recreation and so on are managed by the Band, and CHR input seems only sometimes to be welcomed and given. Mrs. Samson of Hobbema s i t s on the board of the De Tox Centre, Mrs. Youngchief of Kehewin f e e l s 125 free to contact the Chief or pertinent c o u n c i l l o r s about p a r t i c u l a r problems. She t r i e d to s t a r t a teenagers' club, but i t f a i l e d she sai d . On Athabasca, Regina's attempts to have a regular get-together f o r the e l d e r l y f a i l e d . The CHR's support any attempts by others to deal with a l c o h o l . They seem to regard r e c r e a t i o n a l functions such as bingo or sports a c t i v i t i e s as good things, to keep people from drinking mainly, but are not themselves a c t i v e i n these areas. 5. Objective A19 - Workshops The next objectives seem to be two of the l e a s t frequently performed. Organizing or teaching workshops and securing funds f o r them i s a f a i r l y complex undertaking and could probably not be done without a good deal of support from the nurses. Miss Frenchman of Heart Lake was planning a workshop on c h i l d and home management, n u t r i t i o n , safety and hygiene i f funds came through from Indian A f f a i r s ( F i e l d Notes, J u l y 30). On the Blood Reserve, Nora Brewer was a c t i v e i n organizing healthy baby contests, garden contests and community wiener-roast-cum-clean-up, and she and Mrs. T a i l f e a t h e r s a c t i v e l y helped with the yearly workshop on diabetes ( F i e l d Notes, Aug. 21-22). The other CHR's di d not mention a c t i v i t i e s i n t h i s area. 6. Objective A20 - I n t e r d i s c i p l i n a r y work As f a r as working with community leaders and workers, and with government o f f i c i a l s , the functions of the CHR have already 126 been commented on. Co-ordinating a c t i v i t i e s with other community workers was done on an ad hoc b a s i s , as a patient's need d i c t a t e d . Most were reluctant to contact government o f f i c i a l s themselves, p r e f e r r i n g to go through the nurse, and none mentioned that they wished to or had t r i e d to integrate health services more c l o s e l y with other programs on the Reserves. I f the;various professionals on a reserve operated i n a c e r t a i n mode, that i s to say, main-ta i n i n g the t r a d i t i o n a l r e l a t i v e i s o l a t i o n of health, education, recreation, s o c i a l work, and whatever else was happening on the reserve, that i s the way i n which the CHR operated too. Hobbema was an exception, where the nurse-supervisor and CHR were c l o s e l y involved i n school a f f a i r s and the development of youth counsell-ing services ( F i e l d Notes, May 14-15). D. GENERAL ANALYSIS OF OBJECTIVES A13-A20 Objectives t h i r t e e n to twenty are b a s i c a l l y oriented to t r y i n g to get Indians to take more r e s p o n s i b i l i t y f o r t h e i r health, both i n d i v i d u a l l y and c o l l e c t i v e l y . More success i s claimed f o r changing i n d i v i d u a l s ' a t t i t u d e s to health. For c o l l e c t i v e r e s p o n s i b i l i t y , there seems to be a f a i r measure of success on some reserves, as on Morley where the health centre i s administered to a great extent by the l o c a l people. In other reserves, there i s l i t t l e a c t i v i t y i n health or other areas of community l i f e . A number of va r i a b l e s which would a f f e c t the 127 success of these objectives become obvious, i f Indian culture and h i s t o r y before and a f t e r contact i s known. In most P r a i r i e t r i b e s when the Europeans f i r s t a r r i v e d , no authority of a p o l i t i c a l nature was present. The i n d i v i d u a l was expected to r e l y upon h i s own resources to provide f o r him-s e l f . The c h i l d r e n were train e d to do things f o r themselves with minimal help from others. S e l f - r e l i a n c e and a hesitancy to i n -tervene i n the l i v e s of others r e s u l t e d . The accompanying form of s o c i a l organization, wherein small groups l i v e d together f o r short times only, breaking up to carry out hunting and gathering a c t i v i t i e s , permitted l i m i t e d i n t e r a c t i o n with others outside the nuclear family. Formation of voluntary sub-groupings along p o l i t i c a l , r e l i g i o u s or occupational l i n e s was i n h i b i t e d . This e t h i c of non-interference and l a c k of habits of activism i n c e r t a i n spheres worked against the Indians c o n t r o l l i n g t h e i r a f f a i r s l a t e r on, a f t e r contact with the white man. I t could be a f a c t o r i n the d i f f i c u l t y on some reserves now i n i t i a t i n g group a c t i v i t y i n health and other areas. A c t i v i t y and work were not valued i n t r a d i t i o n a l society f o r t h e i r own sake, and thus p r a c t i c a l i t y and the notion of progress were devoid of an underlying r a i s o n d'etre. T r a d i t i o n a l e t h i c s of f e e l i n g , i n t u i t i o n and fate often c o n f l i c t e d with i n d u s t r i a l e t h i c s 128 of observation, measurement, planning and reason. Because of the lack of occupational hierarchy i n t r a d i t i o n a l s o c i e t i e s , Indians did not base improvement i n t h e i r personal status on such f a c t o r s as work, achievement, success and s c i e n t i f i c r a t i o n a l i t y . Work was an a c t i v i t y enjoyed f o r i t s own sake, but hard work rather, than steady work was the r u l e , with c e r t a i n periods of the year reserved as rest times. A dependence on nature, a passive acceptance of i t and emphasis on maintenance of the status quo i n harmony with natural forces i s the dominant motif of the t r a d i t i o n a l culture. Remnants of these b e l i e f s and values are s t i l l extant i n Indian communities, as demonstrated by varying r e l i a n c e on magic or s p i r i t u a l means f o r h e a l i n g i i l l n e s s e s , a d i s l i k e of indoor, "routine" work, d i s l i k e of d i r e c t confrontations, and d i s i n t e r e s t i n accumulating large amounts of material goods. However, these values and b e l i e f s e x i s t to varying degrees and i t i s not possible to generalize about the " t r a d i t i o n a l i s m " or " a s s i m i l a t i o n " of the Indians. This again points up the value of f l e x i b i l i t y i n the CHR program and other Medical Services programs. Up to now, and s t i l l today on many reserves, the planned changes i n Indian society have been d i r e c t e d strongly by outsiders. The motivation and design of change have emerged from non-Indian hands, remote i n terms of geographical, s o c i a l and c u l t u r a l distance. 129 The control and the d i r e c t i o n of the p o l i c i e s have been inconsistent as d i f f e r e n t governments i n s t i t u t e d d i f f e r e n t measures, and even capricious as the government agents, various r e l i g i o u s bodies and charitable organizations became involved. The r e l a t i o n s h i p between the dominant society and the Indians has been e s s e n t i a l l y that of the "administrators" and the "administered". Native leaders have had t h e i r p o s i t i o n weakened by various p r a c t i c e s such as government o f f i c i a l s bypassing the Chief to deal with i n d i v i d u a l s by themselves, leading the people of the community to i n t e r p r e t t h i s as negative evaluations or d i s -respect of t h e i r Chief. There has also been considerable develop-ment of "token" leaders, those with some o r a t o r i c a l a b i l i t y being put forward by the Band when outsiders request i t , but having no r e a l authority. Another s a l i e n t f a c t o r i s that the more ac c u l -turated or the more vigorous members of the group tend to emigrate, leaving behind the more t r a d i t i o n a l , u sually older and conservative 17 Chiefs to r u l e . This helps t r i b a l organizations to stay i n t a c t , but can hinder those t r y i n g to innovate programs. Often the reserves has as Chief a hereditary leader or one who i s head of a large family, and not r e a l l y an able and active Header. F r u s t r a t -ion only can r e s u l t when health personnel t r y to interest]more t r a d i t i o n a l and i n a c t i v e Chiefs and Councils i n t h e i r work, and i t may be more p r o f i t a b l e to expend t h e i r i n f l u e n c i n g e f f o r t s on i n -formal leaders i n the community. 130 This has meaning i n l i g h t of the research which shows that the tendency to adopt new p r a c t i c e s i s g r e a t l y influenced by group opinion. Leaders who give information personally i n face-to-face s i t u a t i o n s , and those most l i k e l y to innovate are thoroughly i n t e -grated i n t o t h e i r s o c i a l or p r o f e s s ional i n s t i t u t i o n s , where they come i n contact with the o p i n i o n - l e a d e r s . ^ It'.is thus important that health workers e s t a b l i s h rapport with respected leaders or else themselves be one of the informal community leaders. There i s a p a r a l l e l to t h i s dominance of white over Indian, and that i s the r o l e of health provider and consumer. Bureaucratic systems bel i e v e i n performing a s e r v i c e , and assume that• a person coming to them w i l l take on the t r a d i t i o n a l s i c k r o l e i . e . he i s w i l l i n g to have h i s problem solved and w i l l allow the system to operate f u l l y and w i l l play the r o l e outlined f o r him by the system. C l i e n t s f a i l i n g to l i v e up to t h i s norm may be c l a s s i f i e d as "unco-operative", and service may be c u r t a i l e d or a l t e r e d i n some way to make the s i t u a t i o n more s a t i s f y i n g to the care-giver. To what extent t h i s operates on reserves i n l i g h t of the antipathy f e l t by some Indians and whites to each other i s not documented. 19 As Poslun notes, i t i s d i f f i c u l t to end dependence without threatening the people who have become addicted to the 131 exercise of authority. Professionals are used to having a good deal of control over t h e i r own a c t i v i t i e s , and white Canadians are used to having a good deal of control over Indians. This whole area of developing indigenous leadership requires a f i n e d i s t i n c t i o n bet-ween stimulating the Indians' desire f o r something and supporting them i n t h e i r attempts to achieve i t , and taking over a project, even i f subtly, and doing i t oneself. Whichever way i s chosen, both the health professionals and the CHR w i l l experience d i f f i c u l t y . The out-group antipathy leads to r i d i c u l e and contempt of those Indians who openly t r y to emulate white society (not to mention work f o r i t ) , yet the t r a d i t i o n a l norms of the community are waning even within the confines of the community. Group support f o r whichever way the 20 i n d i v i d u a l chooses may be l a c k i n g . The o l d moral r e s p o n s i b i l i t y f o r one's own s p i r i t u a l welfare i s s t i l l present, but the source of i t , a consistent upbringing based on supernatural values i s missing. Internal controls have broken down and t r a d i t i o n a l techniques f o r s o c i a l control are now inadequate. There i s l i t t l e incentive to upgrade the s o c i a l conditions which influence the moral aspects of another's behaviour or to con-front persons with the consequences of t h e i r behaviour upon other persons or the societ y at l a r g e . This i s one reason why attempts to form voluntary groupings to deal with health, 132 educational, r e l i g i o u s , occupational or other matters are frequent-l y unsuccessful. I t poses a large problem f o r a c t i o n programs, which to be successful must be desired by the people as well as 21 planned and executed with t h e i r p a r t i c i p a t i o n . Most of the workers prefer to spend the majority of t h e i r time i n a c t i v i t i e s which allow one-to-one involvement, rather than i n group work. They f i n d t h i s more s a t i s f y i n g and appear to think i t more e f f e c t i v e and economical of t h e i r time and energy. They are supported to an extent by-;studies on the importance of personal influence (which presumably would be greater i f the CHR i s concentrating on one person instead of d i v i d i n g her a t t e n t i o n among a group) which show that t h i s i s e s p e c i a l l y important f o r " l a t e adopters", or those slow to 22 accept changes. The CHR's as a r u l e seem to f e e l that they can better influence i n d i v i d u a l s to become more in t e r e s t e d i n and responsible f o r the health of themselves and t h e i r family rather than to influence a community by c o l l e c t i v e means. There are, as always, exceptions, and the a r t l i e s i n deter-mining which method i s most e f f e c t i v e f o r that community. CHAPTER VI CULTURAL LINKING The second objective of the CHR program i s to increase the effec t i v e n e s s of professional health workers by providing a l i n k with the l o c a l community. From a very simple function such as introducing a new nurse to the people and places on a reserve, to the most subtle attempts to persuade i n d i f f e r e n t Band leaders that a new program would be b e n e f i c i a l to the people, the CHR's play, according to Medical Services personnel, a most valuable and appreciated r o l e . The s p e c i f i c job functions outlined f o r the CHR have been used to derive the immediate goals designated as B21-B24. A. OBJECTIVES B21-B24 THE LIAISON ROLE 1. Objectives B21 and B 2 2 — C u l t u r a l Bridging Interpretation of language and behaviour was c a r r i e d out frequently by a l l CHR's. Carolyn Noskiye s a i d she explained to people who complained of long waiting l i n e s at some c l i n i c s about the nurses' busyness, and explained to the nurses that l a c k of transportation and c l i n i c s held during children's nap-times l e d to lack of turn-out at other c l i n i c s . T his CHR had a d i f f i c u l t time with the Band Council, who accused her of "working f o r the white man", but she merely laughed and said she didn't care, that the patients didn't think so. The Council previously f i r e d two CHR's f o r working too much "with the nurses", so when a few f r i e n d l y c o u n c i l l o r s advised her to become a c i v i l servant instead of a Band employee, she d i d so. ( F i e l d Notes, June 3-6). The f i r s t evaluation 1 3 4 of the CHR program, c a r r i e d out i n 1 9 6 4 , also mentioned that t r a d i t i o n a l community suspicion of "white men's ideas" l e d to d i f f i c u l t i e s f o r the CHR, including h o s t i l i t y from leaders and r e f u s a l to co-operate with programs. The nursing supervisors on Blood and Hobbema Reserves mentioned that the CHR's were e s p e c i a l l y valuable to get through to p a r t i c u l a r l y " d i f f i c u l t " people, the unresponsive or h o s t i l e , or simply the non-English-speaking e l d e r l y . They were expressing the idea of the l i n k i n g function of the CHR, who may be f o r c e r t a i n people t h e i r main point of contact with outside sources of information. Being i n f l u e n t i a l i n a system seems to be r e l a t e d to who the i n f l u e n c e r i s (the p e r s o n i f i c a t i o n of c e r t a i n values); what he knows ( h i s competence as perceived by others); and whom he knows (h i s s t r a t e g i c s o c i a l l o c a t i o n i n the system). By working i n the Medical Services system, the CHR i s i n touch with outside sources of information and has the p o t e n t i a l to be i n f l u e n t i a l on t h i s b a s i s . However, i t i s also important f o r an i n f l u e n t i a l person to be well integrated i n t o a system's structure of interpersonal r e l a t i o n s h i p s - a point well-recognized by the nurses who f e l t that, f o r example, Mrs. Samson's work was not hindered by her being married to a former Chief. Opinion leaders are more innovative, more i n contact with outside sources of information, of a somewhat higher s o c i a l status, and more s o c i a l l y and p h y s i c a l l y a v a i l a b l e f o r s o c i a l interaction.''" Thus the emphasis on s e l e c t i n g people f o r CHR t r a i n i n g who are seen as "helping" persons, known and respected by the community. 135 On Hobbema, the nursing supervisor mentioned the value of CHR's i n " p o l i t i c i z i n g " the nurses i . e . making them r e a l i z e the importance of family connections i n Band p o l i t i c s , and the reasons f o r the various machinations which go on i n the Band administration, both necessary knowledge f o r working on a reserve. She asked her CHR's opinions about planned programs such as the appropriateness of various health education sessions and the timing and l o c a t i o n of c l i n i c s , and f e l t that the CHR was e f f e c t i v e i n gaining more respect f o r and ^understanding of the nurses and t h e i r work. 2 Card et. a l . claim that much of the s o c i a l i n t e r a c t i o n assocxated with government i s nomothetic, or conditioned by law - the l o c a l persons don't have to be " s o l d " , only " t o l d " . This type of i n t e r a c t i o n requires l i t t l e exchange of views or knowledge, and minimal consideration of a t t i t u d e s or opinions. Though the process may be softened somewhat by c o n v e n t i o n a l i t i e s , congenial conversation or persuasion, often i t i s characterized by curtness, b r e v i t y and a r e l i a n c e on threats, e s p e c i a l l y when low-status people are involved. T h i s type of i n t e r a c t i o n i s not confined to government. I t i s a usual pattern of behaviour i n Indian f a m i l i e s , and the r e l i g i o n of the area may also function i n t h i s manner. One might make a case f o r i t being a common form of i n t e r a c t i o n between health professionals and c l i e n t s . Other types of i n t e r a c t i o n occur of course. Gossip i s a frequent mode of communication, e s p e c i a l l y where there are great s o c i a l distances between people and language d i f f i c u l t i e s e x i s t . People of l i m i t e d 136 education, subject to the nomothetic type of i n t e r a c t i o n discussed above, have r e s t r i c t e d opportunities to obtain accurate information about various happenings. Rumour substitutes f o r knowledge i n many cases.^ Int e r a c t i o n characterized by patient persuasion, free discussion and c o l l e c -t i v e planning i s l i m i t e d by the considerable time required f o r such discussions; the l a c k of s k i l l or t r a i n i n g i n such type of leadership i n government workers; wide-spread apathy towards areas of supposed concern to the community eg. schools, health services; language d i f f i c u l t i e s ; h o s t i l i t y to white people and so on. The CHR's a l l emphasized that people would t a l k more to them than to the nurse; t h i s and i t s reverse was corroborated on more than one occasion i n front of the author's eyes. For example, on a home v i s i t on one reserve, the nurse, on a tuberculosis follow-up v i s i t , walked i n t o the house without knocking as i s the custom, handed out p i l l s to everybody and watched while the mother, a large baby strapped to her back, wanly t r i e d to force the r e b e l l i o u s c h i l d r e n to swallow them. The nurse a f t e r a few moments of watching the melee, turned to leave, while the CHR j u s t stayed and casually chatted with the mother and c h i l d r e n i n the l o c a l language. Af t e r f i v e minutes of seemingly desultory conversation, the CHR mentioned several problems the woman had talked about, gave the reason they had missed t h e i r l a s t c l i n i c v i s i t , and appeared to be quite s a t i s f i e d with the v i s i t , though she planned to return that afternoon to r e i n f o r c e her health teaching on tuberculosis ( F i e l d Notes, June 10-13)• Such simple h i n t s as t e l l i n g people to take drugs morning, afternoon and evenings instead of a f t e r meals (some people eat only twice a day) and explaining the p o s i t i o n of c e r t a i n people i n the reserve hierarchy so that the r i g h t people are 137 approached f o r information, are important f o r smoothing r e l a t i o n s h i p s between nurses and l o c a l people. 