MARCIA DAY CHILDRESS: Good afternoon.
I'd like to welcome you to today's Medical Center Hour--
First Nations' Resilience-- Two Communities
Take on an Epidemic.
I'm Marcia Day Childress from the Center
for Biomedical Ethics and Humanities
here in the medical school.
We're so pleased to bring you this program.
When the First Nations of Big River and Ahtahkakoop
in Canada, Saskatchewan Province realized
their rural communities were in the throes of an HIV epidemic,
their leadership and health centers
rallied community members to determine
the sociocultural and structural issues behind the epidemic.
One of the driving factors proved
to be injection drug use.
Big River and Ahtahkakoop then developed culturally competent
community-based care to address the intertwined issues of HIV,
hepatitis C, and substance use.
In this presentations, spokespersons
from these two communities describe how
they took on these epidemics.
And then we'll discuss solutions they devised
that have worked for them.
This program, which is both a Medical Center Hour and Medical
Grand Rounds, is part of a larger conference being staged
at UVA yesterday and today at the Center for Global Health
in the Department of Medicine--
Best Practices and Community Mobilization in Response
to Substance Use and Related Epidemics.
Serious infectious disease and epidemic substance abuse
are much in the headlines these days.
And indeed, two medical center hours in October
will examine aspects of the devastating opioid epidemic
in the United States.
But another good reason for this program
is that it's an opportunity to cross cultures--
to see how communities different from ours
but facing similar public health and personal health crises--
and problems solved at a grassroots level
in ways that are locally culturally
consistent and effective.
It's an opportunity for us to recognize
that health-related challenges to individuals and communities
are never just biomedical, but rather biocultural in origin.
And responding to such challenges,
acknowledging, understanding, and managing them
must, therefore, also be fundamentally biocultural.
So what do the Ahtahkakoop and Big River
communities' struggles and their culturally competent
local responses offer us?
Are there lessons from these First Nations
for communities in Virginia, where on average three
people die every day from opioid overdose,
and more widely in Appalachia and other parts of our country?
Are we-- should we be thinking bioculturally
about our own epidemics, their origins, and our solutions?
Our speakers today all hail from the Canadian province
of Saskatchewan.
They include on my immediate right Dr. Stuart Skinner
from the infectious diseases clinic
at Regina General Hospital in Regina, Saskatchewan.
You'll note in your handout that Dr. Skinner disclosed
some financial involvement with pharmaceutical concerns
in relation to his HIV and hepatitis C research.
Our other speakers include representatives
from First Nations health centers,
from the Ahtahkakoop band, Noreen Reed, who
is on the far end, and from Big River, Leslie-Ann
Ironstand-Smith, closest to me, and Vivian Ruby McAdam.
And they will present in sequence and at the close,
we'll have some time for questions and discussion.
So welcome and we are here to learn from you.
Thank you.
STUART SKINNER: Well, thanks everyone for having us here.
It's very humbling and we're very honored
to be here from the two communities
from a province in Canada you probably can't pronounce.
But more importantly for us, it's
rather than being when people talk about HIV
or in Canada, when people talk about First Nations' health,
it's often seen and described in a negative light,
a problem-based light.
And to be here and to talk about positives, and positives
in how solutions were developed and developed locally and led
by those First Nations, is really an honor
to be a part of the program.
I'm an infection doc.
I'm based in Regina, which is--
I guess I'll take a step back.
So this is our province of Saskatchewan.
Regina is based in the southern--
we're in the southern part of the province.
So we're located about near the bottom.
And the two communities I've worked with--
or two of the communities I work with,
Big River and Ahtahkakoop, are about halfway up the province
about 500 kilometers away.
That's about 400 miles away from where
I am and about 150 kilometers away from the closest city
where you can get lab services and clinical care.
Saskatchewan province is a prairie province.
We're landlocked.
We're in kind of the central part of Canada
just above North Dakota and Montana.
You probably don't hear much about us.
We represent about 3% of the Canadian population.
I've basically got five minutes to describe to you
our entire province, country's health system, and all
the underlying issues relating to indigenous peoples
in the country.
So I'll do my best to give you the high-level points.
Saskatchewan is a province.
We have pretty brutal weather.
The summers are nice and hot and dry.
It's a province based on agriculture,
potash oil, and gas but the winters are long and cold.
The summer's about 35 degrees Celsius
and I would say just put a minus sign in front of that
and that's what our winters are like.
So often lots of snow, blizzard conditions, which
makes travel and transportation, particularly
for people in rural communities, that
much more of a significant barrier
when you have to hitchhike to get your methadone,
which is what many of our people have to do
and it's -50 degrees with the wind chill.
It's not really practical that you could ever actually
deal with your opioid addiction.
The Canadian health system, we have--
I would say we have a public health system so all
your hospital care is provided.
Your clinical care is provided.
Medication isn't necessarily provided.
Allied health professional coverage isn't provided,
so I'm not sure I would necessarily consider
it universal health care.
But it is all covered, at least in the hospital where
you don't have to pay, but it's really a provincial mandate.
So the system is set up where the federal government
transfers the funding to the provincial health systems
and then the provincial health systems
will decide how programs specifically are rolled out.
Now on top of all of that, and layered on all of that
for our indigenous people, which is First Nations and Métis
and Inuit, for reserve communities,
which is First Nation communities.
That's on federal land.
So some of the programs are federal jurisdiction
and run by federal First Nations even in the health
branch or Health Canada.
But what happens is any time you get federal or provincial,
you end up in this jurisdictional vacuum where
no one wants to take responsibility,
and sometimes nothing gets done because there's
just a bouncing back and forth of nobody actually
taking the initiative to make a difference.
