HEALTH ISSUES IN
Political and Social Affairs Division
AVAILABILITY AND ACCESS
A. Distribution of Physicians
B. Distribution of Other Health-Care
C. Distribution of Health Care
D. Under-Servicing of Health-Related
E. Under-Servicing of Special Needs
4. Disabled Persons
6. Elderly People
HEALTH NEEDS IN SELECTED RURAL REGIONS
B. People of Aboriginal Original
C. Maritime Fishermen
HEALTH ISSUES IN RURAL CANADA
Canada, the organization and delivery of hospital and medical services
falls to the provinces and territories, each of which administers its
own hospital and health insurance plan. The federal government, however,
also plays an important role by conditionally granting the provinces a
portion of the costs of medical care. To qualify for this grant under
the Established Programs Financing Formula, the provinces' health insurance
programs must be universal, comprehensive, accessible, portable, and publicly
concept of "health" has been evolving over recent decades in
Canada. Before the mid-seventies, "health" largely meant freedom
from disease; more recently it has taken on a broader and more comprehensive
meaning. According to the Constitution of the World Health Organization
(WHO), health is "a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity. It is the
extent to which an individual or group is able, on the one hand, to realize
aspirations and satisfy human needs and, on the other hand, to change
or cope with the environment."(1) In Canada the Lalonde and Epp
reports of 1974 and 1986 broadened the concept of health to include health
promotion. Health promotion, a "process of enabling people to increase
control over, and to improve, their health,"(2)
focuses on the total environment of the population. From this perspective,
health is no longer measured simply in terms of illness and death but
a state which individuals and communities alike strive to achieve,
maintain or regain, and not something that comes about merely
as a result of treating and curing illness and injuries. It is
a basic dynamic force in our daily lives, influenced by our circumstances,
our beliefs, our culture and our social, economic and physical
health status is determined by a combination of factors, such as age,
gender, race, lifestyle, heredity, income, housing, and type of employment.
In Canada, geographic location (urban/rural) can be shown to be one important
factor affecting the quality of health care. Although all residents of
Canada theoretically have equal access to services under the Canada
Health Act, it has become apparent that there are regions in Canada,
mainly rural and northern regions, that are medically underserviced, and
lacking in social services.(4)
term "rural life" tends to evoke images of fresh air, natural
foods, and robust, healthy people, who are often contrasted with stressed,
unhealthy urbanites. In fact, studies suggest that rural residents on
average have shorter life expectancies and lead less healthy lives than
do residents of large urban centres.(5) Moreover, statistics indicate that rural residents
over the age of 15 are more likely to suffer from long-term disabilities
than their urban counterparts.(6)
This can be only partly explained by the greater number of elderly people
in rural areas. Various aspects of rural life influence health status.
paper examines two important issues. The first is the availability of
and access to good quality health care in rural areas, paying particular
attention to needs of women, children, youth, disabled persons, immigrants
and elderly people. The second is the health problems unique to certain
groups in specified rural areas: farmers on the prairies, Indians and
Metis on reserves, and fishermen in single-industry towns in the Maritimes.
has gradually evolved from being a rural to a largely urban society with
almost 70% of the current population living in urban centres. Although
almost 32% of the overall Canadian population lives in rural regions(7)
there are major regional variations in rural-urban distribution as illustrated
in Table 1. In The Northwest Territories and Atlantic Canada, for example,
at least 45% of the population live in rural areas,(8)
as do almost half of the population of Saskatchewan.
RURAL POPULATION DISTRIBUTION IN CANADA
AND THE PROVINCES AND TERRITORIES, 1991
Source: Statistics Canada, Census 1991, Urban Areas
Population and Dwelling Counts. Cat. No. 93-305, Ministry of Industry,
Science & Technology, 1992.
challenge of providing good quality health care close to home in
a country as vast and sparsely populated as Canada is not new; Stories
about the country doctor travelling miles on foot in a snow storm to save
a patient's life are part of our folk culture. In spite of major scientific
advancements and a health insurance system that has been developed over
the past 50 years, the challenge remains.(9)
A number of factors impede the availability of, and access to, good quality
care for rural residents.