2. Objective B23—Use of Resources The next function i n t h i s area i s to advise people of the community of the health and other resources of the community, and to help them to use them. Most of the CHR's sa i d that people telephoned t h e i r home or stopped them on the s t r e e t , asking t h e i r advice on problems. The CHR at Athabasca s a i d that people w i l l ask her i f i t i s " a l l r i g h t " to consult a nurse about a p a r t i c u l a r problem, e s p e c i a l l y i f i t i s not s t r i c t l y a medical or ph y s i c a l problem. The CHR's di d not seem to discourage people from using l o c a l medicine men, and said they would inform the nurses which people were using indigenous medicine f o r p a r t i c u l a r problems, so that the nurse could encourage them to use that plus Western medicine i f she thought i t appropriate. The knowledge of and respect f o r indigenous medicine makes i t more l i k e l y that people w i l l look favorably on Western medicine, the nurses and CHR's believe ( F i e l d Notes, June 10-13, J u l y 23-25* and Aug. 21-22). Work on cognitive dissonance suggests that the carrying out of an a c t i o n , such as u t i l i z i n g a service, may a l t e r b e l i e f s . This could be used by health workers as an a l t e r n a t i v e to d i r e c t l y attacking a t t i t u d e s if or b e l i e f s . Trying out modern medicine as an experiment may r e s u l t from such sources as reports of others or the k i n d l i n e s s or i n t e r e s t of a health worker. I f a treatment i s e f f e c t i v e , the pragmatism of people w i l l u s u a l l y lead to continued use, and eventual acceptance of the b e l i e f s and knowledge behind the procedure. 138 As noted before, the CHR's encourage people to make use of resources generally, but r a r e l y r e f e r them d i r e c t l y to other workers, e s p e c i a l l y white professional workers. They also d i d not mention that they encouraged people to demand resources, but rather saw i t as t h e i r function to a r t i c u l a t e needs and desires to the nurses or Band administration. Medical Services personnel generally expressed appreciation f o r the r o l e of CHR's i n encouraging people to use f a c i l i t i e s wisely, but also implied that they were w i l l i n g to contend with only c e r t a i n demands. This can be a d i f f i c u l t r o l e f o r the CHR, f o r i f she f i n d s many problems she cannot ignore, and brings them to the attention of the nurse, the 'nurse may d i s l i k e the extra work load t h i s implied, or f i n d that she or Medical Services does not have the resources to meet them - a f r u s t r a t i n g experience f o r a l l . The CHR might be subtly discouraged from bringing such problems to the attention of f i e l d personnel by the non-response, or may be viewed as a "rabble-rouser". I t could also have the e f f e c t of f o r c i n g nurses or Medical Services to examine t h e i r goals, norms of operation, t h e i r prejudices - a p o t e n t i a l l y uncom-for t a b l e process as well as a p o t e n t i a l l y b e n e f i c i a l one. Factors besides b e l i e f s , motivations and cues which a f f e c t the d e c i s i o n to use services include the a v a i l a b i l i t y of treatment resources, t h e i r physical proximity, and the monetary and psychological costs of using them. Psychological costs include such things as stigma, humiliation and s o c i a l distance between c l i e n t and p r a c t i t i o n e r . ' Having l o c a l people as CHR's always a v a i l a b l e and reasonably mobile, i s an attempt to reduce these costs. Other f a c t o r s , such as the tolerance threshold of those who are exposed to and evaluate the signs and symptoms, a f f e c t the response made to them. 139 Often noted i n the l i t e r a t u r e i s the Indian l a c k of a f f e c t i v e response and stoicism i n the face of pain, hunger, fatigue and other s t r e s s f u l situations.:' C u l t u r a l patterns and l a c k of knowledge also a f f e c t a person's perception of the seriousness of i l l n e s s , but the r e l a t i o n s h i p s are not very c l e a r . Differences between classes i n the i n t e r p r e t a t i o n s of signs and symptoms of i l l n e s s have been found. The lower-class delayed seeking treatment more, and seemed more w i l l i n g to "put up with" t h e i r symptoms. They also feared c e r t a i n diseases more (tuberculosis, cancer, a r t h r i t i s , b i r t h defects) than those with higher incomes, a f a c t o r a t t r i b u t e d to the greater 7 knowledge of the disease and i t s treatment i n the upper income groups. A l l of these may cause the Indian c l i e n t s to use the health services i n a way which health professionals may consider "inappropriate". As w e l l , Eosenstock has pointed out that health-related motives may not always give r i s e to health-related behaviour, and conversely, health-r e l a t e d behaviour may not always be determined by health-related motives, eg. attending a nursing c l i n i c i n order to partake of the free coffee. An important point i s r a i s e d by t h i s research on b e l i e f s and motivation. Should programs be oriented to f i t with e x i s t i n g b e l i e f s and motives, or should attempts be made to change people's b e l i e f s and motives i n accordance with professional ideas of what i s needed? The l a t t e r presents problems e t h i c a l l y and procedurally. He suggests that where motives are weak, e s p e c i a l l y re prevention, other motives should be tapped, such as s o c i a l , parental, sexual and economic. And since therapeutic care i s more important to people, purely preventive work, including health education, could be combined with curative work, done by people i n a place i d e n t i f i e d 9 with curative work, such as doctors and nurses i n a h o s p i t a l . This could 140 be e s p e c i a l l y acceptable f o r people who handle t h e i r l i f e s i t u a t i o n s on a day to day ba s i s . The CHR program seems to be attempting to do both i . e . accommodating professional ideas of health needs and healthy behaviours, with l o c a l and indigenous p r a c t i c e s , v i a the CHR's, although the end r e s u l t s aimed f o r are preponderantly those of the health professionals. 3. Objective B24—Sensitization T h i s l a s t objective i s not mentioned as a function of the CHR's themselves, but does occur as a r e s u l t of f a i r l y close working r e l a t i o n s h i p s between nurses and CHR's. The nursing supervisor on Hobbema stated the idea most s u c c i n c t l y of a l l the nurses when she s a i d the CHR's could s e n s i t i z e the nurses to t h e i r own biases and prejudices, which they may hold unconsciously ( F i e l d Notes, May 14-15). These biases can be b e l i e f s held by the middle-class about the poor, b e l i e f s about professionals versus a u x i l i a r y a c t i v i t i e s , b e l i e f s about Indian cul t u r e , a t t i t u d e s of paternalism, or appropriate ways to help the Indians and so on. Schneiderman, 1 0 i n a survey of s o c i a l science l i t e r a t u r e l i s t e d a t t r i b u t e s of the poor he found therein. The lower c l a s s were seen by higher classes to have destructive patterns of speech, dress, marriage and family l i f e . Though they were thought to desire money, possessions and prestige, they d i d not know how to achieve i t . The poor were seen as not motivated to use ser v i c e s , l a c k i n g awareness of problems and the way i n which services could be u t i l i z e d , making "inappropriate" requests f o r serv i c e s because they were unable to understand agency p o l i c y andprograms. They had a bad reputation with the higher classes, who l a b e l l e d them d i r t y , l a z y , unambitious, u n w i l l i n g to save, sexually immoral and d i s r e s -141 p e c t f u l of the law and the other classes. The upper c l a s s f e l t that the poor l i k e d t h e i r noisy and crowded huts, that they produced f a r too many chi l d r e n and most of the juvenile delinquency i n society. He concluded that there was much evidence to i n d i c a t e that c l i n i c a l judgment i s infused with middle-class b i a s . Such a t t i t u d e s to the poor would conceivably be present to an extent i n the health personnel working on reserves, as most are from a middle-class background, e s p e c i a l l y i f they are not aware of the sources and functions of the culture on the reserve. Most people are ethnocentric i n t h e i r f i r s t contacts with and approaches to an a l i e n way of l i f e , ; t h e strange culture appearing incongruous, misguided and "wrong", and the people ignorant and super-s t i t i o u s . Such a derisory a t t i t u d e , even i f l a r g e l y unconscious, can be a formidable b a r r i e r to communication i n pu b l i c health work.^ The nurses make up some of the outsiders who l i v e and/or work on the reserve who are usually employees of government agencies or Hudson's Bay, or part of a r e l i g i o u s organization. A sub s t a n t i a l portion of these are immigrants to Canada, others are transferred to these areas by the c i v i l s e r vice. Interest i n and enthusiasm f o r t h e i r s i t u a t i o n i s v a r i a b l e . A l l have high-status p o s i t i o n s on the reserves as representatives 12 of powerful outside organizations. Dunning notes that many developments leading to change on a number of the reserves must be funnelled through these people, which increases t h e i r prestige and gives them inordinate power i n the eyes of the natives, though they may be r e l a t i v e l y j u n i o r employees i n t h e i r organization. Status f o r natives may be attached to contact with them. Because of the i s o l a t i o n of many reserves, these agents are unhampered by many of the s o c i a l and organizational checks which impinge 142 on t h e i r behaviour i n l e s s i s o l a t e d areas. They have power, comparative luxury and are superior i n t h e i r t e c h n i c a l knowledge. I n d i v i d u a l i s t i c i n t e r p r e t a t i o n s of the regulations and laws they are enforcing allow them to be more r i g i d or more f l e x i b l e , varying with the s i t u a t i o n . These f a c t o r s e a s i l y allow the exacerbation of authoritarian tendencies, though they may be disguised i n the form of paternalism. Reactions of natives may be submission (leading to a l a b e l of "good"), evasion, r e j e c t i o n , or attempts at e x p l o i t a t i o n ( a l l leading to a l a b e l of " b a d " ) . ^ This i s p a r t l y a r e s u l t of constraints a r i s i n g from the agent's p o s i t i o n as an employee of an organization, f o r the more successful he i s i n carrying out programs based on organizational goals, the more favorably he i s evaluated by the organization. The greatest number of f u r s brought i n to the Bay, the l a r g e s t number of babies brought i n t o c l i n i c , are avenues to promotion. An area where d i f f e r i n g a t t i t u d e s between whites and natives causes f r i c t i o n i s that of welfare and r e l i e f . Indians generally perceive that the government, Hudson Bay and the churches have been e x p l o i t a t i v e and destructive of t h e i r lands, morality, culture and so on. They may thus f e e l that welfare i s t h e i r just due,'• and not a shameful admission of weakness of some kind. As w e l l , a considerable amount of shrewd c a l c u l a t i o n goes i n t o the d e c i s i o n to take a job or welfare, f o r balancing a steady income against time o f f f o r p a r t i c i p a t i o n i n holidays and customs, picking up odd jobs, f i s h i n g and ihunting i n season and a c e r t a i n amount of welfare, may f i n d a steady job l o s i n g out to these other considerations. This i s an example of planning f o r the future which may not be recognized as such by middle-class people, but viewed as " e x p l o i t a t i o n " and " l a z i n e s s " . 1^3 The CHR's, by pointing out a d i f f e r e n t way to view phenomenon on the reserve may help the professional workers to at l e a s t understand, i f not condone, behaviour, and put them i n a better p o s i t i o n to decide whether to attempt to change behaviour or not, and give them ideas as to how to do i t . B. GENERAL ANALYSIS—CHR ACTIVITIES IN OBJECTIVES B21-B24 The second program objective was one u n i v e r s a l l y commented on by nurses and CHR's as an important and valuable part of t h e i r work: to be a l i n k with l o c a l people i n order to enhance the effectiveness of the p r o f e s s i o n a l s . There are three b a r r i e r s to cross here: that between Indian and white, between lower and middle-class, and that between care-giver and c l i e n t . The CHR's function i n a l l three areas. The difference between the patient's b e l i e f s and the health worker's gives r i s e to what Friedson c a l l s the l a y medical culture and the professional medical cul t u r e , each with i t s own r e f e r r a l system, or •network of consultants from which people seek health information. He points out that the degree of congruence between the two cultures w i l l determine how meaningful the diagnosis and p r e s c r i p t i o n are to the patient, and whether the advice w i l l be followed. Once symptoms are recognized, the i n t e r p r e t a t i o n a person gives to them w i l l determine h i s subsequent behaviour. I f a person has d e f i n i t i o n s of i l l n e s s which contradict those of a professional culture, h i s r e f e r r a l system w i l l not lead to a profes-s i o n a l p r a c t i t i o n e r , but to a f o l k p r a c t i t i o n e r , except i n the case of e i t h e r very minor i l l n e s s e s or i n l i f e - t h r e a t e n i n g s i t u a t i o n s when other 15 resources have failed-. A patient, once he consults with professional p r a c t i t i o n e r s , may f i n d that control over the ensuing procedures has passed out of h i s hands - he may be given services he did not ask for and does not understand. Yet Freidson points out that health professionals p r a c t i s i n g i n an area where indigenous r e f e r r a l systems are extensive must bend themselves to the l a y culture to an extent, or they w i l l have few c l i e n t s . ^ Health p r a c t i t i o n e r s working i n c r o s s - c u l t u r a l s i t u a t i o n s f i n d they have greater success working as adjuncts to indigenous t r a d i t i o n a l p r a c t i t i o n e r s , 17 accepting and incorporating them i n t o the treatment framework. The choosing of a l t e r n a t i v e systems of health b e l i e f s and pra c t i c e s has been outlined i n some d e t a i l by anthropologists f o r some cultures. Where both popular and s c i e n t i f i c b e l i e f s about health and disease co-e x i s t i n a community, i t i s usu a l l y found that modern medicine i s accepted f o r acute i n c a p a c i t a t i n g diseases, and popular medicine i s employed f o r chronic diseases - a very pragmatic approach, as t h i s l a t t e r category i s where s c i e n t i f i c medicine i s l e a s t e f f e c t i v e . The n a t u r a l i s t i c or super-n a t u r a l i s t i c explanations of etiology may p e r s i s t even while modern treatments are incorporated i n t o the p r a c t i c e s of the people. Eventually s c i e n t i f i c p r a c t i t i o n e r s , a f t e r gaining the confidence of people by tr e a t i n g them e f f e c t i v e l y while at l e a s t conceding te p o s s i b i l i t y of the r e a l i t y of the popular explanation, can break down the t r a d i t i o n a l -l8 modern dichotomy. The impact of these a t t i t u d e s and b e l i e f s on Indian patients and the r o l e s of the native and professional health workers w i l l be v a r i a b l e , but the e f f e c t s are l i k e l y to be present i n some form to some degree. L i t t l e systematic information about the persistence of t r a d i t i o n a l medical p r a c t i c e s i s known f o r P l a i n s Indians. Most nurses and CHR's v i s i t e d knew that a few medicine men s t i l l p ractised t h e i r a r t , but they knew nothing about the extent and l i t t l e of the content, and had not set 145 up any s o c i a l or working r e l a t i o n s h i p s with them. The native medicine men seemed to be mostly h e r b a l i s t s , though a few may be also diagnosticians, depending on supernatural forces to in d i c a t e to them the source of the i l l n e s s . I t was recognized too that the medicine men would recommend without apparent c o n f l i c t the use of modern medicine for c e r t a i n diseases. On a few reserves, l o c a l midwives were consulted f o r advice both pre- and post-natally, though almost a l l b i r t h s took place i n h o s p i t a l s . L i t t l e was known of t h e i r influence or the knowledge they imparted to women. I t seems to be kept c a r e f u l l y away from the purview of the white man. One CHR remained convinced of the e f f i c a c y of a t r a d i t i o n a l p o u l t i c e f o r the treatment of colds, and used i t r e g u l a r l y on one of her ch i l d r e n who was prone to colds. Anthropological research reveals that t r a d i t i o n a l p r a c t i t i o n e r s can have enormous influence on t h e i r c l i e n t s . Because they are a part of the patient's community, they are able to see the t o t a l environment of the patient and h i s troubles more c l e a r l y than an outsider, and are more aware of the s i g n i f i c a n c e of various r e l a t i o n s h i p s to an i n d i v i d u a l ' s i l l n e s s . Though they are not " t r a d i t i o n a l p r a c t i t i o n e r s " , the native a u x i l i a r y workers often supplied intimate information about the environment and s i t u a t i o n of c e r t a i n patients whose behaviour was puzzling or f r u s t r a t i n g to the nurses, which made the reasons f o r behaviour c l e a r e r and l e d to new s t r a t e g i e s , or cessation of attempts to intervene. T r a d i t i o n a l p r a c t i t i o n e r s , as well as having a good deal of information ike about the patient, may take a d e t a i l e d and personal i n t e r e s t i n the patient, making home v i s i t s and t a l k i n g about the i l l n e s s and i t s treatment i n language and concepts which are f a m i l i a r . Their function i n reducing anxiety and providing psychological care can be an important adjunct to the bodily treatment provided by modern medicine. To a r e l i g i o u s native, the r i t u a l " f o r g i v i n g " and support provided by the l o c a l curer i s needed to regain 19 correct "balance" i n the t o t a l environment. The CHR's a c t i v i t i e s here can only be guessed at . The comments they made about v i s i t i n g casually i n people's homes and the f a c t that t h e i r family r e l a t i o n s h i p s incluied often a good deal of the reserve population intimates that t h e i r functions had some s i m i l a r i t y to ttose of t r a d i t i o n a l p r a c t i t i o n e r s . Besides i n t e r p r e t i n g between l a y and profession! h a l t h c u l t u r e , the CHR's are much appreciated f o r t h e i r r o l e i n i n t e r p r e t i n g between white and Indian cultures. The f i e l d nurses receive p r a c t i c a l l y no formal o r i e n t a t i o n to Indian culture from Medical Services. The CHR's, mostly by t h e i r example and by explanations of various phenomena as the need occurs, f u l f i l l t h i s job f o r the nurses. By explaining the nurses and community to each other, and by helping people to u t i l i z e the resources available to them, the CHR's may be seen as helping Indian people to integrate i n t o Canadian society. Whether t h i s i s what the Indian people desire or not i s beyond t h i s study. The importance of the question of i n t e g r a t i o n can be understood when Indians, although t r a d i t i o n a l l y very diverse i n language, economy, r e l i g i o n , s o c i a l organization and so on, are looked at from the perspective of t h e i r common re l a t i o n s h i p to the l a r g e r society. 