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UBC Theses and Dissertations

Indian infant mortality in British Columbia Baker-Anderson, Marilyn 1981

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INDIAN INFANT MORTALITY IN BRITISH COLUMBIA by MARILYN(BAKER-ANDERSON B.A., U n i v e r s i t y o f A l b e r t a , 1970 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (S c h o o l o f Community and R e g i o n a l P l a n n i n g ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA O c t o b e r 1981 0 M a r i l y n B a k e r - A n d e r s o n , 1981 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t o f the requirements f o r an advanced degree a t the U n i v e r s i t y of B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and study. I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head o f my department o r by h i s o r her r e p r e s e n t a t i v e s . I t i s understood t h a t copying or p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be allowed without my w r i t t e n p e r m i s s i o n . Department of The U n i v e r s i t y o f B r i t i s h Columbia 2075 Wesbrook P l a c e Vancouver, Canada V6T 1W5 Da te ABSTRACT A l t h o u g h the I n d i a n i n f a n t m o r t a l i t y r a t e has dropped from 66 d e a t h s p e r 1000 l i v e b i r t h s i n 1960 t o 24.6 d e a t h s p e r 1000 l i v e b i r t h s i n 1 9 8 0 , c o n s i d e r a b l e d i s c r e p a n c i e s c o n t i n u e t o e x i s t between the I n d i a n and Non-Indian p o p u l a t i o n i n B r i t i s h Columbia. The h i g h i n c i d e n c e o f I n d i a n i n f a n t m o r t a l i t y i s an i m p o r t a n t i s s u e t o B.C.'s n a t i v e p o p u l a t i o n . While governments have i n s t i t u t e d programs i n an e f f o r t t o improve the h e a l t h s t a t u s o f I n d i a n i n f a n t s , no s t u d i e s have been u n d e r t a k e n i n B r i t i s h Columbia t o i d e n t i f y t h o s e f a c t o r s which i n f l u e n c e I n d i a n i n f a n t m o r t a l i t y . T h i s s t u d y examines the t h e o r e t i c a l and e m p i r i c a l r e l a t i o n s h i p between I n d i a n i n f a n t m o r t a l i t y and a v a r i e t y o f s o c i o - e c o n o m i c and h e a l t h c a r e f a c t o r s . U s i n g data d e r i v e d from matched b i r t h and d e a t h c e r t i f i c a t e s and i n f o r m a t i o n a c q u i r e d from the Department o f I n d i a n A f f a i r s , t h i s s t u d y a s s e s s e s the e f f e c t s o f the f o l l o w i n g v a r i a b l e s on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y : 1. M a t e r n a l A g e / L i v e B i r t h O r d e r , 2. M a r i t a l S t a t u s , 3. P l a c e o f D e l i v e r y , 4. Region, 5. W e l f a r e De-pendency, and 6. H e a l t h J u r i s d i c t i o n . T e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n were performed i n i t i a l l y t o i d e n t i f y t h o s e v a r i a b l e s which were not s i g n i f i c a n t l y r e l a t e d t o t h e B i r t h Outcome. As the r e s u l t s o f t h e s e t e s t s r e v e a l e d t h a t P l a c e o f D e l i v e r y was t h e o n l y s i g n i f i c a n t v a r i a b l e , v a r i o u s r e g r e s s i o n models were c o n s t r u c t e d t o e s t i m a t e the e f f e c t s o f n o n - h o s p i t a l i z a t i o n and h o s p i t a l i z a t i o n on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . The f i n d i n g s i i a f r o m t h e s e t e s t s i n d i c a t e d t h a t when n o n - s i g n i f i c a n t f a c t o r s were e l i m i n a t e d f r o m the r e g r e s s i o n model, the v a r i a b l e , P l a c e o f D e l i v e r y , was n o t s i g n i f i c a n t l y r e l a t e d t o t h e B i r t h Outcome. F a c t o r s t o a c c o u n t f o r t h e s e r e s u l t s were then d i s c u s s e d . In p a r t i c u l a r , c o n s i d e r a t i o n was g i v e n t o the e x t e n t t o which s h o r t c o m i n g s i n the d a t a and s t u d y methodology may have a f f e c t e d t h e r e s u l t s o f s t a t i s t i c a l t e s t s . To d e v e l o p a b e t t e r u n d e r s t a n d i n g about t he n a t u r e o f I n d i a n i n f a n t m o r t a l i t y , t h e major c a u s e s o f I n d i a n i n f a n t d e a t h s were examined o v e r v a r i o u s h i s t o r i c a l p e r i o d s . A f t e r r e v i e w i n g changes i n the d i s t r i b u t i o n o f d e a t h s t h i s s t u d y d e s c r i b e d , t h e o r e t i c a l l y , how changes i n the s o c i a l and economic s t r u c t u r e i n I n d i a n communities a f f e c t e d I n d i a n h e a l t h and more s p e c i f i c a l l y I n d i a n i n f a n t h e a l t h . I t was argued t h a t w h i l e l i f e s t y l e f a c t o r s and c e r t a i n a s p e c t s o f the p h y s i c a l environment may a f f e c t i n f a n t m o r t a l i t y , t h e s e f a c t o r s s h o u l d not be viewed i n i s o l a t i o n . Changes i n I n d i a n economic and s o c i a l systems have had d i r e c t and i n d i r e c t con-sequences on the p h y s i c a l and mental h e a l t h o f n a t i v e p e o p l e . To the e x t e n t t h a t t h e s e changes a r e o n - g o i n g t h e y s t i l l may have some b e a r i n g on I n d i a n i n f a n t h e a l t h problems t o d a y . Based on t h i s t h e o r e t i c a l p e r s p e c t i v e t h i s s t u d y examined t h e ad-equacy o f p a s t and p r e s e n t h e a l t h programs and d e s c r i b e d some o f the l i m i t a t i o n s o f government i n t e r v e n t i o n s t r a t e g i e s . The c o n c l u d i n g s e c t i o n argues t h a t s e l f - h e l p p r e v e n t i v e programs and m e d i c a l / t e c h n i c a l s o l u t i o n s a r e o f l i m i t e d u t i l i t y i n terms o f r e d u c i n g i n f a n t m o r b i d i t y and m o r t a l i t y . F u r t h e r m o r e , w h i l e i t may be p o s s i b l e t o improve t h e s t a n d a r d o f l i v i n g o f I n d i a n p e o p l e t h r o u g h t r a n s f e r payments o r o t h e r s o c i a l w e l f a r e schemes, t h e s e s t r a t e g i e s may p r o v i d e o n l y p a r t i a l s o l u t i o n s i f b r o a d e r s o c i a l problems a r e d i r e c t and i n d i r e c t c a u s a l f a c t o r s o f i l l - h e a l t h . To t h e e x t e n t t h a t s o c i a l problems may be r e l a t e d t o c e r t a i n a s p e c t s o f t h e i r p s y c h o - s o c i a l e n v i r o n m e n t , i t i s e s s e n t i a l t h a t governments a d o p t s t r a t e g i e s w h ich p r o v i d e t h e o p p o r t u n i t i e s f o r I n d i a n s t o r e g a i n s e l f - r e s p e c t and c o n t r o l o v e r the i n s t i t u t i o n s which a f f e c t t h e i r d a i l y l i v e s . TABLE OF CONTENTS ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES LIST OF MAPS ACKNOWLEDGEMENTS CHAPTER ONE: INDIAN INFANT MORTALITY IN BRITISH COLUMBIA 1.1 I n t r o d u c t i o n and S i g n i f i c a n c e o f the Problem •1.2 The Nature o f the Problem 1.3 Purpose o f the Re s e a r c h 1.4 O r g a n i z a t i o n o f the T h e s i s CHAPTER TWO: INFANT MORTALITY 2.1 The Major Causes o f Neonatal and P o s t n e o n a t a l M o r t a l i t y 2.2 The I n f a n t M o r t a l i t y P r o c e s s 2.3 P o l i c i e s and Programs t o Reduce I n f a n t M o r t a l i t y 2.4 E m p i r i c a l S t u d i e s o f I n f a n t M o r t a l i t y CHAPTER THREE: RESEARCH METHODOLOGY AND DATA 3.1 D e s c r i p t i o n o f V a r i a b l e s 3.1.1. Dependent V a r i a b l e s 3.1.2. Independent V a r i a b l e s 3.2 Data S o u r c e s and Study P o p u l a t i o n 3.3 A n a l y t i c a l T e c h n i q u e s CHAPTER FOUR: DISCUSSION OF RESULTS 4.1 T e s t s o f M a r g i n a l and P a r t i a l A s s o c i a t i o n 4.2 R e g r e s s i o n R e s u l t s 4.3 S h o r t c o m i n g s o f the A n a l y s i s 4.4 C o n c l u s i o n s CHAPTER FIVE: AN ANALYSIS OF INDIAN INFANT MORTALITY PROBLEMS HISTORICALLY 5.1 I n t r o d u c t i o n 5.2 A H i s t o r i c a l Overview o f the Major Causes o f I n f a n t Death 5.3 H e a l t h and S o c i o - E c o n o m i c F a c t o r s : A l t e r n a t i v e P e r s p e c t i v e s and P o l i c i e s 5.4 A C o n c e p t u a l E x p l a n a t i o n 5.4.1. D i s e a s e and S o c i o - E c o n o m i c Change 5.5 C o n c l u s i o n s CHAPTER SIX: - AN ANALYSIS: OF.GOVERNMENT INTERVENTION STRATEGIES ON INDIAN INFANT HEALTH.PROBLEMS 6.1 A H i s t o r y o f I n d i a n H e a l t h P o l i c i e s 6.2 The Major Causes o f I n d i a n I n f a n t Death 6.3 An A n a l y s i s o f C u r r e n t H e a l t h P o l i c i e s 6.4 The L i m i t a t i o n s o f S t a t e I n t e r v e n t i o n i n I n d i a n H e a l t h Problems 6.5 C o n c l u s i o n s and P o l i c y S t r a t e g i e s V. Page GLOSSARY 93 NOTES 95 REFERENCES CITED 96 APPENDICES APPENDIX A: FEDERAL HEALTH ZONES 101 APPENDIX B: REGIONS FOR INDIAN AND NON-INDIAN INFANT 102 MORTALITY RATES APPENDIX C: TOTAL LIVEBIRTHS, NEONATAL AND POSTNEONATAL 1 0 3 DEATHS, INDIAN AND NON-INDIAN, 1975-1977 APPENDIX D: DISTRIBUTION OF BIRTHS AND DEATHS FOR STUDY SAMPLE a. R e g i o n a l D i s t r i b u t i o n o f the Study Sample 104 b. D i s t r i b u t i o n o f the Study Sample by H e a l t h J u r i s d i c t i o n 104 c. D i s t r i b u t i o n o f the Study Sample by P l a c e o f D e l i v e r y 105 d. D i s t r i b u t i o n o f the Study Sample by W e l f a r e Dependency 105 e. D i s t r i b u t i o n o f t h e Study Sample by M a r i t a l S t a t u s 106 f . D i s t r i b u t i o n o f the Study Sample by M a t e r n a l Age/ 106 L i v e b i r t h O r d e r APPENDIX E: DISTRIBUTION OF EXPENDITURES, INDIAN HEALTH SERVICES 1975 t o 1980 a. D i s t r i b u t i o n o f I n d i a n H e a l t h S e r v i c e s E x p e n d i t u r e s 107 by A c t i v i t y , 1975/76 t o 1980/81 b. D i s t r i b u t i o n o f I n d i a n H e a l t h S e r v i c e s E x p e n d i t u r e s 107 by Type, 1975/76 t o 1980/81 v i . LIST OF TABLES TABLE Page 1 STATUS INDIAN POSTNEONATAL, NEONATAL AND INFANT MORTALITY 8 RATES: A REGIONAL COMPARISON FOR B.C. INDIANS, 1978-1979 2 STATUS INDIAN INFANT, POSTNEONATAL AND NEONATAL MORTALITY 8 RATES BY HEALTH JURISDICTION, 1975-1979 3 STATUS INDIAN INFANT, NEONATAL, AND POSTNEONATAL MORTALITY 9 RATES BY HEALTH JURISDICTION AND REGIONAL ZONES, 1975-1979 4 STATUS INDIAN AND NON-INDIAN, NEONATAL AND POSTNEONATAL 10 MORTALITY RATES BY REGION, 1975-1977 5 BIRTH OUTCOME BY PLACE OF DELIVERY, MATERNAL AGE/LIVEBIRTH 36 ORDER AND MARITAL STATUS 6 BIRTH OUTCOME BY WELFARE DEPENDENCY, HEALTH JURISDICTION 37 AND REGION 7 TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS 38 PERTAINING TO TABLE 5 8 TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS 39 PERTAINING TO TABLE 6 9 BIRTH OUTCOME BY PLACE OF DELIVERY, WELFARE DEPENDENCY 41 AND REGION 10 . BIRTH OUTCOME BY PLACE OF DELIVERY, HEALTH JURISDICTION 42 AND REGION 11 TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS 43 PERTAINING TO TABLE 9 12 TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS 44 PERTAINING TO TABLE 10 13 ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS 45 PERTAINING TO TABLE 5 14 ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS 46 PERTAINING TO TABLE 9 15 ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS 57 PERTAINING TO TABLE 10 16 BIRTH OUTCOME BY PLACE OF DELIVERY 49 17 ESTIMATES OF LOG-LINEAR PARAMETERS FOR A MODEL PERTAINING 49 TO TABLE 16 TABLE 18 CHI SQUARE VALUES DERIVED FROM THE ANALYSIS OF 2 x 2 CONTINGENCY TABLES 19 DEATHS OF INDIAN INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILLBIRTHS) FOR CERTAIN SPECIFIED CAUSES, 1930-1935 and 1936-1941 20 DEATHS OF INDIAN INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILLBIRTHS) FOR CERTAIN SPECIFIED CAUSES, 1942-1947 and 1948-1953 21 DEATHS OF INDIAN INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILLBIRTHS) FOR CERTAIN CAUSES, 1942-1947 and 1948-1953 22 DEATHS OF REGISTERED INDIAN INFANTS UNDER ONE YEAR FOR CERTAIN SPECIFIED CAUSES, 1968 t o 1973 23 CAUSES OF INFANT DEATH BY AGE FOR STATUS INDIANS IN B.C., 1974-1980 v i i i L IST OF FIGURES FIGURE Page 1 NEONATAL AND POSTNEONATAL MORTALITY RATES: 5 B.C. STATUS INDIANS AND NON-INDIANS, 1952-1978 2 THE RISKS OF NEONATAL MORTALITY 1 6 ' 3 THE RISKS OF POSTNEONATAL MORTALITY 18 4 MORTALITY RATES OF INDIAN INFANTS FOR CERTAIN 64 SPECIFIED CAUSES, 19.30-19.73 \ i x LIST OF MAPS MAP Page 1 F e d e r a l H e a l t h Care Zones 101 2 S t u d y Regions 30 3 Regions f o r I n d i a n and Non-Indian I n f a n t M o r t a l i t y Rates 1 0 2 X . ACKNOWLEDGMENTS T h i s s t u d y c o u l d n o t have been u n d e r t a k e n w i t h o u t t h e s u p p o r t and . a s s i s t a n c e o f many i n d i v i d u a l s t o whom I am d e e p l y i n d e b t e d . I am p l e a s e d t o acknowledge the a s s i s t a n c e o f a number o f o f f i c i a l s o f M e d i c a l S e r v i c e s o f t h e Department o f N a t i o n a l H e a l t h and W e l f a r e . Mr. S t a l and Dr. Murre p r o v i d e d me w i t h i n f o r m a t i o n f o r t h i s r e s e a r c h s t u d y and Mrs. Brown s p e n t many hours r e t r i e v i n g d a t a f o r me. I would a l s o l i k e t o e x p r e s s my g r a t i t u d e t o P r o f e s s o r S t a n b u r y who c a r e f u l l y r e v i e w e d an e a r l i e r d r a f t o f t h i s , m a n u s c r i p t and o f f e r e d many c o n s t r u c t i v e comments and c r i t i c i s m s . F i n a l l y , I would l i k e t o acknowledge w i t h g r a t i t u d e t h e c o n t i n u o u s s u p p o r t and encouragement o f C l y d e Weaver, whose p a t i e n c e and i n s i g h t s made t h i s work a v e r y w o r t h w h i l e l e a r n i n g e x p e r i e n c e . 1. CHAPTER ONE INDIAN INFANT MORTALITY IN BRITISH COLUMBIA 1.1 I n t r o d u c t i o n And S i g n i f i c a n c e Of The Problem Over the l a s t t h i r t y y e a r s we have w i t n e s s e d a r e m a r k a b l e d e c l i n e i n I n d i a n i n f a n t m o r t a l i t y r a t e s . While t h e s e improvements a r e i m p r e s s i v e , l a r g e d i s p a r i t i e s c o n t i n u e - t o e x i s t between the I n d i a n and n o n - I n d i a n p o p u l a t i o n i n B r i t i s h Columbia. In f a c t , r e p o r t s p u b l i s h e d by governments show t h a t the i n f a n t m o r t a l i t y r a t e f o r B.C.'s s t a t u s I n d i a n p o p u l a t i o n was n e a r l y f o u r t i m e s h i g h e r than the r a t e f o r n o n - I n d i a n s i n 1976. The h i g h i n c i d e n c e o f i n f a n t d e a t h s i s an i m p o r t a n t i s s u e f o r B.C.'s I n d i a n p o p u l a t i o n . As I n d i a n groups become more v o c a l and m i l i t a n t , g r e a t e r p r e s s u r e i s . e x e r t e d upon governments t o a d e q u a t e l y a d d r e s s the h e a l t h problems o f t h i s m i n o r i t y group. F u r t h e r m o r e , as h e a l t h e x p e n d i t u r e s . ' i n c r e a s e w i t h o u t commensurate improvements i n the h e a l t h s t a t u s o f Canada's p o p u l a t i o n , g o v e r n -ments have begun t o f o c u s more on d e v i s i n g p r e v e n t i v e s t r a t e g i e s f o r r e d u c i n g m o r b i d i t y and m o r t a l i t y . Because the Department o f N a t i o n a l H e a l t h and Wel-F a r e p r o v i d e s s u b s i d i e s f o r h o s p i t a l i z a t i o n and m e d i c a l c a r e f o r s t a t u s I n d i a n s , the s t a t e o f I n d i a n h e a l t h i s a fundamental c o n c e r n o f the Canadian government. The c o s t s o f I n d i a n i l l - h e a l t h have been w e l l documented i n a s t u d y u n d e r t a k e n by S t a n b u r y ( 1 ) . U s i n g B.C. h o s p i t a l i z a t i o n s t a t i s t i c s , ha 1. compares t h e d i f f e r e n t i a l c o s t s o f h o s p i t a l i z a t i o n a s s o c i a t e d w i t h I n d i a n i l l -h e a l t h . A c c o r d i n g t o h i s f i n d i n g s , i n 1972 I n d i a n s consumed 154,564 p a t i e n t s days o f h o s p i t a l c a r e . Given t h e n o n - I n d i a n r a t e o f h o s p i t a l i z a t i o n , he com-pu t e s t h a t B.C. I n d i a n s used 78,245 a d d i t i o n a l days o f h o s p i t a l c a r e beyond the a v e r a g e f o r the n o n - I n d i a n p o p u l a t i o n . Based on an a v e r a g e c o s t o f $59.90 pe r p a t i e n t day (1972), t h i s f i g u r e r e p r e s e n t s an a d d i t i o n a l e x p e n d i t u r e o f $4.6 m i l l i o n . 2. When we examine B.C. h o s p i t a l i z a t i o n s t a t i s t i c s i n 1977 we note t h a t t h e n o n - I n d i a n and I n d i a n r a t e o f h o s p i t a l i z a t i o n ( p a t i e n t days p e r 1000 p o p u l a t i o n ) were r e s p e c t i v e l y 1.95 and 2.35.^ While d i f f e r e n t i a l s i n h o s p i t a l i z a t i o n r a t e s were much l a r g e r i n 1972, the c o s t s o f h o s p i t a l i -z a t i o n have r i s e n d r a m a t i c a l l y . In 1977, the a v e r a g e c o s t p e r p a t i e n t day p was a p p r o x i m a t e l y $162.00. As I n d i a n s consumed 21,880 days o f c a r e beyond the a v e r a g e f o r n o n - I n d i a n s t h i s r e p r e s e n t s an a d d i t i o n a l e x p e n d i t u r e o f $3.5 mi 11 i o n . The e x t r a e x p e n d i t u r e s on h o s p i t a l i z a t i o n do not measure a l l the s o c i a l c o s t s o f I n d i a n i l l - h e a l t h . While t h e r e a r e p u b l i c and p r i v a t e e x p e n d i t u r e s on m e d i c a l c a r e , i l l n e s s a l s o a f f e c t s o t h e r a s p e c t s o f l i f e . S t a n b u r y des-c r i b e s some o f the c u m u l a t i v e s o c i a l c o s t s o f I n d i a n i l l - h e a l t h . He s t a t e s t h a t : Mothers s u f f e r i n g from m a l n u t r i t i o n have underweight and anemic b a b i e s . The m i l k the i n f a n t r e c e i v e s from the mother may be l e s s than adequate i n both volume and q u a l i t y because o f the mother's d e b i l i t y . The u n d e r n o u r i s h e d c h i l d i s more s u b j e c t t o i n f e c t i o u s d i s e a s e s . Once the y o u n g s t e r r e a c h e s s c h o o l the t e a c h e r n o t e s he i s r e s t l e s s and a p a t h e t i c and h i s a t t e n t i o n span i s s h o r t e r than t h a t o f c h i l d r e n who do n o t s u f f e r from m a l n u t r i t i o n . He may w e l l be l a b e l l e d as d u l l o r e u p h e m e s t i c a l l y , as a 'slow l e a r n e r ' . F r e q u e n t l y , a s h o r t and i n f e r i o r e d u c a t i o n r e s u l t s . The c o m b i n a t i o n o f poor h e a l t h and.a low l e v e l o f e d u c a t i o n p o i n t s the i n d i v i d u a l towards u n s k i l l e d , ' l a s t h i r e d , f i r s t f i r e d 1 j o b s . P h y s i c a l l y such j o b s when t h e y a r e f o u n d , a r e o f t e n o n e r o u s , i n v o l v i n g some d e g r e e o f h a z a r d t o h e a l t h i n t h e m s e l v e s . P e r i o d s o f a b s e n t e e i s m due t o poor h e a l t h , combined w i t h bouts o f i n v o l u n t a r y unemployment, s h a r p l y i n c r e a s e t h e p r o b a b i l i t y o f f r u s t r a t i o n and d e s p a i r . A l c o h o l o f f e r s a c o n v e n i e n t o b l i v i o n . The end r e s u l t o f t h i s c h a i n i s an e a r l y d e a t h . ( 1 , p.146) 3. A l t h o u g h I n d i a n i n f a n t m o r t a l i t y i s o n l y one a s p e c t o f the l a r g e r h e a l t h problems o f I n d i a n p e o p l e , t h i s i s s u e , n e v e r t h e l e s s , d e s e r v e s a t t e n t i o n . In-deed i t has been s u g g e s t e d t h a t the s t a t e o f i n f a n t h e a l t h p r o v i d e s a r e l i a b l e i n dex o f the c a l i b r e o f m e d i c a l c a r e w i t h i n a s o c i e t y and a l s o r e f l e c t s t he s o c i o - e c o n o m i c c o n d i t i o n s which p r e v a i l . D e p r i v e d m i n o r i t y groups i n t h i s a f f l u e n t n a t i o n r i g h t f u l l y demand the e l i m i n a t i o n o f t h e s e d i s p a r i t i e s . I n d i a n i n f a n t m o r t a l i t y r a t e s i n B r i t i s h Columbia a r e , i n f a c t , comparable t o the r a t e s i n o t h e r d e v e l o p i n g c o u n t r i e s . For example, a c c o r d i n g t o the r e p o r t s o f t h e World H e a l t h O r g a n i z a t i o n i n 1977 the i n f a n t m o r t a l i t y r a t e i n C h i l e , N i c a r a g u a and T h a i l a n d were r e s p e c t i v e l y 47.5, 35.2 and 26.5. (2) The r a t e f o r t h e B.C. S t a t u s I n d i a n p o p u l a t i o n i n 1977 was 41.2. ( 3 ) . The h i g h i n c i d e n c e o f I n d i a n i n f a n t d e a t h may o n l y be r e d u c e d b y g a i n i n g a b e t t e r u n d e r s t a n d i n g about the n a t u r e o f t h i s problem. I f I n d i a n i n f a n t m o r t a l i t y i s a consequence o f b r o a d e r s o c i a l and economic pr o b l e m s , then i t may be more e f f e c t i v e f o r governments t o d i r e c t r e s o u r c e s towards i m p r o v i n g the p h y s i c a l , s o c i a l and mental w e l l - b e i n g o f I n d i a n f a m i l i e s . An awareness o f the f a c t o r s i n f l u e n c i n g I n d i a n i n f a n t m o r t a l i t y would seem e s s e n t i a l f o r p r o v i d i n g the b a s i s f o r f o r m u l a t i n g e f f e c t i v e p o l i c i e s . 1.2 The Nature Of The Problem In c o n s i d e r i n g I n d i a n i n f a n t d e a t h s i t i s u s e f u l t o examine t h e two components o f i n f a n t m o r t a l i t y : n e o n a t a l m o r t a l i t y o r i n f a n t d e a t h s , which o c c u r w i t h i n t h e f i r s t f o u r weeks o f l i f e , and p o s t n e o n a t a l m o r t a l i t y o r i n f a n t d e a t h s which o c c u r between one month and one y e a r . F i g u r e 1 i l l u s t r a t e s t he changes which have o c c u r r e d i n t h e n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y r a t e s f o r s t a t u s I n d i a n s and n o n - I n d i a n s i n B.C. o v e r the l a s t t h r e e d e c a d e s . S t a t i s t i c s i n d i c a t e t h a t w h i l e the a b s o l u t e number o f I n d i a n n e o n a t a l d e a t h s has s t e a d i l y d e c l i n e d , the r e l a t i v e I n d i a n / n o n - I n d i a n p o s i t i o n has not a l t e r e d . The I n d i a n n e o n a t a l m o r t a l i t y r a t e has remained o v e r two t i m e s h i g h e r than the r a t e f o r n o n - I n d i a n s . On the o t h e r hand, t h e p o s t n e o n a t a l m o r t a l i t y r a t e has f a l l e n more r a p i d l y f o r the I n d i a n than t h e n o n - I n d i a n p o p u l a t i o n . D e s p i t e t h i s improvement, however, t h e p o s t n e o n a t a l d i f f e r e n t i a l i s s t i l l v e r y Targe. S t a t i s t i c s p r e s e n t e d . i n F i g u r e 1 a l s o r e v e a l d i f f e r e n c e s i n the r e l a t i v e s i z e o f t h e s e two components o f i n f a n t m o r t a l i t y . T h i s graph i n d i c a t e s t h a t the n o n - I n d i a n p o p u l a t i o n has always e x p e r i e n c e d fewer d e a t h s i n the p o s t -n e o n a t a l p e r i o d , whereas t h e p o s t n e o n a t a l component has g e n e r a l l y been l a r g e r than t h e n e o n a t a l component f o r B.C.'s I n d i a n p o p u l a t i o n . While m o r t a l i t y r a t e s p r e s e n t e d i n t h i s d i a g r a m i n d i c a t e l a r g e d i f f e r e n c e s between n o n - I n d i a n and I n d i a n p e o p l e , r e c e n t r e p o r t s i s s u e d by the f e d e r a l government a l s o s u g g e s t t h a t t h e r e i s c o n s i d e r a b l e v a r i a t i o n i n I n d i a n i n f a n t m o r t a l i t y r a t e s both w i t h i n and between r e g i o n s i n B.C. T a b l e 1 examines the m o r t a l i t y r a t e s f o r s t a t u s I n d i a n s i n t h e f o u r f e d e r a l h e a l t h c a r e zones. I t i s i n t e r e s t i n g t o n o t e t h a t the p o s t n e o n a t a l m o r t a l i t y on Vancouver I s l a n d was o v e r two t i m e s h i g h e r than the r a t e r e p o r t e d f o r the South M a i n l a n d Zone. 7 - r -cn 4 5 4 L U < cr >-1-< 3 S H o I S ' sz.0-4 F I G U R E N E O N A T A L AND P O S T N E O N A T A L M O R T A L I T Y R A T E S : B . C . INDIANS AND N O N - I N D I A N S . 1952-1978 Ind ian N e o n a t a l M o r t a l i t y R a t e s N o n - I n d i a n N e o n a t a l M o r t a l i t y R a t e s I n d i a n P o s t n e o n a t a l M o r t a l i t y R a t e s N o n - I n d i a n P o s t n e o n a t a l M o r t a l i t y R a t e s 1 ) 1 j 1 I i 1 1 1 J 1 — I — I ! — 5 — J — i — J — < — I — I ! — 1 I i I r IIS*. « ^ 55 St 57 5V S-i (.0 W frV fcS-tft fcS H 70 -7/ - 7 X - 7 5 . T V i f f 76 77 "7 S Y E A R S S O U R C E : P r o v i n c e of B r i t i s h C o l u m b i a , V i t a l S t a t i s t i c s , 1978 a n d p r e v i o u s y e a r s C a n a d a , D e p a r t m e n t of N a t i o n a l H e a l t h a n d W e l f a r e , M e d i c a l S e r v i c e s , A n n u a l R e p o r t s , 1978 a n d p r e v i o u s y e a r s . 6. S i m i l a r l y , t h e n e o n a t a l m o r t a l i t y r a t e i n t h e North E a s t Zone was much h i g h e r than t he r a t e s f o r both t he North West and South M a i n l a n d Zones. I n d i a n i n f a n t m o r t a l i t y r a t e s a l s o v a r y by h e a l t h j u r i s d i c t i o n . T a b l e 2 r e v e a l s t h a t t h e i n f a n t m o r t a l i t y r a t e f o r I n d i a n s r e s i d i n g i n a r e a s s e r v e d by the P r o v i n c e was h i g h e r than t he r a t e f o r I n d i a n s under f e d e r a l c a r e . In a d d i t i o n , i n T a b l e 3 we note t h a t t he h i g h e s t n e o n a t a l m o r t a l i t y was r e p o r t e d i n the North E a s t Zone i n communities s e r v e d by p r o v i n c i a l o r m u n i c i p a l h e a l t h u n i t s . S i m i l a r l y , t he h i g h e s t p o s t -n e o n a t a l m o r t a l i t y r a t e o c c u r r e d on Vancouver I s l a n d i n a r e a s under p r o v i n c i a l h e a l t h j u r i s d i c t i o n . A l t h o u g h i t i s n o t p o s s i b l e t o compare I n d i a n and n o n - I n d i a n i n f a n t m o r t a l i t y r a t e s o v e r t he same time p e r i o d , f i g u r e s p r e s e n t e d i n T a b l e 4 d e s c r i b e r e g i o n a l r a t e s f o r t h e s e two groups between 1975 and 1977. Wh i l e t he r e g i o n a l n e o n a t a l m o r t a l i t y r a t e s were g e n e r a l l y l a r g e r f o r t h e I n d i a n p o p u l a t i o n , i t i s i n t e r e s t i n g t o note t h a t t he h i g h e s t n e o n a t a l m o r t a l i t y r a t e s f o r both I n d i a n s and n o n - I n d i a n s were r e p o r t e d i n the Peace R i v e r L i a r d Region. In c o n t r a s t i f we examine p o s t n e o n a t a l m o r t a l i t y r a t e s , i t a p p e a r s t h a t t he rank o r d e r o f r e -g i o n a l p o s t n e o n a t a l m o r t a l i t y r a t e s f o r I n d i a n s and n o n - I n d i a n s a r e v e r y d i s s i m i l a r . The f i r s t and second h i g h e s t I n d i a n p o s t n e o n a t a l m o r t a l i t y r a t e s were r e c o r d e d i n the r e g i o n s o f A l b e r n i - C l a y o q u o t and S q u a m i s h - L i l l o o e t / T h o m p s o n - N i c o l a . The s t a t i s t i c s p r e s e n t e d i n t h e s e t a b l e s s u g g e s t t h a t r e g i o n a l I n d i a n i n f a n t m o r t a l i t y r a t e s v a r y c o n s i d e r a b l y i n B r i t i s h Columbia. What f a c t o r s a c c o u n t f o r t h e s e v a r i a t i o n s ? Are the r i s k s o f I n d i a n i n f a n t m o r t a l i t y s t r u c t u r e d by s o c i o - e c o n o m i c c o n d i t i o n s o r a r e v a r i a t i o n s s i m p l y a r e f l e c t i o n o f m a t e r n a l b i o l o g i c a l f a c t o r s ? The answer t o t h e s e q u e s t i o n s have i m p o r t a n t r a m i f i c a t i o n s t o p o l i c y makers c o n c e r n e d w i t h r e d u c i n g I n d i a n i n f a n t m o r t a l i t y . 1.3 Purpose Of The R e s e a r c h I t i s t h e purpose o f t h i s s t u d y t o examine the t h e o r e t i c a l and e m p i r i c a l r e l a t i o n s h i p between I n d i a n i n f a n t m o r t a l i t y and a v a r i e t y o f s o c i o - e c o n o m i c and h e a l t h c a r e f a c t o r s i n B r i t i s h Columbia. More s p e c i f i c a l l y , t h i s s t u d y seeks t o : 1. i d e n t i f y s p e c i f i c v a r i a b l e s which may i n f l u e n c e t h e r i s k s o f I n d i a n i n f a n t d e a t h ; 2. a s s e s s the i n d e p e n d e n t e f f e c t s t h a t each o f t h e s e v a r i a b l e s have on I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y ; 3. examine changes i n the I n d i a n i n f a n t m o r t a l i t y r a t e s by major c a u s e s and d e v e l o p a c o n c e p t u a l e x p l a n a t i o n o f t h e s e changes; 4. r e v i e w p a s t and p r e s e n t I n d i a n h e a l t h p o l i c i e s and a s s e s s t h e adequacy o f t h e s e a p p r o a c h e s f o r r e d u c i n g i n f a n t m o r b i d i t y and m o r t a l i t y ; and 5. d e t e r m i n e what p o l i c y changes may be r e q u i r e d t o improve t h e b i r t h outcome o f I n d i a n i n f a n t s . TABLE 1: STATUS INDIAN POSTNEONATAL, NEONATAL AND INFANT MORTALITY RATES -A REGIONAL* COMPARISON FOR B.C. INDIANS, 1974-1979  8. 