Are subarctic Indians undergoing the epidemiologic transition

Sot. Sci. Med. Vol. 26. No. 6. pp. 659471. Printed in Great Britain

ARE

0277-9536188 $3.00 + 0.00 Pergamon Press plc

1988

SUBARCTIC INDIANS UNDERGOING EPIDEMIOLOGIC TRANSITION?* T. KUE

Department

of Social and Preventive Medicine, 750 Bannatyne Ave., Winnipeg,

THE

YOUNGt

Faculty of Medicine. University Manitoba. Canada R3E OW3

of Manitoba,

Abstract-The applicability of A. R. Omran’s ‘epidemiologic transition’ theory to subarctic Indians in Canada is examined in a historical review of health and demographic data. The major trends since the time of European contact include the rise-and-fall of infectious diseases, the emergence of chronic, degenerative diseases, and the preeminence of the social pathologies in the post-World War II era. The divergences of the Amerindian experience from the 3 models in the epidemiologic transition theory and their implications for health care delivery are discussed. Key words-Canadian

Indians,

cultural

change,

health

INTRODUCTION long term temporal changes in the pattern of health and sickness in a population has been described as its ‘epidemiologic transition’. First formulated by A. R. Omran in 1971, the theory was modelled after that of the better known ‘demographic transition’ [l]. Most populations supposedly undergo 3 ‘ages’-the age of pestilence and famines, the age of receding pandemics, and the age of degenerative and man-made diseases. The pace of transition differs between populations, and Omran distinguished between the classical or western model (exemplified by England and the United States), the accelerated transition model (Japan and Eastern Europe), and the contemporary delayed model where most socalled Third World countries today would belong. Other propositions in this theory include the preeminence of mortality in population dynamics, the important role played by children and young women in mortality decline, and the interplay of demographic, socioeconomic and ecological determinants of health and disease [l, 21. Omran’s theory has not been tested in many historical populations, probably because of the difficulty in reconstructing past disease rates in the absence of adequate records. Subsequent to his original formulation, Omran attempted to validate the ‘classical’ model based on U.S. data [2, 31. Despite the lack of other confirmatory analyses, the concept has found its way into the medical literature [4] and its broad outlines, if not its detailed propositions, are more or less accepted as useful descriptive tools in historical epidemiology. No mention was made in Omran’s papers regarding the aboriginal populations in North America.

The

*This paper is based on a lecture delivered at the course on “Anthropology and Health: Native Populations of the Arctic and Subarctic”, held at the Inter-University Centre for Postgraduate Studies, Dubrovnik, Yugoslavia, 17-23 August, 1986. tDr Young is recipient of a National Health Research Scholar career award from Health and Welfare Canada (6607- 1377-48).

status,

historical

epidemiology

Presumably they would fall under the ‘contemporary delayed’ model, among countries in the Third World, where massive modern medical technology heralded the relatively recent mortality declines. Kunitz, in his monograph on the health status and health care among Navajo Indians in southwestern U.S.A., made specific reference to the epidemiologic transition [5]. The validity of this theory, however, needs to be demonstrated in other Amerindian groups with different cultural histories, social organizations and ecological adaptations. Such an examination has policy implications in that Omran’s theory (and Kunitz’s validation) made implicit judgement as to the relative roles of health services and socioeconomic development in effecting changes in health status. If the model can be shown to fit the past, it might conceivably be predictive of the future. In the debate over the role of health care-two extreme positions can be discerned. On the one hand, the ‘left_’ perspective views the redistribution of health services to the poor and underserved as an important social goal, even if such services have not been proven to be effective. This is contrasted with the ‘right’ view which embraces the charge of ineffectiveness to justify service cutbacks and rationing. This paper reviews the health and demographic data of Canadian Indians, primarily Algonkians in the central subarctic boreal forest. It investigates if the epidemiologic transition theory is applicable in general to subarctic Indians, and if yet a fourth ‘model’ should be established to account for their experience in North America. Ethnohistorians have divided the post-contact history of Indians in the Canadian subarctic into various periods [6]. 1 have adhered to this scheme in Table I, but have also included changes in health status and medical care. This paper will concentrate on health status. The historical development of health services for Canadian Indians has been detailed in a previous paper in this journal [7]. HEALTH

CONSEQUENCEE

OF CONTACT

There is little paleopathological data from the Canadian subarctic to shed light on the prevalence of 659

