'The abiding condition was hunger': Assessing the long-term biological and health effects of malnutrition and hunger in Canada's residential schools / 'La faim était un état permanent': évaluation des effets biologiques et sanitaires à long terme de la malnutrition et de la faim dans les pensionnats autochtones du Canada

Recent studies of residential school survivors and their families focus on the impact of school experiences on the social determinants of health, especially mental health. Less studied is the connection between residential school survivorship and patterns of chronic disease risk among Indigenous peoples in Canada. Narrative accounts, supported by archival records on school food service, provide consistent evidence that children who attended Canada's Indian residential schools experienced chronic undernutrition characterised by insufficient caloric intake, minimal protein and fat, and limited access to fresh produce, often over a period of five to ten years. When examined in the light of literature on the intergenerational effects of twentieth-century famines, this evidence suggests that high prevalence of metabolic risk factors among Indigenous peoples in Canada may be directly associated with the nutritional deprivations experienced by children in residential schools.

Des études récentes sur les survivants des pensionnats Indiens et de leurs familles se sont concentrées sur l'impact de l'expérience scolaire sur les déterminants sociaux de la santé, en particulier la santé mentale. Un aspect moins étudié est le rapport entre la survie à ces pensionnats Indiens et les caractéristiques associées aux risques de maladies chroniques chez les peuples autochtones du Canada. Les comptes-rendus descriptifs, étayés par les documents d'archives relatifs au service d'alimentation scolaire, fournissent des preuves constantes que les enfants qui fréquentaient les pensionnats Indiens du Canada souffraient de sous-nutrition chronique caractérisée par un apport calorique insuffisant, peu de protéines et de lipides et un accès limité aux produits frais, souvent sur une période de cinq à dix ans. Lorsqu'elles sont examinées à la lumière des textes sur les effets intergénérationnels des famines du vingtième siècle, ces preuves suggèrent que la prévalence élevée de facteurs de risques métaboliques chez les peuples autochtones au Canada peut être directement associée aux privations nutritives subies par les enfants dans les pensionnats Indiens.

In recent years, there has been increasing medical consensus that Canada's Indian residential school system–the federally funded and church-run boarding schools which operated between 1883 and 1996–had a lifelong impact on the health of children. What was once referred to vaguely as 'residential school syndrome' (Brasfield 2001) has now been widely recognised as a complex of health outcomes that includes mental, physical, emotional, and cultural traumas experienced by former students as a result of their common experience of surviving what the Truth and Reconciliation Commission of Canada (TRC), the six-year investigation into residential school experiences, has concluded was nothing short of an attempted cultural genocide (TRC 2015a).

Until recently, research on these health effects has focused mostly on survivors' mental health (Bombay et al. 2014; Söchting et al. 2007; Wesley-Esquimaux and Smolewski 2004). Less recognised are the long-term and intergenerational physical consequences of the residential school experience. Perhaps the least understood but potentially most profound of these physical legacies is the impact of chronic malnutrition. This article offers some tentative insights into the possible individual and intergenerational impacts of residential school diets, with the goal of contributing to the growing literature on the health impacts of residential schools. A second and equally important goal is to raise awareness among health care providers as well as public health and health decision makers that the health patterns observed among their patients may, in part, be the result of biological processes arising from residential schools that have previously gone unrecognised.

'Hunger was never absent'

Well before the last residential school closed in 1996,¹ survivors from every region of Canada told harrowing stories of hunger. One such account was written in the fall of 1965 by Russell Moses: an air force veteran and member of the Delaware Band of the Six Nations of Grand River who had attended the Mohawk Institute in Brantford, Ontario between 1942 and 1947. Moses was working for the Federal Indian Affairs Branch at the time and had been asked by his employer to reflect on his residential school experience. 'The food at the institute', he wrote, 'was disgraceful'. For breakfast, children were given:

two slices of bread with either jam or honey as the dressing, oatmeal with worms . . . or corn meal porridge which was minimal in quantity and appalling in quality. The beverage consisted of skim milk and when one stops to consider that we were milking from twenty to thirty head of pure bred Holstein cattle, it seems odd that we did not ever receive whole milk and in my five years at the Institute we never received butter once.