1974 - 1979 MORTALITY RATES SOUTH MAINLAND ZONE VANCOUVER ISLAND ZONE NORTH WEST ZONE NORTH EAST ZONE P o s t n e o n a t a l 12.6 28.9 19.9 21.3 Neonatal 15.5 20.9 11.4 22.0 I n f a n t 28.1 49.8 31.3 43.4 So u r c e : Canada, Department o f N a t i o n a l H e a l t h and W e l f a r e , Annual R e p o r t , f o r t h e y e a r s o f 1974 th r o u g h 1979. *MAP 1 i n Appendix A d e p i c t s t he b o u n d a r i e s o f the f o u r zones. TABLE 2: STATUS INDIAN INFANT, POSTNEONATAL AND NEONATAL MORTALITY RATES BY HEALTH JURISDICTION, 1975-1979  1975 - 1979 MORTALITY FEDERAL JURISDICTION PROVINCIAL/MUNICIPAL RATES JURISDICTION Neonatal 16. ,9 19. ,5 P o s t n e o n a t a l 19. ,2 23. .6 I n f a n t 36. .2 43. .1 + H e a l t h J u r i s d i c t i o n : I n d i a n H e a l t h Care i s the r e s p o n s i b i l i t y o f t h r e e l e v e l s o f government: F e d e r a l , p r o v i n c i a l and m u n i c i p a l . S t a t u s I n d i a n s l i v i n g on r e s e r v e s near urban c e n t r e s and I n d i a n s l i v i n g o f f r e s e r v a t i o n s a r e s e r v e d by P r o v i n c i a l and/or m u n i c i p a l governments. SOURCE: Canada, Department o f N a t i o n a l H e a l t h and W e l f a r e , Annual R e p o r t , f o r the y e a r s o f 1975 th r o u g h 1979. TABLE 3: STATUS INDIAN INFANT, NEONATAL, AND POSTNEONATAL MORTALITY RATES BY HEALTH JURISDICTION AND REGIONAL ZONES, 1975-1979  MORTALITY RATES 1975 - 1979 SOUTH MAINLAND ZONE VANCOUVER ISLAND ZONE NORTH WEST ZONE NORTH EAST ZONE F e d e r a l P r o v . / M u n i c i p a l J u r i s . J u r i s . F e d e r a l P r o v . / M u n i c i p a l F e d e r a l P r o v / M u n i c i p a l F e d e r a l Prov./Mun, J u r i s . J u r i s . J u r i s . J u r i s . J u r i s . J u r i s . ( ) - T o t a l Deaths Neonatal 17.7 (16) 21.8 (21) P o s t n e o n a t a l 19.8 (18) 14.1 (13) I n f a n t 37.5 (34) 37.0 (34) 24,7 (17) 14.3 (13) 20,3 (14) 29.7 (27) 40.7 (28) 44.0 (40) 10.1 (8) 12.6 (9) 15.9 (10)' 29.7 ( l 9 ) 22.7 (18) 25.3 (18) 12.7 (8) 26.6 (17) 32.9 (26) 38.0 (27) 28.7 (18) 56.4 (36) T o t a l L i v e b i r t h s 906 918 687 909 790 709 627 638 SOURCE: Canada, Department o f N a t i o n a l H e a l t h and W e l f a r e , Annual R e p o r t , f o r the y e a r s o f 1974 t h r o u g h 1979. TABLE 4: STATUS INDIAN AND NON-INDIAN NEONATAL AND POSTNEONATAL MORTALITY RATES BY REGION* - 1975-1977 MORTALITY RATES  NEONATAL POSTNEONATAL I n d i a n Non-Indian I n d i a n Non-Indian 1. A l b e r n i - C l a y o q u o t 11. 1 5.8 27- 8 5. 1 2. Bui k l e y - N e c h a k o / F r a s e r - F o r t George 13. 6 8.5 13. 6 4'. 5 3. Capi t a l /Cowi chan/Nanaimo 19. 4 6.7 17. 2 4. 6 4. C a r i b o o 20. 5 11.8 20. 5 4. 9 5. C e n t r a l Coast/Mount Waddington 27. 5 9.5 22. 0 4. 2 6. C e n t r a l F r a s e r V a l l e y / G r e a t e r - V a n . 17. 3 7.5 17. 3 3. 9 7. Okanagan/Columbia/Kootenay/Shuswap 23. 3 10.8 12. 0 12. 1 8. Dewdney-Alouette/Fraser-Cheam 5. 6 7.5 22. 6 5. 3 9. K i t i m a t - S t i k i n e 13. 9 12.6 • 23. 8 6. 3 10. Skeena-Queen C h a r l o t t e 9. 6 13.4 22. 5 2. 9 11. Peace R i v e r - L i a r d 39. 5 14.6. 19. 7 7. 1 12. Powell River/Comox/Sunshine C o a s t 11. 8 9.9 11 • 8 5. 5 13. Squami sh-Li11ooet/Thompson-Ni c o l a 13. 1 8.2 24. 0 3. 1 * R e f e r t o Appendix C f o r a summary o f t o t a l L i v e b i r t h s , Neonatal and P o s t n e o n a t a l Deaths. The r a t i o s o f I n d i a n t o Non-Indian L i v e b i r t h s a r e a l s o i n c l u d e d i n Appendix C. SOURCE: B r i t i s h Columbia M i n i s t r y o f H e a l t h , V i t a l S t a t i s t i c s 1977 and p r e v i o u s y e a r s . 11 1.4 O r g a n i z a t i o n Of The T h e s i s C h a p t e r Two b e g i n s by d e s c r i b i n g the i n f a n t m o r t a l i t y p r o c e s s and then o u t l i n e s the c h a r a c t e r i s t i c s and d e t e r m i n a n t s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . S e c t i o n 2.3 o u t l i n e s v a r i o u s p o l i c i e s and programs which have been implemented t o r e d u c e m o r t a l i t y , and S e c t i o n 2.4 b r i e f l y summarizes the f i n d i n g s o f e m p i r i c a l s t u d i e s and i d e n t i f i e s s p e c i f i c v a r i a b l e s which i n f l u e n c e the r i s k s o f i n f a n t d e a t h . C h a p t e r T h r e e d e s c r i b e s t h e s t u d y v a r i a b l e s and a n a l y t i c a l t e c h n i q u e s which have been adopted f o r p r e c i s e l y a s s e s s i n g t h e s e r e l a t i o n s h i p s . The r e s u l t s o f s t a t i s t i c a l t e s t s a r e p r e s e n t e d and d i s c u s s e d i n C h a p t e r Four. C h a p t e r F i v e r e v i e w s t h e major c a u s e s o f I n d i a n i n f a n t d e a t h h i s t o r i c a l l y and d e v e l o p s an e x p l a n a t i o n o f d i s e a s e and s o c i o - e c o n o m i c s t r u c t u r a l change. The l a s t c h a p t e r then a n a l y z e s the p r e s e n t c a u s e s o f I n d i a n i n f a n t m o r t a l i t y and a s s e s s e s t h e adequacy o f government i n t e r v e n t i o n s t r a t e g i e s t o r e d u c e m o r b i d i t y and m o r t a l i t y . C o n c l u s i o n s and p o l i c y s t r a t e g i e s a r e p r e s e n t e d i n t he f i n a l s e c t i o n o f t h i s c h a p t e r . 12 . CHAPTER TWO INFANT MORTALITY 2.1 The Major Causes o f Neonatal and P o s t n e o n a t a l M o r t a l i t y As t h i s s t u d y i s c o n c e r n e d w i t h a s s e s s i n g t he e f f e c t s o f v a r i o u s f a c t o r s on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y i t i s i m p o r t a n t t o examine the d i f f e r e n t c h a r a c t e r i s t i c s o f p o s t n e o n a t a l and n e o n a t a l d e a t h s . These two e l e m e n t s o f i n f a n t m o r t a l i t y d i f f e r i n t h e i r d e gree o f a s s o c i a t i o n t o e n v i r o n m e n t a l f a c t o r s . F or example, n e o n a t a l m o r t a l i t y tends t o be dominated by d e a t h c l a s s i f i c a t i o n s such as i m m a t u r i t y , p r e m a t u r i t y , b i r t h i n j u r i e s , c o n g e n i t a l m a l f o r m a t i o n s and p o s t n a t a l a s p h y x i a and a t e l e c t a s i s . In g e n e r a l , the c a u s e s o f d e a t h d u r i n g t he n e o n a t a l p e r i o d a r e i n f l u e n c e d by c o n d i t i o n s p r e s e n t b e f o r e o r d u r i n g t h e b i r t h p r o c e s s . On t h e o t h e r hand, d e a t h s d u r i n g the p o s t n e o n a t a l p e r i o d a r e f r e q u e n t l y caused by i n f e c t i o u s o r d i g e s t i v e d i s e a s e s such as d i a r r h o e a o r e n t e r i t i s . A c c i d e n t s a l s o b e g i n t o p l a y a major r o l e i n p o s t n e o n a t a l d e a t h s . S i n c e a g r e a t e r p r o p o r t i o n o f p o s t n e o n a t a l d e a t h s a r e d i r e c t l y i n -f l u e n c e d by e n v i r o n m e n t a l c o n d i t i o n s , p o s t n e o n a t a l m o r t a l i t y i s assumed t o be a r e f l e c t i o n o f the q u a l i t y o f l i f e and the p a r e n t a l c a r e t he c h i l d r e c e i v e s (5). Deaths d u r i n g t h e ne o n a t a l , p e r i o d a r e o f t e n r e l a t e d t o b i o l o g i c a l , g e n e t i c and h e a l t h c a r e f a c t o r s . For example, d e a t h s due t o b i r t h i n j u r i e s o r a n o x i a a r e a s s o c i a t e d w i t h c e r t a i n m e c h a n i c a l a s p e c t s o f the d e l i v e r y . Pro-l o n g e d l a b o u r , and h i g h f o r c e p s d e l i v e r y a r e a l l i m p o r t a n t f a c t o r s which p r e d i s p o s e t he i n f a n t t o b i r t h i n j u r i e s (6). S i m i l a r i l y , a n o x i a s t a t e s may be i n d u c e d by the improper use o f a n e s t h e s i a d u r i n g t he d e l i v e r y . 13 S o c i o b i o l o g i c a l and g e n e t i c f a c t o r s a l l p l a y an i m p o r t a n t r o l e i n c o n g e n i t a l m a l f o r m a t i o n s . F o r example, i t i s w e l l known t h a t c o n g e n i t a l a b n o r m a l i t i e s o c c u r more f r e q u e n t l y amongst i n f a n t s born t o o l d e r women. On t he o t h e r hand, t he g e n e t i c components o f the chromosones i n the sperm c e l l s and ovum a t the time o f f e r t i l i z a t i o n d e t e r m i n e t he b a s i c c h a r a c t e r -i s t i c s and development p o t e n t i a l s o f an i n d i v i d u a l . P r e m a t u r i t y has a l s o been l i n k e d t o mat e r n a l b i o l o g i c a l and s o c i o -b i o l o g i c a l f a c t o r s . S t u d i e s have shown t h a t t h e r i s k s o f p e r m a t u r i t y a r e r e l a t e d t o mat e r n a l age and c h i l d s p a c i n g ( 7 ) . In a d d i t i o n c e r t a i n abnormal-i t i e s Of the g e n i t a l t r a c t a r e r e l a t e d t o p r e m a t u r i t y ( 8 ) . W h i l e h e a l t h c a r e f a c t o r s a r e o f t e n n o t d i r e c t l y r e l a t e d t o the caus e s o f t h e s e d i s e a s e s , m e d i c a l a u t h o r i t i e s b e l i e v e t h a t the q u a l i t y o f o b s t e t r i c a l c a r e does p l a y an i m p o r t a n t r o l e i n the p r e v e n t i o n o f many ca u s e s o f n e o n a t a l m o r t a l i t y . C e r t a i n d i a g n o s t i c t e c h n i q u e s can be used t o d e t e r m i n e t h e p o s s i b i l i t y o f c o n g e n i t a l m a l f o r m a t i o n s . L i k e w i s e , h e a l t h p r o f e s s i o n a l s s u g g e s t t h a t c a r e f u l p r e n a t a l s u p e r v i s i o n o f the h i g h r i s k p r e g n a n t women can o f t e n p r e v e n t t h e o n s e t o f permature l a b o u r . W h ile t he s i z e o f t h e n e o n a t a l component might s u g g e s t t h a t b i o l o g i c a l g e n e t i c and h e a l t h c a r e f a c t o r s a r e more i m p o r t a n t d e t e r m i n a n t s o f i n f a n t m o r t a l i t y than t h e y were h i s t o r i c a l l y , i t i s i m p o r t a n t t o r e c o g n i z e t h a t many ca u s e s o f n e o n a t a l m o r t a l i t y a r e r e l a t e d t o ma t e r n a l m e d i c a l c o n d i t i o n s and t o ma t e r n a l l i f e s t y l e and s o c i o - e c o n o m i c f a c t o r s . The h e a l t h s t a t u s o f the mother and her l i f e s t y l e a f f e c t s t h e growth and development o f t h e f e t u s . S t u d i e s have shown t h a t the use o f c e r t a i n drugs, d u r i n g pregnancy i n c r e a s e s t h e r i s k o f a n o x i a ( 1 0 ) . In a d d i t i o n , f e t a l a b n o r m a l i t i e s can be produced by i r r a d a t i o n and t e r a t o g e n i c a g e n t s (.9,6). M a t e r n a l m e d i c a l c o n d i t i o n s a r e r e l a t e d t o c o n g e n i t a l m a l f o r m a t i o n s and p r e m a t u r i t y . S p e e r t and Conway (7,11) have p o i n t e d o u t t h a t an a c u t e i l l n e s s c o n t r a c t e d d u r i n g pregnancy i n c r e a s e s t h e r i s k s o f p r e m a t u r i t y . B i r t h a b n o r m a l i t i e s a r e more common amongst i n f a n t s born t o d i a b e t i c women o r women who have e x p e r i e n c e d v i r a l i n f e c t i o n s d u r i n g t h e i r pregnancy ( 8 ) . P r e m a t u r i t y and c o n g e n i t a l m a l f o r m a t i o n s a r e a l s o a s s o c i a t e d t o c e r t a i n m a t e r n a l l i f e s t y l e f a c t o r s . There i s some e v i d e n c e t o s u g g e s t t h a t m a t e r n a l smoking r e t a r d s f e t a l growth and development ( 1 2 ) . O t h e r s t u d i e s have d e m o n s t r a t e d t h a t t h e i n c i d e n c e o f p r e m a t u r i t y i s s i g n i f i c a n t l y g r e a t e r f o r i n f a n t s born t o women who smoke d u r i n g t h e i r pregnancy ( 1 3 ) . Recent s t u d i e s i n d i c a t e t h a t t h e o f f s p r i n g o f a l c o h o l i c women o f t e n s u f f e r from a d i s e a s e known as f e t a l a l c o h o l syndrome ( 1 8 ) . I n f a n t s who e x p e r i e n c e t h i s d i s e a s e a r e f r e q u e n t l y m e n t a l l y r e t a r d e d and o f t e n a r e born w i t h s t r u c t u r a l m a l f o r m a t i o n s o f the h e a r t , f a c e and e y e s . F i n a l l y , t h e d i e t o f the mother i s assumed t o d i r e c t l y a f f e c t f e t a l growth and development. Recent s t u d i e s i n d i c a t e t h a t f e t a l m a l n u t r i t i o n has a d e t r i m e n t a l impact on t h e development o f t h e c e n t r a l nervous system and the immunological system (37,38). 2.2 The I n f a n t M o r t a l i t y P r o c e s s The l a s t s e c t i o n examined t he major c a u s e s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y and d e s c r i b e d how v a r i o u s b i o l o g i c a l , e n v i r o n m e n t a l and h e a l t h c a r e f a c t o r s i n f l u e n c e t h e h e a l t h s t a t u s o f the newborn. T h i s s e c t i o n d e s c r i b e s i n f a n t h e a l t h problems from an e c o l o g i c a l p e r s p e c t i v e and then o u t l i n e s the g e n e r a l r e l a t i o n s h i p s and i n t e r r e l a t i o n s h i p which e x i s t between broad c a t e g o r i e s o f f a c t o r s and n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . 15 The r o l e o f e n v i r o n m e n t a l f a c t o r s i n i n f a n t h e a l t h problems was d e s c r i b e d by H a r f o u c h e when he s t a t e d t h a t : The young c h i l d i s a c t u a l l y a b i o l o g i c a l system, s t r i v i n g c o n s t a n t l y t o a d j u s t t o the s t r e s s e s o f the e c o l o g i c a l system. When he f a i l s t o a d j u s t because h i s b a s i c needs a r e n o t ade-q u a t e l y met, he succumbs t o i l l n e s s , d i s a b i l i t y o r d e a t h . In t h i s p r o c e s s he i s i n an u n i q u e l y p a s s i v e p o s i t i o n o f com-p l e t e dependence and h e l p l e s s n e s s . He i s a f f e c t e d by the s t r e s s e s o f r a p i d change i n h i s m i l i e u , and m a l a d j u s t m e n t s t o i t , but ca n n o t i n t r o d u c e any change i n h i s f a v o u r because he i s n o n - v o c a l and n o n - i n s t r u m e n t a l . (2,378) As t h e mother p r o v i d e s t h e envi r o n m e n t f o r the d e v e l o p i n g embryo, her h e a l t h s t a t u s has a d i r e c t b e a r i n g on the growth and the development o f t h e f e t u s . A f t e r b i r t h , t h e newborn i s e n t i r e l y dependent on h i s p a r e n t s t o p r o t e c t him and meet h i s n u t r i t i o n a l r e q u i r e m e n t s . As the i n f a n t e x e r c i s e s no r e s p o n s i b i l i t y o v e r h i s e n v i r o n m e n t , h i s h e a l t h s t a t u s i s i n f l u e n c e d by c o n d i t i o n s i n h i s en v i r o n m e n t . F i g u r e 2 d e p i c t s t h e d i r e c t and i n d i r e c t r e l a t i o n s h i p s which appear t o e x i s t between n e o n a t a l m o r t a l i t y and a v a r i e t y o f f a c t o r s . T h i s d i a g r a m s u g g e s t s t h a t m a t e r n a l l i f e s t y l e f a c t o r s , and m a t e r n a l , m e d i c a l and b i o l o g i c a l c o n d i t i o n s have a d i r e c t impact on the r i s k s o f n e o n a t a l m o r t a l i t y . S o c i a l and economic c o n d i t i o n s , i n t u r n , i n f l u e n c e t h e h e a l t h s t a t u s o f the mother, her l i f e s t y l e and c e r t a i n b i o l o g i c a l c o n d i t i o n s such as mat e r n a l age. Fu r t h e r m o r e w h i l e a c c e s s and u t i l i z a t i o n t o h e a l t h s e r v i c e s may a f f e c t t h e h e a l t h s t a t u s o f the mother, b i o l o g i c a l , g e n e t i c and s o c i o - e c o n o m i c f a c t o r s p l a y a d i r e c t r o l e i n d i s e a s e c a u s a t i o n . FIGURE 2. THE RISKS OF NEONATAL MORTALITY G e n e t i c F a c t o r s S o c i o - E c o n o m i c C o n d i t i o n s M a t e r n a l B i o l o g i c a l C o n d i t i o n s ( i . e . Ma-t e r n a l Age) Mat e r n a l M e d i c a l C o n d i t i o n s H e a l t h Care F a c t o r s The R i s k s o f Neonatal M o r t a l i t y 17 F i g u r e 3 i l l u s t r a t e s t h e r e l a t i o n s h i p s and i n t e r r e l a t i o n s h i p s between p o s t n e o n a t a l m o r t a l i t y and g e n e t i c , s o c i o - e c o n o m i c and h e a l t h c a r e f a c t o r s . I t i n d i c a t e s t h a t the h e a l t h s t a t u s o f t h e ' i n f a n t i s a f f e c t e d by f i v e s e t s o f f a c t o r s : 1. g e n e t i c , 2. s o c i o - e c o n o m i c and s a n i t a r y c o n d i t i o n s i n the community, 3. s o c i o - e c o n o m i c c o n d i t i o n s i n the home, 4. t h e u t i l i z a t i o n o f m e d i c a l c a r e and p u b l i c h e a l t h s e r v i c e s ; and 5. i n f a n t f e e d i n g p r a c t i c e s . F u r t h e r m o r e , . w h i l e the u t i l i z a t i o n o f m e d i c a l c a r e i n f l u e n c e s t h e r i s k s o f p o s t n e o n a t a l m o r t a l i t y , u t i l i z a t i o n o f m e d i c a l s e r v i c e s a r e i n d i r e c t l y i n f l u e n c e d by s o c i o - e c o n o m i c c o n d i t i o n s . 2.3 P o l i c i e s and Programs To Reduce I n f a n t M o r t a l i t y P o l i c i e s and programs, d e s i g n e d t o redu c e t he i n c i d e n c e o f i n f a n t m o r t a l i t y i n Canada, have been d i r e c t e d p r i m a r i l y towards a l t e r i n g t h e l i f e s t y l e o f t h e p r e g n a n t women and i m p r o v i n g t h e q u a l i t y and a c c e s s t o m e d i c a l c a r e . The q u a l i t y o f p r e n a t a l , i n t e r p a r t u m and p o s t p a r t u m c a r e has v a s t l y improved as a r e s u l t o f changes i n c l i n i c a l t e c h n o l o g y . New t r e a t m e n t t e c h n i q u e s and d i a g n o s t i c t o o l s such as u l t r a s o u n d , a m n i o c e n t e s i s and f e t o s c o p y have made i t p o s s i b l e t o d i a g n o s e c e r t a i n c o n d i t i o n s i n the f e t u s and i n t r a v e n e i n the pregnancy when n e c e s s a r y . With u l t r a s o u n d equipment a p h y s i c i a n can view t he f e t u s l o n g b e f o r e the d e l i v e r y and a n t i c i p a t e such e v e n t s as m u l t i p l e b i r t h s o r poor p o s i t i o n i n g . With t h i s knowledge he i s more p r e p a r e d f o r c o m p l i c a t i o n s d u r i n g t h e d e l i v e r y . 18. FIGURE 3. THE RISKS OF POSTNEONATAL MORTALITY G e n e t i c I I So c i o - E c o n o m i c and F a c t o r s | | S a n i t a r y C o n d i t i o n s ] i n the Community • >g I n f a n t F e e d i n g P r a c t i c e s ,.;Socio-Economic C o n d i t i o n s i n the Home A c c e s s ( i . e . , G e o g r a p h i c B a r r i e r s ) A t t i t u d e s and V a l u e s Q u a l i t y o f M e d i c a l Care U t i l i z a t i o n o f M e d i c a l Care and P u b l i c H e a l t h S e r v i c e s The R i s k s o f P o s t n e o n a t a l M o r t a l i t y L i k e w i s e , t h e use o f a m n i o c e n t e s i s o r f e t o s c o p i c e x a m i n a t i o n s e n a b l e the p h y s i c i a n t o d e t e c t g e n e t i c d i s e a s e s o r c o n g e n i t a l m a l f o r m a t i o n s . These new i n n o v a t i o n s have thus made i t p o s s i b l e f o r a p r e g n a n t woman t o be g i v e n t h e c h o i c e o f a b o r t i n g an a f f e c t e d f e t u s . Changes i n t e c h n o l o g y have a l s o improved t he c a r e p r o v i d e d t o the preg n a n t women d u r i n g l a b o u r and d e l i v e r y . The use o f f e t a l m o n i t o r i n g has e n a b l e d m e d i c a l p e r s o n n e l t o a s s e s s t h e b r e a t h i n g p a t t e r n s o f the i n f a n t and t a k e a p p r o p r i a t e a c t i o n s t o a v o i d b i r t h trauma. In a d d i t i o n , heat warmers and s u c t i o n , oxygen and t r a n s f u s i o n a p p a r a t u s can be u t i l i z e d t o s t a b i l i z e the newborn i n f a n t . W hile governments have d i r e c t e d r e s o u r c e s towards i m p r o v i n g d i a g -n o s t i c and t r e a t m e n t t e c h n i q u e s , t h e y have a l s o f o c u s s e d on i m p r o v i n g a c c e s s t o m e d i c a l c a r e . Governments have been a b l e t o e x e r c i s e c o n t r o l o v e r f a c i l i t i e s and equipment and i n r e c e n t y e a r s have attempted t o e l i m i n a t e f i n a n c i a l b a r r i e r s t h r o u g h m e d i c a r e . They have, however, had l i m i t e d s u c c e s s i n i n f l u e n c i n g t h e d i s t r i b u t i o n o f m e d i c a l p e r s o n n e l . To reduce i n e q u a l i t i e s i n t h e d i s t r i b u t i o n o f p h y s i c i a n s , governments have d i r e c t e d r e s o u r c e s towards i n c r e a s i n g t h e s u p p l y o f m e d i c a l p r a c t i t i o n e r s . I n c r e a s i n g the q u a n t i t y o f m e d i c a l p e r s o n n e l does n o t n e c e s s a r i l y i n s u r e b e t t e r a c c e s s . Numerous f a c t o r s i n f l u e n c e the l o c a t i o n a l d e c i s i o n s o f m e d i c a l p e r s o n n e l . P e r s o n a l , f a m i l y , p r o f e s s i o n a l and f i n a n c i a l c o n s i d e r a t i o n s a l l i n f l u e n c e where a p h y s i c i a n chooses t o l o c a t e (35). Under t h e s e c i r c u m s t a n c e s , t h e p o l i c i e s a d o p t e d by governments t o i n c r e a s e the s u p p l y o f m e d i c a l p e r s o n n e l would seem i n e f f e c t i v e and i n e f f i c i e n t . In a d d i t i o n , w h i l e a c c e s s t o m e d i c a l p e r s o n n e l may a f f e c t t h e u t i l i z a t i o n o f p r e n a t a l c a r e and m e d i c a l c a r e t o the newborn, t h e e l i m i n a t i o n o f geo-g r a p h i c b a r r i e r s t o m e d i c a l c a r e does n o t i n s u r e t h e u t i l i z a t i o n o f t h e s e s e r v i c e s . U t i l i z a t i o n i s a l s o d e t e r m i n e d by t h e a t t i t u d e s o f the mother and t h e s e a t t i t u d e s a r e i n t u r n i n f l u e n c e d by o t h e r members o f her immediate o r extended f a m i l y . Health, p r o f e s s i o n a l s o f t e n assume t h a t t he u n d e r - u t i l i . z a t i . o n o f m e d i c a l s e r v i c e s by poor and m i n o r i t y groups i s , i n p a r t , a r e f l e c t i o n o f i g n o r a n c e . C o n s e q u e n t l y , governments have used h e a l t h e d u c a t i o n as a t e c h n i q u e f o r f a c i l i t a t i n g b e h a v i o r a l changes i n i n d i v i d u a l s . Governments have d e v e l o p e d programs t o t r a i n i n d i v i d u a l s t o work i n communities t o e d u c a t e p e o p l e i n the a r e a o f modern h e a l t h p r a c t i c e s . F or example, i n B r i t i s h Columbia t he Department o f N a t i o n a l H e a l t h and W e l f a r e t r a i n s n a t i v e p e o p l e t o work as community h e a l t h r e p r e s e n t a t i v e s on I n d i a n r e s e r v e s . (40) These i n d i v i d u a l s assume two r o l e s . As t e a c h e r s t h e y a r e r e s p o n s i b l e f o r a c q u a i n t i n g t h e i r p e o p l e w i t h modern h e a l t h c o n c e p t s and t e c h n i q u e s . As l i a i s o n o f f i c e r s t h e y attempt t o i n s u r e t h a t i n d i v i d u a l s i n the community a c q u i r e m e d i c a l c a r e when n e c e s s a r y . A l t h o u g h t h e a t t i t u d e and subsequent b e h a v i o r o f i n d i v i d u a l s may be i n f l u e n c e d by h e a l t h e d u c a t o r s , t h i s s t r a t e g y has many l i m i t a t i o n s as w e l l . F i r s t l y , i t assumes t h a t f a u l t y a t t i t u d e s and v a l u e s o f poor and m i n o r i t y groups i n h i b i t t h e use o f m e d i c a l s e r v i c e s . H e a l t h e d u c a t o r s t h u s attempt t o a l t e r t h e v a l u e s o f t h e s e i n d i v i d u a l s so t h a t t h e y a r e c o n s i s t e n t w i t h t h o s e o f the l a r g e r s o c i e t y . The a t t i t u d e s and v a l u e s o f i n d i v i d u a l s a r e shaped by t h e i r e x p e r i e n c e s and s o c i a l r e l a t i o n s h i p s w i t h o t h e r p e o p l e . The a t t i t u d e o f m e d i c a l p e r s o n n e l towards t h e i r p a t i e n t s i n f l u e n c e s t he subsequent use o f t h e s e s e r v i c e s . F u r t h e r m o r e , t he q u a l i t y o f m e d i c a l c a r e may be a s s o c i a t e d w i t h t h e a t t i t u d e s and b e h a v i o r o f the p h y s i c i a n and h i s p a t i e n t . S o c i a l c l a s s and c u l t u r a l b a r r i e r s may a f f e c t t h e d o c t o r ' s a b i l i t y t o i d e n t i f y h e a l t h problems. I f t h e s e b a r r i e r s i n h i b i t both t he q u a n t i t y and q u a l i t y o f m e d i c a l .care, then governments may need t o d e v e l o p programs t o improve t he r e l a t i o n s h i p between the p r o s p e c t i v e c l i e n t and m e d i c a l p e r s o n n e l . Programs d e s i g n e d t o s i m p l y a l t e r the a t t i t u d e and b e h a v i o r o f the c l i e n t a r e o v e r l y s i m p l i s t i c s o l u t i o n s . While h e a l t h e d u c a t i o n has been used t o f a c i l i t a t e t h e u t i l i z a t i o n o f m e d i c a l p e r s o n n e l t h i s a p p roach has a l s o been employed t o a l t e r l i f e s t y l e s . In the p a s t , r e s o u r c e s have been p r i m a r i l y d i r e c t e d towards im-p r o v i n g the q u a l i t y o f m e d i c a l c a r e . In r e c e n t y e a r s , governments have f o c u s s e d on h e a l t h e d u c a t i o n as a mechanism f o r i m p r o v i n g t h e h e a l t h s t a t u s o f i n d i v i d u a l s . More emphasis has been p l a c e d on h e a l t h e d u c a t i o n f o r two r e a s o n s . F i r s t l y , h e a l t h p r o f e s s i o n a l s now r e c o g n i z e the importance o f such l i f e s t y l e f a c t o r s as d i e t , m a t e r n a l smoking and a l c o h o l consumption i n i n f a n t m o r t a l i t y . S e c o n d l y , d e s p i t e v a s t improvements i n m e d i c a l t e c h -n o l o g y and a c c e s s t o h e a l t h s e r v i c e s , i n f a n t m o r t a l i t y r a t e s have not d e c l i n e d s u b s t a n t i a l l y i n the p a s t 10 y e a r s i n Canada. As the r a t i o o f p u b l i c t o p r i v a t e h e a l t h e x p e n d i t u r e s has r i s e n s u b s t a n t i a l l y o v e r t h e l a s t 20 4 y e a r s governments a r e now more c o n c e r n e d w i t h t h e c o s t s o f h e a l t h c a r e . E f f o r t s have been d i r e c t e d towards r e d u c i n g t h e e x p a n s i o n o f m e d i c a l s e r v i c e s . More emphasis i s now p l a c e d on i n d i v i d u a l a c t i o n t o improve t he h e a l t h s t a t u s o f t h e pr e g n a n t woman and the newborn. Governments have d e v e l o p e d programs t o promote s e l f - c a r e . Governments have used the media and the p a r a - p r o f e s s i o n a l s and p r o f e s s i o n a l s t o e d u c a t e t h e g e n e r a l p o p u l a t i o n . N u t r i t i o n c o u n s e l l i n g , a c c i d e n t p r e v e n t i o n , and a l c o h o l and drug abuse c o u n s e l l i n g a r e j u s t a few examples o f p u b l i c h e a l t h programs o f f e r e d t o d a y . In a d d i t i o n t o t h e s e programs, governments have d e v e l o p e d programs s p e c i f i c a l l y f o r p r e g n a n t women. P r e -n a t a l c l a s s e s ane o f f e r e d by p r o v i n c i a l and l o c a l governments t o ed u c a t e and pr e p a r e the pre g n a n t woman f o r the d e l i v e r y o f her c h i l d . W h ile i t i s i m p o r t a n t t o r e c o g n i z e t h a t an i n d i v i d u a l has some d i s c r e t i o n i n r e s p o n d i n g t o e n v i r o n m e n t a l f o r c e s , and i s t h e r e f o r e c a p a b l e o f a l t e r i n g c e r t a i n a s p e c t s o f h i s b e h a v i o u r , t h i s s t r a t e g y o f s e l f - h e l p i s p r o b a b l y o f l i m i t e d u t i l i t y . S e l f - c a r e s t r a t e g i e s assume t h a t i n d i v i d u a l s a r e e s s e n t i a l l y u n c o n s t r a i n e d by s o c i a l e v e n t s and p r o c e s s e s . T h i s b e h a v i o u r model o v e r l o o k s the importance o f i l l n e s s - g e n e r a t i n g c o n d i t i o n s i n the work p l a c e and i n the community. As one c r i t i c p o i n t s o u t , s e l f - c a r e s t r a t e g i e s assume t h a t (14,p.55) the b a s i c cause o f h i s s i c k n e s s o r u n h e a l t h i s the i n d i v i d u a l h i m s e l f , and n o t the system. Emphasis i s t h u s p l a c e d on the b e h a v i o u r o f the i n d i v i d u a l and n o t the s o c i a l and economic system which l a r g e l y d e t e r m i n e d the b e h a v i o r i n i t i a l l y . F o r example, h e a l t h p r o f e s s i o n a l s c o n c e r n e d w i t h t h e u n h e a l t y d i e t o f p r e g n a n t women o f f e r n u t r i t i o n c o u n s e l l i n g i n many p r e n a t a l e d u c a t i o n programs. T h i s a p p r o a c h assumes t h a t a poor d i e t i s r e l a t e d t o l a c k o f knowledge. S e l f -c a r e s t r a t e g i e s such as t h e s e i g n o r e the i m p o r t a n c e o f s o c i a l and economic f o r c e s i n s o c i e t y . W h i l e consumption p a t t e r n s a r e i n f l u e n c e d by i n d i v i d u a l ; p r e f e r e n c e s , o t h e r f a c t o r s p l a y a r o l e i n i n f l u e n c i n g the d i e t o f i n d i v i d u a l s . For example, m e d i c a l p e r s o n n e l s u g g e s t t h a t o u r d i e t i s i n f l u e n c e d by the c o r p o r a t e p r a c t i c e s o f f o o d c o n g l o m e r a t e s ( 3 9 ) . A l s o the income l e v e l o f a f a m i l y . h a s some b e a r i n g on f o o d consumption p a t t e r n s . As an i n d i v i d u a l ' s d i e t i s d e t e r m i n e d t o some e x t e n t by e x t e r n a l f o r c e s , s e l f - c a r e programs would seem t o be an i n e f f e c t i v e s t r a t e g y f o r s o l v i n g g r o u p - s p e c i f i c n u t r i t i o n a l p roblems. I f governments a r e c o n c e r n e d w i t h r e d u c i n g i n f a n t m o r t a l i t y and more s p e c i f i c a l l y r e d u c i n g I n d i a n i n f a n t m o r t a l i t y , then i t i s e s s e n t i a l t o u n d e r s t a n d t h e complex i n t e r r e l a t i o n s h i p s which e x i s t between the numerous f a c t o r s d i s c u s s e d h e r e . T e c h n i c a l s o l u t i o n s and s e l f - c a r e s t r a t e g i e s may f a i l t o r e d u c e f u r t h e r the i n c i d e n c e o f i n f a n t m o r t a l i t y i f the r i s k s o f d e a t h and i l l n e s s a r e s t r u c t u r e d by s o c i a l and economic c o n d i t i o n s which a r e l a r g e l y beyond the c a p a c i t y o f the i n d i v i d u a l t o c o n t r o l . O t h e r more g e n e r a l s o c i a l r e f o r m programs may i n d e e d r e q u i r e c o n s i d e r a t i o n . 