Register Thursday | June 21 | 2018
Nunavut's Nursing Crisis Photograph by Ron Wassink.

Nunavut's Nursing Crisis

The life expectancy in Canada's newest territory is a decade lower than the rest of the country, and those most essential to providing front-line health care are in short supply.

WHEN JOANNE DIGNARD ARRIVED IN QIKIQTARJUAQ, Nunavut in 2007, the hamlet, nestled on a small island approximately 100 kilometres north of the Arctic Circle, had been without a permanent nurse for two years. About 520 people, 90 percent of them Inuit, live in Qik, with its unpaved streets, two grocery/department stores, small hotel, school, community health centre, church and not much else.

Before her arrival, positions at the health centre had been filled by a revolving-door series of nurses who stayed, at most, a few months. Dignard, who’s in her early fifties and hails from the Acadian town of Tracadie-Sheila, New Brunswick, moved here in order to bring stability to the centre. She spent more than a decade at her previous post in Arctic Bay, a slightly larger settlement at the northern tip of Baffin Island. Dignard’s long tenure in the north—the past twenty-three years—makes her one of a tiny minority of southern nurses who have made the territories home. Most nurses from the south stay, on average, about two-and-a-half years—at least that’s a best guess. There are no official statistics on average length of stay. In 2011, ninety-four of the 244 permanent nursing positions were vacant, though many vacancies were filled on a short-term, temporary basis.

I travelled to Nunavut in 2012 (a trip that was affordable only because I had a health journalism grant) to investigate nursing in the north and, in particular, the territory’s problems recruiting nurses and keeping them on the job. Reporting on health care in Nunavut is apparently a sensitive issue: the territory’s deputy minister of health, Peter Ma, made it a condition of my travel that I be accompanied by a “minder” from the health department’s communication division. Ron Wassink, a former publisher of an Ontario community newspaper, would join me, sitting in on most of my interviews and placing his digital recorder next to mine. I’ve been a journalist for more than thirty years and never before had these kinds of conditions placed on my activities.

In a territory where only a few communities have full-time doctors, nurses play a critical role in delivering health care. But Nunavut suffers from a high vacancy rate for full-time positions, a high turnover rate for those jobs and a heavy reliance on casual and temporary nurse positions. The result is a disturbing lack of health care continuity in many Nunavut communities.

NUNAVUT’S APPROXIMATELY 36,000 inhabitants live in twenty-five communities scattered over 2.1 million square kilometres divided into three time zones and three administrative regions. The territory, now fifteen years old, is Canada’s newest and largest jurisdiction and the only one where indigenous people represent the majority (86 percent) of the population. None of Nunavut’s settlements are connected by road and, except for a few summer months when supply boats can reach coastal communities, the only way to get from one community to another is by air.

The geographic and demographic realities of the territory go some way towards explaining the fact that Nunavut has the most expensive health care system in the circumpolar region. At over $13,000 per capita last year, health care costs were more than double the Canadian average. Medical travel and medical evacuations account for about one-quarter of treatment costs. A former health minister once estimated that one out of eight health care dollars goes to jet fuel.

When patients require more care than is available in the territory’s facilities, Nunavut relies on three provinces and one other territory. Residents of Iqaluit and smaller Baffin Island settlements like Qik travel to Ontario for specialized medical appointments and intensive care; Rankin Inlet and the surrounding area links to Manitoba and residents of the most westerly region in Nunavut are flown to the Northwest Territories and Alberta. Altogether, about 40,000 flights every year take Nunavut patients south for care, the territory’s MP Leona Aglukkaq told the Canadian Medical Association in 2012. But bad weather can often delay medical evacuation, leaving nurses to treat or stabilize patients. Dignard told me about one community she worked in where a medical team arrived to evacuate a two-year-old with double pneumonia, but the weather closed in and they couldn’t leave. The child was intubated and attended to twenty-four hours a day for two days until the weather lifted. “If it had been longer, we would have run out of medicine,” she recalled.

Dignard delivered four babies in Qik—all premature. When they are thirty-six weeks pregnant, most women in Nunavut are sent from smaller communities to give birth at the hospital in Iqaluit, the birthing centres in Rankin Inlet and Cambridge Bay or, if they are deemed high risk, to neonatal units in southern hospitals. Physicians and dentists visit regularly, for a few days at a time, but day-to-day care in the territory is predominantly administered by nurses.