660

I-. Km

YOUNG

diseases among the Indians prior to the arrival of Europeans and recorded history [8.9]. One could. of course, apply studies of contemporary huntergatherers [IO-121 and extrapolate them to prehistoric Algonkians, with due allowance made for ecological differences. Thus one could perhaps assume that in pre-contact times, the Indians consumed a high protein diet based on meat and fish and rarely suffered from chronic malnutrition, although acute starvation occurred occasionally. Some infections existed, primarily zoonotic parasitic infestations. but these were probably of low virulence. Particular genotypes in both man and pathogen had evolved over long periods of time to allow both to coexist. Chronic and degenerative diseases-those now termed ‘diseases of westernization’ [13]-were probably rare. In a bibliographic review of the North American Indian demographic change, Johansson concluded that pre-contact Indians were unlikely to have been disease-free or enjoyed low death rates (with violence and accidents playing a major role in mortality). He estimated that life expectancy at birth was probably in the 20s range, comparable to the ‘average’ of modern hunter-gatherers and primitive agriculturalists [ 141. By the early and mid-18th century, various accounts of the Indian’s health began to appear in the journals of fur traders and explorers in the hinterland of Hudson Bay. I have provided a more detailed description of these sources elsewhere [ 151. The near unanimity of these utterances regarding the Indian’s excellent health could have been the result of the observers’ idealized notion of the ‘noble savage’, the poor health of contemporary Europeans from the lower classes, and the ‘healthy survivor’ bias to which cross-sectional observations are always susceptible. Nevertheless, while life was no doubt short, harsh and at times violent. early and pre-contact Indians probably did enjoy a relatively healthy and vigorous existence, at least in comparison to what was to follow. Infectious diseases such as measles. smallpox and influenza, which spread rapidly and immunize a large proportion of the people, were not favored by natural selection and were probably absent among the small, widely scattered bands of Indians in pre-contact times [ 16, 171. It has been estimated that, due to the absence of alternative animal hosts and the short period of infectivity, the number of new cases per year required to sustain the infection would have greatly exceeded the average population size of hunter-gatherer bands [18]. When outsiders introduced these new diseases into the ‘virgin soil’, the impact on the indigenous population was often devastating. The shift from what geneticist J. V. Neel called ‘small band’ to ‘large herd’ epidemiology [19] has been repeatedly demonstrated around the world, and Indians in the subarctic were no exception. One of the earliest recorded epidemics in the subarctic was the smallpox epidemic of 1781, which spread through the boreal forest west of Hudson Bay and across the Plains to the Rocky Mountains. It was graphically described by contemporary observers such as Edward Umfreville and David Thompson [15]. The virulence of the disease and the Indians’ response (e.g. plunging into cold water in a febrile

Are subarctic Indians undergoing the epidemiologic transition? state, abandoning survive)

rate. It

combined

is possible

the sick, and giving up the will to to produce a high case-fatality that

subarctic

could have contact with other tribes further to the east and south. In the first half of the 17th century, the Jesuit Relations recorded various epidemics among the Montagnais and other woodlands Algonkians along the St Lawrence Valley [20,21]. Smallpox was believed to have been introduced by ships from France or indirectly from settlers in New England. Through Indian travellers and European missionaries and traders, the disease spread to the Iroquoians in southern Ontario. In a 7-year period during the 1630s reportedly half of the Huron population succumbed [22]. Among historical demographers there is some dispute over the role of disease in population decline among Amerindians. The estimation of prehistoric Indian populations is fraught with difficulties and uncertainties, and the results show wide ranging variation [23]. Yet it is important to known the pre-contact population, the approximate time the population began to decline, and when it reached its nadir, if one were to assess accurately the impact of disease as a result of European contact. According to Dobyns, based on archival research dealing primarily with Mesoamerica and Florida, indirect contact between tribes could have resulted in long-distance transmission of diseases. Many tribes could have been affected by ‘European diseases’ long before they ever came face to face with a European [24]. There may in fact have been massive epidemics in eastern Canada preceding the historically recorded epidemics in the 17th century [25]. Thus, according levels of mortality to Trigger, “the extraordinary and other misfortunes that followed European contact must have caused [many Indian informants] to idealize earlier times as a halcyon age of physical health, economic prosperity, and social harmony” [22, p. 2441. Regardless of the onset, duration, frequency and severity of introduced epidemics, their impact on Indian societies extended beyond the merely demographic. Virgin-soil epidemics characteristically kill off or debilitate a high proportion of adults in their prime years, people who are responsible for food procurement, defense and procreation [26]. The social disruption which followed involved changes in kinship pattern, band membership and clan organization [27]. The impotence of indigenous belief and healing systems to deal with the new catastrophes prepared the way for inroads by European missionaries. Martin even proposed a spiritual origin of the fur trade: the Indians interpreted their misfortunes as the animals declaring war on them, and they retaliated by embracing fur trade technologies such as guns and traps [25]. Such a novel theory, however, has been seriously challenged by other fur trade scholars [28]. For the subarctic, one could only speculate if there were large-scale epidemics earlier than the mid-18th century. What is beyond dispute is the many more documented epidemics which came in the 19th century, when diseases such as measles, influenza, whooping cough, and scarlet fever-in addition to smallpox-took regular toll of the Indians experienced

