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https://docs.google.com/document/d/1uoz6ULU1HpkWB2yjJtY0CeBMxmlFWkB7pXhRy7N05Is/edit?usp=sharing

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Reclaiming Power and Place

The National Inquiry's Final Report reveals that persistent and deliberate human and Indigenous rights violations and abuses are the root cause behind Canada's staggering rates of violence against Indigenous women, girls and 2SLGBTQQIA people. The two volume report calls for transformative legal and social changes to resolve the crisis that has devastated Indigenous communities across the country.
The Final Report is comprised of the truths of more than 2,380 family members, survivors of violence, experts and Knowledge Keepers shared over two years of cross-country public hearings and evidence gathering. It delivers 231 individual Calls for Justice directed at governments, institutions, social service providers, industries and all Canadians.
As documented in the Final Report, testimony from family members and survivors of violence spoke about a surrounding context marked by multigenerational and intergenerational trauma and marginalization in the form of poverty, insecure housing or homelessness and barriers to education, employment, health care and cultural support. Experts and Knowledge Keepers spoke to specific colonial and patriarchal policies that displaced women from their traditional roles in communities and governance and diminished their status in society, leaving them vulnerable to violence.

Supplementary report: Quebec

The National Inquiry is simultaneously releasing a report specific to Quebec in order to give particular attention to the issue of violence against Indigenous women and girls in that province. The report outlines specific issues such as language barriers, health and social services provide by religious congregations and interaction with Indigenous and provincial police forces.

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Section 1 of the report, made up of Chapters 1-4, sets up the overall context that will be helpful for readers in approaching the information presented in the later sections of the report. In Section 1, we talk about the role of relationships, human and Indigenous rights, the history of colonization, and how each of these contexts can inform our understanding of the issue of violence against First Nations, Inuit, and Métis women, girls, and 2SLGBTQQIA people.
Chapter 1: Centring Relationships to End Violence
Chapter 2: Indigenous Recognitions of Power and Place
Chapter 3: Emphasizing Accountability through Human Rights Tools
Chapter 4: Colonization as Gendered Oppression

Overwhelmingly, the families who testified before the National Inquiry were seeking answers to perceived flaws in the investigations into the loss of their loved ones.

They discussed many ways in which they felt that police services had failed in their duty to properly investigate the crimes committed against them or their loved ones, leading ultimately to a failure to obtain closure and justice within the existing system. In response, the National Inquiry established the Forensic Document Review Project (FDRP), consisting of two teams conducting a review of police and other related institutional files. One team examined files of the Province of Quebec; the second group examined police files in all other provinces and territories throughout the rest of Canada. In this summary, when we refer to the FDRP, we are referring specifically to this second group. Information and recommendations of the Quebec FDRP are located in the Supplementary Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls devoted to Quebec. The purpose of the FDRP was to identify potential systemic barriers or problems and areas of weakness relating to the protection of Indigenous women, girls, and 2SLGBTQQIA people, and to make recommendations to the National Inquiry into Missing and Murdered Indigenous Women and Girls about the systemic causes of their disappearances and deaths.

During the course of the project, the Forensic Document Review Project (FDRP), which was tasked with examining files outside of Quebec, obtained and reviewed 174 files and 35 previous reports and studies on policing related to Indigenous women, girls, and 2SLGBTQQIA people, and analyzed publicly available information related to those files.

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The National Inquiry's Final Report reveals that persistent and deliberate human and Indigenous rights violations and abuses are the root cause behind Canada's staggering rates of violence against Indigenous women, girls and 2SLGBTQQIA people. The two volume report calls for transformative legal and social changes to resolve the crisis that has devastated Indigenous communities across the country.

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A report released by the RCMP earlier this year marks the first time that police in Canada have attempted, at the national level, to identify how many First Nations, Inuit or Métis women and girls have been murdered or have gone missing.

According to the report, 1,017 women and girls identified as Indigenous were murdered between 1980 and 2012-a homicide rate roughly 4.5 times higher than that of all other women in Canada.

In addition, the report states that as of November 2013, at least 105 Indigenous women and girls remained missing under suspicious circumstances or for undetermined reasons.

These appalling statistics are consistent with previous estimates from sources such as Statistics Canada that have long pointed to a greatly disproportionate level of violence against that First Nations, Inuit and Métis women and girls. The latest numbers also underline what Indigenous women and advocacy organizations have long been saying-that this violence requires a specific and concerted response from police and all levels of society.

The RCMP's release of official, national police statistics confirming these previous estimates is an important and welcome step because such numbers are critical to inform and mobilize police and public response.

Unfortunately, in the hands of some government officials and media commentators, the new RCMP statistics have become, not a source of clarity and a resource for action, but an excuse for misrepresenting the reality of Indigenous women's lives and an excuse for continued inaction.

An incomplete picture

The RCMP report does not tell us everything we need to know about violence against Indigenous women. The release of this report is not a substitute for a national inquiry.

The RCMP report does not reflect the voices of affected families and communities. Nor does it provide a vehicle for the consideration and implementation of the solutions that they have identified. And even as a statistical picture of missing and murdered Indigenous women, the RCMP report has important gaps that need to be acknowledged.

In its statistics on homicide, the RCMP report only includes cases where the original investigating police force has concluded that a murder has taken place. The report explicitly does not include unexplained and suspicious deaths.

Amnesty's own research has raised concerns that deaths of Indigenous women and girls are not always fully and properly investigated and that as a result some murders of Indigenous women and girls may have been wrongly classified as accidental deaths.

In addition, police in Canada do not consistently record the Indigenous identity of victims of crime. Statistics Canada reports that in 2009, for example, police recorded failed to note whether the victims of crime were Aboriginal or non-Aboriginal in 384 out of 610 homicides. Some victims of crime are being inaccurately identified as non-Aboriginal because police have not had proper training on why accurate identification is important and how it's to be determined.

The RCMP report acknowledges the unreliability of current police practices of determining Indigenous identity. The report claims that a file review, carried out over a period of several months, established the Aboriginal or non-Aboriginal identity of all but 95 homicide victims whose identity was previously recorded as "unknown." The RCMP did not review files to determine whether Indigenous women had been inaccurately recorded as non-Indigenous.

The RCMP report also does not distinguish between First Nations, Inuit and Métis women and girls. As a consequence, it does not provide any information on whether the homicide rate is the same or differs among these groups. The report provides a number of statistics on the lives of the victims. The nature of many of these statistics-such as history of illegal drug use or involvement in illegal activities-suggests an inappropriate focus on the possible role of the victim's own actions and behaviours.

The report does not include any information on how many of the women and girls previously sought help or protection from the police or service agencies or the response they received.

Although the report breaks down the statistics according to some potentially significant factors-such as whether homicides were committed outside the residence (27% for Indigenous women compared to 20% for non-Indigenous) -it does not provide figures for homicides on and off reserve.

The report does not identify how many of the perpetrators of the crime were Indigenous and how many were non-Indigenous. The report also does not provide any information on the numbers of perpetrators and the role of others in helping carry out or cover up the crime.

However, the report does however provide important information on the relationship of the perpetrators to the victims, suggesting significant differences in the threats faced by Indigenous and non-Indigenous women.

Violence against Indigenous women must be understood within a social context

Previous research, including reports by the Native Women's Association of Canada and Amnesty International's own research, show that violence against Indigenous women and girls is pervasive, taking place in the home and in the streets of Canadian cities, and that the perpetrators include Indigenous and non-Indigenous men alike.

Nothing in the RCMP report changes this conclusion.

The vast majority of murders are committed by someone known to the victim. This is true for Indigenous and non-Indigenous women alike.

However, there is at least one significant difference revealed by the RCMP report.

In the case of Aboriginal women, spouses, family and other intimates account for 62% of homicides, compared to 74% of murders of all other women. The difference is largely accounted for by greater number of murders of Indigenous women and girls by people the police categorize as "acquaintances", including friends, co-workers, neighbours, authority figures and other people known to, but not intimate with the victim.

In the 22 year period covered by the RCMP, acquaintances were found to be responsible for the murder of more than 300 Indigenous women and girls in Canada.

The rate of homicide by acquaintances was 7 times greater for Indigenous women and girls than for all other women in Canada.

During the same period, the RCMP found that strangers were responsible for the murder of 81 Aboriginal women and girls.Clearly, domestic and family violence are critical issues that must be addressed in any meaningful national strategy to address violence against Indigenous women and girls.

At the same time, it's also clear that characterizing the threats to Indigenous women's lives as exclusively about domestic violence - as some government spokespersons and media commentators have done - misrepresents the issues and obscures crucial aspects of these threats.

Regardless of the identity of the perpetrator, or their relationship of the perpetrator to the victim, it's clear that their actions needed to be examined in the context of the discrimination, marginalization, and impoverishment that put Indigenous women in harm's way. Amnesty International's 2004 Stolen Sisters report concluded that all these factors work together to compound the risks to Indigenous women, encouraging some men to target Indigenous women for acts of racist and misogynist violence, and in denying Indigenous women equal access to services such as shelters that are required for their safety.

Moving forward

The kind of statistics released by the RCMP need to collected and made public on an ongoing basis. To ensure the accuracy and completeness of this data, specific guidelines and training need to be provided to officers in all police services to ensure that they understand when to record Indigenous identity and how this information is to be used.

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Missing and murdered Indigenous women and girls: Understanding the numbers

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A report released by the RCMP earlier this year marks the first time that police in Canada have attempted, at the national level, to identify how many First Nations, Inuit or Métis women and girls have been murdered or have gone missing.

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A mural in Winnipeg honoring missing and murdered Indigenous women. Credit... Aaron Vincent Elkaim for The New York Times

As violence against Indigenous women and girls grows, a national inquiry into the causes is drawing to a close, with a report expected on June 3.

A mural in Winnipeg honoring missing and murdered Indigenous women. Credit... Aaron Vincent Elkaim for The New York Times

WINNIPEG - In the 24 hours before the disappearance of Tina Fontaine, a 15-year-old from the Sagkeeng First Nation in Canada, she was seen by provincial child welfare workers, police officers and health care professionals.

Then she was found dead, dumped in Manitoba's Red River, and wrapped in a plastic bag and duvet weighed down with 25 pounds of rocks.

"Canada and the system failed Tina at every step," Thelma Favel, the great-aunt who raised her, said on a recent day from her small home in Powerview, a sleepy town on Lake Winnipeg near the reserve of the Sagkeeng First Nation. "Why are so many of our girls dying?"

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Tina Fontaine's great-aunt, Thelma Favel, who cared for her as a foster parent in Powerview, Manitoba, showing a photo of the girl. Credit... Aaron Vincent Elkaim for The New York Times

Many in Canada have been asking that question.

Tina's death in 2014 - and the acquittal of a white man in her killing - was one of an increasing number of deaths and disappearances of Indigenous women and girls that has shocked Canadians in recent years. The violence galvanized the government of Prime Minister Justin Trudeau to open a $54 million national inquiry three years ago that promised to get at the root causes of the violence.

Part of Mr. Trudeau's pledge to overcome decades of "humiliation, neglect and abuse" of Indigenous populations, and to reconcile with them, the inquiry heard testimony from nearly 1,500 families of victims and survivors in often emotional hearings across the country.

Its findings are to be made public on June 3, and its chief commissioner Marion Buller, a prominent Indigenous judge, recently hinted that it could include, among other things, recommendations that homicides of Indigenous women automatically be treated as first-degree murder. Law enforcement is also expected to be called to account.
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But some Indigenous advocates have said that, however good its intentions, the inquiry has been marred by a lack of transparency and poor communication with families of victims.

"Justin Trudeau is trying to put rose-colored glasses on a very dark chapter of Canadian history," said Kim O'Bomsawin, an Indigenous filmmaker whose documentary " Quiet Killing " examines violence against Indigenous women. "This is just more words."

Yet even before its release, the inquiry has been forcing a national reckoning.

Among the cases attracting renewed scrutiny is that of Cindy Gladue, a 36-year-old Indigenous sex trade worker and mother of three who bled to death in a bathtub in an Edmonton motel room in June 2011; the man accused of her killing, Bradley Barton, an Ontario truck driver, was acquitted by an all-white jury.

Human rights advocates say Ms. Gladue was dehumanized during Mr. Barton's trial, including having her preserved pelvis introduced as evidence.

After the Alberta Court of Appeal ordered a retrial in 2017, Mr. Barton appealed the decision to Canada's Supreme Court, which ruled on Friday that he should be retried for manslaughter. Justice Michael Moldaver wrote that the criminal justice system has let Ms. Gladue down.

The violence against Indigenous girls and women, experts say, is deeply rooted in Canada's history.

From the 1870s until 1996, Canada forced thousands of Indigenous children to go to residential schools in an effort to suppress their language and culture. Many faced physical, sexual and mental abuse.

The trauma from this history has contributed, experts say, to persistently high rates of poverty, drug abuse, alcoholism, domestic violence and suicide.

Cindy Blackstock, a professor of social work at McGill University, who is director of the First Nations Child and Family Caring Society of Canada, said other problems were chronically underfunded social services for vulnerable girls and women and a lack of educational opportunities.

The violence has been unrelenting.

Indigenous women and girls make up about 4 percent of the total female population of Canada but 16 percent of all female homicides, according to government statistics.

Some 1,181 Indigenous women were killed or went missing across the country between 1980 and 2012, according to a 2014 report by the Royal Canadian Mounted Police.

That number has since risen and Patricia Hajdu, who served as minister for the status of women, has estimated that it may be as high as 4,000 since many of the cases go unreported. The police have estimated that 10 percent of missing women in the country are Indigenous.

Winnipeg, whose name is derived from the Cree words for "murky water," has the largest Indigenous population in Canada.

That is where Tina Fontaine's life came to an end.

Her history in many ways reflects the cycle of violence affecting Indigenous communities. Her paternal grandfather was sent to a residential school, and became an alcoholic. Her mother, who became a ward of the state as a child, eventually joined the sex trade.

Ms. Favel said the child was "doomed before she was born." Her mother was 12 when she began dating her father, who was then 23. After their chaotic relationship fell apart and Tina's father was afflicted with cancer, Tina and her sister Sarah went to live with her.

Ms. Favel said Tina was a happy girl who showed promise. She liked math and dancing, and television crime shows. She aspired to be a social worker.

But at 12, the girl's father, who only had four months to live, was beaten to death in an argument with two men over $60.

Despairing, she began to skip school, smoke pot and cut herself. She got a tattoo with two angel wings and her father's name on her back. When asked to write a victim's impact statement during the trial of her father's killers, she fell apart.

"She kept crumpling the paper and said she couldn't do it," recalled Ms. Favel, on whose living room wall hangs a painting of Tina, waifish with big brown eyes.

In June 2014, Tina left Ms. Favel's home and went to Winnipeg, about 75 miles away, to visit her mother. Ms. Favel gave her $50 and a prepaid phone card, telling her to call if she wanted to come home. The call never came.

Instead, she said, the girl texted photographs of herself with a black eye to her sister, saying that their mother, who was working in the sex trade, had beaten her. Alarmed, Ms. Favel said she reached out to three Manitoba family services agencies, which bickered over who was responsible.

Eventually, Tina was placed by child and family services in a series of local motels, from which she ran away. She began living on the streets in Winnipeg's impoverished north end.

A missing person's report was filed with Winnipeg police. On two occasions on Aug. 1, 2014, she was turned away from city shelters, according to a March report by the Manitoba Advocate for Children and Youth, which noted she was vulnerable to sexual exploitation.

On Aug. 8, Winnipeg police pulled over a truck in which Ms. Fontaine was riding with an intoxicated man. The girl was allowed to go despite being the subject of a missing person's report.

Later that day, she was found unconscious in a back alley. After being hospitalized, testing positive for drugs and telling a case worker she was spending time with a much older drug user called Sebastian, she was discharged and placed at a Best Western Hotel in Winnipeg's gritty downtown.

The advocate's report noted that the child abuse unit of the Winnipeg Police should have intervened. Instead, Ms. Fontaine left the hotel on her own.

After Ms. Fontaine was found dead in the Red River, the police arrested Sebastian, whose real name is Raymond Cormier. The New Brunswick native had 92 previous convictions, including assault with a weapon and drug possession.

During an elaborate sting operation, the police bugged his apartment and recorded him. Prosecutors said the recordings showed he had wanted to have sex with Ms. Fontaine and had been enraged after finding she was 15 years old.

"I drew the line and that's why she got killed," he was overheard saying.

The court also heard that Mr. Cormier had owned the same type of duvet that was wrapped around Tina's body.

But the autopsy failed to determine cause of death and there was no evidence of sexual assault and no forensic evidence linking Mr. Cormier to the crime. In February 2018, Mr. Cormier was acquitted of second-degree murder, spawning outrage and protests across the country.