1W7 The Indian people could be considered a minority, i f defined i n Wirth's terms as a group of people who because of t h e i r physical or c u l t u r a l c h a r a c t e r i s t i c s , are singled out from the others i n the society i n which they l i v e f o r d i f f e r e n t i a l and unequal treatment, and who therefore regard themselves as objects of c o l l e c t i v e d i s c r i m i n a t i o n . T h^gxistence of a corresponding dominant group... (p. 3^0 M i n o r i t i e s are debarred from c e r t a i n economic, s o c i a l and p o l i t i c a l opportunities, which circumscribes an i n d i v i d u a l ' s freedom of choice or self-development. The members of minority groups are held by the majority group to be a l l a l i k e . They are held i n low esteem and i n concordance with Cooley's theory of the "looking glass s e l f " , members of the group may accept t h i s d e f i n i t i o n , developing a sel f - h a t r e d - of the group, of i t s culture and even of oneself because one i s a member of the-group. I t i s the opposite of group i d e n t i f i c a t i o n , wherein a p o s i t i v e desire to i d e n t i f y oneself as a member of the group leads to continued 21 a s s o c i a t i o n with the group, creating a community. Many natives f e e l i n f e r i o r to non-natives and use t h i s to r a t i o n a l i z e dependence on others and t h e i r i n a b i l i t y to compete i n the outside s o c i a l structure. The personality c o n f l i c t and str e s s as a r e s u l t of t h i s a t t i t u d e a r e considerable. Evidence of i t s existence might be i n f e r r e d from the s t a t i s t i c s on accidents, 22 suicide and crime among Indians. Janis notes that f e e l i n g s of f a i l u r e or impotence create resistance to change when an i n d i v i d u a l i s l e f t to himself, though a low s e l f - e v a l u a t i o n also makes an in d i v i d u a l - more dependent on others and therefore more l i k e l y to conform to the norms of the group of which he i s a member. This can work both f o r and against the the aims of the CHR, depending on whether a person isamember of groups with aims which c o n f l i c t or agree with those of the CHR. 148 One of the frequent consequences of being a member of a minority group i s the development of a f e e l i n g of a l i e n a t i o n . Such c h a r a c t e r i s t i c s as a l a c k of knowledge and understanding of events i n which a person i s engaged, of the f e e l i n g that he i s e s s e n t i a l l y powerless and that the outcome of a s i t u a t i o n w i l l depend on external forces rather than h i s own behaviour, are part of the phenomenon of a l i e n a t i o n . Other c h a r a c t e r i s t i c s of a l i e n a t i o n are the f e e l i n g s of i s o l a t i o n from the majority of society and the c o n f l i c t of norms such that the behaviour of people i n the society i s not predictable 23 and not sanctioned predictably as i n a stable s o c i a l structure. A l i e n a t i o n i s s i t u a t i o n - r e l e v a n t , nor a personality t r a i t . These f e e l i n g s are deemed to be more prevalent i n lower socio-economic groups. Morris e t . a l . found that the more ch i l d r e n a mother had, and the more d i f f i c u l t i e s she experienced reaching c l i n i c s , the more s o c i a l l y i s o l a t e d and powerless she f e l t . The patients i n a h o s p i t a l who f e l t most powerless were l e s s able to l e a r n about t h e i r disease, showing the relevance of f e e l i n g s to knowledge and motivation. They also found that i n d i v i d u a l s who f e l t powerless and i s o l a t e d had t h e i r f e e l i n g s o f unworthiness reinf o r c e d by u n s a t i s f y i n g contacts with the outside world and i t s i n s t i t u t i o n s . They pointed out that to break the c y c l e , the b a r r i e r s i n the system must be broken. Out-reaching types of programs, and making contacts between workers and c l i e n t s s a t i s f y i n g and p o s i t i v e l y r e i n f o r c i n g f o r each are necessary, rather than, f o r example, the worker showing disapproval to c l i e n t s a r r i v i n g l a t e f o r appointments, and r e c e i v i n g non-cooperation i n return. T h i s i s one area i n which CHR's prove to be very valuable: t h e i r knowledge of the society and contacts with key people allow them legitimate access t o f a m i l i e s who remain i s o l a t e d and withdrawn, even i n the small cmmmunity of a reserve. 149 They often know the background and dynamics of a family's p o s i t i o n , and use t h i s to f i n d ways to p a t i e n t l y break the cycle of a l i e n a t i o n and withdrawal, to make the i n d i v i d u a l ' s contacts with i n s t i t u t i o n s more s a t i s f y i n g . A p r e v a i l i n g antipathy to non-Indian standards and c u l t u r a l t r a i t s m i l i t a t e s against using the health services wich are supplied by white 25 men. The subtle depth of f e e l i n g s of h o s t i l i t y come out i n unexpected ways. One well-educated Metis i n A l b e r t a with a responsible job s a i d that she frequently suspected Indians and Metis would d e l i b e r a t e l y contribute to the f a i l u r e of a program to "cast another defeat at the foot of the white man" 26 even i f thy had to f a i l with i t . At the same time, the permissive nature of Indian c h i l d - r e a r i n g and the ethic of non-interference make i t easy f o r a person to assume the si c k r o l e , leading to the use of i l l n e s s as a reason f o r not working or attending school, and the often-heard comment by health personnel that they are too 27 frequently bothered f o r t r i v i a l complaints. Savin notes that people with the most bodily i l l n e s s e s show the most disturbances of behaviour, and that i l l n e s s behaviour i s often a seeking of help f o r psychological problems. The t h i r d area of i n t e r p r e t a t i o n i s that between middle and lower c l a s s . Many reserves remain l i t t l e enclaves of poverty, distinguished by a lack of a v i a b l e economic system and personal and s o c i a l t r a i t s which bear marked resemblance to the subculture of poverty: m a t r i f o c a l i t y , immediate g r a t i f i c a t i o n of needs, a present time o r i e n t a t i o n , l a c k of formal organi-zation beyond the family and so on. Some of these t r a i t s were functional i n 150 t r a d i t i o n a l s o c i e t y and can be considered to be adaptive to the Indian's present marginal p o s i t i o n . 28 Lewis claims that the culture of poverty repr events an e f f o r t to cope with f e e l i n g s of hopelessness and despair which a r i s e from the r e a l i z a t i o n of the improbability of achieving success i n the l a r g e r society's terms. Many of i t s t r a i t s can be viewed as l o c a l s olutions f o r problems which are not met by e x i s t i n g i n s t i t u t i o n s because the people are not e l i g i b l e f o r them, can't a f f o r d them, or are ignorant or suspicious of them. Like any cul t u r e , i t tends to perpetuate i t s e l f . Many of the t r a i t s already mentioned as part of minority patterns overlap with t h i s one. The lack of e f f e c t i v e p a r t i c i p a t i o n i n the major i n s t i t u t i o n s of the l a r g e r society i s c e n t r a l to the culture. These people have a c r i t i c a l a t t i t u d e towards some of these i n s t i t u t i o n s , d i s l i k e t h e p o l i c e , and mistrust the government and those i n high p o s i t i o n s . They are aware of. middle-class values, but do not l i v e by them, f o r they are not always appropriate to t h e i r s i t u a t i o n of chronic unemployment, l i t t l e wealth, and absence of reserves of any kind. T h i s i s the rationale f o r focussing on the need to adapt services to people, making them a means of service to people, not a means of c o n t r o l . The CHR can have an important r o l e both i n : helping people to use services and i n encouraging service organizations to modify some aspects of t h e i r functioning, though tiis l a t t e r can be usua l l y only i n a minor way. The basic operational structure i s set by regional and national bureaucracies, so that the nurses, as well as the CHR's have l i m i t e d f l e x i b i l i t y . 151 However, no-one the author talked to mentioned explicitly class differences between the reserve Indians and the government personnel. There i s a strong societal belief in the equality of Canadian society, in its essential "classlessness", so that people may be seen to differ in their income levels certainly, but that basically everyone shares middle-class mores, morals and ideals. Needless to say, i f no problem is recognized, no attempts will be made to deal with i t . Both CHR's and nurses mentioned the CHR's efforts in interpreting between Indian and white culture, but their role in the other two areas, professional versus lay, and middle versus lower class, was more subtle and largely unarticulated. 152 CHAPTER VII CONFLICTS IN THE PROGRAM In the previous chapters, several c o n f l i c t s i n the work s i t u a t i o n of the CHR's were mentioned. These c o n f l i c t s i n the work s i t u a t i o n are echoed, and perhaps i n t e n s i f i e d by, c o n f l i c t s which are found i n the goals and objectives of the program per se. Such c o n f l i c t s are to be expected i n a multi-purpose program, The major d i r e c t i o n s i n which c o n f l i c t s are s e t t l e d reveals the actual operating values and objectives, which may be d i f f e r e n t from the stated ones. In t h i s way, an examination of the immediate object-ive and job d e s c r i p t i o n and functions of the CHR's can provide i n d i c a t o r s of the d i r e c t i o n of t h e i r r e s o l u t i o n . A> CONFLICTS IN THE OVERALL GOAL In regard.to the o v e r a l l goal, the aim of improving standards of health and l i v i n g i s presumed to be i n agreement with most Indians' goals. However there i s an even longer-term unwritten goal which has been downplayed i n recent years due to opposition from Indian organizations, which i s that of having r e s p o n s i b i l i t y f o r health s e r v i c e s to Indians (and other s e r v i c e s , such as education) taken over by the provinces, to be provided on the same ba s i s as they are to the remainder of Canadians. The Indian Association of Alberta claims that health care i s a treaty r i g h t and therefore a f e d e r a l r e s p o n s i b i l i t y . To the extent that Indian communities support the Association, and to the extent that 153 t h i s program i s seen as a f e d e r a l move i n the d i r e c t i o n of abdicating r e s p o n s i b i l i t y , the communities would oppose i t . The author d i d not perceive that the program was generally seen as a means to that end, but d i d not s p e c i f i c a l l y seek information on t h i s matter when speak-ing with employees of the Alberta Indian Association. I t could also be at variance with f e d e r a l employees i n Medical Services who might not wish to become part of a p r o v i n c i a l service, with a consequent dis r u p t i o n of t h e i r p o s i t i o n s , work, b e n e f i t s and so on, or indeed, to lose t h e i r p o s i t i o n s e n t i r e l y . B. CONFLICTS BETWEEN GROUP A SUB-OBJECTIVES In regard,, to the f i r s t program objective, i . e . of i n v o l -ving l o c a l people i n health a c t i v i t i e s , encouraging consumers to active p a r t i c i p a t i o n i n the carrying out of a service can contribute to c o n f l i c t s between suppliers and consumers. 'Needs' of the community may be perceived and defined quite d i f f e r e n t l y on occasion by health professionals and l o c a l consumers, and compromises have to be reached, which may be time-consuming and f r u s t r a t i n g . For example, a nurse might have the knowledge and techniques to plan and carry out programs i n the community i n a minimum of time. Allowing committees to do much of the work, or simply allowing the time which may be required to generate widespread enthusiasm and desire f o r a program may c o n f l i c t with the professional worker's need or desire to get a 154 job done quickly. The trade-off between carrying out a program by the professional to solve a problem perceived by the p r o f e s s i o n a l , and allowing a program to a r i s e from and be worked out through community perceptions of need must often be decided i n the i n d i v -i d u a l s i t u a t i o n s . Most of the o p e r a t i o n a l i z i n g of t h i s consumer involvement i s at the v o l i t i o n of the f i e l d nurses and i s not an administrative f i a t . Moral support f o r so doing i s expressed by administration, but the e f f o r t and time, required on the nurse(s part may make i t not worthwhile, e s p e c i a l l y i f i t means a reduction i n the q u a n t i f i a b l e services the nurse provides - percentage of population immunized, numbers seen at prenatal c l i n i c s , and so on. There might be c o n f l i c t s f o r the p r o f e s s i o n a l s , i n v o l v i n g personality t r a i t s and areas of knowledge. CHR's are carrying out functions a f t e r a few months of t r a i n i n g while the nurse has had around f i v e years of education f o r her job. F i e l d nursing on reserves requires independent and s e l f - r e l i a n t i n d i v i d u a l s with reasonably strong and secure p e r s o n a l i t i e s . The nurses are set up i n a r e l a t i v e l y p r e s t i g i o u s job, l i v e i n a good house and have a high standard of l i v i n g by l o c a l standards, but t h i s objective implies that they should be unobstrusive i n t h e i r work on the reserve, and allow Indians to plan and carry out programs i n a way which might be very d i f f e r e n t from the way the nurse would do i t . 155 I t a l so requires that the nurse l e t the l o c a l people take the c r e d i t f o r a successful program even i f she was the prime i n i t i a t o r and a major resource i n the program. D i f f i c u l t f o r any human being. Another c o n f l i c t may a r i s e from the nurses' backgrounds and experience, which may often include l i t t l e contact with, knowledge of, or even i n t e r e s t i n p o l i t i c a l happenings, community development techniques and consumer involvement i n health services. Education i n these spheres i s not provided to any extent i n or i e n t a t i o n or continuing education by Medical Services. The nurses have often not worked with a u x i l i a r y workers before, but are t o l d only b r i e f l y i n t h e i r own o r i e n t a t i o n about the objectives of t h i s program and the CHR's r o l e , and are given l i t t l e preparation (a manual) f o r o r i e n t a t i n g beginning CHR's. This i s part of a perennial problem f o r a l l organizations - h i r i n g only people with s t e r l i n g q u a l i f i c a t i o n s , or h i r i n g people who do not have the i d e a l preparation and hoping they w i l l pick up the necessary expertise on the job, or else providing them with the education and preparation. A l l three ways can be expensive i n terms of money, manpower and mistakes. Having communities i n i t i a t e , plan and carry out programs can also c o n f l i c t with established r u l e s and p o l i c i e s 156 and other "givens". I n i t i a t i o n of programs at the l o c a l l e v e l can be done only i n minor ways, since control of funds i s at the Regional l e v e l , or i n the hands of other departments, mainly the Department of Indian A f f a i r s and Northern Development. New programs which don't cost money can be c a r r i e d out e a s i l y enough. And most programs and services provided by Medical Services are statutory, °r, p o l i c i e s i n some regions to f l y pregnant women i n t o h o s p i t a l one month before b i r t h , e t c . They could not e a s i l y be discontinued, even i f l o c a l people, community or workers, wanted to do so. The administration's objective of making Indians more inte r e s t e d i n and aware of t h e i r health problems, and therefore leading to demands f o r more ac t i o n on them c o n f l i c t s with the l i m i t s on resources i n terms of money, time and manpower to meet problems and demands. A community which/is p o l i t i c a l l y aroused may become "too a c t i v e " or a c t u a l l y h o s t i l e to govern-ment workers, making i t d i f f i c u l t to a t t r a c t white workers to the area. I t creates s t r a i n f o r the a u x i l i a r y workers as w e l l , who^may be disapproved of as 'agents' of the government or of being too much " l i k e the white man". By having the Band administer the CHR program, Medical Services may have to t r a i n Band-selected people of whom;, they may not approve as good candidates f o r the job. The CHR must be 157 f u n c t i o n a l l y accountable to the f i e l d nurses, who are responsible to see the a u x i l i a r y ' s work i s safe and appropriate, but a c e r t a i n amount of control i s removed from the nurse's hands i f the Band i s responsible f o r promotions, h i r i n g , f i r i n g , program approval and so on. The Band may define what the worker's functioning i s to be quite d i f f e r e n t l y from the nurse's d e s i r e s . Band control also c a r r i e s the r i s k of down-playing the importance of health programs and a consequent lessening of a v a i l a b l e resources, since native Band administrators are u s u a l l y p r i m a r i l y concerned with economic development and employment problems on the reserves. Yet one of the ideas behind having the CHR account-able to the Band i s to help ensure that the worker does perform i n the i n t e r e s t s of the community, working on problems the community sees as important - not to be co-opted i n t o the Medical Services way of seeing and doing things. Their primary i d e n t i f i c a t i o n i s i d e a l l y to be with the community, not with the bureaucracy. Another r i s k which i s invoked by having " l o c a l people" involved (here meaning the a u x i l i a r y workers rather than the community) i s that the workers w i l l be seen by the community as a "second-class" mode of s e r v i c e , i n comparison to the professional nurses and doctors they may desire or be used t o . 