In our province, we've had the highest rates
in Canada for the past 10 years fairly consistently.
In the bottom left, you'll see a graft, which kind of--
graft.
I'm thinking as a vascular surgeon.
A graph comparing the Saskatchewan rates
to the Canadian rates.
The Canadian rates have slowly been
declining but Saskatchewan rates have been pretty consistent.
We're about 2 and 1/2 times the national average.
The top graph kind of gives you the number of cases.
Unfortunately, we haven't had the investment
of resources that are required.
So while we had a bit of a reduction in our cases
in 2013 and 2014, the last bar on the right
is your 2015 numbers.
And 2016 actually went up again compared to 2015.
Most of this is related to injection drug use.
And because of that, we have similarly very high rates
of hepatitis C. About 70% co-infections
for the communities we'll talk about today, so 90%
co-infected with hepatitis C.
What started as an outbreak in the urban centers
of Saskatchewan is--
50% of people live in the urban centers.
We have two major tertiary care centers, Regina,
which I mentioned.
Saskatoon is the other one and the rest
is kind of rural and outside.
So we have a very much rural population
with all the challenges that come with that.
Most of the population kind of is in the bottom half
of the province.
When we think about rural communities,
we're thinking about remote communities.
You often think about getting on a plane and flying up north,
but the reality is the challenges
of a rural population are almost the same, even
if you're 30 minutes outside of a major tertiary care center.
If you don't have a car, you have no access
to transportation, and you can't get any access to care.
And that's just one kind of context to put the things in.
And so what happened was this--
the epidemic started in the urban centers.
And then what's happened is it's spread out now
throughout the province.
And we kind of see almost an outbreak situation kind
of happening in various communities in our province,
not dissimilar to what happened in rural Indiana
a couple of years ago.
I'll leave it to the team on the right kind of talk
about the specifics of the program.
But what happened was in--
it's really hard to describe the way
Canada has treated their indigenous
peoples over hundreds of years.
But let's put it this way.
It's been very poor.
The communities are very much underfunded,
and we have a lot of racism within our country,
despite what Canadians may want to tell you.
Saskatchewan has one of the highest populations
of indigenous people, about 15%.
Half of those live in First Nation communities,
and half of those live in the urban centers
or other communities.
But all of that, the way the people
have been treated-- a lot of underlying poverty
and resulting socioeconomic factors.
And then the substance use that people will often
develop to deal with all of that trauma
that they've been dealt with through their lives.
Despite this-- despite having what traditionally people would
think are the hardest to treat--
HIV population, active substance use, rural population, poverty,
transportation, homelessness--
we've achieved the 90-90-90 outcomes with UNAIDS
that they played out.
So 90% of people on treatment, 90% of people--
I'm sorry.
90% of people diagnosed, 90% of people on treatment,
and 90% of those undetectable.
And, in fact, we've reached 95 95 95
where the vast majority of the people are in treatment.
And while that comes and goes, there's
ups and downs, so there's been points and times where
we've had every single person undetectable with a viral load.
And that was done because these communities and the leadership
in the communities who are here, the nurses in the communities
who lead the program, said, you know
what, we need to do something.
And we're not going to wait for government to make a policy
or to make a program.
We just need to do this and let's do this.
And really, I think any successful program comes down
to the people in it that are committed and passionate
and not waiting for other people to come up
with solutions for them.
So that's our situation and to talk a little bit more
about the specifics, I'll pass it onto you guys.
LESLIE-ANN IRONSTAND-SMITH: Good morning, everyone.
I'd like to thank the organizers of this conference.
And I'd like to thank you all for attending today.
I'm very humbled.
OK, great.
So I'm a Health Canada nurse.
I'm a Federal nurse, but I work in the community of Big River
First Nation.
And we developed a Know Your Status rate from nothing
and we started it-- in January, 2010, we started the program.
I bring greetings from our chief, Bruce Morin, and our 12
council members.
Bruce, unfortunately, was not able to attend with us today.
But he's an amazing man and he gives us so much support.
So the Know Your Status program.
I've got a few minutes to talk to you about a program
that I can present for hours.
The Know Your Status--
KYS is what we call it.
Why did we start it?
We started to see high-risk behaviors in our community.
We've seen increase in Chlamydia and gonorrhea,
hep C, sporadic cases of HIV.
And then we found a pocket of intravenous drug
users and the prescription drug abuse.
And the drug of choice is morphine in our area.
One of the interesting things here when
I talk about high-risk behaviors,
when people will say, well, how's Chlamydia and gonorrhea
associated with this?
90% of our clients that have HIV and hep C
had Chlamydia or gonorrhea in the beginning.
And so at that time, that was already
saying there was high-risk behavior there.
And we consider that very much a target for clients
not taking care of themselves.
And everything is 100% preventable.
So we decided that our clients--
we needed to test.
Our clients would not go for follow-up testing.
We would diagnose someone with something
and they wouldn't go for the follow-up testing, which
is an hour away in a neighboring city, Prince Albert.
We even tried the requisition in hand
where they had the medical health officer's number on it.
They could just take the req. right to a lab--
bypass a doctor or nurse practitioner or anything.
And that still wasn't working because there's
so much fear and anxiety that goes
with unfamiliar health-care providers.
They were seeing people and repeating their story,
you know, I'm HIV, I need this done.
And they'd send them to the social worker--
I'm HIV and I need this.
And it just became very--
they got mixed emotions having to do that all the time.
So we also have core access to primary care.
