The Role of Physicians in Recognizing and Supporting
Treatment of Gambling Addiction
(Update November 2005)
Gambling is a common activity in our society. For a small percentage, this behaviour can become pathological, affecting the well-being of gamblers as well as their families and workplaces. This disorder has been described in the "Diagnostic and Statistical Manual of Mental Disorders" Fourth Edition, (DSM IV) and is recognized as an illness by physicians.
Physicians have a role in identifying pathological gambling behaviour and being aware of the resources that exist to treat and support addicted individuals and their families. To assist them in performing this role, the CMA makes the following recommendations:
* The CMA supports the development of core curricula in gambling disorders to be offered at undergraduate and post-graduate levels and through CME programs. These could include inter-professional or interdisciplinary curricula developed in partnership with other health professionals.
* The CMA supports the development and dissemination of resources to help practising physicians screen patients to identify those with gambling addiction and to provide appropriate treatment.
* Governments should ensure the timely availability of quality treatment services appropriate to the age, culture and background of client groups.
* The CMA encourages research into gambling addiction, which could include:
identifying the biological basis for gambling;
identifying best-practice interventions to reduce the prevalence of problem gambling;
measuring the social and economic impacts of gambling on individuals and communities; and
dispelling the myths surrounding gambling addiction.
* Governments and others should work together to implement educational and policy strategies to reduce the prevalence of problem gambling. These could include:
elementary school programs to help prevent pathological gambling disorders;
limiting the number of gambling establishments, particularly video lottery terminals (VLTs) and casinos;
placing age limits on accessibility to VLTs so that children and adolescents are restricted from their use; and
promoting lower risk gambling approaches for primary prevention and harm reduction such as gambling only with a predetermined loss limit and not gambling alone.
HEALTH OF ABORIGINAL PEOPLES 2002
A CMA Policy Statement
That the federal government adopt a comprehensive strategy for improving the health of Aboriginal peoples that involves a partnership among governments, non-governmental organizations, universities and the Aboriginal communities.
2) The Need to Address Health Determinants
The health status of Canada’s Aboriginal peoples is a result of a broad range of factors: social, biological, economic, political, educational and environmental. The complexity and interdependence of these health determinants suggest that the health status of Aboriginal peoples is unlikely to be improved significantly by increasing the quantity of health services. Instead, inequities within a wide range of social and economic factors should be addressed; for example:
interactions with the justice system
racism and social marginalization
water supply and waste disposal
housing quality and infrastructure
cultural identity, (for example, long-term effects of the residential school legacy.)
That all stakeholders work to improve provision for the essential needs of Aboriginal peoples and communities that affect their health (e.g. housing, employment, education, water supply).
3) The Importance of Self-Determination
One characteristic of successful Aboriginal communities is a high degree of self-efficacy and control over their own circumstances. This empowerment can take many forms, from developing community-driven health initiatives to determining how to use lands.
It is increasingly recognized that self-determination in cultural, social, political and economic life improves the health of Aboriginal peoples and their communities, and that Aboriginal peoples can best determine their requirements and the solutions to their problems. Therefore, the CMA encourages and supports the Aboriginal peoples in their move toward increasing self-determination and community control. A just and timely settlement of land claims is one means by which Aboriginal communities can achieve this self-determination and self-sufficiency.
That governments and other stakeholders:
Settle land claims and land use issues expeditiously;
Work toward resolving issues of self-determination for Aboriginal peoples and their communities in areas of cultural, social, political and economic life.
4) Community Control of Health Services
Control by Aboriginal peoples of health and social services is increasing across Canada as part of a broader transfer of control of political power, resources and lands. This transfer has not progressed at the same pace across all Aboriginal communities; the needs of Urban Aboriginal peoples, for example, are only beginning to be addressed.
CMA supports the development of community-driven models for delivery of health care and health promotion, responsive to the culture and needs of individual communities. Successful community-driven models of health care delivery generally recognize that the Aboriginal concept of health is holistic in nature, incorporating mental, emotional and spiritual as well as physical components. Translating this concept into practice may involve:
Development of primary care models that are grounded within Aboriginal culture at a local level;
Integration of disease treatment services with health promotion and health education programs, and with traditional healing practices;
Integration of health and social services;
Interprofessional collaboration within a multi-disciplinary team.
CMA also supports programs to increase the involvement of Aboriginal peoples in professional and other decision-making roles affecting the health of their community – for example, increased representation in health-care management positions, and on health facility boards where there is a significant Aboriginal population.
That all stakeholders actively encourage the development of integrated, holistic primary care service delivery relevant to the needs and culture of Aboriginal communities and under community control.
5) Cultural Responsiveness in the Patient/Physician Relationship
As mentioned above, the concept of “health” in Aboriginal culture is holistic and incorporates many components. The concepts of continuity, wholeness and balance within and among people are important to Aboriginal culture, as is a close affinity with the natural environment – both in practical and spiritual senses , which emphasises the importance of stewardship of the land as a component of individual and community health maintenance for present and future generations.
Physicians should work in collaboration with Aboriginal peoples and groups to promote a greater understanding and acceptance of their respective philosophies and approaches. This could include:
an openness and respect for traditional medicine and traditional healing practices (e.g. sweat lodges, herbal medicines, healing circles). This should be balanced with a recognition that not all Aboriginal people, whether First Nation, Métis or Inuit, adhere to or understand their traditional ceremonial practices.
improved cross-cultural awareness in physicians, which could be facilitated by greater contact with their local Aboriginal communities, better understanding of local Aboriginal cultures, history and current setting,
development of cross-cultural patient-physician communication skills.
a) That educational initiatives in cross-cultural awareness of Aboriginal health issues be developed for the Canadian population, and in particular for health care providers,
b) that practice tools and resources be developed to support physicians (Aboriginal and non-Aboriginal) and other health care professionals practicing in Aboriginal communities.