Visitors regularly pay tribute to Tina at a makeshift memorial of pink roses and photographs near the dock where her body was found. On a recent day, a card said: "sleeping beauty."

Ms. Fontaine's legacy is also felt in other ways.

After her death, volunteers routinely dredge the Red River looking for the bodies of missing and murdered Indigenous women and girls.

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'Why Are So Many of Our Girls Dying?' Canada Grapples With Violence Against Indigenous Women (Published 2019)

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As violence against Indigenous women and girls grows, a national inquiry into the causes is drawing to a close, with a report expected on June 3. A mural in Winnipeg honoring missing and murdered Indigenous women. Credit...

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Missing and Murdered Indigenous Women and Girls
PDF Version
July 2017

Research and Statistics Division

Indigenous women represent 10% of the total population of missing women in Canada

According to the Missing and Murdered Aboriginal Women: 2015 Update to the National Operational Overview report by the Royal Canadian Mounted Police (RCMP), Indigenous women represent 10% (174) of the total population of women in Canada missing for at least 30 days reported by the Canadian Police Information Centre (CPIC) (1,750). Of these, 111 women were identified as missing due to "unknown" circumstances or foul play was suspected.

Proportion of Indigenous women homicide victims increased since 1991

Between 1980 and 2014, there were 6,849 police-reported female homicide cases in Canada. Among the total number of female victims, 16% were Indigenous women. Since 1991, the number of murdered non-Indigenous women has declined. In contrast, the number of murdered Indigenous women has remained relatively stable, thus accounting for an increasing proportion of Indigenous female homicide victims. For example, in 1980, Indigenous women accounted for 9% (18) of female homicide victims, whereas in 2014, they accounted for 21% (30) of female homicide victims. In 2014, the rate of homicide of Indigenous women (3.64 per 100,000) was almost six times higher than non-Indigenous women (0.65 per 100,000).

Higher homicide rate of Indigenous women in the territories

Between 2001 and 2014, the territories had a police-reported homicide rate for Indigenous women that was higher than the overall rate in Canada. The prairies also had a higher police-reported homicide rate of Indigenous women than the overall rate in Canada. The largest difference in police-reported homicide rates between Indigenous women and non-Indigenous women was in the Yukon (12 times higher for Indigenous women) and in Saskatchewan (11 times higher for Indigenous women).

Half of the homicides of Indigenous women were committed by a family member

Of the total solved homicide cases of Indigenous women between 1980 and 2014, half (53%) were committed by a family member, a quarter (26%) by an acquaintance and 8% by strangers. The 2014 homicide survey found that fewer homicides of Indigenous women occurred in a residence (66%) compared to non-Indigenous women (88%). In addition, 17% of homicides of Indigenous women occurred on a street, a road, or a highway compared to 1% of non-Indigenous women.

Footnotes

Footnote 1

Footnote 2

Miladinovic, Z., and Mulligan, L. Homicide in Canada, 2014. Juristat. Statistics Canada Catalogue no. 85-002-X. 2015.

Footnote 3

Footnote 4

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Footnote 9

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Department of Justice Canada's Internet site

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Native Woman's Association of Canada - Native Woman's Association of Canada

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Our Knowledge Centre serves as a hub for resources that will enhance, promote, and foster the social, economic, cultural and political well-being of Indigenous women, girls, and gender diverse people.

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In Canada, official statistics have consistently documented at the national level what is highlighted above in the Intimate Femicide in Ontario study: Indigenous women are significantly more likely to be killed by male partners than non-Indigenous women in Canada. In fact, Indigenous women and girls are overrepresented as victims of femicide more generally. For example, about four percent of the Canadian population is Indigenous and female yet they represented 24 percent of homicide victims in 2015. Despite their higher risk of intimate femicide, however, some research shows that Indigenous women and girls are also often killed by male acquaintances and strangers.

This fact was brought to light by the Sisters in Spirit grassroots initiative launched in 2005 by the Native Women's Association of Canada (NWAC) who documented that, by 2010, over 580 Indigenous women and girls across Canada were murdered or went missing. Among the findings was that Indigenous women and girls were more often killed by male acquaintances or strangers than by male partners, although official statistics indicate that they remain eight times more likely to be killed by male partners than non-Indigenous women.

The initial estimate of femicide documented by the grassroots initiative has risen to almost 1,200 since the Royal Canadian Mounted Police (RCMP) began investigating the issue following the Sisters in Spirit campaign. After repeated calls for an inquiry into the treatment of Indigenous women and girls, the Canadian government launched the National Inquiry into Missing and Murdered Indigenous Women and Girls in 2016. The mandate is to report on systematic causes of all forms of violence against Indigenous women.

The Sisters in Spirit initiative highlighted various systemic issues including the impunity of many of the perpetrators, similar to what is being documented in other world regions. Their study found that nearly half of the cases involving indigenous women and girls remain unsolved and no charges were laid in about 40 percent of the cases. These figures continue to be contested and debated by others, including the RCMP, who reported clearance rates that were much higher, ranging from 80 to 100 percent. The proportion of those that resulted in charges or convictions is not currently known.

Regardless, it is now recognized, most recently in the inquiry's interim report, that the high risk of violence experienced by Indigenous women and girls stems, in large part, from a failure of police and others in the criminal justice system to adequately respond to, or provide for, the needs of Indigenous women and girls.

Femicide can be used to describe the killings of indigenous women and girls. Given the role of racialized violence and the documented impunity of some of the perpetrators, the term 'feminicide' which has become more common in Latin American countries may also be appropriate given that it is meant to capture the impunity of perpetrators and the inadequate state responses to these crimes. Because gender remains an important determinant of their risk of lethal violence in some contexts compared to Indigenous men, femicide has been used to describe these killings.

[For example, http://www.independent.co.uk/news/world/americas/canadas-femicide-epidemic-brings-calls-for-inquiry-9687855.html]

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Murdered and Missing Indigenous Women and Girls

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In Canada, official statistics have consistently documented at the national level what is highlighted above in the Intimate Femicide in Ontario study: Indigenous women are significantly more likely to be killed by male partners than non-Indigenous women in Canada. In fact, Indigenous women and girls are overrepresented as victims of femicide more generally.

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During the 2015 election campaign, Liberal Leader Justin Trudeau promised to eliminate all long-term water advisories on First Nations by March 2021.

Many Indigenous communities have gone for years and years without clean drinking water - living, as one woman put it, "in Third-World conditions in a First-World country."

Some advisories are so old, explains Dawn Martin-Hill, one of the founders of the Indigenous Studies Program at McMaster University, that "you could have a 16-year-old girl growing up in northern Ontario who has never been able to drink or bathe in the water that they have access to."

With 17 months left on the clock, Trudeau's government has nearly halved the number of long-term advisories - those in place for a year or longer - from 105 down to 56, according to government data.

However, that data has its limitations: it doesn't include B.C. or any of the territories. And even if Trudeau eliminates long-term boil water advisories by 2021, experts like Martin-Hill say he won't have actually addressed the issues that led to them - nor will it mean that all First Nations people have guaranteed, long-term access to clean drinking water.

So why, despite the federal government's pledge, do some First Nations still not have potable water, and what exactly needs to be done to get it to them?

"I'm still asking that question many years later," says Martin-Hill, McMaster's Paul R. MacPherson Chair in Indigenous Studies and a Mohawk woman living in the Six Nations of the Grand River in southern Ontario.
WATCH: Trudeau says government 'on track' to fulfill clean-water promise

Trudeau says government 'on track' to fulfill clean water promise

Martin-Hill grew up in Buffalo, N.Y., after her single mother fled Six Nations during the '60s Scoop to avoid having her children taken from her and placed with non-Indigenous families. It was a hard choice but the right one, Martin-Hill says.

One of the side effects of this move was that Martin-Hill grew up with clean water that flowed easily from the tap. It wasn't until she was older - and within a week of being back in Six Nations - that Martin-Hill experienced her first boil water advisory.

She went to university looking for answers:

"How did this inequality happen and who's responsible and how do we fix it?"

As she said, she's still hunting for answers.

Why don't all First Nations have clean water?

Canadian governments have spent many years and billions of dollars trying to make clean water flow from the taps on First Nations. At any given time, some 100 First Nations are under water advisories, according to non-profit organization The Council of Canadians.

There are three types of advisories: boil water, do not consume and do not use. The most common is a boil water advisory, in which communities are told they should boil all water for at least one minute before drinking, brushing their teeth or cooking and that they shouldn't use tap water to bathe infants, toddlers or the elderly.
WATCH (2017): First Nations woman calls on feds to address water crisis on reserves

First Nations woman calls on feds to address water crisis on reserves

The reasons why water on First Nations isn't potable varies, impacted by everything from the water's origin to the pipes through which it flows to how remote the community is.

On July 7, Attawapiskat First Nation declared a state of emergency over concerns about disinfection byproducts called trihalomethanes. A few days later, Eabametoong First Nation followed suit, its chief explaining the decision in a press release on July 15: "The discovery of high levels of trihalomethanes, combined with ongoing issues with our water and wastewater systems, has forced us to declare a state of emergency to protect the health of our community."

In Attawapiskat 's case, the government earmarked $1.5-million to repair an existing treatment plant and said there are plans for a second system. Eabametoong declared a state of emergency after the water developed a "noticeable foul smell and taste,"however the community has been under a boil-water advisory for nearly two decades. Despite the state of emergency, Eabametoong expected the "long-term" advisory to lift in August because of a new water treatment plant.

As of late September, however, the community was still under an advisory.

Why the solutions are flawed

The federal government has a list of solutions to these long-term boil water advisories, including patchwork repairs, permanent repairs, entire new systems, feasibility studies and better training and monitoring.

During the Maclean's leadership debate earlier this month, Conservative leader Andrew Scheer said he would also end long-term boil water advisories, while Green Party leader Elizabeth May said her party would fulfill all "the requirements on the recommendations of the Truth and Reconciliation Commission, and the murdered missing Indigenous women's inquiry." NDP leader Jagmeet Singh has committed to lifting all drinking water advisories, not just long-term ones, by 2021.

Many have made it clear the existing solutions are imperfect.

Take Six Nations, where Martin-Hill lives. The government gave the community money for a treatment plant in 2014, but that was it - "no money to operate it," she says. With few options, Martin-Hill says the community took the money, built their "state-of-the-art treatment plant and said: 'We'll figure it out as we always do.'"
WATCH (2016): Human Rights Watch blasts inaction in providing safe water to First Nations communities

Human Rights Watch blasts inaction in providing safe water to First Nations communities

Now, Six Nations has the treatment plant, Martin-Hill says, but people still live without clean drinking water because almost nobody has piping into their houses that can carry in the newly clean water. In other words, only a small percentage of the population gets clean water - everyone else needs to buy big jugs of fresh water.

Additionally, the Trudeau government's promise focused on "long-term" boil water advisories, not short-and medium-term advisories. While many communities have been dealing with these so-called short-term problems for years, Angela Mashford-Pringle, who works at the Waakebiness-Bryce Institute for Indigenous Health at the University of Toronto, told Global News in July that such communities are being left out because their advisories are not technically "long-term."

"Realistically, if you went across the country, quite a few of the 633 First Nations are on either short-term or medium-term advisories," she said. "I'm not sure if we're doing much to change that."

Add in the fact that, while the government may technically be on track for a promise kept, an investigation from Globe and Mail reporter Matt McClearn analyzed more than a decade of government data and found "the overall reliability of the underlying water systems is little improved since the party came to power."

"There are a lot of systems across the country on First Nations reserves that are in poor shape that aren't on a boil water advisory, and the risk scores reflect that," says McClearn.

The risk scores are updated every year, when the government looks at the design of public water systems, how well they are operated and maintained, the associated record-keeping, the quality of the source water and the operators' qualification to come up with a ranking from one to 10, with 10 being extreme risk.

"The risk scores can tell you about systems that have problems that are not on boil water advisories yet," McClearn says.

"Just because a community doesn't have a boil water advisory doesn't mean that they're happy with their level of water service."

A big chunk of the reason for these issues is money. First Nations get much less from the federal government than they would from the province if they were a municipality of similar size, says McClearn.

"There are a lot of consequences that come along with that. One is that these plants tend to get less maintenance than they need."

And water treatment plants need a lot of maintenance and technical know-how, says Emma Thompson, who did her masters research on water advisories in First Nations.

"It's a really complicated system ... especially remote communities would struggle with that," she says. In fact, her research showed that sometimes, boil water advisories were instituted not because there wasn't a facility in the community but because there wasn't a trained operator available.

That these communities are federally regulated stands out, Thompson says - and not in a good way.

"It's the most decentralized way to manage a drinking water system," she says. "It's a really disconnected way to manage that kind of system with (provincial) regulations... a one-size-fits-all solution isn't going to help."

What needs to be done?

People don't need a lot of information to understand, says Martin-Hill: "We want access to clean water."

Clean-water access is an issue of living and breathing, she says, an issue of environmental concern and also an issue with deep historical roots.

To understand how this system became so unequal and why First Nations receive less funding for clean water than neighbouring municipalities simply because they are regulated federally and not provincially, you have to go back to the beginning of Canada - to colonization.

When Parliament passed the Indian Act in 1876, it established the reserve system that Canadians know now. In conjunction with existing treaties made between the government and different First Nations, the act established which tracts of land would be for First Nations people so that settlers could set up farms.

The government's stated goal was to force the assimilation of First Nations people and to make them Canadian by stripping them of their land, their culture, their autonomy and - as seen through the residential school system and the '60s Scoop - their children. The government didn't give much thought to the land where they sent First Nations, Martin-Hill says.

"They didn't put in roads, housing or infrastructure because they thought we were going to die out ... they never thought we would still be here. The fact that we are is a testimony to our resilience and our strength as a people."

Even though colonization "dictates what (First Nations people) have today" with respect to access to clean drinking water, she says it doesn't have to. "We need to get our land claims settled in a just way and then we would be able to solve our own problems."

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Why some First Nations still don't have clean drinking water - despite Trudeau's promise - National | Globalnews.ca

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During the 2015 election campaign, Liberal Leader Justin Trudeau promised to eliminate all long-term water advisories on First Nations by March 2021. Many Indigenous communities have gone for years and years without clean drinking water - living, as one woman put it, "in Third-World conditions in a First-World country."

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Clean water and sanitation is essential to ensuring good health and ending extreme poverty. The United Nations' Global Goal 6 urges countries to ensure availability and sustainable management of water and sanitation for all. You can join us and take action on this issue here.
Canada is one of the wealthiest and most water-rich countries in the world. Yet many of its First Nations communities continue to lack safe drinking water - a basic human right.

As of February, 61 Indigenous reserves were under long-term drinking water advisories, half of which remain unresolved after more than a decade. These water advisories warn people to either boil water before use, not to consume it, or avoid it altogether because of toxicity levels.

Canadian Prime Minister Justin Trudeau has vowed to end these advisories by March 2021. But while the government presented action plans on many important topics during the speech from the throne on Sept. 23, it failed to mention its promise to bring safe drinking water to all Indigenous reserves by next spring.

The lack of acknowledgement in this year's speech has led some Canadians to doubt the government's ability to meet the deadline.

A senior government source told CBC News that the government is no longer as comfortable with the target date as they were before COVID-19 hit the country. The pandemic has made it more difficult for construction workers to enter communities, potentially resulting in a delay in resolving these critical water supply issues.

"It should not take that long to ... improve people's lives on reserves and in communities when [the government] can do much, much more for regular Canadians at the drop of a hat when something like COVID-19 hits," said Rob Houle, an Indigenous advocate from Swan River First Nation.

The oldest advisory that's still in effect today was put in place back in 1995 on the Neskantaga First Nation. This means that the Neskantaga reserve has now been deprived of safe drinking water for a quarter of a century.

In September 2019, the remote community declared a state of emergency after a water pump failed, leaving some homes completely without running water and others with water that was not safe to use except to flush toilets. One year later, its people still have to boil water for safety.

The severe and prolonged nature of these drinking water advisories is particularly concerning during the COVID-19 pandemic, when access to clean water and sanitation is essential to staying healthy.

Around the world, Indigenous communities have been hit particularly hard by the COVID-19 pandemic because of structural inequalities when it comes to water access, health care, and living conditions.

In Canada, these same inequalities are at play, putting Indigenous people at greater risk, especially if the country experiences a second wave. On reserves with an at-risk water supply, people not only have to take extra precaution with their drinking water, but also with water used for sanitation and hygiene.

Under the boil water advisory, which makes up the majority of all long-term advisories, communities need to boil all water for at least one minute before drinking, brushing their teeth, or cooking, and should not use tap water to bathe infants, toddlers, or the elderly.

The other two advisories - do not consume and do not use - have even stricter guidelines.

In regards to meeting the March 2021 target, the Indigenous Services Minister Marc Miller told CBC News that he is still hopeful, and that the government will be spending more funds in the coming months to make it happen.

