In the Field: Lessons Learnt from Nunavik

By Jessica Matschek 

A view of Kuujjuaq from the top

Last summer, I had the wonderful opportunity to spend four weeks in Nunavik as part of a medical internship. The first two weeks were divided between inpatient wards and the walk-in clinic at the Ungava Tulattavik Health Centre in Kuujjuaq, tending to patients with both common illnesses and pathology unknown to my hometown of Montreal, such as active tuberculosis and botulism poisoning from ingestion of Mattaq, (a traditional food made of fermented beluga). I was amazed to be able to take part in many unique experiences, including assisting in medevacs to fly critically ill patients from remote villages to the hospital in Kuujjuaq for care. Following these two weeks, I was able to spend time volunteering at a halfway house where men living with psychiatric disorders and addiction were supported in transitioning to independent living. Mental health disorders carry a great deal of stigma in Kuujjuaq, often leading to social isolation and exclusion of affected individuals from their community. In my role leading cooking sessions, we focused on preparing well-balanced meals that would be delivered to vulnerable families in the community. In my final week, I travelled four hours north to Kangiqsujuaq, a community of 837 people, where I worked at the CLSC and joined the community in cultural activities such as hunting for Qaulutaq (belugas) and fishing for Iqaluk (arctic char).

While my internship enhanced my medical knowledge, the knowledge I came away with went far beyond the boundaries of traditional medical practice. From consuming meat for sustenance to using furs and bones for crafting jewelry, the resourcefulness and respect that the Inuit hold for their land left a profound impression on me. I learned about the Makivik dog slaughter, when the Québec Government ordered a mass sled dog slaughtering in an effort to further assimilate the Inuit, taking away their main source of transport and forcing them to settle in communities. The loss of their beloved dogs, viewed by many as family members, had a profound psychosocial impact on the community. In Nunavik’s challenging and remote environment, I witnessed the importance of mutual support and the impact neighbours can have on each other. I was deeply moved when I learned that a community member went out of her way every day to care for and bathe her elderly neighbour, whose loss of independence meant she could no longer care for herself. This selflessness epitomized the strong communal sense that is at the heart of life in Nunavik. Small gestures, such as greeting patients with an Ullakut (good morning), went a long way toward showing interest in my patient’s culture and establishing a relationship of trust. Living amongst the Inuit allowed me to gain insight into their deep-rooted traditions and understand the challenges they have to overcome in interacting with the Western world.

What I learned about––and will strive to share with my future colleagues––are the challenges Indigenous peoples face when they travel to secondary and tertiary care centres for medical reasons. Not only are they leaving their families and social support, but they are also stepping into a vastly different cultural milieu that can often be hard to divorce from the intergenerational trauma that has marred the last 200 years of their history.

The experience that marked me the most from my time in the North occurred on a beach after a tragic boating accident that started as a fishing trip. A young man was thrown from the deck of the boat after hitting some rocks, while his partner, a young woman I will refer to as Jane, was knocked unconscious below deck. When Jane awoke, she found her partner face down, awash on the beach. We found her after Jane had spent the next few hours fighting to resuscitate him, to no avail. Unfortunately, there was nothing more the medical team could do for him, and they turned their focus to Jane, who herself had suffered serious injuries, including a pneumothorax and several broken ribs. What I had difficulty coming to grips with was her refusal to be flown down to Montreal to receive the medical care she needed to avoid the same fate as her partner. She explained to us that despite accepting to be cared for, she could not board the same plane that so many of her family members had taken when they were sick, some of whom never came back. For Jane, to accept medical care, she would have to face intergenerational trauma. Her grandfather had been a survivor of the residential school system. She explained that as a way to cope, her grandfather had started consuming alcohol to numb himself. This led to verbally and physically violent outbursts at home and at other times, as well as neglect of Jane’s father. There was also loss of their language, as her grandfather refused to speak Inuktitut, a language he was banned from using throughout his time in the residential schools. She had worked hard to reclaim her language, learning Inuktitut, and reviving other Inuit traditions like getting her Tunniit (traditional face tattoo). For Jane, heading to Montreal and being forced to relive this trauma was too much to handle. This is something that I had never considered before when looking at the faces of the many people I have seen at the hospital, who are receiving care away from home.