We're in rural Saskatchewan, and like Stu said,
we have just over a million people in our whole province.
So to get to the specialist, Stu lives 400 miles away from us
and so that was an issue.
And so we decided in the end, leaving the community is not
the answer.
So we decided to have the Know Your Status program.
We had a local logo contest in our high school.
We had 68 entries from our high school students.
A survey about HIV and what they knew about infectious diseases
was sent out.
Our students did remarkable because we educate them
all the time.
And the first surveys we got back were from the teachers.
And so the short of it, we needed to teach our--
give our educators more information.
So this is Trey Whitefish.
He was in grade 11 at that time and he created our logo
and we're very proud of that logo.
So once we decided we needed this training,
and it needed to come from within the community,
our clients are comfortable in their home communities.
Our nurses were trained-- we're community health nurses so it's
a public health issue.
You don't do phlebotomy.
You don't do diagnosis.
And our nurses expanded their role.
And so our nurses are the phlebotomists.
Our nurses do give diagnosis and they do the complete case
management of HIV, hep C clients and all the other STIs
that go with it.
We have a lab license.
We're regulated.
We just went through accreditation
so we're very proud of that.
But this program was created one day at a time.
We actually developed our forms.
They're living documents and they change every day
with the needs of our clients and what
we're needing in the program.
We also needed client buy-in.
You can develop a program but that doesn't
mean they're going to come.
It's not the old Kevin Costner, build it and they will come.
It's-- we needed to get out there and develop
relationships.
Our clients needed to feel trust.
They needed to know that when they came to the clinic,
they were number one.
I'm a firm believer-- and I really
promote this in our communities and with our nurses
that those clients are number 1.
We're not going to do anything unless it's
for the benefit of those clients.
So relationship and trust was key to success.
Some clients were very quick to engage--
some took months to years.
We would do numerous home visits and we'd--
get lost, get off my land, get out of my yard.
And we'd just say, all right, see you next time.
It was just that you needed to develop that clients are scared
when they have these diagnoses.
They need to know it's not a death sentence anymore.
The social determinates of health
play a huge role in our HIV infections
and the ability of our clients to seek treatment, care
and support.
Many of our clients are couch surfers.
They don't have a home.
They live with relatives, and those relatives get tired
of them and they move on to the next,
and they move on to the next.
So we have a large geographical area.
So finding them at times is difficult.
One thing I have to stress is our program
does not create dependency.
It creates ownership.
Our clients, this is your HIV.
This is your hep C. This is your disease.
What do you want to do with it?
We will walk with you.
We will talk with you.
We will do whatever you need to get you
to that undetectable and that healthy living
but you have to make the plan.
And so we're just there to assist them.
So, like I said, January 6, 2011 was our first lab drop.
Our first KYS clinic.
And our first positive client we tested
had 23 contacts when he came back.
19 of those clients became positive.
And that was from a weekend of sharing needles.
And so we just knew how quickly this could
spread if we didn't stop this.
Day screening is now offered.
We completely case manage his clients.
Social networking to us is huge because we peel back
the layer of the onion.
OK.
So now we have you that's positive.
Who's your social group?
Where are we going with this?
We need to stop this spread and we
need to do it with the client focused
like they're number one.
So three months into the program,
we developed this program without an infectious disease
doctor tagged to it.
We would diagnose our clients.
We would get everything but we'd still
have to send them to the neighboring city.
So our good doctor, Stu Skinner here,
who we absolutely love and adore, Stu phones us and said,
I've heard all the great things you guys are doing.
I'd like to be part of it.
So we didn't trust him at first.
No, I'm kidding.
[LAUGHTER]
So Stu came in and he helped us build
the program a little bit stronger because now you've
got that physician service in there as well.
And Stu comes out to our clinics every three months.
And we have him packed from the moment he walks in that clinic
till he leaves, and we keep him overtime
some times to make sure that everybody's
seen that needs to be seen.
In between his three-month visits,
we telehealth our clients.
So if we get a pregnant woman with HIV
or we have someone who has a low CD4,
we'll telehealth those clients to get
them started on medication.
The clients actually enjoy that.
They just can't believe they can talk to their physician
on the television.
And it works really well because we case
manage all aspects of care.
We're social workers, we're nurses, we're daycare.
Like we deal with the whole family.
Why does our program work in Big River?
Because it's community based.
It's community driven and it's community developed.
This program was developed with the chief, the council,
the CEO, Derek, who's here today.
Ruby's our health director.
She just come in in the last couple of years,
but it's developed with everybody.
And our elders play a big part in this.
We had a band meeting in the beginning that
invited the whole community and there's
2,700, 2,800 living on reserve and there's 3,500 band base.
But they were invited to come and say,
what are we doing about this epidemic
that we're dealing with?
And so the program is not made in isolation.
We're not professionals that dictate what
the community's going to do.
It comes from within.
And it very much comes from our clients.
I'm a firm believer that those clients deserve all the respect
in the world that any of us do.
I don't want to get emotional on this,
but they're someone's baby.
What happened?
They got on that track and they need the support.
They need the respect that we all
get when we go to see health professionals in just
the day-to-day and that's how we treat them.
So the KYS has a mobile unit.
It's a mobile clinic.
We mobile test our high school.
We have a mobile clinic every few months in our high school.
We find Chlamydia, gonorrhea all the time with those students.
We have found a case of HIV in our programming
from our high school and hep C.
But our facts tell us, when we're
starting to get Chlamydia and gonorrhea in the high school,
we get in there and we hammer those kids with knowledge.
It's not pretty because they know
everything is 100% preventable.