AN IQALUIT-BASED DOCTOR recommended I interview Dignard. It turns out she is a bit of a darling with Nunavut’s health department which in 2013 recognized her work with an “excellence in nursing practice” award. She now works as the sole nurse in Grise Fiord, Nunavut. She’s straightforward and unpretentious, not given to discussing the politics of health care.

It’s mid-September 2012 when we visit her in Qik. There’s a sprinkling of snow on the ridges in the distance, but the weather is relatively mild. Children are playing outside wearing only light jackets. Small motorboats used for fishing and hunting are tied up along the shore and at the hamlet’s only pier. When narwhals are reported to be nearby, the hunters take to their boats. They butcher the mammals far from the hamlet to keep polar bears that would be attracted to the smell of the flesh away from the settlement. The hunters return with the narwhals’ ivory tusks, which can be up to 8 feet long, and sealed tubs full of a local delicacy called muktuk, the top layer of blubber and skin from the mammal.

Qik’s community health centre is a one-storey wooden building perched near the shore of the Davis Strait, a stone’s throw from the pier. One wall in the small reception area is covered with snapshots of hamlet residents. Clerk Rosie Kudlualik (who had been on the job for twenty-five years) acts as interpreter and translator. Dignard, who speaks with a trace of a French accent, knows enough Inuktitut to set patients at ease, but she’s not fluent (it’s a notoriously difficult language to learn) and admits “you get kind of lazy when you have a translator available.”

The health centre features a small pharmacy, digital X-ray equipment, two well-equipped examination rooms and a telehealth connection, which allows for audiovisual consultations in real time with family doctors and specialists in Iqaluit and Ottawa. There’s a holding room, with an incubator, for patients and babies awaiting evacuation.

At six o’clock one morning, Dignard picked us up for a tour to points of interest outside the hamlet—the dump, the sewage lagoon, the water supply (water is delivered by truck from the nearby reservoir to the hamlet), her getaway cabin (part of a small encampment on the shores of the Davis Strait, a two-hour walk from the hamlet) and the cemetery.

A white fence surrounds the cemetery and the graves are almost identical—marked with white crosses, bordered (and often covered) with rocks and adorned with an abundance of colourful plastic flowers. There are no ancient graves; Qik was settled in the late 1950s as Broughton Island when a Distant Early Warning Line, a Cold War initiative to monitor possible Soviet aggression, was being built nearby. The semi-nomadic residents of the area were forced into static settlements.

We had hoped to spot a polar bear near the dump but saw only long lines of large black birds perched on the chain link fence. “It’s raven heaven,” Dignard said. The dump is also where Dignard found the plastic roof for her cabin, a makeshift, mostly wooden affair that resembles a long, low tent. It features a plywood vestibule leading into a small room with a small window. Like the regular houses in Qik, it’s built on stilts because it would shift and crack if built directly on the permafrost. Dignard, who shares a townhouse with other nurses, likes to spend time at her cabin. She doesn’t socialize much with community members. “I try not to put myself in a situation where maybe I could slip or say something I shouldn’t,” she says. “I do a lot of stuff, but I kind of spend minimum time here or there. I keep my distance so I can keep more confidentiality—it’s not a strain, it’s part of my personality.”

More than a dozen years ago, she took up the violin—“it’s kind of an Acadian thing”— and she offers free lessons to children. In the beginning, she had five students but, after they gave a school concert, more wanted to join. One Christmas season, she spent every evening fundraising in order to fly a group of them to a regional music workshop. She also offers a free babysitting course—“the kids are already looking after their siblings, so better they should know some first aid and so on”—helps organize twice-weekly evening exercise opportunities for women at the high school gym and teaches cross country skiing to local children.

NURSES HIRED IN NUNAVUT usually hail from opposite ends of the career spectrum: very early in their career or near retirement. Young graduates from the south are attracted to the adventure, the opportunity to work full-time at one job and the signing bonuses ($5,000 to sign, another $5,000 after eighteen months’ continuous service and $10,000 after thirty months’ continuous service). However, quite a few, including those who’ve moved north with spouses, return south when they want to start a family or when their children reach school age.