158 C- CONFLICTS BETWEEN GROUP B SUB-OBJECTIVES In regards to the second objective i . e . of helping professional workers to be more e f f e c t i v e by providing a l i n k with the l o c a l community, several c o n f l i c t s present themselves. This objective implies that services and programs could be a l t e r e d and adapted to l o c a l conditions, c o n f l i c t i n g with administrative need f o r a c e r t a i n amount of standardization and routine, so as to f a c i l i t a t e coordination of s e r v i c e s , allow newcomers to f i t i n t o the system quickly, evaluate services and so on. The problem of resource shortages a r i s e s again - a l t e r a t i o n s require time and knowledge of the l o c a l s i t u a t i o n . A c o n f l i c t i s possible i n the desire to have the a u x i l i a r y worker create a favorable environment f o r the professionals' work, and at the same time be an advocate f o r t h e i r own community, explaining l o c a l b e l i e f s , values and customs to the professionals and helping i n d i v i d u a l s to benefit from the system, not the reverse. Bridging two cultures i s d i f f i c u l t . The community may c r i t i c i z e the worker f o r being "too white", yet i f he remains s u f f i c i e n t l y i n touch with h i s own people, c u l t u r a l l y , s o c i a l l y and economically, he may not always be i n agreement with Medical Services goals and programs, and h i s s o c i a l and working r e l a t i o n s with f i e l d personnel e s p e c i a l l y may be f a r from smooth. Support from the nurses i s c r u c i a l to the success of the a u x i l i a r y ' s work, as the b r i e f t r a i n i n g course may not equip her 1 5 9 with a l l the necessary expertise and knowledge. The p o s i t i o n of the CHR v i s - a - v i s the nurse makes i t d i f f i c u l t f o r her to be too c r i t i c a l of the nurse or agency, f o r she i s dependent on the nurse f o r information, health knowledge, moral support and recommendation f o r pay r a i s e s and continuation i n the job. This i s another dilemma f o r Medical Services. The CHR's need to have s u f f i c i e n t education to carry out t h e i r jobs, and more education would supposedly make them more e f f e c t i v e . There i s also the p h i l o s -ophy expressed by Medical Services of encouraging Indians to continue to educate themselves and b e t t e r t h e i r chances f o r good employment - to r e a l i z e t h e i r p o t e n t i a l i n whichever way they f e e l appropriate. However, further education c a r r i e s the r i s k of reducing t h e i r empathy f o r or even a l i e n a t i n g them from t h e i r own community, e s p e c i a l l y the lower socio-economic groups. Their effectiveness as a l i n k to reaching groups the professionals f i n d hard to reach may be reduced. Are they more valuable as profess-i o n a l workers (and t h i s often means leaving the reserve to work i n the c i t i e s ) or as a u x i l i a r y workers on the reserve? D. CONFLICTS IN THE THIRD OBJECTIVE As regards to the t h i r d objective i . e . of increasing the number of active health workers i n the f i e l d , a few c o n f l i c t s are apparent. A l a r g e r work force, e s p e c i a l l y with t h i s category of 160 worker who has no counterpart in the provincial health services, may make i t more difficult to hand Indian health services over to the provinces. As well, increasing personnel and therefore expenditures conflicts with a limited budget. Besides having more field workers, more administrative personnel to educate, co-ordinate, and administrate the program are necessary, conflicting with the belief in decentralization and a desire to place maximum resources in the field at the delivery level, as claimed 2 by Medical Services administrators. The author's impressions of the major directions of resolution of these conflicts and their implications for the future of the program form the basis for the conclusions and recommendations of the next chapter. 161 CHAPTER VIII CONCLUSIONS AND RECOMMENDATIONS A. ANALYSIS OF OBJECTIVES In analyzing the a c t i v i t i e s and achievements of the CHR's i n the eight chosen reserves, no s t a t i s t i c a l data were av a i l a b l e to measure the concrete achievement of any of the objects l a i d down f o r the program. Instead, an imp r e s s i o n i s t i c a nalysis was done by the author, based on interviews and observations made on the reserves and with Medical Services personnel and other people i n contact with the program. I t w i l l be obvious that the study has a fundamental weakness, which i s the lack of input from the consumer's side, ^he point of view taken i n the evaluation i s that of the provider, and the objectives measured are those set up by white middle-class health professionals. However an impression of the appropriateness of the program objectives to the Indian people can be gained p a r t i a l l y from t h e i r achievement r a t i n g , assuming that those of most i n t e r e s t to CHR's and t h e i r communities would be more e a s i l y and most often c a r r i e d out. This agrees with a d e t a i l e d survey done i n the United States where an inventory was made of CHR's functions. They found that the CHR's performed the tasks they considered of highest p r i o r i t y most frequently.^ The consumer's point of view i s glimpsed only, by h i s p a r t i c i p a t i o n or not i n program a c t i v i t i e s , and surmised from knowledge of the environ-ment and culture on Indian reserves. Only the immediate sub-objectives were evaluated. They do not nece s s a r i l y guarantee achievement of the longer-term sub-objectives, and indeed, i n some cases, the author gained the impression that achievement went no further than the immediate sub-objectives. (See p. 75 to p. 82.) 162 A r a t i n g of 1 to 3 was assigned by the author to each sub-objective. The c r i t e r i a used to assign a r a t i n g were: the i n t e r e s t expressed by the CHR i n t h i s a c t i v i t y , how often she claimed to carry i t out, her f e e l i n g s as to the r e s u l t s she obtained, and the assessment of the nurses as to the achievements of the CHR's i n t h i s function. A r a t i n g of " l " means very l i t t l e a c t i v i t y i n t h i s area, and expressions from the nurses and CHR's that l i t t l e had been or could be achieved here. A r a t i n g of "3" means the most frequently-performed duties and s a t i s -f a c t i o n expressed as to the r e s u l t s of a c t i v i t y . A r a t i n g of "2" i s intermediate i n amount of a c t i v i t y and impressions of ef f e c t i v e n e s s . Below each objective r a t i n g , a b r i e f summary of mainly s i t u a t i o n a l v a r i a b l e s a f f e c t i n g the outcome are presented. P o l i c y v a r i a b l e s w i l l be discussed more f u l l y i n a separate section. 1. Rating of Achievement of Sub-Objectives A1-A12 Objective 1 Rating 3 1. Prenatal care X 2. C h i l d immunization X 3- N u t r i t i o n teaching X k. Dental hygiene X 5. Environmental safety X 6. Family Planning X 7. Exercise promotion X 8. Alcohol use X 9. Home nursing X 10. Support services X 11. Screening X 12. Water sampling X A high r a t i n g was given to a c t i v i t i e s i n the areas of baby immunization, n u t r i t i o n teaching, environmental hygiene and safety, 163 home nursing, transportation and other support duties, physical examinations, and water control duties. A l l these have c e r t a i n c h a r a c t e r i s t i c s which make them l i k e l y to be more frequently per-formed and successful than other duties. The CHR's have had experience i n many of these a c t i v i t i e s before j o i n i n g the CHR program, simply by way of growing up on the reserve and r a i s i n g t h e i r own f a m i l i e s there. Their r e s u l t i n g knowledge and confidence would lead to a concentration on such areas. Most are eas i l y - l e a r n e d duties, requiring no complicated theory or s k i l l s , and they are concrete, active functions, not just verbal a c t i v i t i e s , with v i s i b l e , quickly-seen r e s u l t s . This makes them more s a t i s f y i n g than some other duties. They are also quite legitimate functions i n the eyes of the Indian community, as they are concerned mainly with c h i l d r e n and domestic a f f a i r s ; c h i l d r e n i n most s o c i e t i e s are objects of much attention, e s p e c i a l l y of women which these CHR workers are. As we l l , such basic needs as food, water and s h e l t e r are large problems on Indian reserves and take p r i o r i t y over many other concerns. They are l o g i c a l l y of much concern to CHR's and the community. These also have been the t r a d i t i o n a l areas of concentration of public health programs, and i t can be assumed that the nurses could give the CHR's most support i n the areas i n which they themselves are most knowledgeable. Low and medium ratings were given to achievements i n the areas of dental hygiene, family planning, exercise programs and alcohol programs. I t i s l i k e l y that dental hygiene and regular exercise aire not very important or relevant to Indians, i n view of the other problems they face, and so many s o c i a l and psychological factors are 164 involved i n the regulation of f e r t i l i t y that simply providing the medical supplies and preaching the need for them w i l l not alter the underlying predisposition to use or refuse family planning. Excessive drinking usually involves the men on the reserves more than the women, though of course the results are suffered by a l l . It may not be con-sidered legitimate by the Band for a female worker to "interfere" i n this area, and most CHR's believed the underlying social factors to be complex and beyond their power to affect. They dealt with pro-blems resulting from alcoholic excesses, rather than the drinking i t s e l f . Indeed, to improve the level of people's health i n these areas of dental hygiene, exercise, alcohol and family planning required much active behaviour change on the part of individuals, and even health professionals cannot be said to always be successful at that. The structural supports which would make such achievements easier (running water i n every home, sports f a c i l i t i e s and programs, employment for a l l who wanted i t ) , obviously require much input beyond the scope of the CHR program and Medical Services' power. This i s no different from the response to health education act i v i t i e s i n any other community. The structural supports which decrease the demands placed on people (e^. putting running water into homes) have a greater health impact than service a c t i v i t i e s which ask for an increase i n performance levels (asking people to haul more water and boil i t ) . It was possible to classify the results of achievements of these sub-objectives by the type of reserve only very loosely. The 165 impression i s that the programs req u i r i n g more sophisticated and/or c o l l e c t i v e approaches (alcohol treatment, family planning, organized c h i l d care such as f o s t e r or day care) were more often found on big reserves near c i t i e s (though s t i l l well-defined geographically), where there had been more governmental input and considerable contact between Indians and whites, and on reserves which were economically independent, 1. e. not dependent on large government subsidies f o r t h e i r major source of income. These included Kehewin, Morley, Hobbema and Blood Reserves. Maternal-child work and environmental c l e a n l i n e s s programs are s l i g h t l y l e s s important on these reserves where people have more amenities (housing, water), somewhat higher l e v e l s of education, and have had such programs f o r a long time or at l e a s t access to a l t e r n a t i v e services i n nearby c i t i e s . This points up the m u l t i p l i c i t y of demands which i s placed on health service programs and the problem of t r a i n i n g health workers appropriately f o r t h e i r work s i t u a t i o n . 2. Rating of Achievement of Sub-Objectives A13-A20 Objective Rating 1 2 3 13- Health classes i n schools X Ik. Audio-visual aids X 15. U t i l i z a t i o n of mass media X 16. Attendance at Band meeting X 17. Group organizations X 18. Health committees X 19. Organization of s p e c i a l projects X 20. Mutual work with other service agencies X 166 I t i s noticeable that i n t h i s group there were no high r a t i n g s given. The CHR's had a medium r a t i n g i n attending Band Council meetings; t h i s varied with t h e i r opinion of the Council's effectiveness and i n t e r e s t i n health. There i s evidence that i n some Bands, majority rule and elected Councils are considered by many to be non-Indian customs, and they are h o s t i l e to t h i s mode of govern-ment. In such cases, the CHR may be more e f f e c t i v e by by-passing the formal structures. CHR's f e l t that informal ways of working often aroused l e s s a t t e n t i o n and p o t e n t i a l opposition. The more formal methods of organizing committees and attending Council meetings are more f a m i l i a r and accessible to white government personnel, e s p e c i a l l y i f they do not l i v e on the reserves. The CHR's who are part of a whole network of power r e l a t i o n s h i p s i n the reserve can work e f f e c t i v e l y behind the scenes and after-hours, e s p e c i a l l y where the formal reserve leadership i s l e s s than dynamic and the community i s s p l i t i n t o many facti o n s along c l a s s , kinship or other l i n e s . A low r a t i n g was given to achievements i n health education hy the use of mass media, meetings, e x h i b i t i o n s , f i l m s and so on, i n work with community groups to improve health, work on health committees or involvement i n workshops, health education programs, youth camps and l i k e a c t i v i t i e s . Health education more often involved passive r o l e s f o r the CHR's: l i s t e n i n g to i n d i v i d u a l l y expressed problems and providing i n s t r u c t i o n i f requested, rather than the more aggressive means of meetings and workshops. Mass media such as printed material are not useful i f people do not read much, or i f they do not gather i n groups, to be taught with v i s u a l aids. On one reserve where there was a 167 l o c a l newspaper, the CHR used i t f o r notices or a r t i c l e s about health problems, but such f a c i l i t i e s were not a v a i l a b l e on other reserves. The CHR's f e l t i n general that the preparation required to gather groups for organized teaching sessions was excessive, when compared to the r e s u l t s obtained. Developing indigenous leadership on reserves i s a problem f o r more than the health system, and others have been long involved i n looking f o r ways to allow the Indians a l a r g e r share i n the decision-making on reserves. Leadership s k i l l s are i n short supply i n any community. Other concerns on the reserves, such as the economic problems, are more important than health, and much of the leaders' time i s n a t u r a l l y taken up with them. Health committees have d i f f i c u l t y i n a t t r a c t i n g active members and the i n t e r e s t of the Chief and Council i n t h e i r a f f a i r s . The f a c t that most health commi-ttees are composed of women and the Chief and Council are u s u a l l y men may also reduce the committee's power. I f the CHR i s r e l a t e d or some-how close to the Chief and Council, she may not f e e l that a committee i s so necessary to reaching her ends, and can achieve them through personal influence. The l a s t a c t i v i t y i n t h i s group to be least-performed was that of organizing and conducting workshops, summer camps, youth pro-grams and other group a c t i v i t i e s . These frequently involved substan-t i a l organization, funds, contacts and coordination with other government departments—all rather sophisticated and time-consuming a c t i v i t i e s . On some reserves too, such a f f a i r s were being c a r r i e d out by a sports d i r e c t o r or s o c i a l committee. 168 In addition to the use of informal leaders, a high r a t i n g was also given to teaching young school chi l d r e n , an area e a s i l y -managed by CHR's and one they considered important. To c l a s s i f y these r e s u l t s by reserve i s again only a loose g e n e r a l i z a t i o n . The l a r g e r reserves, which are nearer c i t i e s and economically better o f f , had more overt and aggressive leadership, and more formal group a c t i v i t i e s and reserve programs. These reserves were the ones where CHR's were active i n health committees, Band Coun-c i l meetings and organizing workshops, i e . the worker had a pre-e x i s t i n g structure to support her. The most northern reserves are generally poorer and have l e s s a c t i v i t y o v e r - a l l , both i n terms of government services and among the Indians themselves. However, some Bands i n the north are small enough that formal meetings and meeting-places are not necessary to achieve c o l l e c t i v e ends, and kinship groups may carry out the same functions as elected Councils. Objective 1 Rating 2 3 2 1 . Language i n t e r p r e t a t i o n X 2 2 . C u l t u r a l i n t e r p r e t a t i o n X 2 3 . Information g i v i n g re services X 2k. S e n s i t i z a t i o n to personal b e l i e f s and prejudices X This area of c u l t u r a l bridging was given a uniformly high r a t i n g by CHR's, nurses and Medical Services personnel. The matter of i n t e r p r e t i n g both language and culture would be important to nurses 169 because they usually have a great need of help i n this area, to reduce the obstacles they face i n carrying out their duties. Medical Services nurses know they w i l l be working closely with Indian people and presumably some have joined the service with an interest i n learning about another culture and adapting their work to i t ; advice and help from the CHR i s frequently solicited and much appreciated. It i s also an area where the CHR's knowledge i s superior to that of the nurse and this makes i t a function where she can feel important and be important. It i s also necessary for the CHR's own satisfaction to interpret carefully between the community and nurses, as she i s the bridge between the two and wants to get along with both sides. Both nurses and CHR's have a great need for this function to be performed well and frequently. The help of the CHR i n using resources (mainly government services on or outside the reserve) i s frequently asked for by Indians. The CHR may be a good alternative to personally facing a person from another culture perceived as hostile, having great power, or any other characteristic attributed to the white man, or she may be simply a good and accessible source of information due to her contacts. Many Indians have l i t t l e knowledge or experience of the complicated structure of society off the reserves, and thus cannot use various resources and servives, or are fearful of so doing. Probably these functions of bridging are more important on the most northerly and isolated reserves, where Indians have had less contact with white society, are less educated and speak their own language better than English. However, the problems of social and cultural distance exist on a l l reserves and the linking role of the CHR i s invariably important. 