Cross-jurisdictional pandemic management: providers speaking on the experience of Nunavut Inuit accessing services in Manitoba during the COVID-19 pandemic

ABSTRACT

Across Canada, the COVID-19 pandemic placed considerable stress on territorial and provincial healthcare systems. For Nunavut, the need to continue to provide access to critical care to its citizens meant that medical travel to provincial points of care (Edmonton, Winnipeg and Ottawa) had to continue through the pandemic. This complexity created challenges related to the need to keep Nunavut residents safe while accessing care, and to manage the risk of outbreaks in Nunavut resultant from patients returning home. A number of strategies were adopted to mitigate risk, including the expansion of virtual care, self-isolation requirements before returning from Winnipeg, and a level of cross-jurisdictional coordination previously unprecedented. Structural limitations in Nunavut however limited opportunities to expand virtual care, and to allow providers from Manitoba to access the Nunavut’s electronic medical records of patients requiring follow up. Thus, known and long-standing issues exacerbated vulnerabilities within the Nunavut healthcare system. We conclude that addressing cross-jurisdictional issues would be well served by the development of a more formal Nunavut-Manitoba agreement (with similar agreements with Ontario and Alberta), outlining mutual obligations and accountabilities.

KEYWORDS:

• Epidemic
• Arctic
• primary healthcare
• healthcare system
• coordination

Introduction

The territory of Nunavut Canada manages a very complex and fragmented healthcare system [1]. As a result of history, diseconomies of scale, recruitment and retention issues, and other factors as well, services in Nunavut are broadly limited to primary healthcare provided by nurses with an expanded scope of practice, supplemented by family physicians who may be residents in larger communities, but are most often visiting for a few days of every month. Specialists (for examples, paediatricians, psychiatrists, obstetricians, audiologists, cardiologists, internal medicine specialists, occupational therapists, speech and language therapists) also visit communities intermittently to provide on-site care [2–4].

A large proportion of services that are accessed outside of Nunavut, following flight corridors that provide a north-south link between northerners and southern-based service providers, and bring needed goods to the north [5]. Health services provided in Ontario for residents of the Qikiqtaaluk Region, Manitoba for Kivalliq residents, and Alberta for those living in the Kitikmeot Region, are arranged from and paid by Nunavut. The COVID-19 pandemic impacted all healthcare systems around the world [6] with instances of overwhelmed hospital and public health capacity, highlighting weaknesses and stimulating adaptation and innovation. The Manitoba-Nunavut system, the focus of this article, was not exempt.

This article focuses on systems-level lessons learned as a result of the COVID-19 pandemic. We report findings from a series of interviews conducted with health service providers in Manitoba and Nunavut, focused on how the Kivalliq-Manitoba healthcare system operated in practice, and clarifying how this system adapted to address the challenges of ensuring continued care under COVID-19, and on gaps remaining.

Background

The population of the Kivalliq region of Nunavut counts 10,290 primarily Inuit residents (91% [7]. Challenges associated with service provision in Nunavut are common to other rural or remote regions, but the magnitude of these challenges is unique to the Nunavut and Kivalliq contexts. Nunavut includes 25 small and widely dispersed communities, 8 of which are in the Kivalliq region. Kivalliq communities range from 400 to just under 3000 residents. One of the main factors that impedes service delivery is geographic isolation, with some community members travelling hours by plane in order to access in- and out-patient diagnostics and treatment [8]. Another challenge is Nunavut’s reliance on primarily southern-trained healthcare professionals, many of whom are not familiar with the Inuit ways and values, resulting in culturally incongruent healthcare [9].