I'm not naive to say that I worry
that it could be my grandchild at some time in my life.
So that's why we treat everybody with respect.
So high school testing is very much well received.
We had to go to our school board and then
we had to go to the chief of council and the CEO
to say we want to do this.
We will test 16 and over because they
have to have a good understanding of what
we're testing.
Pre and post-test counseling in our program is--
I'm trying to get it certified right now.
I need clients to understand what they're being tested for
and what could come out of that testing.
The last question we leave our clients with
is what would you do if you didn't come back
positive for HIV?
One in Care testing, the rapid test, we use very little.
I'd say we've done maybe five in the last seven years
because our clients aren't ready for that immediate result.
So we give them their blood test.
We send them off.
And they have 7 to 10 days to think about it
and we give them some homework to think about.
If someone was really worried when they got tested,
we'll touch base with them in about five days.
I know you're probably worried about your blood work
and we just walk through some of the things.
But they need to know it's not a death sentence any more.
We're not only dealing with the HIV,
we're dealing with the addiction.
Our clients are addicts.
They continue.
We have 90% suppressed the times they go in and out of that 90%.
And do we really know they're 90%,
because we hope that we have 90% of the individuals
in the community, but we're not sure.
And so we go through that with them
and we deal with everything in their case management.
I kind of got lost there.
We have a very transient population.
We deal with more than one community.
Our mobile clinic also goes to seven other communities
that I supervise community health nurses in.
And then we train their nurses to case manage their clients
before we leave so that they're comfortable with what
these clients need.
Places that don't have a program,
we talk to them about what will you
do with if an HIV client walks in today?
You engage them.
You ensure that they're engaged.
You take it one day at a time.
Do they take up a lot of time?
They do.
We have our pests, as we call them.
They want to be in there every day, every day.
So from that, what we decided to do,
we've done a day program now.
So the clients three days a week can come in and do crafts.
They can do whatever.
They're artists.
They're smart.
They're intelligent.
We're looking at doing the grade-12 program out
of the day program now.
Our clients forget the dream.
And so the one thing we tell them
is you need to dream again.
You can be anything.
We just need to work with you and your addiction.
Our clients are early detected because of the program
and it's well received.
We have clients that actually bring
in other clients or other friends of theirs that
are doing high-risk behaviors.
We have a seek-and-find program.
We continue to treat--
test every day.
It's a drop-in program.
You don't need to make an appointment and we'll do it.
The diagnosis is powerful.
We have found even clients that don't
go on treatment, when they're diagnosed,
they have that power now.
This is my diagnosis.
This is my disease and I don't have to spread it.
And we don't see the spread like we did in the beginning.
We're getting very sporadic cases now
because they know that there's a program there that will
support them and help them.
Number one is committed staff.
You need the right person to do the right job.
And we have committed staff and we have the right people
and the right physicians.
This is Charlene, who is our Suboxone worker.
And we have a Suboxone program that's direct observed
and they get "carries" on the weekend.
I think we have 17 in that program right now.
It's amazing.
That's Ruby, the health director.
Ruby's sitting here in the middle.
And then one of our Know Your Status nurses, Amanda.
[INAUDIBLE] Anyway, Jolene is our manager.
She'll take on my role when I retire at some point.
She's an amazing young nurse and she has been with me
from the start of this program.
And she has the passion that I do
and that these clients are number one.
This is Dr. Crawford.
We pulled him out of retirement.
He's our Suboxone and our addictions doctor.
And we absolutely love him.
And he comes to community once a month
and reviews the clients and their Suboxone--
their opioid replacement therapy.
We don't do methadone in our community.
We just do Suboxone and, like I said, it's well received.
So that's our program in a nutshell.
Sorry, I've rushed through it.
Here's some contact names and numbers.
That's the program.
Thank you.
RUBY MCADAM: Good afternoon.
My name is Ruby McAdam.
I'm health director for Big River First Nation.
I'm going to be speaking on what we'll be doing moving forward
from here.
Right now, we don't have a day program on our First Nation
so that's what we'll be working toward five days a week,
three hours in the morning.
We're also going to be hiring a full-time RN
to assist with our LPN, with our direct observe therapy
for our Suboxone program.
And we're also looking to eradicate
hep C on our First Nation.
Also, we're going to be looking into hiring a full-time nurse
practitioner because currently right now,
we don't have a doctor or licensed nurse practitioner
on our First Nation.
We're looking towards a new health center
to support our programs as we have grown out of our building
that we currently are in.
We're also going to be working towards establishing
a relationship with the provincial government
so we can have a better relationship.
And we're going to continue testing within our community
and engaging with our community members.
Moving forward, my advice is to have a good relationship
with leadership because without our leadership,
our program wouldn't be where it is right now.
NOREEN REED: Good afternoon.
It's a privilege and an honor to be
able to be here and share a story
and to have this opportunity to showcase.
It's an honor to be here to represent my community,
as well.
So I'm going to try and just change this
up a little bit from yesterday.
Big River is not very far away from us.
They're about 10 miles away from our community.
And so similar issues--
similar programs.
But I'll tell you a little bit about our community.
Our community is about 1,700 on-reserve population.
We have about a 3,500 Band-base.
We have multiple services within our community--
economic development, school-- we
have quite a valuable resourceful community.
We have a community health center.
And we're community-health focused, prevention focused.
Our nurses within our health center--
we're a little bit different.
We are Band employed nurses, so we were directly
for our community.
And so we also have a fabulous team that we work with
and our leadership has been key stakeholders in driving things
forward.
They're on the same page.
They're very much are--
they're leaders.