23 2.4 E m p i r i c a l S t u d i e s Of I n f a n t M o r t a l i t y D i f f e r e n t i a l s i n i n f a n t m o r t a l i t y have been a t o p i c o f r e s e a r c h f o r o v e r 100 y e a r s . P r i o r t o 1930 r e s e a r c h s t u d i e s f o c u s s e d on a s s e s s i n g the r o l e o f s o c i a l and economic f a c t o r s i n i n f a n t m o r t a l i t y . For example, i n the l a t t e r h a l f o f t h e 19th c e n t u r y , Marx (56) examined i n f a n t m o r t a l i t y r a t e s a c r o s s r e g i s t e r e d d i s t r i c t s i n E n g l a n d . He c o n c l u d e d t h a t d i f f e r e n t i a l s i n i n f a n t m o r t a l i t y r a t e s were a consequence o f p o v e r t y , i n a d e q u a t e s a n i t a t i o n , p o or h e a l t h c a r e and i n a d e q u a t e n u t r i t i o n . Recent s t u d i e s u n d e r t a k e n i n the U n i t e d S t a t e s a l s o i n d i c a t e d t h a t p o v e r t y was d i r e c t l y l i n k e d t o i n c r e a s e d r i s k s o f i n f a n t m o r t a l i t y . For example, Gortmaker (20) d e m o n s t r a t e d t h a t b e i n g born i n t o p o v e r t y i n c r e a s e d the r i s k s o f i n f a n t m o r t a l i t y by a l m o s t 50%. S i m i l a r l y , the f i n d i n g s o f o t h e r s t u d i e s r e v e a l e d t h a t r e g i o n a l economic f a c t o r s were d i r e c t l y a s s o c i a t e d w i t h i n f a n t m o r t a l i t y , . .Other s t u d i e s ' a l s o i n d i c a t e t h a t r e g i o n a l economic f a c t o r s were d i r e c t l y a s s o c i a t e d w i t h i n f a n t m o r t a l i t y . Abbey and Shah (21) d e m o n s t r a t e d t h a t t h e r e was 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 p o s t n e o n a t a l m o r t a l i t y and s o c i o - e c o n o m i c c h a r a c t e r i s t i c s o f c e n s u s t r a c t s . W i l l i e (.22) showed t h a t the d i s t r i b u t i o n o f p o s t n e o n a t a l and n e o n a t a l d i s -t r i b u t i o n o f p o s t n e o n a t a l and n e o n a t a l m o r t a l i t y r a t e s were s i g n i f i c a n t l y a s s o c i a t e d w i t h the f a m i l y income c h a r a c t e r i s t i c s o f r e g i o n s . O t h e r s t u d i e s have d e m o n s t r a t e d t h a t c e r t a i n m a t e r n a l , s o c i o - b i o l o g i c a l and s o c i o - e c o n o m i c f a c t o r s a r e d i r e c t l y r e l a t e d t o i n f a n t m o r t a l i t y . Chase (.16) r e v e a l e d the p r e s e n c e o f one o r more o f the f o l l o w i n g f a c t o r s s i g n i f i c a n t l y i n c r e a s e d the r i s k s o f i n f a n t m o r t a l i t y . 1. M a r i t a l S t a t u s : s i n g l e 2. M a t e r n a l E d u c a t i o n : l e s s than 8 y e a r s 3. M a t e r n a l A g e / L i v e b i r t h O r der a. l e s s than 15 y e a r s : one o r more b i r t h s b. 15 t o 19 y e a r s : 2 o r more b i r t h s c. 20 t o 24 y e a r s : 4 o r more b i r t h s d. 25 t o 29 y e a r s : 5 o r more b i r t h s e. 30 t o 35. y e a r s : f i r s t p regnancy and 5 o r more b i r t h s 24 M a t e r n a l m e d i c a l c o n d i t i o n s and l i f e s t y l e f a c t o r s a l s o a r e assumed t o p l a y an i m p o r t a n t r o l e i n i n f a n t m o r t a l i t y . F o r example, one s t u d y showed t h a t t h e o v e r a l l m o r t a l i t y r a t e o f i n f a n t s born t o women a d d i c t e d t o h e r o i n was t h r e e t i m e s h i g h e r than t h e r a t e f o r t h e g e n e r a l p o p u l a t i o n ( 5 2 ) . In a d d i t i o n , a l c o h o l consumption a l s o poses a p o t e n t i a l h a z a r d t o the f e t u s . A r e c e n t s t u d y d e m o n s t r a t e d that, t h e a l c o h o l i n t a k e l e v e l o f t h e p r e g n a n t women was l i n k e d t o n e o n a t a l m o r t a l i t y ( 2 8 ) . W h i l e the l i f e s t y l e o f the pr e g n a n t woman appear s t o a f f e c t t h e r i s k s o f i n f a n t m o r t a l i t y t h e r e i s some e v i d e n c e which s u g g e s t s t h a t c e r t a i n m a t e r n a l m e d i c a l c o n d i t i o n s a r e r e l a t e d t o n e o n a t a l m o r t a l i t y . S t u d i e s have shown t h a t t h e p r e s e n c e o f c e r t a i n m e d i c a l r i s k s , such as a h i s t o r y o f spontaneous f e t a l l o s s i n c r e a s e s t h e l i k e l i h o o d o f n e o n a t a l d e a t h (20,54). F u r t h e r m o r e i n a s t u d y o f Navajo i n f a n t m o r t a l i t y , t h e f i n d i n g s r e v e a l e d t h a t t h e r e was 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 n e o n a t a l m o r t a l i t y and anemia i n t h e mother ( 5 0 ) . A l s o t h i s s t u d y r e v e a l e d t h a t mothers w i t h b r e e c h d e l i v e r i e s , p r o l o n g e d l a b o u r , f a u l t y p l a c e n t a t i o n and i n t e r u t e r i n e i n f e c t i o n s were more l i k e l y t o have i n f a n t s who d i e d d u r i n g t h e f i r s t month o f l i f e . S t u d i e s have a l s o shown t h a t c e r t a i n h e a l t h c a r e f a c t o r s p l a y a s i g n i f i c a n t r o l e i n i n f a n t m o r t a l i t y . I n c r e a s e d r i s k s o f i n f a n t m o r t a l i t y have been a s s o c i a t e d w i t h n o n - h o s p i t a l i z a t i o n (20,16). O t h e r s t u d i e s s u g g e s t t h a t a b o r t i o n and the use o f c e a s e r e a n s e c t i o n p l a y an i m p o r t a n t r o l e i n t h e p r e v e n t i o n o f i n f a n t m o r t a l i t y . (.17,31) V a r i o u s s t u d i e s have a l s o a s s e s s e d t h e e f f e c t s o f p r e n a t a l c a r e on i n f a n t m o r t a l i t y . W h i l e one st u d y i n d i c a t e d t h a t i n f a n t m o r t a l i t y r a t e s were s i g n i f i r -c a n t l y .higher f o r I n d i a n women who r e c e i v e d l i t t l e o r no p r e n a t a l c a r e , t h i s r e s e a r c h s t u d y d i d n o t c o n t r o l f o r the e f f e c t s o f o t h e r f a c t o r s . (.50) A n o t h e r i n f a n t m o r t a l i t y s t u d y i n d i c a t e d t h a t when o t h e r f a c t o r s were c o n t r o l l e d f o r t h e r e was l i t t l e r e l a t i o n s h i p between p r e n a t a l c a r e and i n f a n t m o r t a l i t y (15) ( 5 4 ) . In d e v e l o p i n g c o u n t r i e s , s t u d i e s have examined the e f f e c t s o f i n f a n t f e e d i n g p r a c t i c e s on i n f a n t m o r t a l i t y . One s t u d y u n d e r t a k e n i n r u r a l C h i l e r e v e a l e d t h a t p o s t n e o n a t a l m o r t a l i t y was s i g n i f i c a n t l y more f r e q u e n t amongst i n f a n t s who were b o t t l e f e d i n the f i r s t t h r e e months o f l i f e . ( 5 3 ) Because b r e a s t f e e d i n g d e c r e a s e d w i t h m a t e r n a l e d u c a t i o n and p a t e r n a l income t h e r e was an i n v e r s e r e l a t i o n s h i p between p o s t n e o n a t a l m o r t a l i t y and income, e n v i r o n m e n t a l c o n d i t i o n s and me d i c a l c a r e . P o s t n e o n a t a l m o r t a l i t y r a t e s were h i g h e r i n houses w i t h r u n n i n g water and some form o f sewage system. F u r t h e r m o r e , t he r i s k s o f p o s t n e o n a t a l d e a t h were g r e a t e r i f t h e p r e g n a n t women v i s i t e d a p r i v a t e p h y s i c i a n o r p r e n a t a l c l i n i c than i f she o n l y had p r o f e s s i o n a l c a r e d u r i n g t h e d e l i v e r y o r n o t a t a l l . The r e s u l t s o f t h i s s t u d y s u g g e s t t h a t whatever p r o t e c t i o n a d d i t i o n a l income had, i t s e f f e c t s were n u l l i f i e d by the e f f e c t s o f b o t t l e f e e d i n g . The f i n d i n g s o f t h i s s t u d y were v e r y s i m i l a r t o the r e s u l t s o f a n o t h e r s t u d y i n Luchnow, I n d i a ( 5 5 ) . When m e d i c a l p e r s o n n e l a s s e s s e d the e f f e c t s o f v a r i o u s f a c t o r s on i n f a n t m o r t a l i t y t h e y f o u n d t h a t t h e r i s k s o f i n f a n t m o r t a l i t y were g r e a t e r f o r i n f a n t s who were b o t t l e f e d . In a d d i t i o n , t h e r e was no r e l a t i o n s h i p between p e r i n a t a l o r n e o n a t a l m o r t a l i t y and the p l a c e o f d e l i v e r y and a n t e n a t a l c a r e . W h i l e t he e f f e c t s o f f e e d i n g p r a c t i c e s on i n f a n t m o r t a l i t y has not been examined f o r the North American I n d i a n p o p u l a t i o n t h e r e i s some e v i d e n c e t o s u g g e s t t h a t b o t t l e f e e d i n g i s r e l a t e d t o I n d i a n i n f a n t m o r b i d i t y . F o r example, a s t u d y was u n d e r t a k e n i n two i s o l a t e d I n d i a n communities i n Manitoba t o d e t e r m i n e t he impact o f b o t t l e f e e d i n g on i n f a n t i n f e c t i o n s . (59) The r e s u l t s showed t h a t t h e o n l y v a r i a b l e s i g n i f i c a n t l y r e l a t e d t o i n f a n t h o s p i t a l i z a t i o n was b o t t l e f e e d i n g . On the o t h e r hand, t h e r e was no r e l a t i o n s h i p between h o s p i t a l i z a t i o n and any o f the f o l l o w i n g f a c t o r s : (1) number o f o c c u p a n t s p e r house, (2) f a m i l y income, (3) o c c u p a t i o n and e d u c a t i o n o f p a r e n t s , and (4) f a m i l y s i z e . In a n o t h e r s t u d y o f Eskimo m o r b i d i t y and m o r t a l i t y i n Western A l a s k a m e d i c a l p e r s o n n e l i n v e s t i g a t e d the a s s o c i a t i o n s between the haemoglobin l e v e l s , m o r b i d i t y f r e q u e n c y and f e e d i n g p r a c t i c e s . ( 5 8 ) " T h e r e s u l t s showed-that b o t t l e f e d c h i l d r e n had.lower h a e m o g l o b i n . l e v e l s arid t h a t t h e s e i n f a n t s s u f f e r e d more f r e q u e n t l y from i l l n e s s such as r e s p i r a t o r y i n f e c t i o n s and o t h e r common d i s e a s e s o f c h i l d h o o d . These f i n d i n g s s u g g e s t t h a t b r e a s t f e e d i n g p r o t e c t s i n f a n t s n o t o n l y from i n f e c t i o u s d i a r r h o e a l d i s e a s e s but t h a t i t a l s o p l a y s a d i r e c t r o l e i n the p r e v e n t i o n o f o t h e r i l l n e s s e s . F i n a l l y w h i l e the e v i d e n c e from r e s e a r c h s t u d i e s i n d i c a t e s t h a t b o t t l e f e e d i n g p l a y s a r o l e i n m o r b i d i t y and m o r t a l i t y o t h e r s t u d i e s m a i n t a i n t h a t s a n i t a r y c o n d i t i o n s i n communities have some b e a r i n g on i n f a n t h e a l t h . In a s t u d y o f two I n d i a n r e s e r v a t i o n s i n A r i z o n a , the r e s e a r c h e r s found t h a t the i n s t a l l a t i o n o f i n d o o r plumbing f a c i l i t i e s i n one I n d i a n community s u b s t a n -t i a l l y r e d u c e d the i n c i d e n c e o f i n f a n t h o s p i t a l i z a t i o n f o r i n f e c t i o u s d i a r r h o e a . W h ile the r e s e a r c h e r s c o n c l u d e d t h a t the i n s t a l l a t i o n o f s a n i t a r y f a c i l i t i e s p l a y s a r o l e i n the p r e v e n t i o n o f i l l n e s s t h e y f a i l e d t o c o n t r o l f o r the e f f e c t s o f o t h e r f a c t o r s such as i n f a n t f e e d i n g p r a c t i c e s . In r e v i e w i n g the f i n d i n g s o f i n f a n t m o r t a l i t y and m o r b i d i t y s t u d i e s , i t i s a p p a r e n t t h a t numerous f a c t o r s i n f l u e n c e i n f a n t h e a l t h . C e r t a i n h e a l t h c a r e and m a t e r n a l f a c t o r s have been l i n k e d t o i n f a n t m o r t a l i t y . In a d d i t i o n t h e r e a p p e a r s t o be some r e l a t i o n s h i p b e t w e e n . i n f a n t f e e d i n g p r a c t i c e s and t h e h e a l t h s t a t u s o f t h e c h i l d . A l t h o u g h the f i n d i n g s o f t h e s e s t u d i e s have i m p o r t a n t p o l i c y i m p l i c a t i o n s , s i m i l a r s t u d i e s have no t been under-taken i n B r i t i s h Columbia. F u r t h e r m o r e , w h i l e the outcome o f pregnancy may be the consequence o f many i n t e r a c t i n g b i o l o g i c a l , s o c i a l and economic f a c t o r s , t h i s s t u d y has examined the e f f e c t s o f o n l y a few f a c t o r s . . C hapter 3 p r o v i d e s a d e s c r i p t i o n o f the o p e r a t i o n a l dependent and i n d e p e n d e n t v a r i a b l e d a t a s o u r c e s and the b a s i c model adopted f o r a s s e s s i n g t h e s e r e l a t i o n s h i p s . CHAPTER THREE RESEARCH METHODOLOGY AND DATA DESCRIPTION 3.1 D e s c r i p t i o n Of V a r i a b l e s C h a p t e r 2 r e v i e w e d t h e f i n d i n g s o f r e c e n t e m p i r i c a l s t u d i e s and i d e n t i f i e d a s e r i e s o f v a r i a b l e s which were a s s o c i a t e d w i t h i n f a n t m o r t a l -i t y . As t h i s s t u d y i s c o n c e r n e d w i t h a s s e s s i n g t h e in d e p e n d e n t e f f e c t s o f v a r i o u s f a c t o r s on I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y i t was n e c e s s a r y t o s e l e c t s p e c i f i c v a r i a b l e s f o r a n a l y s i s . T h i s s e c t i o n d e s c r i b e s t h e o p e r -a t i o n a l dependent and i n d e p e n d e n t v a r i a b l e s and i d e n t i f i e s s p e c i f i c r i s k c a t e g o r i e s . 3.1.1. Dependent V a r i a b l e s T h r e e outcomes o f b i r t h a r e p r e d i c t e d : 1. N e o n a t a l m o r t a l i t y ; 2. P o s t n e o n a t a l m o r t a l i t y ; and 3. S u r v i v a l . As t h i s s t u d y i s c o n c e r n e d w i t h a s s e s s i n g t h e e f f e c t s o f v a r i o u s f a c t o r s on ne o n a t a l and p o s t n e o n a t a l m o r t a l i t y , t h e dependent v a r i a b l e s a r e the e x p e c t e d n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y r a t e s f o r a p a r t i c u l a r c e l l o f a c r o s s -c l a s s i f i c a t i o n t a b l e . M o r t a l i t y r a t e s a r e d e f i n e d as t h e r a t i o o f t h e e x p e c t e d number o f d e a t h s i n t h e n e o n a t a l o r p o s t n e o n a t a l p e r i o d t o the e x p e c t e d number o f l i v e b i r t h s i n t h a t p a r t i c u l a r c e l l . 3.1.2. Independent V a r i a b l e s  M a t e r n a l C h a r a c t e r i s t i c s : To d e t e r m i n e the impact o f i n d i v i d u a l c h a r a c t e r i s t i c s o f the mother on i n f a n t m o r t a l i t y two v a r i a b l e s were s e l e c t e d : namely, m a t e r n a l a g e / 1 i v e b i r t h o r d e r and m a r i t a l s t a t u s . Based on t h e f i n d i n g s o f p a s t r e s e a r c h s t u d i e s t h i s compound v a r i a b l e was i n c l u d e d t o a s s e s s the impact o f b i o l o g i c a l ( i . e . m a t e r n a l age) and s o c i a l f a c t o r s on I n d i a n i n f a n t m o r t a l i t y . M a t e r n a l A g e / L i v e b i r t h O r d e r i s d e f i n e d by s i x c a t e g o r i e s : 18 y e a r s o r l e s s : one o r more b i r t h s , 1 9 - 2 4 y e a r s : 4 o r more b i r t h s ; 1 9 - 2 4 y e a r s : 3 o r few b i r t h s ; 25 -34 y e a r s : f o u r o r fewer b i r t h s ; 25 - 34 y e a r s : 4 o r more b i r t h s ; 35 y e a r s o r more: one o r more b i r t h s . b) M a r i t a l S t a t u s The m a r i t a l s t a t u s o f t h e mother was grouped i n t o two c a t e g o r i e s : m a r r i e d and s i n g l e . Based on t h e f i n d i n g s o f p a s t r e s e a r c h s t u d i e s i t was e x p e c t e d t h a t the r i s k s o f m o r t a l i t y would be g r e a t e r f o r i n f a n t s born t o s i n g l e women. Re s i d e n c e and H e a l t h Care F a c t o r s : a) R e s i d e n c e F a c t o r s To d e t e r m i n e t h e impact o f r e s i d e n c e and s o c i o - e c o n o m i c c o n d i t i o n s on I n d i a n i n f a n t m o r t a l i t y two v a r i a b l e s were i d e n t i f i e d f o r s t u d y : r e g i o n and w e l f a r e dependency. ( i ) Region - The f o l l o w i n g s i x r e g i o n s d e p i c t e d i n Map 2 were s e l e c t e d f o r s t u d y : Nanaimo, Vancouver, North West, North E a s t , C o a s t a l and C e n t r a l . As t h e r e were fewer than t h r e e c a s e s i n which the p l a c e o f r e s i d e n c e o f the d e c e a s e d i n f a n t d i f f e r e d from the a d d r e s s o f t h e mother on b i r t h c e r t i f i c a t e , t h i s s t u d y used b i r t h c e r t i f c a t e s t o a l l o c a t e a l l l i v e b i r t h s t o p a r t i c u l a r r e g i o n s . ( i i ) W e l f a r e Dependency - T h i s v a r i a b l e was i n c l u d e d t o measure the impact o f r e g i o n a l economic c o n d i t i o n s on I n d i a n i n f a n t m o r t a l i t y . T h i s v a r i a b l e i s d e f i n e d as the r a t i o o f c a s e months t o t o t a l p o p u l a t i o n . The term c a s e months r e f e r s t o the l e n g t h o f time t h e s t a t u s I n d i a n s i n an a r e a a r e dependent on s o c i a l a s s i s t a n c e . 130° 129° !?»• K ? ' | 126° m i 125° ' i M ' J 2 3 ' 122' " i ; r I2Q- 119° 118" BRITISH COLUMBIA M A P 2 S T U D Y R E G I O N S 1 . N a n a i m o '2. C o a s t a l 3. V a n c o u v e r 4. C e n t r a l 5. N o r t h E a s t 6. N o r t h West ' 31 Annual w e l f a r e dependency r a t e s were c a l c u l a t e d f o r t h e o n - r e s e r v e p o p u l a t i o n i n e ach r e g i o n . As s o c i a l a s s i s t a n c e s t a t i s t i c s were not a v a i l a b l e f o r s t a t u s I n d i a n s l i v i n g o f f r e s e r v a t i o n , t h e w e l f a r e dependency r a t e s were used to d e s c r i b e economic c o n d i t i o n s f o r both the on and o f f - r e s e r v e p o p u l a t i o n i n a p a r t i c u l a r r e g i o n . F u r t h e r m o r e as t h i s s t u d y a d o p t e d q u a n t i t a t i v e methods f o r the a n a l y s i s o f q u a l i t a t i v e / c a t e g o r i c a l d a t a i t was n e c c e s s a r y t o c l a s s i f y w e l f a r e de-pendency r a t e s i n t o t h e f o l l o w i n g g r o u p s : - h i g h w e l f a r e dependency (19172 t o 26127); - medium (14509 to 17724); - low (6136 t o 14476) b) H e a l t h Care F a c t o r s As m e d i c a l p e r s o n n e l assume t h a t the r i s k s o f i n f a n t m o r t a l i t y a r e a s s o c i a t e d w i t h c e r t a i n h e a l t h c a r e f a c t o r s t h i s s t u d y has s e l e c t e d the f o l l o w i n g two v a r i a b l e s f o r a n a l y s i s : ( i ) P l a c e o f D e l i v e r y - T h i s b i n a r y v a r i a b l e was i n c l u d e d t o d e t e r m i n e t h e impact o f h o s p i t a l i z a t i o n and n o n - h o s p i t a l i z a t i o n on I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . As n o n - h o s p i t a l i z a t i o n may be i n d i c a t i v e o f a g e n e r a l l a c k o f any m e d i c a l c a r e i t i s a n t i c i -p a t e d t h a t i n c r e a s e d r i s k s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y w i l l be a s s o c i a t e d w i t h n o n - h o s p i t a l i z a t i o n . ( i i ) H e a l t h J u r i s d i c t i o n - T h i s v a r i a b l e was i n c l u d e d t o a s s e s s the e f f e c t o f d i f f e r e n t t y p e s o f p u b l i c h e a l t h s e r v i c e s on I n d i a n i n f a n t m o r t a l i t y . P r e s e n t l y , t h r e e l e v e l s o f government p r o v i d e p u b l i c h e a l t h s e r v i c e s t o s t a t u s I n d i a n s i n B r i t i s h C o lumbia. The f e d e r a l government p r o v i d e s s e r v i c e s t o s t a t u s I n d i a n s l i v i n g on 32 r e s e r v e s i n B r i t i s h Columbia. On the o t h e r hand, p r o v i n c i a l o r m u n i c i p a l h e a l t h u n i t s o f f e r p u b l i c h e a l t h programs t o I n d i a n s l i v i n g o f f r e s e r v a t i o n s and t o I n d i a n s l i v i n g on r e s e r v a t i o n s near urban c e n t e r s . W hile a l l l e v e l s o f government a r e r e -s p o n s i b l e f o r p r o v i d i n g i n f a n t i m m u n i z a t i o n and p r e n a t a l e d u c a t i o n t h e r e a r e c o n s i d e r a b l e d i f f e r e n c e s between h e a l t h j u r i s d i c t i o n s w i t h r e s p e c t t o o t h e r t y p e s o f p u b l i c h e a l t h s e r v i c e s . F o r example, m e d i c a l p e r s o n n e l employed by the f e d e r a l government m a i n t a i n c o n t a c t w i t h a l l p r e g n a n t women l i v i n g on r e s e r v e s . The p u b l i c ' h e a l t h n u r s e o r community h e a l t h r e p r e s e n t a t i v e v i s i t s t h e p r e g n a n t women a p p r o x i m a t e l y two tim e s a month. In a d d i t i o n , a l l newborn i n f a n t s a r e examined by e i t h e r the p u b l i c h e a l t h n u r s e o r community h e a l t h r e p r e s e n t a t i v e w i t h i n t h e f i r s t f o u r weeks o f b i r t h . A t r i s k i n f a n t s a r e i d e n t i f i e d and a r e examined a p p r o x i m a t e l y t w i c e a month. These p u b l i c h e a l t h s e r v i c e s o f f e r e d by the f e d e r a l government a r e n o t a v a i l a b l e t o I n d i a n women r e s i d i n g i n communities s e r v e d by p r o v i n c i a l o r m u n i c i p a l h e a l t h u n i t s . As t h e n a t u r e o f p u b l i c h e a l t h s e r v i c e s may have some b e a r i n g on t h e b i r t h outcome, two c a t e g o r i e s o f t h e v a r i a b l e h e a l t h j u r i s -d i c t i o n were examined: f e d e r a l j u r i s d i c t i o n and p r o v i n c i a l / m u n i c i p a l j u r i s d i c t i o n . A l t h o u g h no p r e v i o u s s t u d i e s have been u n d e r t a k e n t o a s s e s s t h e e f f e c t s o f t h i s v a r i a b l e , i t i s a n t i c i p a t e d t h a t t h e r i s k s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y w i l l be g r e a t e r i n a r e a s s e r v e d by p r o v i n c i a l / m u n i c i p a l governments. 3.2 Data S o u r c e s and Study P o p u l a t i o n Data f o r t h i s s t u d y was d e r i v e d from matched b i r t h and de a t h c e r t i f i c a t e . and i n f o r m a t i o n a c q u i r e d from t h e Department o f I n d i a n and N o r t h e r n A f f a i r s . . 33. The s t u d y p o p u l a t i o n c o n s i s t s o f a sample o f 889 I n d i a n s i n g l e l i v e b i r t h s r e c o r d e d i n B r i t i s h Columbia between the y e a r s 1974 t h r o u g h 1979. T h i s sample i n c l u d e s a l l i n f a n t s who d i e d w i t h i n t h e f i r s t y e a r o f l i f e and a randomly s e l e c t e d sample o f 614 I n d i a n i n f a n t s who s u r v i v e d t h e i r f i r s t a n n i v e r s a r y . The sample o f s u r v i v o r s r e p r e s e n t s a p p r o x i m a t e l y 10% o f t h e t o t a l p o p u l a t i o n o f s u r v i v o r s d u r i n g t h e s t u d y p e r i o d . Out o f the t o t a l o f 275 I n d i a n i n f a n t d e a t h s , 126 o f t h e s e i n f a n t s d i e d w i t h i n the f i r s t month and 149 d i e d between one month and one y e a r . The c h i e f c a u s e s o f d e a t h were sudden i n f a n t d eath syndrome, i n f l u e n z a and pneumonia, a c c i d e n t s , c o n g e n t i a l m a l f o r m a t i o n s and c e r t a i n r e s p i r a t o r y c o n d i t i o n s a s s o c i a t e d w i t h t h e d e l i v e r y . 3.3 A n a l y t i c a l T e c h n i q u e s To d e t e r m i n e t h e e m p i r i c a l r e l a t i o n s h i p between each s t u d y v a r i a b l e and I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y , t h i s s t u d y used m o d i f i e d m u l t i p l e r e g r e s s i o n models d e v e l o p e d l a r g e l y by Goodman ( 4 6 ) . Q u a n t i t a t i v e models o f the f o l l o w i n g form were used to s p e c i f y and e s t i m a t e t h e e f f e c t s o f each i n d e p e n d e n t v a r i a b l e on t h e r i s k s o f m o r t a l i t y . A B C E ( d e a t h r a t e i , j ... n) = y y- Yj y^ A = M a t e r n a l A g e / L i v e b i r t h O r der B = M a r i t a l S t a t u s C = P l a c e o f D e l i v e r y T h i s f o r m u l a s t a t e s the p r o b a b i l i t y o f d e a t h f o r c e l l i , j . . . n o f a n d i m e n s i o n a l c r o s s c l a s s i f i c a t i o n t a b l e can be w r i t t e n as a p r o d u c t o f y's. The i , j . . . n i n d i c e s r e f e r to l e v e l s o f c a t e g o r i e s o f the v a r i a b l e s , A,.B, and 34 Maximum l i k e l i h o o d e s t i m a t e s o f t h e y ' s f o r each i n d e p e n d e n t v a r i a b l e p r o v i d e an e s t i m a t e o f the p r o b a b i l i t y o f d e a t h a s s o c i a t e d w i t h b e i n g i n a p a r t i c u l a r c a t e g o r y o f a v a r i a b l e . F o r example an odds r a t i o f o r the r i s k f a c t o r " s i n g l e " can be i n t e r p r e t e d t o mean t h a t i f a l l o t h e r f a c t o r s a r e the same t h e p r o b a b i l i t y o f d e a t h w i l l be a p p r o x i m a t e l y two ti m e s g r e a t e r f o r i n f a n t s born t o s i n g l e women. While i t would have been i d e a l t o examine t h e i n d e p e n d e n t e f f e c t s o f a l l t h e s e v a r i a b l e s on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y s i m u l t a n e o u s l y , due t o the s m a l l sample s i z e s t a t i s t i c a l t e s t s were per f o r m e d on m u l t i d i m e n -s i o n a l t a b l e s c o n t a i n i n g no more than t h r e e i n d e p e n d e n t v a r i a b l e s . In a d d i t i o n , a c o n s t a n t ( D e l t a ) o f .05 was added i n each c e l l i n the v a r i o u s m u l t i d i m e n t i o n a l t a b l e s . As some c e l l s c o n t a i n e d z e r o f r e q u e n c y c o u n t s t h e e x p e c t e d v a l u e s i n many c e l l s would be z e r o . When the f i t t e d o r e x p e c t e d v a l u e s a r e z e r o the c h i s q u a r e o r l i k e l i h o o d s t a t i s t i c i s c o r r e c t l y computed but the deg r e e s o f freedom a r e overestimated..^ & y v a d d i n g l a c o n s t a n t t o each t h e s e s t a t i s t i c a l problems a r e a v o i d e d . To i d e n t i f y t h o s e v a r i a b l e s which were n o t s i g n i f i c a n t l y r e l a t e d t o th e b i r t h outcome, t e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n were used i n i t i a l l y t o a n a l y z e s e v e r a l d i f f e r e n t m u l t i d i m e n s i o n a l t a b l e s . These t e s t s use l i k e l i h o o d r a t i o s t a t i s t i c s t o measure the agreement between the o b s e r v e d f r e q u e n c y ( f ) i n a c o n t i n g e n c y t a b l e and the c o r r e s p o n d i n g e s t i m a t e d n o f the e x p e c t e d f r e q u e n c y . As t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n i n d i c a t e d t h a t o n l y one v a r i a b l e was s i g n i f i c a n t l y r e l a t e d t o the b i r t h outcome, v a r i o u s l o g - l i n e a r r e g r e s s i o n models were c o n s t r u c t e d t o e s t i m a t e t he e f f e c t s o f t h i s v a r i a b l e on I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . The r e s u l t s o f a s e r i e s o f r e g r e s s i o n s and t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n a r e o u t l i n e d i n the f o l l o w i n g c h a p t e r . 