Send in the SWAT team, says doctor

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Health Canada's 1999 budget has allocated $55 million in new funding over three years to pay for the Canadian Diabetes Prevention and Control Strategy. The money is targeted to fight "one of the fastest growing chronic diseases in Canada today," and education will form a key component of the strategy, a government press release states.

When and where the money will be divvied up hasn't been decided, according to officials with Health Canada's Medical Services Branch (MSB).

What is known is that the strategy will have two components: one aimed at the general Canadian population and the other at Aboriginal people who fall under MSB's jurisdiction. So far, Health Canada isn't saying what the financial split will be.

Windspeaker asked MSB about its priorities with respect to diabetes program funding in British Columbia and asked some health care providers for their insights into how current programs are working.

At the federal level of MSB, Assistant Deputy Minister Paul Cochrane could not be reached for comment. His media relations spokeswoman said he "would have no information" about the financing available to combat diabetes in individual provinces and sent a press release about the $55 million.

At the provincial level, the acting regional director in MSB's Pacific Region, Garth Corrigall, said he had "no idea" yet what portion of the $55 million British Columbia would receive from federal authorities. Corrigall referred Windspeaker to others, including Charlotte Thompson, regional nursing consultant for MSB in the lower B.C. mainland, for details of the diabetes problem and solutions being tried.

Charlotte Thompson said she was "just amazed" when she started working with Native people in B.C. to find that in some communities a third of the population has diabetes.

She cited the 1990 Health Canada Statistical Report on the Health of First Nations people in British Columbia. The rate of diabetes then among Canadians generally was 8.7 per cent in the Atlantic provinces, 7.6 per cent in Ontario, and only 1.6 per cent in British Columbia. There were 79 diabetics per 1,000 population on Vancouver Island, compared to 66 in the south mainland area which includes Cranbrook, and 49 in northern B.C.

Currently, urban areas associated with the coastal communities are worst hit - Vancouver Island, the Fraser Valley and up along the Sunshine Coast, Thompson said. The disease is less prevalent in northern and central areas of the province, where people follow a more traditional lifestyle.

Thompson thinks both that diabetes is still being under-diagnosed and that there is too much dependence on Community Health Representatives to deal with health problems at the local level.

She added when their portion of the new diabetes strategy funding reaches them, she wants to see "tags on it that are identified," and that communities have a plan in place to use the money. She does not want the money added to existing programs. Nurses, she said, have expressed the need for a nurse committed to diabetes screening in First Nations communities. Diabetes screening is not routinely part of the community health nurse's responsibilities now.

Corrigall also referred Windspeaker to Yousuf Ali, manager of post-transfer relations for MSB, as the person knowledgeable about expenditures. Ali said he doesn't know how much money will go to B.C. via the Aboriginal Diabetes Initiative, because "that hasn't been worked out."

He explained that British Columbia constitutes about 15 per cent of the population, has about 200 Indian bands and approximately 50,000 to 55,000 on-reserve residents. He guesses that the Aboriginal side of the strategy may see $35 million total, or $10 to $15 million a year for the whole country. He conceded British Columbia's share would "not be much."

In response to a question about what MSB is spending now on diabetes programs, he said, "There is not a very significantly funded program right now." MSB Pacific Region has ovided seedfunding to three communities to carry out diabetes prevention and promotion activities on-reserve. Total 1998 funding spent by MSB on diabetes in the Pacific Region was $50,000.

Although it is known that diabetes has reached epidemic proportions among Aboriginal people, many communities say they lack the resources and commitment from government to get the problem under control. Shortages of nurses and doctors is a common complaint. British Columbia is no exception. Interviews with several nurses revealed that not much has changed since a 1987 survey conducted by MSB identified 14 coastal and southern communities "at high risk" because of the prevalence of diabetes. That year, one community of 140 people had a rate of 28 per cent in the over-35 age group, according to information provided by the Canadian Diabetes Association.

In a 1991 report, CDA's director of education services for the B.C. Division, Joan Johnson, noted that better follow-up, care and education would reduce the complications of diabetes in Native people, but that "because of poor compliance, some educators, nutritionists and physicians do not place emphasis on education and follow-up. She observed that involving Native people in planning their own programs and increasing the number of Native health professionals would improve compliance. Johnson also made the point that "respect for and being sensitive to Native tradition and health beliefs is an important part of any program."

Currently, the B.C. Division of CDA has not yet replaced the one Aboriginal nurse they had who until recently was involved in health promotion. The nurse, Lucy Barney, is still concerned with diabetes education and is co-chair of the "Diabetes, Disabilities, and Honouring Mothers Powwow", which will be held May 7 to 9 at the Trout Lake Community Centre in Vancouver.

Improved quality of life is the goal of diabetes education programs. One claiming some success is based in downtown Vancouver's St. Paul's Hosptl. That four-ay program is attended by many Aboriginal people from Waglisla (also known as "new" Bella Bella), Klemtu and the Queen Charlotte Islands.

According to endocrinologist Dr. Hugh Tildesley, director of the diabetes centre at St. Paul's, people who attend their clinic demonstrate a high degree of interest in controlling their diabetes. "We have been able to follow the outcome . . . particularly from Klemtu and Waglisla," Dr. Tildesley said. "We've been very gratified . . . there is almost 100 per cent follow-up rate."

Dr. Tildesley thinks these results are a reflection of the "conscious decision to support diabetes care" made by the communities that St. Paul's serves.

Doctor Tildesley says that St. Paul's has not found it necessary to tailor diabetes education along cultural lines in order to reach Aboriginal people.

"We provide people with information and a respectful environment, and the outcome is successful," he said. "There are two issues here," Dr. Tildesley continued; "one is to get the information out to the most number of people in the most efficient way possible; the other issue is what form that information should take. It is impossible to provide decent diabetes care without regular follow-up. The mere exposure of anyone to diabetes education . . . without follow-up, is a waste of time. If you've got a chronic disease, it's got to be followed chronically."

Dr. Tildesley characterizes diabetes as a "public health emergency."

"I am somewhat chagrined," he said, "at the inactivity of those folks who know how big the problem is and the absolute inability to do the basics in order to improve outcome. We all know that lower limb amputations are far more common in the Native population who have diabetes, and we know that in Caucasian populations the mere teaching of foot examinations eliminates over 80 per cent of those lower limb amputations.

"If I was the minister of health in charge of Native care, the first thing I would do would be to ir a SWAT team of nuses to go out and teach people with diabetes how to examine and care for their feet."

He insists the argument that this would cost too much isn't valid. "You're going to spend them (dollars) with hospitalizations and amputations and incredible morbidity and increased mortality, just on this one complication," Dr. Tildesley concluded.

Some Native communities have taken the initiative on their own behalf. The 6,000 members of 14 Nuu-chah-nulth First Nations on the west coast of Vancouver Island have established culturally based diabetes programs that emphasize complete family involvement. Tee Cha Chitl: Getting Well Again was begun in 1993 and is ongoing.

Debbie David, a nurse from the Nuu-chah-nulth community of Tla-o-qui-aht at Tofino, B.C., said they do one- or two-day workshops, which include glucose monitoring, at all their 14 reserves. She said remoteness of some communities is still problematic.