In Conversation with Dr. Yassen Tcholakov
Clinical lead at the Nunavik Department of Public Health
By Mariane Saroufim
Dr. Yassen Tcholakov is an Assistant Professor in the Department of Epidemiology, Biostatistics and Occupational Health at McGill University. Bulgarian by origin, he completed most of his studies in Canada where he received his medical degree at the University of Montreal and completed his residency training at McGill University in Public Health and Preventiveness. Throughout his medical studies and residency, he’s been involved in global health work and obtained Master’s degrees in International Health at the University of Copenhagen and in Public Health at the London School of Hygiene and Tropical Medicine. He currently works as the Clinical Lead in Infectious Disease at the Nunavik Department of Public Health.
Can you describe your current role at the Nunavik Department of Public Health?
I started my position early in the pandemic after the first wave of COVID-19 in the province. I work on health protection and oversee the teams and programs that work on different communicable diseases such as tuberculosis (TB), sexually transmitted diseases, COVID-19 and vaccine-preventable diseases. The public health department also works on health protection, environmental health, emergency responses such as forest fires and flooding, and surveillance. Overall, we’re responsible for health interventions at the population level. To be effective in this work, we need strong health surveillance systems that stay alert to issues present in Nunavik.
What projects are you currently working on?
I am spread out over many projects. For example, a few months back we had a TB outbreak in a community that hadn’t had an outbreak in 15 years. Our role was then to work with the community and plan screening activities to be able to offer treatment to those with the disease, and we will likely need to follow up every few years to ensure that such a large outbreak does not reoccur. TB is a long-latency disease so people might have it but not show symptoms, which is why regular follow-up is necessary for places with a high disease burden such as Nunavik. Additionally, we also have to work very closely with communities to identify how best to communicate to the population, and how to adapt our programs to the specific needs and resources available in each village. This flexible approach is necessary for all programs in Nunavik.
Another area where the public health department tries to have a greater role is water distribution. 13 of the 14 communities in Nunavik rely on trucks for water delivery and sewage removal. The water distribution systems are fragile, and things such as broken vehicles, and missing workers can greatly affect the availability of water in households and community services. This creates a lot of stress for individuals who lack access to water for basic sanitation as well as community services such as schools, health centers, stores, etc that can’t function appropriately without water. Water distribution is not a public health responsibility but a municipal one. Nevertheless, acknowledging the important health impacts of failures in this system, the Nunavik Regional Board of Health and Social Services adopted a Declaration on Water Supply and Sanitation in June 2022 and has increased its work in this area by collaborating with all the partners involved.
What is the impact of research in your field of work?
Our field of work is applied public health so we usually use a variety of methods that stem from research to get practical and actionable information from the world. In health protection, we mostly use a lot of descriptive epidemiology where we evaluate and use disease transmission knowledge to stop disease progression. In some cases, like food outbreaks, we can use analytic epidemiology methods to look at the causes of outbreaks. Additionally, there are certain health conditions where we work at the frontiers of scientific knowledge and sometimes use our work to further understand the disease and improve our response capacity. For example, TB epidemiology in Nunavik is unique compared to the rest of Canada; national standards and guidelines are only applicable to a certain degree and we try to learn what would best work in our setting. Lastly, program evaluation is an intrinsic part of public health work and we also use a variety of knowledge-gathering and synthesis methods to perform those tasks.
It is important to collaborate in research and in applied public health. What kind of partnerships and collaborations have you formed in your position?
We work closely with the healthcare delivery system and also work a lot with municipalities. Each town has its own CSLC and counsellors interested in health and committees working on health. There are also other regional organizations like the school board with whom we partner closely for vaccination programs for example. Schools are central in these communities because close to 50% of the population is of school age or goes there. We often use facilities like schools for health promotion events. Finally, we collaborate with other regional organizations such as the Makivik corporation and the Kativik Regional Government on specific programs or to share health messages.
What kind of challenges do you encounter in healthcare in this setting?
Unfortunately, only a minority of health workers in Nunavik are Inuit. This poses an important challenge in ensuring that health services are culturally safe and meet the needs of the population. We need to make sure services are appropriate for the population, and we do this by consulting with people about our interventions. For example, during the COVID-19 waves, we would often meet with mayors of towns to explain what we wanted to do next and get feedback. Nothing is perfect since the mayors can only represent the general opinion on certain topics and the general opinion can change over time. We constantly try to address culture by looking for Inuit people to work in our organization and in our teams, but it’s a long process. The history of colonization, and the distrust that it has fostered cannot be solved quickly and while there are some programs which work to address this, there is still much to do.
You have lived most of your life in Montreal, Canada. Having gone through the high school education here, what do you think about the way we’re taught Indigenous history in high school?
Yes, it’s a shame how we’re taught about indigenous people in school. Many important aspects of that history are omitted and we are taught some of the ancient histories better than the recent colonial history of Canada. This lack of education leaves a gap for prejudice to fill in and likely contributes to some of the ongoing systemic discrimination towards indigenous peoples. Without historical knowledge, it is unfortunately much harder to redress injustices.
Do you see hope for solutions to decolonize global health and advance indigenous equity?
Despite what I have said about the fact that the health workforce is mostly non-indigenous, I think that it is important to remark that the majority of people with whom I work share similar features of placing a strong value on equity, cultural humility and curiosity to learn about others. Indeed, most of us come from elsewhere so for only a few people in our current workforce, working in Nunavik has been the “default” choice. Yet, I have not seen among my colleagues some of the “saviour complex” that I have sometimes perceived in individuals that I’ve met who are engaged in international health: all those that I work with acknowledge the challenge of being outsiders and work towards increasing the number of Inuit people working in our organizations.
I originally did my training as a doctor and used to work with patients in clinical work, but I shifted to public health work because I felt I could have an impact on a greater number of people. This same sentiment was also present when I chose to work in an area which had a lot of health disparities like Nunavik. Now, is this a colonial approach? Are we replicating colonial history by doing that? If we were to leave, I don’t think that would serve the community better. This being said, day-in day-out we work to try to ensure that what we do can eventually be handed over to the local community. It would take a long time before the structures can be reintegrated by the people from the community. It’s a long process that could take many decades but we’re working towards that goal.
One example is the midwife training program. In the 1980s, a traditional midwifery program was started where midwives were trained locally and in collaboration with institutions outside of the territory. This program was a great success. People from Nunavik could continue to have their babies delivered in the territory and avoid having to travel hours by plane to access those services in other parts of the province which was, unfortunately, the case for other remote Inuit communities in Canada. In many communities now, midwives are trained in Nunavik and deliver culturally appropriate care to their patients.
Furthermore, we are actively working on developing a program for public health officers. People would learn on the job with healthcare workers, doing different kinds of public health work and getting training in specific issues, acquiring skills that will help them get recognized, and gaining qualifications that could eventually also allow them to pursue healthcare degrees. This way, they can contribute to the health of their population while also learning education credits. There is still a lot of work to be done but this provides an alternative educational pathway within the region, and it’s a way for people to be trained locally without the sacrifice of leaving for a long time.
Thank you Dr. Tchalakov for speaking to me and for sharing your insights on this important topic.
Check back next week to hear Dr. Amy Shawanda, an Anishinaabe Scholar, share her experience and perspective.