When Nunavut was created in 1999, nurses had already lost financial assistance for vacation, which made recruitment difficult for the new territory. Nurses became direct employees of the new government and some longtime nurses left. Nunavut Arctic College opened a nursing program in Iqaluit in 2000 with a focus on training Nunavut residents. A 2005-2006 initiative to fill vacancies with nurses recruited from India and the Philippines proved to be an expensive failure. Accounts differ on the reasons for its lack of success, the total costs of the project and the final retention numbers. But at least fourteen of the thirty-five or so nurses recruited from abroad failed Canadian nursing exams and by 2007, according to former Chief Nursing Officer Fred Montpetit, fifteen at most remained in Nunavut.

By 2008, almost half of the 215 nursing positions in Nunavut were vacant. That year, the government was filling 25 percent of vacancies with agency nurses—sixty agency nurses a month—at a cost of about $23 million a year, says Montpetit. The bill to the government for an agency nurse filling one full-time position is almost $344,000 a year, compared to about $195,000 for a full-time nurse employee.

Since 2008, the government has managed to reduce its dependence on agency nurses by increasing the number of government-employed nurses who work on a casual basis. By the fall of 2011, only ten agency nurses were in place but there were seventy-four casual staff on short-term assignments.

Agency work appeals to sixty-nine-year-old Carol Tyrrell, who was working as a home care nurse out of a small office at the Qik health centre. “Usually my stints are six weeks. Quite frankly, the money is wonderful,” she says. Agency nurses have their transportation paid for and their housing provided.

Tyrrell has worked in Canada’s north on and off for a couple of decades, frequently in home care. She has come to accept a few things about short-term nursing assignments. “You can go into a nursing station that is run like a battleship and someone is in charge and everything is run lock-step. Or, you can go in when it is total chaos. One thing you realize is that in six weeks you aren’t going to change things.” Tyrrell says that nurses must also understand that patients aren’t going to trust them just because they’re wearing a uniform. “Patients have said, ‘But you’re the fourth nurse I have seen in the past year. I really don’t like having different nurses all the time.’” She says she would probably feel exactly the same way. “But you try to develop a positive relationship and it takes three or four visits, having a cup of tea, asking about the children and the grandchildren. Nursing is so much about building relationships.”

Given the importance of those relationships, it’s hard to overstate the problem with the high turnover and the use of agency nurses. Often relief nurses who are flown in are great nurses in the south, says Pertice Moffitt, past president of the Canadian Association for Rural and Remote Nursing who has worked for more than a quarter of a century in the far north. “But they have no understanding of the community, no understanding of the problems of the people. You always hear stories of them telling the patient to go home and do this and that, not realizing that they don’t have the resources. And the patient is not going to speak up and say, ‘I don’t have that.’”

WHEN IT COMES TO WORKERS who move to Nunavut from the south, transience is a key feature of all employment. But lack of continuity is particularly problematic in health care because the health status of the Inuit is a major concern. A 2011 report noted that life expectancy in Nunavut actually dropped between 1996 and 2005, from 70.4 to 69.8 years. Over the same period, the life expectancy gap with the rest of the country widened from eight years to ten years. Nunavut’s mortality rate is over double the national average: Nunavut residents are much more likely to die from cancer (in particular lung and colorectal cancer) than other Canadians. According to the 2013 book Nunavut: A Health System Profile by Gregory P. Marchildon and Renée Torgerson, Inuit children suffer the highest rate of illness, hospitalization and death from lower respiratory tract infections in the world.

Better continuity and improved efficiencies in the provision of health care, such as earlier diagnosis, may help mitigate health problems. But they do nothing to solve the underlying causes of ill health in Nunavut—cramped and often substandard housing, poverty, exorbitant food costs (resulting in poor diets and hunger), problems with the education system, high school drop-out rates, smoking rates more than two times higher than in the rest of the country, lack of recreational activities and, of course, mental health issues. These are predominantly related to a history of displacement and forced resettlement which led to a rapid transition from a traditional, semi-nomadic life on the land to participation in a wage economy, and, beginning in the 1950s, to Inuit children being separated from their families to live in residential schools.

Inuit used to get sufficient vitamin D from traditional “country” foods, such as blubber, but climate change is taking its toll on the arctic habitat: sea ice is less stable, hunting marine mammals is more dangerous and lifestyle changes mean that the number of hunters is declining. Dietary changes have led to deficiencies and even to cases of rickets, characterized by soft bones and teeth.