They're our leaders within our community.
Way back in the '90s, we started to see high-risk behaviors
happening in our community and our clients were not
accessing health services.
They were afraid.
They didn't have the trust in our community health center.
And so we had two really brilliant community
health nurses who learned and implemented our first needle
exchange program.
And, again, with the support of leadership,
that was able to put into place.
And our goal was--
we were seeing increased--
we were seeing hepatitis C increases.
We were also needing those people
to access health services.
So through that, we were able to engage our clients.
And they started to come little by little.
They started to share and tell people.
We would provide education.
We had testing.
We called her the STI nurse.
[INAUDIBLE] used to come out once
every two weeks, maybe for a half a day to do testing
and she was seeing just a few people.
So we've expanded from that into having a nurse with the ability
to do lab work.
And we provide those services on reserve.
And it's a daily--
come in as they request.
Anyway, our "Know Your Status," we were seeing those increased
hepatitis C rates back in the '90s and the treatment
was horrible.
There was very lack of support.
There was just nothing to support
these people going through treatment,
so it kind of fell off the grid.
And as Leslie-Ann spoke, we've seen the increase in HIV
in 2011.
So then we started to mobilize and react to what
was happening in the community.
And similar services-- bringing those services to our clients.
Our clients were being discriminated
in the off-reserve services.
They were infected.
They were injecting drugs and, again, our country--
they were indigenous.
First Nations people are because-- and you
put those three together and you walk through the door
and you're treated very differently.
I've worked in both systems and I've seen it firsthand
how indigenous people are treated
and it's a shame how we treat each other.
OK.
So our successes have been that we achieved 90 90 90.
Dr. Skinner explained what that was with the UNAIDS in 2015.
And we've had ups and downs and--
because a transient population, they kind of move around.
They go back and forth.
But that success has been attributed to multiple things
and bringing our services to the community,
so our clients can feel comfortable.
They feel safe.
Our clients-- our nurses, Tanis [?] is here today--
our clients have this amazing relationship--
or she he has this amazing relationship with the clients
where she just meets them where they're at.
She doesn't see them in a few days-- get concerned.
We have Pat, who is our community caseworker.
She lives in the community.
And so her connections to the community are huge.
She knows-- oh, yeah, I saw so and so at the store yesterday.
Or yeah, they're doing OK.
If we can't find them, they'll go out and find them.
Tanis [?] if clients won't come in for their bloodwork,
she'll go to their home to find them and get
those services done.
Because it's just we want them to be successful
and we want them to feel supported.
Those relationships are key to any success.
I don't have my glasses on.
I can't see what I wrote here.
We also have an incentive program.
It's incentive based so clients needing some bloodwork
or kind of following into--
kind of rewarding them for being a part of the program
and doing for themselves.
So we give them food vouchers.
Food security is a huge thing in our community,
especially amongst our high-risk behavior clients.
We also have what is really unique in our community
is the Cree Nations Treatment Haven.
That is a five week inpatient addiction treatment program.
And there's also a 16 week matrix program,
so it's an outpatient program that part.
One of the unique parts about Cree Nations
is that clients who may be on OST, Suboxone or methadone
are accepted into the treatment program.
That's a part of that program.
They have a very holistic approach where
they look at all the aspects.
The program addresses all the aspects of the individual.
And they also do a day program where
they have a nurse working Monday to Friday.
And then there's a nurse for a few hours each day
on the weekend and they do the daily observed methadone
or Suboxone for our clients.
And as well as on top of that, we've integrated the ARVs
and the hepatitis C medications so that we've
got that additional support.
So it's a huge partnership that we have with them
and it's a big piece of our success with our clients.
Peer involvement.
One of our other caseworkers is a peer and we also just have--
not just, I shouldn't say that.
Some of our clients are peers.
They advocate for us to bring the clients in--
their friends or network.
It's a safe place to go.
If they need to go see Thomas at the clinic and just go
have a conversation or go see Pat.
We have a needle-exchange program that still continues.
And Pat manages that so when the clients come in,
they have a conversation.
And she said, sometimes they just ask her to pray with them
and that's all they need.
They just need that support of someone who's going to listen--
someone is going to just be there for them.
And so we indirectly work them in to our program.
We started an expansion program of our Know Your Status
last year within--
our leadership and our health director at the time
wanted an elimination--
eliminate hepatitis C. Dr. Skinner
brought in a gentleman that did some Lean consulting
work with us.
We had no extra resources so it was
looking at what we could do with what we had to meet
the needs of our community.
And so through all of that, the biggest piece,
I think, that we've done liver screening events
and we follow up with clinics.
And it's a nurse-led model.
And we're learning.
Every time we have a screening day,
we learn and we relearn, redo, and redirect just
to make it better.
And I lost my thought there about where I was going.
So our clients-- when we first started building the program,
it's like--
as a nurse, I am a band member.
I grew up around the community.
And we know as health professionals--
we know what people need.
We think we know what people need.
We know what they have to do and we just want to fix them.
And one thing that I've learned is that we
need to listen to our clients.
They know what they need.
They just may not know how to get there.
So one of the things that we did as part of the planning,
the liver screening was a focus group.
So we met with our community members, elders,
and clients that have been involved in the program
or were living in the community coinfected or substance use.
And our community members really just wanted a well community.
Let's just make everybody better.
Let's get rid of this.
So that's really their direction-- we just
wanted to help the community.
And our clients really just wanted nondiscriminatory care.
They just wanted to be treated like anybody else.
And I shared yesterday that what really rang out to me--
and it kind of is always in the back of my mind--
is one of my clients--
one of the clients said, I did not ask to be addicted.
