The COVID-19 pandemic has shone a spotlight on Canada’s neglected long-term care (LTC) system. Many Canadians are rightly outraged by what has been exposed, and calls for systemic reviews, better regulation, and increased federal and provincial funding dominate current discourse on LTC. What is missing from this conversation is consideration for the unique challenges and opportunities involved in supporting Indigenous elders in equitable, dignified, and healthy aging. Addressing these challenges and opportunities is further complicated by the tendency of settler voices to focus on and celebrate convenient narratives about the resilience of Indigenous communities and families. Indigenous families and communities are resilient, but when drained of nuance these same narratives can obfuscate the role of settler colonialism in fostering health inequities, the diversity of care needs among Indigenous elders, and the key obstacles to providing true support.
Demographic disparities between Indigenous and non-Indigenous communities in Canada influence differing LTC needs. Due to higher fertility rates and lower life expectancies, the Indigenous population is aging at a slower rate than the non-Indigenous population (Statistics Canada, 2017b). Although the Indigenous population is not as old as the non-Indigenous one, it is more likely that younger Indigenous adults will be providing simultaneous care to both young children and older parents (Statistics Canada, 2017a). The growth of this Indigenous “sandwich generation” and the impacts of this phenomenon on Indigenous communities is underacknowledged and understudied (Buchignani & Armstrong-Esther, 1999).
The horrific legacies and on-going impacts of settler colonialism, systemic racism, and cultural genocide cannot be overstated in the context of contemporary Indigenous elder care. Many older Indigenous people are residential school survivors and/or experienced the trauma of having their children sent to these schools, where physical and sexual abuse was rampant and child mortality rates atrociously high (Hadjipavlou et al., 2018). Systemic racism also continues to influence access to health care, employment opportunities, and safe housing (Nelson & Wilson, 2018; Thurston W.E. et al., 2014). Indigenous seniors over the age of 60 are more likely than non-Indigenous seniors to have one or more chronic health conditions, to live in poverty, and to experience food insecurity (Habjan, Prince, & Kelley, 2012). The rate of diabetes among Indigenous elders is more than twice that of non-Indigenous population (Truth and Reconciliation Commission of Canada, 2015).
Health inequities between Indigenous and non-Indigenous populations are often partially attributed to the distance of some Indigenous communities from major urban centres with robust health services (Oosterveer & Young, 2015). However, this claim is called into question by research suggesting that the average health of Indigenous seniors living in Northern communities is better than that of those living on large Southern reserves or in urban centres (McIvor, Napoleon, & Dickie, 2009). Mounting evidence of the importance of culture and language in health outcomes provides some explanation for these divergences (Dickson, 2000). Cultural connections and social contact are not evenly distributed geographically: one study has demonstrated that Indigenous elders living in smaller, more isolated Northern communities are more likely to have regular visitors (McIvor et al., 2009).
Profound reverence and respect for elders within Indigenous culture is often cited as a protective factor for Indigenous seniors (Hadjipavlou et al., 2018). These deeply ingrained values can have positive health outcomes in that they contribute to frequency of visits, maintenance of high social status in old age, and strong networks of kin support, all of which promote good health for older people. As critical Indigenous scholars and activists point out, however, the relationship between Indigenous culture, settler colonialism, and elder care is more complex than these positive depictions might suggest. While multigenerational homes are more common among Indigenous than non-Indigenous families (Statistics Canada, 2017c), there is also a higher distribution of skipped generation homes among Indigenous families, defined as households with grandparents living with grandchildren but not their adult children (Fuller-Thomson 2005; Statistics Canada 2017a; Statistics Canada 2017c). Multigenerational cohabitation patterns are rooted in Indigenous culture, but they are also influenced by poverty, poor health, and insufficient government crisis response (Buchignani & Armstrong-Esther, 1999; Fuller-Thomson, 2005).