170 k. Discussion A l o g i c emerges from t h i s rough a n a l y s i s of achievements. The areas i n which the CHR's function most often and e f f e c t i v e l y seem to be three: 1) areas of most concern to the community and CHR's (and sometimes Medical Services as w e l l ) ; 2) areas where the CHR's have the most knowledge and experience before t h e i r course; and 3) areas where they f e e l t h e i r personal resources are most e f f e c t i v e l y used, and thus gain the most s a t i s f a c t i o n from. Those which clash with the Band's way of accomplishing things, the l o c a l power structure, the ro l e of women, the p r i o r i t i e s of the community, or which are beyond t h e i r f i n a n c i a l and managerial resources, are performed l e s s often. What dampening e f f e c t the nurses had on the CHR's p r o c l i v i t i e s can only be guessed at, but i t i s probably quite strong i n some s i t u a t i o n s . I f the nurses had l e s s control over the CHR's, t h e i r functioning might conceivably be quite d i f f e r e n t . B. POLICY CONSIDERATIONS: COORDINATION AND ISOLATION P o l i c y considerations w i l l be considered i n some d e t a i l , as they are more e a s i l y c o n t r o l l e d or manipulated than many of the s i t u a t i o n a l v a r i a b l e s a f f e c t i n g the program, as well as being impor-tant guides to the administrative decisions which follow upon p o l i c y . The la c k of a c l e a r p o l i c y on fun c t i o n a l r o l e s seen i n the CHR program and i n Medical Services i s p a r t i a l l y an outcome of the continuing changes and un c e r t a i n t i e s i n o v e r - a l l government p o l i c i e s on Indians and on regional development. At the bottom of the c o n f l i c t between Indians and whites i s the struggle f o r power. With roots i n the conquest of North America by Europeans, and development aff e c t e d by the growth of 171 humanistic philosophies over three centuries, the attempts to alter the amount of control held by various factions are seen in such phenomena as the growth of Indian organizations and the idea of community participation i n programs which affect their welfare. What social development and organization theory both are now recognizing i s that community development or participatory manage-ment does not occur just by asking people to discuss their conflicts face-to-face, thus involving everyone in a decision amiably agreed upon by a l l . Power systems have structural elements which must be examined systematically for their effects on people and programs, and structural elements built into them which put control where i t i s deemed desirable, rather than depending on individual personalities for the desired ends. These structural elements are most obvious in the vertical relationships within an organization—the work structure, the technology. But the horizontal relationships an organization has with other organizations which enable i t to coordinate and cooperate with them are also determinants of out-comes and effectiveness, the power of an organization. This i s one reason for emphasizing the organizational isolation of the reserves, health services and the CHR program from institutional links which would alter their functioning so much. The importance of internal factors has been exaggerated to the neglect of the external institutions which figure greatly in the development of Indian communities. In another manifestation of the power struggles, public policy recommendations have been variously sensitive to the implica-tions of cultural dualism, that i s , the persistence of traditional 172 Indian culture or some form of t r a n s i t i o n a l culture., separate from the dominant white culture. This i s complicated by the various degrees of acc u l t u r a t i o n which Indians have undergone. Indians l i v i n g i n or near c i t i e s are considered to be generally more assimilated to the dominant culture than are Indians on i s o l a t e d reserves, making standardized 2 programs more or l e s s appropriate. There i s some evidence that those people who grow up i n an integrated culture, even i f i t i s a small minority, have a h e a l t h i e r ego and are able to f i t themselves i n t o the dominant culture with l e s s psychological s t r e s s and l o s s of i d e n t i t y . Though t h i s may be accepted as true i n Canada now, the t r a n s l a t i o n of t h i s b e l i e f i n t o p o l i c y and programs i s very d i f f i c u l t . The v a c i l l a -t i o n s between a s s i m i l a t i o n , i n t e g r a t i o n and separation which go on make the f i e l d i n which the Indian health service operates unstable and poorly defined; consequently the r o l e of MS i n the CHR program i n "Indian p o l i c y " i s uncertain. The i s o l a t i o n of Indians c u l t u r a l l y i s echoed p o l i t i c a l l y . 1 Since Indian reserves are managed by one fe d e r a l government department, they tend to be i s o l a t e d from p r o v i n c i a l government programs, as well as from any regional development programs which would integrate p r o v i n c i a l and/or federal departments i n the comprehensive development of a region. Health i s an acknowledged partner i n development, though i t must be admitted that the e f f e c t s of development on health have been more studied than the opposite case. But the la c k of a c l e a r and coordinated p o l i c y at the top of e i t h e r government or Indian organizations f o r the development of reserves alone or as parts of regions i s echoed by uncertainty and i s o l a t i o n at the bottom. The i s o l a t i o n of reserves from wider developments and of health services from other government services isrepeated f o r the CHR program, which seems to be an i n s i g n i f i c a n t and awkwardly-placed 173 g r a f t onto the side of National Health and Welfare and Medical Services. I t i s i n t e r e s t i n g to note that although CHR programs e x i s t i n each pro-vince and a l l over the United States, the author heard of l i t t l e active c o l l a b o r a t i o n between the administrators and teachers of such programs, i n terms of meetings, information and l i t e r a t u r e - s h a r i n g , and such l i k e . In f a c t , one CHR t r a i n e r ' s attempts to share ideas, information, l i t e r a t u r e , teaching aids and so on produced so l i t t l e feedback and r e c i p r o c i t y from other CHR t r a i n e r s , that he refused any longer to make such attempts. Excluding health, the Department of Indian A f f a i r s handles a l l aspects of Indian communities, inc l u d i n g community development. The feder a l government has expressed i t s wish that the Indian health service be taken over by the provinces, but at t h i s time the program i s i s o l a t e d from the p r o v i n c i a l health system as well as the mainstream of Indian A f f a i r s a c t i v i t i e s . The CHR's must work across these gaps, as some of t h e i r functions are not r e a l l y the r e s p o n s i b i l i t y of Medical Services. For example, the Department of Indian A f f a i r s i s responsible f o r w e l l -digging, and often arranges f o r i t to be done through the p r o v i n c i a l ser v i c e s , yet Medical Services f e e l s i t i s a health r e s p o n s i b i l i t y to ensure that people have s u f f i c i e n t and safe water to drink. Some functions are c a r r i e d out separately by both departments, eg. auto safety campaigns. The CHR's concern f o r the mental health of the community may mean that she has to contact Indian A f f a i r s and/or the correct p r o v i n c i a l department f o r funds f o r sports a c t i v i t i e s . The r e s u l t of such d i f f i c u l t i e s i s the narrowing of the scope of her a c t i v i t i e s to more manageable i n d i v i d u a l nursing contacts. I f the CHR program i t s e l f i s poorly integrated i n t o the general 17k scheme of things, the workers too can be e a s i l y i s o l a t e d from sharing i n the a c t i v i t i e s of Medical Services, i n terms of access to information outside what the nurses choose to give. Same a l l e v i a t i o n i s provided by t h e i r attendance at the annual conference, but there i s an active provin-c i a l health service with i t s educational programs surrounding a l l of the reserves, which i s not made use of. The province of Alberta also runs a s i m i l a r program to t r a i n a u x i l i a r y public health workers f o r areas of the province with large Metis populations, but contact between the two programs seems to be minimal, and they d i f f e r widely i n s e l e c t i o n , t r a i n i n g , duties and other aspects. With Medical Services i t s e l f , the CHR's are now responsible to the f i e l d nurses, but there are plans to create p o s i t i o n s of CHR super-v i s o r s to advise at Medical Services headquarters and give support to CHR's i n the f i e l d , which w i l l provide a mode of career advancement as well as support separate from that given by nurses. The nurses lack experience i n community development and the use of a u x i l i a r y personnel, which means that they and the CHR's carve out large parts of t h e i r r o l e s f o r themselves i n each reserve s i t u a t i o n . T h i s f l e x i b i l i t y i s a great advantage when the reserves d i f f e r so much, but the r e s u l t i s often that the CHR acts as a nurse's helper, quite dependent f o r any job enlargement on her. T h i s w i l l be enlarged upon i n the following section on r o l e c o n f l i c t . I t i s important that the nurse wants an a u x i l i a r y , and does not mind sharing some of the r e s p o n s i b i l i t y and power of the health service on the reserve. I t i s also important that Medical Services wants a strong Indian involvement i n health care and strong health involvement 175 i n the o v e r - a l l development of the Indian people. The short-sighted approaches seen i n the past to the "Indian problem" i n Canada need to be replaced by much more comprehensive planning and programming, which i s a problem of much greater scope than the r o l e s of Medical Services, DIAND or the Indian Associations themselves. I t involves the p o l i t i c a l system i n Canada as a whole, and the willingness of the majority population to seek out and carry out the p o l i c i e s required. C. FURTHER POLICY CONSIDERATIONS—ROLE CONFLICT One_very noticeable element i n t h i s program i s the basic d i v i s i o n between those workers who acted more as community developers, and those whose emphasis was i n more t r a d i t i o n a l p u b l i c health nursing r o l e s , often acting as a s s i s t a n t s to the nurses. Both r o l e s are described by the pro-gram objectives, but the major emphasis at l e a s t i n the beginning of the program was intended to be on the former.' This study found that i n a c t u a l i t y most of the workers' and nurses' emphases were on t r a d i t i o n a l public health nursing a c t i v i t i e s , i . e . the concentration on one-to-one curative, preventive and educational ser-v i c e . While these are important duties, and go some way to meeting community demands, there seems to be l i t t l e awareness of how these could be used as a l e v e r to community development. I t may be that the personality t r a i t s required f o r e f f e c t i v e one-to-one health work, where the worker cares f o r and counsels a mother, an adolescent or an e l d e r l y c l i e n t , are incompatible with the t r a i t s required f o r e f f e c t i v e community and group work, e.g. teaching i n schools, arousing public demand for pro-grams, or encouraging the formation of committees. Even i f not incompa-t i b l e , they may be very d i f f i c u l t to f i n d combined i n one person, and 176 perhaps should not be expected, unless considerable t r a i n i n g i s given to develop." the workers' s k i l l s i n both areas. The a c t i v i t i e s of public health nursing which are t r a d i t i o n a l are often considered by Indian communities to be the most important duties of the health service, e s p e c i a l l y where reserves are i s o l a t e d from other health services. Such work i s a l s o l i k e l y more s a t i s f y i n g to most nurses and CHR's. They have been trained i n them and r e s u l t s are sooner seen than i n more nebulous and slow-moving committee work. Recognition from one's employing agency follows v i s i b l e , quantified r e s u l t s , and t h i s i s a powerful motivating force. Other pressures a r i s e from the Band, who have an idea of how they want the nurse to function. On one reserve, a Band disapproved of nurses r e s t r i c t i n g c l i n i c hours i n favor of home-visiting and preventive work. The CHR i s obviously subject to the nurse's ideas of what and how functions w i l l be c a r r i e d out, and thus must accommodate her own p r o c l i v i t i e s to the nurse and the Band both. Support i s also given to health workers not j u s t by yea- or nay-saying, but by education and t r a i n i n g as w e l l . Medical Services i n i t s o r i e n t a t i o n program, continuing education and conferences could imply t h e i r support or not by the existence or lack of i n s t r u c t i o n i n community development. The salience of p o l i t i c s to health matters i s l a r g e l y i g -nored i n professional health t r a i n i n g . Most nurses would have been educated i n b i o l o g i c a l - p h y s i o l o g i c a l theories of disease, rather than e c o l o g i c a l concepts of health. Indeed the i n t e r r e l a t i o n s h i p s between health and general economic and s o c i a l development are complex and poorly understood. Medical Services professes the need f o r community development approaches, but has no community developers or anthropologists on s t a f f 177 or as advisers, and gives no training or orientation to its own staff, especially field nurses, in cultural sensitivity or community development. A health worker's belief that most of the causes of poor health on the reserve had their roots in the economic and political situation of the Indians, matters outside the strict purview of Medical Services, could raise some conflicts for her. On the one hand her training and out-lined job functions equip and require her to function independently and decisively in the usual public health mold, while a developmental approach would mean her activities focus also on community organisation and poli-tical action programs, demonstrating a willingness to go along with and encourage the local leadership priorities, taking a less prominent role herself and seeing the indirect benefits to health which can be gained. So far, no systematic evaluation of the growth of indigenous leadership on the reserves has been carried out, though this has been mentioned as a major result of a similar program in the U.S., i.e. an increase of community identity and cooperation, and awareness of its own capabilities. Formal recognition of the difficulties of this process and a description of the roles of the CHR and nurse in i t is not so far forthcoming from Medical Services. The encouragement of local initiative carries with the possibility of confrontation and resistance which may be viewed as simply making the health service's job more frustrating, or alternatively as a sign of healthy dissolution of dependency and passivity, and an increase of organizational skills and sense of pride. An administrator in Medical Services in Edmonton mentioned that the nurses who became "advocates" for the Indians and encouraged them to conflict with Medical Services i f necessary often created the most problems for the bureaucracy in Edmonton, but he considered that they were performing a very valuable 178 function and were worth the trouble.'' I t i s to be hoped that s i m i l a r a c t i v i t y on the part of the CHR i s recognized and encouraged. The author gained a very l i m i t e d impression of the CHR's a c t i v i t y i n s o c i a l advocacy, and i t seemed to involve a very diplomatic covert mode of expression, and l i t t l e overt c o n f l i c t between f i e l d s t a f f and CHR's. Usually i t amounted to explaining or defending a c l i e n t ' s behaviour to a nurse and sometimes standing up f o r c l i e n t s against the Band Council. R o l e - c o n f l i c t could develop to the point where the CHR could be torn between demands of the nurse, the community and the Band Council, and the strength of the pressures coming from each source w i l l decide the CHR's responses d i f f e r e n t l y . Some of the workers f e l t the c o n f l i c t i n g demands more keenly than others: one CHR, for example who had to work with a Band Council she thought partisan and i n e f f e c t i v e , and nurses too new and too young to be able to help her, and thus she f e l t she had to champion the members of the community alone. Another CHR f e l t that she, the nurses and the Band Council had e s s e n t i a l l y harmonizing goals and c o n f l i c t s were rare. For any government bureaucracy, including Medical Services, the temptation to dispense with community involvement i s very great. In health, i t i s claimed to be a v i t a l preliminary to l i n k i n g the health service with wider community goals. T h e o r e t i c a l l y , community involvement should be easier to obtain at t h i s stage of the program, with the spread of the "Red Power" movement i n Canada. This movement i s t r y i n g to help Indians maintain a sense of i n t e g r i t y and community i d e n t i t y , to help b u i l d up native leadership and pride.°" One of the r e s u l t s of i t s e f f o r t s has been a move by some Bands to take control of most of the reserve a f f a i r s , which 179 includes the h i r i n g of people as Band employees to work on the reserve, rather than as government employees. The idea of the community adminis-t e r i n g t h i s program i s regarded favorably by the 1973 Task Force Report on Community Health Workers as a means to community involvement, but makes no mention that t h i s i s a vehicle to further community development. I t i s also questionable that having the Band Council run such programs automatically r a i s e s the l e v e l of t o t a l community p a r t i c i p a t i o n i n them. Not a l l Medical Services administrators and nurses agree with the idea of Indian administration of the CHR's, and several of the Band Coun-c i l s had refused the r e s p o n s i b i l i t y of administering i t , though a l l had helped with the s e l e c t i o n of the CHR. One administrator i n Medical Services f e l t that even though CHR's h i r e d by the Band could more e a s i l y f u l f i l l the s o c i a l advocacy r o l e , i f they had the firm backing of an administrator responsible f o r them i n regional headquarters, i . e . they had t h e i r own advocate, they could stand up f o r t h e i r own people when necessary, even i f hired by Medical Services. He f e l t that Band Councils generally do not know enough about health matters to evaluate a CHR's performance. There i s also the r e a l r i s k that health would be a very low p r i o r i t y i n the face of a l l the other Bank problems, and the CHR's responsible to Medical Services would have more resources a v a i l a b l e to 7 them, which i n i t s e l f would help to e l i c i t Band cooperation. The CHR's, concerned about job b e n e f i t s and s t a b i l i t y , generally wish to be public servants. In the United States, where such workers are hired by the t r i b e s , a frequent problem i s the f i r i n g of the old worker .and the nomination of a new person f o r t r a i n i n g with each turn-over of t r i b a l 180 government, which i n t e r f e r e d greatly with continuity of care given to f a m i l i e s . I t appears the problem has been resolved i n Alberta by the CHR's formally asking to remain on a contract basis with Medical Ser-v i c e s , instead of becoming Band employees, so that the o r i g i n a l objective has been f r u s t r a t e d i n t h i s province. Another very s t r i k i n g element i n the ro l e of CHR's i s the absence" of a c t i v i t i e s to do with problems with alcohol. Medical Services seems notably reluctant to deal with t h i s area, and most alcohol programs are i n i t i a t e d and managed by p r o v i n c i a l alcohol foundations, with the cooperation of the Bands and occasional involvement of nurses and CHR's Alcohol i s usually l i s t e d by anyone involved with Indians as t h e i r major problem, yet the a b i l i t y to deal with i t i s markedly r e s t r i c t e d i n Medical Services, both i n terms of prevention and amelioration of i t s e f f e c t s . I t i s a complex s o c i a l and mental health problem, granted, but ignoring i t s large presence and not encouraging health workers to study about i t or deal with i t a c t i v e l y does not give c r e d i b i l i t y to Medical Services' wish to e f f e c t i v e l y bring the l e v e l of health of Indians up to national l e v e l s . Thus, there are p o l i c y decisions regarding the r o l e of Medical Services i n helping Indian communities to develop, the ro l e of the CHR program i n Medical Services, the r o l e of the Indian community i n the program, and the r o l e of the worker h e r s e l f i n the reserve, which can be affected by conscious and unconscious p o l i c y decisions. Recommen-dations f o r the d i r e c t i o n of p o l i c y i n these areas are offered below. 