Overview of the Health of the Population of Region 18
To be updated in August 2015.
This report on the health status of Eeyouch notes some very positive items and some negative ones. The life expectancy data and infant mortality rates of Eeyouch are close to Quebec’s and much better than those recorded for many other Aboriginal groups. Although many pregnancies are complicated with diabetes, birthing outcomes are generally positive.
The rate of sexually transmitted infections in youth requires intervention, especially in the current context where infections are increasing every year and are already 7 to 11 times higher than those in the rest of Quebec. And the continuing increase in chronic diseases, especially among younger age groups, should be sounding an alarm. The good news is that STIs are preventable, and a great deal can be done to prevent chronic diseases through an active lifestyle, a healthy diet, reduction or cessation of smoking and control of obesity.
Impressions from the region are that changes are happening. More people are becoming active and they are doing so across a wider range of activities. This is part of what is called a “healthy lifestyle.” However, the process through which the communities and the regional entities might begin to address social issues is much more complex. Improving health and social outcomes will require a strong focus on better incorporating marginalised youth and young adults in the successes of the Nation.
This document is a condensed summary of the health status of the population served by the Cree Board of Health and Social Services of James Bay. The text occasionally refers to the status of several factors which determine health, although this is not its primary focus. The Cree Board of Health provides services to all people in the nine communities within Health Region 18. This population is 95% Eeyouch (Cree). The other 5% comprises the non-Eeyou population and is composed mostly of transient professional workers who maintain permanent residence addresses outside of the region. The focus of public health surveillance in Region 18 is to understand the health issues of the Eeyou population and to aid in decision-making and actions leading to improvements.
In mid 2012, the official population of Cree Beneficiaries of the James Bay and Northern Québec Agreement in Eeyou Istchee was 16,010 with almost 60% living in the five coastal communities and just over 40% in the four inland ones. To 2012, the five-year average rate of growth of the beneficiary population was 2.15% per year. A baby boy born in Eeyou Istchee between 2005 and 2009 is expected to live 74.6 years, compared to 78.4 for boys in the rest of Quebec; for a baby girl, life expectancy is 81.8 years compared to 83.1 years. In contrast to patterns elsewhere, Eeyou men continue to outnumber Eeyou women, while women continue to have more diabetes, and at younger ages, although that gap is closing somewhat.
From 1987-1991 to 2007-2011, the total fertility rate per woman in the region has remained almost double that of Quebec. While the numbers of births to women in Eeyou Istchee has been rising steadily since 1983, it is still too soon to know if the sharp decline from the high of 431 births in 2007 is a trend or not. In 2011 there were 372 births, varying by community from a high of 106 to a low of nine.
Data on caesarean sections from 2006-2007 to 2010-2011 suggest for the first time that rates in the region are slightly above the general Quebec rate (27.1% vs23.1%). Eeyou Istchee compares well to Quebec on almost all the indicators related to fetal growth retardation and prematurity. Unlike Quebec, the region has few low-birth-weight infants, and many high-birth-weight ones – around 10% of births – and these figures have remained relatively constant since at least 1987 in proportion to the number of births, despite changes in diet, lifestyle, and obesity rates.
The region has historically had high proportions of mothers under the age of 20. Although the rate has fallen in recent years, almost one baby in five (17.5%) is born to a teenage mother. Between 2007 and 2011, there were an average of 70 births each year to teenage mothers; of these, 45%, or an average of 31 births, were to mothers aged 17 or younger. In the 2003 health survey, one in four mothers who were teens or young adults reported drinking during pregnancy. At the same time, teenagers and young adults have high rates of sexually transmitted infections.
From 2005 and 2007 data, we know that most young children have extended family members involved in their upbringing, whether these family members are living in the household or not. Of children aged nine and under, 218 have been identified with special needs. Children under the age of six are growing up in households with an average size of 6.2 people, including three children. About 30% of children under the age of six are living in three-generation households with parents and grandparents present in the home, in contrast to 5% in this situation in Canada. While one young child in five is being raised in a lone-parent family, these children are also the most likely to be living in three-generation households.
The 2006 census data shows that households are constituted of multiple families at a much higher rate than Quebec (16.6% vs 0.8%), that the number of persons per room is also much higher (0.7 vs 0.4), and that, even if the number of rooms in a dwelling is about the same (6.0 vs 5.8), the number of rooms being used as bedrooms is also higher (3.4 vs 2.5). The housing shortage is generating difficult social and health issues.