In other words, many Indigenous seniors live with adult children and/or grandchildren because they have no other choice. LTC homes have waitlists that are too long, co-payments that are too high, and facilities that are too far from home for Indigenous seniors and their families to seriously consider them. Additionally, some Indigenous grandparents cannot consider LTC, as they are caring for their grandchildren because their adult children have left their communities to find employment or been lost to suicide—an epidemic clearly connected to colonial traumas.1 And while evidence suggests that Indigenous grandparents enjoy some positive outcomes from the practice of grandchild care, elders in skipped generation households are more likely to experience poverty and poor health (Fuller-Thomson, 2005). Similarly, while multigenerational residence can have reciprocal benefits for younger adults, such as help with childcare and housework, this relationship has been found to be asymmetrical: younger Indigenous women bear the biggest care burden. Furthermore, when the care responsibilities of younger Indigenous women act as barriers to paid employment, these circumstances contribute to a cycle of intergenerational poverty (Buchignani & Armstrong-Esther, 1999).
A central paradox is evident: though their care needs are higher than average users of the Canadian health and long-term care systems, Indigenous elders access government programs for seniors at lower rates than non-Indigenous older people (Buchignani & Armstrong-Esther, 1999). Indigenous elders often distrust mainstream “white” programs that have no cultural relevancy (Aboriginal Senior Resource Centre, 2019). At the same time, there is a lack of locally available and accessible programs. While there is a growing awareness of the need for culturally sensitive LTC that includes care providers who are fluent in Indigenous languages, cultural activities, and community-based care (Aboriginal Senior Resource Centre, 2019; Sue Cragg Consulting, 2017), more concrete action and Indigenous control of these initiatives is needed.
In addition, LTC policy discourse needs to move beyond a social problem approach to Indigenous elder care. Adding a care economy analysis to the discussion helps to identify how age demographics, life expectancy, and geography combine with the legacies of settler colonialism to present different care burdens and opportunities for Indigenous LTC. For example, the Canada caregiver credit, which provides tax breaks for care givers, tends to benefit higher income households and has negligible benefits for many Indigenous households. Instead, innovative policy solutions such as cash income supplements for Indigenous family carers should be seriously considered. Investments must be made into community-based care programs that support elders to stay in their own homes for longer. These programs should be part of a broader initiative to address the lack of safe, affordable housing and potable water experienced in too many Indigenous communities for far too long.
In short, we need to find ways to support existing resiliencies within Indigenous communities, instead of simply celebrating them without acknowledgment that these same resiliencies are partially shaped by and can contribute to systemic inequities. Policy interventions also need to recognize the vast and rich cultural variations between Indigenous nations and peoples living across Canada, which can impact perceptions and practices of elder care, such as differences in hierarchical traditions and perspectives on palliative care and dying (Kelley, 2007). Indigenous control is essential to ensure that policy innovations are rooted in geography, land, and local culture. To help achieve this, a critical analysis of colonialism and racism are needed within elder care policy development (Brotman, 2003). As the Truth and Reconciliation Commission Calls to Action 18-24 note, the federal government must work in collaboration with Indigenous peoples to identify, track, and close gaps in health and health service as an essential element of reconciliation (Truth and Reconciliation Commission of Canada, 2015).
It remains to be seen if a silver lining of the global pandemic will be systemic LTC policy improvements in Canada or if neoliberal retrenchment forces will succeed in preventing meaningful LTC policy change once media and public attention subsides. When federal and provincial LTC policy reviews take place, these reviews must take into consideration the unique care needs of Indigenous elders, the existing opportunities within Indigenous communities, and the disproportionate burdens faced by Indigenous peoples. Increased funding for culturally sensitive and Indigenous controlled LTC programming and services are crucial, but so too is a broader view on the situation. Gender- and race-based models accounting for the economic and social impacts of care and the intersections between socioeconomic inequality and health outcomes are indispensable for the development of innovative policy solutions to support family- and community-based care from an anti-racist perspective.
I would like to thank Victoria Grant for her excellent advice at an early writing stage of this piece, as well as Ito Peng and Mark Abraham for their thoughtful edits and suggestions.
1 Indigenous suicide rates are more than 20% higher than the average in Canada (Statistics Canada, 2017a). ▲
Aboriginal Senior Resource Centre. (2019). Aboriginal Senior Resource Centre Winnipeg, MB. http://asrcwpg.ca.