181 D. RECOMMENDATIONS FOR THE CHR PROGRAM One of the themes of t h i s t h e s i s i s that excess emphasis has been l a i d on the f a c t o r s i n t e r n a l to Indian communities and programs which a f f e c t functioning, rather than examining c a r e f u l l y the factors external to i t — t h e p o l i t i c a l , s o c i a l , economic b a r r i e r s to improvement of the l i f e of Indians. That i s why the recommendations given here f o r the CHR program emphasize p o l i c y i n regards to external r e l a t i o n s h i p s . The very small s i z e of the program, the f a c t that i t has never had the i n i t i a l l y recommended quota of CHR workers, i n d i c a t e s a l i n g e r i n g hesitancy about the program, a d i s b e l i e f i n i t s worth. I t cannot be considered to have been e f f e c t i v e i n Alberta, to have had a s i g n i f i c a n t impact, because i t has never r e a l l y been t r i e d . There i s nowhere near the l e v e l of one CHR worker f o r every 600 Indian people i n Alberta (the o r i g i n a l l y described r a t i o ) . The administrative structures which would help to bring that about, such as a permanent educator/supervisor f o r CHR's and regular t r a i n i n g programs with opportunities f o r advancement i n s k i l l s and p o s i t i o n l e v e l s , do not e x i s t . S e l e c t i o n of and t r a i n i n g programs f o r CHR's seem to be haphazard and ad hoc, using resources i n -t e r n a l to Medical Services, and not invo l v i n g the l a r g e r community which could h e l p — u n i v e r s i t i e s , vocational colifeges, DIAND, p r o v i n c i a l programs f o r health aides. Several suggestions a r i s e from t h i s s i t u a t i o n . 1. Go or No-Go? A d e f i n i t e commitment needs to be made. I f Medical Services f e e l s the program i s worthwhile, i t should at l e a s t be brought up to the strength of one worker per 600 natives, with on-going budgetary support f o r 182 strong training programs and back-up by orienting nurses to the role of CHR's, strong Indian representation at a l l levels of decision-making, structures to coordinate this program with other agencies, and other methods described in recommendations below. The belief of this author is that the health of Indians will only be improved when large numbers of Indians are themselves providing health care, both in direct services and administration of services. The CHR program is one base on which to build, but i t needs far more resources put into i t , a much higher status, and some alteration in policy. 2. What is "Responsibility"? A commitment needs to be made as to the role of this program in Medical Services' stated desire to have Indians take more "responsibility" for their health. This occurs in two decisions. One is whether this pro-gram will have structures which act as means to actively encourage native people to become health professionals, or whether CHR's are to remain as sub-professionals with expansion and diversification of their duties dependent mainly on the personalities of the field nurse and the CHR. The second role-decision is whether the program is to be the responsi-bi l i ty of the Indian people, totally or partially. Because of the great variety of reserves and the needs of the people in them, the maximum program flexibility needs to be maintained. Thus, the sub-professional role should be preserved and valued, while making i t a vehicle to professional health careers. On northern reserves, especially where educational levels are low, i t i s difficult to find candidates who will be able to move on to professional training, and means of maximizing their skil ls appropriate to their situation need to 183 be explored. This of course means the various l e v e l s of GHR's: beginner, middle, senior, with recognition f o r experience and further education, be maintained. Some suggestions for t h i s are given below i n recommen-dations on career structure and t r a i n i n g . On reserves where Indians wish to work as professionals, the experiences and t r a i n i n g gained as a CHR need to be given proper c r e d i t . Medical Services could set up , methods of making health careers more accessible to natives as has happened with teacher-training programs i n Alberta, and i n the United States, where members of ethnic m i n o r i t i e s are given p r e f e r e n t i a l status i n u n i v e r s i t i e s . Entrance requirements can be reduced, s p e c i a l tutoring arrangements set up, more f l e x i b l e t r a i n i n g programs arranged which allow people to return home between sessions, and c r e d i t given f o r pre-vious non-professional experience. The professional nursing, nursing aide and s o c i a l worker associations must also be involved i n devising a- plan f o r education and f o r career m o b i l i t y — e i t h e r v e r t i c a l or horizontal—between CHR's, the p r o v i n c i a l Community Health Associates, nursing aides, nurses, mental health nurses, s o c i a l workers and aides, and so on. This has not so f a r been seen as a r e s p o n s i b i l i t y of Medical Services, but neither educational departments nor DIAND have taken i t on, and Medical Services should take the i n i t i a t i v e to f i l l t h i s great gap. Regarding the r e s p o n s i b i l i t y f o r administration of the program, Medical Services has stated that i t wished the Bands to manage i t themselves. There are arguments f o r and against t h i s . One pro i s that accusations that the CHR's "work f o r the white man" would diminish, and a con i s that continuity of care could s u f f e r as successive Band 184 administrations changed the CHR they administer. This author believes that active p a r t i c i p a t i o n of the Indian community i n health programs w i l l come only when they f e e l the program i s t h e i r s to d i r e c t and maintain. The program i s not " t h e i r s " when Band funds are given by DIAND or Medical Services, and the ro l e s and objectives f o r the program set by Medical Services, the t r a i n i n g programs set and run by them, the supervision done by them, and withdrawal of budgetary support con-t r o l l e d by them or DIAND. This harks back to the question r a i s e d i n Chapter VI as to whether a program should be i n accord with the c l i e n t ' s or the professional's d e f i n i t i o n of "needs", or a combination of both. Some improvement can be made by asking the Bands to decide what t h e i r major health problems are, i f they want a CHR, and what services they would wish CHR to provide. They should then se l e c t the person capable of being tra i n e d to meet t h e i r requirements. They should also be responsible f o r the supervision of these workers, and ask the tech n i c a l advice of the professional workers most appropriate to t h e i r CHR's t a s k s — t h e nurse, the s o c i a l worker, the DIAND agent, alcohol treatment workers. This i s admittedly not always f e a s i b l e when the Band wishes to have a CHR but has l i t t l e expertise i n or time f o r health, or i n d i c a t e s i t s desire to have the program adminis-tered by MS. But Medical Services should r e g u l a r l y propose to the Band that i t take over administration of the program and MS should play a tech n i c a l advisory r o l e only to help the Band decide t h e i r health needs, set objectives f o r and evaluate the program. Some safeguards against the problem of p o l i t i c a l h i r i n g s and f i r i n g s of CHR's could be b u i l t 185 into the CHR's contract with the Band, and sufficient funds must be given to the Band that the worker's remuneration is reasonably close to public service levels, i.e. to the levels which CHR's now working receive. Indian involvement in decision-making for the program needs to come at a l l levels. The Alberta Indian Association should work with Medical Services on the policy decisions mentioned in this chapter, and set the basic orientation and objectives of the program. It could be involved in informing Bands about this program and initiating requests from them for i t to Medical Services, rather than Medical Services being the sole source of information on i t to the Bands. The Association could also be involved in evaluation of the program on a regular basis, with Medical Services* help, and assist with the problems' which might arise over employee discipline, firings, promotions, further training and so on. The CHR supervisor/coordinator for each region (two in Alberta) might well be an employee of the Indian Association, rather than of Medical Services, to increase the knowledge and role of the Association in health services to Indians for one thing, and to facilitate the program being managed more and more by Indian hands. 3. What Should the CHR be Doing? The wide variety of functions which are being carried out by CHR's or which are possible to her should be set up in clear job descriptions, and the Band and she should decide in which areas she will function. So far, CHR's are working in the areas of public health nursing and/or community development, with almost no involvement in alcohol problems. 186 I f Medical Services has a deliberate p o l i c y to be non-active i n the problems with a l c o h o l , i t should be c l e a r l y stated so. Nurses arid CHR's should then be given job descriptions which c l e a r l y define the difference between prevention of alcoholism and the treatment of r e s u l t s of a l c o h o l i c excess, and t o l d where t h e i r duties l i e . I t must be said that t h i s i s a head-in-the-sand approach, as alcohol i s d e f i n i t e l y a major problem on most reserves, and Medical Services cannot ignore i t s e f f e c t s . A t r a i n i n g and supervisory structure which allows and encourages CHR's to deal with alcohol i s needed. This i s probably most e a s i l y achieved by asking the p a r t i c i p a t i o n of alcohol foundations or groups such as A l c o h o l i c s Anonymous to allow CHR's to p a r t i c i p a t e i n t r a i n i n g programs and use the expertise of professional alcohol workers. An "apprentice" system could be set up whereby the CHR's spend a d e f i n i t e amount of time with the alcohol workers, using a curriculum with d e f i n i t e learning tasks and assign-ments f o r the t r a i n i n g period, and then having c l e a r and responsible tasks afterwards i n c o l l a b o r a t i o n with the other alcohol workers. E s s e n t i a l l y the same system i s recommended f o r those workers who wish to function mainly i n other modes. Those who want to work i n nursing services w i l l of course receive most of t h e i r t r a i n i n g and support from nurses, and be evaluated by her and the Band. Those who wish to work i n developing group a c t i v i t y on thereserves should have close working r e l a t i o n s h i p s with DIAND agents, e s p e c i a l l y community developers. As the t r a i n i n g component i s basic to the r o l e s taken by CHR's and a major input to the success of the CHR program, i t i s discussed i n some d e t a i l below. 187 k.. The Training Required Training f o r the CHR program occurs i n two areas: f o r the CHR's themselves, and f o r the people who support them t e c h n i c a l l y , mainly Medical Services. Because the program i s so small and new candidates few, i t i s d i f f i c u l t to mount formal and regular educational programs, e s p e c i a l l y to cope with the d i v e r s i f i e d r o l e s of the CHR's suggested above. However, i f Medical Services makes use of resources outside i t s own organization, and sets up educational guides to those doing on-the-job t r a i n i n g f o r CHR's, the problem can be p a r t i a l l y solved. For example, the u n i v e r s i t y , to t h i s point uninvolved, could lend pedagogic expertise to devise c u r r i c u l a , teaching guides and s e l f - i n s t r u c t i o n a l manuals f o r the various task areas i n which CHR's work, as well as help devise and teach formal programs. A program of information exchange with the U.S. Indian Health Service would be valuable, as they have a consider-able number of t r a i n i n g programs set up and have t r i e d various approaches with i n s t r u c t i n g CHR's. The p r o v i n c i a l health aide t r a i n i n g programs at the vocational colleges could be open to q u a l i f i e d CHR's or candidate-CHR 1s, as could the informal workshops and meetings of various agencies, e s p e c i a l l y the p r o v i n c i a l health u n i t s and s o c i a l work agencies. The problem of coordination between federal reserve ser-vices and adjacent p r o v i n c i a l services i s a d i f f i c u l t p o l i t i c a l one, but c e r t a i n l y informal c o l l a b o r a t i o n should be possib l e , and a struc-ture set up by which CHR's and p r o v i n c i a l health aides have access to educational opportunities i n both Medical Services and p r o v i n c i a l agencies. A health educator at regional l e v e l would be valuable i n 188 l i n k i n g CHR's up with such resources. Some thought should be given at t h i s time to developing s i m i l a r s e l e c t i o n c r i t e r i a , t r a i n i n g pro-grams and career patterns between the federal and p r o v i n c i a l a u x i l i a r y programs. E s p e c i a l l y f o r a d d i t i o n a l t r a i n i n g , experiments might be made with c l u s t e r i n g workers by reserves, e.g. those from large and developed reserves versus those from small and l e s s developed (according to l e v e l s of education, employment l e v e l s , c o l l e c t i v e a c t i v i t i e s , other services on the reserve, and such c r i t e r i a ) , so that more appro-p r i a t e material can be offered to trainees. There i s no p o l i c y reason a l s o that a t r a i n i n g program cannot be f o r CHR's from many regions i f i t caters to an i n t e r e s t of only a few workers per region; probably t r a v e l l i n g costs would r e s t r i c t t h i s . I t does require close collabora-t i o n from a l l educators and supervisors involved with CHR's i n a l l the regions. In spite of the widely divergent r o l e s of CHR's, some core elements are seen i n t h e i r functions, and basic t r a i n i n g can be given f o r a l l i n these task areas. According to t h i s a n a l y s i s and to others done i n the U.S., most CHR's function i n physical health care a c t i v i t i e s , maternal-child health, environmental health, patient care, homemaking services, transportation, coordination and l i a i s o n a c t i v i t i e s . A few work with groups and some do "mass" health education; some are i n alcohol programs and mental health. Thus the core t r a i n i n g should involve home nursing, c h i l d and home management, environmental concerns and interpersonal helping s k i l l s , and, i f necessary, d r i v i n g lessons. Later on, more s p e c i a l i z e d i n s t r u c t i o n i n areas of s p e c i a l i n t e r e s t 189 or need of CHR's should be made av a i l a b l e to them. A determined e f f o r t i n a l l such t r a i n i n g has to be made to not subsume the workers i n t o the value systems of the t r a i n e r s (who w i l l be mostly whites, though Indians should be used when a v a i l a b l e ) , but to help them a r t i c u l a t e t h e i r own values and maintain t h e i r i d e n t i t y with t h e i r c l i e n t s . L i k e l y , the Indian Association could give advice and do some t r a i n i n g here. The important thing i s that such t r a i n i n g structures be b u i l t i n t o the program, to reduce the almost t o t a l dependence of the CHR on the nurse f o r d i v e r s i f i c a t i o n of s k i l l s and duties. Because i t i s foreseen that CHR's w i l l continue to have much contact with the nurses, structures to support the nurses i n t h i s new ro l e need to be included. One i s o r i e n t a t i o n f o r nurses to the culture on the reserves, using anthropologists and Indian representatives. Another i s the intr o d u c t i o n to community development processes, and pract i c e i n carrying out some of the techniques, or at l e a s t i n not hindering others as they carry them out. The f a c t that c o n f l i c t i s i n -herent i n the process of community development and s o c i a l advocacy should be openly expressed and the nurses and CHR's helped to deal with i t with as much objective knowledge and understanding as possible. L a s t l y , the nurses need c a r e f u l guidance i n the t r a i n i n g , development and functions of CHR's. They should l e a r n how to allow the CHR to make maximum use of her t a l e n t s and help her to d i v e r s i f y her s k i l l s , i n the i n i t i a l nursing o r i e n t a t i o n , through teaching guides, and by con-tinued supervision. This i s a point on which to evaluate the nurses as much as on any of the t r a d i t i o n a l nursing duties--the development 190 of the CHR's with whom she i s working, as measured by a d i v e r s i f i c a t i o n i n t h e i r duties and increase i n s k i l l s . 5. The Place of Evaluation Evaluation i s also part of the process of r o l e - d e f i n i t i o n of the CHR program. I f administrators are s t i l l unsure of the worth of the program, then some evaluation should be c a r r i e d out to help decide whether i t should be expanded or contracted or terminated. On the premise that i t should be, and w i l l be, expanded, then both routine and s p e c i a l evaluation e f f o r t s need to be made. Ongoing evaluation, or monitoring, would be a help to s e t t i n g up t r a i n i n g programs. The services c a r r i e d out by CHR's should at l e a s t be compiled r e g u l a r l y by region, and supplemented by interviews of c l i e n t s and observations of the CHR i n the f i e l d , as input to making minor modifications i n s e l e c t i o n and t r a i n i n g processes, and administration of the program. A more thorough-going evaluation would involve s e l e c t i n g reserves which do not have CHR's and monitoring c e r t a i n v a r i a b l e s f o r a year before a CHR i s placed there, to e s t a b l i s h a baseline. The variables could include the areas i n which she would l i k e l y function, plus the changes i n the reserve's environment which w i l l a f f e c t the program, such as the services provided to the reserve, changes i n i t s economy, changes i n transportation f a c i l i t i e s , extensive migration, and so on. The variables measured as outcomes of her work could include such v a r i a b l e s as the extent to which health and s o c i a l services are used by the community, changes i n the l e v e l s of environmental c l e a n l i n e s s , 1 9 1 incidence of a few selected diseases and accidents and violence, changes i n number and character of voluntary groups, and changes i n the Band budget f o r health. Where programs are considered "successful", a thorough study could be made to determine which are the elements common to successful programs, so that attempts can be made to include those v a r i a b l e s i n other reserves.