Distribution of Physicians
uneven rural-urban distribution of physicians has been at the centre of
discussion for a number of years.(10)
Recently, the Canadian Medical Association (CMA) struck an advisory panel
that examined the deficiencies in the provision of medical services in
rural and medium-sized communities in Canada and proposed strategies to
help correct them.(11) The
panel found that approximately 10% of all physicians in Canada in 1986
practised in rural areas (with populations of less than 10,000), where
slightly less than 25% of the Canadian population resided. When the data
were broken down between family physicians general practitioners and specialists,
it was clear that specialists were even more under-represented in rural
regions encounter difficulties in recruiting and retaining physicians.(13) The decision to enter rural practice has
both personal and professional dimensions. Physicians most interested
in working in rural areas often come from rural backgrounds and are committed
to working in this environment. Physicians' decisions to leave rural practice
are usually influenced by non-monetary factors, such as a shortage of
professional back-up, long hours of work, limited opportunities for further
medical training, insufficient job opportunities for partners, and concerns
over children's educational opportunities. Levels of satisfaction with
rural work appear to rise with proximity to large urban centres.(14)
Incentives to encourage and retain physicians in rural regions have been
implemented by most provinces and new strategies are currently being discussed
by the CMA.(15)
suggestion for dealing with the shortage of rural physicians is to make
rural health a more important part of the curriculum in medical schools
across Canada. The CMA argues that "the education of physicians for
rural practice deserves special attention to ensure adequacy and appropriateness
of learning experiences to meet the unique needs of rural Canada."(16)
specialists are clearly under-represented in rural areas with, according
to the CMA advisory panel, only 5% of the total number of Canadian specialists
practising there.(17) In Ontario, only 2.5% of specialists
practise in rural communities.(18)
This situation is expected to become worse in the next 20 years, when
two-thirds of retiring physicians will be specialists and one-third family
physicians/general practitioners.(19) This shortage of specialists
will undoubtedly have an impact on the rural community.
medical specialties are more commonly found in rural areas than others;
the CMA advisory panel noted, for example, that general surgeons were
the most common and pediatricians the least common.
Percentage of Medical Specialties
Practising in Rural Regions
|medical and surgical
Canadian Medical Association. Report of the Advisory Panel on the Provision
of Medical Services in Underserviced Regions. March 1992. p. 15.
Distribution of Other Health-Care Professionals
the distribution of physicians appears to be the aspect of rural health
most commonly discussed in the literature, the availability of and access
to, other health care professionals are also of concern. The Saskatchewan
Commission on Directions in Health Care, for example, found that there
is a serious shortage of psychiatric nurses, physical and occupational
therapists, and speech and language pathologists in rural areas of that
has been a movement, particularly in the United States, to hire nurse
practitioners to help overcome the problem of inaccessible and fragmented
health-care services in isolated, rural and under-served areas, but this
has not proved to answer all the needs of rural regions.(21)
of Health Care Facilities
distribution of hospital services reflects the uneven supply of medical
personnel. A major problem for people in rural regions is the distance
they have to travel to reach medical facilities. As well as adding to
the discomfort of the ill person, travelling requires time and money.
In many small rural communities there are no hospitals and, though the
larger rural centres may have hospitals with basic facilities, patients
have to be transported to larger urban centres for specialized treatment.
In Ontario, for example, larger rural communities have hospitals that
provide essential services such as 24-hour emergency care, obstetrics,
anaesthesia, and general surgery. Smaller hospitals may provide surgery
and obstetric services but these provisions are dependent on anaesthetists,
who are often difficult to recruit to rural areas.(22)
large urban centres, rural areas offer a limited choice of hospitals.
This can become an issue if a hospital has made a decision not to provide
certain services. In some provinces, for example, hospitals are operated
by religious orders that do not provide abortion services and people seeking
these services must travel to other centres.
of Health-Related Services
important aspect of health promotion in Canada is the creation of the
The environment consists of "the buildings where we live, the air
we breathe and the jobs we do, as well as the education, transportation
and health systems."(24) Fully addressing the disparities in rural
health within the context of the healthy environment involves going beyond
medical care to include issues of poverty, unemployment, environmental
health, workplace health and safety, child care facilities, and quality
provision of social services, education, and job training influence people's
quality of life, and ultimately their health. Rural communities often
lack the services of counsellors, therapists, social workers, and child
care workers. This problem is exacerbated by a lack of information and
support in a number of areas such as sex education for children and youth,
information on the adverse effects of drugs, alcohol and smoking, education
about childbirth, breastfeeding and infant care, healthy eating, parenting,
and the prevention of violence in the home.
of Special Needs Groups
people have needs for special services in addition to basic health care.