Brotman, S. (2003). The limits of multiculturalism in elder care services. Journal of Aging Studies, 17(2), 209–229. https://doi.org/10.1016/S0890-4065(03)00003-3.
Buchignani, N. & Armstrong-Esther, C. (1999). Informal care and older Native Canadians. Ageing and Society, 19(1), 3–32. https://doi.org/10.1017/S0144686X99007254.
Dickson, G. (2000). Aboriginal grandmothers’ experience with health promotion and participatory action research. Qualitative Health Research, 10(2), 188–213. https://doi.org/10.1177/104973200129118363.
Fuller-Thomson, E. (2005). Canadian First Nations grandparents raising grandchildren: A portrait in resilience. International Journal of Aging and Human Development, 60(4), 331–342. https://doi.org/10.2190/LCR8-FJNM-F73L-58G3.
Habjan, S., Prince, H., & Kelley, M.L. (2012). Caregiving for elders in first nations communities: Social system perspective on barriers and challenges. Canadian Journal on Aging, 31(2), 209–222. https://doi.org/10.1017/S071498081200013X.
Hadjipavlou, G., Varcoe, C., Tu, D., Dehoney, J., Price, R., & Browne, A. J. (2018). “All my relations”: Experiences and perceptions of Indigenous patients connecting with Indigenous Elders in an inner city primary care partnership for mental health and well-being. CMAJ, 190(20), E608–E615. https://doi.org/10.1503/cmaj.171390.
Kelley, M.L. (2007). An Indigenous issue: Why now? Journal of Palliative Care, 26(1), 5. https://doi.org/10.1177/082585971002600102.
McIvor, O., Napoleon, A., & Dickie, K.M. (2009). Language and culture as protective. Journal of Aboriginal Health, (November), 6–25. https://doi.org/10.18357/ijih51200912327.
Nelson, S.E. & Wilson, K. (2018). Understanding barriers to health care access through cultural safety and ethical space: Indigenous people’s experiences in Prince George, Canada. Social Science and Medicine, 218(August), 21–27. https://doi.org/10.1016/j.socscimed.2018.09.017.
Oosterveer, T.M. & Young, T.K. (2015). Primary health care accessibility challenges in remote indigenous communities in Canada’s North. International Journal of Circumpolar Health, 74, 1–7. https://doi.org/10.3402/ijch.v74.29576.
Statistics Canada. (2017a). Aboriginal peoples in Canada: Key results from the 2016 Census. http://www.statcan.gc.ca/daily-quotidien/171025/dq171025a-eng.htm.
Statistics Canada. (2017b). Aboriginal Peoples Survey, 2012&emdash;Aboriginal seniors in population centres in Canada. https://www150.statcan.gc.ca/n1/pub/89-653-x/89-653-x2017013-eng.htm.
Statistics Canada. (2017c). Diverse family characteristics of Aboriginal children aged 0 to 4. https://www12.statcan.gc.ca/census-recensement/2016/as-sa/98-200-x/2016020/98-200-x2016020-eng.cfm.
Sue Cragg Consulting & Program, C. (2017). Supporting Indigenous Culture in Ontario’s Long-Term Care Homes: Needs Assessment and Ideas for 2017-18. 1–56. https://the-ria.ca/wp-content/uploads/2018/10/Supporting-Indigenous-Culture-in-LTCH-Report-Final-March-31-2017_updated_A.pdf.
Thurston W.E., Coupal S., Jones C.A., Crowshoe L.F.J., Marshall D.A., Homik J., & Barnabe C. (2014). Discordant indigenous and provider frames explain challenges in improving access to arthritis care: A qualitative study using constructivist grounded theory. International Journal for Equity in Health, 13(1), 1-10. https://doi.org/10.1186/1475-9276-13-46.
Truth and Reconciliation Commission of Canada. (2015). Honouring the Truth, Reconciling for the Future: Summary of the Final Report of the Truth and Reconciliation Commission of Canada. https://publications.gc.ca/collections/collection_2015/trc/IR4-7-2015-eng.pdf.