In my last six years of work, I had the privilege of working in the Canadian Arctic on five occasions – three two-week locums for the Inuvik Health and Social Services Board in the NWT, and two one-month locums in Kitikmeot, the westernmost District of Nunavut. My mandate was primarily dermatology, but I often saw regular general practice. Unlike most general practice locums, who would be based primarily in either Inuvik or Cambridge Bay (the major town in Kitikmeot), I had the opportunity to visit every town in both districts for periods as short as a day to as long as two weeks. This gave me an unusual opportunity to experience the medical and cultural characteristics of a large area of the western Canadian Arctic.
I was a family practitioner who had worked in a small community in southern BC for 30 years. Over those years, I was able to develop a special interest in dermatology and about a third of my practice was referral based dermatology. The NWT and Nunavut like to employ general practitioners with special training – if there is no specialist work, one can still see outpatients. A specialist would have little to do if there were no patients in their field to see. Inuvik and Cambridge Bay both have regular outreach specialist clinics with specialists usually from Yellowknife but they rarely work outside of those two communities.
The majority of health care in the Arctic is provided by Registered Nurses who work out of Health Centres located in every town. These RNs have a widely variable amount of training – from no extra training to full Nurse Practitioners. Most have at least an 8 week basic course in remote nursing in order to help them deal with the greatly increased scope of practice required of nurses in these remote settings. Each district always has a medical doctor on call, available for telephone consultation to help with cases requiring a second opinion. Each community also receives regular visits from GPs, usually once a month for periods up to a week. Attempts are made to have the same physician visit each community so that there is some continuity of care. The nurses compile a list of more complex cases for whom they need a second opinion and attempt to have these patients see the doctor.
There is great difficulty recruiting enough doctors to work in the Arctic. Because of the general shortage of GPs everywhere, it is necessary to pay a premium. Physicians are paid for their travel days (it took me two days to arrive – I was paid for both days in the NWT but only for one in Nunavut), and for everyday we are there (including weekends and any stat holidays when we see no patients). All transportation and housing costs (but usually not food) are covered. The total costs for my nineteen working days in May of 2006 amounted to over $36,000.
The plan is to have a hospital in the major towns of Nunavut, Iqualuit, Rankin Inlet, and Cambridge Bay. Instead of all pregnant women flying out at 36 weeks to deliver, they would deliver in local hospitals, a much more cost efficient plan. Cambridge Bay would require three full time doctors to cover emergency 24/7, cover obstetrics, and provide outreach care to all the outlying communities. The ability to provide Caesarian Sections and the accompanying anaesthesia is required. It seems like a daunting task to find the medical manpower to fill these roles in Rankin Inlet and Cambridge Bay.
In the NWT, the communities I worked in included Deline on Great Bear Lake, Tulita at the junction of the Great Bear River and the McKenzie, Norman Wells on the McKenzie, Fort Good Hope on the Peel River, Colville Lake, Tsigichik and Fort McPherson on the Dempster Highway, Aklavik on the McKenzie delta, Tuktoyaktuk on the Arctic ocean, Palatuk, Holman on Victoria Island, and Inuvik (the main town, site of the only hospital, and where the three cultures of Indian, Caucasian and Inuit converge). The Medical Director there, Dr. Bram de Klerk has provided many outstanding years of service to the north (he does anaesthesia, caesarians and general practice).
In Kitikmeot, I spent time in all five communities which lie on the Northwest Passage – Kugluktuk (Coppermine) on the Arctic mainland, Gjoa Haven on King William Island, Taloyaluk (Spence Bay) on the Boothia Peninsula, Kugaruk (Pelly Bay) on the Somerset Peninsula, and Cambridge Bay on Victoria Island and the main community with a new hospital which opened in the fall of 2005.
In distinction to the well oiled organization in the NWT, Nunavut was a disaster. My airline tickets arrived the day before I was to leave. The resulting late booking inflated the cost of all my flights for the month to $5600. I signed the contract for work four weeks after I finished work there (it sat on the deputy minister of health’s desk waiting for his signature for three weeks and then followed me around until finally arriving at my home in BC). I could not get paid until I had signed it. This typifies the frustrations of working for contract for a bureaucracy that is inefficient, and doesn’t look after its employees well.