the disease

Indians

earlier through

661

[15,29,30]. Many of these epidemics can be traced from their origins in the new settler colony on the Red River and Norway House. a major trading post on Lake Winnipeg. From these they spread along fur trading routes into the forests of northern Ontario, Manitoba and Saskatchewan (3 I]. Similar epidemics were also documented among the northern Athaspaskans in the MacKenzie Valley with equally devastating effects [27,32]. The impact of introduced diseases in depopulation, however. has been disputed by some scholars. The same historical records led Helm to conclude that there were no severe epidemics among Athapaskans living in the MacKenzie/Liard drainage basins before 1820. Instead, it was intermittent starvation and female infanticide which had kept population at low levels [33]. At any rate. according to one tally, there was hardly a 50-year period without a major outbreak in the subarctic. The frequency of epidemics occurring in ‘overlapping clusters’ with very short intervals of respite allowed little chance for population recovery

1291. Compounding the problem of epidemics were periodic famines resulting from the depletion of game due to both natural cycles and overtrapping and hunting [29, 341. To counter the environmental threats the Indians adopted various strategies such as limitation of population, diversification of food sources, innovation in food gathering and preservation, and just plain endurance. Those living near trading posts also came to rely on relief rations or borrowed against future fur harvests. (Here again, one should also be cautious in examining historical materials, particularly fur traders’ journals. While starvation undoubtedly occurred, its magnitude and extent may have been exaggerated. Scholars in semantics have pointed out the biased view of Indian culture in such sources, and the use of such terms as ‘starving’ and its variants carried metaphysical and ritual messages in addition to their literal and technical meanings [35].) THE STRUGGLE FOR SURVIVAL

By the beginning of the 20th century, the Indians in the subarctic had been involved in the fur trade for over 200 years. While greatly debilitated by ever present famines and epidemics, they had probably recovered from the depopulation of the initial ‘contact shock’. Still, from the descriptions of contemporary physicians, a generally bleak picture emerges. Thus Dr Meindl, a physician who accompanied the Treaty No. 9 Commissioner to Indian settlements in northern Ontario, observed that the Indians were “far below the average size and weight of the white man, their muscles and bones undeveloped, their stature stooping, with long narrow, thin chest” [15]. Tuberculosis was already rife in many communities, as were scabies, pediculosis, impetigo, and intestinal infections, reflecting the poor personal hygiene, housing conditions, and environmental sanitation in the permanent settlements, where the Indians were by then increasingly congregated. Venereal diseases were prevalent in areas closer to the towns but were relatively rare in the more remote settlements. The ethnologist Alanson Skinner who