"That deadline is very much one that we are working aggressively to meet," Miller said. "This isn't a question of funds, this is a question of planning."

In its 2016 budget, the government had committed $1.8 million over five years to fix and maintain the on-reserve water and wastewater infrastructure. Now with only half a year left, the government has lifted 88 long-term drinking water advisories, and still has more than 60 remaining.

Over the past two decades, Canada has shown a pattern of overpromising and underperforming on water and sanitation on Indigenous reserves, according to the Human Rights Watch. Whether Trudeau's government will continue on this path of disappointment is to be determined.

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61 Indigenous Communities in Canada Still Face Water Crisis

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Clean water is a basic human right, but dozens of Indigenous communities in Canada have been deprived of safe drinking water for more than a decade now.

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In October, more than 250 members of the Neskantaga First Nation were evacuated to Thunder Bay after an oily sheen was found on their reservoir. The discovery left the community, located in northern Ontario, without access to running water.

The evacuation drew attention to the federal government's 2015 commitment to end all on reserve long-term drinking water advisories (in place for more than one year) by March 31, 2021. Neskantaga has been living under a boil-water advisory for 26 years.

An end to long-term advisories would be marked progress towards addressing these historic issues. But the federal government's decision to choose long-term advisories as the measure for clean drinking water on First Nations reserves is faulty. Long-term advisory statistics are more of a policy performance measure than a true indicator of First Nations water security and well-being.

The focus on eliminating long-term on-reserve drinking-water advisories diverts attention from the equally devastating impacts of short-term advisories, lack of running water, as well as the anticipated effects of climate change on drinking water quality.

As a former advisor on water quality and infrastructure for a federal department, I now research barriers that keep First Nations communities from accessing safe wate. That a new hazard forced Neskantaga's evacuation while engineers are addressing historic ones underscores the need to examine drinking-water risks holistically.

What are drinking water advisories?

Authorities issue notifications to the public when its drinking water supply has potential or real health risks. They caution people to boil the water, not to consume it or not to use it. As of Feb. 15, there were 61 long-term drinking water advisories in place in First Nations communities located south of 60 degrees north.

Although the terms drinking water advisory and boil-water advisory are sometimes used interchangeably, they point to different types of contaminants. Boiling is effective for removing bacteria, viruses and parasites, but not for removing toxic metals, for example.

Emergency advisories are issued when there is a confirmed water quality risk, and precautionary advisories signal a technical problem that could make the water unsafe. Both cause socio-economic disruptions.

Read more: Mining push continues despite water crisis in Neskantaga First Nation and Ontario's Ring of Fire

First Nations advisories are predominantly precautionary - making up more than 90 per cent of Ontario advisories - meaning the majority are about operations and maintenance challenges, not an indicator of clean water as such.

What is clean water?

Different jurisdictions have different standards. Health Canada issues Guidelines for Canadian Drinking Water Quality, yet provinces and territories can set their own. This means that water considered acceptable on reserve may not be acceptable off reserve.

Perception, too, defines what is clean water. The smell and taste of chlorine, cultural beliefs and lack of trust in the water system has some community members choosing to use untreated, running water. Even when there isn't an advisory in effect, people may still be at risk of illness by avoiding tap water or drinking less water than they should.

Advisories don't reflect the status of the "disconnected." Statistics track centralized water systems, but not all homes are connected because communities often can't afford to lay the pipes. As a consequence, many households rely on standpipes, water trucks, buckets and cisterns - all at risk of contamination. This means that even when there isn't an advisory in effect some community members may still experience water insecurity.

The bigger picture

The government's focus on long-term advisories detracts from the broader impacts that a lack of clean, safe running water has on people.

Excessive water boiling leads to mould that deteriorates housing, causing overcrowding. Overcrowding and lack of running water contribute to the contraction of methicillin-resistant Staphylococcus aureus bacteria (MRSA), the main antibiotic-resistant infection that disproportionately affects Indigenous people.

Buying water because what's coming from the tap isn't fit to drink or wash with costs money that might have otherwise been used for food. Evacuations separate families and friends.

The government quantifies water advisories, but not their effects on mental, physical and spiritual health, educational success and cultural continuity. Yet these factors can lead " stamina, endurance, tolerance and resiliency [to be] stretched beyond human limits," the Office of the Chief Coroner of Ontario wrote in its report on the children and youth who died by suicide in the Pikangikum First Nation between January 2006 and December 2008.

Communication about solutions is typically framed around technological fixes. Researchers surveying Canadian news articles from 2000 to 2015 found that "most stories focused on government responses to water-related issues, and less often covered preventative measures such as source water protection."

First Nations water advisories are about much more. Root causes are found in colonialism and the forced relocation of many communities to areas where resource extraction puts stress on drinking water sources. The reasons behind advisories range from lack of trained staff and funding to difficulties obtaining replacement parts due to remoteness.

The children and youth of the Neskantaga First Nation are asking when they can go home again. They have been displaced from their community, and are owed a commitment from the government to long-term goals above and beyond what drinking water advisories measure.

International infrastructure scholarship and Canadian water researchers advocate the adoption of values beyond merely health and safety. Integrating understandings about what communities need from their social, economic, natural and built environments with Indigenous planning principles could smooth Canada's path toward reconciliation and " grow the circle of wellness."

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Water crisis in First Nations communities runs deeper than long-term drinking water advisories

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In October, more than 250 members of the Neskantaga First Nation were evacuated to Thunder Bay after an oily sheen was found on their reservoir. The discovery left the community, located in northern Ontario, without access to running water.

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(Toronto) - The next Canadian government needs to compensate Neskantaga First Nation for the costs associated with evacuating the community after a water infrastructure failure, Human Rights Watch said today. The government should also have a mechanism to deal with major infrastructure failures in remote First Nations communities.

On September 12, 2019, the water pump at the community's water treatment facility failed, leaving some homes completely without running water and others with water that was not safe to use except to flush toilets. The remote community - only accessible by plane or winter roads - declared a state of emergency on September 14 and began evacuation by air of the majority of community members to Thunder Bay, including chronically ill adults and infants. Indigenous Services Canada refused to provide evacuation assistance at the time.

"Facing a potential human rights and health crisis after a water pump failure, the Chief and Council were left to act alone to protect the health and safety of their community," said Amanda Klasing, water expert at Human Rights Watch. "The government failed to help the people of Neskantaga, and they should not be on the hook for the cost of dealing with this crisis."

Indigenous Services Canada denied the community evacuation assistance when the pump failed, claiming that it would be a quick repair and there was no immediate health or safety risk. Chief Chris Moonias disputed that finding, saying that providing bottled water in the interim was insufficient to address the community's health and safety needs.

Grand Chief Alvin Fiddler of Nishnawbe Aski Nation said that Indigenous Services Canada officials told Neskantaga that no precedent or policy existed to provide evacuation or other forms of assistance to remote communities affected by a major infrastructure failure. The cost to the community of dealing with the evacuation alone puts it at risk of losing control of its finances.

A pump was flown in from southern Ontario, and water tests conducted on September 18 and 19 were sufficient to lift the do-not-consume warning. Members began returning on September 23.

In 2016, Human Rights Watch documented the impact of serious and prolonged drinking water and sanitation problems for thousands of First Nations people - indigenous peoples in Canada - living on reserves. The findings detailed problems with safe water and sanitation on reserves, including a lack of binding water quality regulations, insufficient funding, faulty or substandard infrastructure, and degraded source waters. The federal government's own audits over two decades show a pattern of overpromising and underperforming on water and sanitation on reserves.

Human Rights Watch research focused on the unique human rights challenges faced by Neskantaga First Nation, which has operated under a boil-water advisory for nearly 25 years. Situated on the banks of Attawapiskat Lake in Northern Ontario, Neskantaga First Nation is a remote Oji-Cree community of approximately 300 registered members. Its main settlement, previously known as Lansdowne House, was relocated beginning in the 1980s, with the promise of better services, including housing, water, and sanitation.

The community's water system, funded by Indigenous and Northern Affairs Canada, an agency that has since been divided and renamed, was built in 1991. The system that was designed never met the needs of the community in practice. A "boil water" advisory put in place in 1995 has remained in effect ever since. The community requested a new plant, but it was only years later, in 2017, that the federal government finally secured funding. The intended completion date was 2018, but construction has been beset by delays and, in early 2019, the community fired the contractors. With a new contractor, Neskantaga's new water treatment facility will not be operational until the end of October or November, according to officials who have spoken with the contractors. Meanwhile, Neskantaga remains dependent on the old system, which includes a machine that refills bottles with water for drinking but is difficult to use.

The community cannot pay for the emergency action from its budget without putting it at risk of default status with Indigenous Services Canada and placement into third-party funding agreement management, and loss of budget control.

"In the absence of policy guidance from Indigenous Services Canada, First Nations leaders should not be punished when they act quickly to avert a potential human rights and public health crisis," Klasing said. "Such action creates an incentive to sacrifice community health and safety to avoid financial risk."

Since 2015, Canadian officials have worked to eliminate drinking water advisories in First Nations reserves, lifting 87 long-term advisories through dedicated investments. However, at least 56 drinking water advisories remain in place and the underlying systemic water and wastewater problems facing First Nations in Canada remain, including a lack of regulations to protect drinking water on reserves.

Parliament passed the Safe Drinking Water for First Nations Act (SDWFA), which entered into force in November 2013, and called for regulations. In December 2015, a special Assembly of Chiefs sponsored by the Assembly of First Nations passed a resolution on safe drinking water for First Nations, which declared that the act "was developed without meaningful consultation with First Nations, is contrary to inherent authority of First Nation governments and does not reflect the principles of Customary Laws regarding water." The resolution called for the repeal of the act. It reiterated the call for repeal in 2017 and called for the federal government to develop in partnership with First Nations the next steps in engaging with the SDWFA.

The human right to water entitles everyone to sufficient, safe, acceptable, physically accessible, and affordable water for personal and domestic uses. Among other obligations to guarantee the right to water, Canada should ensure a continuous water supply for drinking, personal sanitation, washing clothes, food preparation, and personal and household hygiene. Canada also has an obligation to ensure that First Nations have the resources to design, deliver, and control their water access.

The Canadian government is aware of the condition of water infrastructure on First Nations reserves and should have contingency plans for major infrastructure failure, particularly in remote, fly-in communities. These plans should define roles and responsibilities around decision-making on possible evacuations or other extraordinary measures to protect the health and safety of community members.

In the absence of these procedures, the government should recognize the urgent dilemma faced by Neskantaga leaders when faced with a pump failure and potential liability for the resulting harm to health and human rights. Neskantaga should not have to bear the financial brunt for an infrastructure failure, and Indigenous Services Canada should work swiftly to compensate the community for the cost of evacuation, Human Rights Watch said.

"The federal government was unprepared to act to prevent serious harm from a failed water system, but that is no excuse to financially penalize Neskantaga leaders and community members for prioritizing their own health, safety and rights," Klasing said.

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Canada: Blind Eye to First Nation Water Crisis

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The next Canadian government needs to compensate Neskantaga First Nation for the costs associated with evacuating the community after a water infrastructure failure, Human Rights Watch said today. The government should also have a mechanism to deal with major infrastructure failures in remote First Nations communities.

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The federal government has not done enough to ensure people in First Nations communities have reliable access to safe drinking water, says the federal auditor general.

In an audit report tabled in Parliament today, Auditor General Karen Hogan said many First Nations will continue to live without access to clean water without long-term solutions to address deficiencies in their water systems.

Prime Minister Justin Trudeau committed during the 2015 election to eliminating all long-term drinking water advisories on public water systems on First Nations reserves by March 31, 2021.

The auditor general found that since the prime minister made that commitment, 100 advisories have been lifted. But 60 remained in effect in 41 First Nations communities as of November 2020, and some communities won't be able to get clean water out of their taps for many years.

"I am very concerned and honestly disheartened that this longstanding issue is still not resolved," Hogan told a press conference in Ottawa today.

"Access to safe drinking water is a basic human necessity. I don't believe anyone would say that this is in any way an acceptable situation in Canada in 2021."
WATCH | AG has strong words for Ottawa on First Nations drinking water:

The findings are in one of five audit reports issued by Hogan today. One of those reports raises concerns about Transport Canada's lack of progress in ensuring safety oversight of railway companies, while another concluded Canada's national shipbuilding strategy has been slow to deliver new ships.

The auditor's review of the First Nations drinking water crisis found Indigenous Services Canada's efforts to lift boil water advisories have been constrained by a funding policy that hasn't been updated in 30 years, and by the lack of a regulatory regime that includes legal protections comparable with other communities in Canada.

Delays predate COVID-19: AG

Last fall, a CBC News survey determined the Liberal government would miss its March 2021 deadline to lift all long-term boil water advisories - something that Indigenous Services Minister Marc Miller acknowledged in December 2020.

The audit found that COVID-19 pushed the timeline back on some water projects, but Indigenous Services Canada was already behind schedule by the end of March 2020 - before the pandemic hit.

The problems persist despite the Liberal government allocating over $3 billion to resolve the issue.

Hogan recommended the department work with First Nations to proactively identify and address deficiencies in water systems, with a focus on long-term solutions that prevent recurring problems.

She also called on the government to commit sufficient funding to operations and maintenance of water infrastructure and pass legislation that includes legal protections comparable with other communities in Canada.

"Until these solutions are implemented, First Nations communities will continue to experience challenges in accessing safe drinking water," the report said.
WATCH | Indigenous Services minister responds to AG report criticizing First Nations water plan:

Indigenous Services Minister Marc Miller said the federal government welcomes the auditor general's report and agrees with her recommendations. He said the government is committed to funding 100 per cent of the operations and maintenance costs for water and wastewater on reserves.

He said there are project plans in place to lift all remaining boil water advisories, but he couldn't say when he expects them all to be lifted.

"Despite the challenges, we're confident we're on the right path," said Miller.

Opposition politicians slammed the Liberal government for what they called a lack of progress.

"Government success isn't measured by funding announcements, it's measured by outcomes," said Conservative MP Gary Vidal. "The Liberals like to make eye-catching promises in order to win elections but their consistent failure to deliver on these promises is undermining trust and hurting reconciliation."

"Indigenous communities are no better off now after six years of the Liberals being in government," said NDP Leader Jagmeet Singh.

Shipbuilding strategy slow to replace federal fleet

The auditor general's review of the national shipbuilding strategy - implemented in 2010 to manufacture combat and non-combat ships for the Canadian Navy and the Coast Guard - found that it has been plagued by delays and cost overruns.

"[The federal departments] did not manage the National Shipbuilding Strategy in a manner that supported timely renewal of the federal large vessel fleet during the audit period, but they did address issues that threatened the future renewal of the federal fleet," Hogan concluded.

The audit was conducted between Jan. 1, 2018 and Jan. 30, 2020. Only two of four ships scheduled for delivery during that period arrived, but both were late, the audit found. The delivery dates for some other vessels also were pushed back during the audit period - in some cases by several years.

Design and construction delays have added hundreds of millions of dollars to the cost of procuring the ships and threaten to leave Canada ill-equipped to defend and patrol its waters, Hogan warned.

"The late delivery of ships for the Royal Canadian Navy and the Canadian Coast Guard could put at risk Canada's ability to perform critical operations," the auditor's report said.

"These operations support the navy's peace, defence and security missions in Canada and around the world and the coast guard's search and rescue missions, icebreaking and other operations to ensure safety in Canadian waters."

Since the audit period, the COVID-19 pandemic has further delayed ship construction. Irving Shipbuilding and Vancouver Shipyards were forced to either temporarily shut down operations or operate at reduced capacities for periods of time because of public health restrictions.

The auditor general's report comes one day after Canada's budget watchdog predicted that construction of the navy's new frigate fleet could cost at least $77.3 billion - a number that could rise even higher if the frequently-delayed program faces any more setbacks.

Other findings

Among the other findings released by the auditor general on Thursday:

The Canada Revenue Agency was praised for its management of the Canada Child Benefit program, which the audit found paid out $24 billion promptly and to the right people during the fiscal year 2019-2020. But the auditors found that the government in some cases kept making payments based on outdated information - and the program's assumption that female parents are the primary caregivers isn't always correct, causing problems for some families.

A one-time top-up payment of $300 per child to help families during the pandemic, announced in May 2020, paid out $88 million to almost 265,000 higher-income families who wouldn't normally qualify for the benefit.

Transport Canada was criticized for failing to implement a number of recommendations included in a 2013 audit of its safety management practices. The most recent audit found that Transport Canada's checks on rail safety have improved to focus more on riskier areas and to better follow up on safety deficiencies in rail companies' practices. The department has not, however, examined the companies' safety management systems for effectiveness, according to the auditors - only for whether they tick the necessary regulatory boxes.