* Along with the monitoring of successful programs, modifications can be made i n approaches i n other reserves, to see i f such changes make a difference i n c l e a r l y i d e n t i f i e d outcome varia b l e s . E. The Future P r o v i n c i a l or federal government's plans f o r the administra-t i o n of treaty Indians are not c l e a r . Nor i s i t c l e a r what plans are for area development i n the province, and what share i f any the reserves w i l l have i n them. The answers to general questions of Indian develop-ment are basic to the r o l e of Medical Services, f o r they w i l l require a continuing re-thinking of objectives, programs and functions. What can be said i s that at l e a s t the health service should t r y not to obstruct or disrupt the e f f o r t s of the native people to maintain or develop an integrated culture f o r themselves. The key requirement on the part of the health service i s f l e x i b i l i t y i n t h i s changing context. One of the great strengths of the CHR program i s i t s * The World Health Organization i s currently conducting a world-wide study i n community development programs, to t r y to determine the necessary and s u f f i c i e n t causes of community development. Health i s considered both an input and a r e s u l t of community development processes. (Personal communication, Dr. H. Strudwick, D i v i s i o n of Family Health, WHO, 2 8 Oct., 1 9 7 6 ) 1 9 2 f l e x i b i l i t y , i t s a b i l i t y to be appropriate to l o c a l s i t u a t i o n s . I t i s important, f o r example, that s e l e c t i o n of CHR's continue to be done by the Band, a f t e r c a r e f u l explanation by Medical Services or the Indian Association of the r o l e s and expectations f o r workers. I f the Indian health service and t h i s program eventually become the r e s p o n s i b i l i t y of the province, the scope and the circum-stances under which the CHR's w i l l be operating w i l l widen. There are i n d i c a t i o n s that t h i s may indeed be what w i l l happen: the scanty back-up i n terms of administrative supports, education and evaluation, coordination with other federal departments and with the province may be signs that Medical Services does not want to put great e f f o r t s i n t o expanding and strengthening the program i f these e f f o r t s w i l l be made superfluous by l a t e r events. I f the province does take over, the advantages of having the large p r o v i n c i a l health services' resources a v a i l a b l e to the program are great. As we l l , the p o s s i b i l i t y of closer i n t e g r a t i o n with p r o v i n c i a l development programs e x i s t s , along with the expansion of the program o f f the reserve. The CHR's could be an appropriate adjunct to the use of native s o c i a l worker aides. The rate of Indian migration o f f the reserves i s increasing, and s e l e c t i n g CHR's from those who Made the adjustment to c i t y l i f e to work among Indians i n the c i t y could help to a l l e v i a t e some of the problems experienced by Indians i n the c i t i e s . The broadened areas of functioning of the CHR's w i l l require concomitant changes i n t r a i n i n g and supervision. The l a r g e r resources of the p r o v i n c i a l health service could manage t h i s , but the 193 obvious danger i s i n the pressure to conform to the r i g i d i t i e s of large bureaucracies. The program must not be swallowed up; i t must maintain a small but separate i d e n t i t y to cope with the separate needs of the native part of the population. 19k LITERATURE CITED INTRODUCTION 1. H. H. Weidman and J. A. Egeland, "A Behavioural Science Perspective i n the Comparative Approach to the Delivery of Health Care," Social  Science and Medicine, Vol. 7 (1973), PP» 845-860. 2. David Woods, "Yellowknife Symposium, Part II: changing health patterns i n the circumpolar regions," Canadian Medical Association Journal, Vol. I l l (September, 1974), pp. 457-458. 3. Julien Bryan, "Canada's Alarming Suicide Pattern," i n Social Problems: A Canadian Profile, ed. Richard Laskin (Toronto: McGraw-Hill, 1964), p. 402. 4. B. MacMahon and T. F. Pugh, eds., Epidemiology: Principles and Methods (Boston: L i t t l e , Brown and Co.,1.1970;, p. 128. 5* National Indian Brotherhood, "Statement on Economic Development of Indian Communities, July 13, 1973 (Paper prepared for the Western-Federal-Provincial Conference on Economic Opportunities, July 24, 25 and 26, 1973). 6. Walter Dieter, Chief, National Indian Brotherhood, and Walter Currie, President, Indian-Eskimo Association of Canada, "Presentation to the Senate Committee on Poverty," Ottawa, AFebruary 10, 1970 (Mimeograph). 7. Ibid. 8. Ibid. 9. Oscar Lewis, "La Vida," i n Minority Responses: Comparative Views of  Reactions to Subordination, ed. Minako Kurokawa (New York: Random House, 1970), pp. 219-226. 10. National Indian Brotherhood, "Statement on Economic Development". 11. quoted i n Weidman and Egeland, "A Behavioural Science Perspective", p. 846. 12. J . A. Egeland, "Belief and Behaviour as Related to Illness" Ph. D. Thesis, Yale University, 1975),.p. 428. 13« Henry Zentner, "The Pre-Machine Ethic of the Athabascan-Speaking Indians: Avenue or Barrier to Assimilation?" i n A Northern Dilemma:  reference papers, eds. Arthur Kent Davis, V. C. Serl and P. T. Spaulding (Bellingham: Western .Washington .State College, A p r i l , 1967), PP* 69-89. 14. Richard Slobodin, "The Indians of Canada Today: Questions on Identity," i n Canada: A Sociological Profile, ed. W. E. Mann (Toronto: Copp Clark, 196b"), pp. 286-292. 195 cont'd... 15. Ibid. 16. Victor Barnouw, "Acculturation and Personality among the Wisconsin Chippewa," in .Acculturation: Critical Abstracts, North America, ed. Bernard J. Siegel, Stanford Anthropological Series, No. 2 (Stanford: Stanford University Press, 1955), p. 24. 17. S'., M. Garn, "Biological Correlates of Malnutrition in Man," in Nutrition, Growth and Development of North American Indian Children, eds. W. M. Moore, M. M. Silverberg and M. S. Read (Washington, D. C., Dept. of Health, Education and Welfare, 1968), pp. 129-149. 18. Louis Wirth,"The Problems of Minority Groups," in Minority Responses, pp. 34-42. 19. Stanley Lieberson, "A Societal Theory of Race and Ethnic Relations," in Minority Responses, pp. 16-21. 20. Pearl R. Roberts, "The Etiology of a New Careers Program in Public Health," American Journal of Public Health, Vol. 63 (July, 1973), pp. 635-638. 21. Marc Lalonde, Minister of National Health and Welfare, A New  Perspective on the Health of Canadians—A Working Document (Ottawa: Information Canada, April, 1974), p. 20. CHAPTER I •.ll. Edward J. Abramson, Robert Arnold, and Gerald Piper, The Community  Health Worker Programme. Report submitted to Medical Services, Dept. of National Health and Welfare, Ottawa, 1964. 2. Ethel G. Martens, Mexico And Canada, A Comparison of Two Programs  Where Indians are Trained in Community Development (Ottawa: Dept. of National Health and Welfare, November, i960). 3. National Health and Welfare, Task Force Report on Community Health  Auxiliaries (Ottawa: National Health and Welfare, 1973). CHAPTER II 1. A. Etzioni, "Two Approaches to Organizational Analysis: A Critique and a Suggestion," Administrative Science 'Quarterly, Vol. 5 (I960), pp. 257-278. 2. E. Yuchtman and S. Seashore, "A System Resource Approach to Organizational Effectivesness," in Organizational Systems: General  Systems Approach to Complex Organizations, ed. F. Baker (Georgetown, Ontario: Irwin-Dorsey, 1973), p. 495• 3. A. Etzioni and E. Lehman, "Some Dangers in 'Valid' Social Measurement," The Annals of the American Academy of Social and Political Science, Vol. 373 (September, 1967), p. 1-10. 196 cont'd... 4. E. Yuchtman and S. , Seashore, "A System," p. 491. 5. Ibid.,, p.492. 6. E. A. Suchman, "Evaluation Research: An Overview," in Readings in  Evaluation Research, ed. F. G. Caro (New York: Russell-Sage, 1971), p. 24. 7. G. B. Hutchinson, "Evaluation of Preventive Services," Journal of  Chronic Diseases, Vol. 11 (May, i960), p. .497-508. 8. F. Baker, "Introduction: Organizations as Open Systems," in Organi- zational Systems, p. 86. 9. Ibid., p. 10. 10. A. Etzioni and E. Lehman, "Some Dangers," pp. 1-10. 11. N. P. Roos, "Evaluation, Quasi-Experimentation, and Public Policy,"" in Quasi-Experimental Approaches, eds J. A. Caporaso and L. L. Boos (Evanston, Illinois: North Western University Press, 1973,) P« 299-CHAPTER III 1. A. Cicourel, The Social Organization of Juvenile Justice (New York: Wiley, 1967), p. 28. 2. B. S. Hetzel, "The Implications of Health Indicators: A Comment," International Journal of Epidemiology, Vol. 1 (1972), pp. 315-318. 3« A. D. Biderman, "Social Indicators and Goals," in Social Indicators, ed. R. A. Bauer (Cambridge: The M. I. T. Press, 1971), pp. 68-153. 4. Dept. of National Health and Welfare, Medical Services jBranch, Alberta Region, Annual Report, 1973, Edmonton, p. 50. 5- G. Graham-Cumming, "Infant Care in Canadian Indian Homes," Canadian  Journal of Public Health, Vol. 67 (September, 1967), PP* 391-394. 6. Dept. of National Health and Welfare, Medical Services Branch, Alberta Region, .Annual Report, 1972, Edmonton, p. 15* 7- S. M. Garn, "Biological Correlates of Nutrition in Man," in Nutrition, Growth and Development of North American Indian Children, eds. W. M. Moore, M. M. Silverberg and M. S. Read (Washington, D. C;: Dept. of Health, Education and Welfare, 1969), pp. 129-149. 8. Dept. of National Health and Welfare, The Bureau of Nutritional Sciences, The Indian Survey Report--A Report from Nutrition Canada (Ottawa: Information Canada, 1975). 197 cont'd.... 9. A. H. Leighton and J . M. Murphy, Approaches to Cross-Cultural y Psychiatry (New York: C o r n e l l U n i v e r s i t y Press, 1965), p. I85 . 1 0 . J . K. Myers and L. L. Bean, A Decade Later: A Follow-Up of S o c i a l Class and Mental I l l n e s s (New York: Wiley and Sons, i960). See also A. B. Hollingshead and F. C. Redlich, S o c i a l Class and Mental I l l n e s s :  A Community Study (New York: Wiley, 1958). 11. Medical Services, A l b e r t a Region, Annual Report, 1965, 1969, 1973* 12. K a r l Menninger, A P s y c h i a t r i s t ' s World (New York: Viking, 1920), p. 347. 13* M. J . Hinman, "Community Analysis," (Unpublished essay on Blood Indian Reserve, Cardston-Standoff, 1973). 14. R. C u t l e r and N. Morrison, "Sudden Death," Vancouver: Alcoholism Foundation of B r i t i s h Columbia, 1971 (Mimeograph). 15- Dr. 0. Schaefer, l e t t e r to the Canadian Medical Ass o c i a t i o n Journal, V o l . 9k (March 26, 1966), p. 684. 16. A. D. Biderman, " S o c i a l Indicators and Goals," p. 6 8 . 17. P. J . Henriot, " P o l i t i c a l Questions about S o c i a l Indicators," The  Western P o l i t i c a l Quarterly,, V o l . 23 (June, 1970), pp 235-255* 18. A. D. Biderman,"Social Indicators and Goals," p. 134. 19* A. E t z i o n i and E. Lehman, "Some Dangers i n 'Valid' S o c i a l Measurement," The Annals of the American Academy of P o l i t i c a l and S o c i a l Science, V o l . 373 (September, 1967), pp. 1-15 . 20. S. M. M i l l e r , M. Rein, P. Roby and B. M. Gross, "Poverty, Inequality and ' C o n f l i c t , " The Annals of the American Academy of P o l i t i c a l and  S o c i a l Science, V o l . 373, (September, 1967), pp. 16-52. 21. quoted i n P. J . Henriot, " P o l i t i c a l Questions," p. 2 4 l . 22. Economic Council of Canada, F i f t h Annual Review: The Challenge of Growth and Change (Ottawa: Queen's P r i n t e r , 1968), pp. 108-110. 23. H. B. Hawthorn, A Survey of the Contemporary Indians of Canada, (Ottawa: Indian A f f a i r s Brachn, 1966), p. 102. 2 4 . I b i d . , p. 23. 2 5 . National Indian Brotherhood, >"Statement on Economic Development of IndiahuQommunities, J u l y 13, 1973" (Paper prepared f o r the Western-F e d e r a l - P r o v i n c i a l Conference on Economic Opportunities, J u l y 24, 25 and 2 6 , 1973), p. 8. 198 cont'd... 26. Dept. of Indian A f f a i r s and Northern Development, The Canadian Indian;  S t a t i s t i c s (Ottawa: Information Canada, 1973), p. 26. 27. C. A. Sauve, The B-15 Plan—-An Outline for Rural Development i n Alberta's  Census D i v i s i o n 15 (Edmonton: Research and Planning D i v i s i o n , Human ~~ Resources Development Authority, Government of Alberta, 1969), p. 308. 28. R. Banta, "An Inventory o f P r o v i n c i a l Government Services provided to the Indian and Metis People of Alberta," Edmonton: Albe r t a Health and S o c i a l Development, January 3 , 1974, p. 16 (Mimeograph) 29. quoted i n H. B. Hawthorn, "A Survey," p. 101. 30. Indian A s s o c i a t i o n of Alberta, "Proposals f o r the Future Education of Treaty Indians i n A l b e r t a , " ( B r i e f to the Educational Planning Commission of the Province of A l b e r t a , January, 1971), p. 4 . 31. R. Banta, "An Inventory," p. 8 . 32. W. J . Wacko, "Indian Alcohol and Drug Abuse i n A l b e r t a — D i s c u s s i o n Paper f o r the Indian People and the S t a f f of Indian A f f a i r s and Northern Development," Edmonton; Dept. of Indian A f f a i r s and Northern Develop-ment, 1974, p. 7 (Mimeograph). 33« P« K. Bock, "Patterns of I l l e g i t i m a c y on a Canadian Indian Reserve," Journal of Marriage and the Family, V o l . 64 (May, 1964), pp. 142-148. 34. quoted i n W. J . Wacko, "Indian Alcohol," p. 6. 35* J . A. P r i c e , "An Applied Analysis of North American Indian Drinking Patterns," Human Organization, v o l . 34 (Spring, 1975), pp. 17-26. CHAPTER, IV 1. P. F. Drucker, Management Tasks, R e s p o n s i b i l i t i e s , P r a c t i c e s (New York: Harper and Row, 1973) p. 99» 2. E t h e l G. Martens, "Health Education and Community Development," Canadian Health Education S p e c i a l i s t s ' Society Technical P u b l i c a t i o n s , No. 3, Ottawa, January, 1969• 3. J . E. T. Eldridge and A. D. Crombie, A Sociology of Organizations (London: George A l l e n and Unwin, 1974), p. 66. 4. J . A. Olmstead, Working Papers No. 2, Organizational Structure and  Climate: Implications f o r Agencies. National Study of S o c i a l Welfare and R e h a b i l i t a t i o n Workers, Work and Organizational Contexts. (Washington, D. C.: Human Resources Research Organization, U. S. Dept. of Health, Education and Welfare, S o c i a l and R e h a b i l i t a t i o n Service, (SRS) 73-05403, February, 1973), pp. 70-73-199 cont'd.... 5. Ethel G. Martens, "Health Education and Community Development." 6. Interview with Dr. A. Shedden, June 24, 1975. 7. Interview with Dr. A. Shedden, June 24, 1975* CHAPTER V 1. J . R. Stolpe, R. E. Mechlenberg and R. L. Lathrop, "The Effectiveness of Two Educational Programmes i n Changing the Performance of Oral Hygiene by Elementary School Children,"Journal of Public Health  Dentistry, Vol. 31 (Winter, 1970), pp. 48-59. 2. E. P. Dozier, "Problem Drinking among American Indians: The Role of S o c i o c u l t u r a l Deprivation," Quarterly Journal of Studies On Alcohol, Vol. 27 (March, 1966), pp. T^Sf. 3. K. Lewin, "Group Decision and S o c i a l Change," i n Readings i n S o c i a l  Psychology, 3rd e d i t i o n , ed. E. E. Maccoby (New York: Holt, Rinehart and Winston, 1958). , 4. H. A. Tyr o l e r , S. L. Johnston, and J . T. Fulton, "Patterns of Preventive Health Behaviour i n Populations," Journal of Health and  Human Behaviour, Vol. 6 ( F a l l , 1965), PP« 135-169. 5. R. A. Scott, "The S e l e c t i o n of C l i e n t s by S o c i a l Welfare Agencies: The Case of the B l i n d , " S o c i a l Problems, V o l . 14 (Winter, 1967), pp. 248-256. 6. J . Levin and G. Taube, "Bureaucracy and the S o c i a l l y Handicapped: A Study of Lower-Status Tenants i n Public Housing," Sociology and  S o c i a l Research, Vol. 54 (January, 1970), pp. 209-219. 7. H. Zentner, "The Pre-Machine E t h i c of the Athabascan-Speaking Indian: Avenue or B a r r i e r to A s s i m i l a t i o n ? " i n Arthur Kent Davis, V. C. S e r l , and P. T. Spaulding, eds., A Northern Dilemma: reference papers (Bellingham: Western Washington State College, A p r i l , 1967), pp. 69-89• 8. Dr. B. N e i f e l , "Time, Saving and Work," i n The Indian: As s i m i l a t i o n, Integration or Separation?, eds. R. P. Bowles, J . L. Hanley, B. W. Hodgins and G. A. Rawlyk (Scarborough: P r e n t i c e - H a l l , 1972). 9. H. C. Kelman and C. I. Houland, "Reinstatement of the Communicator i n Delayed Measurement of Opinion Change," Journal of Abnormal S o c i a l  Psychology, Vol. 48 (1953), pp. 327-335-10. E> A. Suchman, "Health Orientation and Medical Care," American Journal  of Public Health, Vol. 56 (January, 1966), pp. 97-105. 200 cont'd... 11. : N. Morris, M. Hatch and S. S. Chipman, "A l i e n a t i o n as a Deterrent to Well-Child Supervision," American Journal of Public Health, Vol. 56 (Novamber 19-66), pp.l874-l882. 12. 0. G. Simmons, "Implications of S o c i a l Class f o r Public Health," Human Organization, Vol. 16 ( F a l l , 1957)» pp. 7-10. 13. J . Brightman, H. Notkin, W. A. Brumfield, S.M. Dorsey, and H. S. Solomon, "Knowledge and U t i l i z a t i o n of Health Resources by Public Assistance Recipients," American Journal of Pub l i c Health, V o l . 48 (February, 1958), pp. 188-199. 14. Interview with Mrs. A. Newman, J u l y 28, 1975. 15. I. T. Sanders, "Public Health i n the Community," i n Handbook of  Medical Sociology, 2nd e d i t i o n , eds. H. E. Freeman, S. Levine and L. G. Reeder (Englewood C l i f f s , New Jersey: P r e n t i c e - H a l l , 1972).. 16. D. G. Smith, "The Implications of Pluralism f o r S o c i a l Change Programs i n a Canadian A r c t i c Community," AnthropolQgica, Vol. 13 (1977), pp. 193-214. 17. E. P. Dozier, G. E. Simpson, and J . M. Yinger, "The Integration of Americans of Indian Descent," i n Perspectives on the North American  Indian, ed. M. Nagler (Toronto: McClelland and Stewart, 1972). 18. J . S. Coleman, E. Katz and H. Menzel, Medical Innovation - A  D i f f u s i o n Study (New York: Bobs M e r r i l , 1966), p. 96. 19. G. Poslun, The Fourth World: An Indian R e a l i t y (Toronto: C o l l i e r -Macmillan Canada, 1974), p. 152. 20. H. Zentner, "Factors i n the S o c i a l Pathology of a North American Indian Society," Anthropologica, Vol. 5 (1963), pp. 119-130. 21. A. Caro, "Ideals of an Action Program," Human Organization, Vol. 17 (Spring, 1958), pp. 27-29. 22. E. M. Rogers and G. M. Beal, "The Importance of Personal Influences i n the Adoption of Technological Changes," S o c i a l Forces,Vol. 36 (May, 1958), pp. 329-335. CHAPTER VI 1. E. M. Rogers, d i f f u s i o n of Innovations (New York: The Free Press of Glencoe, 1962), p. 189.. 2. B. Y. Card, G. K. Hirabayashi, and C. L. French, "The Metis i n Alberta Society: A Report on Project A (1960-63)". Report of a Unive r s i t y of Alberta Committee f o r Social Research prepared f o r the the Alberta Tuberculosis Association, Edmonton, October, 1963t P* !50 (Mimeograph). 201 cont'd... 3. I b i d . , p. 153. k. I. M. Rosenstock, "Prevention of I l l n e s s and Maintenance of Health," American Journal of Public Health, V ol. 48 (February, 1958), PP-• 175-185-5- Steven Polgar, "Health Action i n Cross-Cultural Perspective," i n Handbook of Medical Sociology» 2nd e d i t i o n , eds. H. E. Freeman, S. Levine and L. G. Reeder (Englewood C l i f f s , New Jersey; Prentice-H a l l , 1972). 6.,< P. S. S i n d e l l , "Some D i s c o n t i n u i t i e s i n the Enculturation of M i s t a s s i n i Gree Children," i n C o n f l i c t i n ; Culture; Problems of  Developmental Change among the Cree, ed. N. A. Change (Ottawa: •'.]• Canadian Research Centre f o r Anthropology, Universite Saint-Paul, 1968). 7. E. I. Koos, The Health of Regi o n v i l l e (New York: Columbia Uni v e r s i t y Press, 1954), p. 205. 8. I. M. Rosenstock, "What Research i n Motivation Suggests f o r Public Health," American Journal of Public Health, V ol. 56 1. (March, 1966), PP- 295-302: 9. I b i d . 10. L. Schneiderman, " S o c i a l C l a s s , Diagnosis and Treatment," American  Journal of Orthopsychiatry, V ol. 35 (January, 1965)» PP- 99-105-11. M. Mead, Culture, Health and Disease (London: Tavistock, 1966), p. 52. 12. R. W. Dunning, "Ethnic Relations and the Marginal Man i n Canada," Human Organization, V o l . l 8 ( F a l l , 1959), PP- 117-122. 13. F. K. Hatt, "Metis of the Lac La Biche Area - Community Opportunity Assessment.'! Edmonton, Government of Alberta, Human Resources: Research and Development, March, 1967 (Mimeograph). Ik. Card e t . a l . , "The Metis i n Alb e r t a Society," p. 381. 15. E. Freidson, " C l i e n t Control and Medical P r a c t i c e , " i n Medical Care -Readings i n the Sociology of Medical I n s t i t u t i o n s , eds. W. R. Scott and E. H. Volkart (New York: Wiley and Sons, 1966)„ 16. I b i d . 17- J . G l i t t e n b e r g , "Adapting Health Care to a C u l t u r a l S e t t i n g , " American Journal of Nursing, Vol. 7k (December, 1974), pp. 2218-2221. 