662

T. KUE YOUNG

travelled down the Albany River, reported that “pneumonia, consumption and la grippe were the best known and most fatal diseases”, while “in spite of their great immorality [sic], syphilis and gonorrhea were almost unknown” [36]. During the first decade of this century, statistics on notifiable diseases began to be collected, and these were appended to the Annual Reports of the Chief Medical Officer of the Department of Indian Affairs. Among the infectious diseases reported, in descending order of frequency, were: tuberculosis and scrofula, diarrhea, dysentery, enteritis, syphilis, malarial fever, erysipelas, septicemia, influenza, measles, whooping cough, diphtheria, croup, smallpox. scarlet fever, and typhoid fever. During the inter-war years the overwhelming problem among Indians in the subarctic. indeed Indians anywhere in Canada, was tuberculosis. Doubts were often entertained by physicians and administrators as to the very survival of the Indian ‘race’. In the 1920s a study in the Norway House Agency in northern Manitoba showed that the tuberculosis mortality rate was 20/1000, while the average mortality rate from all causes was about ZSjlOOO, if one excluded the flu year of 1919 when mortality reached 140/1000 [37]. With the institution of vaccination by the Hudson’s Bay Company since the early-19th century and later by the Canadian government (particularly at annual Treaty visits), the threat of smallpox was substantially reduced, although there were still sporadic outbreak during the first 3 decades of this century. It was in 1946 that the last two indigenous cases in Canada occurred [30]. The importance of smallpox in subarctic settlements a century or two ago caused some concern recently. In York Factory on the Hudson Bay coast, the erosion of gravesites led to the disinterment of bodies of victims who might have died of smallpox, raising the spectre of dormant viruses re-emerging in a smallpox-eradicated world ]381. In the 1940s among the Cree and Ojibwa Indians in northern Manitoba and the James Bay coast two health and nutrition surveys were conducted [39,40]. The Indians surveyed showed deficient intakes of calories and most types of nutrients, far below the recommended allowances of the time. They also suffered from an excessive disease burden, particularly turberculosis and childhood diseases. The findings of these two teams, composed of leading public health and nutrition experts of the day, underscored the plight of the Indians, and gave impetus to the massive government intervention in the post-War years. Rapid changes occurred in subarctic Canada in the 4 decades since the end of World War II. Government involvement in the areas of health care, social assistance, education, and econonic development increased substantially. While these efforts resulted in increasing dependence of Indian communities on external Euro-Canadian institutions and personnel, they nevertheless assurred a basic level of living that was superior to that of the 1940s and before. The recent changes in the health pattern of subarctic Indians will be discussed in terms of population trends, causes of mortality, incidence of selected diseases, and nutritional status. Attempts will be

made to reconstruct trends from the 1920s onwards but I will caution that historical statistical data for Indians prior to the 1960s should be viewed with a healthy dose of skepticism. TRENDS IN FERTILITY AND MORTALITY

Romaniuc has constructed a time series of fertility rates for Canadian Indians from 1900 to 1973 and the James Bay Cree from 1927 to 1972. He showed that the crude birth rate increased from about 40/1000 in the pre-World War II years to just under 50/1000 in the early 1960s [41]. The increase in fertility during the early stages of the ‘modernization’ period was believed to occur as a result of the weakening or removal of biocultural inhibitions of childbearing in traditional societies. Some of the contributing factors include a decline in birth intervals, breast-feeding, pregnancy wastage and spousal separation [42]. From the mid 1960s the birth rate began to decline (Fig. 1). Similar fertility trends have also been observed among Alaska Natives [43]. The relatively high fertility rate has resulted in an age-sex pyramid which is more typical of developing countries today or that of Canada half a century or more ago (Fig. 2). In terms of mortality an impressive decline in the infant mortality rate has occurred over the past several decades, although the gap between Indians and Canadians nationally has still not been closed (Fig. 3). It is important to note that the Indian/nonIndian disparity in infant mortality is primarily due to the high Indian postneonatal (28 days to 1 year) mortality rate. The neonatal mortality rate among Canadian Indians is in fact quite close to that of the Canadian population nationally. A review of the causes of death of the Cree-Ojibwa in northwestern Ontario during 1972-198 1 indicated that tuberculosis and other infectious diseases were, by then, no longer important causes, their places having been taken over by accidents and violence, which constituted over a third of the deaths (Fig. 4)

WI. By computing standardized mortality ratios one can determine the risk of death from particular diseases in the Indian population relative to the Canadian population, taking the different age structures into consideration. In most categories of causes, there were excessive risks of death among Indians (Fig. 5). Exceptions included circulatory diseases where the risks were lower, and neoplasms, where the risks were not significantly different. Similar mortality patterns have been demonstrated in other regional studies of Indians, e.g. in Alberta [45], among the James Bay Cree in northern Quebec [46], and Natives in Labrador [47]. Nationally, data on Indian mortality in 7 provinces for the years 1977-1982 have been compiled [48]. Of note is that no infectious diseases were within the 10 highest ranking causes of death. For coronary heart disease and stroke, Indians were either close to or have already exceeded Canadian national rates (Fig. 6). For the more isolated (and presumably less ‘acculturated’) Indians in the subarctic, this may be a portent of things to come. It is difficult to construct time trends for causespecific mortality rates for Canadian Indians,

Are subarctic

Indians

undergoing

the epidemiologic

663

transition?