(Moses 1965: 1)

Lunch consisted of 'water as the beverage [and] if you were a senior boy or girl you received . . . one and a half slices of dry bread and the main course consisted of a "rotten soup" (local terminology) (i.e. scraps of beef, vegetables, some in a state of decay)'. For supper, 'students were given two slices of bread and jam, fried potatoes, NO MEAT, a bun baked by the girls . . . and every other night a piece of cake or possibly an apple in the summer months' (Moses 1965: 1). Moses went on to say, 'The diet remained constant; hunger was never absent'. He even recalled hungry children 'eating from the swill barrel, picking out soggy bits of food that was intended for the pigs' (Moses 1965: 2).

Moses was not alone in his memories of hunger. In 1974 Secwepemc leader and president of the National Indian Brotherhood, George Manuel, wrote that hunger was one of the overriding memories of his time at the Kamloops Indian Residential School in the 1920s. 'Every Indian student smelled of hunger', he wrote, recounting how students had to steal raw potatoes from the kitchens to stave off their ever-present hunger pangs and how, at many points, they were reduced to eating dandelion roots, rosebuds, and leaves (Manuel and Posluns 1974: 65). And nearly forty years later Manuel's son, Arthur, attempted an aborted hunger strike at the St Mary's Residential School in Mission, British Columbia, upon realising that 'the food they were serving us was worse than the food they serve in jail'. This was because, while spending a month in the Spy Hill Gaol in Calgary on a minor trespassing charge during his summer break in the early 1960s, Manuel was shocked to find that–while meat and vegetables were 'almost unknown' at the residential school–prisoners were being 'served meat and potatoes, pork chops, broiled chicken, and sometimes even steak' (Manuel and Derrickson 2015: 13–15).

Other residential school survivors have recorded similar experiences across diverse geographies and time periods. In his 1988 memoir, Anishinaabe scholar Basil Johnston wrote that, during his time at Spanish Indian Residential School between 1939 and 1950, 'the abiding condition was hunger'. According to Johnston, students were fed just enough 'to blunt the sharp edge of hunger for three or four hours, never enough to dispel hunger completely until the next meal' (Johnston 1988: 40). Secwepemc writer Bev Sellars similarly recalled her time as a student at the St Joseph's Mission in Williams Lake, BC between 1962 and 1967: 'We felt hungry all the time. I can remember my stomach aching and feeling empty' (Sellars 2013: 57). The food, she recalls, was not just inadequate but was also often spoiled. In fact, years later, she discovered her regular bouts of what she called 'yellow jaundice' as a student were likely the result of food poisoning.

The TRC heard many similar accounts of hunger, malnutrition, and food-borne illness from survivors at schools across the country. In his statement to the TRC, for instance, Andrew Paul spoke of the unrelenting hunger he experienced during his time at Aklavik Roman Catholic Residential School:

We cried to have something good to eat before we sleep. A lot of the times the food we had was rancid, full of maggots, stink. Sometimes we would sneak away from school to go visit our aunts or uncles just to have a piece of bannock. They stayed in tents not far from the school. And when it's raining outside we could smell them frying doughnuts, homemade doughnuts, and those were the days when we ate good.

(TRC 2015b: 71)

In his statement, Ray Silver told the TRC of being reduced to scavenging through garbage in order to get enough to eat at the Alberni Indian Residential School on Vancouver Island:

And us kids, we used to sneak from the school, we must have had to walk about a mile, sneak away from the school, sneak over the bridge, and go to that dump, and pick up apples, they were half rotten or something, and they threw out, they were no more good to sell, but us kids that were starving, we'd go there and pick that stuff up, fill up our shirts, and run back across the bridge, and go back to the school.

(TRC 2015b: 72)

In statement after statement, survivors told the TRC how they struggled to overcome hunger in whatever way they could–whether it was stealing food, eating spoiled food, or even catching wild animals like hares to supplement their meagre diet (TRC 2015b: 69–77).

These reports of widespread hunger and inadequate diets have largely been confirmed by leading historians of the residential school system (Haig-Brown 1988; Miller 1996; Milloy 1999; Kelm 1996). As historian J.R. Miller sums up the food service in residential schools, 'the food was inadequate, frequently unappetizing, and all too often consumed in inhospitable and intimidating surroundings' (Miller 1996: 290). In fact, malnutrition and inadequate diets were common enough in the early post-war years that, between 1948 and 1952, scientists and doctors working for the federal government were able to conduct a series of nutrition experiments on malnourished children at six residential schools across the country (Mosby 2013). At each of the six schools, existing levels of malnutrition were used as a baseline for investigations into the effectiveness of vitamins, fortified foods, and other nutritional interventions. For example, researchers selected the Shubenacadie Indian Residential School in Nova Scotia for a double-blind, randomised controlled trial of the effects of vitamin C supplementation; the school was considered an ideal location for the experiment because of widespread clinical ascorbic acid deficiencies observed among its students (Mosby 2013: 161–2).