MEDICAL EXPERIENCE. The scope of practice is both interesting and frustrating. Taking a good history is usually crucial to arriving at a diagnosis but is virtually impossible when dealing with the Inuit. Their only time frame is the present and determining the duration of illness is not possible. They also rarely can tell you any exacerbating or relieving factors in relation to their problem. For example, on my second visit to Kitikmeot, I saw many repeat patients. None remembered that they had ever seen me before. Despite giving as aggressive treatment as possible the first time, there was often no change in the status of their disease. In trying to find out what went wrong, it was not possible to determine if they had even used the therapies I had prescribed. In the end I became completely disillusioned. I wondered whether my coming to the Arctic had any value. Teenage girls rarely gave verbal answers to questions. It took a long time to understand that they communicated by facial expression – frowning meant no and opening their eyes wider meant yes. This pattern of expression is often evident in infants as young as six months. Fortunately, as dermatology is a very visual specialty – the diagnosis is usually evident at first glance – the ability to take a history is not as important as it is in other types of medicine.
Compared to the very hectic practice I had down south, work proceeded at a very casual pace. Often only ten patients were booked in any one day. Many patients missed their appointments, especially in the spring when the hours of day light lengthen. Everyone seemed to have their clocks reversed. I tried to discourage booking Inuit patients in the mornings as they often slept through them. As a result, I spent a significant part of everyday reading personal books. As May came around, the people began to spend a great deal of time on the land and many were simply not in town. They love to camp, fish and hunt.
The most common dermatologic diagnosis was atopic dermatitis (usually called eczema by the lay person). Their genetic predisposition is exacerbated by the fact that the arctic is a polar desert and environmental dryness worsens the problem. Other common problems were alopecia areata (a patchy type of hair loss), vitiligo (loss of skin pigmentation), and photosensitivity. However, the Inuit are generally a healthy people. For example diabetes and cardiovascular disease are relatively uncommon. On the other hand, problems associated with alcohol abuse and smoking are common. Respiratory problems, especially in infants are a major cause of morbidity. As the cost of transfer to hospitals down south, usually Yellowknife or less often Edmonton, made up a significant part of the cost of medical care, we tried to prevent unnecessary transfers. Avoiding one transfer more than made up for my salary for that day. This wasn’t always what the clients wanted.
Every town in Nunavut has their own MLA, 25 in total. More than once, I was threatened that if I didn’t comply with a patients wishes, they would phone the local representative and get action!
DRUG ABUSE. Drug abuse is common. Most communities are “dry” with no liquor outlets in town. A 26 oz bottle of hard liquor is worth $200. Alcoholism and alcohol abuse is still common and fetal alcohol syndrome is not rare. Alcohol plays a role in suicides and spousal abuse. Marijuana is used actively by mainly young adults. One joint costs $10. I did not see other types of drug abuse.
REPRODUCTIVE HISTORY OF INUIT WOMEN. The reproductive history of the average Inuit woman was an eye opener. It was not unusual for these women to have had ten pregnancies by age 30. Genetically, Inuit women have easy deliveries, but typically, those ten pregnancies may have resulted in 2 miscarriages, 2 therapeutic abortions, six live births of which she might have 3 children at home. The other three children would have been adopted by her mother, someone in her extended family or the family next door. Most older women seem to be caring for an infant. They are very family orientated people.
INUIT DIET. The dietary habits of many Inuit are poor. The most common foods sold were pop, potato chips and premade sandwiches. Food was understandably very expensive. For example, a gallon of milk often cost $12 or more. The use of their traditional or country food was strongly encouraged, but the lure of processed products of questionable nutritional value seemed overwhelming. Once in Taloyaluk, while standing at the Northern Store check out line, a young woman was unable to pay for the $92 worth of groceries she wanted. She proceeded to remove items until she got down to $40. Everything was of minimal food value.