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Year Fig. 1. Change in birth rate in Canadian Indian and Canadian national population, 1921-1984. Source: 1921-1974 Canadian data from Leacy F. H. (Ed.) Historical Statistics of Canada, 2nd edn. Statistics Canada, Ottawa 1983. 1975-1984 Canadian data from Statistics Canada, Viral Srafisfics, Vol. I. Birrhs and Deaths for relevant years. 1921-1973 Canadian Indian data from Romaniuc (Ref. [41]). 19741981 Canadian Indian rates computed from estimated number of births in Ram B. and Romaniuc A. Fertility Projections of Registered Indians 1982-1996. Indian and Northern Affairs Canada, Ottawa, 1985, Table 5, p. II, and estimated Indian population data from Perreault J., Paquette L. and George M. V. Popularion Projections of Registered Indian Population, 1982-1996. Indian and Northern Affairs Canada, Ottawa. 1985, Table 6.1, p. 58.

whether national or for regional groups, due to incomplete reporting and inconsistent coding practices in official sources. Figure 7 shows the changes in the crude mortality rate for major groups of causes from the 1940s to 1980. It is evident that a shift from infectious diseases to the chronic diseases and accidents and violence has indeed occurred.

POPULATION

.s.

8

4

a

0

0

a

OF CANADA

.

INDIAN AND NON-INDIAN

6

THE DECLINE AND PERSISTENCE OF INFECTIOUS DISEASES

The rapid decline in tuberculosis incidence is graphically presented in Fig. 8, narrowing somewhat the gap between Indians and Canadians in general. TB is one disease where medical care factors in the

: CENSUS

a!4

POPULATION

YEARS

0.

I

OF CANADA

1881,

4

1021.

a

: CENSUS

1001

0

YEAR

0

2

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1001

Fig. 2. Population structure of Canadian Indians 1981 compared with Canada 1881, 1921, 1961 and 1981. Source: Canadian data for 1881-1961 from Peron Y. and Strohmenger C. Demographic and Health Indicators. Statistics Canada, Ottawa, 1985, Fig. 4, p. 7. Indian and non-Indian data for 1981 from Statistics Canada 1981 Census of Canada: Canada’s Narive People, 1984, chart 4.

T. KUE YOUNG

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120 110

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CANADIAN ‘NfVANS

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1945

1955

1965

1975

Years Fig. 3. Change in infant mortality rate: Canadian Indians and Canada, 1925-1984. Source: 1925-1974 Canadian data from Leacy F. H. (Ed.) Historical Sfatistics ofCunodu, 2nd edn. Statistics Canada, Ottawa, 1983. 19251963 Canadian Indian data from Latulippe-Sakamoto C. Estimation de la mortaliti des indiens du Canada. 190&1968. MA dissertation, Universite de Ottawa, 1971. 196476 Canadian Indian data from Siggner A. J. An Overview of Demographic, Social and Economic Conditions Among Canudu’s Registered Indian Population. Ottawa: Indian and Northern Affairs Canada, 1979. 1977-83 Canadian Indian data from Medical Services Branch, Health and Welfare Canada, Annual Reviews, for relevant years.

short term seem to have been remarkably successful in reducing the disease burden [49]. The problem, however, is far from being eradicated and outbreaks continue to occur sporadically in different parts of the country. The dramatic decline in infectious diseases notwithstanding, the risk of such diseases among Indians relative to the whole of Canada is still substantial. Table 2 provides hospital separation data from Manitoba. It can be seen that the standardized

morbidity ratio are quite high for most diseases with an infectious etiology. Clinical studies on respiratory infections indicate that Indian children suffer from more severe illness, multiple recurrent episodes and long term sequalae [50]. While death and severe morbidity rarely result from infections with organisms such as diphtheria, their presence in the Indian population is still regularly demonstrated [51]. Epidemics of viral and bacterial gastroenteritis still occur in Indian com-

Infectious

Injuries/ Poisonings

Unknown/ Ill-defined

Fig. 4. Distribution

of deaths

Perinatal

by cause for Indians in northwestern on data in Young (Ref. [44]).

Ontario,

1972-1981.

Source:

based

Are subarctic Indians undergoing the epidemiologic transition?

Fig.

5.

Standardized

mortality ratios for selected causes among Indians in northwestern 1972-1981. Source: based on data in Young (Ref. [44]).