I did not ask to be infected.
So simple words like that, it really raised a lot of I
didn't ask to fall down and break my leg
and I've got good care, right?
So it's just a matter of choices.
I may could go on and on with that.
So we've have some liver-screening events and then
follow-up with clinics.
And we've started treatment in cohorts of six to eight people
at a time just to make nursing more
manageable to work with the clients with the bloodwork.
It's so that they can support each other through treatment.
We have a support group there where they can come and go
as they please.
Just to have those extras support.
Sometimes it's just to come listen
and sometimes they share their stories.
So that's coming along.
It just needs a little bit more media in the community about it
from peer to peer
So one of the things when we look at engaging our community
and our population in anything, is,
like I said, we all think as health professionals,
we all know what the answers are.
But about looking at the whole team and partnerships--
looking at the partnerships.
And when I say partnerships, I just
don't mean our partnership with the federal government
for funding.
I'm talking about those partnerships and relationships
of clients to the bureaucratic level
where we do get our funding.
And we need to be those advocates in between.
Partnerships and advocacy go hand-in-hand.
We need to be open-minded and allow for those relationships
to build.
Communicating.
We need to continually communicate with each other.
We need to communicate with our clients and listen.
When I say communication, I don't just mean talking--
listening, really good listening, and hearing
what's being said.
And actually sometimes having to change your own outlook
on things and moving forward.
And addressing culture.
Culture-- our community, our indigenous people,
have lost a lot of their culture.
So we're looking at ways to help support
them to find that culture.
I was listening to one of the community members and he was
talking about the '70s--
all the drugs and how it grew and grew
and grew and grew and grew.
And he talked about the culture of how those drugs came
and it just became a normal way.
That was a very [INAUDIBLE] timing
of when our culture was really lost within our communities.
So replacing-- I'm going to think about what I'm saying,
but you're replacing one culture with another.
So supporting those positive cultures,
whether they believe traditionally,
Christian-based, land-based.
Land-based learning is something that we're
going to integrate into our programs going forward.
And it's so that people have that place
to go where it doesn't matter who you are
or where you came from, but connecting
with the earth-- connecting with the activities on the land
and learning some of those traditional activities
to help move it along.
So in going forward, we're just going to keep asking for things
that we need based on what our clients and our community
is asking for--
an ongoing advocacy.
Expanding our services.
As I said, we're community-health based.
Our nurses are community-health nurses-- public-health nurses
and we're working, as Leslie talked about,
in her nurses with the expanded role.
So we're kind of moving into that primary-care piece.
So advocating for those services that we need for our people.
And working with leadership.
Our leadership are key in our community,
and working with awesome partners
like Dr. Skinner and team and even
our neighboring communities supporting each other.
That's all I have to say.
Thank you.
[APPLAUSE]
MATT ALBRECHT: How are you doing?
Hi, I'm Dr. Albrecht.
I'm one of the chief medicine residents.
Thank you so much.
That was an outstanding discussion and a very inspiring
story.
Having an issue like this, it seems
like it takes a critical massive buy-in
from community leaders, health-care providers,
the patients, or just family and friends of the patients
to get something like this done.
I was wondering in terms of getting this started,
was it a daunting task?
I imagine you were met with sort of resistance
and at least defeatist language about could this even be done
and what strategy sort of employ to overcome
that sort of obstacles along the way.
LESLIE-ANN IRONSTAND-SMITH: [INAUDIBLE]
In Big River, how we first began is that leadership.
You needed to have your leadership
because what comes with a program
like this can come stigma and discrimination.
From rural Saskatchewan, from the non-First
Nation population.
When we started, we started with 30 cases of HIV.
And the next thing you know on social media, we had 780.
And the next thing you know, the whole reserve had HIV.
So it was just having that support
to move forward because when you get your leadership
and when I talk about our chief and our council, that's
our government.
And so when we have their support to move forward,
we can do anything.
And then you build the program and it was so inspiring
because they see the immediate results.
We also started the program with no money.
There was no extra money.
And the big thing with that was getting people
to quit doing stuff that wasn't part of their profession.
Like our nurses were driving, and they were filing,
and they were doing all kinds of stuff
and that stuff needed to go.
And so we had that support from, again, the leadership
to not have to do all that non-nursing stuff where
we could focus on the priority and the epidemic that
was in front of us.
But there are communities in our province
that are not willing to take on the KYS
yet because of those issues with the stigma that's going to come
with it and the discrimination.
And so it's education.
You need to educate your community.
You need to let them know the outcome--
how much better it's going to be for our professionals,
for our community members, for our family members.
And they just see that it was such a success
in the beginning.
And we have many of the families that are involved
and their brothers, sisters, sons, daughters,
grandchild's care now.
So you have to have the support from your governing
body, for sure, because then nobody can debate it
with you because they're telling us move forward.
They know what we're moving forward, though.
Our program lives and breathes with our governing body,
our chief of counsel, because they're
the ones that go out and get questioned
so they have to have that knowledge of what we're doing.
Does that make sense?
MATT ALBRECHT: Yes.
LESLIE-ANN IRONSTAND-SMITH: Does that answer your question?
MARCIA DAY CHILDRESS: So we have an opportunity and others
of you who may wish to respond to Matt's question,
please go ahead.
For the other audience, we'll take your questions
and comments.
And please identify yourself when you ask your question.
Anyone else want to reply to Matt's question
before we turn to others?
NOREEN REED: [INAUDIBLE]
PRESTON REYNOLDS: Preston Reynolds,
Department of Medicine.