In every survey since the 1990s, Eeyouch report strong social supports and identify with their communities while also expressing concern about social issues. In a 2006-2007 survey, 44% of men and 50% of women reported having been physically abused in their lifetime, and 23% of men and 35% of women reported having been sexually abused. As well, just over 3% of all self-described gamblers meet the criteria as “problem” gamblers, while close to 30% can be classified as moderate to high risk gamblers. Suicide attempts are the top cause of female hospitalisations for injuries, and the rate of hospitalisations for suicide attempts and suicide ideation remains roughly ten times that found in the rest of Québec. Young men and women are increasing hospitalised for assaults, and these incidents are much more common than in the rest of Quebec and the Nord du Quebec region.
Youth and young adults up to age 29 continue to show very high rates of sexually transmitted infections (STIs), with the highest rates in the 15-24 age group. The rise in STIs is linked to the lowering of the age at which young people become sexually active and the risky behaviours in which they engage, including multiple partners and the absence of protection. Since 2000, the number of cases of chlamydia and gonorrhoea infections has increased every year, and the rates of these two infections in Eeyou Istchee are 7 to 11 times higher than the rates in Quebec.
Between 2007 and 2011, the average age at diagnosis with any STI was 22.5 years for women and 24.3 years for men. From 2006 data, we know that 10.8% of the people diagnosed with an STI that year had had a previous diagnosis.
Over the six-year period from 2006-2007 to 2011-2012, there were 18,802 hospitalizations for the residents of Eeyou Istchee, or on average, 3,134 per year. Over this period, almost 6,500 individuals were hospitalised at least once, representing about 35% of the population. Excluding hospitalisations for normal pregnancy and childbirth, as well as those pertaining to factors to do with people in the system (e.g. waiting for long-term care beds, etc), there were, on average, 2,150 hospitalisations each year. Rates of hospitalisations are higher in Eeyou Istchee for almost all health conditions. The principal causes in descending order were problems from diseases of the respiratory system (mostly in infants and older people), diseases of the digestive system, and injuries, often intentional.
There has been a significant increase in some areas of hospitalisations for injuries in recent years. Comparing the three-year period of 2006-2007 to 2008-2009 with the three-year period of 2009-2010 to 2011-2012, hospitalizations for injuries were relatively stable in Region 10 and Quebec as a whole and declined significantly in Nunavik. However, there was a 42% increase in Region 18. This change was due to the following: an increase in “falls” where, unlike Québec, 90% of patients from Eeyou Istchee were under the age of 65; an increase (almost double) for “intentional self-harm,” mostly by “self-poisoning with pills”; an increase of “assaults” and especially “assault by bodily force”; and an increase for “complications of medical and surgical care,” mostly concerning surgical wound infections.
Cancers and mortality
Even though the cancer rate in Eeyou Istchee has been increasing over the last 20 years, people in the region continue to have less cancer than people in Quebec in general. However, only Eeyou men have a significantly lower incidence of cancer. Between 2007 and 2011, Eeyouch died from cancer (21.2% of all deaths), circulatory diseases (17.9%), and external causes which were mainly due to injuries (16.1%). This contrasts slightly with the rest of Quebec, where the top three causes of death are cancer (33.3%), circulatory diseases (26.4%) and respiratory diseases (9.0%). Mortality rates of infants under one year of age in Eeyou Istchee have fallen from 50 per 1,000 live births in 1976 to 9 per 1,000 in the 2000–2009 period, which is an average of three infant deaths per year. While there has been improvement, the region‘s rate remains double that of Quebec’s. A portion of the rate involves an incurable genetic condition.
By contrast with the high rates for hospitalisations, the rate of completed suicide in Eeyou Istchee is at or even slightly below the Quebec average, and, except for the sudden “cluster” of female suicides in 2004 and 2005, has involved mostly young men.
In 1983, 2.4% of Eeyouch had diabetes; by 2011, this had increased to 22.1%, or 2096 individuals. In 2009, the rate was already 3.3 times higher than the rate in Québec. Adjusting the Eeyou data for age and sex to make it more comparable to that of Québec shows the 2011 Eeyou diabetes prevalence rate to be 27.8%, compared to the 2008-2009 prevalence of 8.3% in the rest of Quebec. More than one Eeyou adult in five has diabetes.
In 2011, the proportion in each community of Eeyouch 20 years and older with diabetes varied from 12.9%, in the community with the lowest rate, to 28.9% in the community with the highest. The Coastal communities continued to have a lower rate of diabetes compared to the Inland communities (18.7% vs 27.0%, respectively).