Iron and vitamin deficiency are common and Dignard jokes that she “pushes” vitamin D, which is available for free at the community centre. Lack of high-quality, affordable food is a critical issue in Nunavut. Residents of the territory spend, on average, three times as much on food as other Canadians. The government, through the Nunavut Food Guide, tries to promote healthy store-bought foods and traditional food sources obtained by hunting, fishing and gathering. The day that we drove around Qik, we saw an Inuk man walking along with a large bag slung over his back. He told Dignard that it was full of halibut that he’d caught and was distributing for free to land claim beneficiaries. It was reassuring to witness traditional sharing practices in action. According to the 2007-2008 Inuit Child Health Survey, 70 percent of Inuit children ages three to five in Nunavut live in homes that are food insecure.

High nurse turnover rates and demands for acute care leave little time for health promotion activities that could help mitigate these issues: Joanne Dignard is on call when she’s not at the clinic during her 8:30 AM to 5 PM weekday work hours. But nurses still find time for public health initiatives. One afternoon, Dignard took us to a small classroom in the school where Grade Six girls were sent for their human papillomavirus (HPV) vaccination. The Inuk community health representative explains the purpose of the shots to the girls (the vaccine is given to prevent HPV infections which can cause cancer of the cervix) and Dignard gives the needles.

MY FLIGHT TO PANGNIRTUNG, a forty-minute hop from Qik, was delayed one day because of bad weather. Pangnirtung is in a stunningly beautiful location on the Cumberland Sound, surrounded by snow-capped peaks. It’s home to about 1,400 people and the settlement is spread out on a grid pattern of streets.

Pang is a good town for walking—too small to get lost, but with lots to see: polar bear skins stretched out to dry on porches or on frames leaning against houses, soap stone carvers working at grinders outside their homes and children and dogs racing around. I’d often see men and women smoking on front porches—a public health victory, as indoor smoking in crowded housing has contributed to high rates of respiratory illness.

It’s a ten-minute walk from the hamlet office to the modern health centre, a spacious, light-filled building with a large reception area and high ceilings. This building opened in the summer of 2010, two years behind schedule because of delays in construction and in ordering and delivering furniture, which had to come by the sealift supply vessel.

I met there with nurse Jacqueline Babchishin, the supervisor for health services at the centre, and Heather Hackney, a nurse and the Pangnirtung-based director of health for the South Baffin communities. My government minder, Wassink, didn’t come with me to Pang and instead Hackney played that role.

Babchishin, an attractive, intense woman with shoulder-length blond hair, had arrived at the community health centre in October of 2010 to fill the last of five nursing positions. When we spoke two years later, she was the only one left from that group. Three of the five full-time positions were vacant, filled temporarily by nurses employed on a casual basis.

Babchishin, who used to work as a clinical support nurse at the Hospital for Sick Children in multi-ethnic Toronto, found herself unprepared for the extent of the cultural differences in Nunavut. Nurses recruited to the north get a couple of weeks of orientation and that includes some cultural training. But, like Dignard, Babchishin speaks a little Inuktitut and relies on the health centre’s two clerk interpreters as well as other Inuit staff who can fill in to translate as needed (English is taught in schools, but some elders are unilingual). It’s not just language that is different. She says there are deep cultural differences in “ways of living in the world” and describing oneself. “It takes a long time to understand the differences and the implications.”

Hackney, a tall slim woman with the nervous manner of a beleaguered bureaucrat, jumps in to explain that newcomers learn from support staff and the community. “It’s not just what’s said, but what isn’t said. It takes a while to recognize the cues, and sometimes mistakes are made, and you have to be open to learning from them.” The longer nurses are in a community, the more people will open up, she says. But she acknowledges that the Inuit watch nurses “come and go all the time, and that is sometimes hard for the population.”

The opinion of the population doesn’t hold much sway in Nunavut’s current health care system. Ron Mongeau, the long-time senior administrative officer for the hamlet, told me about the time that a file, “inches thick,” of complaints from community members about a particular nurse was sent to the territorial government in Iqaluit. The nurse “did not have the trust of the community,” he explained. But the concerns were “completely ignored” and she remained at the health centre (though she had moved on to another community before my visit).

In most provinces, there’s a regional health authority or hospital board for patients to turn to with concerns about health care delivery—some mechanism for accountability. But in Nunavut, Mongeau (who has since left his position) explains, there’s “no independent third party review.” It’s a sore point for many communities that in 2000, a year after Nunavut was created, the government disbanded the regional health boards that had been set up in the early 1980s. This left all health care management for the vast territory in the hands of the Nunavut government (referred to as the GN).