The nursing role in remote communities comes with increased autonomy and responsibilities – a mix of primary care, public health, emergency care and transport care – which can be attractive to some and daunting to others [1]. Care is delivered in the context of not only a therapeutic relationship, but also as community members caring for each other. Patients and providers likely encounter each other frequently outside of the health centre. Family tragedies have a direct impact on nursing staff, who may be providing critical care to community members they consider friends and acquaintances. Community criticisms of the care provided or of the organisation of services can then be felt deeply. Many communities experience recruitment and retention issues, with physicians and nurses staying in Nunavut for a year or two, and providing the majority of primary care services, supplemented by visits from family physicians and providers, occurring monthly to a few times a year [10–12]. A physician on call is available 24/7 for consultations. To address attrition, the Government of Nunavut, like many others, has increased its reliance on short term contract nurses, who have limited connection to the community, and often no cultural orientation [4]. As a result, community confidence and continuity of care can be compromised. Finally, the lingering effects of colonisation such as discrimination within and outside the healthcare system, and social and financial factors such as lack of affordable housing, household crowding, and food insecurity, also present specific difficulties [13].

We documented at least 1500 Inuit living in Manitoba, primarily in Winnipeg (90%) [3]. In addition, Inuit from Kivalliq have been coming to Manitoba for decades to purchase goods and access services not available in Nunavut. These “visits”, estimated at 16,000 per year for health services alone [14], may be punctual (a day or two, a few weeks) to access specific services, or may be extended to months and years, to access educational, employment, or long term care services [2].

The relationships of care between the Kivalliq region and Manitoba have been in place for over five decades. Some physicians and specialists have been travelling to Kivalliq to provide care for over 20 years. Services provided in Manitoba are paid for by the Government of Nunavut. A memorandum of understanding exists between Manitoba and Nunavut, highlighting the following commitment:

Health – The Participants agree to jointly develop a framework that identifies key health service deliverables and to pursue opportunities to improve health outcomes for our citizens and reduce the growth in service delivery costs, including sharing best practices and identifying opportunities for increasing health service delivery closer to Nunavut residents, as well as working together to address mental health issues in both jurisdictions. [15]p. 3)

A copy of the framework could not be located.

Inuit who travel to Winnipeg to access services might be housed at the Kivalliq Inuit Centre, a residence which also houses nurses employed by the Government of Nunavut to provide health system navigation and facilitate discharge planning as well as in-city support to Kivalliq Inuit [2]. In practice however, the current residence is often at full capacity. Those who cannot be housed at the residence are housed in local hotels contracted to serve this patient population. Some may elect to stay with family members.

We discussed elsewhere policy-level adaptations that were put in place at the onset of the pandemic, to better serve Inuit [16,17]. A main innovation was the inclusion of representatives from the Manitoba Inuit Association, a non-government organisation, at the Provincial Indigenous (First Nations, Métis, Inuit) COVID-19 Collaboration, a cross-jurisdictional pandemic coordination table hosted by the provincial government. Although First Nation and Métis organisations had historically been included in policy and programme planning, this was a first for Inuit [16]. As a result of this shift, the Manitoba Inuit Association was able to advocate for the provincial government to use an algorithm created in the context of our research project (see [3]for a detailed description), to identify the number of Inuit being tested, positive cases, cases hospitalised and deaths. This resulted in bi-weekly reports being sent to the Manitoba Inuit Association, thereby facilitating programme planning and delivery, as well as advocacy [16,18].

This article focuses on additional innovations, adaptations and challenges. This study is an extension of a long-term partnership established between the Manitoba Inuit Association, a group of Inuit Elders and university-based researchers, who have been working together for nearly a decade. The purpose of our partnership was to bring to light the experience of Inuit accessing services in Manitoba, and to support the development of Inuit-centric services [2,3,16,19–22]. Since this partnership was created, the Manitoba Inuit Association has grown from 2 to nearly 20 staff, and the needs of Inuit has become increasingly recognised and addressed. This article aims to continue to support this trend.

Methods

This article brings findings from two inter-connected studies. The overarching study is entitled Qanuinngitsiarutiksait: Developing Population-Based Health and Well-Being Strategies for Inuit in Manitoba. The word Qanuinngitsiarutiksait means tools for the well-being/safety of Inuit/people. The purpose of this Canadian Institutes for Health Research-funded study was to develop detailed profiles of Manitoba health and other services accessed by Inuit from the Kivalliq region and Inuit living in Manitoba. This study was managed by a committee of six Isumataiit Sivuliuqtii (Inuit Elders), researchers from the University of Manitoba and the Manitoba Inuit Association.