PHYSICIAN HOUSING AND HOTELS. Housing was always an interesting experience. I preferred to stay in an apartment in the health centre but that depended on the availability of a bedroom and whether a nurse was willing to share their apartment, which usually didn’t happen. As a result I was most often put up in the local hotel for $200 per night. In addition to high cost, there was a possibility that you would have to share your room with a stranger who also had to pay $200 per night! That almost happened in Taloyaluk when the entire judicial court came to town.
The hotels had their own idiosyncrasies. As doctors were often on telephone call for the entire district, we needed a telephone in our room. In Gjoa Haven the only phone was in the manager’s room and fortunately, he had just quit that morning. I was given his entire ring of keys, which I needed to get into the laundry room to get clean bedding and towels and to change TVs when mine stopped working. There was no water on alternate days everyday I was there. The hotel had only one waste water storage tank. Once full, which happened quickly if even one toilet was left running, the entire water system shut down. Gjoa Haven had had an expensive water treatment plant installed but this facility seemed to have innumerable problems and it was recommended that you boil drinking water. It seems that instead of the special sand necessary for filtration, other sand had been used.
Most of the hotels had a restaurant which served one set meal at dinner time, usually for $35. Sometimes there was a qualified cook, but often the food was of poor quality. Again in Gjoa Haven, the regular cook quit suddenly – keeping qualified staff is notoriously hard in the north – and the hotel manager’s wife was recruited to fill in. This very pleasant women had no experience cooking, but came up with some interesting results. One of her best meals was when she phoned one of her friends in the Maritimes to find how to cook pork chops with mushroom soup.
HUNTERS. One of the side benefits of staying in the hotels, was the opportunity to meet hunters, mostly wealthy Americans, in the north to get a polar bear. Most had huge trophy rooms at home full of stuffed animals. Polar bear represent a big part of the local economies. The fees paid ranged from $12,000 in Holman in 2003 to $25,000 in Taloyaluk in 2006. The hunters go out for up to ten days. A snowmobile pulls a sled, a dog team and the hunter bundled up in a sled with a wind shield. Some pass up several bears until they find one large enough to satisfy their trophy requirements. The dogs hold the bear at bay making for an easy target. In contradistinction to the Hudson’s Bay area, the Inuit believe there are lots of bears. I didn’t see any being killed just for local food – they were much too valuable for hunting. However the hunters took only the pelt and made sure the meat was used as country food.
CHILDREN. The parking lot outside our rooms in Gjoa Haven was the play ground for all the kids in town. Once it starts to be light for most of the day, by the end of April in most places, children tend to gets their clocks reversed and stay up most of the night, sleeping during the day. Needless to say our sleep was very disturbed. When I tried to change this disruptive behavior, I was simply told it would do no good as “they wouldn’t listen anyway.” Inuit children are generally not disciplined. When I questioned this policy, I was told to mind my own business. This method of raising children probably worked well when the Inuit were hunter gatherers living a nomadic life in small groups of one or two families. In the winter, when their entire existence was dependent on hunting seals, each small area could only support a few people. Children who didn’t follow unspoken rules may not have survived many winters.
In Taloyaluk, when looking out my apartment window in the Health Centre one May night, I counted 34 children out “playing” at 3AM. I don’t imagine many went to school the next day. Besides attendance, the educational system had many problems. Grade twelve graduation rates are low. When tested, the level reached by many who graduate is low, often at a grade seven level or lower. Nobody fails and children simply pass through the system. It is no wonder that few go on to college and those that do are unable to compete with their southern counterparts. I believe that the lack of discipline is a big factor. If a child doesn’t want to go to school, even in elementary grades, they simply stay at home. Education doesn’t seem to have high value.
CULTURAL EXPERIENCES. I enjoyed the many cultural experiences available. The Muskrat Jamboree, Inuvik’s annual spring community festival, occurs in early April, the dates I was there for all three visits. Northern sports, dog sled racing, snowmobile races, traditional games, drum dancing and community feasts are enjoyed by everyone. Cambridge Bay’s Carnival in May was highlighted by games and a great display of drum dancing. Two women from Kugluktuk, both in their nineties, dressed in fur parkas, put on a great show. A local man and his wife have started a drum dancing troupe with dancers of all ages.