In May 2011, the Nunavut Association of Municipalities passed a resolution, for the second time, calling for a return to more local control over health issues. The GN has refused to act on the association’s demand, but in 2013 it made one apparent concession to concerns about the lack of accountability in the system. It opened an “office of patient relations.”

As government employees, nurses are members of the Nunavut Employees Union (NEU) but many nurses complain that neither the GN nor the NEU adequately understand issues relevant to the professional standards set by legislation and enforced by nurses’ regulatory colleges.

At the end of my formal, chaperoned interview with her, Babchishin told me about a friend, a fellow nurse from the south, who’d been in a terrible one-vehicle accident in a government truck during winter but had mostly recovered. She remained up north and, still a GN employee, had been given work that accommodated her physical limitations. I sought to interview this woman—it interested me that she stayed up north and was given different work—but, for some reason alarmed at my request, Hackney lost no time consulting with her superiors in Iqaluit. I was forbidden to speak to the employee.

IT SEEMED LIKE EVERYONE I’d met (or heard of) in Pang was at the airport on the morning that I flew out to Nunavut’s capital city, Iqaluit. First Air and Canadian North airplanes were both scheduled to arrive at about the same time, but the planes would be heading out in different directions.

After I settled into Iqaluit, one of my first visits was to Nunavut Arctic College to find out about its nursing program. The advantages of graduating Inuit nurses are obvious in terms of the continuity of the workforce and the ability to provide culturally sensitive care. Furthermore, Article 23 of the Nunavut Land Claims Agreement, the basis for the creation of the new territory, stipulates that Nunavut is committed to the goal of having government employment patterns mirror local demographics, which translated to having 85 percent of jobs filled by Inuit. GN figures for 2012 indicate that about half of all government employees are Inuit.

In Iqaluit, my chaperone Wassink was back on the job. It’s hard to tell whether, or how much, his presence influenced my interviewees. I did, however, find it annoying when he occasionally interrupted to lob his own softball questions to the nurses—“What do you like about working here?”—or when he scoffed at some information I’d been given by the Nunavut Employees Union.

Sally Naphan, the lively and enthusiastic manager of nursing and health sciences at Arctic College, told us that the four-year nursing program, affiliated with Dalhousie University’s school of nursing in Halifax, began graduating nurses in 2004. While she says there is no explicit mission statement, the program aims to educate nurses who will stay in the north and Inuit are particularly encouraged to apply.

Of the thirty-nine graduates to date, fourteen are Inuit. Some of the others grew up in Nunavut, and all the applicants are required to have lived in the territory for at least one year before applying. Inuit students in particular face multiple challenges. The program is offered only in Iqaluit and, given the vast size of Nunavut and the high cost of air travel, most students from other communities spend the school year isolated from family. The Inuit place a priority on family life and the separation has contributed to a high first-year drop-out rate. Only two students graduated as part of the first class in 2004.

The pregnancy rate of women between the ages of fourteen and nineteen in Nunavut is more than five times the national average and the territory has the youngest and fastest-growing population in Canada. Inuit nursing students often have young children and must juggle the demanding course work along with parenthood, made more difficult when extended family is far away.

Pallulaaq Ford is one of the five graduates from the class of 2006. She already had a five-year-old and a three-year-old when, after finishing high school, she flew from her home in Rankin Inlet across Hudson Bay to Iqaluit. “That first year was really hard for me and my family. I took my partner and two boys [to Iqaluit]. It was rough. I don’t know how many times I wanted to come home. The only reason that I stuck it out is that my older sister was in Iqaluit, so we weren’t completely alone, we had family there.”

Academic requirements pose another challenge. Nunavut has a high school drop-out rate of 50 percent, the highest in Canada, and this reduces the potential pool of applicants for the nursing program. Prerequisites include Grade Twelve academic science courses, but these aren’t taught in all the community high schools. The college offers a pre-nursing program to allow for this upgrading, and since 2002 has developed more rigorous acceptance standards in an effort to improve retention. Naphan is proud that Nunavut Arctic College nursing students have always had a very high success rate on national exams.

Nancy Gordon is a soft-spoken, serious woman who answers questions slowly and carefully (though she laughed when I joked that she was a “poster girl” for the nursing program because her image is on Arctic College promotional material). She grew up in Rankin Inlet—her father is Inuk, her great-grandfather was white—and when we spoke she was in her fourth year of the nursing program. When she enrolled in the program she was separated, had two young teenagers and, in her mid-thirties, was older than most other students. The college provided her with some extra tutoring in sciences and math to improve her high school marks.