The second study is part of a broader Circumpolar research study managed by the Iqaluit-based Qaujigiartiit Health Research Centre, entitled COVID-19 Public Health Outcomes in Arctic Communities: A Multi-site Case Study Analysis. This study was conducted simultaneously in eight Arctic countries, including the United States, Canada, Greenland, Norway, Finland, Sweden, Iceland, and Russia, by a team of Fulbright Arctic Initiative¹ Alumni and aims to assess the positive and negative societal outcomes associated with the COVID-19 pandemic in Arctic communities. This study was funded by the Government of Canada. Preliminary findings have been reported elsewhere [23].

Ethics

The study received ethics approval from the University of Manitoba Health Research Ethics Board and data access approval from the Government of Manitoba Health Information Privacy Committee. Throughout this study, we engaged MIA and a Council of Nunavut and Manitoba Inuit Isumataiit Sivuliuqtii (Elders or knowledge keepers), to ensure that analyses and interpretations resonated with their experience, and that results inform the develop of strategies to address unmet needs, grounded in Inuit Qaujimajatuqangit (Inuit Ways of knowing) [24]. This engagement process was guided by a protocol, co-developed with the Isumataiit Sivuliuqtii [21].

Researchers working with relatively small communities must be aware of the potential to maintain confidentiality is more limited. The University of Manitoba’s ethics committee thus recommend the following text, which was used in our consent forms:

Information gathered in this research study may be published or presented in public forums; however, your name or other identifying information will not be used or revealed. Despite efforts to keep your personal information confidential, absolute confidentiality cannot be guaranteed.

Data Collection

We conducted an initial series of five interviews with service providers in 2017–18. A second series of 12 interviews that focused on systems’ adaptation during the pandemic were conducted between March and June 2021. We identified potential participants through a purposeful sampling process, where members of our team identified key individuals to be interviewed, and where those interviewed were asked to further suggest individuals to be approached. Criteria for participation in interviews included roles within the healthcare system, expertise and availability. As shown in Table 1, we interviewed 14 participants in 17 interviews. Of these, three participants were interviewed twice (pre- and during COVID). Participants included both service providers (family physicians, nurses) and service planners (service directors, programme coordinators). Semi-structured interviews were conducted in person (initial series) or via telephone or video conferencing (pandemic series). An interview guide included general questions about the participant’s working environment, education, and experiences of the healthcare system during the COVID pandemic. Interviews were digitally audio-recorded and transcribed verbatim. Prior to the pandemic, we had planned to interview Inuit community members. We however decided to limit ourselves to providers once the pandemic began because of the challenges and trauma associated with accessing care during the pandemic, and our inability to create a trust-based relationship with community members prior to an interview, to assess their emotional needs that might be triggered by an interview and limited opportunities to provide aftercare should a trigger potentially result in harm.

Table 1. Characteristics of participants.

		Interviewed		Role
Participant	Gender	Pre-COVID	Since COVID	Service planner	Service provider
701	Female	701a	701b	√
702	Female	702a	702b		√
703	Female	703			√
704	Male	704			√
705	Female	705a	705b		√
706	Female		706	√
707	Female		707	√
708	Female		708		√
709	Female		709		√
711	Female		711	√
713	Female		713	√
714	Female		714	√
715	Female		715	√
717	Male		717		√

Analysis

We conducted an interpretive thematic analysis, to understand challenges to the Manitoba-Nunavut healthcare system, identify how these challenges might have been exacerbated by the pandemic, and document innovations implemented to address systems’ limitations associated with the pandemic. Two researchers familiar with the study read through the data to extract themes, which were grouped under codes. These were discussed with members of the team and further refined through discussions.

Results

Manitoba saw its first confirmed COVID-19 case on NaN Invalid Date NaN. Restrictions began on March 20^th, with the declaration of a state of emergency, and restrictions on gatherings, the business sector, the closure of schools, and a whole scale shift to working remotely. Additional restrictions were implemented once community transmission became evident, on NaN Invalid Date NaN [25].

