PoPulationand Public HealtH etHics

The case narrative argues that First Nations communities “appeared to be at
higher risk of more complicated or severe illness,” and that this was due, at
least in part, to poor living conditions, inadequate health services and remote
or rural locations. However, the exact contribution of these factors to H1N1
morbidity and mortality is unclear. The case narrative cites a 2009 study indicating
that 25.6% of all people admitted to hospital for H1N1-related conditions
were of Aboriginal ancestry, even though they only make up about 4% of the
Canadian population — clearly a disproportionate burden. The same study
notes that obesity, hypertension and a history of smoking or diabetes occurred
among 30–40% of the patients, and that “all these conditions are known to be
increased in frequency in the Aboriginal population that comprises a substantial
portion of cases within this cohort. The extent to which these comorbidities
contribute to severity of disease is unclear because a large portion of the Aboriginal
population (which may be a risk factor itself on the basis of genetic
susceptibility) often have such comorbidities.” Indeed, obesity alone — which
is significantly higher in First Nations communities than in the general population
— has been identified as a significant risk factor for H1N1 hospitalization
and mortality. 3 This observation raises the possibility that the increased proportion
of Aboriginals among H1N1 hospital admissions was due in large part
to underlying comorbidities and health behaviours, not living conditions.
Conversely, the cause of this health inequality may be unknown. One study
found that Aboriginal people who were admitted to hospital with H1N1 influenza
were no more likely to suffer a severe outcome than any other group. 4
Another study of Manitoba residents found, conversely, that the greater risk
of hospital admissions among Aboriginals persisted even after accounting
for age, sex, co-morbidities, rural residence and income level. This finding is
consistent with findings of higher morbidity and mortality among Aboriginal
populations during previous pandemics and in other countries, suggesting
some unknown genetic or social factor. 5
To return to our previous discussion, a utilitarian might argue that, since
we cannot yet identify a clear connection between living conditions and increased
risk of complicated or severe illness, this increased risk cannot justify
ameliorating those living conditions. We may still justify this intervention
on the basis of other concerns discussed above, but we do not have adequate
information to justify it on the basis of increased utility — in this case reduced
risk of severe H1N1-related health outcomes — alone.
Health Inequities in First Nations Communities and Canada’s Response to the H1N1 Influenza Pandemic
161