Kabloonas (white folks) tend not to socialize with Inuit and don’t often go to homes unless for work purposes. The Inuit tend to be embarrassed by their “simple” home furnishings. Language and communication may be an issue. Culturally, there is often a big piece of raw meat in the corner, they would normally cut off a piece and eat it raw, and they don’t want to advertise that.
ARTISTS. Over the years, I tried to support the many artists present in each community and I now have a large collection of prints, drawings and soapstone carvings. This is a significant source of income for those with talent. I enjoyed dealing with the many artists and this was often my most rewarding interaction with the local people. Many are elderly and one wonders if this artistic expression is going to die out. When word is out that a doctor is in town, I was often bombarded with artists knocking on my door.
TOWNS. The towns themselves are not very attractive. Because of permafrost, all houses are elevated on stilts. Once the snow melts, garbage is everywhere. The streets are not paved and water and mud are the norm. Snowmobiles and ATVs, many in all states of disrepair litter every front yard. Many houses have some major appliance – washers, dryers, stoves – also in the front yard. Despite the fact that the Inuit are mechanically gifted people, few towns have an appliance repairman.
EMPLOYMENT. The major employer is the government. Others work in the diamond mines but the rest are unemployed. Most of the important jobs, like managing the local Northern or Coop stores, or the hotels, are done by Caucasians from down south. If a large job requiring trades people is done, rarely are there any Inuit to do specialized work and tradesmen come from the south. In Kitikmeot, the job of supplying all the nurses stations with medical supplies was contracted out to an Inuit company with disastrous results. Backordered supplies were the routine and important items like drugs were often not available. Inefficient employees are common. Frequently, employees simply don’t show up. When the nursing stations have no front receptionists, things don’t go well that day.
NURSES. In every nursing station, I made an attempt to give educational sessions to the nurses on all types of eczema. I also tried to give a brief overview of the diagnosis and treatment of common dermatologic problems. In some communities, especially those that where I stayed for longer periods, other common medical conditions were also reviewed.
The nurses work under either of two very different contractual relationships with the government. Each government prefers to hire nurses under a direct contract as this costs significantly less. Most nurses, however, work for agencies who hire them, pay them and “look after” them. They cost at least 40% more as the agencies provide transportation and housing. Pay is deposited directly into the nurses’ bank accounts, is accurate and occurs promptly. The contract nurses pay for their own accommodation (often $1000-1200 per month usually in government owned apartments in the health centres themselves). For obvious reasons most nurses opt for the agency method.
Because of the siginificant shortage of nurses in Canada, obtaining nurses to work in the Arctic is difficult and very expensive. Because of the extensive call necessary to cover the nursing station 24/7, and as most nursing stations have as few as 2 nurses, it is not unusual for an agency RN to make $120,000 for as little as seven months work.
To overcome the need for agency nurses, the government of Nunavut hired a recruiter to go to the Philipines to find RNs (at a cost of $40,000 per nurse) to work in Nunavut. With the prospect of obtaining permanent residency in Canada, they had little difficulty getting 40 nurses to sign three year contracts and they arrived in the fall of 2005. In order to work in Canada it was necessary that they pass the RN exams required of every nurse but only nine did! Their English skills were also often poor (communicating with the Inuit is already difficult for Nurses with good English skills). When I was in Cambridge Bay for the last two weeks of May, 2006, the five Philipino nurses working there had no patient contact and basically sat around for eight hours per day often studying for their next try at the RN exams. The opening of the brand new inpatient facility in CB had been delayed for multiple reasons. This experiment looks like a very costly failure.
This was a difficult article to write as I felt I had little positive to say. Indeed I have little optimism about the ability of the Inuit to achieve true happiness. Education is not highly valued. Children are not disciplined. There is limited employment in most towns. Drug abuse and suicide are common. The Inuit must be one of the most amazing people to have survived in the harshest, least accommodating environment on earth, one where starvation was always a threat. However they are no longer living nomadic existences out on the land. How to integrate their cultural identity with those values we from southern Canada believe important to achieve happiness and success seems to be the problem.