In contrast, Nunavut had no confirmed COVID-19 cases until November 2020 [23]. The first confirmed COVID-19 case was in Sanikiluaq on NaN Invalid Date NaN, with a second case confirmed on November 8^th. By November 18^th, Nunavut had 26 cases, mostly concentrated in the community of Arviat [23], which led Nunavut to order a 14 day territory lockdown: gatherings were limited to five people, and all non-essential businesses, bars, restaurants, community facilities, and schools were closed [26]. As was the case for other circumpolar locales, the pandemic’s direct impact became more pronounced from March 2021 onward, with rapidly growing care rates and relatively low mortality.

While Manitoba closed its borders to international and in Canada-travels, throughout the pandemic, Inuit requiring access to care not available in Kivalliq were considered “Manitobans” (Interviews 701b, 711) and continued to access care in Manitoba. They were however required to isolate for 14 days in an isolation hub, a designated hotel in Winnipeg, prior to returning home. The cost of isolation was covered by the Government of Nunavut. From March to June 2021, Nunavut decreed that patients could only travel for urgent care. In Winnipeg, pressures on the healthcare system at time meant that patients from the Kivalliq could not be accommodated, and were required to travel to Ottawa or other cities to access care usually accessed in Winnipeg.

All participants explained that the COVID-19 pandemic exacerbated long standing challenges Inuit experience when trying to navigate a “system” that spans a territory and a province. Several systems-level adaptations were implemented to address emergent COVID-19 related issues, resulting in important lessons.

Impact of public health response/Scope of response

Public health responses and mandates had direct impacts on programming and the community. Many restrictions came about quickly and organisations were faced with issues they had never experienced before.

being pulled within Public Health responses and the restrictions that we went into almost immediately? That obviously had a direct impact on Manitoba Inuit Association, staff, programming, and programming is in community … That overnight disappeared. (Interview 706)

Pressing needs were identified by listening to the community:

COVID-19 has amplified the issues that have been particularly running rampant over decades, within Indigenous communities. Whether you are talking about urban, or on reserve, or in the North. COVID-19 has put, it has amplified it … All I can tell you is [we were] responsive, and we were just able to do what we needed to do. (Interview 706)

Local access versus travel for services

The providers we interviewed reported that the pandemic had a direct impact on providers’ ability to travel to Kivalliq to provide care. Overnight, all care that could be provided virtually had to do so (Interview 701b). The pandemic also shifted Inuit’s views on medical travel, particularly in light of high infection numbers in Manitoba:

[Prior to the pandemic], [m]ost people would say I’d rather go to Winnipeg, and just know that everything’s OK. Or have these tests that you’re telling me, something like that. Whereas now they’re, well, how much do I really need that?. (Interview 707)

[W]e had a lot of people cancelling. And we were phoning up and saying we don’t think this client, like this could be a serious diagnosis. They need to come down here and at least find out what it is. But the government has initiated some new programs, like you can come down, [g]o to your appointment and then go home. So, they are trying to minimize people’s length of stay in Winnipeg … They go [to their appointment] in PPE. They cannot leave the [isolation] hub. They’re isolated, following all the hub rules. If they do that, they can go home the next day or after their appointment. (Interview 705b)

Nunavut also attempted to provide as much care as possible in the territory:

And really, if a person needs a level of care that we’re not able to give them, it’s never a second thought. We just, you go out. But if there are things that we can safely do within the territory, and that we have the right support for and the ability to do, absolutely. (Interview 707)

[I]nitially we were involved in sending midwives up to the Kivalliq, up to Rankin Inlet to that because they were trying to keep all deliveries in Nunavut when the [COVID] numbers were high in Manitoba and there were no cases in Nunavut. (Interview 711)

This had a direct impact on providers, who were asked to remain in the territory:

I think it was very stressful for a lot of the doctors and the worker in Nunavut who couldn’t leave for like nine months. I think like they weren’t allowed to leave it all and I think that was incredibly stressful, the rehab team, like adapted, and they were redeployed to help with testing. Then with immunization, and they’ve adapted well, so the providers to my knowledge, it hasn’t been excessively stressful. (Interview 711)

An opportunity to expand access to virtual care:

Definitely COVID’s made people look at more use of – like virtual appointments … like sending people down for a six-month appointment for five minutes. But some people, again, like the face-to-face but other people say, “Well, I came all this way and it was 10 minutes with the doctor”. (Interview 705b)

