Largest outbreak of COVID-19 in an Indigenous community in Canada offers important lessons

In the wake of a large outbreak of COVID-19 in northwestern Saskatchewan the most serious of any Indigenous community in Canada health officials and local leaders are relying on what they learned during the three-month ordeal to plan for potential outbreaks in other remote, rural areas.

"When it first hit us, we were basically clueless of how to contain this," said Chief Teddy Clark of the Clearwater River Dene Nation (CRDN), 600 kilometres northwest of Saskatoon.

But now, given what he's learned, Clark said he feels "a little bit at ease" that he'd be ready for a surge in cases.

Despite dire predictions early in the pandemic, theon-reserve infection rate among First Nations people in Canada is four times lower than the rest of the population, according to the federal government, with a total of639confirmed cases as of Sept. 25. The on-reserve First Nations population in Canada is about 329,000, as of the 2016 census.

I think it's a success story of how things can be handled.- Carrie Bourassa, Institute of Indigenous Peoples' Health

In mid-April, the first case of COVID-19 in northwestern Saskatchewan was traced to travel from an oilsands camp near Fort McMurray, Alta. The virus spread to a long-term care home in the village of La Loche and then moved quickly through overcrowded homes in the community and its neighbour, the Clearwater River Dene Nation.

The two Dene communities have a combined population of 3,800, and people frequently move back and forth between the village and reserve.

From the beginning of the outbreak, Indigenous leaders warned public health officials that any response needed to be led by the community and elders, with their culture in mind. They also warned that people in their communities were particularly vulnerable.

"Our people suffer from extremely high rates of co-morbid conditions, with issues like diabetes, respiratory, HIV, heart conditionsand trauma-induced addictions, that put them at high risk of death from COVID-19," Rick Laliberte, the commander of the North West Communities Incident Command Centre, said in a letter to Saskatchewan's chief medical health officer.

Over the next three months, 282 people in the village and First Nation would test positive for the disease about seven per cent of the population and five people died.

Still, many applaud the efforts that eventually contained the outbreakand say there are lessons to be learned.

"I think it's a success story of how things can be handled," said Carrie Bourassa, the scientific director at the federal Institute of Indigenous Peoples'Health.

"They have an excellent model that I think can be scaled up in other rural, remote northern communities."

CBC News interviewed several local leaders, health officialsand residents to determine the five things they deemed most effective in containing the outbreak in these Indigenous communities.

Collaboration and communication

When the outbreak began, local leaders came up with their own pandemic response plan.

Chief Clark of the CRDN joined forces withthe mayor of La Loche and the northern Mtis representative toset up a joint emergency operations centre at the high school in La Loche that wouldserve people both on and off reserve.

"I said, 'Look, guys, we need to join up here and make an alliance here and start looking at things so we don't duplicate and we don't confuse things,'" Clark said.

Randy Herman, deputy mayor of La Loche, knew that one of the main challenges would be getting local residents to trust government and health officials, given the history of colonization and strained relationships.

"Governments roll into town and promise everything but the moon, and then they don't deliver, so that's where the mistrust is from [for] years and years and years," said Herman, who is also a schoolteacher.

But faced with a pandemic, all levels of governmentworked together like never before, he said.

Herman translated messages into Dene for health officials during regular radio briefings that featured updates from local leaders, the Saskatchewan Health Authority and the Northern Inter-Tribal Health Authority, an organization that supports 33 First Nations.

Herman knew elders would listen to local leaders, particularly in Dene, in a way they wouldn't listen to outsiders.

"They know us, we know them. They trust us," he said.

And since there was a real risk the virus would spread to surrounding communities, a group of 24 Indigenous communities along Highway 155 to La Loche, called the "155 Collective," set up a command centre to co-ordinate check stops and communicate with residents and the government.

It had daily phone calls with the health authority.

But there were hiccups.

Three weeks into the outbreak, the group wrote a sternly worded letter to the province's chief medical health officer demanding more consultation and respect for local culture and expertise.

"We ask you to learn from us, and with us," the letter said.

