Mitigating the impact of the COVID-19 pandemic on Inuit living in Manitoba: community responses

ABSTRACT

We document community responses to the COVID-19 pandemic among Inuit living in the province of Manitoba, Canada. This study was conducted by the Manitoba Inuit Association and a Council of Inuit Elders, in partnership with researchers from the University of Manitoba. We present findings from 12 health services providers and decision-makers, collected in 2021.Although Public Health orders led to the closure of the Manitoba Inuit Association’s doors to community events and drop-in activities, it also created opportunities for the creation of programming and events delivered virtually and through outreach. The pandemic exacerbated pre-existing health and social system’s shortcomings (limited access to safe housing, food insecurity) and trauma-related tensions within the community. The Manitoba Inuit Association achieved unprecedented visibility with the provincial government, receiving bi-weekly reports of COVID-19 testing, results and vaccination rates for Inuit. We conclude that after over a decade of advocacy received with at best tepid enthusiasm by federal and provincial governments, the Manitoba Inuit Association was able effectively advocate for Inuit-centric programming, and respond to Inuit community’s needs, bringing visibility to a community that had until then been largely invisible. Still, many programs have been fueled with COVID-19 funding, raising the issue of sustainability.

KEYWORDS:

• Epidemic
• Arctic
• primary health care
• health care system
• non-government organisations
• voluntary sector
• vaccine

Introduction

Over the past decades, Inuit communities have emerged outside of Nunangat, the original homelands of Canadian Inuit. Nunangat includes the Inuvialuit region of the Northwest Territories, Nunavut, Nunavik which is part of Quebec, and Nunatsiavut in Newfoundland and Labrador. Statistics Canada reports that 27.2% of Inuit live outside of Nunangat [1]. Urban Inuit communities have emerged primarily in St John’s Newfoundland; Montreal Quebec, Ottawa Ontario, Winnipeg Manitoba; and Edmonton Alberta: these cities are southern locales where Nunavut Inuit have been accessing specialised medical care and other services for decades [2,3]. Our previous work suggests that mobility between Nunangat and southern locales is recurrent for many, with extended times in southern locales and Nunangat. This mobility goes beyond accessing health and social services, and extend to pursuing higher education, and pursuing new career and employment opportunities. Some work has documented the needs of Inuit living in urban environments in Ontario [4–6], and Newfoundland and Labrador [7]. Until recently, little was known about urban Inuit communities elsewhere.

For the past 7 years, the Qanuinngitsiarutiksait study has been working with the Manitoba Inuit Association (MIA) to support its need for evidence to more effectively advocate for Inuit-centric services. The word Qanuinngitsiarutiksait means tools for the well-being/safety of Inuit/people. Our collaboration has yielded in a number of publications [2,3,8–11]. At the beginning of the pandemic, we mobilised to support MIA’s COVID-19 response [12,13]. We have published a manuscript on the impact of the pandemic on Inuit who travelled to Manitoba to access services [14].

In this article, we focus on how the COVID-19 pandemic impacted Inuit living in Manitoba as reported by providers and decision-makers, and on the response to these needs. We report findings from a series of interviews conducted with service providers and decision-makers in Manitoba.

Background

The Qanuinngitsiarutiksait study is the result of long-standing discussions among members of MIA’s Board of Directors. MIA was created in 2008, with a mission of enhancing the lives of Inuit in Manitoba by promoting Inuit values, community and culture while connecting to services that meet our evolving needs [15]. In 2015, researchers from the University of Manitoba were approached by MIA to support MIA’s advocacy efforts by documenting Inuit’s health and social services utilisation in Manitoba. At the time, Inuit remained largely invisible in Manitoba. Estimates of this population by Statistics Canada underestimated the size of the population [1]. The reporting of population size, while grounded in how participants in the census report their home location at the time of the census, cannot reflect the fact that many Inuit move back and forth between living in Nunavut and in southern locales to pursue different opportunities.