… like I know the Government of Nunavut was trying to shift more to virtual care for psychiatric services and there is advocacy among the psychiatrists who feel that going up is still incredibly important, so we are working to advocate to continue the services and augment what’s there. So that is a – I think that’s a source of stress for specialists who are concerned about changing their model to less in-person care where they feel like there’s importance of being in the community. (Interview 711)

Experience resulted in a better understanding of care that can be delivered virtually versus care that must be provided face-to-face:

And with the virtual care whether Telehealth telephone calls, you know, Zoom meetings, whatever has happened. We’ve learned about certain limitations of what can be provided in that way and certain barriers that occur with the virtual care. So now specialists are traveling up … kind of remembering how important in-person visits are as well as augmenting with virtual care. (Interview 701b)

Limitations to Nunavut’s telecommunication infrastructure created challenges:

[Y]ou have to you have to book Telehealth in advance. Sometimes … there’s only one [telehealth] bridge [for the whole territory] so [bookings] can be like at least a week beforehand. So it’s not so flexible. There are ways that the doctors can apply to be able to provide [care] from their [home] computer. So you don’t have to, it used to be that the docs would have to go to a telehealth hub. Which might be like a 15-minute walk from where they’re working or in a different building. So that was another barrier. But it also is a barrier in the communities because the nurses would have to take the patients to the Telehealth room. So it’s away from where they’re actually doing their work. So it’s problematic. But it’s not very flexible, as it’s a big issue, and needs planning and kind of disrupts the flow of the day often. It requires one person to be dedicated, and a nurse to be dedicated to the telehealth and ideally, it’s the most experienced nurse, because the specialist on the other end will might say can you feel their belly? Can you do this or do that? So they would want the most experienced nurse with the clinical skills ….

(Interview 701b)

Some providers pursued getting a special permission to access the Nunavut electronic medical records (EMRs), and opted to follow up with their patients by calling them at home (Interview 701b). Again, because of infrastructure limitations, only a limited number of providers can access the EMR at once, thus the Government of Nunavut had to limit the number of out of territory providers with access privileges.

Access to care in Winnipeg

Providers reported that patient charting systems are not accessible across jurisdictions. Therefore, a physician or specialist seeing a patient in Manitoba does not have access to the patient’s Nunavut chart and is providing care with a fraction of information (a letter provided or what the patient knows and shares). That provider is then expected to write a letter summarising the care provided and send this letter to the patient’s community health centre (this often takes 3–4 months) to ensure that any continuity of care expected when the patient returns home is respected (Interview 701a). Such a system is cumbersome, has been noted as problematic for years, and has yet to be addressed.

In the context of the pandemic, Government of Nunavut nurses working for the Kivalliq Inuit Services (co-located with but independent from the Kivalliq Inuit Centre) were initially unable to access Kivalliq Inuit patients’ COVID-19 testing results upon discharge from Winnipeg hospitals. Since these patients were likely staying at the Kivalliq Inuit Centre where other patients were residing, or in the community with family members, this created some challenges in ensuring the safety of all patients and their relatives (Interviews 705b, 715). This issue was raised at the Provincial Indigenous COVID-19 Collaboration table, and quickly resolved.

COVID-19 placed undue pressures on the Manitoba healthcare system, exacerbating on-going issues of trust.

… for Inuit having had incredibly traumatic experiences when interfacing with, [air quote} “the health system” … … There is that history, as well as the current and present medical travel down to Manitoba, still having to leave community in accessing healthcare. And, you know, not particularly having a very positive experience on that health journey. (Interview 706)

One participant noted that self-advocacy is always necessary when navigating the healthcare system:

So, you really have to be able to advocate for yourself. So, if you can do that you may get better access but that would be sort of luck of the draw and having relationships and having a good doctor and really being on top of it, right. (Interview 715)

In pre-COVID time, translation services were generally available to patients requesting them. As a result of additional workloads associated with COVID-19, translation services became patchy if available.