Table 2. Standardized morbidity ratios for selected Manitoba Indians, 1981-82 ICD-9 code I

II III VI VII VIII xv XVII

001-139 001-009 010-018 140-239 240-279 320-389 32CL322 390-459 460-519 48M87 7*119 E8OO-E999

665

causes among

munities

periodically,

Ontario,

in areas facilities [52].

particularly

deficient water and sanitation

with

SMR

Diagnosis Infectious/parasitic intestinal infections tuberculosis Neoplasms Endocrine/nutritional/metabolic Nervous system/sense organs meningitis Circulatory system Respiratory system pneumonia/influenza Perinatal conditions Injury/poisoning

4.3 5.0 23.8 0.7 3.9 2.7 3.3 1.8 3.0 6.7 1.9 3.3

Source: computed from unpublished data provided by the Manitoba Health Services Commission. The SMR compares the rate of hospitahzation for Indians with that of the total Manitoba provincial population adjusting for age.

CWD WA

LCA

Cause 0

Canada

THE EMERGENCE

OF NEW DISEASES

Of increasing interest is the emergence of chronic diseases such as cancer, heart disease, stroke and diabetes among Indians. In terms of mortality, previously discussed national data suggest that some Indians may have ‘caught up’ with the rest of the Canadian population. The hospital morbidity data from Manitoba (Table 2) also show slight excess in circulatory diseases and Cfold excess of endocrine diseases, mainly due to diabetes. Baseline epidemiologic studies have only begun to be conducted in the past several years, on cancer [53,54], diabetes [55,56] and hypertension [571. Con-

MVTA

cm,

CVA

LCA

YVTA

of Death md

Indian8

Fig. 6. Age-standardized mortality rates for selected causes: Canada and Canadian Indians. 1977-1982. Source: based on data in Mao ef al. (Ref. [SS]). Notes: CHD-coronary heart disease, CVAcerebrovascular disease, LCA-lung cancer, MVTA-motor vehicle traffic accidents.

T. KUE YOUNG

666

260 240 220 200 180

1942-44

1a51-55

195&60

RESW-

Pneumonia

tNF(a)-

Tuberculoaia

INF(b)-

Mosales

1964+8

h Influenza

6 Pertush

1971-76

1977-80

Fig. 7. Changes in Canadian Indian crude mortality rates for selected causes. Note: all mortality rates expressed as deaths per 100,000. Source: 1944 data from the submission to the Senate-House of Commons Committee on the Indian Act by the Minister of National Health and Welfare, in Minures, Appendix B, p. 91, 1947. 1964-68 data from Latulippe-Sakamoto C. Estimation de la mortalhe des indiens du Canada, 1900-1968. MA dissertation, Universite de Ottawa, 1971. 1951450, 1971-76, 1977-80 data from Medical Services Branch, Health and Welfare Canada, Annual Reuiew~s, relevant years. tinuing surveillance is required to determine if an upward trend in these diseases is present. While Indians are at lower risk for cancer compared with Canadians nationally, large excesses have been found for several sites, namely gallbladder and kidney, while deficits are observed for sites such as lung and breast [53,54]. A variety of environmental and genetic factors are likely to be responsible for such a pattern. It is, however, reasonable to project that the gap between Indians and Canadians in the so-called cancers of ‘westernization’ would be narrowed in the future. The prevalence of physician-diagnosed diabetes among the Cree-Ojibwa in northwestern Ontario and northeastern Manitoba was higher than Canadians nationally, with a female:male ratio of 2.5: 1. Almost half of the known cases were diagnosed within the past 5 years of a 25-year period, suggesting an increase in incidence as well [55]. In southwestern Ontario the age-adjusted prevalence rate of diabetes among one group of Indians was 7 times that of whites living in surrounding rural areas [58]. Among the Athapaskan-speaking Dogribs, where clinical diabetes is reputedly rare, a glucose tolerance survey

revealed abnormal curves for 10% of the subjects tested [56]. There is still a large gap in our understanding and knowledge of circulatory diseases such as ischemic heart disease, stroke and hypertension. Research is currently underway among the Cree and Ojibwa of northern Ontario and Manitoba to establish the prevalence of various risk factors and their associations with the development of various chronic diseases. DIETARY

CHANGE

AND

NUTRITIONAL

STATUS

Health and nutritional status are intimately related. Indeed, the poor hea!th status of Indians is often attributed to their poor nutrition. Although protein-calorie malnutrition is generally absent, other nutritionally associated health problems include obesity, iron-deficiency anemia, vitamin inadequacy, and dental caries. According to the Nutrition Canada Indian Survey conducted during the 1970s [59], the intakes of calories, proteins, and B vitamins among Indians were comparable to Canadians nationally. The intake of

Are subarctic Indians undergoing the epidemiologic transition?