Staff who work in federal departments that buy complex information technology systems need better training. Public Services and Procurement Canada, Shared Services Canada, the Treasury Board and Employment and Social Development Canada are adopting "agile" procurement models that involve a lot more back-and-forth with potential vendors - something for which the officials doing the procuring aren't always equipped. The auditors also concluded procurement agencies should make more use of data analytics to spot cases of potential bid-rigging and other problems.

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Too many First Nations lack clean drinking water and it's Ottawa's fault, says auditor general | CBC News

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The federal government has not done enough to ensure people in First Nations communities have reliable access to safe drinking water, says the federal auditor general.

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Statistics Canada's report on suicide among First Nations people, Métis and Inuit (2011-2016) released June, 2019, found that Indigenous people in Canada die by suicide at a rate three times higher than that for non-Indigenous Canadians. The preamble starts by noting:

"Suicide rates have consistently been shown to be higher among First Nations people, Métis and Inuit in Canada than the rate among non-Indigenous people; however, suicide rates vary by community, Indigenous group, age group and sex. The historical and ongoing impacts of colonization, forced placement of Indigenous children in residential schools in the 19 th and 20 th centuries, removal of Indigenous children from their families and communities during the "Sixties scoop" and the forced relocation of communities has been well documented. These resulted in the breakdown of families, communities, political and economic structures; loss of language, culture and traditions; exposure to abuse; intergenerational transmission of trauma; and marginalization, which are suggested to be associated with the high rates of suicide."

An important recognition is the historical conditions that contribute to fractures of self-worth, opportunities, and alienation driving too many young people to the depths of depression, even a half century after the well documented injustices. Impacts of which continue to be transmitted and inherited by young people who were not even living then.

Yet, once again, the systemic reaction to failed futures and the resulting consequences continue to rely too heavily on institutionalized responses, rather than on humanitarian ones; responses that rely too highly on effective jails, corrections systems, and legislation for control.

Highly effective institutional systems that gobble up huge amounts of revenues for policing, social workers, probation officers, nurses, and teachers; each adept and replete with quantitative justifications for their effective and efficient management of resources. But in spite of the effectiveness and efficiency, too many lives continue to be marginalized, warehoused and lost.

And in many cases, the cost of issuing an apology and paying compensation after the fact are far less costly than actually instituting the more intensive application of social care and accountability necessary to mitigate ongoing cycles of crime, violence, neglect and marginalization.

If this were not the case we would not be repeating the same policies, guised in politics of law and order, entitlements and rights, and the otherization of peoples and issues that have so clearly failed in the past; and systems that seem to thrive on their ability for self perpetuation.

The late auditor general Michael Ferguson warned and cautioned as far back as 2015 that Correctional Service of Canada officials (CSC) were failing to prepare offenders for parole in a timely fashion, driving up prison costs by nearly $100 million a year and undermining efforts to prepare offenders to re-enter society without committing more crimes.

Three years later the Auditor General again reported in Report 6: Community Supervision-Correctional Service Canada , of the deteriorating support for those subject to the corrections system. Amongst his findings:

That CSC did not properly manage offenders under community supervision, did not give parole officers all the information they needed to help offenders with their health needs, and that parole officers did not meet with offenders as often as they should have.

That CSC was not able to properly monitor many offenders under community supervision.

That the number of offenders released into community supervision had grown and was expected to keep growing.

That CSC had reached the limit of the numbers of offenders it could house in the community, and that it did not have a long-term plan to respond to its housing pressures.

That it could take CSC more than two years from the time a site was selected with a community partner to the time an offender was placed at a facility, and that these shortages were likely to get worse.

How much has really changed since Michael Ferguson's report, and how much money has been spent on a system that has deteriorated and continues to deteriorate remains unclear.

According to The Office of the Parliamentary Budget Officer: Update on Costs of Incarceration 22 March 2018, CSC's expenditures associated with custody centers in 2016-17 alone totaled $1.63 billion ($114,587 per inmate) of which $1.57 billion ($109,971 per inmate or ninety-six percent) was attributable to CSC custody program.

And as to the effectiveness of CSC, despite research and performance measurement in the field of corrections and criminal justice, CSC still lacks a regularly maintained, national recidivism database- a valuable indicator of the effectiveness of "corrections". According to reports the last time CSC fully measured its two-year reconviction rate in 1995, it stood at forty-one percent, compared to 20 percent for Norway.

This, despite what some in frustration have called, a tinkering with the system - changes to the Criminal Code requiring judges to consider sanctions other than incarceration, for all offenders but particular attention to the circumstances of Indigenous offenders, following the 1999 decision by the Supreme Court of Canada in Regina vs. Gladue; a decision that should have changed incarceration patterns.

It is considered tinkering because it would again require the Supreme Court, in 2012, through the decision on Regina vs. Ipeelee, to remind the judiciary that they were mandated to follow the legislation and decision in Gladue.

Among the provinces in 2016/2017, Aboriginal adults accounted for the largest proportion of admissions to custody in Saskatchewan (seventy-six percent) and Manitoba (seventy-four percent).

These are the cold impersonal numbers of broken and failed lives that contribute to, and conceal far more tragic consequences. They are the mathematical impersonalization of systemic institutionalization.

Statistics can impersonalize even the worst human tragedies, and news reports have not been short on the tragic consequences of desperation reflected in instances of First Nations suicides.

For decades the suicide rates among First Nations, Inuit, and Métis people in Canada have been alarmingly higher than for the rest of Canadians. These suicides, in small and closed knit communities with close family ties, result in immense grief, bereavement, stigmatization and despair, particularly when the loss is of a young person.

In the spring of 2016 the remote Manitoba community of Pimicikamak Cree Nation, known as Cross Lake declared a state of emergency after six suicides within two months and 140 attempts within a two weeks period.

During the summer of 2019 the God's Lake First Nation, about 550 kilometres northeast of Winnipeg, experienced a rash of suicides that left four young people dead, twenty-two attempted suicides, and an epidemic of meth and alcohol addictions.

While these statistics may come as a surprise to some, they have been the tragic reality faced by First Nations communities across Canada for decades. There is a sense of helplessness in the statements of chiefs and elders struggling to alleviate the deep pain and isolation felt by their young peoples. There is a sense of deep caring and desperation in their calls for help, repeated across the country.

The new report on Indigenous suicide in Canada, released at the end of June, is aimed at providing a comprehensive picture of the crisis, unfortunately limited to the data collected during as part of the 2016 census and, therefore, is already four years and many lives short.

The ongoing impacts of disproportionate sentencing, forced placement of children in foster care, removal of young men and women from healthy social development, and deprival of employable skills and opportunities today continues to perpetuate the impact of the "Sixties scoop" and forced relocation of communities of the past. Impacts of which will continue to be transmitted and inherited by young people not yet living.

Given these statistics, how can one possibly be surprised with disproportionately higher suicide rates among First Nations peoples?

The Assembly of First Nations National Chief, Perry Bellegarde, notes: "The time is now for bold vision and decisive action." Perhaps it is not asking too much to expect the religious institutions that so energetically took to saving souls through assimilation to now respond as energetically to saving lives. A new bold vision must focus our gaze towards countries like the Netherlands where since 2014, twenty-three prisons have been shut, turning into temporary asylum centres, housing and hotels.

Big bureaucracy and billions spent on corrections has not offered the solutions other jurisdictions have achieved.

Michael Ferguson's report in 2016, four years ago referenced to an additional ten-year period prior to that during which little or no progress had been achieved with regards to First Nations issues:

There is nothing that should be more important to a society than the care and safety of its children; a universal value across race, class, religion or status. The reality is that this value has been conditional on those children being of ones' own community. Children of others should not seem to mean less.

More than ever we need a problem-solving mindset to develop solutions built around people instead of defaulting to litigation, institutionalization, and simply spending more money without meaningful outcomes.

Federal, provincial, and local governments need to strengthen partnership with Indigenous organizations to develop strategies to recruit, retain and train Indigenous partners to support wider access to mental health services. At the same time communities themselves need to widen support and long-term capacity, building in health and mental health responses and to expect meaningful and transformative change.

There can be no solution without federal and provincial departments, and the Assembly of First Nations working together to bring about meaningful educational, healthcare, and social support systems that provide support on a per community based approach; for developing strategies that recognize different needs for different communities and for distinct measures.

Perhaps most crucially, communities also need to look for a helping hand at the end of their arms, grass roots movements, that are no longer willing to let governments and politicians get away with the easy solutions - payouts and promises without real solutions and outcomes.
Anil Anand is a research associate with the Frontier Centre for Public Policy. Anil served as a police officer for 29 years; during his career some of his assignments included divisional officer, undercover narcotics officer, and intelligence officer. He has worked in Professional Standards, Business Intelligence, Corporate Communications, the Ipperwash Inquiry (judicial public inquiry), and Interpol.
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Mental wellness resources available for First Nations people, Métis and Inuit:
Hope for Wellness: Help Line: 1-855-242-3310

Live chat: www.hopeforwellness.ca

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The Institutionalization and Suicide Crisis Among Indigenous Youth

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Statistics Canada's report on suicide among First Nations people, Métis and Inuit (2011-2016) released June, 2019, found that Indigenous people in Canada die by suicide at a rate three times higher than that for non-Indigenous Canadians.

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Research article

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BMC Medicine 16, Article number: 145 (2018) Cite this article

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Abstract

Background

Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available. Our objective was to examine the global incidence of suicide among Indigenous peoples and assess disparities through comparisons with non-Indigenous populations.

Methods

We conducted a systematic review of suicide rates among Indigenous peoples worldwide and assessed disparities between Indigenous and non-Indigenous populations. We performed text word and Medical Subject Headings searches in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SciELO) for observational studies in any language, indexed from database inception until June 1, 2017. Eligible studies examined crude or standardized suicide rates in Indigenous populations at national, regional, or local levels, and examined rate ratios for comparisons to non-Indigenous populations.

Results

The search identified 13,736 papers and we included 99. Eligible studies examined suicide rates among Indigenous peoples in 30 countries and territories, though the majority focused on populations in high-income nations. Results showed that suicide rates are elevated in many Indigenous populations worldwide, though rate variation is common, and suicide incidence ranges from 0 to 187.5 suicide deaths per 100,000 population. We found evidence of suicide rate parity between Indigenous and non-Indigenous populations in some contexts, while elsewhere rates were more than 20 times higher among Indigenous peoples.

Conclusions

This review showed that suicide rates in Indigenous populations vary globally, and that suicide rate disparities between Indigenous and non-Indigenous populations are substantial in some settings but not universal. Including Indigenous identifiers and disaggregating national suicide mortality data by geography and ethnicity will improve the quality and relevance of evidence that informs community, clinical, and public health practice in Indigenous suicide prevention.

Peer Review reports

Background

Globally, suicide accounts for approximately 800,000 deaths annually [ 1] and is the second leading cause of mortality among adolescents [ 2]. According to the World Health Organization (WHO), low- and middle-income countries and high-income countries have similar annual age-standardized suicide rates at 11.2 and 12.7 per 100,000 respectively; however, low- and middle-income countries account for 75% of suicide deaths worldwide [ 1]. National suicide rates range from less than one to 44 per 100,000 population, though there is often a disproportionate burden among specific subgroups within countries, such as Indigenous peoples [ 1]. Studies from high-income countries including Australia [ 3, 4], New Zealand [ 5], the USA [ 6, 7], Canada [ 8, 9, 10], and other Arctic nations [ 11, 12, 13, 14] consistently find elevated suicide rates among Indigenous populations, with substantial rate disparities compared to non-Indigenous populations. Several studies have shown that regional suicide rates vary greatly among Indigenous peoples, and that some Indigenous populations have low rates or no incidence of suicide [ 15, 16].

Indigenous peoples and nations differ vastly in culture, language, political autonomy, and relative wealth, yet many face similar social disadvantages and health disparities as a result of colonization [ 17, 18, 19]. Colonial governments have used discriminatory legislation and policies to deny rights and economic opportunities, and have attempted to acculturate Indigenous people into non-Indigenous societies [ 17, 19, 20]. Structural violence meted out by governments has taken many forms including dispossessing Indigenous peoples from traditional and sovereign lands, forced settlement and relocation, and outlawing cultural practices and languages [ 17, 18, 19, 20, 21]. This violence is grossly evident in the twentieth century assimilationist policies of former British colonies such as Canada and Australia. Indigenous children were systematically removed from their communities and placed in non-Indigenous institutions or families with the policy mandate to "weaken family ties and cultural linkages, and to indoctrinate children into a new culture" ([ 20], p. v). The contemporary legacy of this type of social engineering manifests in differential exposures to health threats and in inequitable outcomes that show up across generations [ 20, 22]. Intergenerational trauma from institutionalized abuse and racism experienced by Indigenous peoples has been linked to persistent social and mental health problems in some communities [ 19, 20, 23].

Although evidence has shown a disproportionate burden of suicide among Indigenous populations in national and regional studies, a global and systematic investigation of this topic has not been undertaken to date. Previous reviews of suicide epidemiology among Indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth [ 24, 25], high-income countries [ 9, 26], or regions such as Oceania [ 27] or the Arctic [ 24, 28]. Given that approximately 80% of the world's more than 300 million Indigenous people live in Asia, Latin America, and Africa [ 17, 18], a comprehensive study of global suicide rates that includes low- and middle-income countries is needed. Our aim was to examine the published findings on the incidence of suicide among Indigenous peoples worldwide, and to compare rates with non-Indigenous or general populations to assess relative disparities.

Methods

Search strategy

We systematically reviewed findings on the incidence of suicide in Indigenous populations worldwide. We searched for studies that analyzed population-based data on suicide deaths, and included papers that reported crude or standardized mortality rates. Health science librarians were consulted about the design of the search strategy with the aim to capture all peer-reviewed literature. The search combined terms related to three concept areas: population (Indigenous), outcome (suicide mortality rates), and study design (observational). Term selection was based on previous systematic reviews and combined key terms adapted for each database and also Medical Subject Headings (MeSH) as applicable. The study protocol is available in Additional file 1: Supplement 1. Additional details about the methods are reported in Additional file 1: Supplement 2, including citations for previous reviews, a list of included terms, a description of the procedures used for study selection and eligibility criteria, and a complete list of databases and hand-searched review articles.

One author (NJP) performed online text word and MeSH searches for articles indexed in PubMed, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), PsycINFO, Latin American and Caribbean Health Sciences Literature (LILACS), and Scientific Electronic Library Online (SCiELO). A second author (KN) replicated the search in PubMed and obtained the same number of articles as the first author. We searched for studies in any language, indexed from database inception until June 1, 2017. We conducted a secondary search with a comprehensive list of terms for specific tribal groups, nations, and populations identified in previous reviews. As no additional studies were identified, this approach validated the primary search. We also searched the WHO's regional medical literature indexes, Indigenous-specific online research portals, and journals focused on Indigenous health. We hand-searched the reference lists of included articles and previous reviews to identify other eligible studies. Additional file 1: Supplement 2 includes a list of all databases and hand-searched sources.

One author (NJP) imported the results into a reference management program and removed duplicates. Two authors (NJP and KN) read the abstracts and screened in papers if they (1) reported a population-based crude and/or standardized suicide rate, or count and population data; (2) reported a rate for an Indigenous population; and (3) used an observational design. We excluded articles that did not include an Indigenous population, focused only on a specific age, gender, clinical subgroup, or deaths from a specific cause (for example, firearms), or were not peer-reviewed. Articles were also excluded if they were iterations, program evaluations or experimental studies, not primary studies, from the gray literature, or used identical data sources as prior studies.

Although there is no international consensus on the definition of Indigenous, we used the United Nation's working definition to assess study population eligibility [ 17, 18]. The UN's conceptualization of Indigenous involves self and group identification; a special attachment to and use of traditional land, distinct knowledge, language, and culture; distinct social, economic, and political systems; common ancestry with original territorial occupants; participation in maintenance and reproduction of distinct ethnic identity; and a non-dominant socio-political status [ 17, 18]. A paper was eligible based on this criterion if it reported an outcome for an Indigenous population, tribe, community, nation, or group, including papers that used the geographic proxy method. For the proxy method, census data is used to detect areas where Indigenous people are a majority population [ 29, 30]. We considered an area to be a proxy identifier if 80% or more of the population self-identified as Indigenous.

Two authors reviewed the full text of each paper and assessed eligibility based on inclusion criteria. At this stage, we excluded papers that did not report rates for the majority of the population (aged 15-65 years), did not conduct the primary data analysis, or provided rates in figures only and did not report count and population data. If two eligible articles used the same data source with a period of overlap, we included the article with the longer study period. During screening, full text review, and data extraction, we resolved disagreements through discussion or consultation with a third author. Translators helped assess non-English language articles and assisted with data extraction for four included studies. The following data was independently extracted by two authors (AL and NJP), then compared: citation, study design, country and region/community, Indigenous population, data source, standard population, number of suicide deaths, population count, crude and standardized suicide rates (overall and by gender and age group), comparative rates for a non-Indigenous or general population, and the measure of relative effect (incidence rate ratio).