6) Access to Health Services
Canada is often considered to have one of the best health care systems in the world and is typically described as providing “universal access”. However, our system does not provide equal access to services for all people living in Canada – the most underserviced being those in northern Canada, which contains many Aboriginal communities.
Several kinds of access problems exist in Aboriginal communities:
Lack of access to employment, adequate housing, nutritious food, clean water and other social or economic determinants of health.
Factors that impede access to health care services, particularly in remote locations; for example, language and cultural differences, and the difficulty of transporting patients to tertiary centres.
Lack of specific services (for example, mental health services) for Aboriginal peoples in many regions of Canada. Specific groups, such as women and the elderly, have unique and distinct needs that should be addressed.
Program delivery that involves multiple federal, provincial and municipal funding agencies. Physicians and patients alike have trouble obtaining information about and entry into existing programs and funding for new programs because of jurisdictional confusion.
CMA has previously recommended that the Canadian health system develop and apply agreed-upon standards for timely access to care. This includes the need to increase timely and appropriate access by Aboriginal peoples to health care and health promotion services, geared to different segments of the population according to their needs.
a) That governments and other stakeholders simplify and clarify jurisdictional responsibilities with respect to Aboriginal health at the federal, provincial and municipal level, with a goal of simplifying access to service delivery.
b) That strategies be explored to increase access to health services by remote communities; for example, through the use of technology (e.g. Web sites, telemedicine) to connect them with academic medical centres.
7) Health Human Resources
There is an urgent need to increase the training, recruitment and retention of Aboriginal health care providers. The 1996 Royal Commission on Aboriginal Peoples recommended that a cadre of 10,000 Aboriginal health care and social service workers be trained to meet the needs of a complex and diverse community. While progress has been made in recent years, an intensive focus on recruitment, training and retention is required in order to achieve this goal.
A comprehensive health human resource strategy should be developed, to increase the recruitment, training and retention of Aboriginal students in medicine and other health disciplines. Such a strategy could include:
Outreach programs to interest Aboriginal young people in the health sciences.
Access and support programs for Aboriginal medical students.
Residency positions for recently graduated Aboriginal physicians or physicians wishing to practice in Aboriginal populations, including re-entry positions for physicians currently in practice.
Mentoring and leadership-development programs for Aboriginal medical students, residents and physicians.
Programs to counter racism and discrimination in the health-care system.
Initiatives to recruit and train Community Health Representatives/ Workers, birth attendants and other para-professionals within Aboriginal communities.
a) That CMA and others work to develop a health human resource strategy aimed at improving the recruitment, training, retention of Aboriginal physicians and other health-care workers;
b) That medical and other health faculties increase access and support programs to encourage enrollment of Aboriginal students.
8) Health Information
Information about the health status and health care experience of Aboriginal peoples, is essential for future planning and advocacy. For Aboriginal peoples to effectively develop self-determination in health care delivery, they should have access to data that can be converted into useful information on their population. The “OCAP” principle (ownership, control, access to and possession of health data) is seen as integral to First Nation community empowerment, but may prove acceptable to other Aboriginal groups as well.
A considerable amount of data currently exists, though there are gaps in coverage, particularly regarding Métis, Inuit and urban and rural off-reserve First Nations populations. This data can come from a variety of federal and provincial/territorial sources, including periodic surveys, federal censuses, Aboriginal Peoples Survey data holdings, and also regional physician and hospital utilization statistics. However, jurisdictional and ownership issues have hindered Aboriginal people from accessing and making use of this data.
CMA supports the development and maintenance of mechanisms to systematically collect and analyze longitudinal health information for Aboriginal people, and the removal of barriers that prevent Aboriginal organizations from fully accessing information in government databases. Aboriginal health information should be subject to guarantees of privacy and confidentiality. The CMA urges relevant government departments to ensure that revisions to the Indian Act do not infringe on the privacy of health information of Aboriginal peoples in Canada.
That the Government of Canada support the First Nations and Inuit Regional Longitudinal Health Survey Process, and the First Nations and Inuit Health Information System, and parallel interests for the Métis and Inuit. These programs should be operated under the control of their respective Aboriginal communities
The CMA supports culturally relevant research into the determinants of Aboriginal health and effective treatment and health-promotion strategies to address them. Specifically, the CMA supports the efforts of the Institute of Aboriginal Peoples’ Health at the Canadian Institute for Health Research, in addressing the needs of Canada’s Aboriginal peoples.
Aboriginal peoples should be involved in research design, data collection and analysis; research should support the communities as they build capacity and develop initiatives to address their health needs. Ideally, research should address not only determinants of ill health but also the reasons for positive health outcomes.
The CMA also acknowledges the need to communicate research results to Aboriginal communities to help them develop and evaluate health programs. In particular there is an urgent need among Aboriginal communities for the sharing of successes.
That government and other stakeholders
Support Aboriginal peoples and communities in the development of Aboriginal research and the means of interpreting its findings.
Make public communication of health research results a priority in order to facilitate its use by Aboriginal communities.
CMA’S CONTINUED COMMITMENT
The Canadian Medical Association, consistent with its mandate to advocate for the highest standards of health and health care in Canada, will continue to work with the Aboriginal community and other stakeholders on activities addressing the following issue areas:
Research and Practice Enhancement:.
Public and Community Health Programming:.
Advocacy for healthy public policy.
November 15, 2002