Thank you.
It's really wonderful that you love the people
that you live with so much.
To ask about how the community itself
has used their relationships with their own family members
to help expand and spread the program.
Do they refer-- they encourage their children
to seek out this knowledge?
I mean, what's the level of acceptance
with the people themselves, it's spreading
building, promoting, and expanding what you're doing?
LESLIE-ANN IRONSTAND-SMITH: So, again, for Big River I'll start
and Noreen can expand on what they're doing.
Just getting into that high school.
And when you get into high schools and you're talking sex,
and you're talking disease, and you're
talking about these kids having sexual relations,
many people don't get that opportunity
to even get into their high schools.
So to get that permission from the parents
and from the leadership to get in there
and promote all of this program--
and there's no sugarcoating.
It's this is how it is.
This is 100% preventable.
You kids need to start taking care of your bodies.
Your body is your temple.
Those conversations and just having
that permission from parents to talk to their children
about what's happening in the community about the drugs being
abused.
We started with morphine.
We have prescription drug sellers in the community.
Our clients are now leaning towards crystal meth.
Those kids are aware of it because I
see that school as those kids are future drug addicts.
They're our future diabetics.
They're our future everything and they don't have to be.
And so I would say the community embracing
us getting into that high school on a monthly basis
and filling those kids with so much knowledge,
that I think that in itself speaks
for what we're doing because people
want to shelter their children.
You're not going to talk to my grade-six child about sex
and drugs.
You know, people used to think you're
promoting it by doing it, just like the needle exchange.
Oh, you're promoting drugs by giving
your needle-exchange program out.
No, we're not.
It's harm reduction.
We're not finding the dirty needles in our communities
anymore.
Our clients are coming in and it's called needle recovery.
You bring your needles in, I'll give you back.
You're using 100 times a day, you're getting 100 needles.
Because we showed the one client shared--
had 23 contacts and 19 were positive from a weekend
of sharing.
That just speaks in itself.
So I think just like all the things
that were brought forward in this community
rapidly because this community--
this program went like wildfire.
And just from what we can do in this traditional
culturally-based community in and of itself
speaks for the clients knowing I want to protect my children.
And that's a conversation I have.
We need to protect our children.
We need to protect our grandchildren.
We need to fill them with the knowledge
to go out into this world and manage
because there's a lot of scary things in our world nowadays.
Drugs and alcohol are one of them and intravenous drug use.
NOREEN REED: I think just one to add to that is--
we still have family members and community
members that are fearful.
They're fearful for their relative
that might have a diagnosis.
And I think it's just having those difficult conversations
with people and really that ongoing community-wide
education.
Like educate, educate, educate, and just
having those open doors to you to have those conversations.
CAROLYN ENGELHARD: Hi, my name is Carolyn Engelhard.
I'm on the faculty in the Department of Public Health
Sciences.
This is for Dr. Skinner and the rest of you.
So in the United States, both private insurance
and public health programs resist access
to very expensive pharmaceuticals
for hepatitis C. In Canada, you have price
controls for pharmaceuticals.
So my question is do you find that your patients have
adequate access to those kinds of drugs when they need them?
STUART SKINNER: Yes, we do.
Like the cost of the drugs, at least the list price,
like say, it's about $20,000 per month.
So, I mean, the costs are still significant.
There's a debate that always goes on about well,
they're just going to get reinfected
and we're wasting money.
And there are groups--
there are physicians and bureaucrats
would argue that, no, we shouldn't be treating them.
You know, we're one of the most aggressive treaters of people
who are kind of actively using.
And part of that is it comes back
to treating that individual as a person, right?
They should be offered the same treatment whether they're
using substances or not.
And it really builds the trust and relationship for me
as a physician to those patients when you can offer them a cure
and they take that and they take it on
and they say, OK, you know what?
I recognize the opportunity and I'm going to try.
Addiction is a chronic disease and relapses happen.
And I never say to someone you can never use again.
I say, look, you need to be safe.
But they take it on.
The number of people who've come back in three months,
you know what?
I haven't touched a needle in six months,
and I haven't drank alcohol in six months,
and I'm going back to get my grade 12.
It's really been inspiring to see them kind of take
that illness on when you kind of provide
that opportunity for them.
I also believe from a public health standpoint, the number
one priority to treat should be people who are actively using.
Because if you actually want to make a dent
and stop the spread-- like Noreen
mentioned cohort treating.
So I was like, why are we just treating this one person?
Because you're most likely to get
reinfected from your spouse or your partner
or your friends who maybe you're in the same group.
Let's treat, if we can, right?
Let's treat the network together and let's
get rid of this virus out of your group
and try to take it on from a public health perspective.
The coverage is pretty good.
Like for in Canada--
it's F2 or higher or if you're HIV coinfected or hepatitis B
or a young, pregnant woman or a woman of pregnancy age,
diabetic, fatty liver, transplants.
That's kind of the current criteria.
My understanding is come April 1st, 2018,
it will open up for everybody.
But I mean, what a horrible thing, right?
You say, hey, we've got this great cure.
It's like placebo, we're going to get rid of it.
There's no doubt about it.
But you can't get it.
And really, it's deflated for people--
it's deflating to the doctor when
they can't get that treatment.
We really use it as an opportunity
to engage people in the care and engage them,
like I said, beyond.
They all get into mental health and addiction program
as part of that treatment package.
I don't think we can look at hep C as an isolated illness.
We've got to look at it together and use that opportunity to--
I mean, anyone who can now have a curative-- cure someone.
It's motivating for somebody to influence behavior change.