Data analysis

We summarized all included studies in a table and reported counts, population, crude and standardized suicide mortality rates, and rate ratios. We calculated crude suicide mortality incidence rates for articles that reported only count and population data, and we estimated rate ratios when not otherwise reported by dividing the Indigenous population rate by the comparison population rate. To identify global patterns, we presented rates and rate ratios in tables and figures grouped by WHO region, country, population, and gender; we did not pool the data due to heterogeneity. We also reported on trends in suicide mortality over time and by age group; reported time trends reflect results from included studies, not pooled and recalculated rates. We modified the Newcastle-Ottawa Scale and used it to assess the quality of included articles. Additional file 1: Supplement 2 includes a description of the quality assessment procedures and scoring, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist is provided in Additional file 1: Supplement 4 [ 31].

Results

The search identified 13,736 papers; after removing duplicates, screening abstracts, and full text review, we included 99 in our analysis (Fig. 1). Included studies examined suicide rates in Indigenous populations in 30 countries and territories across six decades (Table 1), though the majority focused on those in high-income countries such as American Indian and Alaska Natives in the USA ( n = 35) and Inuit and First Nations in Canada ( n = 14). Studies in low- and middle-income countries ( n = 22) were mostly from Brazil ( n = 4), China and Taiwan ( n = 6), and Fiji ( n = 5). Coverage included circumpolar Indigenous peoples such as Sámi ( n = 3) and Nenets ( n = 1), and populations from the Western Pacific region including Aboriginal and Torres Strait Islanders in Australia ( n = 6) and Māori and other Pacific peoples ( n = 16). Four studies were transnational comparisons [ 32, 33, 34, 35], though numerous papers included multiple Indigenous groups within a single country. Studies were mostly of moderate quality (mean 2.79 on a 4-point scale) based on our assessment of study characteristics, as reported in Additional file 1: Supplement 3, Tables S1 and S2.

Flow diagram of study selection

Table 1 Overview of included studies

Incidence

We extracted population-based suicide mortality rates from 93 papers (Table 2) and included gender-specific incidence data from six additional studies [ 5, 10, 36, 37, 38, 39]. Overall, suicide rates among Indigenous peoples varied at all levels of aggregation in both high-income and low- and middle-income countries, and spanned from zero to 187.5 deaths per 100,000 person-years (PY; Table 2). In high-income countries, national and provincial suicide rates among Indigenous peoples ranged from 1.7 per 100,000 in Brunei Darussalam [ 40] to 50.4 per 100,000 among Aboriginal and Torres Strait Islanders in Northern Territory, Australia [ 41]. Rates in high-income countries were highest among rural Indigenous populations and in sparsely populated regions such as the Arctic. Among low- and middle-income countries, Palawan communities in the Philippines had the highest crude suicide rates (134 per 100,000) [ 42], while Indigenous peoples in Malaysia [ 43] and some Pacific small island states such as Fiji had crude rates under 7 per 100,000 population. The number of suicide deaths used for rate calculations ranged from zero to 4219 (Table 2).

Table 2 Suicide mortality rates among Indigenous populations by WHO region and country

Measure of relative effect

Incidence rate ratios were reported or calculated for 102 Indigenous populations in 69 studies. The results showed rate disparities in the majority of studies (Fig. 2), though 22 reported rate ratios below one. The rate ratios ranged from 0.04 in China [ 44] to more than 20 in Brazil [ 45] and Canada [ 30] (Additional file 1: Supplement 3, Table S4). Most Indigenous populations had higher suicide rates than comparison groups; disparities were widest in studies with small populations. One study reported a suicide rate of zero for an urban Indigenous population in Brazil compared the general population rate of 4.8 per 100,000 in the same city [ 46].

Global suicide mortality incidence rate ratios among Indigenous and comparison populations. a Western Pacific Region (Oceania and Australia). b Western Pacific Region (East Asia). c European Region. d Region of the Americas (Canada and Brazil). e Region of the Americas (USA, National). f Region of the Americas (USA, Alaska). g Region of the Americas (Lower 48 states and Hawaii). NWT Northwest Territories, IHSA Indian Health Services Area. The dotted line indicates a rate ratio of one (RR = 1). This means that there is rate parity (no difference) between the incidence of suicide in Indigenous and comparative populations. Rate ratios to the left of the dotted line (RR < 1) indicate that rates are comparatively higher in the non-Indigenous population. Conversely, rate ratios to the right of the dotted line (RR > 1) show that the Indigenous population has a comparatively higher rate. Citations for each study are reported in Additional file 1: Supplement 3, Table S4

Time trends

Suicide rates appeared to increase over time, especially in the latter half of the twentieth century, though reports were limited. Among studies with reported time series ( n = 24), most (83%, n = 20) had fewer than 10 data points and covered an average of 19 years. A study in Greenland was the exception; it reported longitudinal data that showed a steady suicide rate increase among Inuit that began with the near absence of suicide in the early part of the twentieth century (2.4 per 100,000) and climbed exponentially to a rate of 110.4 per 100,000 in 2010-2011; the average number of suicides per year changed from less than one to 55 during this period [ 12]. Aboriginal and Torres Strait Islanders in Northern Territory, Australia experienced similar rate accelerations (6.1 per 100,000 in 1981 to 50.4 per 100,000 in 2002) [ 41], while incidence among Alaska Natives was relatively stable, though high, from the 1980s to the early 2000s [ 47, 48]. Indigenous peoples in the Micronesian islands experienced a sixfold increase in suicide rates between the 1960s and the late 1980s (from 4.3 to 25.8 per 100,000) [ 35], and one study reported slight rate declines for both Māori and non-Māori in New Zealand from 1996 to 2002 [ 5]. Annual rates tended to fluctuate in studies with small populations.

Age differences

Age-specific rates were reported in 39 studies; various age categories were used, and rates were often only available for select strata. Youth less than 30 years old, especially those aged 15-24 years old, had the highest suicide rates of any age group in 89% of studies ( n  = 34) that reported age-specific rates. In the larger studies (> 100 total suicides) with age-specific incidence, youth suicide rates ranged from 15.9 to 108 per 100,000 population. Very few studies reported deaths or rate estimates for adults more than 60 years old.

Gender differences

Men accounted for the majority of suicide deaths in all but four studies; only two of these four studies reported a greater number of suicide deaths among women [ 49, 50]. Studies with gender-specific crude and age-standardized rates ( n = 35) ranged from zero to 75.5 per 100,000 among Indigenous women (Additional file 1: Supplement 3, Table S3). Suicide rates were higher among Indigenous men compared to Indigenous women, though rate differences were marginal among some Pacific populations [ 33, 51]. Suicide rates were also higher among Indigenous men than for men in comparison populations in all countries except Israel and Fiji. Outside of the relatively low rates among Indigenous men in these countries, estimates ranged from 19.5 among Sámi [ 13] to 248.7 per 100,000 among Inuit [ 30].

Discussion

This study showed that the rate of suicide is elevated in many Indigenous populations globally, but that rate variation is common (Fig. 1). The evidence of substantial rate disparities for Indigenous peoples in Australia, Brazil, Taiwan, and circumpolar countries is notable. Equally important, we found that disparities were marginal or non-existent in some US territories and Pacific nations; we also identified 21 studies in which Indigenous populations had lower suicide rates than non-Indigenous populations. These results demonstrate that the high incidence of suicide and large rate disparities are not universal among Indigenous peoples. This confirms and extends findings from prior research that reported variation in localized estimates in the USA [ 52] and Canada [ 16].

Worldwide variation in the incidence of suicide among Indigenous peoples has complex and place-based social origins. These origins are traceable to regional differences in the impact of colonization, which is widely recognized as a major determinant of Indigenous health [ 17, 18, 19, 53]. Colonial governments have historically threatened the well-being of Indigenous peoples through chronic and often state-sanctioned discrimination and human rights abuses, and continue to do so in many countries [ 18, 20, 23]. Until 2016, several high-income countries had not ratified the United Nations Declaration on the Rights of Indigenous Peoples, and therefore legislative reforms to recognize Indigenous self-determination lagged. As a result, many Indigenous nations have yet to attain political sovereignty over lands and natural resources, education, or health care.

Globally, Indigenous peoples commonly experience social and economic marginalization and, as a consequence, some of the most disparate health outcomes [ 17, 18, 53]. In this context, the extent and the persistence of high suicide rates and rate disparities reveal a striking deficit in the global effort to prevent suicide and achieve social and health equity. This is further challenged by overlapping barriers to accessing health care and community supports, especially in rural areas and low- and middle-income countries. Barriers include fragmented care networks, lack of access to services due to geography, discriminatory attitudes from health care providers, and services that are not culturally safe or provided in the necessary language [ 18, 54, 55]. In resource-limited and conflict settings in particular, mental health services are inadequate in scope and quality, chronically under-funded, and in some places non-existent [ 18, 54].

Challenges in accessing mental health care are compounded by the limited relevance and generalizability of some "best practice" interventions in Indigenous contexts [ 56, 57]. Recent clinical trials with gatekeeper training [ 57], hospital-based interventions [ 58], and mobile self-help applications [ 59] reported adverse and limited effects on suicide-related outcomes for Indigenous peoples. Overall, intervention studies with Indigenous populations are rare, and community-based programs are often not evaluated or have weak study designs [ 60, 61, 62, 63]. These challenges point to a need to expand efforts to generate Indigenous-specific evidence [ 23, 56, 60]. Indeed, many communities have developed contextualized and complex approaches to suicide prevention that respond to local priorities. There is emergent evidence that such programs increase protective factors and reduce suicide-related behavior [ 63, 64, 65]. However, knowledge about programs' effectiveness, implementation, and capacity to scale up is limited, and many programs are not sustainably funded [ 56, 60, 61, 62].

Indigenous organizations and governments in New Zealand, Canada, and several Arctic states have moved beyond programmatic approaches and designed Indigenous-specific suicide prevention strategies [ 23, 55, 66]. These strategies integrate evidence-based public health and clinical interventions with Indigenous knowledge about the consequences of colonization, institutionalized violence and racism, and the value of culture. They also recognize that social conditions have an important role in shaping mental health, especially during the early years of life, and that improving these conditions can have a positive impact on population mental health and suicide-related outcomes. The path to lowering the incidence of suicide among Indigenous peoples and achieving health equity requires broader social transformation both within states and globally. This transformation must be collaborative, with Indigenous organizations and communities as leaders and rights-holders in knowledge production and decision-making [ 23, 29, 53, 56, 66, 67]. Public health systems can also enhance capacity for Indigenous suicide prevention with efforts to increase the visibility of community-level differences in health status and by accurately tracking changes in suicide mortality over time.

Limitations

This study is a comprehensive synthesis of the published evidence on the global epidemiology of suicide among Indigenous peoples. Although it is the first review of this scale, our study has several important limitations. First, included studies varied their methods of identifying Indigenous populations. Self-identification is the gold standard in administrative and registry data [ 67]. However, this is a recent benchmark. Its uptake has varied internationally, and some countries do not identify Indigenous populations in health data at all [ 53, 67]. The majority of included studies relied on linkages with census or registry data, geographic proxies, or observer-determined assessments. These procedures are useful approximations, but they use varied definitions and tend to under-count Indigenous people, especially groups without legal recognition [ 29, 53, 67]. This can lead to ascertainment bias and underestimation of inequities [ 53, 67]. A second and related limitation is the under-representation of studies from low- and middle-income countries. In our review, we may have missed studies, particularly from the Global South, due to the conceptualization of Indigenous and the search terms used, which do not necessarily apply in all contexts. We attempted to limit this bias by searching databases focused on low- and middle-income countries and including non-English language papers.

The third limitation was that it was difficult to compare suicide rates between countries. Included studies were heterogeneous in population size, number of cases, aggregation, data source and outcome assessment, method of identifying Indigenous peoples, and coverage period. Many papers provided crude estimates only and did not report numerator and denominator data by age group, gender, or ethnicity. For studies with adjusted rates, different standard populations were used, and confidence intervals were rarely reported. Differences in analytic and reporting practices made it challenging to directly and reliably compare suicide rates across studies. To address this, we examined rate ratios to assess relative differences between Indigenous and non-Indigenous/general populations. This allowed us to estimate rate disparities, which were compared globally.

The fourth limitation was that studies reporting low suicide rates may be under-represented, which is a potential publication bias. It is unclear whether the lack of low incidence populations is related to the common finding of elevated rates of suicide among Indigenous peoples compared to non-Indigenous populations or, as we suspect is more likely, to the possibility that suicide rates are rarely studied when they are low. Additional low incidence reports may exist outside of peer-reviewed studies; however, these were not identified because we did not search the gray literature. The primary reason for excluding gray literature reports was the extensive volume of sources with variable quality and also the risk of over-including data from high-income nations where public reporting of mortality data is common and vital statistics infrastructure is of high quality. Nonetheless, we identified 23 papers that reported rate parity or had a rate ratio below one, but these tended to use older data. A related problem is that case studies tended to examine suicide clusters in small populations [ 42, 68]. The advantage of using localized data is the ability to contextualize a complex health issue. The disadvantage is that the potential to compare health status between multiple groups, across regions, and over time is reduced.

Strengthening surveillance in Indigenous suicide prevention

Our results substantiate previous work [ 16, 52] to demonstrate that elevated suicide rates are not universal among Indigenous people and debunk notions that Indigeneity increases risk for suicide. Our results also point to several gaps in knowledge about the epidemiology of suicide in Indigenous populations globally. The lack of published suicide data on Indigenous populations in low- and middle-income countries is a glaring absence. Previous studies noted a scarcity of Indigenous-specific data in the Global South overall [ 18, 53]. Poor infrastructure for death registration is a key limitation [ 1]. In the context of suicide, this is especially problematic, because countries in Asia, Africa, and Latin and South America are the homelands for the majority of the world's Indigenous populations [ 18] and, at a national level, account for more than three quarters of all suicide deaths [ 1]. Suicide data in high-income countries tends to be of better quality than that in low- and middle-income countries; however, many governments do not include Indigenous or other ethnic identifiers in administrative health data, and do not routinely link census or Indigenous registries with national health datasets such as vital statistics. In Canada for example, the federal government does not know how many Indigenous people die by suicide in a given year. Globally, there is a critical need to strengthen capacity for surveillance in Indigenous suicide prevention.

National governments can take several steps to improve suicide surveillance in Indigenous populations. Actions should include efforts to enhance suicide data quality and standardized classification by improving vital registration infrastructure, especially in low- and middle-income countries, and integrating mortality data with monitoring of suicide attempts [ 1]. Countries should adopt an equity-based approach to data collection that includes Indigenous identifiers derived from self-reported sources and linked to registries or census data to address gaps in identification, and align Indigenous identification procedures with recommendations from the International Group for Indigenous Health Measurement, adapted for each national context [ 1, 53, 56, 67, 69]. Building inclusive, Indigenous-centered models of data governance in suicide prevention will be a critical element of strengthened surveillance. To achieve this will require national statistical agencies to not only consult Indigenous communities, organizations, and leaders about priorities, but to respect Indigenous rights to determine the parameters of data ownership, custodianship, access, and use [ 29, 32, 67].

Future research and global suicide surveillance efforts will be further strengthened with longitudinal and up-to-date national and state-level datasets that allow disaggregation and comparisons of outcomes in small areas and subpopulations by ethnicity [ 1, 17, 53, 56]. Overall, these actions will help maintain robust public health surveillance systems in order to monitor health status, increase knowledge about the social determinants of suicide, target interventions, and evaluate strategies aimed at reducing the incidence of suicide among Indigenous peoples worldwide [ 1, 56]. Increasing the visibility of populations that bear the greatest burden from suicide can help drive efforts to achieve the WHO and Sustainable Development Goals of reducing national suicide rates by up to 30% [ 1, 69].

Conclusions

Suicide among Indigenous peoples is not a universal or intractable problem. Our study showed substantial global rate variation, with striking disparities in some countries. Efforts to understand these differences and to continue to build the knowledge base for effective interventions will require sustained political and financial investments in Indigenous communities, health systems, and governments. Across sectors and countries, Indigenous peoples have called for suicide prevention strategies that are community-led, strengths-based, and trauma-informed, and that redress intersecting forms of structural discrimination, social inequity, and their downstream consequences. Global efforts to reduce suicide rates among Indigenous peoples must include actions focused on communities that experience the most profound disparities, while also seeking to promote population mental health and improve health equity.