5

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61

62

63

64

65

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67

68

69

70

71

72

73

74

75

76

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77

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79

80

Year

Fig. 8. Decline in incidence of new and reactivated cases of tuberculosis among Indians, lnuit and Canadians, 196&1980. Source: unpublished data from Medical Services Branch, Health and Welfare Canada.

A, however, was lower than the group. Among Indians, those living in remote, isolated areas such as the James Bay coast in northern Quebec had even lower intakes of these vitamins [60]. The low dietary intake of vitamin D and the short daylight during the winter months put many Indian children in the subarctic at risk for rickets. This disease is still being diagnosed in northern Ontario and Manitoba during the 1980s (611. The Nutrition Canada survey also indicated that Indian men had lower mean weight-for-age than Canadians up to age 4049, but showed substantial gain beyond 50. Among women, Indians were heavier at all age groups [62] (Fig. 9). Current research among the Athapaskans and Algonkians in the subarctic will provide more data on the problem of obesity, overweight, fat patterning and. their role in chronic diseases such as diabetes and ischemic heart disease. The change from a state of inadequate calories in the pre-War years to one of excessive obesity among Indians is due to the profound changes in their food habits. With the establishment of trading posts. European foods such as flour, oatmeal, sugar, lard and tea were introduced. After World War II and the trend towards permanent settlements and abandoning of hunting and fishing, dependence on store bought foods became more important, a fact documented by ethnographers working in many subarctic communities [63,64]. Dietary changes can also occur

vitamin national

C and

relatively rapidly as a result of modern resource development projects, as was demonstrated in a northern Manitoba band affected by a hydroelectric power project [65]. Despite their nutritional superiority [66] and the lower costs, ‘country foods’ are decreasing in importance in the diet of many Indian groups. At particular risk are children, with their predilection for sweetened carbonated drinks and sugary snacks. The immediate consequences could be seen in the deplorable dental health status [67)-the long term effects have yet to be assessed. THE SOCIAL PATHOLOGIES

Kunitz [5] coined the term ‘social pathologies’ to include accidents, violence (self-inflicted and interpersonal) and the health effects of alcohol abuse. Among Canadian Indians, these causes contribute to about a third or more of all deaths [44,48]. Historically the rising trend can be seen to begin steadily from the end of the Second World War (Fig. 7). Detailed sociological inquiries have provided further information on the circumstances surrounding ‘accidental’ deaths, many of which were in fact associated with alcohol intoxication [68]. In many Indian communities across Canada, suicide ‘epidemics’, especially among the young, are periodically reported (691. An indication of the severity of alcohol related health problems among Indians can be obtained

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Age

Fig. 9. Mean body weight-for age: Canadian, Canadian Indian, and Indians in the Sioux lookout zone (northwestern Ontario), early 1970s. Source: Canadian and Canadian Indian data from nutrition Canada survey (Ref. [62]). Sioux Lookout Zone data from author’s unpublished survey data.

indirectly from a geographical study of Ontario counties. The District of Kenora, which has one of the highest proportion of Indians in the population among all Ontario counties (about 30%), ranked highest in terms of alcohol consumption, alcoholrelated offences, and hospital admissions (under the diagnostic rubrics of ‘alcoholism’, ‘alcoholic psychoses’, and ‘liver cirrhosis’). Interestingly, the District of Kenora ranked quite low in terms of mortality from liver cirrhosis [70]. This finding supports the observation that drinking among northern Indians is mainly of the ‘binge’ type, which results in deaths from accidents and violence rather than from cirrhosis. The Indian experience with alcohol has been studied extensively [e.g. 711. While initially alcohol may have served some beneficial communal integrating function [72], in recent times excessive drinking has become a widespread social and health problem. Research on the one hand has attempted to seek a ‘biological’ explanation, i.e. genetically determined enzyme deficiency [73], and on the other, attributed causes to social, economic and political factors [74,7.5]. The devastation of social pathologies mediated by alcohol-a ‘poison stronger than love’-in one northwestern Ontario Ojibwa community, has been meticulously documented [76]. Whatever their causes, the impact of accidents and violence on population change and the epidemiologic transition lies in their exceedingly high rates among young adults. This is reminiscent of the ‘virgin soil’ epidemics of infectious diseases during early contact. These conditions now serve as ‘competing causes’ for the chronic diseases by removing a large number of potentially at risk individuals earlier on in life.