[F]or example, if someone came down from Nunavut and they weren’t staying at the Kivalliq Inuit Centre, and they needed an interpreter and they were here on their own or for whatever reason they came down and they didn’t have an interpreter or an escort with them, then they wouldn’t have that advocacy or somebody at the hospital or at their appointment to translate for them. (Interview 709)

With COVID-19, patients were precluded from travelling with an escort, and from having a relative or friend attending to their care with them. Medical interpreters from Kivalliq Health Services, who might visit an Inuit patient to assist with advocacy in pre-COVID times, were also unable to visit. Support could only be provided through telephone calls. As a result, opportunities for supporting Inuit patients were curtailed (Interviews 706b, 715).

The isolation hubs

As of the end of March 2020, Nunavut patients accessing care in Winnipeg were expected to self-isolate for 14 days prior to their return to Nunavut. Health professionals who live in Manitoba and travel to Nunavut to provide care were also expected to self-isolate prior to flying to Nunavut, and upon their return from Nunavut to Manitoba (Interviews 701b, 705b, 711). One participant mentioned the effect of isolation mandates on Inuit accessing health services, specifically leaving home for long periods of time to access services:

… on the whole, people don’t want to be gone from home for three weeks just to attend an MRI or CT. (Interview 705b)

Having to be isolated, especially if you’re alone and you don’t have an escort, it was quite stressful. Or if you’re a young mom or pregnant mom I think it was quite stressful for many people and continues to be quite stressful. (Interview 711)

Prior to the pandemic, patients discharged or having completed their treatment would return to their own community and access the community health centre if they needed follow-up care such as the removal of sutures or if they experienced some challenges. While in isolation in Winnipeg, provisions were made for nurses from Kivalliq Inuit Services to visit patients in isolation hubs to ensure that their primary care needs were being met (Interview 705b). For new mothers however, spending the first 2 weeks of their infant’s life in a hotel in isolation remained understandably stressful. For others, 2 more weeks away from home and perhaps other children also added considerable hardship.

Isolation mandates also affected service providers living in Winnipeg and travelling to Nunavut to provide care:

… [This provider] wasn’t able, she didn’t feel able to do that two week isolation, she ended up backing out of a position because she just didn’t feel like, with needs at home that she could spend two weeks in isolation prior to work. If she came down, she’d have to go back to isolation, it was too much uncertainty for her. (Interview 713)

Vaccine rollout

In Nunavut, health centre nurses added COVID-19 related activities, while continuing to look after the primary healthcare needs of the community to the best of their stretched abilities. Other providers were redeployed to COVID-19 testing and vaccination.

There are two physios, two occupational therapists and there’s no speech language right now, but they were [redeployed], because they were non-essential services. They were, their services were shut down and then they were redeployed to testing and then to support the immunization process too. (Interview 711)

In Manitoba, the Manitoba Inuit Association was concerned about vaccine acceptability and uptake.

There is a distrust and mistrust. In the general population as well, there are lots of questions about the vaccines and what are we really putting into our bodies? And that type of thing that would be no different for Indigenous communities. (Interview 706)

That, and also there’s some that still believe it’s a hoax, don’t believe it’s real. (Interview 708)

One participant shared concern about younger people not getting vaccinated:

And I think the older population, you know, like let’s say 50 and older, I think that won’t be a problem getting those people immunized because I believe they will. I think it’s more the 18 to 30 that – you know, and they’re probably – and also have young families …. (Interview 708)

The Manitoba Inuit Association advocated for the right to host vaccination clinics. Although a majority of Inuit living in Manitoba are in Winnipeg, others live in Churchill or are distributed across the province. There was uncertainty about what the vaccine rollout would look like, particularly how they would be delivered to community members in various locations around Manitoba.

[W]hile we were all in Christmas mode in December [2020] the federal government was busy then in their next stage of the pandemic, which was acquiring vaccine. When we all resumed our roles back at work at the beginning of January, we began to have conversations internally about likely, we are going to be looking at requiring some vaccines for the Inuit community. What on earth is that going to look like? With [the Manitoba Inuit Association]’s mandate being provincial, it’s the complexity of the rural remote folks and then the urban centres. (Interview 706)

The Manitoba Inuit Association opted to vaccinate Inuit families, including non-Inuit partners, in Winnipeg. This family-centric approach facilitated vaccine uptake. Others pursued vaccinations through Manitoba’s supersites.