Abbreviations

CI:

Confidence interval

CSIR:

Crude suicide incidence rate

FSM:

Federated States of Micronesia

IHSA:

Indian Health Services Area (USA)

NWT:

Northwest Territories (Canada)

SSIR:

Standardized suicide incidence rate

UN:

United Nations

USA:

United States of America

WHO:

World Health Organization

Acknowledgements

Work on this study was conducted while the authors resided in communities in Newfoundland and Labrador, Canada situated on the homelands of the Innu, Inuit, Mi'kmaq, and Beothuk peoples, and in communities in Ontario, Canada situated on the traditional and unceded territory of the Algonquin Nation. We respectfully acknowledge their ancestral and continued ties to the lands and waters.

We wish to thank the health science librarians who contributed their expertise to the design of this study: Janice Linton, University of Manitoba; Lindsay Alcock, Memorial University; and Lindsey Sikora, University of Ottawa. Thank you as well to our colleagues who assisted with translation, data extraction, and article access, and provided feedback on previous versions of this manuscript: Dr. Marina Sokolova, University of Ottawa; Dr. Albert Formanek, Laval University; Dr. Joseph Murray, University of Pelotas; Dr. Peter Bjerregaard, University of Southern Denmark; Dr. Yanqing Yi, Memorial University; Christopher Penney, Indigenous and Northern Affairs Canada, Government of Canada; Dr. Joyce Law, Labrador-Grenfell Health; Michele Wood, Department of Health and Social Development, Nunatsiavut Government; and Morgon Mills, Labrador Institute, Memorial University. We also recognize and are grateful for ongoing partnerships and research collaborations with the Nunatsiavut Government, Innu Nation, NunatuKavut Community Council, and Labrador-Grenfell Regional Health Authority, and for administrative support from the Labrador Institute and Faculty of Medicine at Memorial University, and the University of Ottawa.

Funding

NJP was supported by doctoral scholarships from the Canadian Institutes of Health Research and is a research associate at the Labrador Institute of Memorial University with salary funding from the Government of Canada's Atlantic Canada Opportunities Agency. KN was supported by a studentship from the Ontario Mental Health Foundation. IC is an associate professor at the University of Ottawa and received salary support through the Canada Research Chairs program. SM is a professor in the Faculty of Medicine at Memorial University. There was no direct funding source for this study. All authors had full access to all the data in the study, take responsibility for the integrity and accuracy of the data, and had the final responsibility for the decision to submit for publication.

Availability of data and materials

All data relevant to this study has been reported in the manuscript or included in the additional file.

Author information

Affiliations

1. Division of Community Health and Humanities, Faculty of Medicine, Memorial University, Prince Philip Drive, St. John's, Newfoundland and Labrador, A1B 3V6, Canada

Nathaniel J. Pollock & Shree Mulay

2. Labrador Institute of Memorial University, P.O. Box 490, Stn. B, 219 Hamilton River Road, Happy Valley-Goose Bay, ,Newfoundland and Labrador, A0P 1E0, Canada

Nathaniel J. Pollock

3. School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, 600 Peter Morand Cr, Room 308C, Ottawa, ON, K1G 5Z3, Canada

Kiyuri Naicker, Alex Loro & Ian Colman

Contributions

NJP, KN, AL, SM, and IC met the International Committee of Medical Journal Editors criteria for authorship, and no individual who met these criteria was excluded. NJP, IC, KN, SM, and AL conceived and designed the review; NJP and KN conducted the searches and screened titles and abstracts; NJP, IC, KN, and SM reviewed full text articles; AL, NJP, and KN extracted and cleaned the data; NP and IC analyzed the data; and NJP and IC planned and drafted the manuscript. All authors interpreted the results, revised the manuscript, and approved the final version of the article. NJP is the guarantor.

Corresponding author

Correspondence to Nathaniel J. Pollock.

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Pollock, N.J., Naicker, K., Loro, A. et al. Global incidence of suicide among Indigenous peoples: a systematic review. BMC Med 16, 145 (2018). https://doi.org/10.1186/s12916-018-1115-6
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Keywords

Indigenous

First peoples

Inuit

Health disparities

Suicide

Mortality

Surveillance

Epidemiology

# data[].attributes.attachment_link.title
Global incidence of suicide among Indigenous peoples: a systematic review

# data[].attributes.attachment_link.description
Background Suicide is the second leading cause of death among adolescents worldwide, and is a major driver of health inequity among Indigenous people in high-income countries. However, little is known about the burden of suicide among Indigenous populations in low- and middle-income nations, and no synthesis of the global data is currently available.

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Note: This content may be emotionally difficult. The Hope For Wellness help line is 1-855-242-3310 or via online chat, Additional supports are available through We Matter.

A new report on Indigenous suicide in Canada has generated the most comprehensive picture of the crisis to date, despite health authorities continuing not to collect data about the problem.

Released at the end of June, the Statistics Canada report titled " Suicide among First Nations people, Métis and Inuit (2011-2016)" found that, overall, Indigenous people in Canada die by suicide at a rate three times as high as non-Indigenous Canadians.

While comprehensive, the report acknowledges there are limitations to the findings that likely result in underestimations of the actual rates. The report's analysis includes a number of socio-economic factors, as well as comparative differences based on age, sex and location - on or off reserve.

The lead researcher of the report, Mohan Kumar, said he wants readers to remember that for each of the numbers in the report "there is a person behind them, and their deaths meant an incredible loss to family, friends, community and the society at large."

He also contextualizes the findings in light of existing research that shows how aspects of colonization contribute to the Indigenous suicide crisis. So that the high rates, he says, shouldn't be taken as indicative of personal, community or cultural failings.

Canada doesn't track suicides specifically by Indigenous identity, and the process that Kumar and co-researcher Michael Tjepkema used to overcome this is important to look at, as are the limitations inherent to these findings. The findings are estimations not full counts, as they're based on only a sample portion of the full population, and there are some population groups not surveyed.

But as Indigenous researchers Roland Chrisjohn and Shaunessy McKay wrote in Dying To Please You: Indigenous Suicide in Contemporary Canada, their 2017 book on the suicide crisis, discourse about the problem and solutions is often unhelpful and not evidence-based: "It sounds like drumbeats of a PR bandwagon, like Native people are being recruited to a mainstream viewpoint rather than being convinced with real data; with all parties repeating a mantra over and over again until they parrot it without any real understanding."

Thus, the Statistics Canada report's contributions in terms of new, fuller data analysis are important.

The report's central finding - that First Nations people die by suicide at three times the rate of non-Indigenous Canadians, Inuit at nine times the rate, and Métis at two times - illustrates a crisis but is not likely to surprise those familiar with previous statistics. For those unfamiliar, it puts Inuit among the people with the highest rates of suicide anywhere in the world.

The report examines each of the three groups separately, and is based on 2011 populations, when the census had 851,560 people self-identify as First Nations, 59,445 as Inuit and 451,795 as Métis .

The report estimates that there were 1,845 total deaths by suicide of the Indigenous population in Canada from May 10, 2011, through Dec. 31, 2016. This total consists of 1,180 First Nations people, 250 Inuit and 415 Métis.

Looking at it side by side with murder data can help contextualize the scale of the problem.

For the five years since StatCan started tracking homicides by Indigenous identity, there have been 710 recorded Indigenous victims of homicide. The number of estimated suicides from the StatCan report is approximately two and a half times larger, though it applies to a slightly longer period.

The public interest in addressing the problem of missing and murdered Indigenous women and girls (MMIWG) in Canada illustrates the scale of the energy that could be mustered in service of a similar reckoning with the suicide crisis.

A Statistics Canada report found that Indigenous people die by suicide at a rate three times as high as non-Indigenous Canadians. But the report acknowledges there are limitations to the findings that likely result in underestimations of actual rates

Younger Indigenous people suffer higher rates of suicide

When comparing overall populations of the identity groups, the report uses age-standardized suicide rates to account for the groups' different age distributions - the 2011 census shows median age was 26 for First Nations, 23 for Inuit, 31 for Métis and 41 for non-Indigenous. Kumar said the approach ensured that the findings were in the form of "the rate that would be expected if the age structures of the populations were the same."

The highest rates of Indigenous suicide are seen in youth and young adults, between the ages of 15 and 24, Kumar told National Observer. For First Nations people, the rate for these ages is 6.2 times higher than for non-Indigenous population in the same age range; for Inuit people, the rate is 23.9 times higher. (There wasn't enough data to generate accurate rates for Métis by age range.)

Not all communities are equally affected by the suicide crisis

For the First Nations population, the suicide rate was two times as high for those living on-reserve as those living off-reserve.

While a critique of much of the general discourse around Indigenous issues is that it is negative or problem-focused, this report did aim to "to look at it from the perspective of resiliency (instead) of having a deficiency-based estimate," according to Kumar.

In conversation, he highlighted that the report's findings show that of "close to 600 bands ... 60% of those FN bands had not experienced suicides (of any people in the sampled population), so they have a zero suicide rate."

For Inuit Nunangat, "11 out of 50 Inuit communites had a zero suicide rate."

These numbers do need qualifying, as these zero suicide rates don't necessarily mean there were no deaths by suicide from these bands and Inuit communities over the roughly five-and-a-half-year period covered by the report. This is due to the methodology.

How to count Indigenous suicides when the government doesn't track Indigenous suicides

This research is based on the 2011 National Household Survey (NHS), which replaced the long-form census, and was based on voluntary responses. These responses accounted for a total of just over six million of the Canadian population, including what was then approximately a third (466,000) of self-identified Indigenous people in the country.

For the First Nations communities that participated in the NHS (over 90 per cent of the over 600 in Canada), all households on reserve received the survey while First Nations people living off-reserve were, like those in the general population, selected to receive the survey at random. All Métis living in households in surveyed areas, including the Métis Settlements of Alberta, received the survey while Métis living outside of survey areas were part of the random selection process to receive the survey.

For Inuit, every household in Inuit Nunangat (spanning parts of Northwest Territories, Quebec, and Labrador as well as all of Nunavut) received the survey, but individuals outside of the territory were selected for the NHS at random as part of the general population.

The NHS was used as a way to determine who among the suicide deaths were Indigenous, because the Canadian government doesn't track that in its records of health statistics.

"In the Canadian Vital Statistics Database (CVSD), there are no Indigenous identifiers, so you can't say if a death that occurred is of a First Nations person or a Métis or Inuit," Kumar explained.

"So the only way we can do that is we link the mortality records (from the CVSD) to the National Household Survey records, and in the NHS people self-identified as either a First Nations person, Inuit or Métis, or they didn't identify as Indigenous and so they would be considered non-Indigenous."

He noted a small percentage identify as belonging to more than one of the three Indigenous groups, about 0.8 per cent of the 2011 Indigenous population, though there is no separate analysis of their data in this report.

The report uses the deaths by suicide recorded in the CVSD starting from the day the NHS was collected, May 10, 2011, through the end of December 2016 - the period of 5.6 years.

Who - and what - was and wasn't counted

The NHS is a survey of private dwellings that omits people living in institutions (jails, medical facilities, etc.), collective dwellings (group homes, hostels, etc.), and many of those who are homeless.

These unmeasured groups may have higher rates of death by suicide compared with those who were surveyed; also, a higher proportion of the Indigenous population may be in those unmeasured groups than of the non-Indigenous population. It is for these reasons, and other less specific factors relating to the counting of deaths by suicide, that the report states "suicide rates presented (here) may underestimate the true rates."

The NHS also doesn't include data on gender or sexual identity, so there are no specific suicide rates in this report for two-spirit people or by sexual orientation or trans and non-binary gender identities - though these individuals are part of the overall statistics, except for those who are part of the unmeasured groups.

Kumar said the government is looking at having gender identity and sexual orientation identification included for the 2021 long-form census in consultation with Indigenous organizations.

"There are so many other factors that are behind the suicide rate we couldn't look into because we were restricted to what was collected in the NHS," Kumar said. The report itself identified some of these factors: "historical and intergenerational trauma, community distress, cultural continuity, family strength and mental wellness were not explored here."

Socio-economic factors

The report was able to do an analysis based on five socio-economic factors contained in the NHS: household income, level of education, labour force status, marital status, and, for First Nations, on- or off-reserve, while for Métis and Inuit, the size of the community in which they lived.

This itself, may be a unique contribution to the knowledge base of research on Indigenous suicide, especially with the large population range covered in this research.

But there were limitations to this too: only individuals 25 and older could be included to accurately analyze the roles of education, labour and marital status. This is a problem, because suicide rates for Indigenous youths and young adults are disproportionately high, and they are not reflected in this part of the report's analysis.

Adjusting for these socio-economic factors found that for the applicable age groups, 78 per cent of the difference in suicide rates disappears when the five factors are controlled for between First Nations and non-Indigenous; for Métis, 37 per cent of the difference disappears; and for Inuit, 40 per cent disappears (and closer to 50 per cent when household income was factored with the northern higher costs of living).

To illustrate what this adjustment means (in statistical terms, 'controlling for' these variables), is that First Nations median income in 2011 was $15,615 compared to $28,239 for non-Indigenous, but this part of the analysis compared the rates of suicide for First Nations and non-Indigenous who have similar incomes (and similarly adjusts for the other four factors), and found rates that were only 22% different. This also implies that for the non-Indigenous population in and of itself, suicide rates are not uniform, but vary corresponding with these socio-economic factors.

Kumar commented on the differing percentages of difference (i.e. the 78, 37, and 40 per cents, respectively) that disappeared for First Nations, Métis, or Inuit: "There are so many other things that are going on ... probably the better answer is that we don't quite understand why there is a difference."

It's also important to note the difference between causation and correlation: this analysis doesn't necessarily mean these factors are the cause of the different suicide rates, but that they are occurring together, which may be indicative of what is behind the problem.

Where to go from here

This analysis indicates that widespread societal imbalances between Indigenous and non-Indigenous populations are a large aspect of the Indigenous suicide crisis. Thus, individual-focused suicide-prevention programs are not a full solution.

That idea is parallel to how the Calls For Justice from the MMIWG inquiry final report do not solely focus on directly stopping murderers or murders, nor say that the murders and disappearances are the genocide itself, but look more to changing the current conditions that result from the continuity of genocidal practices and that cause Indigenous victimization.

Three of the five socio-economic factors - the areas of education, employment and poverty - are included in parts of the MMIWG inquiry Calls For Justice ( pages 170-221), as well as in the " Master List of Report Recommendations" that the inquiry compiled from 100 previous reports they reviewed during their process.

The need for repair, to create equitable conditions and treatment, was also recognized recently when the Canadian government was ordered by the Canadian Human Rights Tribunal to pay $40,000 each to all individual First Nations children and some parents/grandparents who were affected by the government's discriminatory practices in child welfare and service provision, including in the area of suicide-prevention services, as part of an ongoing tribunal case to end discriminatory policies.

The Statistics Canada report findings may help shape future research on Indigenous suicide, "There are lots of questions that probably come up (based on this report), which need to be addressed in future research," Kumar said. "I think it's up to other researchers to come up with questions or what sort of direction other research should go."

Kumar, who previously worked at the National Aboriginal Health Organization, also noted the importance of the involvement of national Indigenous organizations, including Inuit Tapiriit Kanatami, the Métis National Council, and the National Association of Friendship Centres, and their contributions to the research process: it's important that Indigenous peoples do have a leading role in such knowledge production, and in developing approaches to these problems.

​​What people, communities, organizations, and governments do about the continuing suicide crises is crucial. It is a long-term problem that hasn't been adequately addressed, often only appearing in the general public consciousness when a specific community is forced to declare a state of emergency - as God's Lake First Nation, about 1,000 kilometres northwest of Winnipeg, did at the end of August.

International Suicide Awareness Day was marked on Sept. 10, with the annual Celebrate Life event hosted by Inuit at Canada's Parliament Hill and other events across the country. The report's findings will add to these discussions, as well as those at the bi-annual World International Suicide Prevention Conference, being held next Aug. 25-27 in Winnipeg, an opportunity for all working on this problem.

But perhaps the most important part of the report may be its affirmation, with the best quantitative evidence currently available, that there continues to be a crisis and that the approaches used to address it have not been sufficient.

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Canada's Indigenous suicide crisis is worse than we thought

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A Statistics Canada report's central finding - that First Nations people die by suicide at three times the rate of non-Indigenous Canadians, Inuit at nine times the rate, and Métis at two times - illustrates a crisis but is not likely to surprise those familiar with previous statistics.

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The suicide rate among First Nations people was three times higher than in non-Indigenous populations between 2011 and 2016 in Canada, according to Statistics Canada.

The agency reported Friday on the rates of death by suicide for self-identifying First Nations people, Metis and Inuit from 2011 to 2016, compared to non-Indigenous people.

The suicide rate among First Nations people was 24.3 deaths per 100,000 person-years at risk, which StatsCan says is "roughly understood as number of deaths per persons per year." That is compared to eight deaths per 100,000 person-years at risk for non-Indigenous people.