Pre-diabetes is defined as glucose levels which lie between “normal” and those which meet the criteria for type 2 diabetes. Up to the end of 2011, we had data on 810 cases of pre-diabetes, and 200 of them had been diagnosed for less than five years. It is likely that this significantly underestimates the true rate of pre-diabetes in the region, as the patient management system from which the numbers are obtained is not being used to manage all Eeyou patients with pre-diabetes. By the end of 2011, within the group of 810 identified with pre-diabetes, 310 (37.8%) had gone on to develop diabetes. The majority (73%) had been diagnosed with type 2 diabetes within five years after being diagnosed with pre-diabetes.
Although our data is not complete, of 422 women with a history of gestational diabetes in a previous pregnancy, one third subsequently developed diabetes and, of these, half had progressed to diabetes within five years of their original diagnosis of gestational diabetes. Babies born to women who have diabetes during pregnancy (either gestational diabetes or type 2 diabetes) are at much higher risk of becoming obese during childhood and developing diabetes at a young age. In this way, the risk of diabetes is passed to future generations.
Gestational diabetes is a strong risk factor for developing type 2 diabetes. Diabetes continues to affect 50% more women than men, which is the opposite of the pattern in the rest of Québec, where 10% more men than women are diagnosed. Reversing this trend will require interventions to help women with a history of gestational diabetes to prevent or delay type 2 diabetes.
Since 1983, the number of Cree being diagnosed with new onset diabetes has doubled every decade. The decade following 1981 saw an average of 30 new cases each year. This has increased four-fold, and from 2001-2010 there has been an average of 120 new cases each year.
Eeyouch are being diagnosed with diabetes at a younger age than people in the rest of Québec, which puts them at greater risk of developing diabetes complications during their lifetime. In 2011, the average age at diagnosis of diabetes was 39.8 years, compared to 48 years in 1989. In the 2007-2011 period, almost half of all Eeyou patients living with diabetes (49.2%) had been diagnosed before the age of 40. This means that in 2011, almost one in four individuals (24.1%) living with diabetes was under 40 years of age. In 2011, the average age of Eeyouch living with diabetes was 51.4 years
At the end of 2011, more than a quarter of all patients (26.3%) had been diagnosed with diabetes within the past five years, and 56.1% had been diagnosed in the past ten years. The average duration patients had been living with diabetes was 9.7 years, compared to 8.9 years reported in 2009.
Complications from diabetes
Over time, diabetes can lead to complications in different parts of the body. However, not everyone with diabetes will develop complications. The ACR test checks the level of protein in the urine and so measures the beginning of kidney damage from diabetes. Using 2010 or 2011 data, 87 Eeyouch had been living with diabetes for longer than 20 years and almost seven in ten (68.9%) had a normal ACR test. However, among Eeyouch under the age of 30 with diabetes, only 29% had an ACR urine test in the normal range.
Complications develop over time as a result of unstable blood glucose levels. These are measured according to the glycated hemoglobin (A1C) test, which identifies the average plasma glucose concentration over the previous three months. High A1Cs are associated with the development of complications from diabetes. In the region, we find the average results of these tests increased from 2006 to 2010-2011, which means that more people with diabetes had poorer control at stabilising their blood glucose levels. What is most disturbing is that the people under the age of 30 with diabetes were the most likely to have poor control.
In 2011, half the people with diabetes had some level of kidney disease. But this was most evident among Eeyouch under the age of 30 with diabetes, of whom 71% were already showing some degree of kidney disease, or nephropathy, with 6.5% of them at an advanced stage and showing high levels of protein in their urine (nephrotic stage proteinuria).
Reversing the trends
Heart disease is also increasing, in Eeyouch both with and without diabetes. This rise is not surprising since the lifestyle choices that increase a person’s risk for diabetes are the same as those that increase risks for heart disease and cancer: poor diet, lack of a physically active lifestyle, smoking, and obesity. The statistics for diabetes show the importance of mobilizing the communities to halt or slow the diabetes epidemic, which would also have an impact on the heart disease epidemic and would help to slow the rise of colorectal cancer in men, and possibly also kidney cancer in women. However, the poor diet and sedentary lifestyles of youth may be the hidden time bomb. Overall, it is not clear how the health care system will be able to manage the growing numbers of people with serious chronic diseases, and these trends in chronic diseases are unlikely to change unless the underlying social issues are first addressed.
Source: Public Health Department 2013
Prepared by Jill Elaine Torrie, Pierre Lejeune, Marcellin Gangbè, Alan Penn, David Dannenbaum, Elizabeth Robinson and Kianoush Dehghani
The sources of the data for this summary come from the Cree Board of Health’s Public Health Surveillance System and are based on administrative data banks from the Cree Board of Health and the Ministère de la santé et des services sociaux du Québec (MSSS), the registry of Cree beneficiaries maintained by the MSSS, census reports, some survey reports and the occasional research report. Most of this information is already available in the numerous publications found at www.creehealth.org.