Despite Inuit from the Kivalliq region accessing services in Manitoba for over five decades,¹ and a growing Inuit community living in Manitoba, Manitoba-based Inuit-centric nor Inuit-informed services did not exist beyond what is offered by the Nunavut government (boarding home and discharge planning back to Nunavut) and two fairly young Inuit non-government organisations. Primary care, specialist, birthing and mental health services, for examples, remain mainstream and from what we hear (from Inuit Elders and workers at the Manitoba Inuit Association, co-authors relating their experience and that of their family and friends), fairly uninformed of Inuit culture and circumstances.

At the time, MIA was facing considerable barriers to develop services to meet the needs of Inuit living in Manitoba and for Inuit from the Kivalliq region accessing services, and had since its creation in 2008 (see [2, 3, 10]for more detail). The Government of Manitoba did not acknowledge a responsibility towards Inuit based on their identity and Indigenous rights, and federal sources of funding for Inuit in urban centres did not exist [16]. The lack of provincial recognition of obligations, and the lack of federal support, given Indigenous rights, are misaligned with the Truth and Reconciliation’s call to action, and the United Nation Declaration on the rights of Indigenous Peoples [17,18]. To address this, University researchers worked with MIA to create detailed profiles of Manitoba health and other services accessed by Inuit from the Kivalliq region and Inuit living in Manitoba, to help bring Inuit needs to light. This study was managed by a committee of five Isumataiit Sivuliuqtii (Inuit Elders), researchers from MIA, the University of Manitoba, the University of British Columbia and the Manitoba Metis Federation.

Qanuinngitsiarutiksait documented that the Inuit community in Manitoba, which we estimate to be at least 1,500 strong, was somewhat fractured [10]. This was largely due to the consequences of colonialism, the negative impact of residential schools, the undermining of Inuit self-determination and economies, and unmet infrastructure pressures in Nunavut [3]. These factors resulted in multigenerational stress and trauma, self-medicated emotional distress, marginalisation, alienation, and poverty [19]. As a result, one in five Inuit living in Manitoba depends on Manitoba’s income assistance programme, suggesting that food insecurity is a likely challenge. On average, 12.6% of Inuit in Manitoba had been charged (but not necessarily convicted) of a crime, and 6.5% of Inuit had been the victim of a crime [3]. Finally, one of every 10 Inuit children is being followed by Manitoba Child and Family Services, either because families requested support to improve their parenting skills, or for child protection [3]. We also documented the top reasons for which Inuit living in Manitoba are being hospitalised, and identified that mental disorders as the leading cause [2].

With new funding opportunities emerging from a change in the federal government, and new visibility facilitated by evidence, MIA was able to move to a new and easily accessible community-based facility in 2018. Another independent Inuit-centric drop-in centre also opened its doors in 2018. Opportunities for programme development were improving when the COVID-19 pandemic was declared in March 2020.

Methods

This article presents the results of two related studies. Qanuinngitsiarutiksait: Developing Population-Based Health and Well-Being Strategies for Inuit in Manitoba is the name of the comprehensive study. The word “Qanuinngitsiarutiksait” refers to equipment for Inuit people’s safety and well-being. The goal of this project, which was financed by the Canadian Institutes for Health Research, was to create comprehensive profiles of the health and other services in Manitoba that Inuit from the Kivalliq region and Inuit who reside in Manitoba may access. A committee made up of five Isumataiit Sivuliuqtii (Inuit Elders), researchers from the University of Manitoba, and members of MIA oversaw this study. The second study, COVID-19 Public Health Outcomes in Arctic Communities: A Multi-site Case Study Analysis, is a component of a larger Circumpolar research project focused on community adaptations to COVID-19, led by the Qaujigiartiit Health Research Centre in Iqaluit. This research was funded by the Government of Canada. This paper presents the results of a subset of the Canadian case study. This subset was conducted under the leadership of the Qanuinngitsiarutiksait partnership.

Ethics

We received ethics approval from the University of Manitoba Health Research Ethics Board. Throughout the Qanuinngitsiarutiksait study, we engaged MIA and the Isumataiit Sivuliuqtii (Elders or knowledge keepers), to ensure that analyses and interpretations resonated with their experience, and that results informed the develop of strategies to address unmet needs, grounded in Inuit Qaujimajatuqangit (Inuit Ways of knowing) [20]. This engagement process was guided by a protocol, co-developed with the Isumataiit Sivuliuqtii [9].