35 CHAPTER FOUR DISCUSSION OF RESULTS 4.1 T e s t s Of M a r g i n a l And P a r t i a l A s s o c i a t i o n The f o l l o w i n g m u l t i d i m e n s i o n a l c o n t i n g e n c y t a b l e s were a n a l y z e d : 1. T a b l e 5. B i r t h Outcome by M a t e r n a l A g e / L i v e b i r t h O r d e r , M a r i t a l S t a t u s and P l a c e o f D e l i v e r y 2. • T a b l e 6. B i r t h Outcome by H e a l t h J u r i s d i c t i o n , Region and W e l f a r e Dependency. T h i s s t u d y began by p e r f o r m i n g t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n on d a t a i n T a b l e 5. The r e s u l t s o f t h e s e t e s t s p r e s e n t e d i n T a b l e 7 show t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between the b i r t h outcome and t he p l a c e o f d e l i v e r y . The p r o b a b i l i t y v a l u e s f o r OP ('.Outcome, P l a c e o f D e l i v e r y ) were .05 f o r t e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n . On the o t h e r hand, the p r o b a b i l i t y v a l u e s f o r t e s t s o f a s s o c i a t i o n between B i r t h Outcome and M a r i t a l S t a t u s and B i r t h Outcome and M a t e r n a l A g e / L i v e b i r t h O rder exceeded the .05 l e v e l o f s i g n i f i c a n c e . The r e s u l t s o f t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n p erformed on d a t a i n T a b l e 6 r e v e a l t h a t none o f the i n d e p e n d e n t v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d t o B i r t h Outcome. The p r o b a b i l i t y v a l u e s f o r OE (Outcome, R e g i o n ) , OR (Outcome, H e a l t h J u r i s d i c t i o n ) , and OW (Outcome, W e l f a r e and Dependency) were r e s p e c t i v e l y .38, .38 and .91 f o r t e s t s o f p a r t i a l a s s o c i a t i o n . To a s s e s s t h e s i g n i f i c a n c e o f P l a c e o f D e l i v e r y on B i r t h Outcome when i t i s combined w i t h o t h e r f a c t o r s , t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n were p e r f o r m e d by a n a l y z i n g d a t a i n T a b l e s 9 and 10. The f i n d i n g s o f t h e s e t e s t s o u t l i n e d i n T a b l e s 11 and 12 i n d i c a t e t h a t t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between P l a c e o f D e l i v e r y and B i r t h Outcome. TABLE 5. BIRTH OUTCOME BY PLACE OF DELIVERY, MATERNAL AGE/LIVEBIRTH ORDER AND MARITAL STATUS . for ana lys is 0.5 i s added to each c e l l Place of Del ivery OTHER HOSPITAL Maternal Age/Live B i r th Order 18 yrs and under: one or more b i r ths 19-24 y r s : 3 or fewer b i r ths 19-24 y r s : 4 or more b i r ths 25-34 y r s : 4 of fewer b i r ths 25-34 y r s : 5 or more b i r ths 35 yrs and over: one or more b i r ths 18 y r s . and under: one or more b i r ths 19-24 y r s : 3 or fewer b i r ths 19-24 y r s : 4 or more b i r ths 25-34 y r s : 4 or fewer b i r ths 25-34 y r s : 5 or more b i r ths 35 yrs or over: one or more b i r ths Mari ta l Status Single Married Single Married Single Married Single Married Single Married Single Married Single Married Single Married Single Married Single Married Single Married Single Married BIRTH OUTCOME Neonatal 23 31 17 12 Postneonatal 33 44 14 14 Surv ival 130 16 173 15 16 42 55 18 24 11 TABLE 6. BIRTH,.OUTCOME BY WELFARE DEPENDENCY HEALTH JURISDICTION AND REGION 3/ WELFARE DEPENDENCY HEALTH REGION B l R l H OUICOME Neonatal P o s t n e o n a t a l S u r v i v a l low F e d e r a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l 3 0 5 11 3 2 3 0 6 7 6 3 4 0 36 53 33 10 P r o v i n c i a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l 1 0 5 10 4 2 . 7 0 5 6 8 3 6 1 23 35 22 5 medium F e d e r a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l 0 0 3 3 4 7 0 0 4 6 7 4 0 0 23 23 49 32 P r o v i n c i a l Nanaimo Vancouver C e n t r a l N o r t h E a s t North West C o a s t a l 0 0 4 6 8 1 1 0 2 6 8 1 1 0 20 10 31 18 h i g h F e d e r a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l 9 6 0 1 1 3 9 7 0 2 5 1 39 14 0 1 9 4 P r o v i n c i a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l 12 9 0 1 1 1 22 7 0 2 2 0 49 50 0 5 5 2 f o r a n a l y s i s 0.5 i s added t o each c e l l TABLE 7. TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS PERTAINING TO TABLE 5 MODEL EFFECT., ( d i f f e r e n c e due t o ) D.F. PARTIAL A SSOCIATION MARGINAL ASSOCIATION L i k e l i h o o d r a t i o c h i square P r o b a b i l i t y L i k e l i h o o d r a t i o c h i square P r o b a b i l i t y M, OC, OP OM 2 1.17 0.5562 0.59 0.7457 C, OM, OC OC 10 5.39 0.8636 5.17 0.8798 P, OM, OC OP 2 5.84 0.0539 6.40 0.0407 C, MO, MP MC 5 116.62 0.0 115.16 0.0 P, MO, MC MP 1 1.06 0.3033 0.38 0.5376 P, CO, CM CP 5 10.39 0.0649 10.08 . 0.0730 0 - Outcome M - M a r i t a l S t a t u s P - P l a c e o f D e l i v e r y C - M a t e r n a l A g e / L i v e b i r t h Order Second O r d e r Model i s : M, 0, C, P, OM, OC, OP, MC, MP, CP. TABLE 8. TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS PERTAINING TO TABLE 6 EFFECT PARTIAL ASSOCIATION MARGINAL ASSOCIATION MODEL ( d i f f e r e n c e due t o ) D.F. L i k e l i h o o d r a t i o c h i square P r o b a b i l i t y L i k e l i h o o d r a t i o c h i square P r o b a b i l i t y E, OW, OR OE 10 10.73 0.3789 15.76 0.1067 R, OE, OW ' OR 2 1.91 0.3842 3.06 0.2170 W, OR, OE OW 4 0.97 0.9144 5.95 0.2031 R, EW, EO ER 5 17.68 0.0034 40.26 0.0 W, ER, EO EW 10 618.26 0.0 644.68 0.0 W, RO, RE RW 2 0.15 0.9299 22.68 0.0 0 - Outcome E - Region R - H e a l t h J u r i s d i c t i o n W - W e l f a r e Dependency Second O r d e r Model i s : 0, E, R, W, OE, OR, OW, RE, RW, EW As the r e s u l t s o f t h e s e t e s t s i n d i c a t e t h a t P l a c e o f D e l i v e r y was the o n l y v a r i a b l e s i g n i f i c a n t l y r e l a t e d t o B i r t h Outcome, r e g r e s s i o n models were c o n s t r u c t e d t o d e t e r m i n e the e f f e c t s o f n o n - h o s p i t a l i z a t i o n and h o s p i t -a l i z a t i o n on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . Two t y p e s o f models were e s t i -mated.. . In the f i r s t c a s e , l o g - l i n e a r r e g r e s s i o n s models were used to e s t i -mate the e f f e c t s o f P l a c e o f D e l i v e r y on n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y , w h i l e c o n t r o l l i n g f o r the e f f e c t s o f o t h e r v a r i a b l e s . Due t o the s m a l l sample s i z e , r e g r e s s i o n e q u a t i o n s were s t r u c t u r e d so t h a t each dependent f u n c t i o n c o n t a i n e d o n l y t h r e e i n d e p e n d e n t v a r i a b l e s . In the second c a s e , a l l non-s i g n i f i c a n t v a r i a b l e s were e x c l u d e d and r e g r e s s i o n a n a l y s i s was performed by a n a l y z i n g a 2 x 2 c o n t i n g e n c y t a b l e . 4.2 R e g r e s s i o n R e s u l t s T a b l e s 13 t h r o u g h 15 summarize the r e g r e s s i o n r e s u l t s d e r i v e d by a n a l y z i n g t h r e e m u ltiway c o n t i n g e n c y t a b l e s . E s t i m a t e s o f the l o g - l i n e a r p a r a m e t e r s p r e s e n t e d i n T a b l e 13 d e m o n s t r a t e t h a t n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y was p o s i t i v e l y a s s o c i a t e d w i t h i n f a n t s who were not born i n h o s p i t a l s . W h ile the s i g n s o f the c o e f f i c i e n t s a l s o s u g g e s t t h a t i n c r e a s e d r i s k s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y a r e a l s o a s s o c i a t e d w i t h c e r t a i n c a t e g o r i e s o f the v a r i a b l e s , M a r i t a l S t a t u s , and M a t e r n a l A g e / L i v e b i r t h O r d e r , t h e s e e f f e c t s were not s t a t i s t i c a l l y s i g n i f i c a n t a t the .05 l e v e l . When r e g r e s s i o n a n a l y s i s was performed t o d e t e r m i n e the e f f e c t s o f P l a c e o f D e l i v e r y , Region and W e l f a r e Dependency on I n d i a n n e o n a t a l and p o s t -n e o n a t a l m o r t a l i t y , the r e s u l t s d e m o n s t r a t e d , once a g a i n , t h a t n o n - h o s p i t a l i z a t i o n was p o s i t i v e l y a s s o c i a t e d w i t h n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . The f i n d i n g s summarized i n T a b l e 15 a l s o r e v e a l t h a t n e o n a t a l m o r t a l i t y was p o s i t i v e l y a s s o c i a t e d w i t h the N orth E a s t , C o a s t a l and Vancouver Regions and t h a t i n c r e a s e d r i s k s o f p o s t n e o n a t a l m o r t a l i t y were a s s o c i a t e d w i t h Nanaimo and N o r t h West TABLE 9. BIRTH OUTCOME BY PLACE OF DELIVERY, WELFARE DEPENDENCY AND REGION 41 P l a c e o f D e l i v e r y W e l f a r e Dependency Region B i r t h Outcome Neonatal P o s t n e o n a t a l S u r v i v a l Other Low Medium High H o s p i t a l Low Medium High Nanaimo Vancouver C e n t r a l N o rth E a s t N o rth West C o a s t a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o r t h West C o a s t a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o rth West C o a s t a l Nanaimo Vancouver C e n t r a l N o rth E a s t N o r t h West C o a s t a l Nanaimo Vancouver C e n t r a l N o r t h E a s t N o rth West C o a s t a l Nanaimo Vancouver C e n t r a l N o rth E a s t N o r t h West C o a s t a l 0 0 0 2 0 0 0 0 0 1 0 1 0 0' 0 1 0 0 4 0 10 19 7 4 0 0 7 8 12 7 21 14 0 1 2 4 0 0 0 4 0 1 0 0 0 0 1 0 0 2 0 0 0 0 9 0 11 9 14 5 1 0 6 12 14 5 31 12 0 4 7 T 0 0 2 6 3 0 0 0 1 2 2 2 1 2 0 0 0 0 10 1 57 82 52 15 1 0 42 31 78 48 87 62 0 6 14 6 For a n a l y s i s 0.50 i s added t o each c e l l above TABLE 10. BIRTH OUTCOME BY PLACE OF DELIVERY, HEALTH JURISDICTION AND REGION B i r t h Outcome D I a s+ r\ /-\ -f D s\ rt -I f\tn r l a C e OT nea itn Kegion D e l i v e r y J u r i s d i c t i o n N eonatal P o s t n e o n a t a l S u r v i v a l O t h e r F e d e r a l Nanaimo 0 0 1 Vancouver 0 2 0 C e n t r a l 0 0 2 North E a s t 3 4 7 North West 0 1 4 C o a s t a l 1 0 1 P r o v i n c i a l Nanaimo 0 0 0 Vancouver 0 0 2 C e n t r a l 0 0 1 No r t h E a s t 1 0 1 N o r t h West 0 0 1 C o a s t a l 0 1 1 H o s p i t a l F e d e r a l Nanaimo 12 12 42 Vancouver 6 5 14 C e n t r a l 8 10 57 North E a s t 12 11 70 North. West 8 17 87 C o a s t a l 11 8 45 P r o v i n c i a l Nanaimo 13 29 56 Vancouver 8 7 49 C e n t r a l 9 7 42 N o r t h E a s t 16 14 49 No r t h West 13 18 57 C o a s t a l 4 3 24 Fo r a n a l y s i s 0.50 i s added t o each c e l l above TABLE 11. TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS PERTAINING TO TABLE 9 EFFECT PARTIAL ASSOCIATION MARGINAL ASSOCIATION MODEL ( d i f f e r e n c e due t o ) D.F. L i k e l i h o o d r a t i o c h i squa r e P r o b a b i l i t y L i k e l i h o o d r a t i o c h i squa r e P r o b a b i l i t y E, OW, OP OE 10 10.22 0.4216 14.81 0.1390 W, OE, OP OW 4 1.06 0.9010 5.83 0.2124 P, ow, OE OP 2 9.60 0.0082 8.90 0.0117 E, WO, WP EW 10 637.78 0.0000 644.28 0.000 E, PO, PW EP 5 9.40 0.9042 10.41 0.0643 W, PO, PE WP 2 0.84 0.6573 2.03 0.3622 0 - Outcome E - Region P - P l a c e o f D e l i v e r y W - W e l f a r e Dependency Second O r d e r Model i s 0, E, W, P, OE, OW, OP, EW, EP, WP. TABLE 12. TESTS OF MARGINAL AND PARTIAL ASSOCIATION FOR SOME MODELS PERTAINING TO TABLE 10 EFFECT ( d i f f e r e n c e due t o ) PARTIAL ASSOCIATION MARGINAL ASSOCIATION MODEL D.F. L i k e l i h o o d r a t i o c h i squa r e P r o b a b i l i t y L i k e l i h o o d r a t i o c h i sq u a r e P r o b a b i l i t y E, OP, OR OE 10 14.78 0.1401 15.31 0.1212 R, OP, OE OR 2 2.35 0.3094 2.78 0.2491 P, OE, OR OP 2 7.17 0.0278 5.97 0.0506 P, EO, EP ER 5 38.50 0.0000 40.15 0.0000 P, EO, ER EP 5 11.61 0.0405 11.63 0.0402 P, RO, RE RP 1 5.44 0.0197 5.37 0.0205 0 - B i r t h Outcome E - Region R - H e a l t h J u r i s d i c t i o n P - P l a c e o f D e l i v e r y Second O r d e r Model i s 0, E, R, P, OE, 0, R, OP, ER, EP, RP. TABLE 13. ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS PERTAINING TO TABLE 5 BIRTH OUTCOME P l a c e o f il ." Neonatal P o s t n e o n a t a l S u r v i v a l D e l i v e r y H o s p i t a l - .109* - .135* + .244* O t h e r + .109* + .135* - .244* M a r i t a l M a r r i e d _ .039 + .004 + .036 S t a t u s S i n g l e + .039 — .004 — .036 M a t e r n a l 18: 1 + .169 + .125 + .044 A g e / L i v e 19-24: 3 - .052 - .036 + .088 B i r t h 19-24: 4 + .085 - .037 - .048 Roder 25-34: 4 + .014 - .109 + .095 25-34: 5 - .055 + .228 - .173 35+ : 1+ + .176 — .170 — .006 * s i g n i f i c a n t a t .05 l e v e l TABLE 14. ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS PERTAINING TO TABLE 9 BIRTH OUTCOME Neonatal P o s t n e o n a t a l S u r v i v a l P l a c e o f D e l i v e r y H o s p i t a l .122* .144* + .266* O t h e r + .122* + .144* — .166* Region Nanaimo - .056 + .294 - .239 Vancouver + .064 - .038 - .026 C e n t r a l - .027 - .129 - .156 North E a s t + .118 - .073 - .045 North West - .251 + .132 + .119 C o a s t a l + .151 .187 .035 Wei f a r e Dependency low + .001 - .022 + .021 Medium - .020 - .100 + .120 -h i g h + .019 + .122 .141 * s i g n i f i c a n t a t .01 l e v e l TABLE 15: ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR SOME MODELS PERTAINING TO TABLE 10 BIRTH OUTCOME Neonatal P o s t n e o n a t a l S u r v i v a l P l a c e o f H o s p i t a l . 095* . 139* + .234* D e l i v e r y O t h e r + .095* + . 139* + .234* Region Nanaimo - .057 + .305 — .248 Vancouver + .061 — .043 .018 C e n t r a l - .028 - .132 + .161 North E a s t + .125 - .072 - .053 N o r t h West + .256 + .142 + .114 C o a s t a l + .155 — .200 + .044 H e a l t h F e d e r a l .021 .055 + .076 J u r i s d i c - P r o v i n c i a l / t i o n M u n i c i p a l + .021 + .055 — .076 \ * s i g n i f i c a n t a t .05 l e v e l r 48. r e g i o n and w i t h W e l f a r e Dependency, HIGH. The e f f e c t o f Region and W e l f a r e Dependency were however not s a t i s t i c a l l y s i g n i f i c a n t . T a b l e 15 o u t l i n e s the r e g r e s s i o n r e s u l t s p e r f o r m e d by a n a l y z i n g d a t a i n T a b l e 10. These f i n d i n g s r e v e a l t h a t the e s t i m a t e s f o r the e f f e c t s OP (Outcome, P l a c e o f D e l i v e r y ) and OE (Outcome, Region) were s i m i l a r i n s i g n t o .the r e s u l t s p r e v i o u s l y o b t a i n e d . F u r t h e r m o r e , w h i l e t h e r e was n o t a s t a t i s t i c a l l y s i g n i f i c a n t r e l a t i o n s h i p between H e a l t h J u r i s d i c t i o n and B i r t h Outcome t h e r e s u l t s do i n d i c a t e t h a t i n c r e a s e d r i s k s o f n e o n a t a l and p o s t -n e o n a t a l m o r t a l i t y were a s s o c i a t e d w i t h i n f a n t s born i n a r e a s s e r v e d by m u n i c i p a l governments o r the P r o v i n c e as opposed t o the f e d e r a l government. A l t h o u g h t h e r e s u l t s o f t h e s e r e g r e s s i o n models s u g g e s t t h a t non-h o s p i t a l i z a t i o n i s p o s i t i v e l y and s i g n i f i c a n t l y r e l a t e d t o n e o n a t a l and p o s t -n e o n a t a l m o r t a l i t y , when n o n - s i g n i f i c a n t v a r i a b l e s were e l i m i n a t e d from the a n a l y s i s the r e g r e s s i o n r e s u l t s r e v e a l t h a t t h e e f f e c t OP (Outcome, P l a c e o f D e l i v e r y ) was n o t s a t i s t i c a l l y s i g n i f i c a n t . In a d d i t i o n the f i n d i n g s p r e s e n t e d i n T a b l e 17 i n d i c a t e t h a t h o s p i t a l i z a t i o n i s p o s i t i v e l y a s s o c i a t e d w i t h n e o n a t a l m o r t a l i t y . I t a p p e a r s , t h e n , t h a t the v a r i a b l e , P l a c e o f D e l i v e r y , i s o n l y s i g n i f i -c a n t l y r e l a t e d t o B i r t h Outcome when i t i s examined i n c o n j u n c t i o n w i t h o t h e r n o n - s i g n i f i c a n t v a r i a b l e s . As r e g r e s s i o n a n a l y s i s was p e r f o r m e d p r e v i o u s l y on m u l t i d i m e n s i o n a l c o n t i n g e n c y t a b l e s w i t h v e r y s m a l l c e l l f r e q u e n c y c o u n t s , one can p l a c e g r e a t e r c o n f i d e n c e i n t h e r e s u l t s o f t h e f i n a l r e g r e s s i o n model. In summary t h e h y p o t h e s i s t h a t i n c r e a s e d r i s k s o f m o r t a l i t y would be a s s o c i a t e d w i t h n o n - h o s p i t a l i z a t i o n was n o t s u p p o r t e d . 4.3 S h o r t c o m i n g s Of The A n a l y s i s T h i s s e c t i o n c o n s i d e r s the e x t e n t t o which m e t h o d o l o g i c a l o r c o n c e p t u a l weaknesses i n t h i s s t u d y may have c o n t r i b u t e d t o the r e s u l t s o b t a i n e d . We b e g i n by f i r s t c o n s i d e r i n g two p o s s i b l e s o u r c e s o f e r r o r which may have TABLE 16. BIRTH OUTCOME BY PLACE OF DELIVERY PLACE OF DELIVERY BIRTH. OUTCOME Neonatal Postneonata1 S u r v i v a l O t h e r 5 8 21 H o s p i t a l 120 141 592 TABLE 17. ESTIMATES OF LOG-LINEAR PARAMETERS (LAMBDA) FOR A MODEL PERTAINING TO TABLE 16 E s t i m a t e s o f L o g - L i n e a r Parameters BIRTH OUTCOME Neonatal P o s t n e o n a t a l S u r v i v a l P l a c e Of D e l i v e r y H o s p i t a l + .008 - .130 + .122 Ot h e r - .008 + .130 - .122 5( a f f e c t e d the o v e r a l l r e s u l t s o f t e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n . T h i s s e c t i o n t h e n examines each o f t h e i n d e p e n d e n t v a r i a b l e s t h e p o s s i b l e e f f e c t s o f d a t a and m e t h o d o l o g i c a l c o n s t r a i n t s on the s t u d y f i n d i n g s . The r e s u l t s o f t e s t s o f m a r g i n a l and p a r t i a l a s s o c i a t i o n i n d i c a t e d t h a t o n l y one v a r i a b l e was s i g n i f i c a n t l y r e l a t e d t o B i r t h Outcome. The s i z e o f the o b s e r v e d c e l l f r e q u e n c y c o u n t s may have had a s e r i o u s e f f e c t on t h e s e r e s u l t s . T e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n use e i t h e r the P e a r s o n ' s g o o d n e s s - o f - f i t c h i s q u a r e s t a t i s t i c x 2 = E i j k 1 ( f i j k 1 - F i j k I ) 2 F i j k 1 f = o b s e r v e d f r e q u e n c y F = e x p e c t e d f r e q u e n c y o r the l i k e l i h o o d r a t i o s t a t i s t i c . G 2 = 2 E i j k l f 1 J k 1 l n ( f i j k 1/ f i j k 1) The s i z e o f the c h i s q u a r e v a l u e i s i n f l u e n c e d by both the magnitude o f d i f f e r e n c e s between t h e o b s e r v e d and e x p e c t e d f r e q u e n c i e s and the number o f o b s e r v a t i o n s i n a p a r t i c u l a r c e l l . I f t h e o b s e r v e d v a l u e s i n many c e l l s a r e sm a l l then t h e c h i s q u a r e v a l u e s w i l l a l s o be s m a l l . Under t h e s e c i r c u m s t a n c e s i t i s more d i f f i c u l t t o d e m o n s t r a t e 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 v a r i a b l e s . As t e s t s o f p a r t i a l and m a r g i n a l a s s o c i a t i o n were performed by a n a l y z i n g m u l t i w a y f r e q u e n c y t a b l e s c o n t a i n i n g c e l l s w i t h s m a l l f r e q u e n c y c o u n t s we c o u l d c o n c l u d e t h a t t h i s f a c t o r may have i n f l u e n c e d t h e r e s u l t s o f t h e s e t e s t s . To e l i m i n a t e t h e s e problems, independence t e s t s were performed on a s e r i e s o f 2 x 2 c o n t i n g e n c y t a b l e s . The r e s u l t s p r e s e n t e d i n T a b l e 18 r e v e a l t h a t i n c r e a s i n g t h e o b s e r v e d c e l l f r e q u e n c y c o u n t s had no impact on t h e r e s u l t s . None o f the i n d e p e n d e n t v a r i a b l e s were s i g n i f i c a n t l y r e l a t e d t o B i r t h Outcome ,51 TABLE 18. CHI SQUARE VALUES DERIVED FROM THE ANALYSIS OF 2 x 2 CONTINGENCY TABLES 2 x 2 C o n t i n g e n c y T a b l e Chi Square V a l u e P r o b a b i l i t y V a l u e n d f = 887 2 B i r t h Outcome by P l a c e o f D e l i v e r y 1.239 .5382 n d f = 878 10 B i r t h Outcome by M a t e r n a l A g e / L i v e b i r t h O r d er 4.847 .9012 n d f = 889 2 B i r t h Outcome by M a r i t a l S t a t u s 1.769 .4129 n d f = 889 B i r t h Outcome by H e a l t h J u r i s d i c t i o n 3.177 .2043 n d f = 889 10 B i r t h Outcome by Region 17.890 .0568 n d f = 889 4 B i r t h Outcome by W e l f a r e Dependency 6.474 .1664 a t t h e .05 l e v e l of s i g n i f i c a n c e . The c h i s q u a r e v a l u e d e r i v e d from t h e a n a l y s i s o f the 2 x 2 c o n t i n g e n c y t a b l e s B i r t h Outcome by Region was, however, s i g n i f i c a n t a t the .06 l e v e l . As t h e s i z e of t h e o b s e r v e d c e l l f r e q u e n c y c a n n o t a c c o u n t f o r t h e s e r e s u l t s then one c o u l d assume t h a t e r r o r s i n s a m p l i n g may p o s s i b l y have a f f e c t e d t h e s e r e s u l t s . To a s s e s s t h e e f f e c t s o f t h e in d e p e n d e n t v a r i a b l e s on In d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y a random sample o f s u r v i v o r s was ' s e l e c t e d d u r i n g the s t u d y p e r i o d . I f the c h a r a c t e r i s t i c s of the sample of s u r v i v o r s were n o t r e p r e s e n t a t i v e o f the t o t a l p o p u l a t i o n o f s u r v i v o r s then t h i s c o u l d s e r i o u s l y a f f e c t t h e r e s u l t s of t h e s e t e s t s . As i t i s n o t p o s s i b l e t o o b t a i n s t a t i s t i c s on the t o t a l p o p u l a t i o n i t i s d i f f i c u l t t o do more than s p e c u l a t e on t h e degree o f e r r o r which may have been i n t r o d u c e d here. While e r r o r s i n sa m p l i n g may p r o v i d e one e x p l a n a t i o n f o r t h e s e d i s a p p o i n -t i n g r e s u l t s , o t h e r f a c t o r s may a l s o have a f f e c t e d t h e r e s u l t s of t e s t s of p a r t i a l and m a r g i n a l a s s o c i a t i o n . Next we c o n s i d e r t h e e x t e n t t o which con-c e p t u a l o r m e t h o d o l o g i c a l weaknesses i n the i n d e p e n d e n t v a r i a b l e s may a c c o u n t f o r t h e l a c k o f 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 B i r t h Outcome and each i n d e p e n d e n t v a r i a b l e . F i r s t l y , t h e a b i l i t y t o a d e q u a t e l y measure t he c o n c e p t u a l e x p l a n a t i o n s o r hypotheses was s e v e r e l y hampered by d a t a i n a d e q u a c i e s . F o r example, t he v a r i a b l e , M a r i t a l S t a t u s , was used t o p r o v i d e a p r o x y measure of d i f f e r e n t s o c i o - e c o n o m i c c h a r a c t e r i s t i c s of the mother. I t was assumed t h a t t h e r i s k s of m o r t a l i t y would be g r e a t e r f o r i n f a n t s born t o s i n g l e women as t h e s e women may be more r e l u c t a n t t o o b t a i n p r e n a t a l c a r e and t h e y may l a c k s o c i a l and economic s u p p o r t n e c e s s a r y f o r c h i l d r e a r i n g . As i t was n o t p o s s i b l e t o d i f f e r e n t i a t e between s i n g l e I n d i a n women and women l i v i n g i n common law, o r i d e n t i f y t h o s e s i n g l e women who r e c e i v e s o c i a l and economic s u p p o r t from t h e i r extended f a m i l y , t h i s s t u d y was u n a b l e t o a d e q u a t e l y measure t he e f f e c t s o f l a c k of s o c i a l and economic s u p p o r t on I n d i a n i n f a n t m o r t a l i t y . F u r t h e r m o r e , w h i l e p a s t s t u d i e s have d e m o n s t r a t e d t h a t i n a d e q u a t e p r e n a t a l c a r e i s a s s o c i a t e d w i t h s i n g l e women, t h e s e a s s u m p t i o n s may n o t be t r u e f o r the I n d i a n p o p u l a t i o n . Measurement problems may a l s o a c c o u n t f o r t h e l a c k o f 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 B i r t h Outcome and W e l f a r e Dependency. As s o c i a l w e l -f a r e s t a t i s t i c s were o n l y a v a i l a b l e f o r the on r e s e r v e p o p u l a t i o n i t was n e c e s s a r y t o use t h e s e r a t e s t o d e s c r i b e t h e e n t i r e on and o f f - r e s e r v e p o p u l a t i o n i n an a r e a . W hile a s u r v e y by t h e B.C. Department o f Human Resources i n 1967 dem o n s t r a t e d t h a t the i n c i d e n c e o f w e l f a r e dependency was as g r e a t amongst t h o s e l i v i n g o f f r e s e r v a t i o n s t h e s e f i n d i n g s may not be v a l i d t o d a y . I f w e l f a r e dependency r a t e s a r e c o n s i d e r a b l y d i f f e r e n t f o r t h e s e p o p u l a t i o n s , then t h e use o f t h i s d a t a may have had an impact on t h e st u d y f i n d i n g s . In a d d i t i o n , i t c o u l d a l s o be argued t h a t t h e u n i t o f a n a l y s i s was t o o l a r g e . I t may be t h a t i n d i v i d u a l economic c h a r a c t e r i s t i c s o f t h e f a m i l y a r e more i m p o r t a n t d e t e r m i n a n t s o f I n d i a n i n f a n t m o r t a l i t y . W h ile measurement problems may a c c o u n t f o r t h e r e s u l t s o f some s t a t i s -t i c a l t e s t s , o t h e r m e t h o d o l o g i c a l weaknesses i n t h i s s t u d y may e x p l a i n t h e l a c k o f 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 M a t e r n a l A g e / L i v e b i r t h O r d e r and the B i r t h Outcome. F i r s t l y , t h e s i z e o f t h e sample a f f e c t e d t h e number o f c a t e g o r i e s which c o u l d be examined. In a d d i t i o n , w h i l e i t may have been p r e f e r a b l e t o examine t h e e f f e c t s o f c h i l d s p a c i n g on I n d i a n i n f a n t m o r t a l i t y t h i s d a t a was n o t a v a i l a b l e on b i r t h and d e a t h c e r t i f i c a t e s . M e t h o d o l o g i c a l weakness may a l s o e x p l a i n t h e r e s u l t s o f s i g n i f i c a n c e t e s t s f o r t h e e f f e c t OR (Outcome, H e a l t h J u r i s d i c t i o n ) . The v a r i a b l e H e a l t h J u r i s d i c t i o n was s e l e c t e d t o d e t e r m i n e t he a f f e c t s o f d i f f e r e n t t y p e s o f p u b l i c h e a l t h s e r v i c e s on I n d i a n n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y . As the f e d e r a l government o f f e r s programs t o m o n i t o r t he normal and h i g h r i s : k p r e g n a n c i e s , i t "was e x p e c t e d t h a t - t h e " f i s k s ' f o f i n f a n t m o r t a l i t y would b e n e g a t i v e l y a s s o e i a t e d w i t h a r e a s under f e d e r a l h e a l t h j u r i s d i c t i o n . A l t h o u g h d a t a i n T a b l e 15 i n d i c a t e d t h a t n e o n a t a l , and p o s t n e o n a t a l m o r t a l i t y was n e g a t i v e l y a s s o c i a t e d w i t h FEDERAL t h e s e e f f e c t s were n o t s t a t i s t i c a l l y s i g n i f i c a n t . One p o s s i b l e e x p l a n a t i o n f o r t h e s e r e s u l t s c o u l d be t h a t the v a r i a b l e H e a l t h J u r i s d i c -t i o n i s a l s o i n d i c a t i v e o f o t h e r h e a l t h c a r e f a c t o r s . In p a r t i c u l a r t h i s v a r i a b l e may p r o v i d e a measure o f a c c e s s t o h e a l t h c a r e . As a r e a s under p r o v i n c i a l / m u n i c i p a l j u r i s d i c t i o n a r e l o c a t e d near urban c e n t e r s one c o u l d c o n c l u d e t h a t I n d i a n s r e s i d i n g i n t h e s e a r e a s may have b e t t e r a c c e s s t o m e d i c a l c a r e . I f a c c e s s t o m e d i c a l c a r e has an impact on the r i s k s o f i n f a n t m o r t a l i t y , t h e n t h e s e e f f e c t s may compensate f o r t h e d i f f e r e n c e s i n p u b l i c h e a l t h s e r v i c e s p r o v i d e d by v a r i o u s l e v e l s o f government. 