202 cont'd... l 8 . 0. G. Simmons, "Popular and Modern Medicine i n Mestizo Communities of Coastal Peru and C h i l e , " i n S o c i o l o g i c a l Studies on Health and Sickness, ed. D. Apple (Toronto! McGraw-Hill, i960),. <\ , 19. M. Mead, Culture, Health and Disease, p. 23. 20. L. Wirth, "The Problem of Minority Groups,** i n Minority Responses;  Comparative Views of Reactions to Subordination, ed. M. Kurokawa' (New York: Random House, 1970), p. 3k. 21. M. Kurokawa, "Introduction: Some D e f i n i t i o n s , " i n Minority Responses. 22. I. L. Jan i s , "Personality as a Factor i n S u s c e p t i b i l i t y to Persuasion," i n The Science of Human Communication, ed. W. Schramm (New York: Basic Books, 1963).• 23- M. Seeman, "The Meaning of A l i e n a t i o n , " American S o c i o l o g i c a l Review, Vol . 2k (December, 1959), PP- 783-791. 2k. N. Morris, M. Hatch and S. S. Chipman, "A l i e n a t i o n as a Deterrent to Well-Child Supervision," American Journal of Pub l i c Health, V o l . 56, (November, 1966), pp. l 8?4 - l 8 8 2 . 25* H. Zentner, "Reservation S o c i a l Structure and Anomie: A Case Study," Anthropologica, Vol. 5 (1963), pp. 119-130. 26. Card et. a l . , "The Metis i n Alberta Society," p. 382. 27. J . A. Savin, " S o c i a l Behaviour and the Use of Medical Services," B r i t i s h Journal.-, of Preventive and S o c i a l Medicine, Vol. 23 (February, 1969), PP. 52-55. 28. Oscar Lewis, "La Vida," i n Minority Responses. CHAPTER VII 1. Interview with Mr. C. Brooks, August 27, 1975« 2. Interview with Dr. Shedden, June 24, 1975* CHAPTER VIII 1. E. William Brodt, "The B a t t l e to Meet People's Needs: Challenge of the Indian Community Health Representative," Tucson, Arizona, Indian Health Service, O f f i c e of Research and Development, undated, (Mimeograph). cont'd.. 203 2. D. Gold, "Psychological Changes Associated with Acculturation of Saskatchewan Indians," The Journal of S o c i a l Psychology, Vol. 71 (1967), PP. 177-184. 3. Ethel G. Martens, "Training A u x i l i a r y Health Workers i n Community Development";(Paper prepared f o r Community Development Seminar of the Department of Health Education, School of Public Health, U n i v e r s i t y of North C a r o l i n a , Chapel H i l l , May 5-9, 1963), P« 1. 4. P. D. Mail, "Health Education Project Description," Washington, Western Washington Service Unit, Indian Health Service, undated, p. 7 (Mimeograph). 5. Interview with Dr. K i r k b r i d e , September 2, 1975. 6. E. Z. Vogt, "The Acculturation of American Indians," i n Perspectives  on the North American Indian, ed. M. Nagler (Toronto: McClelland and Stewart, 1972). 7. Interview with Mr. G. Brooks, August 27, 1975. 8. Interview with P. D. M a i l , May 5 , 1975-OTHER LITERATURE CONSULTED 1. Ian Adams, William Cameron, Brian H i l l and Peter Penz, The Real  Poverty Report (Edmonton: M. G. Hurtig, 1971). 2. Ahenakew, Voices of the P l a i n s Cree (Toronto: McClelland and Stewart, 1973T 3« R. G. Beck, "Economic Class and Access to Physician Services under Public Medical Care Insurance," I n t e r n a t i o n a l Journal of Health  Services, V o l . 3 (1973), pp. 341-355. 4. Lawrence M. Brammer, The Helping Relationship - Process and S k i l l s (Englewood C l i f f s , New Jersey: P r e n t i c e - H a l l , 1973). 5. Hugh Brody, "Indians on Skid Row," Ottawa, Northern Science Research Group, Dept. of Indian A f f a i r s and Northern Development, 1971. 6. Maria Campbell, Halfbreed (Toronto: McClelland and Stewart, 1973). 7. Harold Cardinal, The Unjust Society: The Tragedy of Canada's Indians (Edmonton: M. G. Hurtig, 1969). 8. B. Challenor, J . Schermerhorn, J . A. C o l l i n s , B. H i l l , B. Wornum, and N. Perlman, "An Educational Prog am f o r A l l i e d Health Personnel," American Journal of Public Health, V o l . 62 (February, 1972), pp. 223-228. 204 cont'd... . . 9. Jean Chretien, Minister of Indian A f f a i r s and Northern Development, Statement of the Government of Canada on Indian P o l i c y , 1969» Presented to the F i r s t Session of the 28th Parliament,(Ottawa: Queen's Pr i n t e r , 1969* 10. Peter A. Cumming and N e i l H. Mickenberg, Native Rights i n Canada (Toronto: Indian-Eskimo Association of Canada, 1970). 11. Department of National Health and Welfare, Medical Services Branch, "A Treatment Manual for Community Health A u x i l i a r i e s , " Ottawa, 1973 (Mimeograph). 12. Department of National Health and Welfare, Medical Services Branch, "A Guide f o r F i e l d Orientation of Community Health A u x i l i a r i e s , " Ottawa, 1973 (Mimeograph). Ik. V. Djukanovic and Ey P. Mach, Alternative Approaches to Meeting  Basic Health Needs i n Developing Countries (Geneva: World Health Organization, 1975)• 15. Edgar J . Dosman, Indians: The Urban Dilemma (Toronto: McClelland and Stewart, 1972TT 16. B. Dyck, "The Indigenous Worker: Staff Development and Supervision, Northern Issues,(Spring, 1975), pp. 15-23. 17. W. G. Goldthorpe, "Infant Health i n an Outpost Area," Canadian  Family Physician, Vol. 75 (May, 1975)1 PP« 75-78. 18. L. C. Green, "Canada's Indians - Federal P o l i c y , International and Constitutional Law," Edmonton, Government of Alberta, undated (Mimeograph). 19. L. W. Green, V. L. Wang, P. H. Ephross, "A 3-Year, Longitudinal Study of the Impact of N u t r i t i o n Aides on the Knowledge, Attitudes and Practices of Rural Poor Homemakers," American Journal of Public  Health, Vol. 6k (July, 1974), pp. 722-724. 20. T. J . Harrison, "Training for V i l l a g e Health Aides i n the Kotzebue Area of Alaska," Public Health Reports, Vol. 80 (July, 1965), PP. 565-572. 21. G. K. Herbert, M. C. Chevalier, and C. L. Myers, "Factors Contributing to the Successful Use of Indigenous Mental Health Workers," Hospital and Community Psychiatry, Vol. 25 (May, 1974) pp. 308-310. 22i Charles W. Hobart, "Non-Whites i n Canada: Indians, Eskimos, Negroes," i n S o c i a l Problems: A Canadian P r o f i l e , ed. Richard Laskin (Toronto: McGraw-Hill, 1964). 23. Inayatullah, Transfer of Western Development Model to Asia and i t s  Impact (Kuala Lumpur: Asian Centre for Development Administration, 1975). 205 cont'd... 24. Diamond Jenness, The Indians of Canada (Ottawa: P r i n t e r to the King's Most Excellent Majesty, 1932). 25. Henry J . Kenneally, "The Advocacy Team Concept: A New Look at Approaches to Problem Solving," (Reprint of a paper presented at the 99th Annual Forum and Exposition National Conference on S o c i a l Welfare, Chicago, I l l i n o i s , May 29, 1972). 26. Henry J . Kenneally, "The Advocacy Role i n an Apache Indian Community," (Reprint of a paper presented at the Annual Meeting of the Society for Applied Anthropology, Montreal, A p r i l 8, 1972). 27. Henry J . Kenneally, " P a r t i c i p a t i o n by the I n d i v i d u a l i n Community Problem-Solving," i n Proceedings of the Dorothy Nyswander In t e r n a t i o n a l  Health Education Symposium, Berkeley, C a l i f o r n i a , September 27-29, 1974 (Mimeograph) 28. J . D. K i n z i e , J . H. Shore, and E. M. Pattison, "Anatomy of P s y c h i a t r i c Consultation to Rural Indians," Community Mental Health Journal, V o l . 8 (1972), pp. 196-207. 29. J . I . Kitsuse and A. V. C i c o u r e l , "A Note on the Uses of O f f i c i a l S t a t i s t i c s , " S o c i a l Problems, V o l . 11 ( F a l l , 1963), pp. 131-139. 30. P. M. Moodie, A b o r i g i n a l Health. Aborigines i n A u s t r a l i a n Society Ser i e s , No. 9 (Canberra: A u s t r a l i a n National U n i v e r s i t y Press, 1973). 31. Emily Mumford, "Poverty and Health," Nursing Outlook, V o l . 17 (September, 1969), pp. 32-35. 32. Kermit Nash and V i c t o r i a M i t t l e f e h l d t , "Supervision and the Emerging Pr o f e s s i o n a l , " American Journal of Orthopsychiatry, V o l . 45 (January, 1975), pp. 93-101. 33* Barbara Novak, "Home Nursing Care on an Indian Reservation," Public Health Reports, V o l . 89 (November-December, 1974), pp. 545-550. 34. Ralph ©sborne, ed., "Who i s the Chairman of t h i s Meeting?" - A  C o l l e c t i o n of Essays (Toronto: Neewin Publishing, 1972). 35« E. Palmer Patterson, The Canadian Indian: A History since 1500 (Don M i l l s : Collier-MacMcillan, 1972). 36. Benjamin D. Paul, ed., with c o l l a b o r a t i o n of Walter B. . M i l l e r , Health, Culture and Community - Case Studies of Public Reactions  to Health Care Programs (New York: R u s s e l l Sage, 1955). 37« L. P r a t t , A. Seligman, and G. Reeder, "Physicians' Views on the Level of Medical Information among Patients," American Journal of Public  Health, V o l . 47 (October, 1957), pp. 1277-1283. 206 cont'd... 38. George I . Quimby, "A Year with a Chippewa Family, 1763-1764," Ethnohistory, V o l . 9 (Summer, 1962), pp. 217-239. 39. A. J . Radford, "The Use of A l l i e d Health Workers by General P r a c t i t i o n e r s i n Various S i t u a t i o n s , " The Medical Journal of A u s t r a l i a , V o l . 2 (November 3, 1973), PP- 860-862. . 40. R. Richter, B. Bengen, P. A. Alsup, B. Bruun, M. M. Kilcoyne, and B. D. Challenor, "The Community Health Worker—A Resource f o r Improved Health Care Delivery," American Journal of Public Health, V o l . 64 (November, 1974), pp. 1056-1061. " 41. Helene R. Robertson, "Removing B a r r i e r s to Health Care," Nursing  Outlook, V o l . 17 (September, 1969), pp. 43-46. 42. P. Sampson and P. Grunby, "Health Representative: a New T r i b a l Role," Journal of the American Medical Association, V o l . 2l8 (November 1, 197D, pp. 665-671. 43. Richard A. Schermerhorn, "A P o l a r i t y i n the Approach to Comparative Research i n Ethnic Relations," Sociology and S o c i a l Research, V o l . 51 (January, 1967), pp. 233=2rTol 44. Science Council of Canada, Science f o r Health Services. Report No. 22 (Ottawa: Information Canada, 1974). * 45. M. Spiegelman, Introduction to Demography, rev. ed. (Cambridge, Massachusetts: Harvard U n i v e r s i t y Press, I968). 46. Robert J . Surtees, The O r i g i n a l People (Toronto: Holt, Rinehart and Winston, 1971). 47. E.^A. Suchman, Sociology and the F i e l d of Public Health (New York: R u s s e l l Sage, 1963). 48. Thomas Szasz, The Myth of Mental I l l n e s s : Foundations of a Theory  of Personal Conduct (London: Paladin, 1962). 49. C. A. Valentine, Culture and Poverty: C r i t i q u e and Counterproposals (Chicago: U n i v e r s i t y o f Chicago Press, 1968). 50. V. F. Valentine and R. G. Young, "The S i t u a t i o n o f the Metis o f Northern Saskatchewan i n Relation to His Physical and S o c i a l Environment," The Canadian Geographer, V o l . 4 (1954), pp. 49-56. 51. Howard Waitzkin and H i l a r y Modell, "Medicine, Socialism and T o t a l i t a r i a n i s m ; Lessons from C h i l e , " H ospital Administration i n  Canada, V o l . 291 ( A p r i l , 1974), pp. 171-177. 207 cont'd.... 52. William Foote Whyte, Organizing f o r A g r i c u l t u r a l Development (New Brunswick, New Jersey: Transaction Books, 1975). 53. H. Clyde Wilson, "An Inquiry i n t o the Nature of P l a i n s Indian C u l t u r a l Development," American Anthropoogist, V o l . 65 (1963), PP. 355-369. 54. World Health Organization, Measurement of Levels of Health: Report  of a Study Group. Technical Report Se r i e s , No. 137 (Geneva: WHO, October, 1953). 55. William I . C. Wuttunee, R u f f l e d Feathers: Indians i n Canadian Society, 2nd e d i t i o n (Toronto: B e l l , 1971)• 208 APPENDIX I: FIELD VISITS TO COMMUNITY HEALTH REPRESENTATIVES ON FEDERAL INDIAN RESERVES IN ALBERTA  1. May 14-15, 1975 Pigeon Lake Reserve, Hobbema Health Unit, Mrs. Samson, CHR. 2. June 3-6, 1975 Wabasca-Desmarais, Bigstone Reserves A,B,C, and D, Mrs. Carolyn Noskiye, CHR, and Rosemary Stang, Public Health Nurse. 3 . June 5 , 1975 Chipewyan Lake, Mrs. S t e l l a Noskiye, Family Health Aide. 4. June 10-13, 1975 Assumption, Hay Lakes Reserve, Mrs. Regina Pastion, CHR, and V a l e r i e Beynon, Public Health Nurse. 5. J u l y 19, 1975 Morley, Stoney Indian Reserve, Mrs. Emily Wesley, CHR. 6. J u l y 24-25, 1975 Bonneyville, Kehewin Indian Reserve, Mrs. Florence Youngchief, CHR, and Mrs. Ida Sansom, Public Health Nurse. 7. J u l y 30, 1975 Lac La Biche, Beaver Lake Reserve and Heart Lake Reserve, Miss Louise Frenchman, CHR. 8. August 21-22, 1975 Cardston-Standoff, Blood Indian Reserve, Mrs. N e l l i e T a i l f e a t h e r s , CHR, and Miss Nora Brewer, CHR, and Mrs. J . Hinman, Public Health Nurse. 209 APPENDIX I I : INTERVIEWS CONDUCTED IN THE COURSE OF THE STUDY 1. May 5 , 1975 P a t r i c i a D. M a i l , Health Educator, U.S. P u b l i c Health Service, Indian Health Service, Western ^Washington Service Unit, S e a t t l e , Washington. 2. June 18, 1975 David A. Rosner, Regional Health Educator, Medical Services Branch, Winnipeg, Manitoba. 3 . June 2 7 , 1975 Dr. A. Shedden, Zone Dire c t o r , Southern A l b e r t a Zone, Medical Services Branch, Edmonton, A l b e r t a . 4 . J u l y 8 , 1975 Ms. Marion Iverson, teacher at A l b e r t a Vocational College, Community Health Associate Program, Lac La Biche. 5. J u l y 16-17, 1975 Mrs. Rosalee D e s j a r l a i s , Community Health Associate, Grand Centre Health Unit, Grand Centre, Alberta* 6. J u l y 16-17, 1975 Mrs. Laura C o l l i n s , Community Health Associate, E l i z a b e t h Metis Colony, near Grand Centre. 7. J u l y 18, 1975 Mrs. Robertson, Public Health Nursing Supervisor, St. Paul Health Unit, St. Paul, A l b e r t a . 8. J u l y 24-25, 1975 Joe Dion, Chief, Kehewin Reserve, Bonnyville, A l b e r t a . 9. J u l y 27, 1975 Mrs. A. Newman, former Public Health Nurse on Morley Indian Reserve, and Mr. M. Newman, Economic Advisor, Morley Reserve. 10. J u l y 28, 1975 Dr. John Read, Professor of P e d i a t r i c s , U n i v e r s i t y of Calgary, Faculty of Medicine, i n i t i a t o r of the Health Centre on Morley Reserve. 11. August 27, 1975 Mr. Charles Brooks, Regional Health Educator, Medical Services Branch, Regina, Saskatchewan. 12. September 2, 1975 Dr. Kirkbride, Regional Director, P r a i r i e Region, Medical Services, Edmonton, A l b e r t a . 210 APPENDIX I I I ; JOB DESCRIPTION AND SPECIFICATION REPORT FOR CHR'S (from undated mimeograph of Dept. of National Health and Welfare) 1. Job Summary Under the general supervision of the Nurse In Charge provides a va r i e t y of health care services s p e c i f i c to community needs; demonstrates and teaches community and family health care, s a n i t a t i o n and hygiene; teaches or provides home nursing care to the s i c k , aged or i n f i r m ; i n t e r p r e t s federal and p r o v i n c i a l health programs and services to the native people; organizes new groups or works with e x i s t i n g community groups to ameliorate the community's health; prepares posters, displays and other audio-visual aids suitable f o r the community; acts as an i n t e r p r e t e r f o r health professionals and other government o f f i c i a l s ; plans and organizes own work and c a r r i e s out duties with a minimum of supervision; performs other r e l a t e d duties. 2. Job Duties 1) Provides consultation, advice and assistance to i n d i v i d u a l s and f a m i l i e s on health matters and makes appropriate r e f e r r a l s when necessary (45% of time) by making home v i s i t s to prenatals, mothers with i n f a n t s and young c h i l d r e n and other f a m i l i e s i n the community i n order to teach and a s s i s t i n the provision of safe nurture and health care i . g . d i e t , budgeting, n u t r i t i o n , family planning, s a n i t a t i o n , dental health, alcohol abuse etc. by v i s i t i n g the s i c k , aged or i n f i r m to teach and/or provide home nursing care e.g. gives bed baths, changes dressings, and to make r e f e r r a l s to health professionals and other agencies by a s s i s t i n g the nurse or doctor to obtain personal health h i s t o r y data at c l i n i c s and i n home v i s i t s by measuring weights and heights, temperatures, pulses; gross v i s i o n screening; taking and dispatching sputum specimens, throat swabs, s t o o l specimens; demonstrating personal hygiene pr a c t i c e s and basic home nursing procedures; reading Mantoux t e s t s ; or other appropriate t e s t s or measurements. (continued....) 211 ( APPENDIX I I I continued) by taking and recording water samples f o r a n a l y s i s and taking appropriate action on r e s u l t s of such t e s t s e.g. advising c l i e n t to p u r i f y water, advising l o c a l administration to dig new wells by a s s i s t i n g f a m i l i e s to plan n u t r i t i o u s meals and how to budget income to meet d a i l y food requirements by a s s i s t i n g i n prenatal, maternal, well-baby, c h i l d care, dental and other health c l i n i c s by doing patient education e s p e c i a l l y i n the l o c a l and native d i a l e c t ; by i n t e r p r e t i n g ; by acting as r e c e p t i o n i s t etc. by making home v i s i t s to introduce new f i e l d s t a f f to members of the community and to orient f i e l d s t a f f and v i s i t o r s to the community to l o c a l customs and mores by advising i n d i v i d u a l s and f a m i l i e s regarding a v a i l a b l e health resources or resources of DIAND, RCMP, Native Organiza-t i o n s or other agencies. 2) A s s i s t s the community and groups within the community to improve t h e i r health status {kQ% of time) by working with community leaders, other community workers and government o f f i c i a l s to resolve problems a f f e c t i n g the health of the community by regular attendance at band and chief and council meetings to recommend needed l o c a l improvements such as garbage c o l l e c t i o n systems, i n d i v i d u a l and community water supply, housing, r e c r e a t i o n a l f a c i l i t i e s etc. by organizing new groups (e.g. health committees) or working with e x i s t i n g community groups to ameliorate the community's health by taking an a c t i v e r o l e on Health Committees and i n t h i s con-text drawing up budgets, securing funding from the Band, planning expenditures including a c t i v i t i e s such as supervising garbage c o l l e c t o r s , water d e l i v e r y man, housekeeping aides or others employed by the Health Committee by organizing, planning and conducting workshops, short courses, continuing health education programs, youth summer programs and camps and securing funding f o r these programs by teaching health classes i n f e d e r a l schools at l e a s t once per month e s p e c i a l l y i n the l o c a l native language when necessary (continued....) 212 ..APPENDIX I I I Ccontinued) by u t i l i z i n g a v a i l a b l e mass media to disseminate health information such as researching and writing news releases f o r native press and radio by developing and producing posters and dis p l a y s , 35ram s l i d e s e r i e s etc. by s e l e c t i n g , scheduling and showing f i l m s , s l i d e s , f i l m s t r i p s , videotapes etc. i n health teaching programs by explaining and a s s i s t i n g the people of the community to under-stand and make proper use of ava i l a b l e health services e.g. well-baby c l i n i c , treatment c l i n i c , doctor's c l i n i c , d e n t i s t's c l i n i c etc. by advising health care personnel and other v i s i t i n g health professionals on culture t r a d i t i o n and way of l i f e and helping to improve two-way communication. 3) Performs other duties such as (15% of time) keeping records of d a i l y a c t i v i t i e s and submitting monthly reports to the nurse i n charge attending regular f i e l d s t a f f conferences and other recommended in - s e r v i c e or continuing education programs providing her own transportation to ensure mobility as required within the community being served acting as i n t e r p r e t e r when necessary by accompanying doctors, nurses and other f i e l d s t a f f i n v i s i t s to Indian homes as required, to tra n s l a t e conversation i n t o the l o c a l d i a l e c t and i n t o E n g l i s h . 

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