AUDIENCE: So I have two quick questions.
One, you've really demonstrated-- first
of all, a remarkable story.
Thank you for sharing it.
It's so inspiring.
You're doing something that we rarely
do in my experience in this country, which is really
outreach-based health care.
You're getting out there.
In my experience, having done that,
it was a really joyful thing to do.
It really enhanced the meaning of my work
to get out beyond the clinic walls.
So what's been the effect on your staff by this program
that you've done?
And then the second is, what was the added thing
that the peer program brought to what you
were doing when you started it?
LESLIE-ANN IRONSTAND-SMITH: Well, I can speak on our staff
because we've erased all that non-nursing stuff that nurses
don't need to be doing.
We have staff that are so satisfied with what they do.
It's amazing.
Like I said, they're passionate.
They love coming to work.
One of our staff was off for a week, she says, oh,
"I'm so glad to get back."
Because we're doing new things-- we're groundbreaking.
They feel like they're part of something that has really
been recognized nationally and they just have great support.
But our staff satisfaction is up there.
We're all on the same page and--
STUART SKINNER: No, I just-- yeah.
Same thing.
Are most people here physicians?
Is that kind of the-- about half of it?
STUART SKINNER: Know what, like I love it.
Like it, for me, is rejuvenating to get out
and it's like you're doing something.
You know, I see people and I'm like, I didn't come--
you might be dead or you might get health care--
I know that's kind of egocentric to think that
but it's you're part of a team.
So I look at it-- people say, well, I can't do that
and there's no way this would work.
I'm like, I go up one day every three months.
So one day every three months I go to Big River.
One day every three months, I go to Ahtahkakoop.
We hit the UNAIDS targets.
We're eliminating hepatitis C and now we're
building a chronic disease program.
That's happening with such a small amount of time.
Like the physician, I'm the least important part
of the program.
What we're doing is a team-based approach.
And it's such a small thing.
It doesn't take much to have a real tremendous impact.
The unfortunate thing is, right, I mean,
as physicians, we're listened to, right?
Whereas other members of the team should be
listened to equal.
But we do have a powerful voice and we can bring that even
with that one day every three months.
And for me, it's rewarding.
I love working.
I love the patients.
I love working with these guys.
And just even getting out to a real kind
of raw type of medicine, it's been tremendously rewarding.
LESLIE-ANN IRONSTAND-SMITH: And I think one of the most
rewarding parts and--
is up until six months ago--
and we started the program in 2010, the formal program.
We had no hospitalizations.
Our clients were completely case managed and healthy.
But up until six months ago, we had a client pass away.
What got him was his uncontrolled diabetes.
So they have other illnesses and chronic illnesses
that we're trying to-- because you've
got to deal with the whole person here.
We're not just dealing with their HIV and hep C.
We're dealing with their mental health.
We're dealing with all those aspects of care.
And like I said, many of our clients--
and I'm sorry but I do use the word addict.
Many of our clients continue to abuse drugs
and are addicts so we're still dealing with that.
But the rewarding part--
and this is why our provincial counterparts we try
to tell them, do you know how much money we're saving you
by not having any emergency room visits, no hospitalization
in seven years?
Like give us a phlebotomist every six weeks.
Like just to me it makes no sense because we're proven.
And so it is very rewarding.
I go home at night.
Some nights I'm sad but I feel good because I
feel good what we're doing.
Go ahead.
KAREN MANN: Karen Mann, Family Medicine, also Canadian.
I also want to echo the gratitude
for you sharing your story.
It's incredibly inspiring.
I have two questions.
One, have you see any collateral change in your addiction
rate with all this education?
It seems like education is the number one
key thing that you're doing.
The second question is, you must also be incredibly
inspiring to your youth.
You're going into the high school.
You're educating them like they've never
been educated before.
Are you using your youth at all to go out and educate, as well,
in a peer-to-peer fashion?
NOREEN REED: Just comment on the students.
We do various programming aside from nursing and-- multiple
programming.
And a lot of the ways that we utilize
our students and the school is with reflective learning.
So we give them the information.
We run a contest, a poster contest, a poem, a story,
whatever it might be.
We offer them a classroom incentive for a pizza party
or something like that.
And they come up with these amazing posters
and wording and messages after we've
given them the information.
And then we display it in the community.
And so they have that opportunity
to have those conversations amongst themselves
and show what they've learned.
That's some of the projects that we've done.
LESLIE-ANN IRONSTAND-SMITH: Our students
are very much ambassadors to our health program.
I've had numerous conversations with people that said,
oh, I've talked with some of your Big River band members,
the high school students, at one of our sporting events
and they know so much about HIV.
And someone was wearing a hoodie that said KYS, and they said,
what is that all about?
She said they were just able to explain it with almost
the passion that we teach it.
So that felt right because they're getting the message.
They know that everything is 100% preventable
and they need to protect themselves.
MARCIA DAY CHILDRESS: We are at the end of our hour,
but I would just like to say on behalf of our audience,
you all are amazing.
And the programs you've created are, also.
And a part of it is the energy, the compassion, and commitment
that you all have brought to this.
It's really quite inspiring.
Our program next week is the Opioid Epidemic's Impact
on Public Health and Patient Care.
Looking at the situation here in the US
and here locally with Richard Bonnie
from the school of law and Leslie Blackhall
from the Department of Medicine.
So to our audience, we have a week
to think about how might we begin
to mount some local efforts kind of out of our own community
to begin to meet some of these challenges, health
professionals, and students, and others.
So please join us next week.
And now please join me in thanking all of these people.
[APPLAUSE]