The summer before we spoke she had worked alongside a non-Inuit home-care nurse. “I did have patients who were unilingual, and I did speak with them in Inuktitut, but I didn’t know some of the medical terminology [in Inuktitut].” In fact, not all medical terms have been translated, and Inuktitut-speaking nurses and interpreters often find themselves having to describe symptoms and conditions at some length. In 2012, an Inuit women’s group took it upon themselves to compile and publish a glossary of sexual health terms in five major dialects of Inuktitut.

An interpreter travelled with Gordon and the home-care nurse, but Gordon says she sometimes noticed the interpreter mistranslating in ways that “made a difference for the person.” And the dialects also pose a challenge. For example, the word for doctor is different in Rankin Inlet (in the Kivalliq region) than in Iqaluit (on Baffin Island in the Qikiqtaaluk region).

Rebecca Akulujuk Lonsdale, who has a quietly professional manner and excellent posture, was acting clinic manager at Iqaluit’s Qikiqtani General Hospital (QGH) when I visited. Her first language is Inuktitut and after graduating from high school in Iqaluit, she worked at an administrative job with the government. For high school graduates like Lonsdale, there are lots of well-paid job opportunities in Iqaluit—ones that don’t require the four additional years of nursing college. But Lonsdale wanted something different. “I needed to be with people, not at a desk job.” So at age twenty-six, she enrolled in the Arctic College nursing program. Like many other Inuit students, she already had a young child and so had to balance getting an education with being a parent. After graduation, she was hired directly into a mentorship program at QGH. I spoke with Lonsdale at the hospital. It’s a modern facility completed, more than a decade after planning had begun, in 2007. The main entrance features a high-ceilinged atrium whose pale yellow walls are decorated with fish and bird motifs.

The mentorship program was a big plus for Lonsdale because she faced a steep learning curve. The in-patient ward at QGH is not specialized, so nurses have to care for many different kinds of patients on the same floor—from mental health and cardiac patients to children. For nurses hired from the south, this is also a big adjustment. Most come from having worked on specialty wards and aren’t accustomed to dealing with a wide range of patient illnesses. Cultural sensitivity is an issue here as well. Lonsdale says she’s often called on to explain custom adoption, birthing practices, attitudes towards pain and ways of grieving. If a patient is near death, and a certain food is in season, family members will go out of their way to obtain some of that food “so the patient has a well-nourished death.” She pauses and picks her words carefully, judiciously: “Knowing or learning more about our culture beforehand I think would be helpful. Sometimes comments are made because [southern nurses] don’t understand a cultural practice, and it can be difficult not to be offended.”

PETER MA, the deputy minister of health, was keen that I visit a region of Nunavut outside Baffin Island so I took a flight west from Iqaluit to Rankin Inlet. Wassink would meet up with me there. With about 2,300 inhabitants, Rankin is usually deemed the second-largest centre in Nunavut after Iqaluit, though these days it’s neck-and-neck with Arviat for that distinction. Rankin is built on flat land—markedly different from the hilly and scenic places I visited on Baffin Island—and the town, which is the gateway to Nunavut for central and western Canada, has a far more business-like atmosphere.

I made my way to my accommodations, Tara’s Bed and Breakfast, which often serves as a temporary home to pregnant women who come from smaller communities to give birth at Rankin’s birthing centre. (Colleen, who runs the B and B, told of one baby who was born early and unexpectedly when her mother was upstairs enjoying a bath in the large spa-like tub.)

From Tara’s, I managed to find my way to the health centre, where Linda Sawyers is the nurse manager for the outpatient department, emergency and travel. Sawyers began heading to Nunavut in 2000 to work during summers off from her nursing job at the health centre at Brock University in Ontario. Sawyers worked in a number of different communities. Eventually, her husband told her she seemed happier working in the north so he joined her here. She’s been a full-time nurse manager at the Kivalliq Health Centre since 2007.