[Inuit clients from the Kivalliq] have been very proactive. They have been phoning the super sites and two of them have gotten their vaccinations … So, they have actually gone to the Super site and … the boarding home will approve rides, if they need a ride. A lot of them are pretty self-sufficient, they will take a taxi and submit the receipt. (Interview 705b)

The Kivalliq Inuit Services coordinated with the Manitoba Inuit Association’s vaccination clinic to ensure that Kivalliq Inuit in Winnipeg for extended periods of time for medical care could be vaccinated.

Long term impacts

Those interviewed noted the potential lasting effects of public health restrictions on ceremony/cultural events:

… in the long term people haven’t had the opportunity to mourn properly and what are the impacts of that on people’s mental health and their family structures and you know, their ability to be so resilient as is required here. (Interview 702b)

Discussion

In comparison to other circumpolar settings, Nunavut experienced lower cases per 100,000, and a lower death rate as well, than other circumpolar locales [27]. The pandemic began later than in Manitoba, creating opportunities for Nunavut to adapt. Still, our results show that both systems were intertwined at the onset, and that decisions in Manitoba had a direct impact on Kivalliq patients accessing care.

Steps were taken to decrease the fragmentation of care for Inuit (e.g. care in place through the incorporation of virtual care; formation of provincial Indigenous COVID-19 collaboration team to support a coordinated approach). The provincial COVID-10 collaboration team provided multiple jurisdictions an opportunity to work together and not be encumbered by “jurisdictional” turf [3,16,18].

The inclusion of Inuit at the coordination table reflects the enduring relationship that exists between Manitoba and Nunavut, and an emerging relationship between the province and the Manitoba Inuit Association. This emerging relationship was pivotal for the implementation of an effective vaccine campaign for Inuit.

The long-standing relationships between health service providers living in Winnipeg and travelling to Nunavut to provide care, many of whom working for Ongomiizwin Health Services, resulted in creative solutions when travel was not possible, such as an expansion of virtual care and phone conversations supplemented by remote access to the Nunavut EMR.

Our results nevertheless lay bare the long-standing discontinuities in the Nunavut-Manitoba healthcare systems, increasing the potential for harm. Some were bridged through relationships and pragmatism (a shift to virtual care), while others were simply side-stepped on a case per case basis through the Provincial Indigenous (First Nations, Métis, Inuit) COVID-19 Collaboration, or remained unresolved (access to EMRs across jurisdictions).

The Provincial Indigenous (First Nations, Métis, Inuit) COVID-19 Collaboration table created by the Government of Manitoba to support a coordinated approach to pandemic planning, provided an unprecedented opportunity for representatives from the Regional Health Authorities; municipalities; First Nation, Métis and Inuit organisations; Kivalliq Health Services; and health system decision-makers from Nunavut and Manitoba, to discuss emerging issues and address them (see [16; 18]for a more detailed discussion). This coordination table was focused on addressing emergent issues such as how to operationalise self-isolation orders in communities where crowding has been on-going concerns for decades, or how to roll out vaccination strategies in Indigenous communities where justifiable distrust of the healthcare system remains an ongoing issue. This table was however not empowered or resourced to address long standing system-wide barriers, such as the lack of access to patient charts across jurisdiction or limitations to the Nunavut telehealth system.

We acknowledge that our study has notable limitations. To begin, we recognise that a documentation of health systems’ issues from the perspective of providers is useful, but can only represent a fraction of issues encountered by Inuit patients themselves. As mentioned, we decided to focus on providers once the pandemic began, because we could not provide the aftercare required of patients who might disclose painful experiences and might require support. While a limitation, we believe that focusing on the Nunavut-Manitoba healthcare systems’ limitations and adaptations is timely and fills an important gap in the literature. Another limitation is related to the workload providers experienced during the COVID-19 pandemic. As a result, interviews we would have liked to undertake could not be scheduled. Despite these limitations, we are confident that our analysis is a fair, and comprehensive, portrayal of the Nunavut-Manitoba healthcare systems.