Another example that comes to mind is that of an older man we will call John. John is a frequent flyer at the Kuujjuaq hospital. He has a long list of physical and social problems, so it was no surprise when he showed up at 9pm asking to stay at the hospital overnight with his pyjamas in his bag. When asked why he came to the hospital, he said he had stomach pain. After running several tests and chatting with John, I found out that the reason he wanted to stay at the hospital was because he was sharing his home with his ex-wife as well as three members of her extended family, his two daughters, and his parents. The house, a standard government-issued two-bedroom home, was housing nine people, and John’s mental health was being negatively impacted. His ex-wife and her family were staying with him while they waited for their own house to be repaired, as mold had been found in the walls, and the construction workers and supplies had not yet arrived for the scheduled summer repairs. This is a very common situation in Nunavik, with three or more generations often living in a two-bedroom home. Additionally, as it is government housing, repairs can often be delayed due to funding or weather. I would want my colleagues to keep this in mind while treating these patients as oftentimes patients are living in poor quality housing that may impact their mental and physical health.

From my short time in the North, a recurring theme I’ve encountered involves Inuit getting the typical advice that we would give a patient from the South but not realizing that this is not applicable to their situation. While conducting a prenatal visit in a higher risk pregnant woman I will call Alexandra, she told me about how when she flew to Montreal to see her specialist, she was instructed to “eat more fruits and vegetables” and “do more low-impact exercise, like swimming.” She chuckled at this, mentioning that the physician was taken aback when Alexandra said that the advice was impractical for her. Living in the North, it can be very difficult to eat what Southerners consider to be healthy, when a small bag of not-so-fresh grapes will cost you $24. Oftentimes, grocery store shelves are empty or have rotting produce that is both unappetizing and unaffordable. Furthermore, as construction supplies need to be shipped by boat, when infrastructure breaks, it can remain in disrepair until the summer, when the ice melts and ships are finally able to get through. In the case of the Kuujjuaq pool, it had been broken for over eight months when this patient received this advice. 

Lastly, I would talk to my colleagues about the things we take for granted. Hardware stores around us, a stable home to come back to, stocked grocery stores with fruits and vegetables at affordable prices, and a large selection of stores and places to go. We have to keep the situations faced by Jane, John, and Alexandra in mind because these are not uncommon experiences amongst Inuit. As physicians, we need to provide culturally appropriate care when prescribing lifestyle interventions. We have to take more than the 10 seconds to give the patient “the usual” instructions and think about what is actually viable for the patients we are treating. 

My internship illuminated the many cultural and social factors affecting Inuit hesitancy to seek care in Montreal, even to the detriment of their own health. Inuktitut is the official language of instruction in Inuit schools, meaning that children only learn English or French when they get to secondary school. This language barrier makes explaining one’s symptoms to fly-in physicians and healthcare professionals in local hospitals difficult. Translators, while necessary, are hard to reliably access and often consist of non-medical members of the community, leading to serious confidentiality problems. Seeking advanced care in Montreal requires travelling over 1400km, leaving behind the familiarity of home and one’s social support network to stay in unfamiliar, temporary housing in a foreign city with language barriers and a completely alien way of life. Moreover, the “big city” can be a sensory overload compared to the tranquility of the Nunavik taiga and tundra. This can further contribute to the emotional and mental stress patients already experience while sick. I have borne witness to the judgement these patients face while receiving care and the negative perception that some healthcare staff can have of them, all of which creates a hostile environment. I wish to help my fellow colleagues understand where these patients are coming from and the barriers they face when seeking care. Empathy is needed for all in order to provide compassionate, culturally informed patient care.

Jessica Matschek is a medical student at McGill University. Her academic interests are rooted in advancing research that addresses health disparities and promotes equitable healthcare solutions. Driven by a strong commitment to improving global health outcomes, Jessica is dedicated to exploring innovative approaches and contributing to impactful research in the field. In recognition of her commitment to global health, Jessica was the recipient of the Dr. Yuk Chan Ma and Dr. Yuen Kok Chan Prize in Multicultural and International Medicine Award in 2023. She tweets at @Jess_Matschek.