4.4 C o n c l u s i o n s The p r e c e d i n g s e c t i o n d i s c u s s e d s p e c i f i c s h o r t c o m i n g s i n the d a t a and t h e methodology. T h i s s e c t i o n o u t l i n e s the purpose and some g e n e r a l l i m i t a t i o n s o f s t a t i s t i c a l models f o r problem s o l v i n g and then s u g g e s t s o t h e r approaches which c o u l d be adopted f o r f u t u r e s t u d i e s on I n d i a n i n f a n t m o r t a l i t y o r m o r b i d i t y . To d e t e r m i n e how t o a l t e r a system towards a more d e s i r a b l e s t a t e , we d e v e l o p t h e o r i e s which d e s c r i b e t h e h y p o t h e s i z e d r e l a t i o n s h i p between t h e phenomenon and o t h e r f a c t o r s . S t a t i s t i c a l models a r e then used as a means f o r e s t a b l i s h i n g a p r e c i s e r e l a t i o n s h i p between the phenomenon and v a r i o u s components o r f a c t o r s . The purpose o f a model i s t o s i m p l i f y a system so t h a t one can comprehend and d e a l w i t h i t . Out o f an i n f i n i t e number o f r e l a t i o n s h i p s which e x i s t i n the r e a l w o r l d we s e l e c t o n l y a few f a c t o r s f o r s t u d y . Models a r e t h u s c l o s e d systems as t h e y i n c l u d e o n l y a few o f the many f a c t o r s and c o n n e c t i o n s which e x i s t i n the r e a l w o r l d s . One o f t h e major weaknesses i n t h e c a s e o f models i s t h a t t h e y r e d u c e a system o f complex i n t e r r e l a t i o n s h i p s t o s i m p l e v a r i a b l e s which do not a l l o w an u n d e r s t a n d i n g o f a l l t h e d i m e n s i o n s o f a p a r t i c u l a r phenomenon i n i t s t o t a l i t y . F u r t h e r m o r e , t h e r e i s a t e n d e n c y t o r e l y s o l e l y on the r e s u l t s o f the s t a t i s t i c a l a n a l y s i s f o r f o r m u l a t i n g i n t e r v e n t i o n s t r a t e g i e s . For example, the f i n d i n g s o f one r e c e n t s t u d y i n d i c a t e d t h a t i n c r e a s e d r i s k s o f n e o n a t a l and p o s t n e o n a t a l m o r t a l i t y were a s s o c i a t e d w i t h b e i n g born i n t o p o v e r t y . (20) As a r e s u l t o f t h e s e f i n d i n g s , the r e s e a r c h e r s u g g e s t e d t h a t i n o r d e r t o r e d u c e m o r t a l i t y governments s h o u l d d e v e l o p programs t o a s s i s t f a m i l i e s i n p o v e r t y by p r o v i d i n g income supplements and o f f e r i n g employment programs. While i n f a n t m o r t a l i t y r a t e s may be r e d u c e d by r a i s i n g the income l e v e l o f poor f a m i l i e s , p o v e r t y may a l s o be i n d i c a t i v e o f o t h e r a t t i t u d e s and b e h a v i o r s which have some b e a r i n g on the h e a l t h o f the newborn. For i n s t a n c e , p o v e r t y may be i n -d i c a t i v e o f l i f e s t y l e f a c t o r s such as m a t e r n a l a l c o h o l i s m and m a t e r n a l smoking o r c e r t a i n m a t e r n a l m e d i c a l c o n d i t i o n s . While t h e s e f a c t o r s may be r e l a t e d t o some de g r e e t o p o v e r t y , o t h e r phenomenon i n f l u e n c e m a t e r n a l l i f e s t y l e f a c t o r s . Under t h e s e c i r c u m s t a n c e s an 'adequate' income may be a n e c e s s a r y but not a s u f f i c i e n t c o n d i t i o n f o r r e d u c i n g i n f a n t m o r t a l i t y . The methods adopt e d f o r i m p r o v i n g the p h y s i c a l and mental w e l l - b e i n g o f the f a m i l y may d e t e r m i n e the outcome o f the i n t e r v e n t i o n s t r a t e g y . T r a n s f e r payments may p r o v i d e a con-v e n i e n t s o l u t i o n f o r governments; however, t h i s a p p roach may n o t produce the i n t e n d e d r e s u l t s . While s t a t i s t i c a l models may be u s e f u l f o r t e s t i n g the v a l i d i t y o f o u r assumptions i n o r d e r t o f o r m u l a t e e f f e c t i v e p o l i c i e s i t i s n e c e s s a r y t o r e c o g n i z e both the r e l a t i o n s h i p s and i n t e r r e l a t i o n s h i p s which e x i s t between v a r i o u s f a c t o r s . A n o t h e r problem a s s o c i a t e d w i t h s t a t i s t i c a l models i s t h a t the h y p o t h e s e s o r assumptions a r e based i n p a r t on t h e v a l u e s o f the s o c i a l s c i e n t i s t . While some r e s e a r c h e r s would s u g g e s t t h a t s u c c e s s f u l i n t e r v e n t i o n i n t o the r e a l w o r l d depends on t h e v a l i d i t y o f the a s s o c i a t e d model, i t c o u l d be argued t h a t models s i m p l y d e t e r m i n e the e x i s t e n c e o f a r e l a t i o n s h i p between v a r i a b l e s and do n o t n e c e s s a r i l y e x p l a i n t h e r e a s o n s f o r t h i s r e l a t i o n s h i p . For i n s t a n c e , w h i l e one c o u l d demonstrate t h a t i n c r e a s e d r i s k s o f i n f a n t m o r t a l i t y a r e d i r e c t l y a s s o c i a t e d w i t h younger mothers i t i s a l s o n e c e s s a r y t o d e v e l o p a c o n c e p t u a l e x p l a n a t i o n f o r t h i s r e l a t i o n s h i p . S t a t i s t i c a l models do not n e c e s s a r i l y t e s t the v a l i d i t y o f t h e s e e x p l a n a t i o n s . F u r t h e r m o r e , t h e v a r i a b l e s s e l e c t e d f o r a n a l y s i s a r e o f t e n used t o p r o v i d e proxy measures o f o t h e r phenomena. However, a v a r i a b l e can e x p r e s s a number o f t h i n g s i n d i f f e r -e n t e n v i r o n m e n t s . As was noted 1 p r e v i o u s l y , t h e v a r i a b l e , M a r i t a l S t a t u s , may not p r o v i d e a proxy measure o f d i f f e r e n t s o c i a l and economic c o n d i t i o n s o f I n d i a n women. The s o c i a l and economic c o n d i t i o n s o f pre g n a n t s i n g l e I n d i a n women may v a r y c o n s i d e r a b l y t h r o u g h o u t t h e P r o v i n c e . P r o x i m i t y t o t h e extended f a m i l y and the e x t e n t t o which h i s t o r i c a l c u l t u r a l v a l u e s and norms a r e m a i n t a i n e d , a r e j u s t two f a c t o r s which may i n f l u e n c e t h e l e v e l o f s o c i a l and economic s u p p o r t t h e s i n g l e mother r e c e i v e s . F i n a l l y , s t a t i s t i c a l methods a r e s e n s i t i v e t o the s t r e n g t h s and weaknesses o f the d a t a used. As r e g r e s s i o n models o f t e n r e q u i r e f a i r l y l a r g e samples, r e s e a r c h e r s o f t e n r e l y on s e c o n d a r y d a t a . The use o f t h i s i n f o r m a t i o n , i n many i n s t a n c e s , a f f e c t s the scope o f the s t u d y and t h e r e f o r e may s e r i o u s l y a f f e c t o u r a b i l i t y t o d e v e l o p e f f e c t i v e p o l i c i e s . F u r t h e r m o r e , as r e s e a r c h e r s use s i m i l a r d a t a s o u r c e s t h e i r r e s e a r c h i s o f t e n s i m p l y a r e p l i c a t i o n o f p a s t s t u d i e s , i n d i f f e r e n t g e o g r a p h i c s e t t i n g s . C o n s e q u e n t l y , o u r l e v e l o f knowledge may n o t s u b s t a n t i a l l y i n c r e a s e i f s e c o n d a r y d a t a i s used e x c l u s i v e l y i n such s t u d i e s . D e s p i t e t h e problems a s s o c i a t e d w i t h s t a t i s t i c a l models t h e s e methods can be used i n c o n j u n c t i o n w i t h o t h e r a p p r o a c h e s t o d e v e l o p comprehensive s t u d i e s . Many o f t h e problems e n c o u n t e r e d i n t h i s s t u d y c o u l d have been a v o i d e d by u s i n g o t h e r d a t a s o u r c e s . P u b l i c h e a l t h n u r s e s employed by the Department o f N a t i o n a l H e a l t h and W e l f a r e have r e c e n t l y begun to c o l l e c t i n f o r m a t i o n on the l e v e l o f p r e n a t a l c a r e r e c e i v e d by I n d i a n mothers. As p u b l i c o f f i c i a l s assume t h a t the l e v e l o f p r e n a t a l c a r e has a d i r e c t b e a r i n g on h e a l t h s t a t u s o f the newborn i n f a n t and the r i s k s o f m o r t a l i t y , i t might be u s e f u l t o u n d e r t a k e s t u d i e s t o d e t e r m i n e the e f f e c t s o f t h i s f a c t o r on the b i r t h outcome. As low b i r t h w e i g h t s a r e d i r e c t l y a s s o c i a t e d w i t h t h e r i s k s o f m o r t a l i t y , i t would be a d v i s a b l e t o use t h i s v a r i a b l e and a v o i d the s t a t i s t i c a l problems o f s m a l l samples e n c o u n t e r e d when m o r t a l i t y r a t e s a r e used. While s t a t i s t i c a l methods c o u l d be used t o a s s e s s the r e l a t i o n s h i p between c e r t a i n h e a l t h c a r e , b i o l o g i c a l and s o c i o - e c o n o m i c f a c t o r s , t h e s e l e c t i o n o f t h e s e v a r i a b l e s s h o u l d be based on an u n d e r s t a n d i n g o f the p a r t i c u l a r group's c u l t u r a l v a l u e s and b e l i e f s . As I n d i a n s a r e not one homogeneous group, i t would be more u s e f u l t o examine I n d i a n i n f a n t problems f o r s e l e c t p o p u l a t i o n groups i n B r i t i s h Columbia. By f o c u s s i n g on a s p e c i f i c group i t may be p o s s i b l e t o i d e n t i f y more p r e c i s e l y the f a c t o r s i n f l u e n c i n g m o r b i d i t y o r m o r t a l i t y . F i n a l l y , w h i l e i t may be p o s s i b l e t o demonstrate t h a t b i o l o g i c a l f a c t o r s a r e t o some degree a s s o c i a t e d w i t h i n f a n t m o r t a l i t y , t h e s e r e l a t i o n s h i p s s h o u l d not be c o n s t r u e d t o mean t h a t a l l m o r t a l i t y a s s o c i a t e d w i t h b i o l o g i c a l f a c t o r s r e p r e s e n t s an i n e v i t a b l e l o s s o f l i f e . R a t h e r , i t s h o u l d be r e a l i z e d t h a t b i o l o g i c a l f a c t o r s may a t t i m e s be m o d i f i e d by c h a n g i n g s o c i a l and economic c o n d i t i o n s . F u t u r e s t u d i e s o f I n d i a n i n f a n t m o r t a l i t y s h o u l d be based on a sound t h e o r e t i c a l p e r s p e c t i v e . A l t h o u g h o t h e r s o c i a l s c i e n t i s t s may s e l e c t h i g h l y s o p h i s t i c a t e d s t a t i s t i c a l t e c h n i q u e s t o t e s t the v a l i d i t y o f t h e i r h y p o t h e s e s , t h i s approach s h o u l d be c o n s i d e r e d i n c o n j u n c t i o n w i t h o t h e r methods. I f the q u a n t i t a t i v e model f a i l s t o i n c o r p o r a t e the complex r e l a t i o n s h i p s and i n t e r r e l a t i o n s h i p s , t h e r e s u l t s may be o f l i m i t e d u t i l i t y . As one o f the o b j e c t i v e s o f t h i s s t u d y was t o i d e n t i f y p o s s i b l e p o l i c y a c t i o n s , which c o u l d be u n d e r t a k e n t o f u r t h e r r e d u c e i n f a n t m o r t a l i t y , i t was n e c e s s a r y t o a n a l y z e d i f f e r e n t t h e o r e t i c a l a p proaches t o t h i s problem. C h a p t e r 5 examines the major causes o f I n d i a n i n f a n t d e a t h h i s t o r i c a l l y and d e s c r i b e s how I n d i a n h e a l t h problems and more s p e c i f i c a l l y I n d i a n i n f a n t h e a l t h may be t h e consequence o f changes i n s o c i a l and economic s t r u c t u r e o f I n d i a n s o c i e t i e s . A l t h o u g h t h i s c h a p t e r d e a l s w i t h p a s t i n f a n t h e a l t h problems, the m a t e r i a l p r e s e n t e d here p r o v i d e s the f o u n d a t i o n f o r u n d e r s t a n d i n c u r r e n t h e a l t h problems. CHAPTER FIVE AN ANALYSIS OF INDIAN INFANT MORTALITY PROBLEMS HISTORICALLY 5.1 I n t r o d u c t i o n To g a i n a b e t t e r u n d e r s t a n d i n g about the c h a n g i n g n a t u r e o f I n d i a n i n f a n t h e a l t h p r o b l e m s , t h i s c h a p t e r b e g i n s by e x a m i n i n g the major c a u s e s o f I n d i a n i n f a n t d e a t h o v e r seven d i f f e r e n t h i s t o r i c a l p e r i o d s . S e c t i o n 5.3 then d e s c r i b e s t h r e e d i f f e r e n t a n a l y t i c a l p e r s p e c t i v e s f o r e x p l a i n i n g d i s e a s e c a u s a t i o n . A f t e r r e v i e w i n g the g e n e r a l c h a r a c t e r i s t i c s and p o l i c y s t r a t e g i e s adopted under t h e s e v a r i o u s p e r s p e c t i v e s , t h i s c h a p t e r p r e c e d e s t o d e v e l o p a t h e o r e t i c a l e x p l a n a t i o n o f I n d i a n i n f a n t m o r b i d i t y and m o r t a l i t y . 5.2 An H i s t o r i c a l Overview Of.The Major Causes Of I n f a n t Death T a b l e s 19 t h r o u g h 22.:.describe the i n c i d e n c e d i s t r i b u t i o n and i n f a n t m o r t a l i t y r a t e s f o r c e r t a i n s p e c i f i c c a u s e s f o r B.C.'s I n d i a n p o p u l a t i o n . F i g u r e 4 d e p i c t s o v e r a l l changes i n i n f a n t m o r t a l i t y r a t e s f o r s e v e r a l s e l e c t e d c a u s e s . B e f o r e commenting on the changes i n the d i s t r i b u t i o n and m o r t a l i t y r a t e s f o r t h e s e d i s e a s e s , i t i s i m p o r t a n t t o note a l t e r a t i o n s i n t h e d i s e a s e c l a s s i f i c a t i o n schemes d u r i n g v a r i o u s p e r i o d s . Between the y e a r s o f 1930 and 1947 d e a t h s due t o i m m a t u r i t y were n o t r e c o r d e d i n t h e r e p o r t s o f V i t a l S t a t i s t i c s . In a d d i t i o n , i n 1952 t h e s e r e p o r t s began t o d i f f e r e n t i a t e between pneumonia and pneumonia o f t h e newborn ( i . e . , i n f a n t s under f o u r weeks). A l s o i n t h a t y e a r , the f o r m e r d i a g n o s t i c c l a s s , d i a r r h o e a and e n t e r i t i s . . , , was r e p l a c e d by t h e f o l l o w i n g t h r e e c a t e g o r i e s : 1. d i a r r h o e a o f t h e newborn; 2. d y s e n t e r y ; and 3. g a s t r o - e n t e r i t i s and c o l i t i s . TABLE 19. DEATHS OF INDIAN + INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILL BIRTHS). FOR CERTAIN SPECIFIED CAUSES, 1930-1935, and 1936-1941 DISEASE 1930 t o 1935 19.36 t o 1941 T o t a l no. o f c a u s e s P e r c e n t a g e o f t o t a l d e a t h s I n c i d e n c e r a t e s * p e r 1000 l i v e -b i r t h s T o t a l no. o f c a s e s P e r c e n t a g e o f t o t a l d e a t h s I n c i d e n c e r a t e s * per 1000 l i v e -b i r t h s M e a s l e s 2 0.35 0.49 57 6.37 10.95 Whopping Cough 19 3.33 4.65 25 2.79 4 .80 I n f l u e n z a 31 5.43 7.60 64 7.15 12.29 T u b e r c u l o s i s 42 7.36 10.30 69 7.70 13.25 B r o n c h i t i s 12 2.10 2.94 23 2.57 4.42 Pneumonia n o 19.29 26.97 149 16.64 28.62 D i a r r h o e a & E n t e r i t i s 28 4.91 6.86 42 4.69 8.06 S y p h i l i s 12 2.10 2.94 17 1.89 3.26 D e b i l i t i e s & M a l f o r m a t i o n 87 15.26 21.33 83 9.27 15.94 B i r t h I n j u r i e s 15 0.17 3.68 14 1.56 2.69 Premature B i r t h s 62 10.80 15.20 89 9.94 17.10 Unknown & U n s p e c i f i e d Causes 66 11.58 16.18 44 4.91 8.45 T o t a l no. o f d e a t h s 1930 t o 1935 570 + The Bureau o f V i t a l S t a t i s t i c s does n o t d i f f e r e n t i a t e T ^ I ~ * T u- *u 3 2 ™ t 0 !~4! 8 9 5 between r e g i s t e r e d and n o n - r e g i s t e r e d I n d i a n s T o t a l no. o f l i v e b i r t h s 1930 to 1935 4078 1936 to 1941 5206 * I n c i d e n c e Rates T o t a l no. o f c a s e s T o t a l no. o f l i v e b i r t h s x 1 0 1 SOURCE: P r o v i n c e o f B r i t i s h C o l u m b i a , V i t a l S t a t i s t i c s , . T9'41 and p r e v i o u s y e a r s TABLE 20. DEATHS OF INDIAN+ INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILL BIRTHS) FOR CERTAIN SPECIFIED CAUSES, 1942-1947, and 1948-1953 1942 to 1947 ! 1948 to i . . 1953 DISEASE Total no. of cases Percentage of tota l deaths Incidence rates* per 1000 l i v e -b i r ths i Total no. | of cases Percentage of tota l deaths Incidence ra tes* per 1000 l i v e -b i r ths Measles 26 2 .37 3 57 i 20 1 87 2 29 Whooping Cough 21 1 .92 2 88 13 1 22 1 49 Influenza 60 5 .47 8 24 71 6 64 8 12 Tuberculosi s 50 4 .56 6 86 ! 20 1 87 2 29 Bronch i t is 19 1 .73 2 61 9 0 84 0 10 Pneumonia 293 26 .75 40 24 330 30 86 37 73 Diarrhoea & E n t e r i t i s 98 8 .94 13 46 84 7 86 9 60 Syph i l i s 11 1 .00 1 51 4 0 37 0 46 D e b i l i t i e s & Malformation 107 9 .77 14 69 252 23 57 28 81 B i r t h In jur ies 17 1 55 2 33 21 1 96 2 40 Immaturity & Premature B i r ths 136 12 42 18 68 119 11 13 13 60 Unknown & Unspeci f ied Causes 86 7 85 11 81 66 6 17 0 46 Vio lent Deaths 23 2 .10 3 16 39 4 34 Accidental Mechanical Suf focat ion Total no. of deaths 1942 to 1947 1948 to 1953 Total no. of l i v e b i r t h s 1942 to 1947 1948 to 1953 1095 1069 7282 8746 + Indian refers to tota l population status and non-status Indians * Incidence rates Total no. of cases Total no. of l i v e b i r t h s x 1000 SOURCE: Province of B r i t i s h Columbia, V i ta l S t a t i s t i c s , 1953 and previous years <N ID TABLE 21. DEATHS OF INDIAN* INFANTS UNDER ONE YEAR (EXCLUSIVE OF STILL BIRTHS) FOR CERTAIN SPECIFIED CAUSES 1954-1960 AND 1961 to 1967 I 1954 to 1960 1961 to 1967 •~ ' DISEASE Total no. Percentage Incidence Total no. Percentage Incidence 1 of cases to ta l death rate* per 1000 of cases tota l death ra te* per i 1ivebir ths 1 C ? ? t h i v e ; Measles 17 1 41 1 .22 8 0.85 0.50 Whooping Cough 9 0 .74 0 64 1 0 .11 0.06 Influenza 25 2 .07 1 .80 6 0 64 i 0.37 Tuberculosis 4 0 33 0 28 0 0 00 0 Bronch i t is 19 1 58 1 36 30 3 22 1.89 Pneumonia 417 34 60 30 00 287 30.82 26.38 four weeks & over 375 29 63 25 67 244 26 21 15.44 pneumonia of newborn 60 4 98 1 22 43 4 62 2.72 Dysentery 11 0 91 0 79 2 0 21 0.12 Gastro E n t e r i t i s X C o l i t i s 110 9 13 8 04 218 23 41 13.70 Diarrhoea of newborn 11 0 91 0 79 10 1 07 0.63 Immaturity 150 12 44 10 79 125 13 42 7.91 Malformations 53 4 40 3 81 54 5 80 3.42 B i r th In jur ies 53 4 40 3 81 51 5 48 3.22 Postnatal Asphyxia & A te lec tas i s 79 6 55 5 68 75 8 06 4.74 with mention of immaturity 49 4 07 3 52 41 4 40 2.59 without mention of immaturity 30 2 49 2 15 34 3 65 2.15 111-Defined & Unknown Causes 32 2 66 2 30 46 4 94 2.91 Accidents & V io lent Deaths 28 2 32 2 01 22 2 36 1.39 F i res 17 1 41 1 22 10 1 07 0.63 Other Accidents 11 0 91 79 12 1 29 0.76 Accidental Mechanical Suffocat ion 10 0 83 72 14 1 50 0.88 Total. No. of Deaths 1954 to 1960 1205 Total No. of L i veb i r th 1961 to 1967 931 INDIANS* includes non-status and status Indian Incidence rate* Total No. of Cases Total No. L iveb i r ths x 1000 SOURCE: Province of B r i t i s h Columbia, V i ta l S t a t i s t i c s . 1967 and previous years TABLE 22. DEATHS OF REGISTERED-INDIAN INFANTS UNDER ONE YEAR FOR CERTAIN SPECIFIED CAUSES, 1968 t o 1973 \ DISEASE TOTAL NO. OF CASES PERCENTAGE OF TOTAL DEATHS INCIDENCE RATE PER 1000 LIVEBIRTHS Mea s l e s 0 0 0 Whooping Cough 2 0.47 0.20 I n f l u e n z a 3 0.70 0.31 T u b e r c u l o s i s 0 0 0 B r o n c h i t i s 4 0.94 0.41 Pneumonia 88 20.70 9.19 4 weeks and o v e r 76 17.89 7.94 pneumonia o f newborn 12 2.82 1.25 D y s e n t e r y (2 weeks & o v e r ) 17 4.00 1.77 G a s t r o E n t e r i t i s & C o l i t i s (4 weeks & o v e r ) 3 0.70 0.31 D i a r r h o e a o f newborn nr n r n r Immaturity 37 8.71 3.80 M a l f o r m a t i o n s 18 ' 4.23 1.88 B i r t h I n j u r i e s 7 1.65 0.73 P o s t n a t a l A s p h y x i a & A t e l e c t a s i s nr nr n r w i t h mention o f i m m a t u r i t y n r n r n r w i t h o u t mention o f i m m a t u r i t y n r n r n r 111-Defined & Unknown Causes 15 3.53 1.57 A c c i d e n t s & V i o l e n t Deaths 13 3.06 1.36 F i r e s 7 1.64 0.73 O t h e r A c c i d e n t s 6 1.41 0.63 A c c i d e n t a l M e c h a n i c a l S u f f o c a t i o n 10 2.35 1.04 No r e c o r d s o f no. o f c a s e s o f d e a t h due t o P o s t n a t a l A s p h y x i a and A t e l e c t a s i s between the y e a r s o f 1968 and 1973 o r D i a r r h o e a o f newborn. T o t a l no. o f d e a t h s 425 T o t a l no. o f l i v e b i r t h s 9568 SOURCE: P r o v i n c e o f B r i t i s h C olumbia, V i t a l S t a t i s t i c s , 1973 and p r e v i o u s y e a r s 64. FIGURE 4. MORTALITY RATES+ OF INDIAN INFANTS FOR CERTAIN SPECIFIED CAUSES, 1930-1973 Pneumonia (of the newborn and during the postneonatal period) Congenital Malformations Diarrhoea & E n t e r i t i s ( i n -cludes dysentery, gastro-n t e r i t i s and diarrhoea of of the newborn) /<l«J8-53 llSf-io Mor ta l i t y Rate = Number of deaths x 1000 Total number of l i v e b i r t h s 65. Changes i n t h e d i s e a s e c l a s s i f i c a t i o n schemes d u r i n g t h e s e v a r i o u s p e r i o d s have i m p o r t a n t c o n s e q u e n c e s , i n terms o f the c o n c l u s i o n s one can draw, as t o the r e l a t i v e i m p o r t a n c e o f e n v i r o n m e n t a l o r b i o l o g i c a l f a c t o r s i n d i s e a s e c a u s a t i o n . The more i n f o r m a t i o n a v a i l a b l e on both the c h a r a c t e r i s t i c s o f the v i c t i m , and the cause o r c a u s e s o f d e a t h , the more p r e c i s e l y one can i d e n t i f y p o s s i b l e c a u s a l r e l a t i o n s h i p s . F o r example when an i n f a n t d i e s o n l y the major cause o f d e a t h i s r e c o r d e d on t h e d e a t h c e r t i f i c a t e . W h i l e t h e major cause o f d e a t h may be p o s t n a t a l a s p h y x i a t h e i n f a n t may a l s o be premature. F u r t h e r m o r e , d e a t h c e r t i f i c a t e s may i n d i c a t e t h a t the cause o f d e a t h was due t o s u f f o c a t i o n ; however, t h e s e c e r t i f i c a t e s do not e l a b o r a t e i n d e t a i l on the c i r c u m s t a n c e s s u r r o u n d i n g the d e a t h . While d i s e a s e c l a s s i f i c a t i o n schemes used between 1930 and 1973 s e v e r e l y hamper ou r a b i l i t y t o i d e n t i f y p o s s i b l e c a u s a l f a c t o r s , t h i s i n f o r m a t i o n , n e v e r t h e l e s s , can be used t o g a i n a b e t t e r u n d e r s t a n d i n g o f I n d i a n i n f a n t m o r t a l i t y problems. T a b l e s 1 t h r o u g h 4 d e s c r i b e t h e d i s t r i b u t i o n o f I n d i a n i n f a n t d e a t h s i n B r i t i s h Columbia. In each o f t h e s e d i f f e r e n t p e r i o d s pneumonia was the l e a d i n g cause o f d e a t h . In f a c t , even f o r the l a s t two p e r i o d s pneumonia d u r i n g the p o s t n e o n a t a l p e r i o d a c c o u n t e d a s i z e a b l e p r o p o r t i o n o f the t o t a l number o f I n d i a n i n f a n t d e a t h s . Deaths due t o c o n g e n i t a l m a l f o r m a t i o n s a l s o was one o f the major c a u s e s o f I n d i a n i n f a n t d e a t h . Between the y e a r s o f 1930 and 1953, 15% o f a l l d e a t h s were due t o c o n g e n i t a l a n o m a l i e s . L i k e w i s e between the y e a r s 1954 and 1973 d e a t h s due t o c o n g e n t i a l m a l f o r m a t i o n s a c c o u n t e d f o r 8% o f a l l d e a t h s . F i g u r e *} d e p i c t s t h e v a r i o u s changes i n the m o r t a l i t y r a t e f o r c e r t a i n s p e c i f i e d c a u s e s i n t h e seven p e r i o d s . T h i s g r a p h i n d i c a t e s t h a t w i t h t h e e x c e p t i o n o f c o n g e n i t a l m a l f o r m a t i o n s , t h e m o r t a l i t y r a t e s i n c r e a s e d d u r i n g the p e r i o d between 1936 and 1941. More s p e c i f i c a l l y s t a t i s t i c s p r e s e n t e d i n T a b l e 19 r e v e a l t h a t d u r i n g t h e y e a r s o f 1936 t o 1941 t h e r e was a t e n f o l d i n c r e a s e i n t h e m o r t a l i t y r a t e s f o r d e a t h s due t o measles and the m o r t a l i t y r a t e s f o r d e a t h s due t o b r o n c h i t i s , t u b e r c u l o s i s and pneumonia had r i s e n s i g n i f i c a n t l y . The y e a r s between 1942 and 1947 marked the b e g i n n i n g o f a d e c l i n e i n the m o r t a l i t y r a t e s f o r many c a u s e s o f d e a t h . The r a t e s f o r d e a t h s due t o such d i s e a s e s as m e a s l e s , whopping cough, i n f l u e n z a , t u b e r c u l o s e s and b r o n c h i t i s a l l dropped d u r i n g t h i s f i v e y e a r p e r i o d . W hile a r e d u c t i o n i n the i n c i d e n c e o f d e a t h s due t o c e r t a i n communicable d i s e a s e s may be a t t r i b u -t e d t o improved m e d i c a l c a r e and t r e a t m e n t t e c h n i q u e s , o t h e r f a c t o r s undoub-t e d l y i n f l u e n c e the p r e s e n c e o f t h e s e d i s e a s e s . The f a c t t h a t d u r i n g t h i s time p e r i o d t h e r e was a s u b s t a n t i a l r i s e i n t h e i n c i d e n c e o f d e a t h s due t o pneumonia and d i a r r h o e a and e n t e r i t i s would s u g g e s t t h a t e n v i r o n m e n t a l c on-d i t i o n s p l a y e d an i m p o r t a n t r o l e i n d i s e a s e c a u s a t i o n and m o r t a l i t y . F i g u r e 4 i n d i c a t e s t h a t i n the l a s t f o u r p e r i o d s between 1948 and 1973 t h e r e was a s t e a d y d e c l i n e i n the m o r t a l i t y r a t e s f o r most major c a u s e s . S t a t i s t i c s o u t l i n e d i n T a b l e 20 r e v e a l t h a t between the y e a r s 1948 and 1953 the m o r t a l i t y r a t e f o r d eaths due t o pneumonia, t u b e r c u l o s i s , p r e m a t u r i t y and measles dropped. While m o r t a l i t y r a t e s c o n t i n u e d t o d e c l i n e i n each o f t h e s e subsequent p e r i o d s s t a t i s t i c s p r e s e n t e d i n T a b l e 21 do i n d i c a t e t h a t d e a t h s due t o g a s t r o -e n t e r i t i s and c o h i t i . s c o n t i n u e d t o p l a y an i m p o r t a n t r o l e i n i n f a n t m o r t a l i t y u n t i l the l a s t h i s t o r i c a l p e r i o d . In f a c t , f i g u r e s i n T a b l e 21 r e v e a l t h a t o v e r 23% o f a l l i n f a n t d e a t h s i n the y e a r s o f 1961 t h r o u g h 1967 were c l a s s -i f i e d i n t h i s d i a g n o s t i c c a t e g o r y . A r e d u c t i o n i n t h e s e m o r t a l i t y r a t e s o v e r the l a s t two decades may be r e l a t e d t o a number o f f a c t o r s . B e f o r e c o n s i d e r i n g the p o s s i b l e r e a s o n s f o r t h e s e improvements, i t i s n e c e s s a r y t o d e v e l o p a c o n c e p t u a l e x p l a n a t i o n o f d i s e a s e c a u s a t i o n . The f o l l o w i n g s e c t i o n d e s c r i b e s d i f f e r e n t a n a l y t i c a l a pproaches which c o u l d be used t o u n d e r s t a n d the o c c u r r e n c e o f d i s e a s e i n s o c i e t i e s . 67. 5.3 H e a l t h And S o c i o - E c o n o m i c F a c t o r s : A l t e r n a t i v e P e r s p e c t i v e s And P o l i c i e s Jacobs and S t e v e n s o n (23) d e s c r i b e t h r e e d i f f e r e n t a n a l y t i c a l p e r s p e c t i v e s f o r c o n s i d e r i n g the e f f e c t s o f s o c i o - e c o n o m i c c o n d i t i o n s on h e a l t h : i n d i v i d u -a l i s t i c , r e f o r m i s t i c , and d i a l e c t i c a l m a t e r i a l i s t i c . The f i r s t a p p r o a c h , the i n d i v i d u a l i s t i c p e r s p e c t i v e s , does not e x p l i c i t l y r e c o g n i z e a r e l a t i o n s h i p between h e a l t h and s o c i o - e c o n o m i c c o n d i t i o n s . Under t h i s p e r s p e c t i v e i l l n e s s i s r e g a r d e d as a n a t u r a l p r o c e s s t o be t r e a t e d by an a r r a y o f e x p e r t s u t i l i z i n g complex t e c h n o l o g i e s . Proponents o f the i n d i v i d u -a l i s t i c p e r s p e c t i v e would s u g g e s t t h a t the h e a l t h problems o f i n d i v i d u a l s may be overcome by i m p r o v i n g d i a g n o s t i c and t r e a t m e n t t e c h n i q u e s and by i n c r e a s i n g the u t i l i z a t i o n o f m e d i c a l s e r v i c e s . The r e f o r m i s t ' s a p p r o a c h , on the o t h e r hand, r e c o g n i z e s the importance o f s o c i o - e c o n o m i c c o n d i t i o n s on h e a l t h ; however, t h e s e f a c t o r s a r e viewed i n i s o l a t i o n and i n a a h i s t o r i c a l form. T h i s a p p roach examines r e l a t i o n s h i p s between s o c i o -economic phenomena and h e a l t h but does n o t a t tempt t o examine the fundamental causes o f t h e s e s o c i o - e c o n o m i c c o n d i t i o n s . U s i n g t h i s a p p r o a c h , i t i s argued t h a t the h e a l t h problems o f a p a r t i c u l a r group can be e l i m i n a t e d by s i m p l y im-p r o v i n g l i v i n g c o n d i t i o n s , and t h e s e r e s u l t s may be a c h i e v e d w i t h o u t c h a n g i n g the b a s i c s o c i a l and economic r e l a t i o n s h i p s w i t h i n s o c i e t i e s . The d i a l e c t i c a l m a t e r i a l i s t i c p e r s p e c t i v e d i f f e r s from the o t h e r a p p r o a c h e s i n t h a t i t s t r e s s e s i n t e r r e l a t i o n s h i p s and views h e a l t h and s o c i o - e c o n o m i c f a c t o r s w i t h i n the c o n t e x t o f a dynamic system. The t h e o r e t i c a l p o s i t i o n adopted by d i a l e c t i c a l m a t e r i a l i s t s i s t h a t the economic s t r u c t u r e and the s o c i a l r e l a t i o n s o f p r o d u c t i o n and exchange d e t e r m i n e t h e n a t u r e o f r e l a t i o n s h i p s between man and h i s e nvironment and thus d e t e r m i n e the type o f p a t h o l o g i e s a f f l i c t i n g him. A c c o r d i n g t o the one d i a l e c t i c a l m a t e r i a l i s t the p a t t e r n s o f m o r b i d i t y p r e s e n t w i t h i n a s o c i e t y a r e m e r e l y e x p r e s s i o n s o f the a c t u a l and dynamic s o c i a l and econ-omic systems..