Informed consent was secured in writing. We discussed how every effort would be made to protect participants’ privacy and ensure confidentiality, with the following caveat: despite efforts to keep your personal information confidential, absolute confidentiality cannot be guaranteed.

Data Collection

Between March and June 2021, we conducted 12 interviews focused on health and social systems’ adaptation during the pandemic. We used a snowball recruitment technique to recruit participants. The number of providers and decision-makers who are Inuit-informed remain small and includes providers and decision-makers (primary care physicians, specialists), travelling to Nunavut to provide care, discharge planning nurses working for the government of Nunavut and located within the Winnipeg-based Kivalliq Centre, staff from MIA, and providers from Nunavut. We first approached providers and decision-makers known to us and sought advice on who else might be able to contribute to our study. Table 1 provides a breakdown.

Table 1. Characteristics of participants.

Interview number	Gender	Role
701	Female	Health services planning
702	Female	Health services provider
705	Female	Health services provider
706	Female	Health services planning
707	Female	Health services planning
708	Female	Health services provider
709	Female	Health services provider
711	Female	Health services planning
713	Female	Health services planning
714	Female	Health services planning
715	Male	Health services planning
717	Male	Health services provider

Semi-structured interviews were conducted virtually (telephone or video conferencing). An interview guide included general questions about participants’ 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 decided to limit ourselves to providers and decision-makers 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.

Analysis

We conducted an interpretive thematic analysis, to document 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. Following Kovach [21], we discussed our findings from individual interviews broadly with the Isumataiit Sivuliuqtii and team members at our monthly meetings, with verification with specific Elders through one on one conversations as needed. These discussions guided the generation of key themes, which were then used to summarise findings, refine the themes and extract particularly eloquent quotes. This was reviewed again by the Isumataiit Sivuliuqtii and team members before further summarising and organising the material into key findings.

Results

In Manitoba, the first case of COVID-19 was confirmed on 13 March 2020. Recommendations from the provincial public health authorities included recommendations to all employers to allow staff to work remotely, when possible [22]. For the Inuit community, this meant that community programming and drop-in centres dedicated to meet their social-cultural needs, in operation for less than two years, were now closed.

I am just casting my mind back to March [2020], when our federal leadership started to say the word pandemic, and then we were seeing levers being pulled within Public Health responses and the restrictions that we went into almost immediately. That obviously had a direct impact on [MIA], our staff, our programming, and our programming in the community. It brings community together at our Centre … , [our programming] is very, obviously, hands-on, communicative, and communal… That overnight disappeared. (Interview 706)

As a result of the pandemic, new funding opportunities opened up for non-government organisations including MIA, resulting in expanded abilities to respond to community needs, albeit differently.

[A]t the very beginning, you could tell it was sort of palpable that clearly at a community level we all needed some resources, to be able to respond to some basic needs in terms of how COVID-19 and the positivity rates of COVID-19 were beginning to move through Indigenous communities, in particular within homeless population … And within the Inuit population, given that there is still some overcrowded living situation in urban centres for Inuit. And then the [federal government] quite quickly rolled out their COVID-19 Community Response funds. It was interesting because they delivered it quite quickly. It was a very streamlined application process. Nothing like we have seen before… It was available to agencies to just respond at kind of the most basic level. (Interview 706)

MIA was able to hire four new staff, and to build its COVID-19 response to address food insecurity through the distribution of food baskets which also included cleaning supplies and personal protection supplies; support COVID-19 guidelines through the distribution of masks, hand sanitisers and cleaning supplies which were initially in short supply in stores, and prohibitively expensive for many families; and provide transportation so that Inuit concerned with a potential COVID exposure could get tested.

Cultural events

Public health restrictions intended to curb community transmission resulted in rules that limited or barred cultural events and other ceremonies. While necessary, these restrictions had a profound impact on community cohesion:

And so that becomes a really awkward place for them right because they were telling people they can’t have funerals for their loved ones … in a way that’s traditional, they can’t get together and mourn together … … 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 702)

Opportunities to connect the community via online programming was discussed.