THE EPIDEMIOLOGIC

TRANSIT’ION

To the extent that disease patterns have changed during the past 3 centuries, one can say that subarctic Indians and indeed Canadian Indians nationally, have undergone an epidemiologic transition. While the 3 ‘ages’ of Omran can be broadly discerned, there are several notable features which distinguish subarctic Indians from any of the 3 basic models proposed (western, accelerated, and delayed modern). The ‘age of pestilence and famines’ for subarctic Indians probably did not begin until contact with Europeans (during the late 17th century in the Hudson Bay hinterland), or perhaps up to a century before actual contact if one accepts the possibility of long-distance transmission of diseases via other Indians with an earlier contact date. There should be a pre-contact ‘age’ not Fharacterized by pestilence and famines, though not necessarily of low mortality. There was no allowance for this in Omran’s original theory, which appeared not to have considered widely scattered nonagricultural, pre-industrial, ‘primitive’ hunter-gatherer societies. After contact, the health history of subarctic Indians followed roughly the ‘rise-and-fall’ course of infectious diseases. Smallpox was one of the earliest to be recorded, and appeared to have been largely controlled by the late 19th and early 20th centuries. Tuberculosis did not show a dramatic decline until the 1960s. In the post World War II decades, by virtue of their being incorporated into the larger EuroCanadian society, Canadian Indians have been subjected to massive interventions in social welfare, medical care and economic development. While these

Are subarctic Indians undergoing the epidemiologic transition? are sometimes arguably ofdubious benefits, one must concede that they have resulted in overall reduction in the incidence and mortality of many infectious disesases and in infant mortality rate (largely the result also of infectious diseases). Canadian Indians therefore cannot be considered to be comparable to the developing countries, particularly the ‘least developed’ ones, which are still suffering

measures

from an exceedingly high infant mortality rate and infectious disease burden. Yet, these countries can only muster perhaps less than 1% of the resources in health and social services per capita currently enjoyed by Canadian Indians [77]. While collectively subarctic Indians do not share the epidemiologic pattern of countries in the ‘contem-

porary delayed model’, they have also not followed exactly the patterns set by either the ‘western’ or ‘accelerated’ models. There is disturbing evidence that the decline in infectious diseases among Indians has stabilized and persisted at a level still higher than that experienced by other Canadians, and the risk of recrudescence still remains. Against such a background, other ‘new’ diseasesthe chronic, degenerative diseases-have slowly but unmistakably been rising in importance. However, even among this group of diseases, genetic factors peculiar to the Amerindians may favor some diseases, such as diabetes and gallbladder diseases, over others, such as ischemic heart disease. The ‘New World Syndrome’ hypothesis [78] maintains that underlying metabolic defects mediating through obesity have resulted in the emergence of extremely high rates of diabetes and gallbladder disease, over and above that which could have been attributed to lifestyle changes alone. Another major deviation from the ‘age of degenerative and man-made diseases’ of Omran is the high mortality rate from accidents and violence-a rate that is perhaps unparalleled in the world-which ‘compete’ with the chronic diseases. Unfortunately there is no purely medical strategy which can reduce these largely socially determined conditions. At present, it would appear that the health of Canadian Indians has reached a sort of limbo. They seem to occupy an unenviable position of having more of just about every category of disease than their co-nationals. This situation has been depicted by Kunitz, writing about the Navajos: [The] stagnant reservation economy coupled with an increasing sophisticated social service and health care system had placed a floor under the [Indians] below which immiseration was unlikely to fall and a ceiling above which development was unlikely to rise [S, p. 1791.

A clear understanding of past, current and likely future epidemiological situation of a population is fundamental to establishing public health policies. Which one of Omran’s models of epidemiological transition fits a particular region or country best has important policy implications. Under the western model the steepest decline in mortality occurred primarily as a result of improvement in living standards, while in the contemporary delayed model, changes in health status has often been attributed to medical-technological interventions. There is indeed widespread perception among many health policy

669

makers in developing countries that they cannot ‘wait’ for socioeconomic development to occur. The health experience of subarctic Indians does not fit well with either the First or Third World. Increasingly, scholars have used the term ‘Fourth

World’ to describe the ‘internal colonial’ situation of indigenous peoples in industrialized countries such as Canada [79]. There is some justification for such a category on epidemiological grounds also. The health care debate, however. need not center on the medical care versus socioeconomic development dichotomy. It would appear that concurrent action in both areas are necessary, with neither one being the ‘prerequisite’ of the other. For indigenous peoples, medical care will perhaps ensure that the ‘floor’ does not sink any lower, while broad social measures will push the ‘ceiling’ upwards.

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