(48) Changes i n the s o c i a l and economic s t r u c t u r e o f t h e s e s o c i e t i e s can thus have p r o f o u n d e f f e c t s on the h e a l t h o f i n d i v i d u a l s . U n l i k e the r e f o r m i s t ' s a p p r o a c h , which l a r g e l y uses q u a n t i t a t i v e methods f o r a s s e s s i n g r e l a t i o n s h i p s , the m e t h o d o l o g i c a l a p p r o a c h adopted by d i a l e c t i c a l m a t e r i a l i s t s v a r i e s c o n s i d e r a b l y . As d i a l e c t i c a l m a t e r i a l -i s t s a r e c o n c e r n e d w i t h t h e e f f e c t s o f change on h e a l t h , t h e y o f t e n a t t e m p t t o compare d i f f e r e n t groups w i t h i n a s o c i e t y . Q u a n t i t a t i v e methods a r e o c c a s i o n a l l y used t o a s s e s s the e f f e c t s o f change on the h e a l t h s t a t u s o f i n d i v i d u a l s . The p o l i c y s t r a t e g i e s s u g g e s t e d by d i a l e c t i c a l m a t e r i a l i s t s d i f f e r r a d i c a l l y from t h o s e s u g g e s t e d by r e f o r m i s t s . D i a l e c t i c m a t e r i a l i s t s argue t h a t the o n l y e f f e c t i v e way t o r e d u c e the i n c i d e n c e o f d i s e a s e and m o r t a l i t y i s t o a l t e r the r e l a t i o n s h i p between man and n a t u r e and the s o c i a l and e c o n -omic s t r u c t u r e w i t h i n s o c i e t i e s . There a r e s e v e r a l weaknesses i n t h e t h r e e a n a l y t i c a l p e r s p e c t i v e s which have been d e s c r i b e d h e r e . The i n d i v i d u a l i s t i c p e r s p e c t i v e i s c o n c e r n e d m o s t l y w i t h t r e a t i n g symptoms and f a i l s t o a p p r e c i a t e the importance o f s o c i o - e c o n o m i c phenomena i n d i s e a s e c a u s a t i o n . W hile t e c h n o l o g i c a l i n n o v a t i o n s and i n c r e a s e d a c c e s s and u t i l i z a t i o n o f h e a l t h s e r v i c e s may p l a y an i m p o r t a n t r o l e i n r e d u c i n g the i n c i d e n c e o f d e a t h s due t o c e r t a i n t y p e s o f d i s e a s e s , the u t i l i -i t y o f t h e s e s o l u t i o n s a r e l i m i t e d . In f a c t t o d a y , m e d i c a l p r a c t i t i o n e r s a r e b e g i n n i n g t o r e a l i z e t h a t the s o - c a l l e d d i s e a s e s o f c i v i l i z a t i o n a r e n o t s i m p l y a g e - r e l a t e d d e g e n e r a t i v e p r o c e s s e s but a r e r a t h e r d i r e c t l y r e l a t e d to changes i n b e h a v i o r a s s o c i a t e d w i t h economic development and i n d u s t r i a l i z a -t i o n . S i m i l a r i l y , w h i l e the r e f o r m i s t ' s a p p r o a c h has g a i n e d p o p u l a r i t y i n r e c e n t y e a r s , t h i s a p p roach and t h e s o l u t i o n s a d o p t e d under t h i s p e r s p e c t i v e a r e a t b e s t too s i m p l i s t i c . T e c h n i c a l s o l u t i o n s t o improve s a n i t a r y o r l i v i n g c o n d i t i o n s may p r o v i d e o n l y p a r t i a l s o l u t i o n s t o complex h e a l t h problems. A l -though q u a n t i t a t i v e methods can be used t o a s s e s s r e l a t i o n s h i p s between v a r i -a b l e s , i t i s a l s o i m p o r t a n t t o r e c o g n i z e the i n t e r r e l a t i o n s h i p s which e x i s t between the c a u s a l f a c t o r and o t h e r phenomena. The s o l u t i o n s t o many h e a l t h problems a r e not s i m p l e o r e a s i l y r e a c h e d . The t e c h n i q u e s adopted f o r a l t e r -i n g l i v i n g c o n d i t i o n s have i m p o r t a n t r a m i f i c a t i o n s on the outcome o f i n t e r -v e n t i o n s t r a t e g i e s . As r e f o r m i s t s o f t e n f a i l t o c o n s i d e r the complex r e l a -t i o n s h i p s and i n t e r r e l a t i o n s h i p s which e x i s t , t h e y a r e o f t e n i n c a p a b l e o f d e v e l o p i n g e f f e c t i v e p o l i c i e s t o r e s o l v e h e a l t h problems. A l t h o u g h the t h e o r e t i c a l model o f d i a l e c t i c a l m a t e r i a l i s t s a t t e m p t s t o examine the r e l a t i o n s h i p s and i n t e r r e l a t i o n s h i p s between phenomena, t h e i r r a -d i c a l s o l u t i o n s may be u n a c c e p t a b l e t o d i s a d v a n t a g e d groups i n Canada. Indeed, the need f o r r a d i c a l change may not be r e c o g n i z e d by many members o f d i s a d v a n -t a g e d groups f o r s e v e r a l r e a s o n s . F i r s t l y , t h e y s t i l l may p l a c e some f a i t h i n m e d i c a l / t e c h n i c a l s o l u t i o n s f o r r e s o l v i n g t h e i r h e a l t h problems. The b e l i e f i n m e d i c a l c u r e s may be based on the a s s umption t h a t both improved a c c e s s t o m e d i c a l c a r e and p r e v e n t i v e p u b l i c h e a l t h measures (e.g., i m m u n i z a t i o n ) have c o n t r i b u t e d s u b s t a n t i a l l y t o a d e c l i n e i n m o r t a l i t y i n the p a s t . The i m p o r t a n c e o f both i n c r e a s e d consumption o f m e d i c a l c a r e and s c i e n t i f i c knowledge t o r e -s o l v e h e a l t h problems i s a w i d e l y a c c e p t e d phenomenon i n N o r t h A m e r i c a . D i s -advantaged groups may assume t h a t t h e s e t e c h n i q u e s may p r o v i d e a s o l u t i o n t o many o f t h e i r h e a l t h problems. The need f o r r a d i c a l change may not be a p p a r e n t f o r o t h e r r e a s o n s . While d i s a d v a n t a g e d groups may be d i s t r u s t f u l o f governments and may, i n f a c t , b e l i e v e t h a t governments do n o t a c t on t h e i r b e h a l f , t h e y may s t i l l p r e f e r t o use v a r i o u s i n t e r e s t groups t o e x e r t p r e s s u r e on governments t o r e s o l v e h e a l t h problems.. F o r example, t h r o u g h r e g u l a t i o n s , and l e g i s l a t i o n t h e s t a t e can reduce the harmful e f f e c t s c r e a t e d i n c e r t a i n p r o d u c t i o n p r o c e s s e s . In s h o r t , the s t a t e has the power t o manage c r i s e s and can d e v e l o p a v o i d a n c e s t r a t e g i e s f o r r e d u c i n g s o c i a l c o n f l i c t s . As l o n g as governments a r e c a p a b l e o f d e v i s i n g methods f o r a p p e a s i n g v a r i o u s i n t e r e s t s g r o u p s , the c l i m a t e f o r r a d i c a l change may n o t e x i s t . In c o n s i d e r i n g I n d i a n i n f a n t h e a l t h p roblems, i t i s i m p o r t a n t t o under-s t a n d the r o l e o f v a r i o u s f a c t o r s i n d i s e a s e c a u s a t i o n . A l t h o u g h the p o l i c y s t r a t e g i e s s u g g e s t e d by d i a l e c t i c a l m a t e r i a l i s t s may be p o l i t i c a l l y u n a c c e p t a b l e t o members o f d i s a d v a n t a g e d g r o u p s , t h i s t h e o r e t i c a l p e r s p e c t i v e may be the most u s e f u l f o r u n d e r s t a n d i n g i n f a n t m o r b i d i t y and m o r t a l i t y . 5.4 A C o n c e p t u a l E x p l a n a t i o n S e c t i o n 5.1 d e s c r i b e d the major c a u s e s o f I n d i a n i n f a n t d e a t h between the y e a r s o f 1930 and 1973. We noted t h a t between 1936 and 1941 m o r t a l i t y r a t e s f o r most major c a u s e s o f I n d i a n i n f a n t d e a t h i n c r e a s e d s u b s t a n t a n t i a l l y . By 1973 I n d i a n i n f a n t m o r t a l i t y r a t e s had dropped t o l e s s than o n e - t h i r d o f what i t was t h r e e decades ago ( 1 , p.353). T h i s s e c t i o n d e s c r i b e s , i n g e n e r a l terms, how changes i n the s o c i a l and economic s t r u c t u r e o f I n d i a n groups may have a f f e c t e d t h e i r h e a l t h and more p a r t i c u l a r l y I n d i a n i n f a n t m o r b i d i t y and m o r t a l i t y . The t h e o r e t i c a l p o s i t i o n adopted i n t h i s c h a p t e r can b e s t be summarized as f o l l o w s : Both a l t e r a t i o n s i n I n d i a n s o c i a l and economic systems and the c r e a t i o n o f permanent I n d i a n communities was d i r e c t l y r e s p o n s i b l e f o r p r o v o k i n g a number o f h e a l t h p r o b l e m s , t h e m o r t a l i t y r a t e s i n c r e a s e d d u r i n g t h e 1930's and 1940's. While government a g e n c i e s i n the l a s t t h i r t y y e a r s have p r i m a r i l y adopted t e c h n i c a l s o l u t i o n s t o r e d u c e o r e l i m i n a t e deaths due t o i n f e c t i o u s o r pulmonary d i s e a s e s , t h e s e s o l u t i o n s may n o t be adequate f o r d e a l i n g w i t h t o d a y ' s problems. E f f o r t s t o improve the q u a l i t y and q u a n t i t y o f m e d i c a l c a r e may e f f e c t i v e l y reduce i n f a n t m o r t a l i t y r a t e s but may not reduce m o r b i d i t y s i g n i f i c a n t l y . S i m i l a r i l y , w h i l e i t may be p o s s i b l e t o improve the s t a n d a r d o f l i v i n g o f I n d i a n p e o p l e t h r o u g h t r a n s f e r payments o r o t h e r s o c i a l w e l f a r e schemes, t h e s e methods may p r o v i d e o n l y p a r t i a l s o l u t i o n s , i f s o c i a l problems p l a y a s i g n i f i c a n t r o l e i n m o r t a l i t y . 5.4.1.Disease and S o c i o - E c o n o m i c Change Changes from semi-nomadic o r nomadic s u b s i s t e n c e economies to m o n e t i z e d economies have i m p o r t a n t consequences on the h e a l t h o f i n d i v i d u a l s . F i r s t l y , as the r e s o u r c e s o f the l a n d : c e a s e t o go d i r e c t l y i n t o the p r o d u c t i o n :-o f the f a m i l y ' s f o o d and a r e c o n v e r t e d i n t o a means f o r o b t a i n i n g c a s h f o r the p u r c h a s e o f goods, the d i e t o f i n d i v i d u a l s may be a l t e r e d and t h i s i n t u r n may a f f e c t t h e i r h e a l t h and w e l l - b e i n g . In a s u b s i s t e n c e economy the f o o d consump-t i o n p a t t e r n s a r e d e t e r m i n e d by the s u p p l y o f n a t u r a l r e s o u r c e s and a c c e s s t o t h e s e r e s o u r c e s . On the o t h e r hand, i n a m o n e t i z e d economy, the d i e t o f the i n d i v i d u a l i s d e t e r m i n e d i n p a r t by an i n d i v i d u a l ' s s o c i a l - e c o n o m i c p o s i t i o n . The p a t t e r n s o f ownership and a b i l i t y t o e x t r a c t and s e l l t he n a t u r a l r e s o u r c e s w i l l a f f e c t h i s income l e v e l , which thus a f f e c t s h i s a b i l i t y t o p u r c h a s e f o o d and o t h e r : b a s i c n e c e s s i t i e s . A l t h o u g h the g r a d u a l t r a n s i t i o n from a s u b s i s t e n c e t o a c a s h economy d i d o c c u r a t d i f f e r e n t p e r i o d s i n B r i t i s h Columbia f o r d i f f e r e n t I n d i a n g r o u p s , r e p o r t s p u b l i s h e d by the Department o f I n d i a n A f f a i r s i n the l a t e 1920s i n d i c a t e t h a t I n d i a n s i n a l l r e g i o n s o f B.C. were dependent on c a s h f o r t h e p u r c h a s e o f c e r t a i n commodities. For example i n the 1928 Annual R e p o r t the D i r e c t o r s t a t e s t h a t : The o c c u p a t i o n o f the I n d i a n s i n B.C. v a r i e s w i t h t h e i r h a b i t a t . The I n d i a n s s i t u a t e d a l o n g the c o a s t e a r n t h e i r l i v e l i h o o d p r i n c i p a l l y from f i s h i n g . In many i n s t a n c e s 72. t h e y own t h e i r own motor l a u n c h e s , n e t s and g e a r , w h i l e o t h e r s a r e s u p p l i e d by t h e v a r i o u s c a n n e r i e s . Many o f the women a r e a l s o employed i n the c a n n e r i e s o r i n t h e hop f i e l d s and e a r n a s t e a d y income. In th e i n l a n d p a r t s o f t h e p r o v i n c e some f a r m i n g i s c a r r i e d on ... In the Kootenay, Kamloops and New Westminster r e g i o n s I n d i a n s own l a r g e herds o f h o r s e s and c a t t l e . The I n d i a n s i n n o r t h e r n and remote p a r t s o f the p r o v i n c e s t i l l depend upon h u n t i n g and t r a p p i n g f o r t h e i r l i v e l i h o o d s . (24, p.40) While t h e s e r e p o r t s r e v e a l t h a t f a r m i n g , f i s h i n g and t r a p p i n g p r o -v i d e d a s o u r c e o f income f o r B.C.'s I n d i a n p o p u l a t i o n , t h e i r income l e v e l s were v e r y low. In 1939 the t o t a l p e r c a p i t a income o f I n d i a n s d e r i v e d from wages, m i n i n g , t i m b e r , l a n d r e n t a l s and i n t e r e s t p a i d on a n n u i t i e s and t r u s t f unds amounted t o $75. ( 2 5 ) . The low income l e v e l o f I n d i a n s and t h e i r r e -l i a n c e on c a s h f o r t h e pu r c h a s e o f b a s i c n e c e s s i t i e s d i r e c t l y a f f e c t e d t h e i r d i e t . S t u d i e s u n d e r t a k e n by the f e d e r a l government i n 1928 r e v e a l t h a t 34.7% o f I n d i a n s l i v i n g on v a r i o u s r e s e r v e s i n Western Canada e x i s t e d on government f o o d r a t i o n s o f f l o u r , t e a , r i c e and bacon o r b e e f ( 2 6 ) . The D i r e c t o r o f I n d i a n H e a l t h S e r v i c e s commented a t t h a t time t h a t t h e i r d i e t s were i n a d e q u a t e and d i r e c t l y c o n t r i b u t e d t o h e a l t h problems i n I n d i a n communities. F u r t h e r -more, s t u d i e s u n d e r t a k e n i n 1942 a l s o d e m o n s t r a t e t h a t l a r g e s e c t i o n s o f the In d i a n p o p u l a t i o n i n Canada were s u f f e r i n g from d i s e a s e s which were r e l a t e d to d i e t a r y d e f i c i e n c i e s ( 2 7 ) . While government o f f i c i a l s acknowledged the importance on an i n a d e q u a t e d i e t i n I n d i a n h e a l t h problems, o t h e r f a c t o r s u n d o u b t e d l y p l a y e d a r o l e i n d i s e a s e c a u s a t i o n . The e r o s i o n o f t h e i r economic systems and s o c i a l i n s t i t u -t i o n s and the f o r m a t i o n o f permanent I n d i a n communities had a p r o f o u n d impact on t h e i r h e a l t h . In nomadic o r semi-nomadic s o c i e t i e s , t h e o p p o r t u n i t i e s f o r the s p r e a d o f i n f e c t i o u s d i s e a s e s o u t s i d e t h e nomadic group, a r e - l i m i t e d . In a d d i t i o r i n m i g r a t o r y s o c i e t i e s where the p o p u l a t i o n d e n s i t i e s a r e - l o w , h e a l t h , problems a s s o -c i a t e d w i t h e n v i r o n m e n t a l p o l l u t i o n a r e not common. The n a t u r e o f h e a l t h problems i n t h e s e nomadic s o c i e t i e s p r o b a b l y d i f f e r e d r a d i c a l l y from t h e h e a l t h problems t h e y e x p e r i e n c e d d u r i n g t h e 20th c e n t u r y . For example, w i t h o u t s o p h i s t i c a t e d m e d i c a l t e c h n i q u e s , i t i s p o s s i b l e t o s p e c u l a t e t h a t p r o p o r t i o n a l l y more mothers d i e d g i v i n g b i r t h t o a c h i l d . The t r a n s i t i o n from nomadic t o s e d e n t a r y s o c i e t i e s had i m p o r t a n t r a m i f i -c a t i o n s on the t y p e s o f d i s e a s e s a f f l e c t i n g I n d i a n p e o p l e . T h i s t r a n s i t i o n o c c u r r e d a t d i f f e r e n t time p e r i o d s f o r d i f f e r e n t I n d i a n groups i n B r i t i s h C o lumbia. A c c o r d i n g t o K n i g h t (41) t e r r i t o r i a l d e s t a b i l i z a t i o n d e v e l o p e d as e a r l y as the f u r t r a d e e r a , when some t r i b e s around F t . Simpson and F t . Rupert c o n s o l i d a t e d around major f u r t r a d e p o s t s t o promote t h e i r i n t e r e s t as m i d d l e -men t r a d e r s . The g r a d u a l t r a n s i t i o n to s e d e n t a r y s o c i e t i e s f o r most I n d i a n groups o c c u r r e d much l a t e r . When t r a c t s o f l a n d were s e t a s i d e by t h e f e d e r a l government i n the 1880 1s i t was i n i t i a l l y assumed t h a t I n d i a n s would c o n t i n u e to engage i n t h e i r t r a d i t i o n a l s u b s i s t e n c e a c t i v i t i e s . As t h e p o p u l a t i o n o f B r i t i s h Columbia i n c r e a s e d , the government began t o encourage I n d i a n s t o s e e k : employment and/or u t i l i z e t h e i r l a n d f o r the p r o d u c t i o n o f commodities f o r e x p o r t . Changes i n t h e economic s t r u c t u r e i n t u r n a f f e c t e d t h e p a t t e r n s o f I n d i a n s e t t l e m e n t and t h e p o p u l a t i o n d e n s i t i e s w i t h i n t h e s e g e o g r a p h i c a r e a s . The f o r m a t i o n o f permanent I n d i a n s e t t l e m e n t s f o s t e r e d t he s p r e a d o f i n f e c -t i o u s d i s e a s e s and provoked o t h e r h e a l t h problems. Without adequate m e d i c a l c a r e o r funds t o i n s u r e proper s a n i t a r y i n s t a l l a t i o n s , t h e h e a l t h problems e x p e r i e n c e d by t h e n a t i v e p o p u l a t i o n i n c r e a s e d . The i m p o r t a n c e o f e n v i r o n m e n t a l c o n d i t i o n s i n I n d i a n h e a l t h problems has, i n the p a s t , been w e l l documented. R e p o r t s p r e p a r e d by government o f f i c i a l s have acknowledged t he e f f e c t s o f poor h o u s i n g and u n s a n i t a r y con-d i t i o n s on I n d i a n h e a l t h . In 1940 a r e p o r t p u b l i s h e d by an employee o f the I n d i a n A f f a i r s Branch s u g g e s t e d t h a t t h e h i g h i n c i d e n c e o f pulmonary d i s e a s e ( i . e . pneumonia, b r o n c h i t i s and t u b e r c u l o s i s ) was r e l a t e d to poor h o u s i n g on I n d i a n r e s e r v e s ( 2 6 ) . In a d d i t i o n , t h i s r e s e a r c h e r c o n c l u d e d t h a t c o l d and d r a u g h t y houses e x e r t e d a f a t a l i n f l u e n c e on o u t b r e a k s o f such communicable Other s t u d i e s u n d e r t a k e n by t h e D i v i s i o n o f I n d i a n H e a l t h S e r v i c e s between 1929 and 1930 a l s o s u g g e s t t h a t o v e r c r o w d i n g and u n s a n i t a r y c o n -d i t i o n s w i t h i n I n d i a n r e s i d e n t i a l s c h o o l s c o n t r i b u t e d t o t h e s p r e a d o f t u b e r c u l o s i s . While t h e e v i d e n c e p r e s e n t e d i n t h e s e s t u d i e s and r e p o r t s , s u g g e s t t h a t i l l n e s s was r e l a t e d t o h o u s i n g and u n s a n i t a r y c o n d i t i o n s , t he q u a l i t y o f h o u s i n g and s a n i t a r y c o n d i t i o n s may o n l y be i m p o r t a n t d e t e r m i n a n t s o f d i s e a s e i n c e r t a i n forms o f s o c i e t i e s . In s u b s i s t e n c e economies, a l l a s p e c t s o f t h e i r m a t e r i a l c u l t u r e ( e . g . , h o u s i n g and c l o t h i n g ) were r e l a t e d t o the p a r t i c u l a r t y p e s o f economic a c t i v i t y . A l t h o u g h p u b l i c o f f i c i a l s may n o t have p e r c e i v e d t he i m p o r t a n t impact o f changes i n t h e i r m a t e r i a l c u l t u r e on I n d i a n h e a l t h and w e l l - b e i n g , t h e s e changes u n d o u b t e d l y c o n t r i b u t e d t o I n d i a n m o r b i d i t y and m o r t a l i t y . D e s p i t e t h e f a c t t h a t i n a d e q u a t e m e d i c a l c a r e may be d i r e c t l y r e l a t e d t o h i g h m o r b i d i t y and m o r t a l i t y r a t e s , d i s e a s e i s a l s o a consequence o f changes i n b e h a v i o r a s s o c i a t e d w i t h changes i n the economic s t r u c t u r e . As Holtzman s t a t e s : "Human b e h a v i o r i s a r e s u l t o f g e n e t i c and e n v i r o n m e n t a l i n t e r a c t i o n s and i t s e l f i n f l u e n c e s t he o c c u r r e n c e o f d i s e a s e . " (32, p.31) The more r a p i d t he t e c h n o l o g i c a l and s o c i a l c h a n g e s , t h e g r e a t e r i s t h e l i k e -l i h o o d t h a t new and unexpected c a u s e s o f d i s e a s e w i l l appear. The h i g h i n c i d e n c e o f I n d i a n i n f a n t m o r t a l i t y h i s t o r i c a l l y may be a r e f l e c t i o n o f l a r g e r h e a l t h problems e x p e r i e n c e d by t h e n a t i v e p o p u l a t i o n i n B r i t i s h Columbia. As S t a n b u r y (1) n o t e d : u n h e a l t y p r e g n a n t women produce u n h e a l t y o f f s p r i n g , which i n t u r n a r e more s u s c e p t i b l e t o d i s e a s e and i n f e c t i o n . A l t h o u g h t he m e d i c a l community may a t t r i b u t e a d e c l i n e i n m o r t a l i t y f r o m i n f e c t i o u s d i s e a s e s t o improvements i n t r e a t m e n t t e c h -n i q u e s and i m m u n i z a t i o n , t he v a l i d i t y o f t h e s e a s s u m p t i o n s may be q u e s t i o n n e d by some i n d i v i d u a l s . Indeed, h i s t o r i a n s who have examined t he n a t u r e o f h e a l t h problems i n Western Europe and North America have c o n c l u d e d t h a t m o r t a l i t y due t o i n f e c t i o u s d i s e a s e s began t o r e c e d e l o n g b e f o r e t he i n t r o -d u c t i o n o f s p e c i f i c methods o f t h e r a p y . A c c o r d i n g t o Dubos (29) the g r e a t e s t advances i n the h e a l t h o f p e o p l e i n Western Europe were p r o b a b l y t he d i r e c t r e s u l t s o f improvements i n t h e i r s a n i t a r y and l i v i n g c o n d i t i o n s . Based on the c o n c l u s i o n s drawn by o t h e r s o c i a l s c i e n t i s t s i t i s p o s s i b l e t o s p e c u l a t e t h a t a d e c l i n e i n t h e i n c i d e n c e o f de a t h s due t o r e s p i r a t o r y and i n f e c t i o u s d i s e a s e s may be d i r e c t l y r e l a t e d t o g e n e r a l improvements i n the l i v i n g c on-d i t i o n s o f I.nd.iaTrr p e o p l e . 5.5 C o n c l u s i o n s The l a s t s e c t i o n examined t he impact o f e n v i r o n m e n t a l c o n d i t i o n s on I n d i a n h e a l t h h i s t o r i c a l l y . I t was argued t h a t u n f a v o u r a b l e e n v i r o n m e n t a l c o n d i t i o n s were d i r e c t l y and i n d i r e c t l y r e l a t e d t o t h e c h a n g i n g mode o f p r o d u c t i o n and s o c i a l r e l a t i o n s h i p s between I n d i a n and n o n - I n d i a n p e o p l e . G i v e n t h e f a c t t h a t I n d i a n i l l - h e a l t h may be viewed as a consequence o f s o c i a l and economic s t r u c t u r a l changes, what measures were adopted by g o v e r n -ments t o c o r r e c t t he a d v e r s e e f f e c t s o f t h e s e changes? Were t h e s e programs d e s i g n e d t o t r e a t t h e c a u s e s o f I n d i a n i l l - h e a l t h ? The f o l l o w i n g c h a p t e r examines t h e h i s t o r y o f I n d i a n h e a l t h p o l i c i e s and d e s c r i b e s some o f t h e l i m i t a t i o n s o f t h e s e a p p r o a c h e s . CHAPTER SIX AN ANALYSIS OF GOVERNMENT INTERVENTION STRATEGIES ON INDIAN INFANT HEALTH PROBLEMS 6.1 A H i s t o r y o f I n d i a n H e a l t h P o l i c i e s B e f o r e c o n s i d e r i n g t h e adequacy o f v a r i o u s p o l i c i e s adopted by the Canadian government d u r i n g d i f f e r e n t h i s t o r i c a l p e r i o d s , i t i s i m p o r t a n t to note t h a t the f e d e r a l government has ne v e r r e c o g n i z e d t h a t i t has any l e g a l o r s t a t u t o r y o b l i g a t i o n t o p r o v i d e h e a l t h c a r e f o r I n d i a n s . A l t h o u g h 5 T r e a t y #6 c o n t a i n e d p r o v i s i o n s f o r m e d i c a l c h e s t s t o be p r o v i d e d f o r the use and b e n e f i t o f I n d i a n p e o p l e t h i s was the o n l y t r e a t y i n which t h e r e were s p e c i f i c p r o v i s i o n s f o r h e a l t h c a r e . Thus, w h i l e t h e government does not r e c o g n i z e any l e g a l o b l i g a t i o n t o p r o v i d e h e a l t h o r t r e a t m e n t s e r v i c e s f o r t h e n a t i v e p o p u l a t i o n t h e government has acknowledged t h a t i t has a moral r e s p o n s i b i l i t y t o p r o v i d e s e r v i c e s f o r "a group whose economy would n o t o t h e r w i s e p e r m i t them t o a d e q u a t e l y c a r e f o r t h e m s e l v e s " (30, p.78). The f i r s t h e a l t h s e r v i c e s f o r I n d i a n s o c c u r r e d l a r g e l y as a r e s u l t o f p u b l i c p r e s s u r e f r o m new i m m i g r a n t s , who p e r c e i v e d t h a t the h e a l t h problems o f I n d i a n s were becoming so s e r i o u s t h a t I n d i a n s were c o n s i d e r e d a h e a l t h h a z a r d t o the r e s t o f the p o p u l a t i o n ( 2 6 ) . In the 1880's t he f i r s t p a r t - t i m e p h y s i c i a n s were h i r e d by the f e d e r a l government t o c a r e f o r n a t i v e groups i n E a s t e r n Canada. L a t e r , i n 1905, the S u p e r i n t e n d e n c y o f M e d i c a l S e r v i c e s was e s t a b l i s h e d w i t h i n the Department o f I n d i a n A f f a i r s . Between t he y e a r s o f 1905 and 1909 major I n d i a n h e a l t h s t u d i e s were under-t a k e n by Dr. Br y c e . A l t h o u g h t h e r e s u l t s o f the f i r s t s t u d i e s r e v e a l e d t h a t t u b e r c u l o s i s was d e c i m a t i n g t h e I n d i a n p o p u l a t i o n , Dr. B r y c e ' s r e q u e s t f o r funds t o t r e a t T.B. v i c t i m s was d e n i e d by P a r l i a m e n t . In 1909 Dr. Bryce s u g g e s t e d t h a t I n d i a n r e s i d e n t i a l s c h o o l s were r e s p o n -s i b l e f o r the s p r e a d o f t u b e r c u l o s i s and s h o u l d t h e r e f o r e be taken o v e r by h i s Branch and c o n v e r t e d i n t o T.B. s a n i t o r i urns. H i s remarks caused c o n s i d e r a b l e o u t c r y amongst c h u r c h o f f i c i a l s , who were d i r e c t l y i n v o l v e d i n I n d i a n e d u c a t i o n . Dr. B r y c e ' s s e r v i c e s were t e r m i n a t e d s h o r t l y t h e r e -a f t e r . (26) .While^no s u c c e s s o r c w a s . a p p o i n t e d - t o repflace-iDr. B r y c e ? r t h e g o v e r n -ment . c o n t i n u e d t o p r o v i d e some t r e a t m e n t s e r v i c e s f o r I n d i a n s and e s -t a b l i s h e d t h e f i r s t I n d i a n h o s p i t a l s , which were t o be used f o r t r e a t i n g T.B. v i c t i m s . (26) In 1922 the f i r s t t r a v e l l i n g n u r s e s were a p p o i n t e d t o i n s t r u c t I n d i a n women on hygiene and c h i l d c a r e . T h i s y e a r marked the b e g i n n i n g o f a new s t r a t e g y adopted by governments t o d e a l w i t h I n d i a n h e a l t h problems. P r i o r t o t h i s t i m e , the government was c o n c e r n e d w i t h p r o v i d i n g m e d i c a t i o n and s p o r a d i c m e d i c a l c a r e t o I n d i a n s s u f f e r i n g from communicable d i s e a s e s . ( 2 6 ) In s h o r t , p a s t governments adopted p o l i c y s t r a t e g i e s s i m i l a r t o t h o s e p r e s c r i b e d by a d v o c a t e s o f the i n d i v i d u a l i s t i c p e r s p e c t i v e . F u r t h e r m o r e , w h i l e h e a l t h was equated w i t h the consumption o f m e d i c a l s e r v i c e s , t h e r e was no compre-h e n s i v e h e a l t h program i n e x i s t e n c e . The h e a l t h s e r v i c e s p r o v i d e d f o r In d i a n p e o p l e were i n r e s p o n s e t o emergency s i t u a t i o n s . When the f i r s t p u b l i c h e a l t h n u r s e s were h i r e d t h e y were g i v e n t h e r e s p o n s i b i l i t y t o t e a c h I n d i a n mothers how t o p r o p e r l y c a r e f o r t h e i r c h i l d r e n . With the i n t r o d u c t i o n o f t h e s e new p r e v e n t i v e p u b l i c h e a l t h e d u c a t i o n programs, governments had begun t o f o r m a l l y acknowledge the importance o f e n v i r o n m e n t a l c o n d i t i o n s on I n d i a n h e a l t h problems. However, the p r e v e n t i v e s t r a t e g i e s s e l e c t e d were based on the n o t i o n o f s e l f - h e l p and i n d i v i d u a l r e s p o n s i -b i l i t y . By a d o p t i n g a r e f o r m i s t a p p r o a c h t o I n d i a n h e a l t h , t h i s government had f a i l e d t o acknowledge the complex n a t u r e o f h e a l t h problems. When a new s u p e r i n t e n d e n t was a p p o i n t e d i n 1927, the government began t o expand h e a l t h s e r v i c e s and t r e a t m e n t f a c i l i t i e s . D u r i n g t he next n i n e y e a r s numerous s u r v e y s were un d e r t a k e n on I n d i a n h e a l t h p r o b l e m s . ( 2 6 D e s p i t e t h e f a c t t h a t the r e s u l t o f t h e s e s t u d i e s i n d i c a t e d t h a t d e f i c i e n c y d i s e a s e s were r e l a t e d t o the changes i n I n d i a n d i e t , l o s s o f s u n s h i n e and the a d o p t i o n o f w h i t e man's d r e s s , l i t t l e was done t o improve t he c o n d i t i o n s o f I n d i a n p e o p l e . Indeed, a l t h o u g h governments were aware t h a t u n f a v o u r a b l e e n v i r o n m e n t a l c o n d i t i o n s were r e l a t e d t o changes i n the p a t t e r n o f s o c i a l and economic a c t i v i t y , new p o l i c y s t r a t e g i e s were n o t ado p t e d . D i e t a r y supplements were p r o v i d e d t o some communities on the a d v i c e o f m e d i c a l o f f i c e r s ; however, emphasis was p l a c e d on t r e a t m e n t and p u b l i c e d u c a t i o n . Lack o f fu n d s a l s o hampered any e f f o r t s o f I n d i a n H e a l t h S e r v i c e s . D e s p i t e the s e r i o u s h e a l t h problems i n I n d i a n communities, e x p e n d i t u r e s on I n d i a n h e a l t h c a r e were v e r y s m a l l . In 1934 the p e r c a p i t a e x p e n d i t u r e f o r h e a l t h s e r v i c e s f o r I n d i a n p e o p l e amounted t o $9.60. In c o n t r a s t , f o r n o n - I n d i a n s the p e r c a p i t a h e a l t h e x p e n d i t u r e s amounted t o $31.00 ( 2 6 ) . A l t h o u g h h e a l t h s e r v i c e s were g r a d u a l l y expanded d u r i n g t he l a t e 1 930 1s and e a r l y 1940's, t h e major impetus t o the development o f I n d i a n m e d i c a l and p u b l i c h e a l t h s e r v i c e s o c c u r r e d i n 1945 when I n d i a n H e a l t h S e r v i c e s was t r a n s f e r r e d from I n d i a n A f f a i r s t o the Department o f N a t i o n a l H e a l t h and W e l f a r e . ( 2 6 ) I t is°tnteresting t o n o t e t t h a t ' w h l l e " t h e s e ' h e a l t h s e r v i c e s were t r a n s f e r r e d , a l l o t h e r s e r v i c e s f o r I n d i a n p e o p l e ( i . e . l a n d , h o u s i n g , e d u c a t i o n and w e l f a r e ) remained w i t h T t h e I n d i a n A f f a i r s - Branch.