Very little has been written about health systems innovations as a result of COVID-19, and much less so in a cross-jurisdictional Indigenous context. The shift to virtual care has drawn most attention [28,29], and none have addressed the fostering and maintenance of trust and relationships through virtual care. We found only one (somewhat dated) publication on telehealth policy development to support allied health professionals’ virtual practice in Nunavut [30]. A key limitation highlighted by participants in our study is that Nunavut only has one telehealth bridge, thus Nunavut-wide, only one patient can be seen via telehealth at a time, using this platform. Additional bridges would have enabled for more flexible scheduling and an expansion of services delivered virtually.

Another system’s level limitation noted what that providers cannot access Nunavut EMRs from Manitoba, and vice versa. This combined with the lack of escort accompanying patients because of COVID-19, meant that providers are quite limited in the information they can draw from when seeing Inuit patients in Manitoba, and when attempting to provide follow-up care in Nunavut. This is known and has been in the planning for some time. Addressing this issue of particularly complex because it requires interoperability across Nunavut, and between Nunavut and Alberta (for the Kitikmeot Region), Manitoba (for the Kivalliq) and Ontario (for the Qikiqtaaluk Region). This may require Alberta, Manitoba and Ontario to modify and harmonise existing systems to accommodate Nunavut. This is a daunting task: for scale, Manitoba is a province of 1.4 million residents, and see approximately 16,000 consults from Nunavut yearly, which represents a tiny fraction of all consults provided in Manitoba. The same can be said of Alberta and Ontario. Expecting Alberta, Manitoba and Ontario to modify their EMRs to facilitate interoperability is likely to take considerable energies for times to come. Still, this begs the question, when will Canada requires that all EMRs be interoperable, to ensure that Canadians accessing care across Canada can access the best and most informed car available. The issue goes beyond Nunavut.

Conclusions

COVID-19 placed unprecedented pressures on healthcare systems world-wide. This is also true of the cross-jurisdictional Nunavut-Manitoba systems. Extraordinary efforts were made to ensure that Inuit would continue to access necessary care in Manitoba or in Nunavut through virtual care. Barriers experienced were related to infrastructure limitations in Nunavut, along with long standing system-wide issues. A provincial coordination table allowed for some of these issues to be addressed.

Nunavut remains probably the most complex and fragmented healthcare system in Canada, as a result of infrastructure limitations, in part related to low population density. Addressing cross-jurisdictional issues would be well served by the development of a more formal Nunavut-Manitoba agreement (and similar agreements with Ontario and Alberta), outlining mutual obligations and accountabilities. This may be the case for other circumpolar settings, such as the Yukon and the Northwest Territories, Greenland where access to specialised care is in Copenhagen Denmark. In these locales, where diseconomies of scale and recruitment issues makes partnerships invaluable, clarifying expectations and mutual obligations ahead of the next pandemic, might improve outcomes and reduce hardship. One important lesson to take away from this is that Inuit communities must have effective mechanisms in place to support their Indigenous rights and their ability to actively participate in discussions with provincial authorities regarding policies and programmes that affect them. This requires a comprehensive understanding of the challenges and perspectives unique to them.

As mentioned, this study is part of a comparative Circumpolar programme of research on COVID-19, undertaken in the United States, Canada, Greenland, Norway, Finland, Sweden, Iceland, and Russia. A series papers is forthcoming, to be published in a special edition of this journal.

Acknowledgments

We would like to acknowledge the contributions of Elders Fred Ford and Caroline Anawak, who passed away too early at the beginning of this study. Our team miss their smiles and their teachings.

Disclosure statement

No potential conflict of interest was reported by the authors.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

The work was supported by the Canadian Institutes of Health Research [Application Number 461824]; Government of Canada [1718-HQ-000294 Amendment 0011].

Notes

¹ The Fulbright Arctic Initiative creates a network to stimulate international scientific collaboration on Arctic issues while increasing mutual understanding among the people of the Arctic Council member states. Using a collaborative model to translate theory into practice, program participants will spend 18 months engaged in addressing public policy research questions relevant to Arctic nations’ shared challenges. For more information, please see https://fulbrightscholars.org/arctic.