The suicide rate for First Nations people living on a reserve was twice as high than those living off reserve, according to the agency.

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WATCH: Indigenous leader says he's waiting for a national strategy around issue of suicides
Indigenous leader says he's waiting for a national strategy around issue of suicides

For those who self-identify as Metis, their suicide rate was around twice as high as the rate of non-Indigenous people, at 14.7 deaths per 100,000 person-years at risk.

For Inuit, the rate was around nine times higher than non-Indigenous, at 72.3 deaths per 100,000 person-years at risk.

Suicide rates were highest for youth and young adults aged 15 to 24 years old among First Nations men and Inuit men and women.

However, StatsCan did point out that there is a high level of variability for suicide rates "at the community level" for Indigenous people.

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"When examined by First Nations band, just over 60 per cent of bands had a suicide rate of zero," the agency reported.

Statistics Canada says the higher risk of suicide for Indigenous people compared to non-Indigenous is due to "socioeconomic characteristics," such as household income, labour force status, level of education, marital status, as well as whether they live on or off a reserve and the community size.
WATCH: Cape Breton's Eskasoni First Nation experiencing mental health crisis
Cape Breton's Eskasoni First Nation experiencing mental health crisis

"Among First Nations people, 78 per cent of the higher risk of death by suicide was accounted for by these characteristics, while it was 37 per cent among Metis and 40 per cent among Inuit adults aged 25 years and older," the report stated.
If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911 for immediate help. The Canadian Association for Suicide Prevention, Depression Hurts and Kids Help Phone 1-800-668-6868 all offer ways of getting help if you, or someone you know, may be suffering from mental health issues.

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First Nations suicide rate 3 times higher than for non-Indigenous people: StatsCan | Globalnews.ca

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The suicide rate among First Nations people was three times higher than in non-Indigenous populations between 2011 and 2016 in Canada, according to Statistics Canada. The agency reported Friday on the rates of death by suicide for self-identifying First Nations people, Metis and Inuit from 2011 to 2016, compared to non-Indigenous people.

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Mental wellness resources and crisis help for First Nations people, Métis and Inuit
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Acknowledgments

We would like to acknowledge the review of preliminary findings and/or draft versions of the report by Indigenous organizations, including Inuit Tapiriit Kanatami, the Métis National Council, and the National Association of Friendship Centres, and federal departments including Indigenous Services Canada and Crown Indigenous Relations and Northern Affairs Canada. The analysis and the report were greatly strengthened by the suggestions and recommendations provided in the process. We also thank Jodie Golden, Public Health Agency of Canada ( PHAC) for reviewing the draft report for safe messaging.

Abstract

Suicide rates have consistently been shown to be higher among First Nations people, Métis and Inuit in Canada than the rate among non-Indigenous people; however, suicide rates vary by community, Indigenous group, age group and sex. The historical and ongoing impacts of colonization, forced placement of Indigenous children in residential schools in the 19th and 20th centuries, removal of Indigenous children from their families and communities during the "Sixties scoop" and the forced relocation of communities has been well documented. These resulted in the breakdown of families, communities, political and economic structures; loss of language, culture and traditions; exposure to abuse; intergenerational transmission of trauma; and marginalization, which are suggested to be associated with the high rates of suicide. While suicide among Indigenous people has been examined previously, studies were based on a decades-old cohort or used an area-based geozones approach. Past studies also examined suicides among only one or two Indigenous groups using the same methodology. Finally, they did not examine suicide among Indigenous people for some geographies such as on and off reserve, rural areas and small, medium and large population centres.

This article attempts to fill some of these knowledge gaps using the 2011 Canadian Census Health and Environment Cohort (CanCHEC), resulting from a record integration between the 2011 National Household Survey (NHS) and the Canadian Vital Statistics Database (CVSD). It presents suicide rates for the 2011 to 2016 time period among self-identifying First Nations, Métis, Inuit, and non-Indigenous people in private dwellings in Canada. It also explores the influence of socioeconomic factors in the disparity in risk of suicide between First Nations people, Métis, Inuit and non-Indigenous people in Canada.

Suicide rates among First Nations people, Métis and Inuit were significantly higher than the rate among non-Indigenous people. The rate among First Nations people (24.3 deaths per 100,000 person-years at risk) was three times higher than the rate among non-Indigenous people (8.0 deaths per 100,000 person-years at risk). Among First Nations people living on reserve, the rate was about twice as high as that among those living off reserve. However, suicide rates varied by First Nations band, with just over 60% of bands having a zero suicide rate. The rate among Métis (14.7 Note E: Use with caution deaths per 100,000 person-years at risk) was approximately twice as high as the rate among non-Indigenous people. Among Inuit, the rate was approximately nine times higher than the non-Indigenous rate (72.3 versus 8.0 deaths per 100,000 person-years at risk). Suicide rates and disparities were highest in youth and young adults (15 to 24 years) among First Nations males and Inuit male and females.

Socioeconomic factors, including household income, labour force status, level of education, marital status and geographic factors such as living on or off reserve (First Nations people) and community size (Inuit) accounted for a notable proportion of the disparity in risk of death by suicide among First Nations people (78%), Métis (37%) and Inuit (40%) adults, 25 years or older. However, due to limitations of the data, the role of other previously-identified factors such as historical and intergenerational trauma, community distress, cultural continuity, family strength and mental wellness were not explored here.

The findings from this study could contribute further to the understanding of suicide among First Nations people, Métis and Inuit in Canada, particularly with respect to the variability in suicide rates and socioeconomic factors associated with the disparity in suicide risk.

Introduction

First Nations people living on and off reserve, Métis and Inuit, die by suicide at a higher rate than non-Indigenous people. These suicides not only result in loss to family, friends and peers leading to immense grief and bereavement, but also to the community and society at large, in particular when the deceased is a young person. The impact of suicide is more widespread and severe in small Indigenous communities where many people are related and many experience similar personal and collective adversity.

The suicide rate for children and youth was previously reported to be 10 times higher among males and 22 times higher among females between 2005 and 2007 in areas with a high percentage of First Nations people compared with low-percentage areas. In Inuit Nunangat, the Inuit homeland made up of the Inuvialuit Region (northwest part of Northwest Territories), Nunavut, Nunavik (Northern Québec), and Nunatsiavut (Northern Labrador), the suicide rate among children and youth was 33 times higher than for the rest of Canada between 2004 and 2008. In fact, suicide is one of the leading causes of death among children and youth in areas with a high proportion of First Nations people and in Inuit Nunangat.

In adults, the suicide rates (1991 to 2006) among First Nations people and Métis have been reported to be twice as high as that among non-Indigenous adults. The suicide rate among adults in Inuit Nunangat (1999 to 2003) was four times higher than the rate among all adults in Canada; the disparity was greater among men than women.

It is important to note, however, that national level suicide rates may underestimate regional or community level differences. For example, previous reports have shown that suicide rates among First Nations youth in British Columbia range from 0 to 633 deaths per 100,000 people by tribal council. In fact, the majority of these tribal councils had a zero or very low suicide rate. A similar regional variance has been seen among Inuit communities in Nunavut. The suicide rate varied from under 50 deaths per 100,000 in Whale Cove to just over 250 deaths per 100,000 people in Qikiqtarjuaq.

Several representatives of Indigenous peoples and governments, communities and government agencies have developed programs, policies or strategies to address the high suicide rate among First Nations people, Inuit and Métis. Development and evaluation of these require timely data on suicide rates. Many existing estimates of suicide rates are based on an older cohort (1991 Census cohort), which excluded non-tax filers and those under 25, or are from studies that used an area-based geozones approach. The latter classified areas with higher proportions of First Nations residents as First Nations "identity areas" or examined mortality rate in Inuit Nunangat as a proxy for the rate among Inuit. These approaches may have led to under or over estimation of suicide rates. In addition, past reports have only estimated suicide rates among one or two Indigenous groups using the same methodology. Finally, there are gaps in knowledge of suicide rates among Indigenous people for certain geographical areas, including urban areas and on or off reserve.

This article presents suicide rates among self-identifying First Nations, Métis, Inuit and non-Indigenous peoples, who lived in private dwellings (i.e., excluding those who were in collective dwellings and institutions), for the 2011 to 2016 time period. These findings are based on the 2011 Canadian Census Health and Environment Cohort (CanCHEC), which was developed by integrating records in the the 2011 National Household Survey (NHS) and the Canadian Vital Statistics - Deaths Database (CSVD from 2011 to 2016). Suicides that occurred over the follow up period of 5.63 years (from Census day on May 10, 2011 to end of follow-up on December 31, 2016) were used to generate age-standardized and age-specific mortality rates. These are presented as estimated number of deaths by suicide per 100,000 person-years at risk. The person-year concept is often used in cohort studies and represents unit of time when individuals are at risk of dying, and can be roughly understood as persons per year. Specifically, the article (1) presents suicide rates among First Nations people, Métis and Inuit alongside comparisons with the suicide rates of non-Indigenous people to explore disparities, a better understading of which could inform prevention strategies, (2) presents the estimated proportion of First Nations bands that experienced no suicides as an estimate of the variability in suicide rates, and (3) explores the role of socioeconomic and geographic factors in explaining the excess mortality from suicide among the three groups.

Results

Suicide among First Nations people in Canada

In the current analyses, among the 851,280 First Nations people (based on population estimates using the 2011 CanCHEC and its weights), including status and non-status individuals, living on and off reserve and in private dwellings in 2011, an estimated 1,180 people died by suicide between 2011 and 2016. This resulted in an age-standardized suicide rate of 24.3 deaths per 100,000 person-years at risk (Table 1), which was three times higher than the suicide rate among non-Indigenous people (8.0). The suicide rate was higher among males than females (29.6 versus 19.5, respectively). This pattern is similar to that seen among non-Indigenous people among whom males (12.3) also had a higher suicide rate than females (3.9). However, these numbers indicate that the disparity in suicide rates - measured by dividing the suicide rate among First Nations people by that among non-Indigenous people (or rate ratios [ RR]) - between First Nations and non-Indigenous peoples is higher among females than males (RR = 5.0 among First Nations females and RR = 2.4 among First Nations males; Table 1).

﻿

Suicide rates were highest among youth aged 15 to 24 (48.7; non age-standardized) (data not shown) when compared with other age groups. Suicide rates were lower among the older age groups. They were significantly higher among First Nations people than non-Indigenous people in most age groups under 45 years of age, but the disparities were widest among those under 15 years ( RR = 8.9) and 15 to 24 years ( RR = 6.3) (data not shown). This was particularly apparent among females between 15 and 24 years of age ( RR = 12.0; Table A.1 in appendix).

The suicide rate was nearly twice as high among First Nations people living on reserve than among First Nations people living off reserve (non age-standardized rate of 34.1 versus 19.5, respectively). Among on-reserve First Nations people, suicide rates were highest for males aged 15 to 24 years (78.8) (Chart 1). Rates were lower in the older age groups among both males and females on reserve (Table A.2 in appendix). Disparities were particularly elevated among 15 to 24-year-old First Nations females living on reserve ( RR = 15.8) in comparison to non-Indigenous females across Canada. Disparities were smaller in the older age groups, but continued to be seen until age 55 for females and age 45 for males. For those aged 55 and older, suicide rates were not statistically different between on-reserve First Nations and non-Indigenous people. A similar comparison to rates among First Nations people living off reserve was not done since most age-specific estimates were not published due to low cell counts or precision (table A.2 in appendix).

No significant differences were seen in the suicide rates among First Nations people (on and off reserve combined) by province and territory. However, in every province, the suicide rate among First Nations people was higher than the non-Indigenous rate (Atlantic provinces were grouped together to increase sample size; suicide rates were not reportable for the non-Indigenous population in Yukon, Northwest Territories and Nunavut). And, the rate ratios were notably higher in the Prairie provinces. It was 4.6, 4.5 and 3.5 in Manitoba, Saskatchewan and Alberta, respectively. In other provinces, it ranged from 1.9 to 2.6. Suicide rates did not differ significantly by type of population centre. It was 28.8 among First Nations people in rural areas, 22.9 Note E: Use with caution among those in small population centres and 18.8 Note E: Use with caution among those in large population centres. The suicide rate among First Nations people in each of these areas was significantly higher compared with non-Indigenous rates (9.3 for rural areas, 9.0 for small population centres and 7.2 for large population centres).

These national and provincial level estimates, while useful, underestimate the variability in the suicide rates among individual First Nations communities. Suicide rates were estimated at the band level using a geographic approach (for more details, please refer to the methods section). Of the just over 600 First Nations bands in Canada, 555 were associated with reserves that were enumerated in the 2011 NHS and with individuals in the CanCHEC cohort. Just over 60% of First Nations bands had experienced no suicides between 2011 and 2016. The proportion of bands without suicides, when examined in the context of the overall on-reserve suicide rate among First Nations people (34.1) highlights the obscuring of variability in the national level estimate. This proportion of bands with zero suicide rate varied by province and territory. A larger proportion of bands in the Atlantic provinces (55%), Ontario (71%), Saskatchewan (53%), British Columbia (78%), Yukon (80%) and Northwest Territories (74%) had zero suicide rates. In the other provinces, the proportion ranged from 39% to 44%. It should be noted that 31 reserves were incompletely enumerated in the 2011 Census many of which were in Ontario and Québec (a brief description of these reserves can be found in the methods section), and were not included in this analysis. Also, band members who did not live on their band's reserve at the time of the Census were not included in the analysis.

Socioeconomic factors have previously been shown to be associated with suicide among Indigenous people in North America. To examine if similar patterns were evident in the 2011 CanCHEC cohort, the role of individual socioeconomic factors such as household income, labour force status, level of education, marital status and geographic factors such as living on or off reserve on risk of death by suicide were examined for First Nations people aged 25 years or older. After adjusting for age and sex, the risk of suicide among First Nations adults was twice as high as that among non-Indigenous adults (hazard ratio [HR] = 2.0; Table A.4 in appendix). Adjusting for household income resulted in a decrease in risk by 35%. After further adjusting for labour force status, level of education and marital status, First Nations adults were still at a higher risk of suicide than non-Indigenous adults ( HR = 1.4). Together, these factors accounted for 66% of the excess suicide risk. Further adjusting for living on and off reserve resulted in a HR of 1.2, which was not significantly different from 1.0. Together, all these factors accounted for 78% of the excess suicide risk among First Nations adults.

Suicide among Métis in Canada

Based on the current analysis, of the 452,985 self-identifying Métis (based on population estimates using the 2011 CanCHEC and its weights) who lived in private households in 2011, approximately 415 individuals died by suicide in the 2011 to 2016 period. As a result, the suicide rate was 14.7 Note E: Use with caution deaths per 100,000 person-years at risk (Table 2), which was nearly twice as high as the rate among non-Indigenous people (8.0). The rate among Métis males (22.6 Note E: Use with caution ) was more than three times higher than the rate among Métis females (7.2 Note E: Use with caution ). The suicide rate was nearly twice as high among Métis (22.6 Note E: Use with caution ) as non-Indigenous males (12.3). However, the suicide rates for Métis (7.2 Note E: Use with caution ) and non-Indigenous females (3.9) were not significantly different from each other.

﻿

Among the provinces and territories, because of low counts when broken down, suicide rates for Métis could only be generated for Ontario, Manitoba, Saskatchewan, Alberta and British Columbia combined (Ontario and west). In these provinces, the rate among Métis (13.4 Note E: Use with caution ) were higher than that among non-Indigenous people (7.6). Suicide rates among Métis in rural (16.5 Note E: Use with caution ), small (12.8 Note E: Use with caution ) and large population centres (15.5 Note E: Use with caution ) were not significantly different. The rate among Métis in large population centres was higher than the rate among non-Indigenous people (7.2; marginally significant). Suicide rates could not be published for medium population centres due to low cell counts.

Among Métis adults over 25, after adjusting for age and sex, the risk of suicide was twice as high as that among non-Indigenous adults (hazard ratio = 1.9; Table A.4 in appendix). Adjusting for household income, labour force status, population centre type of place of residence, level of education and marital status accounted for 37% of excess suicide risk. The risk of suicide was 1.6 times higher among Métis than non-Indigenous people after adjusting for these factors.

Suicide among Inuit in Canada

There were approximately 59,220 Inuit in Canada in 2011 who lived in private households (based on population estimates using the 2011 CanCHEC and its weights). Among them, there were an estimated 250 deaths by suicide between 2011 and 2016. This lead to a suicide rate of 72.3 deaths per 100,000 person-years at risk (Table 3). This was nine times higher ( RR = 9.0) than the suicide rate among non-Indigenous people (8.0). The suicide rate was three times higher among Inuit males than Inuit females (109.3 versus 35.4 Note E: Use with caution , respectively).