Recent research published by Paul Hackett and colleagues reveals that the malnutrition observed at residential schools in the 1940s and 1950s was largely the product of the school environment, and that students were actually well-nourished prior to entering the schools (Hackett et al. 2016). In fact, even during the 1940s, it was widely recognised that the malnutrition among residential school students was likely caused by the inadequate funding provided to the schools. The lead researcher on the nutrition experiments, Dr Lionel Pett, noted in 1948 that the per capita grant provided for food in most schools was often half of that required to maintain a balanced and nutritionally adequate diet (Mosby 2013: 159). And while the funding formula was revised in the late 1950s, the TRC concluded in its final report that

The federal government knowingly chose not to provide schools with enough money to ensure that kitchens and dining rooms were properly equipped, that cooks were properly trained, and, most significantly, that food was purchased in sufficient quantity and quality for growing children. It was a decision that left thousands of Aboriginal children vulnerable to disease.

(TRC Canada 2015a: 92)

Comparison studies

It is hard to estimate with any accuracy the average caloric intake or the overall nutritional status of children attending residential schools in Canada. In large part this is due to the limitations of the existing archival record. Records related to food service and other areas of residential school administration, after all, were routinely destroyed as a matter of official policy. A 2006 investigation by the Shingwauk Project at Algoma University found that 'there was a general federal government policy to destroy many government files and that there was a very high level of records destruction activity that occurred between 1936 and 1956' (Sadowski 2006: 3). For example, between 1936 and 1944 alone, it was estimated that at least 200,000 Indian Affairs files were destroyed. Although a moratorium was placed on records destruction in 1973, a wide range of records related to residential schools prior to then has likely been destroyed. The files related to residential schools at particular risk of being destroyed include school returns and requisitions, monthly reports, diaries and returns, and reports of inspectors, among others. According to the TRC, student health records were also regularly destroyed as a matter of policy (TRC 2015c: 10–11).

When combined with the inconsistent and unpredictable record keeping practices of the churches responsible for running these schools, it is clear that any attempt to reconstruct the specific diet of students in a particular school at any given time is extraordinarily difficult.² The general picture of students' diets, however, is quite clear–especially when we take survivor testimony into account. Moses' (1965) description, for instance, is consistent with the existing archival records documenting school food procurement and practices at the Mohawk Institute as well as the testimony from other former students (Graham 1997). While there was considerable variability in school food service, the widespread nature of narrative accounts of hunger across the entire country and at schools operated by all religious denominations suggests that this experience was common if not ubiquitous. As J.R. Miller argued in 1996: '"We were always hungry," could serve as the slogan for any organization of former residential school students' (Miller 1996: 290).

Overall, then, the picture of residential school diets is one of sustained malnutrition characterised by insufficient caloric intake; minimal protein and fat; severely limited access to fresh fruit and vegetables; and frequent bouts of food-borne infection. A generous interpretation of Moses' account describes a regime delivering a maximum of 1260 kcal per day. From this account and others available, we estimate the average daily caloric intake at many residential schools like those described above to be in the range of 1000–1450 kcal per day; requirements for moderately active, healthy children aged 4 to 18 years range from 1400–3200 kcal (Institutes of Medicine 2002/2005). Over the course of a five-to-ten-year period, exposure to poor diet quality and caloric restriction of this magnitude has significant consequences on the biology and health of individuals.

For comparison, we draw on studies documenting impacts on growth and development in high-poverty environments where chronic under-nutrition is endemic and in so-called 'natural experiments' arising from famine events that occurred during the twentieth century. Much recent work on the long-term health effects of nutritional deprivation has been carried out by Ana Lydia Sawaya and colleagues on malnourished populations living in Sao Paulo, Brazil (Sawaya 2006; Martins and Sawaya 2006). Recent reviews of the literature on child malnutrition (de Onis and Branca 2016; Li et al. 2016) also provide excellent resources for those seeking to understand the health implications of dietary restriction in childhood.