They would probably want more like cultural workshops … we wanted to do virtual activities over Facebook or stuff like that, but who knows how long this pandemic is going to last. So we did talk about some of that kind of stuff, doing some stuff virtually and having some workshops online. But I know a lot of the community is missing being in-person and doing some in-person. (Interview 709)

In partnership with MIA, the Qanuinngitsiarutiksait hosted three virtual community events around the 2020 holidays, including Story Time with Michael Kusugak, Holiday Greetings, Pualak Making and Amaut Display. These events were live and recorded for later viewing. These events generated over 2,500 views [23], a considerable success given our estimates of 1,500 Inuit living in Manitoba. This suggests that the reach of MIA is well beyond the Manitoba border.

Housing and homelessness

The COVID-19 pandemic negatively impacted access to safe housing for marginalised populations, including Inuit. Those experiencing homelessness were impacted inequitably by the pandemic, bringing up issues of safety:

I was evicted during a pandemic in November, like – … … .and some of the stories that I hear and see are really concerning for safety, for some of the homeless, or the really marginalized community. (Interview 708)

Yeah so I know from, like just from a pan-indigenous standpoint, like the challenges there and so the pandemic really heightened the homelessness and also the access other social services. (Interview 715)

It’s very hard for people to find housing. I feel like we’ve made a few partnerships with the different people in finding housing for homeless, but I feel like it’s hard for them to look for places and there’s not very many places that are affordable for low incomes or people that are homeless. (Interview 709)

In addition, public health’s requirements for self-isolation proved impossible to comply with for many Inuit living in crowded environments:

… and so quite frequently when we were calling people for contact tracing … it was like well I live with 16 other people in a one bedroomed house with a toilet. (Interview 702)

Food security

The pandemic brought major changes to the financial stability of Canadians, posing a threat to food security. The pandemic also increased the cost of food:

This is absolutely impacting women, who are those primary caregivers for their family to feed them. You need to be able to provide food. (Interview 704)

Some organisations focused their responses to target this issue. It also impacted Inuit organisations in terms of allocating time and staff to meet the immense need for food baskets.

… [So] we moved one of our staff into the position of coordinating this response program and hired four casual staff because the actual hamper program was big … and it’s gotten very large… there was a lot of communications that needed to be done to go into communities so that everybody was aware that they had this resource at their fingertips. (Interview 706)

COVID did interrupt everyone’s life and work, since then we had to kind of pivot our job duties, because what we were seeing was a lot of food insecurity in the community … Yeah. That just goes to show you that our community is starving. (Interview 708)

We are reaching over 400 Inuit over the hamper program and that is across the province. (Interview 706)

A challenge for the Inuit community is that although Inuit-centric organisations are located in Winnipeg, Inuit also live in Churchill and other Manitoba locales. Serving needs outside of Winnipeg was a challenge, which was nevertheless met with the distribution of food baskets.

A distinction-based Inuit-centric response to COVID-19

At the beginning of the pandemic, Inuit-relevant COVID-19 information was sorely lacking.

… it was really tough because we were trying to respond to the community needs … At the time, we were not anywhere near understanding what is the COVID-19 rate with Inuit in Manitoba. (Interview 706)

One participant spoke of Inuit patients feeling left out of other Indigenous programmes, highlighting a need for Inuit-specific programmes:

… Inuit patients have said as well is that they feel that even any of the programs that are done through [the federal government], or any of the other First Nations, is not specific to them. And I, they voice that before to me that it really, they feel sometimes left out of it. Or that it’s just not. It’s an afterthought. It’s oh, yeah, Inuit people are a whole different kind of group and have different belief systems. (Interview 707)

Interestingly, Inuit from Nunavut could benefit from greater access to supports, whereas Inuit living in Manitoba remain somewhat invisible.