These needs, which can be acute (emergencies) or long-term (chronic diseases),
are often not easily met in rural environments. Six categories of people
with unique and specialized health care needs are examined below. They
include: women, children, adolescents, immigrants, disabled people, and
average, women in Canada live longer than men but they suffer from more
ill health and are more frequent users of the health care system.(25)
Women's contact with the system is often related to their reproductive
health. They may require special services to deal with problems to do
with menstruation, unintended pregnancies, infertility, sexually transmitted
diseases, birth control, childbirth, new reproductive technologies, and
menopause. However, gynaecological/obstetrical services are often not
readily available to women in rural regions. The rise of female cancers,
particularly breast and ovarian cancer, raises the issue of the availability
of cancer treatment facilities in rural regions.(26)
Rural women may thus be forced to travel (at considerable expense and
discomfort) to urban centres where the required facilities are available.
against women is a serious problem in both rural and urban Canada.(27) Rural women face additional problems
of isolation, absence of privacy, and in some cases, limited mobility.
One rural women explains, "You have no idea how important 1-800 numbers
are in these areas....Most help is long distance, so the call will be
on the husband's telephone bill at the end of the month." Moreover,
telephone party lines invade the privacy of women: "It's pretty damn
intimidating to call for support. It's not rare to hear someone listening
to my calls or for someone to pick up the phone and join the conversation."(28)
women who leave abusive situations often do so at great economic cost.
Unlike many of their urban counterparts, farm women's work is usually
directly linked to that of their spouses, and their job experience is
on the farm.(29) In other
words, when farm women leave an abusive situation they also leave their
jobs, a fact that can make leaving more difficult. One woman told the
panel of the Task Force on Violence against Women that "her husband
becomes most abusive at harvest time. Because she has an economic interest
in getting the harvest off, she puts up with the abuse."(30)
shortages of women's shelters in Canada is more pronounced in rural areas,
and women may have to travel vast distances to reach one.(31)
The House of Commons sub-committee on the Status of Women heard in 1991
that some women in Saskatchewan had to travel 500 miles to reach a 16-bed
may not be able to leave abusive situations because they do not have any
money, they do not have access to vehicles, buses and trains do not travel
through many small rural centres, and the nearest telephone may be miles
Canadian children are physically healthy and do not require the services
of medical specialists. In cases where a child is seriously ill, the rural
family, particularly if living in an isolated community, faces serious
problems. Required services may be difficult to reach, compelling the
sick child to travel long distances and spend long periods away from home
and family while undergoing treatment. Distance may make it impossible
for parents (or siblings) to stay with the child, or even to pay regular
visits. In some cases, one parent may stay with the child while the other
remains in the family home with the other children. Either situation causes
serious stress on the family and on the ill child who may feel alienated,
lonely, homesick and afraid--conditions not conducive to convalescence.
promotion and education tend to be underdeveloped in many rural communities.(33) Like all children, those living
in rural areas could benefit from early exposure to health promotion information
on matters such as healthy diets healthy sexuality, fitness, positive
human relations, the dangers of drug abuse, alcohol abuse, smoking, and
children in rural areas face some of the same frustrations as rural abused
women; namely, geographic isolation and lack of information, mobility,
and support services.
is a period during which children are developing into adults. These transition
years involve pronounced physiological changes, such as rapid growth and
sexual maturation as well as emotional development and identity formation.
For many young people this period of life is stressful; adolescents may
be concerned about poor body image, which can lead to eating disorders
such as anorexia nervosa and bulimia and problems with sexual identity,
sexuality, school work, family relationships and interpersonal relationships.
Particularly frightening has been the dramatic increase in the number
of youth suicides over the past 20 years, especially among 15-19 years
sexual activity can result in unwanted pregnancy and/or sexually transmitted
diseases (STDs), including HIV/AIDS and chlamydia. Although the devastating
effects of AIDS are well established, studies suggest that adolescents
are not modifying their behaviour to protect themselves against this disease.(35)
Chlamydia is the most common sexually transmitted disease amongst youth;
rates of infection have been rapidly rising over the past years, particularly
in the 15-19 year old age group. Since chlamydia is usually asymptomatic,
it is particularly dangerous; like other STDs, it can lead to pelvic inflammatory
disease (PID), which can put fertility at risk.
number of adolescents use alcohol and drugs; studies indicate that in
recent years more women than men between the ages of 15 and 19 are smoking.(36)
The negative health effects of drug and alcohol abuse and smoking are
well documented, yet this information has not made a major impact on adolescent
of the problems facing adolescents can be circumvented with education
and adequate support services, including drug and alcohol abuse counselling,
birth control information, STD clinics, social workers, family counsellors,
and nurses. In rural regions, however, these services are rare, if not
areas have a disproportionately high proportion of long-term disabled
people compared to the urban population.(37)
There are two types of problems that disabled people are more likely to
encounter in rural, rather than urban settings: a lack of specific needed
facilities and a lack of access to the standard services.