﻿

Suicide rates among Inuit were highest in youth; the highest suicide rate was seen among Inuit males between 15 and 24 years of age (363.2; non age-standardized) living in Inuit Nunangat (Chart 2). Publishable estimates could only be produced for Inuit females between the ages of 15 and 24 and 25 to 34. Suicide rate among females 15 to 24 years of age was 108.9 Note E: Use with caution , which was 33 times higher than non-Indigenous females of that age (Table A.3 in appendix).

Rates among Inuit were also compared by Inuit Nunangat region. Rates were significantly higher among Inuit in Nunatsiavut (188.2 Note E: Use with caution ; non age-standardized) than those in Nunavik (98.1) and Nunavut (94.0). Rates among Inuit in Inuvialuit region could not be published due to low reliability of estimates.

The national, Inuit Nunangat and Inuit regional level estimates underestimate the variation in rates among individual Inuit communities. Among the 50 Inuit communities, 11 communities had a suicide rate of zero. However, for most communities (66%), estimates were too unreliable to be published. It should be noted that some deaths may not have linked to the NHS and others may not have been in Vital Statistics at the time of data integration. The latter shortcoming has previously been reported by Jack Hicks. These exclusions may have biased the estimate of number of communities without suicides.

In multivariate analyses, among Inuit adults 25 years and older, the risk of death by suicide was 4.8 times higher than the risk among non-Indigenous adults, after accounting for age and sex (Table A.4 in appendix). After further adjusting for household income, labour force status, level of education and marital status, the hazard ratio decreased to 3.4 suggesting that these factors accounted for 37% of the excess risk of death by suicide among Inuit. After adjusting for size of community (population centre type), Inuit adults were still at 3.3 times higher risk of suicide than non-Indigenous adults ( HR = 3.3). All combined, these factors accounted for 40% of the excess risk of suicide among Inuit adults.

Discussion

The report is the first to examine suicide rates among all three Indigenous peoples, including First Nations people, Métis and Inuit, of different age groups and living in different geographies using one methodology. However, gaps in knowledge remain. Further research is needed to assess long-term trends and estimate the role of other risk and protective factors of suicide among Indigenous peoples, which should be done in consultation with First Nations people, Métis and Inuit, as recommended by the Truth and Reconciliation Commission of Canada.

In the current analysis, the suicide rates among First Nations people, Métis and Inuit were many times higher than the non-Indigenous rate during the 2011 to 2016 time period. The rates were highest among Inuit and, specifically, adolescents and young adults. The suicide rate among First Nations people living on reserve was higher than that among those living off reserve, and among males than females. The higher suicide rate among males has been attributed to their tendency to use more lethal methods and to the differential effect of specific stressors in the two sexes. However, greater disparities were observed among First Nations females, where higher suicide rates were seen when compared with non-Indigenous females. These patterns are similar to what has been previously reported.

Of particular concern is the high rate of suicide among Indigenous children under 15. The suicide rate among First Nations boys, nationally, was four times higher than among non-Indigenous boys. It was ten times higher among First Nations boys living on reserve. As with other national trends, this rate may obscure regional differences. Previously reports have suggested that in some remote First Nations communities in Ontario, under-15 suicide rates were nearly 50 times higher than non-Indigenous rates. And, among Inuit communities of Nunatsiavut, the age-specific disparity was largest among 10 to 19-year-olds relative to their non-Indigenous counterparts outside Inuit Nunangat ( RR = 15.8). Also, rate of death by suicide among Inuit children 10 to 14 years of age appears to be increasing since 1989 although significant fluctuations are seen across time. In line with these rates among children, suicidal ideation among grade 5 to 8 school children in Saskatoon was nearly twice as high among Indigenous children as non-Indigenous children after accounting for mental health, cognitive abilities and bullying experiences. While risk factors for suicide among children are numerous and complex, a recent report suggests that Inuit children and youth in Nunavut experience a lack of mental health services that are specific to them, culturally relevant and of adequate quality.

And, while time trends were not examined here, suicide attempts among First Nations people in British Columbia have been reported elsewhere to be declining. Risk of self-inflicted injury hospitalization among Registered Indians, and disparity between them and their non-Indigenous counterparts decreased between 1991 to 2010. However, this is in contrast to trends in remote First Nations communities in Ontario. There, Indigenous youth suicide was previously reported to be on the rise because of the emergence of suicide among communities that previously did not experience it, exposure to suicide or suicide attempts among family members and peers, and increase in clusters of suicides.

Methods

Data

The 2011 Canadian Census Health and Environment Cohort (CanCHEC) used here is a population-based integrated dataset that follows the non-institutional (household) population enumerated in the 2011 National Household Survey (NHS) for different health outcomes such as mortality, cancer, and hospitalizations. Briefly, record integration for the 2011 CanCHEC was carried out using Statistics Canada's Social Data Linkage Environment (SDLE). The SDLE helps create linked population data files for social analysis through integration to the Derived Record Depository (DRD), a dynamic relational database containing only basic personal identifiers. Survey and administrative data are linked to the DRD using a generalized record integration software that supports deterministic and probabilistic integration.

The NHS is a voluntary survey, conducted in May 2011, of approximately 4.5 million (30%) private dwellings randomly selected from the 2011 Census of Population. The NHS covers all persons who usually live in Canada, including permanent and non-permanent residents, and individuals living on First Nations reserves, Métis settlements or Inuit communities. There were 36 incompletely enumerated First Nations reserves in the 2011 NHS. In 13 of these communities, enumeration was delayed because of forest fires in Northern Ontario and occurred at a later date. The NHS excludes residents of institutions (for example, hospitals, nursing homes, penitentiaries) and collective dwellings (for example, work camps, hotels, shelters).

Records for approximately 6.7 million NHS respondents were eligible for integration; 97% linked to the DRD using a probabilistic approach based on telephone number, surnames, given names, birthdate, and place of residence. No differences in integration rates were found by collection mode, province, sex, or birth decade. To ensure representativeness of the linked cohort, weights were calculated to adjust for non-integration.

To protect the confidentiality of Census respondents, data made available for analysis did not contain personal identifiers such as name, and address. In addition, estimates based on small cell counts (fewer than five deaths or fewer than 10 total individuals) were suppressed.

Variables

Self-reported Indigenous identity, age, sex, household income, labour force status, highest level of education, marital status and province of residence variables were available in the 2011 NHS dissemination dataset. Variables for the Inuit Nunangat regions were generated using Standard Geographical Classification (SGC) codes. Similarly, a variable for on and off-reserve areas of residence was generated using SGC. A binary suicide variable was created using ICD-10 codes in the "Underlying cause of death" variable in the CVSD. Generation of suicide and person-years at risk variables are described in the following section.

Estimation of weighted suicide rates

For suicide rate estimates, each person's time at risk of death by suicide was split into single years of follow-up, and within each year of follow-up, into durations before and after birth date. In the process, each person was aged on his or her birthday. This allows for the appropriate categorization into age groups for computing suicide rates. Weighted age-standardized suicide rates (ASMRs) (see figure 1 for a brief description of this measure) and their 95% confidence intervals were estimated. Those under the age of one were excluded from the analysis due to under-representation of this group in the integrated dataset. Briefly, ASMRs were computed by dividing the count of cohort members who died by suicide in the follow-up period by the total person-years at risk. Age standardization was done with age-specific mortality rates in 5-year age groups using the 2011 total Indigenous population as the reference population. Weighted age-specific suicide rates generated without age standardization were used for comparisons between age groups within an Indigenous group or between an Indigenous group and the non-Indigenous population. These rates were also used to compare suicide rates in the on and off-reserve First Nations populations since their age structures were somewhat similar in 2011 (median age: 23.9 and 27.1 years, respectively). Suicides were identified using the following International Statistical Classification of Diseases and Related Health Problems 10th Revisions ( ICD-10) codes: X60-X84, Y87.0. For each member of the cohort, person-years of follow-up were calculated as the number of days from the beginning of the study period to the date of death or end of study divided by 365.25. Variance was calculated using 500 bootstrap weights.

Description for Figure 1
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Figure 1 is a schematic showing the method used to estimate the suicide rate using number of deaths as the numerator and person-years as the denominator. The schematic illustrates a hypothetical example with seven individuals who were "followed" from May 10, 2011 (Census day) to December 31, 2016 (end of follow-up period) to see if they had died. In this example, three of the seven individuals died during follow-up. Person 1, 4 and 7, who died during the follow-up period, each contributed 3.0, 1.5 and 4.2 person-years at risk, respectively, to the denominator. The others, who were alive as of December 31, 2016, each contributed 5.6 person-years to the denominator. In all, the seven individuals contributed 31.1 person-years to the denominator. The crude mortality rate is calculated by dividing the number of deaths by the total person-years contributed by the seven individuals, and multiplied by 100,000. In this hypothetical example, the crude suicide-related mortality rate is 9,646.3 deaths per 100,000 person-years of follow-up.

Age-standardized and age-specific suicide rates, expressed as the number of deaths by suicide per 100,000 person-years at risk, were generated by sex, Indigenous identity and select geographic areas. Indigenous identity, as self-reported in the 2011 NHS Survey, included: First Nations, Métis, Inuit, Multiple Indigenous identity, Indigenous identity responses not indicated elsewhere and non-Indigenous. However, in this paper, only estimates for single identity groups are presented. Geographic areas studied include: province/territory; on or off-reserve; rural areas or small, medium and large population centres, and for Inuit, inside/outside Inuit Nunangat and by the four regions of Inuit Nunangat (Nunatsiavut, Nunavik, Nunavut, and the Inuvialuit region), as well as outside Inuit Nunangat. Rate ratios, or the ratio of suicide rate among First Nations people, Métis or Inuit over suicide rate among non-Indigenous people were computed to examine the magnitude of disparity in the Indigenous group compared to the non-Indigenous population. To estimate variance of the rate ratios, variance and covariance of the mortality rates in the Indigenous group of interest and non-Indigenous population were estimated using PROC RATIO in SAS-callable SUDAAN. Variance of the rate ratios was then computed using Taylor linearization and the variance and covariance estimates from PROC RATIO, and used in generating 95% confidence intervals.

Hypothesis testing was done to identify suicide rates that were significantly different from one another using p<0.05. The weighted number of suicides and suicide rates were not published if (1) the unweighted number of suicides in a cell was less than five, (2) the weighted population count in the cell were less than 10, or (3) coefficient of variance (CV) was greater than 33.3% (40% for those under 15 years). Weighted numbers of suicides were also randomly rounded to base five. ASMRs with CV greater than 16.6% and less than or equal to 33.3% are presented with an "E" to indicate that these should be used with caution.

Estimation of suicide rate by First Nations band

For estimating suicide rates by First Nations band, reserve CSDs associated with each band were grouped. Reserves that were shared by multiple bands were grouped separately. This was done for seven reserves. Three of these had a population of 10 or less. And, one was incompletely enumerated in the 2011 NHS. This grouping resulted in about 600 First Nations bands. Of these, 561 included individuals that were in the 2011 CanCHEC. Others were associated with reserves that were incompletely enumerated in the 2011 NHS or had participated in the 2011 Census and not the NHS. In the end, 555 bands were included in the analysis. Suicide rates were computed by First Nations band, from which the number and percentage of bands with a reportable zero suicide rate were identified. The percentage of bands with a zero suicide rate were calculated with and without the reserves that were associated with multiple bands and were found to be similar.

Multivariate analysis

To examine the role of socioeconomic and geographic factors in the excess risk of suicide among Indigenous people relative to non-Indigenous people, Cox proportional hazards modelling was performed. Analyses were restricted to those 25 years and older to allow for the use of labour force status, level of education and marital status as covariates. For this analysis, age at baseline on Census day, was used since other covariates also had the same reference period. Hazard ratios for suicide were estimated among First Nations people, Métis and Inuit (with non-Indigenous people as the reference group). Covariates were entered sequentially into the model in this order: age group together with sex, household income quintile (based on after-tax income adjusted for economic family size), labour force status (employed, unemployed and not in the labour force), highest level of education (less than high school, high school, post-secondary education below Bachelor's level and university degree), marital status (never legally married or single, legally married and not separated, separated but still legally married, divorced or widowed) and living on or off reserve (for First Nations people) or in population centres or rural areas (for Métis and Inuit). Household income quintiles were generated for each province and territory separately to account for regional differences. In secondary analysis, household income was used as a continuous variable or household income quintiles were generated at the national level and used in place of the original income quintile variable to examine the robustness of the influence of this predictor on the relative risk of death by suicide among First Nations people, Métis and Inuit. Covariates were chosen based on previous literature on the relationship between socioeconomic factors and suicide. and the availability of related variables in the 2011 NHS data.

From the hazard ratios (age and sex-adjusted and additionally adjusted for socioeconomic factors), the percent of excess risk of suicide among First Nations, Métis and Inuit people accounted for by household income, labour force status, highest level of education, marital status and geography was computed. The proportion of excess mortality explained was calculated as the difference between the age and sex-adjusted and the final hazard ratios, divided by the former minus 1. Analyses were not carried out separately by sex due to sample size limitations.

Assessing validity of suicide rates

Suicide rates based on the linked 2011 CanCHEC cohort were compared with previously generated estimates using different methodologies to assess validity.

The non age-standardized suicide rate for the total population of Canada between 2009 and 2013 was previously estimated to be 11.4 deaths per 100,000 people; in comparison, in the CanCHEC cohort, the overall suicide rate was 10.5 deaths per 100,000 person years between 2011 and 2016. While there are no published rates of suicide for First Nations people, Métis and Inuit for the 2011 to 2016 period, suicide rates for all individuals in Inuit Nunangat, which is home to 73% of Inuit in Canada, was previously estimated to be 83.5 deaths per 100,000 people. In the 2011 CanCHEC cohort, the rate was 83.5 deaths per 100,000 person years at risk. However, the estimates by Inuit Nunangat region between 2011 and 2016 (167.3 Note E: Use with caution in Nunatsiavut, 87.5 in Nunavik and 83.1 in Nunavut) were somewhat different in comparison to previous estimates from the 2009 to 2013 period (185.4, 98.3, 79.0, respectively). While, the estimates are similar, there are several potential reasons for this discrepancy between the two sets of estimates. While there is some overlap in time periods for the two estimates (2009 to 2013 for previous estimates and 2011 to 2016 for the estimates in this report), they are not identical. There is some year-to-year fluctuation in suicides rates. For example, in Nunavut, previous estimates suggest that the rate ranged from 58.2 to 108.5 deaths per 100,000 people. Some deaths that occurred between 2011 and 2016 were not linked to the 2011 NHS. Also, the CanCHEC cohort excludes institutional population (e.g., nursing homes, jails), and those living in collective dwellings (e.g., motels, hotels, rooming houses) at the time of census collection and those that were not enumerated by the 2011 NHS. The denominators used in the two studies are also different; in the previously published tables, the suicide rates are per 100,000 people; in the current study, the rates are per 100,000 person years.

Limitations

Several limitations of the analysis should be noted. Suicide rates presented in this article may underestimate the true rates because of (1) exclusion of the institutional population and population living in collective dwelling, (2) exclusion of persons not enumerated by the 2011 NHS including the homeless among whom Indigenous people are overrepresented, (3) non-integration of some deaths between 2011 and 2016 to the 2011 NHS, (4) potential integration error, (5) potential misclassification of suicides in the CVSD to avoid stigmatization or as a result of misclassification as an accident, or inability in ascribing a cause, etc., and (6) potentially missing deaths, due to processing delays, in Vital Statistics at the time of data integration. Furthermore, Indigenous identity in the Census is self-reported, which may have led to underestimation or overestimation of suicide rates in some Indigenous groups. Also, 36 Indian reserves and Indian settlements were incompletely enumerated in the 2011 NHS, which could have resulted in under or over-estimation of suicide rates. Most (29) of these reserves were in Québec and Ontario, with the rest in Saskatchewan, Alberta and British Columbia. Among the ones in Québec and Ontario, some are proximal to Census Metropolitan Areas (CMA) while others were rural or remote. The former includes Kahnawake, Kanesatake and Wendake. Mortality rates for small areas and small subgroups of the population may experience substantial year-to-year random fluctuations since death is a relatively rare event, particularly death by suicide. Finally, baseline socioeconomic and demographic factors used in the multivariate analysis may not reflect conditions at the time of death. This may have led to some biases in the findings.

Appendix

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# data[].attributes.attachment_link.title
Suicide among First Nations people, Métis and Inuit (2011-2016): Findings from the 2011 Canadian Census Health and Environment Cohort (CanCHEC)

# data[].attributes.attachment_link.description
The article presents suicide rates for the 2011-2016 time period among self-identifying First Nations, Métis, Inuit, and non-Indigenous people in private dwellings in Canada. It also explores the influence of socioeconomic factors in the disparity in risk of suicide between First Nations people, Métis, Inuit and non-Indigenous people in Canada.