The lens through which we view the health impacts of malnutrition has widened appreciably in recent years with the publication of cohort studies examining the intergenerational impacts of devastating famines. The most widely known of these may be the Dutch Famine studies exploring chronic disease risk among the offspring of famine survivors (Lumey et al., 2007). The Dutch Famine or 'Hunger Winter' was the result of military blockades imposed by both Allied and Nazi forces during the German occupation of the Netherlands during the Second World War. From 1944 to 1945, it is estimated that residents of cities in the western region of the Netherlands subsisted on an average of 1000 kcal per day. Equally compelling are the Russian and Chinese famine cohorts. The Russian Empire and Soviet Union experienced a series of widespread famines, the worst of which occurred from 1932 to 1934 in what is now Kazakhstan, Ukraine, and the Volga Region of Russia (Sharygin 2010) and is estimated to have affected 70 million people. The Chinese Famine of 1959 to 1961 was the result of a combination of crop failures and the mobilisation of rural populations to work in industrial centres as part of Mao's Great Leap Forward (Chen and Zhou 2007; Gørgens et al. 2012). With an estimated thirty million deaths over the course of the famine, it was determined that daily energy intake fell to an average of about 1500 kcal per person (Ashton et al. 1984).

By drawing on archival sources and employing methods of observational epidemiology, famine studies document the lifelong and intergenerational effects of famine exposure during the biologically sensitive period in utero. However, this body of literature also examines comparison groups of children born before and after famine events, thereby documenting the effects of severe caloric restriction on development throughout childhood. Follow-up studies of these cohorts have examined the biological consequences of childhood hunger throughout the life-course and in succeeding generations of children born to famine survivors. We believe this research provides a roadmap for examining the physical impacts of Canada's residential school legacy.

Individual effects

The long-term health effects of malnutrition in childhood are well documented. The most evident of these impacts is stunted growth (low height for age). The effect of malnutrition on achieved stature is pronounced: child survivors of twentieth-century famines are height stunted by an average of 1–3 cm compared with their age-matched peers (Gørgens et al. 2012; Sharygin 2010). Stunting is the most common growth impairment observed in developing countries (more common than low weight for height), with fully 74 per cent of the global burden of stunting confined to the world's poorest countries in Africa and South-Central Asia (Dewey and Begum 2010). Even in developed nations, height stunting persists in areas of poverty where malnutrition is endemic; thus eradication of stunting is now a leading global health priority (de Onis and Branca 2016).

Stunting has profound health effects throughout the life-course. Children whose growth falters due to malnutrition have lower fat-free mass, impaired bone development, and a tendency to prioritise fat-over lean-mass deposition (Martins et al. 2011; Sawaya 2006). Stunted adolescents exhibit lower insulin levels and greater insulin sensitivity than non-stunted controls and are therefore at greater risk of developing Type II diabetes (Martins and Sawaya 2006). Studies document a strong association between stunting and high blood pressure among height-stunted adolescents and adults living in northeastern Brazil (Fernandes et al. 2003; Florêncio et al. 2004). Prolonged under-nutrition also alters thyroid function in an attempt to reduce energy expenditure, resulting in hypothyroidism and lower basal metabolic rates among height-stunted individuals (Sawaya et al. 2006).

Stunted women have greater risk of stillbirths, miscarriages, pre-term births, complications of labour and delivery, and decreased offspring birth weight (Cai and Feng 2005; Dewey and Begum 2010; Victoria et al. 2008). Stunting is known to affect both cognitive development and educational attainment negatively (Victoria et al. 2008; Wang et al. 2016), and has been associated with delayed school entry, greater grade repetition and dropout rates, decreased graduation rates from primary and secondary school, and lower school performance (Daniels and Adair 2004; Jukes 2005). The effects of stunting on adult employment are well documented. Cohort studies demonstrate reduced work capacity among adults who experienced height stunting through childhood exposures (Martins et al. 2011) and lower income levels among height-stunted individuals (Chen and Zhou 2007; Dewey and Begum 2010; Victoria et al. 2008).

Malnutrition produces a cascade of immune system effects leading to both acute and chronic changes in immune response and ultimately heightening risk of infectious disease, even in moderately malnourished children (Rytter et al. 2014). The impact of nutritional deprivation on immune function is one of a number of effects that has led Ptelletier and colleagues (1993) to describe malnutrition as a "potentiator" of childhood mortality. It is estimated that about half of all deaths among young children globally are ultimately caused by malnutrition, most commonly mild to moderate malnutrition (Martorell 1999; World Health Organization 2017). Furthermore, it has been cited as a leading contributor to disproportionately high tuberculosis mortality among residential school students compared with their non-Indigenous counterparts (Stoops 2006; TRC 2015c).