people often require specialized services such as surgery, physiotherapy,
dialysis, chemotherapy and counselling. These specialized services may
not be available in smaller rural centres, so that the disabled person
must travel to reach them. If the person is a child, an elderly person,
severely disabled or seriously ill, travelling becomes even more complex
because the assistance of another person may be required.
persons living in rural areas encounter the additional problem of access
to services that are generally available to other people. Ramps, elevators,
sloping curbs, automatically opening doors, grab bars in washrooms, and
washrooms that can accommodate wheel chairs are only starting to be introduced
into such areas. Moreover, special transportation for the disabled person
is usually not available in rural areas, making the rural disabled person
more dependent on family and friends for medical appointments, social
engagements, and work.
in health services and informational material in rural areas are more
pronounced for recent immigrants, especially immigrant women, since women
have more contact with the health care system. Some problems are "lack
of information about services, insensitivity on the part of health care
personnel because of cultural practices, and problems associated with
services designed for a mainstream population."(38) In some cultures, for example,
women are used to delivering their babies in their own homes with the
help of a midwife, yet midwives in rural Canada are almost non-existent.
immigrant woman may not able to communicate her problem effectively and
as a result receive inappropriate diagnosis or treatment for a medical
problem. Language training centres are not as available in rural communities
and women generally have less access to them than do immigrant men.(39)
(those 65 years and older) in Canada are over-represented in rural regions.
In 1991 close to one third of Canada's seniors lived in rural areas and
small towns.(40) Seniors are also the largest consumers of
number of health problems are particularly prevalent among elderly Canadians,
including depression, dementia (including Alzheimer's Disease), osteoporosis,
malnutrition, and loss of bodily functions (sight, hearing, mobility,
continence). All of these may require specialized medical care and support
services. Travelling long distances to reach required services is particularly
challenging for seniors with mobility problems.
majority of senior Canadians live independently and studies repeatedly
show that independence is a crucial factor in seniors' housing choices.(41)
The capacity to live independently, however, depends upon a number of
factors, including health, financial status, and the availability of support
services, which include professional services, such as medical or personal
care. Over the years, a number of support services have been developed
to help seniors but many of these services - meals for seniors, special
transportation, homecare, visiting homemakers, social and recreational
programs, and counselling and information - are available only in larger
UNIQUE HEALTH NEEDS IN SELECTED
most rural residents, particularly those who live in isolated communities,
experience difficulties with access to services and information, residents
of specific regions and workers in specific occupations face additional
or unique health concerns. Some of these concerns for three samples
of the rural population are highlighted below.
to the 1986 census, approximately 3.8% of the Canadian labour force were
employed in the agriculture industry.(42)
Although there are many different types of farming (e.g., cattle, fruit,
vegetable, dairy, grain, mixed), each with its own specific health and
safety risks, some health concerns are common to most farmers, farm families
and farm labourers.(43)
is a hazardous occupation; farmers, farm workers and farm families(44) are routinely exposed to health hazards from
use of chemicals (pesticides, insecticides, fertilizers), dangerous machinery,
infectious diseases, noise, and stress.
evidence in the scientific literature indicates that exposure to farming
chemicals may lead to greater risks of certain cancers (e.g., cancer of
the stomach, testes, and brain).(45) Chemicals have also been implicated
in neurological diseases, skin disorders, and reproductive health problems
in both men and women (e.g., disrupted sperm production, menstrual irregularity,
spontaneous abortion, stillbirth, neonatal death, infant mortality and
congenital anomalies).(46) People on farms often suffer from lung disease
(e.g., "farmer's lung" from exposure to mouldy hay, "silo
filler's" lung from exposure to oxides of nitrogen from unventilated
silos, and asthma), infectious diseases (e.g., leptospirosis, salmonella,
brucellosis, tularaemia, Q fever, ornithosis, toxoplasmosis) carried by
several animals, hearing loss due to exposure to noisy machinery, and
musculo-skeletal diseases related to repetitive motion and adverse ergonomic
accidents are also common in farming; the tractor is a central agent in
farm accidents but other machines such as grain augers, balers, combines
and power shafts are also implicated.(48)
An estimated 150 to 200 people die from farm-related accidents each year
in Canada,(49) and accidents to children are increasing
at alarming rates.(50)
work, especially grain, fruit and vegetable farming, is regulated largely
by weather; when crops are ready and the weather permits, farmers work
extended hours. During these seasonal peaks most members of the farm family
may be required to help. If there are small children in the home, child
care becomes an urgent need. The children are sometimes required to look
after themselves or must accompany their parents in tractors, combines,
and trucks.(51) This very dangerous situation
has caused deaths and injuries and has become the issue of a grass roots
movement amongst Saskatchewan and Alberta farm women, who are calling
for rural child care services.(52)
stress is not unique to the farming industry, it has become a big problem
there because of increasing economic pressures from low market prices,
high interest rates, and drought. The economic pressures confronting prairie
farmers have created incredible uncertainty in the lives of farm families,(53)
and the stress is felt by all family members, including children.