She took us on a tour of the centre, where it’s obvious that she’s respected by her staff and by visiting physicians. At sixty-three, she told me she’s definitely “not ready to go home to be a senior.” The health centre had three Inuit nurses on staff, more than any other health centre in Nunavut, as well as two of the international nurses who were recruited to Nunavut back in 2006. (Now, one Inuit nurse and one white nurse, Andrea McLarty, born in Nunavut and fluent in Inuktitut, work here alongside the international recruits.) The health centre is clearly well run, but Sawyers (who’s still on the job at sixty-five) noted that it’s understaffed.

Pallulaaq Ford has been working at the centre since she graduated in 2006. She has a gentle manner and a wide smile. She is the manager of clinical nurse education for the Kivalliq region and supplements the standard orientation for nurses. She holds talks about cultural issues “to give them a heads up about things I know they won’t understand or will misinterpret.” For example, when a nurse explains something to Inuit patients, especially elders, they may sometimes “not seem interested or give you a weird look because they are not used to being told what is going on or being given an explanation.” That attitude, she thinks, can be attributed to the history of health care in the north. In the 1950s, large numbers of Inuit with tuberculosis were separated from their families and taken away to sanatoriums in the south, not knowing where or why they were being taken. Some of these Inuit, Ford says, “aren’t trusting of people at health centres.” But when it comes to questions posed by nurses from the south, Ford says she sometimes feels a bit awkward because she doesn’t always know if she’s speaking for all other Inuit or just for herself. Traditionally, it is elders who represent the community. 

When we spoke in her office, Sawyers was more forthright about her concerns than many other interviewees. She was pleased that, because of a recent policy change, she could interview and recruit her own nurses for casual appointments; previously, the human resources department, operating out of Iqaluit, had to set up the interviews. (In the fall of 2013, that policy change was reversed.) But the problems don’t stop once new staff arrive in Rankin. The health centre had just managed to recruit two new doctors, but whether they would be able to remain depended on the availability of housing. In the end, one doctor was able to stay and the other, who had four children, had to leave because they could only find him a three-bedroom house. Finding accommodation for nurses is equally difficult. Housing, Sawyers said, “is a nightmare.”

I DIDN’T HAVE ANY official interviews in Cape Dorset but I wanted to visit this settlement, internationally famous for carvers and for a print shop that nurtured the talents of Inuit printmakers such as Kenojuak Ashevak, Pitseolak Niviasi and Kananginak Pootoogook.

With about 1,200 residents, Cape Dorset appears relatively wealthy—there are more ATVs and other vehicles roaming around the streets—likely because of the market for Inuit carvings and prints. Most of the art is sent south to agents and buyers but I was approached on the street by a few artists.

I stayed two nights. Other guests at my hotel included a dentist from Montreal on a brief trip to provide care to residents (within Canada, rates of dental surgery due to tooth decay among children ages one to five is highest in Nunavut); a tradesman, Winston, from Grand Falls-Windsor, Newfoundland; and Joanne, a social worker who’s worked in Nunavut for more than a decade. She and I went for a walk outside the town proper one afternoon, spotting tent rings (circles of rock) from when the Thule people lived in the Arctic hundreds of years ago. We came upon a few feet of thick rope on a beach. “I get nervous whenever I see a rope,” she confided. Hanging is a preferred method of suicide in Nunavut, where the suicide rate is thirteen times the Canadian average.

The local co-op store in Cape Dorset is clearly a hangout—young men and women seemed always to be lingering around the grated iron steps, smoking, chatting and watching the ATVs come and go. I went there just to check out the local action. Inside, it was the usual crowded aisles of food and other items, like a combination grocery and dry goods store in the south—except for the much higher prices.

At the checkout, the friendly young woman asked, “Are you a nurse or a teacher?”

AT ONE POINT on my trip, frustrated with the constraints the government was putting on my reporting, I managed to set up a “secret” meeting with some staff and a visiting physician. I had been exploring the community wearing my bright purple rain jacket, so I resorted to subterfuge, walking through town to the assignation in a borrowed black coat and hat—a sort of half-hearted disguise. At the meeting, it became clear that the conduct of some of the staff who’d previously delivered health care in the community had left a legacy of paranoia, fear and bitterness. “A world turned upside down,” is how one nurse described the situation. I heard stories of management making threats towards nurses accused of being “on the side of the community,” of poor control of pharmaceuticals, of nurses routinely moved to work in other communities when too many patient complaints surfaced, of some staff regularly using abusive language to describe Inuit (“fucking Eskimos”) and of staff on extended stress leave. One of the people at my clandestine meeting observed, “So much is swept under the carpet here that it looks like a mattress.”