So it’s like if you’re here and if you need someone to advocate for you there’s not really that – you can’t go to the [Kivalliq] Inuit Centre² on Burnell and say, “Hey, can you come help me?” they won’t help you because you’re not staying there. (Interview 709)

A provincial Indigenous (FN, M, I) 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 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 [2]for a more detailed discussion [11]. Emerging issues were discussed at weekly and later bi-weekly meetings, including how to operationalise self-isolation orders in communities where crowding has been an ongoing issue for decades, or how to roll out vaccination strategies in Indigenous communities where distrust of the health system has developed.

In the early phase of the pandemic, when MIA asked Manitoba for health surveillance information on Inuit COVID-19 testing and positivity rates, hospital and intensive care admissions, and COVID-19 deaths (the first steps to understand the health impacts of COVID-19), the government had no answers. MIA was able to negotiate an integrated service agreement with Manitoba Health, allowing Manitoba Health epidemiologists to use the algorithm created in the Qanuinngitsiarutiksait study [2]. As of 19 May 2020, epidemiologists employed by the province of Manitoba began to develop bi-weekly reports on the progressing of the pandemic in the Inuit community. The first report included the number and results of tests performed in Manitoba. A first case was reported in the early summer. Vaccination data was added to the report by May 2021. These reports were used strategically by MIA to advocate for COVID-19 related programming (food baskets) and for the need to be a designated host for vaccination.

These reports laid the foundation for MIA successfully advocating for the right to offer Inuit-led distinction-based COVID-19 pop-up clinics for Inuit families at their offices in Winnipeg. They dispensed over 480 doses of vaccine to Inuit families from April – December 2021. MIA’s distinctions-based approach to a public health emergency, i.e. Inuit vaccine clinics, had measurable impacts on decreasing vaccine hesitancy among Inuit: Inuit shared their stories with MIA and with their permission, their vaccine journeys were shared on MIA’s social media platforms, thereby assisting in curbing the vaccine hesitancy. MIA’s family-first approach, which vaccinated Inuit and non-Inuit family members together – an inclusive approach – increased vaccine uptake 24

The overall visibility of the Inuit community, achieved through the pandemic and partially as a result of our research partnership, culminated with the inclusion of Inuit in the Legislative Assembly’s land recognition statement.

We acknowledge northern Manitoba includes lands that were and are the ancestral lands of the Inuit. We respect the spirit and intent of Treaties and Treaty Making and remain committed to working in partnership with First Nations, Inuit and Métis people in the spirit of truth, reconciliation and collaboration. [25]

Land acknowledgements recognise that Indigenous peoples lived, and continue to live, on the land now largely occupied by settlers and new comers across Canada. While largely ceremonial and symbolic, the Legislative Assembly’s land acknowledgement, read at the beginning of each government sessions, can be a powerful way to ensure that Indigenous peoples are at least considered in Legislative Assembly debates. Further, the inclusion of Inuit in the land acknowledgement is very important, as it entrenches a provincial responsibility towards Inuit, which MIA may be able to leverage to further advance the development of Inuit-centric programmes.

Discussion

Our findings show that, according to the providers and decision-makers we interviewed, the COVID-19 pandemic had a number of negative impacts on the Manitoba Inuit community, in that the pandemic heightened food insecurity; it increased the vulnerability of Inuit who are homeless and precariously housed; and it increased isolation, and mental health stress. These stressed added to the context of Inuit live in Manitoba, where about 1 in 10 adult Inuit in Manitoba have had contact with the justice system; 1 in 10 Inuit children interact with the Child and Family Services system; and one in 5 is on income assistance [3].

Still, the pandemic also created new opportunities for MIA to engage in pandemic planning and management with federal and provincial governments; it improved funding opportunities for Indigenous organisations to address increased needs related to the pandemic; it increased the visibility and profile of MIA provincially and nationally; it increased the visibility of Inuit in Manitoba, and with the federal and provincial governments; and it expanded MIA’s programmatic scope from a socio-cultural service provider to a primary health care provider, in the delivery of vaccinations.