B. People of Aboriginal
federal government has jurisdictional responsibility for Canada's Indian
and Inuit populations. When it comes to health and social services, the
federal government is responsible for those populations living on reserves;
however, there is ongoing discussion about transferring this authority
to band councils.(54) For
status Indians and Inuit not living on reserves, the federal government
provides access to the provincial medicare systems and supplemental programs
and covers provincial health insurance premiums and user fees.
the Department of Health and Welfare, the federal government provides
"non-insured" health benefits to Indians and Inuit living both
on and off reserves. These services include medical transportation of
patients, drugs, glasses, orthopaedic appliances and supplies and dental
3% of the Canadian population is of aboriginal origin (Indian, Metis,
Inuit).(56) These people have traditionally
been concentrated in rural regions (on reserves or in small communities);
however, they are increasingly moving to urban centres in search of employment.
According to the 1986 census, slightly less than three-quarters of the
Canadian population of aboriginal origin are now living outside reserves.(57)
Their educational levels and labour market participation are closer to
that of the total Canadian population than to that of their on-reserve
counterparts, but they still have higher rates of unemployment, lower
levels of education, lower income patterns and poorer health than the
rest of Canadian society.(58)
poor health status of Canadians of aboriginal origin is most marked in
the Indian population living on reserves.(59)
Like unemployment, illiteracy and poor housing, the lack of availability
of, and access to, health information and services are linked to poverty.
Populations living on reserves have higher mortality and morbidity rates
than the total Canadian population; their life expectancies are estimated
to be ten years less than the national average.(60) Residents of reserves have higher rates of
diabetes, respiratory and infectious diseases, anaemia, gall bladder disease,
lung disease, hearing impairments, vision, dental, and mental health problems,
alcohol and drug dependence, and violence.(61)
In a study conducted by the Ontario Native Women's Association, 84% of
respondents (45% of whom lived on reserves, and 62% of whom lived in communities
of under 2,000 people) reported family violence in their communities.(62)
Abused women on reserves face the same problems of isolation and transportation
as other abused rural women.(63)
reserves, infant mortality and postnatal mortality rates are respectively
60% and 100% higher than those for Canada as a whole.(64)
Moreover, the incidence of suicide is more common among aboriginal populations
on reserves, as is the incidence of all violent deaths and disabilities.
Young people are at higher risk for contracting sexually transmitted diseases
(especially chlamydia and gonorrhoea), including HIV infections.(65)
There is also the growing problem of teenage pregnancies.
causes of the poor health status of aboriginal people living on reserves
are complex and result from "centuries of oppression, of the domination
of one society by another."(66) Poor conditions of housing,
high illiteracy rates, high unemployment, and poverty are also relevant.(67) In addition, there is a shortage of health
education materials and of health educators, nutritionists, therapists,
and mental health workers who can communicate with residents of reserves.
In Canada, most health information is disseminated by televised public
service announcements or by printed materials, neither of which may be
appropriate for remote communities or communities with high rates of illiteracy.(68)
role for traditional aboriginal medicine in the health care system has
been an issue for aboriginal peoples for many years.(69)
Currently the government of Saskatchewan is attempting to incorporate
traditional aboriginal medicine into a redesigned Saskatchewan health
care system. The Saskatchewan Commission on Directions in Health Care
the culture of the Indian population, the medicine man provides
a special service that touches on the meaning of life and on the
relationships between an individual and the realities which are
beyond him or her. It is a very personal service which cannot
be defined within constrictive parameters because it will vary
with persons and with circumstances. However, it must be recognized
as important, and it must be seen as complementing the scientific
and clinical approaches used by the formal health care system
in our society.(70)
recent years, efforts have been made to encourage Canadians of aboriginal
origin to attend medical schools. In 1990, however, there were only an
estimated 17 native doctors in Canada, most of them practising in Ontario,
Manitoba and Alberta.(71)
C. Maritime Fishermen
important facets of the lives of fishermen and their families undoubtedly
have major implications for their health status. First, it is clear that
fishing in Canada (east coast, west coast and inland) is replete with
serious health hazards.(72) Each year fishermen are lost at sea, or drowned,
but "unless there is a multiple drowning or the loss of a boat, it
does not receive much comment."(73)
As well, fishing is a highly developed industry that uses complex machinery
(e.g., winches) with the potential to cause serious accidents.(74)
Fishermen are injured on boats each year in Canada and there is continuing
discussion about how health and safety education and regulations can help
alleviate this problem.(75)
second factor is poverty. Since fishing provides seasonal employment,
low incomes are part of the fisherman's life, and Maritime fishermen and
their families are regularly dependent on unemployment insurance to supplement
their incomes.(76) Even with unemployment benefits, "as
many as one in three full-time fishermen and their households live below
the rural poverty line."(77) The direct relationship between
poverty and health has been well documented; poverty is regularly accompanied
by malnutrition and disease.(78)
In regions where poverty exists there is a strong need for increased medical
facilities and social support services.