-- I n d i i H e a l t h S e r v i c e s i n 1945 was r e s p o n s i b l e f o r d i a g n o s t i c and t r e a t m e n t s e r v i c e s . F u r t h e r m o r e , w h i l e t h e i r s t a f f c o u l d a c t as a d v i s o r s on h e a l t h m a t t e r s , the I n d i a n a g e n t s were the l e g a l l y d e s i g n a t e d H e a l t h O f f i c e r s on I n d i a n r e s e r v e s . The s p l i t i n the a d m i n i s t r a t i o n o f s e r v i c e s t o I n d i a n s was done p r i m a r i l y t o i n c r e a s e e f f i c i e n c y . In the p a s t , I n d i a n A f f a i r s and more p a r -t i c u l a r l y I n d i a n H e a l t h S e r v i c e s was the r e s p o n s i b i l i t y o f the D e p a r t -ment o f Mines and R e s o u r c e s . As t h e s e m i n i s t e r s were a l s o ^ r e s p o n s i b l e f o r o t h e r m a t t e r s , i t was f e l t t h a t I n d i a n H e a l t h S e r v i c e s was not r e c e i v i n g the a t t e n t i o n t h a t i t d e s e r v e d . (:26) A l t h o u g h e x p e n d i t u r e s f o r I n d i a n h e a l t h c a r e i n c r e a s e d d r a m a t i c a l l y when t h e s e s e r v i c e s were t r a n s f e r r e d , i t seems r a t h e r u n f o r t u n a t e t h a t t h e r e was such a d e c i s i v e s e p a r a t i o n i n t h e a d m i n i s t r a t i o n o f I n d i a n s e r v i c e s . One would assume t h a t the Department r e s p o n s i b l e f o r w e l f a r e , h o u s i n g , water and s a n i t a t i o n s h o u l d a l s o be c o n c e r n e d w i t h h e a l t h s e r v i c e s . As i t becomes i n c r e a s i n g l y e v i d e n t t h a t I n d i a n i l l - h e a l t h i s not o n l y a m e d i c a l problem but l a r g e l y a s o c i o - e c o n o m i c problem, i t would seem t h a t a c u r e l i e s p r i m a r i l y i n an enhanced s t a n d a r d o f l i v i n g . P u b l i c h e a l t h and m e d i c a l s e r v i c e s can p r o b a b l y n e v e r a c h i e v e more than a moderate degree o f s u c c e s s i n r e d u c i n g e i t h e r ^ m o r b i d i t y o r - m o r t a l i t y - . In T f a c t i t c o u l d be argued t h a t p u b l i c h e a l t h s e r v i c e s a r e c o n c e r n e d l e s s w i t h h e a l t h than w i t h t h e c o n t r o l o f s p e c i f i c d i s e a s e s . They do l i t t l e t o d e f i n e , r e c o g n i z e o r measure the h e a l t h y s t a t e ( 2 9 ) . As the Department o f N a t i o n a l H e a l t h and W e l f a r e has no j u r i s d i c t i o n o v e r m a t t e r s which a f f e c t I n d i a n h e a l t h , the s t r a t e g i e s a v a i l a b l e t o them have been l i m i t e d . Indeed, as o f f i c i a l s o f the Union o f B.C. I n d i a n C h i e f s p o i n t o u t : " M e d i c a l S e r v i c e s can i n s p e c t water s u p p l i e s and sewage systems, t h e y can warn o f overcrowded c o n d i t i o n s , t h e y can i n s t i t u t e d r u g and a l c o h o l t r e a t m e n t programs, but i t i s a c o m p l e t e l y d i f f e r e n t government agency, which c o n t r o l s the means f o r d e a l i n g w i t h t h e s e p r o b l e m s " ( 3 6 , p. 24). The problems o f i m p r o v i n g the h e a l t h o f I n d i a n p e o p l e a r e f u r t h e r compounded when one c o n s i d e r s the f a c t t h a t the Department o f N a t i o n a l H e a l t h and W e l f a r e i s r e s p o n s i b l e o n l y f o r Canada's s t a t u s I n d i a n popu-l a t i o n and p r o v i d e s p u b l i c h e a l t h s e r v i c e s t o I n d i a n s r e s i d i n g on some r e s e r v e s . While the f e d e r a l government pays the d a i l y h o s p i t a l c o - i n s u r -ance c h a r g e s o f a l l s t a t u s I n d i a n s i n B.C., and pays the m e d i c a r e premiums f o r some o f B.C.'s o f f - r e s e r v e s t a t u s I n d i a n p o p u l a t i o n , the h e a l t h problems o f the n o n - s t a t u s and s t a t u s I n d i a n s l i v i n g o f f - r e s e r v e s a r e the r e s p o n s i b i l i t y o f t h e p r o v i n c i a l government. The p r o v i n c i a l government i n r e c e n t y e a r s has e x p r e s s e d c o n c e r n o v e r i n e q u a l i t i e s which e x i s t between n o n - I n d i a n and I n d i a n s , w i t h r e s p e c t t o a c c e s s t o m e d i c a l c a r e . However, because the p r o v i n c i a l government i s c o n c e r n e d w i t h h e a l t h and h e a l t h s e r v i c e s f o r a l l r e s i d e n t s i n B.C., t h e y have not d e v e l o p e d programs to s p e c i f i c a l l y a d d r e s s the h e a l t h problems o f B.C.'s n a t i v e p o p u l a t i o n . D e s p i t e the f a c t t h a t p u b l i c h e a l t h programs and improved a c c e s s t o m e d i c a l c a r e may have been r e s p o n s i b l e f o r a r e d u c t i o n t o I n d i a n i n f a n t m o r t a l i t y r a t e s , and may p l a y a r o l e i n the p r e v e n t i o n o f i n f a n t d e a t h s i n t h e f u t u r e , t h e s e s t r a t e g i e s p r o v i d e o n l y p a r t i a l s o l u t i o n s t o p r e s e n t I n d i a n i n f a n t m o r b i d i t y and m o r t a l i t y . B e f o r e s u g g e s t i n g o t h e r s t r a t e g i e s which may be more e f f e c t i v e , i t i s i m p o r t a n t t o examine the n a t u r e o f I n d i a n i n f a n t m o r t a l i t y problems i n more r e c e n t y e a r s . The f o l l o w i n g s e c t i o n a n a l y z e s I n d i a n n e o n a t a l and p o s t -n e o n a t a l death by major d i a g n o s t i c c a t e g o r i e s between the y e a r s o f 1974 and 1980. 6.2 The Causes Of I n d i a n I n f a n t Death A c c o r d i n g t o the r e c o r d s o f I n d i a n H e a l t h S e r v i c e s , o v e r the l a s t seven y e a r s we have w i t n e s s e d a d e c l i n e i n the i n c i d e n c e and m o r t a l i t y r a t e s f o r p o s t n e o n a t a l d e a t h s due t o pneumonia, d y s e n t e r y and o t h e r i n -f e c t i o u s d i s e a s e s d i r e c t l y o r i n d i r e c t l y r e l a t e d t o e n v i r o n m e n t a l c o n d i t i o n s . For example, the Annual R e p o r t s o f the P a c i f i c Region M e d i c a l S e r v i c e s i n -d i c a t e t h a t between the y e a r s o f 1974 and 1980, 38 p o s t n e o n a t a l d e a t h s were due t o pneumonia. T h i s f i g u r e r e p r e s e n t s a m o r t a l i t y r a t e o f 4.3 p e r 1000 l i v e b i r t h s , which c o n t r a s t s f a v o u r a b l y t o a r a t e o f 7.9 f o r the y e a r s o f 1968 t h r o u g h 1973. A l t h o u g h t h e s e improvements a r e i m p r e s s i v e , t h e r e a r e s t i l l a number o f u n r e s o l v e d problems. T a b l e 24 d e s c r i b e s the i n c i d e n c e , d i s t r i b u t i o n and m o r t a l i t y r a t e s o f i n f a n t d e a t h s by major d i a g n o s t i c c l a s s between the y e a r s o f 1974 and 1980. These s t a t i s t i c s ,s;h.owvthat Qver.'^ne-thifd.^of a l l ]rn.di;anininfa.n.ttdea.tbs. were grouped i n t o the d i a g n o s t i c c a t e g o r y XV. C e r t a i n Causes o f P e r i n a t a l M o r t a l -i t y . Many c a u s e s o f p e r i n a t a l m o r t a l i t y r e l a t e t o c e r t a i n m a t e r n a l and p l a c e n t a c o n d i t i o n s which a f f e c t l a b o u r and the d e l i v e r y . Deaths c l a s s i f i e d i n t o t h i s d i a g n o s t i c c a t e g o r y i n c l u d e such c a u s e s as i m m a t u r i t y , h y p o x i a , a s p h y x i a and c o n g e n i t a l pneumonia. T a b l e 24 a l s o r e v e a l s t h a t 8% o f a l l d e a t h s were due t o c o n g e n i t a l a n o m a l i e s . In c o n t r a s t between the y e a r s o f 1968 t h r o u g h 1973 o n l y 4.2% o f a l l d e a t h s were due t o t h i s c a u s e . . In f a c t , the s t a t i s t i c s p r e s e n t e d here i n d i c a t e t h a t o v e r the l a s t seven y e a r s the m o r t a l i t y r a t e f o r d e a t h s due t o c o n g e n i t a l a n o m a l i e s has i n c r e a s e d . What f a c t o r s a c c o u n t f o r the r i s e i n the i n c i d e n c e o f c o n g e n i t a l a n o m a l i e s ? Is the h i g h i n c i d e n c e o f p e r i n a t a l d e a t h s r e l a t e d t o b i o l o g i c a l f a c t o r s , g e n e t i c f a c t o r s and h e a l t h c a r e f a c t o r s ? TABLE 23. CAUSE OF INFANT DEATH BY AGE FOR STATUS INDIANS IN B.C"., 1974-1980 Age Percentage of total Infant CAUSE OF DEATH 6-28 days 29 days-1 y r . Infant Deaths Mortal i ty Rates I Infectious and Paras i t ic Diseases 2 12 4.4% 1.6% II Neoplasms 1 0 0.3% .1% III Endocrine, Nutr i t ional & Metabolic Diseases 1 5 1.9% 0.7% IV Diseases of Blood & Blood Forming Organs 0 1 0.3% 0.1% V Mental Disorders 0 0 0% 0% VI Diseases of the Nervous System & Sense Organs 1 9 3.2% 1.1% VII Diseases of the Circulatory System 0 6 1.9% .7% VIII Diseases of the Respiratory System 1 47 15.3% 5.4% IX Diseases of the Digestive 'System 3 3 1 . 9 % . 0.7% X Diseases of the Genito-Urinary Tract o : 4 1.3% 0.4% XI Complications of Pregnancy, Chi ldb i r th & the Puerperium 4 4 2.5% 0.9% XII Diseases of the Skin and sub-cutaneous Tissue 0 1 0% 0% XIII Diseases of the musculoskeletal System 0 0 0% 0% XIV Congenital Anomalies 13 12 8.0% 2.8% XV Certain Causes of Perinatal Morta l i ty 105 2 34.1% 12.1% XVI Symptoms and I l l -de f ined condit ions 3 53 17.8% 6.3% XVII Accidents, poisoning and violence 1 20 6.7% 2.4% Total Number of Deaths 314 Mortal i ty Rate - Total No. of Deaths , n n n Total Number of Live Births 8847 Total No. of Live Births x SOURCE: Canada, Department of National Health and Welfare Annual Reports, Pac i f ic Region, 1980 and previous years. The s t a t i s t i c s p r e s e n t e d here might s u g g e s t t h a t e n v i r o n m e n t a l c o n d i t i o n s a r e l e s s d i r e c t l y r e l a t e d t o I n d i a n i n f a n t m o r t a l i t y t o d a y than t h e y were h i s t o r i c a l l y . A l t h o u g h t h e l i n k between e n v i r o n m e n t a l c o n d i t i o n s and I n d i a n i n f a n t m o r t a l i t y may be l e s s a p p a r e n t t o d a y , i t would be i n c o r r e c t t o assume t h a t t h e s e c o n d i t i o n s a r e o f no s i g n i f i c a n c e . As we p o i n t e d o u t p r e v i o u s l y many c a u s e s o f i n f a n t m o r t a l i t y a r e a s s o c i a t e d w i t h the h e a l t h s t a t u s o f t h e mother and h e r l i f e s t y l e . These f a c t o r s a r e i n t u r n i n f l u e n c e d by s o c i a l and economic c o n d i t i o n s i n the home and the community. While s t r u c t u r a l changes i n I n d i a n communities had an impact on the h e a l t h o f I n d i a n s i n the p a s t , t h e s e changes may s t i l l p l a y a r o l e i n I n d i a n h e a l t h problems today. P a s t and p r e s e n t governments have i n t r o d u c e d programs t o improve t h e s t a n d a r d o f l i v i n g and p h y s i c a l e n vironment i n I n d i a n communities. S o c i a l w e l f a r e schemes, however, do n o t i n s u r e t h a t h e a l t h problems w i l l be e l i m i n a t e d . C e r t a i n a s p e c t s o f t h e i r p s y c h o - s o c i a l e n v i r o n m e n t a f f e c t t h e p h y s i c a l and mental w e l l -b e i n g o f I n d i a n p e o p l e . As one m e d i c a l o f f i c e r p o i n t s o u t "the d e s i r e t o be h e a l t h y c a n n o t be t a u g h t , o r d e r e d , l e g i s l a t e d o r bought" (34, p.320). I f i n d i v i d u a l s have no c o n t r o l o v e r t h e i r e n v i r o n m e n t and l a c k o f s e l f - r e s p e c t , the d e s i r e t o be h e a l t h y may n o t be p r e s e n t . S o c i a l and economic s t r u c t u r a l changes had p r o f o u n d consequences on both the p h y s i c a l and p s y c h o - s o c i a l e n vironment o f n a t i v e p e o p l e . Thus w h i l e i t may be p o s s i b l e t o l i n k I n d i a n i n f a n t m o r t a l i t y t o c e r t a i n m a t e r n a l l i f e s t y l e f a c t o r s o r mat e r n a l m e d i c a l c o n d i t i o n s , t h e s e f a c t o r s s h o u l d not be viewed i n i s o l a t i o n . In a d d i t i o n w h i l e some c o u l d argue t h a t t h e q u a l i t y o f p r e n a t a l , i n t e r p a r -tum and postpartum c a r e have a d i r e c t impact on the b i r t h outcome, i t i s i m p o r t a n t t o r e c o g n i z e t h e l i m i t a t i o n s o f m e d i c a l / t e c h n i c a l s o l u t i o n s . For example, a l t h o u g h p r e n a t a l c a r e i s u s e f u l f o r m o n i t o r i n g t h e pre g n a n c y , t h e q u a n t i t y and q u a l i t y o f p r e n a t a l c a r e has l i t t l e o r no e f f e c t on f e t a l growth and development. 6.3 An A n a l y s i s Of C u r r e n t H e a l t h Programs M e d i c a l p e r s o n n e l o f the Department o f N a t i o n a l H e a l t h and W e l f a r e acknowledge t he imp o r t a n c e o f ma t e r n a l m e d i c a l c o n d i t i o n s and l i f e i s t y ! e and h e a l t h c a r e f a c t o r s i n I n d i a n i n f a n t m o r t a l i t y . To improve t h e h e a l t h s t a t u s o f I n d i a n i n f a n t s governments have d e v e l o p e d s p e c i f i c programs t o a d d r e s s t h e s e h e a l t h problems. In a d d i t i o n , t o improve t h e h e a l t h o f I n d i a n women and the g e n e r a l I n d i a n p o p u l a t i o n , t h e Department o f N a t i o n a l H e a l t h and W e l f a r e o f f e r s programs t o f o c u s on e n v i r o n m e n t a l problems and c o n t i n u e s t o m a i n t a i n some p r e v e n t i v e , d i a g n o s t i c and t r e a t m e n t s e r v i c e s . T h i s s e c t i o n o u t l i n e s t h e v a r i o u s programs o f f e r e d by the f e d e r a l government. The l i m i t a t i o n s o f t h e s e approaches a r e examined i n . S e c t i o n 6.4. As t he f e d e r a l government b e l i e v e s t h a t t h e h i g h i n c i d e n c e o f i n f a n t m o r t a l i t y may be a r e f l e c t i o n o f i n a d e q u a t e p r e n a t a l c a r e , they,;ha.ve i n s t i t u t e d programs which f o c u s on i m p r o v i n g t h e c a r e t o p r e g n a n t women. In remote communities, p r e n a t a l e x a m i n a t i o n s a r e performed by v i s i t i n g d o c t o r s o r p u b l i c h e a l t h n u r s e s . (44). In.^l-esscisoTated, reg.igns, p u b l i e s : h e a l t h n u r s e s o r community h e a l t h r e p r e s e n t a t i v e s v i s i t p r e g n a n t women on r e s e r v e s , and a s s i s t them i n o b t a i n i n g m e d i c a l c a r e d u r i n g t h e i r p regnancy.(42) P r o v i n c i a l , f e d e r a l and m u n i c i p a l governments a l s o o f f e r p r e n a t a l c l a s s e s . A l t h o u g h t h e r e a r e no s t a t i s t i c s a v a i l a b l e on the u t i l i z a t i o n o f t h e s e s e r v i c e s i n a r e a s under p r o v i n c i a l / m u n i c i p a l j u r i s d i c t i o n , the 85. r e p o r t s o f t h e f e d e r a l government i n d i c a t e t h a t the u t i l i z a t i o n o f t h e s e s e r v i c e s v a r i e s c o n s i d e r a b l y between d i f f e r e n t a r e a s o f the p r o v i n c e . While t h e f e d e r a l government has e s t a b l i s h e d programs t o improve the l e v e l o f p r e n a t a l c a r e , t h e y have a l s o i n s t i t u t e d programs t o d e a l w i t h I n d i a n p o s t n a t a l h e a l t h problems. P u b l i c h e a l t h n u r s e s o r community h e a l t h r e p r e s e n t a t i v e s a t t e m p t t o v i s i t a l l I n d i a n i n f a n t s r e s i d i n g on r e s e r v e w i t h i n the f i r s t month a f t e r d e l i v e r y . In a d d i t i o n , f e d e r a l p u b l i c h e a l t h n u r s e s m o n i t o r the growth and development o f the i n f a n t t h r o u g h d e v e l o p m e n t a l s c r e e n i n g t e s t s which a r e performed on i n f a n t s a t 6 months, 12 months and 18 months o f age. In r e g i o n s s e r v e d by the P r o v i n c e , p u b l i c h e a l t h n u r s e s v i s i t newborn i n f a n t s a t home, s h o r t l y a f t e r t h e i r r e l e a s e from h o s p i t a l s . A l l i n f a n t s under 2500 gms a r e g i v e n development s c r e e n i n g t e s t s a t 3 months, 6 months and 9 months. I f h e a l t h problems a r e d e t e c t e d the p u b l i c h e a l t h n u r s e a d v i s e s the p a r e n t s t o c o n s u l t w i t h t h e i r own f a m i l y p h y s i c i a n . ( 4 3 ) In o t h e r a r e a s , t h e f e d e r a l government has adopted programs to d e a l w i t h h e a l t h problems e x p e r i e n c e d by t h e g e n e r a l I n d i a n p o p u l a t i o n . To p r e v e n t the s p r e a d o f communicable d i s e a s e s , the M e d i c a l S e r v i c e s Branch c o n t i n u e s t o o f f e r i m m u n i z a t i o n c l i n i c s f o r I n d i a n s r e s i d i n g on r e s e r v e s under f e d e r a l j u r i s d i c t i o n . S i m i l a r l y , , the p r o v i n c i a l government o f f e r s i m m u n i s a t i o n t o i n f a n t s and c h i l d r e n l i v i n g o f f r e s e r v e s and on r e s e r v e s i n a r e a s under p r o v i n c i a l h e a l t h j u r i s d i c t i o n . T u b e r c u l o s i s s u r v e i l l a n c e programs a r e ' a l s o o f f e r e d '.by the M e d i c a l S e r v i c e s Branch o f t h e Department o f N a t i o n a l H e a l t h and W e l f a r e . S u r v e y s a r e con-d u c t e d on a l 1 r e s e r v e s t o d e t e c t a c t i v e and r e a c t i v a t e d c a s e s o f t u b e r -c u l o s i s . I n d i v i d u a l s who a r e i n f e c t i o u s a r e then h o s p i t a l i z e d f o r up t o a p e r i o d o f t h r e e months. O u t p a t i e n t chemotherapy programs, on the o t h e r hand, a r e funded by the p r o v i n c i a l government. These programs a r e admin-86. istered by community health representatives, employed by Band Councils, or by federal or provincial public health nurses. While environmental health problems on reserves are generally the responsibility of the Department of Indian Affairs and Band Councils, the Medical Services Branch does employ personnel to inspect public facilities, and water and sewage systems. In addition, all plans for major water and sewer projects on reserves are submitted to Medical Services for review and aPRroyal. (44) in recent years, there has been some disagreements between the Department of National Health and Welfare and the Department of Indian Affairs regarding the standards which should be applied to reserve water and sewage treatment systems. To resolve these conflicts an interdepart-mental committee has been created recently, to formulate standards which could be applied to the future-construction of reserve water and sewage sys-tems;2jT;(;44) Furthermore, environmental health officers have expressed con-cern over the lack of maintenance of reserve utilities. According to the opinion of one environmental health Ojffffii|ers, the Department of Indian Affairs does not allocate sufficient funds for the maintenance of these existing systems. (4_5,)/irQf.fil&ijalis;o,f it-he-Me/dtea\ S.ejsv/icesxB;r.aiicihihavecsugge.s.ted.nthat .some Indian health problems are directly linked to the deterioration„of a reserve utilities. (44) Other environmental health problems on Indian reserves are monitored by officials of the Medical Services Branch. For example, in 1975 a mer-cury program was established to identify possible health problems associated with TO^\&7l»>yi^3utt1tftl Based on these survey findings, federal officials advised certain bands to reduce their intake of char or eliminate char from their diet completely. A l t h o u g h a l a r g e p r o p o r t i o n o f r e s o u r c e s a r e d i r e c t e d towards e n v i r o n -mental h e a l t h programs, M e d i c a l S e r v i c e s a l s o p r o v i d e s c o u n s e l l i n g s e r v i c e s i n such a r e a s as mental h e a l t h , and a l c o h o l and drug abuse. As f e d e r a l o f f i c i a l s a l s o acknowledge t h a t many ca u s e s o f I n d i a n m o r t a l i t y and more s p e c i f i c a l l y I n d i a n i n f a n t m o r b i d i t y and m o r t a l i t y a r e r e l a t e d t o a l c o h o l abuse, the M e d i c a l S e r v i c e s Branch p r o v i d e s some f u n d i n g f o r a l c o h o l abuse and t r e a t m e n t p r o j e c t s . In 1980 the M e d i c a l S e r v i c e s Branch c o n t r i b u t e d a p p r o x i m a t e l y $845,000 towards 28 d i f f e r e n t p r o j e c t s t h r o u g h o u t B.C. (44) E x p e n d i t u r e s d i r e c t e d towards a l c o h o l and t r e a t m e n t p r o j e c t s a c c o u n t e d f o r 6% o f t h e t o t a l e x p e n d i t u r e s o f I n d i a n H e a l t h S e r v i c e s f o r the f i s c a l y e a r 1980/81. A l t h o u g h t h i s f i g u r e does n o t t a k e i n t o a c c o u n t the e x p e n d i t u r e s f o r p r e v e n t i v e p u b l i c e d u c a t i o n programs, i t does p r o v i d e an a p p r o x i m a t i o n o f t h e p r o p o r t i o n o f t h e t o t a l h e a l t h budget s p e n t i n t h i s a r e a . In view o f the f a c t t h a t the M e d i c a l S e r v i c e s Branch e s t i m a t e s t h a t up t o 50% o f a l l I n d i a n d e a t h s a r e r e l a t e d t o a l c o h o l abuse, i t would seem t h a t a l c o h o l - r e l a t e d h e a l t h problems a r e n o t r e c e i v i n g the a t t e n t i o n t h e y d e s e r v e . (47) L a s t l y , p u b l i c h e a l t h e d u c a t i o n programs c o n t i n u e t o be o f f e r e d by p r o f e s s i o n a l s and p a r a - p r o f e s s i o n a l s employed by t h e M e d i c a l S e r v i c e s Branch o r l o c a l Band C o u n c i l s . P r e v e n t i v e p u b l i c h e a l t h programs a r e a l s o o f f e r e d t o o f f - r e s e r v e I n d i a n s t h r o u g h l o c a l s c h o o l boards and h e a l t h and s o c i a l s e r v i c e a g e n c i e s . While the M e d i c a l S e r v i c e s Branch o f the Department o f N a t i o n a l and H e a l t h and W e l f a r e has expanded i t s h e a l t h s e r v i c e s so t h a t t o d a y g r e a t e r emphasis i s p l a c e d on e n v i r o n m e n t a l s u r v e i l l a n c e a c t i v i t i e s , i t has s t i l l r e t a i n e d i t s r o l e as a d v i s o r on m a t t e r s which a r e assumed t o a f f e c t the h e a l t h o f I n d i a n p e o p l e . In r e c e n t y e a r s the f e d e r a l government has adopted a p o l i c y t o t r a n s f e r h e a l t h s e r v i c e s t o Band o r T r i b a l C o u n c i l s . A t p r e s e n t , n a t i v e groups a r e i n v o l v e d i n program p l a n n i n g a t the n a t i o n a l , r e g i o n a l , and zone l e v e l s . A c c o r d i n g t o the 1980 Annual R e p o r t , H e a l t h Committees have a l s o been formed i n t h i r t e e n I n d i a n communities and c o n t r a c t s have been n e g o t i a t e d w i t h c e r t a i n bands t o \ h i r e t h e i r own h e a l t h p e r s o n n e l . T h i s new p o l i c y s t r a t e g y . a d o p t e d by the f e d e r a l government d i f f e r s r a d i c a l l y from t he approaches s e l e c t e d under p r e v i o u s a d m i n i s t r a t i o n s . When I n d i a n H e a l t h S e r v i c e s was c r e a t e d i n 1905, t h e r e was no i n p u t from n a t i v e p e o p l e on h e a l t h m a t t e r s . They were s i m p l y t he r e c i p i e n t s o f m e d i c a l and p u b l i c h e a l t h s e r v i c e s p r o v i d e d by a government who was l a r g e l y c o n c e r n e d w i t h c o n t r o l l i n g t h e s p r e a d o f i n f e c t i o u s d i s e a s e s . W h i l e t h e f e d e r a l government t o d a y o f f e r s a wide v a r i e t y o f h e a l t h programs, i t i s i m p o r t a n t t o c o n s i d e r the u t i l i t y o f t h e s e d i f f e r e n t a p p r o a c h e s f o r r e s o l v i n g I n d i a n i n f a n t h e a l t h p r o b l e m s . The f o l l o w i n g s e c t i o n d e s c r i b e s some o f the s t r u c t u r a l c o n s t r a i n t s o f t h e s e i n t e r v e n t i o n s t r a t e g i e s . 6.4 The L i m i t a t i o n s o f S t a t e I n t e r v e n t i o n S t r a t e g i e s As M e d i c a l S e r v i c e s o f t h e Department o f N a t i o n a l H e a l t h and W e l f a r e has no j u r i s d i c t i o n o v e r m a t t e r s which a f f e c t h e a l t h , t h e y have l i m i t e d o p p o r t u n i t i e s t o improve the p h y s i c a l environment i n I n d i a n communities. For example, t h e y can a d v i s e the Department o f I n d i a n A f f a i r s o f p o t e n t i a l h e a l t h problems a s s o c i a t e d w i t h poor h o u s i n g or u n s a n i t a r y c o n d i t i o n s , but the power t o a l t e r t h e s e c o n d i t i o n s l i e s l a r g e l y w i t h t he Department o f I n d i a n A f f a i r s , who c o n t r o l s the f u n d i n g . L i k e w i s e , w h i l e e n v i r o n m e n t a l h e a l t h o f f i c e r s have t a k e n s t e p s to a s s i s t Band C o u n c i l s p r e p a r e e n v i r o n -mental by-laws, t h e s e by-laws o n l y a f f e c t a c t i v i t i e s which t a k e p l a c e on r e s e r v e l a n d s . I f t h e s o u r c e o f p o l l u t i o n o c c u r s i n a r e a s under p r o v i n c i a l j u r i s d i c t i o n t hen i t i s the r e s p o n s i b i l i t y o f t h e p r o v i n c i a l government t o r e g u l a t e o r m o n i t o r t h e s e a c t i v i t i e s . Band C o u n c i l s a r e p o w e r l e s s t o e l i m i n a t e p o l l u t i o n problems a f f e c t i n g r e s e r v e s when the s o u r c e o r i g i n a t e s from a s i t e o f f t h e r e s e r v e . 