We acknowledge that our study has limitations. To begin, and as previously mentioned, we decided to focus on gathering information from providers and decision-makers once the pandemic began since we could not provide the aftercare required by patients who may disclose painful experiences and may need support. We recognise that identifying health systems’ issues from the perspective of health care providers and decision-makers is useful, but that it can only represent a fraction of the issues faced by Inuit patients. For example, providers working for different agencies may feel compelled to represent opportunities and challenges in a way that favour their agency. We also believe that looking at the limitations and adaptations of the Nunavut-Manitoba health system would be timely and would fill an important information gap. Another limitation is related to the impact COVID-19 had on the workload of providers. We had some difficulties booking interviews, and some of the interviews we would have liked to conduct could not be scheduled. Although our analysis has limitations, we believe that it presents a fair, if not necessarily comprehensive, picture of the Nunavut-Manitoba healthcare system.

Despite these limitations, our findings align remarkably well to previous work. A considerable literature exists, documenting the role of Indigenous non-government organisations (NGOs) in meeting the needs of populations underserved by mainstream services [25-36]. Empirical evidence has shown that First Nations who have greater control over their primary care services have better health outcomes [37,38]. Sadly, in urban contexts, Indigenous NGOs are generally funded through a patchwork of short term funding streams [30,32], undermining, the sustainability of positions within these organisations, the continuity of programmes and ultimately, the potential for Indigenous NGOs to play a more active role in improving health equity.

As a team, we are mindful that MIA’s success in securing funding to mitigate the impact of the pandemic was supported by analyses produced as part of our partnership. Our timing was ideal: the creation of the algorithm was used (with permission) by Manitoba Health to track the progression of the pandemic and vaccination in the Inuit community. Other results were used to advocate for services. Further, different stakeholders’ (government, MIA, researchers) timelines aligned and coalesced around common interests and agendas. Rarely do researchers witness such an immediate and extensive uptake of results, transformed into tangible benefits, bettering the wellbeing of the community.

A key lesson is that our work shows the value of the evidence, and the possibility of efficiently translating evidence into programmes. We see the overall results of our collaboration as particularly important for Nunavut, where a large proportion of care is accessed in Alberta, Manitoba and Ontario. Still, evidence is only helpful if it can unlock funding and mobilise energies to address issues identified. We hope for the sustainability of funding pathways for programming MIA was able to access, to ensure that its work continues.

Conclusions

The COVID-19 pandemic had a profound impact on Indigenous communities across Canada, and on the Inuit community in Manitoba. Thankfully, previous work to support the Manitoba Inuit Association meant that the organisation was uniquely poised to respond to emerging needs, access federal and provincial budgets for new programmes, and advocate at policy tables for the opportunity to hold vaccination clinics. Previous work by our research team, under the leadership of Elders and the Manitoba Inuit Association, provided key supporting evidence of needs (see [10,12]for a more detailed discussion). The algorithm developed by our team to identify Inuit in datasets was mobilised to produce bi-weekly COVID-19 specific data [14]. While opportune, it is somewhat concerning to think that other urban jurisdictions which are home to Inuit (St Johns, Montreal, Ottawa, Edmonton) have not been extended the same opportunities.

A key lesson then is that urban Inuit communities require mechanisms support their Indigenous rights and their need to engage with provincial authorities in the development of policies and programmes that impact them. Pathways for Indigenous self-determination in urban centres, which include sustained funding pathways, have long been lacking [32]. For Inuit, this has resulted in virtual invisibility. In the Manitoba context, the Inuit community seems to be emerging from this invisibility.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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 Government of Canada [1718-HQ-000294 Amendment 0011]; Canadian Institutes of Health Research [Application Number 461824].

Notes

¹ The Nunavut health care system is largely limited to the provision of primary health care provided by nurses with an expanded scope of practice, supplemented by periodic visits from family physicians and specialists. Complex care is accessed in Edmonton Alberta for Nunavut residents of the Kitikmeot region, Winnipeg for residents of the Kivalliq, and Ottawa for residents of Qikiqtaaluk.

² Staffed with nurses hired by the Government of Nunavut to meet the needs of Inuit patients from the Kivalliq, travelling to Winnipeg to receive specialised care