there are barriers to good quality health care in rural and remote communities
in Canada. Availability of and access to medical services are often perceived
as the major problems, but, although these are important, many other complex
factors influence the health status of rural Canadians. In many cases
these barriers to health have their origins in larger systemic problems
in society; rural residents are confronted with particular hazards to
their health and safety. Moreover, the general socio-economic climate
for employment, income, and the environment has important implications
for the health of rural Canadians. Solving these problems will undoubtedly
require a range of comprehensive and multi-faceted social strategies.
Health Organization, International Conference on Primary Health Care,
World Health Organization, Geneva, 1978.
(2) Health and Welfare Canada, A New Perspective
on the Health of Canadians: A Working Document, Marc Lalonde, Minister
of National Health and Welfare, Ottawa, 1974; Health and Welfare Canada,
Achieving Health For All: A Framework for Health Promotion, Jake
Epp, Minister of National Health and Welfare, Ottawa, 1986.
(3) Achieving Health for All (1986),
(4) Canadian Medical Association, Report
of the Advisory Panel on the Provision of Medical Services in Underserviced
Regions, March 1992, p. 1. National Anti-Poverty Organization. Rural
Health. Ottawa, n.d.
(5) CMA, (1992), p. 1; Russell Wilkins and Owen
Adams, Healthfulness of Life: A Unified View of Mortality, Institutionalization
and Non-Institutionalized Disability in Canada, 1978, The Institute
for Research on Public Policy, Montreal, 1983.
(6) CMA, (1992); Statistics Canada and Secretary
of State, Report of the Canadian Health and Disability Survey,
1983-84, Supply and Services, Ottawa, 1986.
(7) For the purposes of this paper "rural
community" refers to communities with populations of less than 10,000.
This definition comprises the Statistics Canada definition of "rural"
and the Statistics Canada definition of "small urban centres
under 10,000." According to Statistics Canada, "rural populations"
refer to "persons living outside urban areas"; urban area population
"refers to persons living in a continuously built-up area having
a population concentration of 1,000 or more and a population density of
400 or more per square kilometre, based on the previous census,"
Statistics Canada. 91 Census, Urban Areas: Population and Dwelling
Counts, Minister of Industry, Science and Technology, Ottawa, 1992,
(8) R. Mitchell, Canada's Population from
Ocean to Ocean, Supply and Services, Ottawa, 1989.
(9) Rural residents living near large urban
centres with relatively easy access to high quality services do not have
the same barriers to health care as rural residents living in smaller,
more remote communities, with whose problems this paper primarily deals.
(10) Various studies have addressed the issue
of physician distribution in rural and urban Canada. See, for example:
Canadian Medical Association, Report of the Advisory Panel on the Provision
of Medical Services in Underserviced Regions (1982); Report of the Minister's
Advisory Committee on Rural Medical Practice, Regina, 1985; Gerald
Higgins, Olga Szafran. "Profile of Rural Physicians in Alberta,"
Canadian Family Physician, Vol 36, July 1990; Alberta Medical Association,
Report on the Task Force on Rural Medical Care, Edmonton, AMA,
1989; M. Barer and G. Stoddart, Toward Integrated Medical Resource
Policies for Canada, Winnipeg, 1991.
(11) CMA, (1992), p. 1.
(12) Ibid, p. i, 11-27.
(13) Ibid, p. 34.
(14) Ibid., p. 27.
(15) Ralph Sutherland and Jane Fulton, Health
Care in Canada: A Discussion and Analysis of Canadian Health Services.