Dr. Rim Zayed, the Saskatchewan Health Authority's northern medical health officer, called the relationship-building during the outbreak "the silver lining of the crisis."

"We have more understanding, communication, engagement, solidarity," she said.

Jurisdictional snafus between the province and Indigenous Services Canada had to be quickly smoothed out.

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Travel restrictions

Local leaders took it upon themselves to set up check stops at the edges of their communities to share information and monitor the movements of residents.

The village of La Loche and CRDNalso imposed a curfew and hired security to police the streets at night.

As the outbreak worsened, the province introduced an unprecedented travel ban that outlawed all non-essential travel into and out of the northern half of the province. It required northern residents to remain in their local communities, except for grocery runs and medical appointments, and to maintain physical distancing.

The province began staffing highway checkpoints with employees from the Saskatchewan Public Safety Agency.

Eventually those travel restrictions and roadblocks triggered backlash among many northern residents who felt they were being discriminated against and treated like "caged animals." The 155 Collective said employing more Indigenous people and traditional language speakers at the roadblocks would have reduced confusion and smoothed tensions.

Still, most northern leaders said the lockdown was effective.

Remote testing

The Saskatchewan Health Authority deployed more than 50 health-care workers to the northern community to launch an aggressive testing and contact-tracing campaign. Mobile testing teams wentdoor-to-door to swab people in 813 households. Each team included a local outreach worker to interview people and translate.

Dr.Moliehi Khaketla, who leads the Northern Population Health Unit, said that "local knowledge was invaluable."

Initially, test swabshad to be shipped south to the provincial lab, delaying results. The province then sent a portable GeneXpert testing machine to the region to do on-site testing, delivering test results within an hour. It had limited capacity, so the province also used a government plane to ship tests south.

To prepare for more outbreaks, the province hasstationed a GeneXperttesting unit in more than 20 locations in the province, including the north, and arranged for more testing supplies to increase capacity to 1,200 tests a week, rather than 200.

Temporary housing

A chronic housing shortage and lack of hotels in La Loche and CRDN made it difficult for people in the remote region to self-isolate.

Creative solutions included setting up a makeshift homeless shelter in mobile trailers to house transient couch-surfers, as well as hauling in RV campers to serve as isolation units for people who tested positive for COVID-19 but couldn't isolate at home.

"There's a lot of logistics behind this," said Leonard Montgrand, a northern representative with the Mtis Nation-Saskatchewan. "We just don't throw a person into a trailer and say, 'Here, you're isolated, see you in 14 days.' No, we have to do daily monitoring, we have to provide sustenance."

The La Loche Friendship Centre cooked and delivered hot meals twice a day to people isolated in their homes, RV campersand the homeless shelter.

As temperatures drop, local leaders are arranging for winterized trailers and other isolation centres to prepare for another surge.

Programs to help those with chronic issues

From the outset, local leaders and health officials were concerned about caring for people living in poverty, as well as those with multiple chronic health issues, such as diabetes, respiratory problems and mental health challenges.

The emergency operations centre arranged deliveries of food hampers, cleaning suppliesand masks to families. The First Nation sent out fishermen to catch fish for elders.

Leaders were blunt that people dealing with addictions were gathering to drink, frequently flouting physical-distancing restrictions and isolation orders, thus fuelling infections.

La Loche Mayor Robert St. Pierreand the council asked the province to cut off alcohol sales in the community. That prompted fears that people with serious addictions would suffer life-threatening withdrawals and overwhelm the local health centre.

So, the health authority quickly launched a managed alcohol program (MAP) that gave daily allotments of alcohol to people.

"We have all these pieces of the puzzle," Montgrandsaid.

The community leaders all agreed that it was a steep learning curve, with some hard lessons along the way.

Chief Teddy Clark saidhe can summarize his advice in just two words: "Be ready."

Asked if he was proud of what the community had accomplished, St. Pierre said: "How do you be proud of something when five people died? We still had loss of life. There's still a sense of sadness and loss ... but yes, what we accomplished was phenomenal and our people proved how resilient they are."