89. The Department o f N a t i o n a l H e a l t h and W e l f a r e has a l s o l i m i t e d o p p o r t u n i t i e s t o r e s o l v e h e a l t h problems a s s o c i a t e d w i t h o t h e r s o c i a l phenomenon. T h i s department can c o n d u c t s u r v e y s and i d e n t i f y c h i l d r e n s u f f e r i n g from f e t a l a l c o h o l syndrome, and t h e y can p r o v i d e p u b l i c h e a l t h e d u c a t i o n programs t o i n f o r m I n d i a n p e o p l e o f the haz a r d s a s s o c i -a t e d w i t h a l c o h o l abuse, but t h e s e a p p r o a c h e s do n o t at t e m p t t o t r e a t t h e cau s e s o f I n d i a n a l c o h o l i s m . While t h i s department does p r o v i d e funds f o r t r e a t m e n t s e r v i c e s , t h e s e measures p r i m a r i l y f o c u s on t h e i n d i v i d u a l and the m o d i f i c a t i o n o f h i s b e h a v i o r s . The o v e r a l l l o n g - t e r m g a i n s o f c o u n s e l l i n g s e r v i c e s and i n d i v i d u a l s e l f - h e l p s t r a t e g i e s may n o t be as g r e a t as o t h e r approaches which f o c u s on a l t e r i n g c o n d i t i o n s which a f f e c t b e h a v i o r ; . While b e h a v i o r , p a t t e r n s a r e d e t e r m i n e d i n p a r t by i n d i v i d u a l f a c t o r s , o t h e r e x t e r n a l f o r c e s i n f l u e n c e the a t t i t u d e s and b e h a v i o r ^ f i n d i v i d u a l s . I f I n d i a n a l c o h o l i s m i s r e l a t e d t o o t h e r f a c t o r s which e x t e n d beyond t he b o u n d a r i e s o f I n d i a n commun-i t i e s , t hen the s o l u t i o n s t o t h e s e problems may o n l y be found by exam i n i n g t h e s o c i a l and economic r e l a t i o n s h i p s between I n d i a n and n o n - I n d i a n p e o p l e . P u b l i c h e a l t h e d u c a t i o n programs a l s o may have l i t t l e impact on mat e r n a l h e a l t h and i n f a n t m o r b i d i t y and m o r t a l i t y . As we p o i n t e d o u t i n C h a p t e r Two programs which f o c u s on a l t e r i n g b e h a v i o r w i t h o u t c o n s i d e r i n g t h e causes o f . t h i s b e h a v i o r a r e u n l i k e l y t o produce the i n t e n d e d r e s u l t s . The h e a l t h o f the pre g n a n t women may o n l y be improved by a l t e r i n g t h o s e c o n d i t i o n s which a f f e c t h e r p h y s i c a l and mental h e a l t h s t a t e . F u r t h e r m o r e , w h i l e programs which attempt t o m o n i t o r the pregnancy and subsequent development o f the newborn may be w o r t h w h i l e , t h e g r e a t e s t o p p o r t u n i t y f o r i m p r o v i n g t h e h e a l t h s t a t u s o f I n d i a n i n f a n t s T i e s i n a r e a s which e x t e n d beyond t he j u r i s d i c t i o n a l b o u n d a r i e s o f h e a l t h d e p a r t m e n t s . The p o t e n t i a l f o r f o r m u l a t i n g new s t r a t e g i e s f o r i n f a n t h e a l t h i s p o s s i b l e i f h e a l t h p l a n n i n g i s t r a n s f e r r e d t o l o c a l I n d i a n governments. However, F e d e r a l o f f i c i a l s r e c o u n t a number o f o b s t a c l e s which h i n d e r t h e de-v o l u t i o n o f I n d i a n H e a l t h S e r v i c e s . F i r s t l y , s l i g h t l y l e s s than one h a l f o f a l l r e g i s t e r e d I n d i a n s r e s i d i n g on reserves,'• a r e s e r v e d by the P r o v i n c e , S e c o n d l y , t h e r e a r e a l a r g e number o f bands and I n d i a n communities. As most communities a r e v e r y s m a l l t h e y may n o t r e q u i r e t h e f u l l t i m e s e r v i c e s o f h e a l t h p r o f e s s i o n a l s . A l s o , because some communities a r e l o c a t e d i n remote a r e a s o f B r i t i s h Columbia t h e s e I n d i a n groups may have d i f f i c u l t y a t t r a c t i n g p e r s o n n e l . The M e d i c a l S e r v i c e s Branch o f t h e Department o f N a t i o n a l H e a l t h and W e l f a r e has e x p e r i e n c e d problems r e c r u i t i n g h e a l t h p e r s o n n e l t o work i n the n o r t h e r n r e g i o n s o f B.C. S i m i l a r problems w i l l u n d o u b t e d l y o c c u r when I n d i a n governments g a i n c o n t r o l F i n a l l y , a l t h o u g h I n d i a n groups a r e i n the b e s t p o s i t i o n t o i d e n t i f y t h e i r p a r t i c u l a r h e a l t h problems and f o r m u l a t e s t r a t e g i e s , t h e r e may be a t e n d e n c y t o r e i n s t i t u t e t h e same programs o f f e r e d p r e s e n t l y . P r e v e n -t i v e and m e d i c a l t e c h n i q u e s a r e u s e f u l t o some d e g r e e , but I n d i a n groups must be aware o f t h e l i m i t a t i o n s o f t h e s e s t r a t e g i e s . The b e l i e f t h a t h e a l t h problems can be overcome by i n c r e a s i n g the consumption o f m e d i c a l s e r v i c e s o r i m p r o v i n g d i a g n o s t i c and t r e a t m e n t t e c h n i q u e s i s a w i d e s p r e a d phenomenon t h r o u g h o u t N o r t h American. As h e a l t h c o s t s i n c r e a s e governments embrace the new s e l f - h e l p p r e v e n t i v e s t r a t e g i e s . The s o l u t i o n s p r o v i d e o n l y p a r t i a l s o l u t i o n s and i n some i n s t a n c e s t h e y may be i r r e l e v a n t t o t h e h e a l t h problems o f the I n d i a n p o p u l a t i o n . 6.5 C o n c l u s i o n s and P o l i c y S t r a t e g i e s I f p r e v e n t i v e , d i a g n o s t i c and t r e a t m e n t s e r v i c e s a r e o f l i m i t e d u t i l i t y i n terms o f r e d u c i n g I n d i a n i n f a n t h e a l t h p r o b l e m s , then what s t r a t e g i e s s h o u l d be a d o p t e d t o improve t h e h e a l t h o f I n d i a n i n f a n t s ? W h i l e t h e r o l e o f e n v i r o n m e n t c o n d i t i o n s may be l e s s a p p a r e n t t o d a y than i t was p r e v i o u s l y , the h i g h i n c i d e n c e o f dea t h s d u r i n g t h e p e r i n a t a l p e r i o d would s u g g e s t t h a t l i f e s y t l e f a c t o r s and m a t e r n a l m e d i c a l c o n d i t i o n s a r e r e l a t e d t o I n d i a n i n f a n t m o r t a l i t y . I n d i a n i n f a n t m o r t a l i t y i s a m u l t i f a c e t e d problem. The h e a l t h problems posed may have d e t e r m i n a n t s which a r e p e c u l i a r t o each r e g i o n and i n f a c t t o each I n d i a n community o r group. In some i n s t a n c e s i n f a n t and mate r n a l h e a l t h problems may be l i n k e d t o c e r t a i n a s p e c t s o f the p h y s i c a l e nvironment on r e s e r v e s o r t o o t h e r e n v i r o n m e n t a l h e a l t h problems which o r i g i n a t e from s i t e s n e a r r e s e r v e s . F o r exam p l e , i n r u r a l a r e a s o f B r i t i s h Columbia u n d e r p r i v i l e g e d I n d i a n women may e x p e r i e n c e p r e g n a n c i e s a t s h o r t i n t e r v a l s and may have h i g h r a t e s o f i l l - h e a l t h as a r e s u l t o f u n f a v o u r a b l e e n v i r o n m e n t a l c o n d i t i o n s o r an i n a d e q u a t e d i e t . In o t h e r i n s t a n c e s , i n f a n t h e a l t h problems may be l i n k e d t o s o c i a l phenomena. In the urban s e c t o r , u n d e r p r i v i l e g e d I n d i a n women may be worse o f f than t h e i r r u r a l c o u n t e r p a r t s . As a new m i g r a n t i n a n u c l e a r f a m i l y t h e I n d i a n woman may n o t r e c e i v e t h e s o c i a l s u p p o r t o f o t h e r i n d i v i d u a l s i n h e r l o c a l i t y . F u r thermore c i t y l i f e s t y l e s expose her t o the ha z a r d s o f c a u s a l s e x u a l r e l a t i o n s h i p s . As a s i n g l e p a r e n t w i t h a low l e v e l o f e d u c a t i o n she may be un a b l e t o a c q u i r e a j o b t o s u p p o r t h e r s e l f and her o f f s p r i n g . Her f e e l i n g s o f f r u s t r a t i o n and d e s p a i r a r e compounded f u r t h e r when she r e a l i z e s t h a t as an I n d i a n she i s r e g a r d e d by many n o n - I n d i a n s as a second c l a s s c i t i z e n . Her i n f e r i o r sense o f w e l l - b e i n g may have d i r e c t and i n d i r e c t consequences on her h e a l t h and the h e a l t h s t a t u s o f the newborn. A l t h o u g h t h e r e l a t i o n s h i p between b i o l o g i c a l , s o c i a l and economic f a c t o r s may v a r y c o n s i d e r a b l y i n d i f f e r e n t a r e a s o f B r i t i s h C o lumbia, i t i s i m p o r t a n t t h a t I n d i a n groups r e c o g n i z e t h a t m e d i c a l / t e c h n i c a l s o l u t i o n s and s e l f - h e l p p r e v e n t i v e s t r a t e g i e s c a n n o t p r o v i d e r e a l s o l u t i o n s t o i n f a n t h e a l t h problems. To improve the h e a l t h s t a t u s o f I n d i a n i n f a n t s , r e s o u r c e s s h o u l d be d i r e c t e d towards i m p r o v i n g t h e m a t e r i a l and mental w e l l - b e i n g o f I n d i a n p e o p l e . To a c h i e v e t h e s e o b j e c t i v e s , i t i s e s s e n t i a l t h a t governments p r o v i d e I n d i a n s w i t h t h e o p p o r t u n i t i e s t o r e g a i n s e l f - r e s p e c t and c o n t r o l o v e r the i n s t i t u t i o n s which a f f e c t t h e i r d a i l y l i v e s . To improve the s o c i a l and economic c o n d i t i o n s o f I n d i a n p e o p l e governments s h o u l d adopt two s t r a t e g i e s . F i r s t l y , i t i s e s s e n t i a l t h a t governments d e v e l o p programs to reduce the e d u c a t i o n a l gap between I n d i a n and n o n - I n d i a n p e o p l e . S e c o n d l y , r e s o u r c e s s h o u l d be d i r e c t e d towards economic development on r e s e r v e s . In d e v i s i n g economic development s t r a t e g i e s emphasis s h o u l d be p l a c e d on u s i n g l o c a l r e s o u r c e s t o c r e a t e j o b s f o r the unemployed. As R u f f i n g p o i n t s o u t , g i v e n l i m i t e d , f i n a n c i a l c a p i t a l and m a n a g e r i a l s k i l l s i t may be more d e s i r a b l e , from a p s y c h o l o g i c a l and s o c i o l o g i c a l p e r s p e c t i v e , t o e s t a b l i s h band o r t r i b a l e n t e r p r i s e s which a r e l a b o u r i n t e n s i v e as opposed t o c a p i t a l i n t e n s i v e (49). In any c a s e , I n d i a n s must be i n v o l v e d a t a g r a s s - r o o t s l e v e l i n p l a n n i n g and i n s t i t u t i n g t h e s e programs i f t h e s e i n t e r v e n t i o n s t r a t e g i e s a r e t o be s u c c e s s f u l . F i n a l l y w h i l e some might argue t h a t I n d i a n i n f a n t m o r t a l i t y problems a r e n o t s e r i o u s enough to w a r r a n t o u r a t t e n t i o n , i t i s i m p o r t a n t t o r e c o g n i z e t h a t the l o n g term c o s t s o f i n f a n t i l l - h e a l t h may be f a r g r e a t e r than the c o s t s o f implementing human r e s o u r c e development programs. GLOSSARY A m n i o c e n t e s i s A n o x i a A s p h y x i a A t e l e c t a s i s o f the Newborn A s u r g i c a l t e c h n i q u e whereby a m n i o t i c f l u i d i s withdrawn from the u t e r u s and examined t o d e t e r m i n e sex o r chromosonal a b n o r m a l i t i e s . A c o n d i t i o n o f extreme oxygen d e f i c i e n c y due e i t h e r t o the f a i l u r e o f the t i s s u e t o r e c e i v e o r u t i l i z e an adequate amount o f oxygen. A s t a t e o f i n s u f f i c i e n t oxygen c a r b o n d i o x i d e exchange g e n e r a l l y r e s u l t i n g i n r e s p i r a t o r y f a i l u r e . A s t a t e o f i n c o m p l e t e e x p a n s i o n o f the l u n g s B i r t h I n j u r y Cesarean S e c t i o n C o l i t i s C o n g e n i t a l M a l f o r m a t i o n s o r C o n g e n i t a l Anomalies E n t e r i t i s F e t o s c o p y Immaturity Neonatal Death A d e b i l i t y s u f f e r e d by a neonate d u r i n g the b i r t h p r o c e s s . Examples o f b i r t h i n j u r i e s i n c l u d e bone f r a c t u r e s and i n t e r c r a n i a l hemorrhage. A s u r g i c a l i n c i s i o n i n the abdominal and u t e r i n e w a l l t o e x t r a c t t h e f e t u s and p l a c e n t a An i n f l a m m a t i o n o f the c o l o n which i s p a r t o f the l a r g e i n t e s t i n e . A d e f o r m i t y which o c c u r s as a r e s u l t o f abnormal f e t a l growth and development. M a l -f o r m a t i o n may r e s u l t from an e a r l y a r r e s t o f t i s s u e development o r i n c e r t a i n c a s e s t h e r e i s an o v e r g r o w t h o r overdevelopment o f l o c a l t i s s u e s . An i n f l a m m a t i o n o f the i n t e s t i n a l t r a c t e s p e c i a l l y o f the mucus membrane. A s u r g i c a l t e c h n i q u e f o r examining the f e t u s and e x t r a c t i n g f e t a l b l o o d t o i d e n t i f y such c o n d i t i o n s as s i c k l e c e l l d i s e a s e , c l e f t l i p and p l a t e , l i m b d e f o r m i t i e s and low s p i n a b i f i d a . A l i v e b o r n i n f a n t which i s n o t f u l l y d e v e l o p e d The death o f a l i v e b o r n i n f a n t w i t h i n t he f i r s t 27 d a y s , 23 hours and 59 minutes o f l i f e . P r e i n a t a l Death I n f a n t d e a t h which o c c u r s 0 - 7 days i n c l u s i v e o f l i f e . 94. P o s t n e o n a t a l Death Premature I n f a n t S t a t u s I n d i a n S t i l l b i r t h T e r a t o g e n i c Agents A d e a t h o f an i n f a n t which o c c u r s between 29 days and one y e a r . A neonate born b e f o r e the 37th t o 38th week o f g e s t a t i o n . F o r m e r l y i n f a n t s w e i g h i n g l e s s than 2500 gms. a t b i r t h were c l a s s i f i e d as premature i n f a n t s . A p e r s o n who i s r e g i s t e r e d o r who i s e n t i t l e d t o be r e g i s t e r e d under p r o v i s i o n s o f the I n d i a n A c t . L e g a l s t a t u s i s o b t a i n e d a t b i r t h i f t h e i n f a n t ' s f a t h e r i s a r e g i s t e r e d I n d i a n . Non-Indian women may a l s o become r e g i s t e r e d o r s t a t u s I n d i a n s i f t h e y marry a r e g i s t e r e d I n d i a n . On the o t h e r hand, r e g i s t e r e d I n d i a n women a u t o m a t i c a l l y f o r f e i t t h e i r r e g i s t e r e d I n d i a n s t a t u s i f t h e y marry a n o n - I n d i a n man. An i n f a n t born dead F a c t o r s such as dr u g s t h a t c a u s e m a l f o r m a t i o n s d u r i n g p r e n a t a l development. T h a l i d o m i d e i s one example o f a t e r a t o g e n i c agent. 95. NOTES 1. The r a t e o f h o s p i t a l i z a t i o n f o r r e g i s t e r e d I n d i a n s was d e r i v e d from the Annual R e p o r t , P a c i f i c R e g i o n , 1977. Non-Indian h o s p i t a l i z a t i o n r a t e s were d e r i v e d from S t a t i s t i c s o f H o s p i t a l Cases D i s c h a r g e d d u r i n g 1977, M i n i s t r y o f H e a l t h , H o s p i t a l Programs, V i c t o r i a , 1977- p. 13. 2. The average c o s t per p a t i e n t day (1977) was d e r i v e d from the f o l l o w i n g s o u r c e s : B r i t i s h C o lumbia, M i n i s t r y o f F i n a n c e , P u b l i c A c c o u n t s , H o s p i t a l Program S p e n d i n g , 1977, H e a l t h Annual R e p o r t , 1978, V i c t o r i a , 1978 3. R e p o r t s o f V i t a l S t a t i s t i c s r e v e a l t h a t between 1970 and 1978 the Canadian i n f a n t m o r t a l i t y r a t e dropped from 18.8 d e a t h s per 1000 l i v e b i r t h s t o 12.0. In c o n t r a s t between 1950 and 1958 the i n f a n t m o r t a l i t y r a t e dropped 11.3 p o i n t s - 41.5 t o 30.2. Thus w h i l e i n f a n t m o r t a l i t y r a t e s a r e d e c l i n i n g , t h e s e improvements a r e not as s i g n i f i c a n t t o d a y as t h e y were p r e v i o u s l y . 4. The d i s t r i b u t i o n o f Canadian h e a l t h e x p e n d i t u r e s i n r e c e n t y e a r s has been w e l l documented i n B o u l e t , J . and G r e n i e r , G. H e a l t h E x p e n d i t u r e s  i n Canada and the Impact o f Demographic Changes on F u t u r e Government  H e a l t h I n s u r a n c e Programs Ottawa: M i n i s t r y o f S u p p l y and S e r v i c e s , 1978. A c c o r d i n g t o t h e i r f i n d i n g s i n 1960 p r i v a t e and p u b l i c h e a l t h e x p e n d i t u r e s a c c o u n t e d f o r r e s p e c t i v e l y 57% and 43% o f t o t a l h e a l t h e x p e n d i t u r e s . In c o n t r a s t , i n 1975 p r i v a t e h e a l t h e x p e n d i t u r e s had dropped t o 25% o f t o t a l h e a l t h e x p e n d i t u r e s . 5. T r e a t y #6 was n e g o t i a t e d between the Crown and the P l a i n s Cree I n d i a n s i n Saskatchewan i n 1876. T h i s t r e a t y c o n t a i n e d p r o v i s i o n s f o r a m e d i c i n e c h e s t t o be kept i n the home o f the I n d i a n agent f o r the use and b e n e f i t o f I n d i a n p e o p l e . 6. C a l c u l a t i o n s were based on the f i n a n c i a l s t a t e m e n t s i n the M e d i c a l S e r v i c e s B r a n c h , Annual R e p o r t , P a c i f i c R e g i o n , 1980. For a d e t a i l e d breakdown o f e x p e n d i t u r e s f o r I n d i a n H e a l t h S e r v i c e s between 1975 and 1980 r e f e r t o Appendix D. 7. The Annual R e p o r t , P a c i f i c Region 1980 i n d i c a t e s t h a t t h e r e a r e 194 Bands and 350 communities i n B r i t i s h Columbia. 96. REFERENCES CITED 1. S t a n b u r y , W.T. a s s i s t e d by S i e g e ! , J.H. Succes.s and F a i l u r e : I n d i a n s i n Urban S o c i e t y , Vancouver: U.B.C. P r e s s 1975 2. 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"A R e s e a r c h Note on the Changing A s s o c i a t i o n Between I n f a n t M o r t a l i t y and S o c i o - E c o n o m i c S t a t u s " , S o c i a l F o r c e s , 37: 221-227, 1959 23. J a c o b s , M. and S t e v e n s o n , G. " H e a l t h and H o u s i n g : An H i s t o r i c a l E x a m i n a t i o n o f A l t e r n a t i v e P e r s p e c t i v e s " , I n t e r n a t i o n a l J o u r n a l  o f H e a l t h S e r v i c e s , 1 1 ( 1 ) : 105-122, 1981 ? » Canada. Department o f I n d i a n A f f a i r s . Annual R e p o r t , 1929, Ottawa: Queen's P r i n t e r , 1929. 25. Canada. Department o f Mines and R e s o u r c e s . Annual Report. Ottawa: Queen's P r i n t e r , 1939 26. Graham-Cummings, G. "The H e a l t h o f the O r i g i n a l C a n a d i a n s , 1867-1967" M e d i c a l S e r v i c e s J o u r n a l , 23(1 ): 115-174, 1967 27. Canada. Department o f Mines and R e s o u r c e s . Annual R e p o r t . Ottawa: Queen's P r i n t e r , 1942 28. F i e l d i n g , J . E . and YanKauer. "The Pregnant D r i n k e r " , American J o u r n a l o f P u b l i c H e a l t h 68: 836-838, 1978 R e f e r e n c e s C i t e d 29. Dubos, R. Man A d a p t i n g , London: Y a l e U n i v e r s i t y P r e s s , 1965 30. Canada. Department o f N a t i o n a l H e a l t h and W e l f a r e . Annual Report. Ottawa: Queen's P r i n t e r , 1955 31. Rush, D.H. e t a l " A n t e c e d e n t s o f low b i r t h w e i g h t i n Harlem, New York C i t y " , I n t e r n a t i o n a l J o u r n a l o f E p i d e m i o l o g y , 4:3775-87, 1972 32. Holtzman, N.A. " P r e v e n t i o n : R h e t o r i c and R e a l i t y " , I n t e r n a t i o n a l J o u r n a l o f H e a l t h S e r v i c e s , 9 ( 1 ) : 25-39, 1979 33. B r i t i s h Columbia, M i n i s t r y o f H e a l t h " I n d i a n H e a l t h C a r e : R o l e s and R e s p o n s i b i l i t i e s o f the P r o v i n c i a l and F e d e r a l Governments", u n p u b l i s h e d p a p e r , n.d. o? 1979 34. Simpson, C A . " I n d i a n H e a l t h n o t a m e d i c a l problem", B.C. M e d i c a l J o u r n a l , 1 6 ( 1 1 ) : 320-322, 1974 35. C o r d e s , S.M., " D i s t r i b u t i o n o f P h y s i c a l Manpower" p. 56-81 i n H a s s i n g e r , E.W. and W h i t i n g , L. R u r a l H e a l t h S e r v i c e s : O r g a n i z a t i o n , D e l i v e r y and Use. Ames, Iowa: Iowa S t a t e U n i v e r s i t y P r e s s , 1976 36. Union o f B.C. I n d i a n C h i e f s " I n d i a n H e a l t h " u n p u b l i s h e d p o s i t i o n p a p e r , n.d. c. 1979 37. W i n n i c k , M. " C e l l u l a r Growth i n I n t r a u t e r i n e M a l n u t r i t i o n " Ped. C l i n o f N.A. 1 7 ( 1 ) : 69, 1970 38. Chandra, R. " F e t a l M a l n u t r i t i o n and P o s t n a t a l Imuno-competence" American J o u r n a l o f D i s a b l e d C h i l d r e n 129:450, 1975 39. C o m e l y , P.B. "The Hidden Enemies o f H e a l t h and the American P u b l i c H e a l t h A s s o c i a t i o n " American J o u r n a l o f P u b l i c H e a l t h 6 1 ( 1 ) : 7-18, 1971 40. ' Canada. Department o f N a t i o n a l H e a l t h and W e l f a r e . "Annual R e p o r t - 1976, P a c i f i c R e g i o n " , Mineo n.d., p.18. 41. K n i g h t , R. I n d i a n s a t Work: An Informal H i s t o r y o f N a t i v e I n d i a n Labour  i n B r i t i s h C olumbia, 1958-1930; Vancouver: New S t a r Books, 1978. 42. M u r i e , J . M e d i c a l S e r v i c e s Branch. Department o f N a t i o n a l H e a l t h and W e l f a r e . I n t e r v i e w w i t h a u t h o u r , March, 1981. R e f e r e n c e s C i t e d 43. P u l l e n , P., N u r s i n g S u p e r v i s o r , Boundary H e a l t h U n i t . M i n i s t r y o f H e a l t h , I n t e r v i e w w i t h A u t h o u r September, 1981. 44. Canada. Department o f N a t i o n a l H e a l t h and W e l f a r e "Annual R e p o r t , 1980 - P a c i f i c R e g i o n " , Mineo, n.d. 45. Schwinghamer, D., E n v i r o n m e n t a l H e a l t h O f f i c e r . M e d i c a l S e r v i c e s B r a n c h . Department o f N a t i o n a l H e a l t h and W e l f a r e . I n t e r v i e w w i t h a u t h o u r , September, 1981. 46. Goodman, L. A n a l y z i n g Q u a l i t a t i v e / C a t e g o r i c a l Data Cambridge: Abt Books, 1978. 47. Canada. Department o f N a t i o n a l H e a l t h and W e l f a r e "Annual R e p o r t , 1978 -P a c i f i c Region", mimeo. n.d. 48. L a u r e l l , A. e t a l " D i s e a s e and R u r a l Development: A S o c i o l o g i c a l A n a l y s i s o f M o r b i d i t y i n Two Mexican V i l l a g e s " I n t e r n a t i o n a l J o u r n a l  o f H e a l t h S e r v i c e s 7 ( 3 ) : 401-425, 1977. 49. R u f f i n g , L.T. "Navajo Economic Development: A Dual P e r s p e c t i v e " i n S t a n l e y , S. ( e d ) , American I n d i a n Economic Development. C h i c a g o : Mouton P u b l i s h e r s , 1978. 50. B r e n n e r , C. e t a l "Navajo I n f a n t M o r t a l i t y , 1970" P u b l i c H e a l t h R e p o r t s 8 9 ( 4 ) : 353-359, 1974. 51. R u b e n s t e i n , A. e t a l " E f f e c t o f Improved S a n i t a r y F a c i l i t i e s on I n f a n t D i a r r h e a i n a Hopi V i l l a g e " P u b l i c H e a l t h R e p o r t s 8 4 ( 1 2 ) : 1093-1097, 1969 52. F i n n e g a n , L.P. e t a l "The E f f e c t s o f M a t e r n a l Drug Dependence on Neonatal M o r t a l i t y " Drug and A l c o h o l Dependence 2: 131-140, 1977 53. P l a n k , S.L., M i l o n e s i , M.L. " I n f a n t F e e d i n g and I n f a n t M o r t a l i t y i n R u r a l C h i l e " B u l l e t i n , World H e a l t h O r g a n i z a t i o n 48:203-210, 1973 54. S t r i c k l e , G., P a u l , M.A. "Some S o c i a l and M e d i c a l C o r r e l a t e s o f Pregnancy Outcome" American J o u r n a l o f O b s t e t r i c s and Gynecology 1 2 7 ( 2 ) : 162-166, 1977 55. Upadhyay, B.V. e t a l "A Study o f P e r i n a t a l and Neonatal M o r t a l i t y i n a R u r a l P o p u l a t i o n , Lucknow I n d i a " Canadian J o u r n a l o f P u b l i c H e a l t h , 65:214-220, 1974 56. Marx, K. C a p i t a l : A C r i t i q u e o f P o l i t i c a l Economy V o l . 1 o f F r e d r i c k E n g e l s (ed) I he P r o c e s s o f C a p i t a l i s t P r o d u c t i o n . T r a n s . Samuel Moore and Edward A v e l i n g , New York: I n t e r n a t i o n a l P u b l i s h e r s , (1867) 1967. 57. H a r f o u c h e , J.R. " H e a l t h c a r e problems o f the young c h i l d i n a d e v e l o p i n g e c o l o g i c a l c o n t e x t " , B u l l e t i n , World H e a l t h O r g a n i z a t i o n . 5 7 ( 3 ) : 387-403, 1979. ^ TOO R e f e r e n c e s C i t e d 58. Maynard, J . E . , Mannes, L.M. "A Study o f Growth M o r b i d i t y and M o r t a l i t y among Eskimo I n f a n t s o f Western A l a s k a " B u l l e t i n , World H e a l t h O r g a n i z a t i o n 4 2 ( 4 ) : 613-622, 1970. :  59. Elestad-^Sayed, J . e t a l " B r e a s t - f e e d i n g p r o t e c t s a g a i n s t i n f e c t i o n i n I n d i a n i n f a n t s " Canadian M e d i c a l A s s o c i a t i o n J o u r n a l 1 2 0 ( 3 ) : 296-298, 1979 101 . MS PAC. 14-7/8 I MAP 3 REGIONS FOR INDIAN AND NON-INDIAN INFANT MORTALITY RATES 1 i 0 I N 0 C I T I I l Rtflaail OUKItl ••v*4»f'i Ministry of Municipal Allniri Province Ot Brtlian Co<umblt. May 190t K l l l r o U -Bt lk lu* Bulk lay -Neohako Central Co*«t 1 f fUMr - Fort OeorR^l dnrlboo \ ^ Columbia.-pfcj^ ^w a p \ 3 Mount .Wad ding Ion Thyfopaon-Nlonil BcruaroUh-LIHooetV ) Boundary\ ffmllkaiitMmi o 103 APPENDIX C TOTAL LIVEBIRTHS, NEONATAL AND POSTNEONATAL DEATHS BY REGION, INDIANS ( I ) AND NON-INDIANS ( N I ) , 1975-1977 REGION LIVEB [RTHS R a t i o o f I n d i a n t o Neonatal Deaths P o s t n e o n a t a l Deaths I NI Non-Indian L i v e b i r t h s I NI I NI 1. A l b e r n i - C l a y o q u o t 180 1379 .025 2 8 5 7 2. B u l k l e y - N e c h a k o / F r a s e r F o r t George 369 7143 .051 5 61 5 32 3. C a p i t o l / C o w i c h a n / Nanaimo 464 12064 .038 9 81 8 55 4. C a r i b o o 293 3053 .096 6 36 6 15 5. C e n t r a l C o a s t / Mt. Waddington 182 951 .191 5 9 4 4 6. C e n t r a l F r a s e r V a l l e y / G r e a t e r Vancouver 289 46267 .006 5 349 5 182 7. Okanagnon/Columbia-Shushwap/Kootenay 167 14034 .012 4 152 2 70 8. Dewdney-Alouette/ Fraser-Cheam 177 4690 .038 1 35 4 25 9. K i t i m a t - S t r i k i n e 505 2067 .244 7 26 2 13 10.. ;Skeena-Queen C h a r l o t t e 311 1047 .297 3 14 7 3 11. Peace R i v e r L i a r d 152 1979 .077 6 29 3 14 12. Powell River/Comox/ Sunshine C o a s t . 169 4154 .041 2 41 2 23 13. S q u a m i s h - L i l l o o e t / Thompson-Nicola 458 6707 .068 6 55 1 21 R a t i o o f I n d i a n t o Non-Indian B i r t h s f o r BRITISH COLUMBIA 1975-1977 -.036 SOURCE: B r i t i s h Columbia, M i n i s t r y o f H e a l t h , V i t a l S t a t i s t i c s , 1977 and p r e v i o u s y e a r s APPENDIX D DISTRIBUTION OF BIRTHS AND DEATHS FOR STUDY SAMPLE (a) D i s t r i b u t i o n o f the Study Sample Region T o t a l S i n g l e L i v e b i r t h s S u r v i v a l s Deal „hs Neonatal Deaths P o s t n e o n a t a l Deaths tenaimo # % # % # % # % # % 166 18.7% 99 16.1% 67 24.4 25 19.8% 42 28.2% Vancouver 94 10.6 65 10.6 29 10.5 15 11.9 14 9.4 C o a s t a l 99 11.1 71 11.5 28 10.2 16 12.7 12 8.0 C e n t r a l 136 15.3 103 16.8 33 12.0 17 13.5 16 10.7 torth E a s t •188 21.1 127 20.7 61 22.2 32 25.4 29 19.5 torth West "206 23.2 149 24.3 57 20.7 21 16.7 36 24.2 TOTAL y, n? 889 100% n= 614 100% n= 275 100% n= 126 100% n= 149 100% # = number = n (b) D i s t r i b u t i o n o f the Study Sample by H e a l t h J u r i s d i c t i o n tealth J u r -i s d i c t i o n T o t a l S i n g l e L i v e b i r t h s S u r v i v a l s Dea ths Neonatal Deaths P o s t n e o n a t a l Deaths F e d e r a l # % # % # % # % # % 461 51.9 330 53.7 131 47.6 61 48.4 70 47.0 Prov./ Aun. 428 48.1 284 46.3 144 52.4 65 51.6 79 53.0 TOTAL CTl II CO S= 00 100% n= 614 100% n= 275 100% n= 126 100% n= 149 100% # = number = n (c) D i s t r i b u t i o n o f the Study Sample by P l a c e o f D e l i v e r y P l a c e o f D e l i v e r y T o t a L i v e 1 S i n g l e D i r t h s S u r v i v a l s Deal ths Neot Deal l a t a l ths P o s t n e o n a t a l Deaths H o s p i t a l # % # % # % # % # % 853 96.2 593 96.6 260 95.2 120 96.0 140 94.6 Other 34 3.8 21 3.4 13 4.8 5 4.0 8 5.4 T o t a l n= 887* 100% n= 614 100% n= 273 100% n= 125 100% n= 148 100% # = number = n *2 m i s s i n g c a s e s (d) D i s t r i b u t i o n o f the Study Sample By W e l f a r e Dependency Welfare Dependency T o t a l S i n g l e L i v e b i r t h s S u r v i v a l s Deai ths Neonatal Deaths P o s t n e o n a t a l Deaths .OW % % # % # . % § % 328 36.9 228 37.1 100 36.3 46 36.5 54 36.2 Medium 282 31.7 208 33.9 74 27.0 36 28.5 38 25.5 High 279 31.4 178 29.0 101 36.7 44 16.0 57 38.3 TOTAL n= 889 100% n= 614 100% n= 275 100% n= 126 100% n= 149 100% # = number = n 106. (e) D is t r ibut ion of the Study Sample By Marital Status Marital Status Total Single Livebir ths Survivals Deaths Neonatal Deaths Postneonatal Deaths Married # % # % a % # % u % 300 33.7 215 35.0 85 30.9 37 29. 48 32.2 Single 589 66.3 399 65.0 190 69.1 89 70.6 101 67.8 TOTAL n= 889 100% n= 614 100% n= 275 100% n= 126 100% n= 149 100% # = number = n (f) D ist r ibut ion of the Study Sample by Maternal Age/Live Bir th Order Maternal Age and Live Bir th Order Total Single Livebir ths Survivals Deaths Neonatal Deaths Postneonatal Deaths Category 1 18 yrs or l e s s : One or more bir ths # % # % # % # I % ii 7T % 222 25.3 153 25.0 69 26.0 27 22.7 42 28.8 Category 2 19 to 24 years: Three or' fewer births 378 43.0 267 43.6 111 41.9 52 43.7 59 40.4 Category 3 19 to 24 years: Fuur or more births 46 5.2 32 5.2 14 5.3 7 5.9 7 4.8 Category 4 25 to 34 years: Four or more births 141 16.0 101 16.5 40 15.1 20 16.8 20 13.7 Category 5 24 to 34 years: Five or more births 70 8.1 44 7.1 26 9.8 10 8.4 16 10.9 Category 6 35 years or more: One or more births 21 2.4 16 2.6 5 1.9 3 2.5 2 1.4 TOTAL "= * 878 100% n= 613 100% n= 265 100% n= 119 100% n= 146 1 00% *11 missing cases # = number = n 1 07. APPENDIX E DISTRIBUTION OF EXPENDITURES, INDIAN HEALTH SERVICES, 1975 to 1980 (a) Dist r ibut ion of Indian Health Service Expenditures by A c t i v i t y 1975/76 to 1980/81 Expenditure % of TOTAL by YEAR Act iv i ty 1975/76 1977/78 1978/79 1979/80 1980/81 Public Health 15.1 15.3 15.1 16.4 17.2 14.1 Indian Involve-nent 8.1 9.0 9.7 10.5 12.1 13.0 Support Services 14.2 14.6 14.7 16.7 16.0 16.6 Treatment 51.8 51.4 51.2 46.2 42.9 45.3 SOURCE: Annual Report, Medical Services Branch, 1980 and previous years (b) D is t r ibut ion of Indian Health Service Expenditures by Type 1975/76 to 1980/81 Expenditure % of TOTAL by YEAR Type 1975/76 1976/77 1977/78 1978/79 1979/80 1980/31 Salar ies 31.5 30 4 36 1 38 6 30 8 27.5 Staff Travel. 5.3 4 7 4 1 4 3 4 9 4.5 Non-Staff Travel 6.3 6 I 6 0 5 7 6 4 8.1 Hospita l izat ion 4.2 3 2 2 5 2 6 2 5 1.7 Hospital Co-Ins. 2.2 5 8 5 5 4 8 4 1 4.9 Medicare Premiums 4.5 • 5 5 4 9 3 7 3 1 3.0 Medical/Dental Prof. Services 17.3 15 8 19 7 17 9 13 7 14.4 CHR* Contributions 4.8 4 6 nf nf 9 4 11.1 Other Cont. Nurses nf nf nf nf nf 0.1 Other Prof .Serv. 1.7 1 0 1 0 1 6 1 6 0.8 . Eyeglass & Orthopaedic Goods 1.4 1 4 nf nf 1 8 2.6 Drugs 14.1 13 7 11 8 12 0 13 4 12.6 3ther Expendi-tures 6.6 7 8 8 1 8 8 8 2 8.6 SOURCE: Annual Report, Medical Services Branch, 1980 and previous years *CHR - Community Health Representative 

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