The Health Group, Ottawa, 1988, p. 215, 216; CMA. Report of the Advisory
Panel (1992). An article in the Ottawa Citizen, 24 August 1992,
suggested that the Ontario Medical Association is thinking of new strategies
for diverting new doctors and some specialists away from Toronto to underserviced
areas such as northern Ontario.
(16) CMA (1992), p. 15.
(17) Ibid., p. 1.
(18) James T. Rourke, "Rural Medical Care
in Ontario: Problems and Possible Solutions for the next Decade,"
Canadian Family Physician, Volume 35, June 1989, p. 1225.
(19) CMA (1992), p. 15.
(20) Saskatchewan Department of Health, Saskatchewan
Commission on Directions in Health Care, Future Directions for Health
Care in Saskatchewan, Summary, 1990. p. 14.
(21) Therese Lawler and Mary Valand, "Patterns
of Practice of Nurse Practitioners in an Underserved Rural Region,"
Journal of Community Health Nursing, 5(3) 1988, p. 187-94.
(22) Rourke, "Small Hospital Medical Services
in Ontario; Part 4." p. 1889.
(23) Health and Welfare Canada (1986).
Working Group on Women's Health, Working Together for Women's Health:
A Framework for the Development of Policies and Programs, With assistance
from Anne Rochon Ford. April 1990. p. i.
(26) One of the recommendations of the House
of Commons Sub-committee on the Status of Women examining the issue of
breast cancer in Canadian women was to evaluate access to and availability
of radiation therapy for breast cancer patients and to devise strategies
to deal with extended delays. See: House of Commons Standing Committee
on Health and Welfare, Social Affairs, Seniors and the Status of Women,
Breast Cancer: Unanswered Questions, Ottawa, June 1992. p. 34.
(27) See: Patricia Begin, Violence Against
Women: Current Responses, Background Paper, Research Branch, Library
of Parliament, 1991; Linda McLeod, Battered But Not Beaten...Preventing
Wife Battering in Canada, Canadian Advisory Council on the Status
of Women, Ottawa, 1987. Currently the Federal Task Force on violence against
women is hearing testimony from women across Canada.
(28) Wendy McLellan, "Victimized by Rural
Setting," "Rural Help: Isolation Makes It Too Easy to Hide Family
Violence," Vancouver Sun, 5 May 1992. (Prairie Print Clipping
Limited, Regina, Saskatchewan.)
(29) Canadian Advisory Council on the Status
of Women, Growing Strong: Women in Agriculture, Ottawa, November
(30) Therese Stecyk, "Rural Abuse,"
Western Producer, 23 April 1992 (Prairie Print Clipping Ltd., p. 75)
(31) Canadian Advisory Council on the Status
of Women (November 1987), p. 33; McLeod (1987).
(32) House of Commons, Sub-Committee on the
Status of Women, The War Against Women. Report of the Standing Committee
on Health and Welfare, Social Affairs, Seniors and the Status of Women,
Barbara Greene, Chair, June 1991, p. 32.
(33) National Anti-Poverty Organization, Rural
Communities, NAPO, Ottawa, 1989, p. 13.
National Task Force on Suicide in Canada, Report: Suicide in Canada,
1987, p. 30.
A.J.C., King, et al; Canada Youth and AIDS Study, Queens
University, Kingston, 1988.
(36) Statistics Canada, (New Data from the
1991 General Social Survey), "A Trend to a Healthier Life Style,"
(37) CMA (1992) p. 1.
(38) Federal/Provincial/Territorial Working
Group on Women's Health, Working Together for Women's Health, p.
(40) CMHC, Maintaining Seniors'
Independence in Rural Areas: A Guide to Planning for Housing and Support
Services, CMHC, Ottawa, 1991, p. v.
(41) Health and Welfare Canada, Living Accommodations
for Seniors, Volume 1. p. 8, 37.
(42) Statistics Canada, 1986 Census of Population,
(43) A thorough study of health and safety
in agriculture was prepared by the Ontario government in 1985. See: Ontario
Task Force on Health and Safety in Agriculture, Report, A Joint
project of the Ministries of Agriculture and Food and Labour, Toronto,
(44) See, for example, Tye Arbuckle, principal
investigator, Ontario Farm Family Health Study, Joint Effort by
Health and Welfare Canada, and the University of North Carolina. Study
(45) Task Force on Health and Safety in Agriculture,
"Appendix 3: Summary of Potential Health Problems on Farms; Extracts
from Health of Persons Engaged in Farm Work," by Occupational Health
Program, McMaster University, Hamilton, Ontario, 1985, p. 5-7.
(47) Ibid., p. 17-26.
(48) Ibid., p. 26.
(49) Centre for Agricultural Medicine, "Survey
of Saskatchewan Farm Accidents and injuries, 1989-1900: Who are the Victims?"
Fact Sheet No. 2, July 1990.
Task Force on Health and Safety in Agriculture (1985), p. 27.
Farm Safety Hike Program, 1991 Report, Edmonton, Alberta; Information
sheet on Alberta Rural Childcare Pilot Project Committee.
(52) For example, the Women of Unifarm in Alberta
have started the "Alberta Rural Child Care Pilot Project."
(53) Linda Pipke, Kenneth Svenson and Florence
Drieger, "There Are No More Dreams": A Proposal for Action
in Support of Farm Families in Saskatchewan, 28 September 1987.
Health and Welfare Canada, Annual Report, 1990-1991, p. 18-19.
The precise provincial/territorial-federal division of power over aboriginal
health care is not entirely clear. Although the federal government has
responsibility for Indians on reserves, health and social services are
not specifically addressed in legislation. The provinces' traditional
refusal to extent their jurisdiction to reserves gradually resulted in
the federal government's role of funding health services on reserves.
Jack Woodward, Native Law, Carswell, Toronto, 1989, p. 388.
(56) Statistics Canada, A Data Book on Canada's
Aboriginal Population from the 1986 Census of Canada, Prepared by
Aboriginal People's Output Program, 1986 Census, Statistics Canada. 1989,
p. vi; Secretary of State, Canada's Off-Reserve Aboriginal Population:
A Statistical Overview, Prepared for the Native Citizens Directorate
by The Social Trend Analysis Directorate, Secretary of State, 1991.
(57) Statistics Canada, A Data Book on Canada's
Aboriginal Population, p. 4.
(58) Ibid., p. 23.
(59) The unique health concerns of the Inuit
of northern Canada and Innu of Labrador, which are equally pressing, involve
study that goes beyond the scope of this paper.
(60) Health and Welfare Canada, Joint National
Committee on Aboriginal AIDS Education and Prevention, Findings Document,
Ottawa, 1990. p. 30; Anne Gilmore, "Canada's Native MDs: Small in
Number, Big on Helping Their Community," Canadian Medical Association
Journal, Vol. 142, No. 1, 1 January 1990, p. 52.
(61) Health and Welfare Canada, Joint National
Committee on Aboriginal AIDS Education and Prevention, Findings Document,
Ottawa, 1990. p. 30.
(62) Ontario Women's Association, Breaking
Free: A Proposal for Change to Aboriginal Family Violence, 1989, p.
(63) Laura Rance, "Isolation Traps Rural
Women." Western Producer 23 April 1992, (Prairie Print Clipping
Ltd.,) p. 75.
(64) Joint National Committee on Aboriginal
AIDS Education and Prevention (1990), p. 30.
(65) Ibid., Ottawa. 1990. p. 53.
(66) Health and Welfare, Advisory Commission
on Indian and Inuit Health Consultation, Report, February, 1980,
(67) Indian and Northern Affairs Canada, The
Health Effects of Housing and Community Infrastructure on Canadian Indian
Reserves, Northern Health Research Unit, Department of Community Health
Sciences, University of Manitoba, 1991.
(68) Joint National Committee on Aboriginal
AIDS Education and Prevention (1990), p. 30-31.
(69) Thomas Berger, Report of Advisory Commission
on Indian and Inuit Health Consultation, Ottawa, 1980.
(70) Saskatchewan Commission on Directions
in Health Care, Summary, Regina, 1990.
(71) "Canada's Native MDs: Small in Number,
Big on Helping Their Community" (1990).
(72) See, for example: Susan Williams and Barbara
Neis, Occupational Health in Newfoundland's Deepest Fishing Industry:
Stress and Repetitive Strain Injuries Among Plantworkers; Accidents on
Board Trawlers, Final Report. Appendix B; Barbara Neis. "Trends
in Fatality Rates and Lost time Accidents among Newfoundland Trawler Workers,
1980-88," Memorial University, Institute of Social and Economic Research,
(73) R.J. Gray, An Examination of the Occupational
Safety and Health Situation in the Fisheries of Canada: Overviews and
Consolidated Recommendations, Vancouver, 1987, p. 5.
(74) Transport Canada, Canada Coast Guard
Manual of Safety and Health for Fishermen, Introduction, Ottawa, n.d.
(75) Gray (1987).
(76) National Anti-Poverty Organization, Rural
Communities, NAPO, Ottawa, 1989, p. 8-11.
(77) Ibid., p. 9.
(78) See for example, Wilkins and Owens (1978).