Recent research is also shedding light on the physiological connections between childhood malnutrition and risk of chronic disease in adulthood. Shorter stature, lower lean mass, lower resting metabolic rates, and greater insulin sensitivity predispose individuals to obesity and a range of chronic diseases, including Type II diabetes and cardiovascular disease (de Onis and Branca 2016; van Abeelen et al. 2012a; Sawaya 2006). In addition, malnutrition is itself a powerful stressor. Nutritional deprivation activates the hypothalamic-pituitary-adrenal stress response, causing a prolonged increase in cortisol secretion. An elevated cortisol level is exacerbated by the reduced rate of metabolic clearance of circulating cortisol due to lower basal metabolic rate (Martins et al. 2011; Sawaya 2006). Elevated cortisol further blunts insulin response, inhibits the function of insulin-like growth factor (IGF-1), and produces long-term changes in lipid metabolism (Martins et al. 2011), thereby worsening growth impairment and further increasing risk of obesity and chronic disease. This cascade of effects leads almost inexorably to a complex of obesity, hypertension, and diabetes. The effects are not reversed once adequate diets are re-established; rather, the individual's physiology has been programmed, in a sense, by childhood deprivation to continue the cycle of worsening effects (Florêncio et al. 2004; Martins et al. 2011; Sawaya 2006).

This process matches descriptions of famine survivors emerging from observational studies of post-famine cohorts. Compared to controls, children exposed to twentieth-century famines are significantly more likely to be obese (van Abeelen et al. 2012b; Wang et al. 2010). Scholars report higher BMI and fasting plasma glucose, unfavourable lipid profiles, higher prevalence of diabetes and hypertension, and higher incidence of heart attack and stroke at ages 40 to 60 among famine survivors (Li et al. 2016; Huang et al. 2010; Wang et al. 2010). Women exposed as girls to the Dutch Famine are significantly more as likely to develop diabetes than their non-exposed peers (van Abeelen et al. 2012a). The odds of developing diabetes increase with the severity of famine exposure; women who reported only moderate caloric restriction as children were 1.3 times as likely to develop diabetes, while women who underwent severe caloric restriction were 1.5 times more likely to develop diabetes than their non-exposed peers.

Taken together, this research describes how sustained exposure to caloric restriction produces a biological complex of height stunting together with metabolic changes that lead to greater risk of obesity and chronic disease in people who experience malnutrition in childhood.

Intergenerational effects

While observational studies are revealing the impact of malnutrition on the biology of those directly exposed to malnutrition, they are also revealing a complex of intergenerational effects on the children and grandchildren of famine survivors. Height-stunted women have been found to be more likely to give birth to low-birthweight babies (Dewey and Begum 2010). Maternal obesity and diabetes have also been associated with greater risk of inter-uterine growth failure, both low and high birthweight with their attendant risks, growth faltering, and the development of insulin resistance and diabetes, in offspring (Leddy et al. 2008). These effects appear to continue into the following generation: adult grandchildren of famine survivors have significantly higher BMI and prevalence of obesity than the general population (Li et al. 2016, Wang et al. 2010, Veenendaal et al. 2013). Among grandchildren, there is an interesting reversal of the first-generation pattern, whereby these effects are significant among grandchildren whose fathers (not mothers) are the offspring of famine survivors (Veenendaal et al. 2013).

Although we are only beginning to understand these complex biological and epigenetic processes, it is clear that the negative health impacts of sustained malnutrition are multi-generational. A further part of the intergenerational impact, it seems, has to do with the psychological and cultural–and not just biological–impacts of residential schools on the dietary practices of survivors and their families. Many former students and their families trace contemporary unhealthy eating habits and a range of diet-related diseases to their residential school experience (Oster et al., 2014). Not only did residential schools, themselves, attempt forcibly to strip students of their Indigenous dietary practices–leaving generations of children alienated from their own culinary traditions during their formative years–but they supplanted them with diets formed predominantly of unhealthy, nutritionally inadequate starch-heavy alternatives. Theodore Fontaine, former chief of the Sagkeeng Ojibway First Nation and survivor of the Fort Alexander Residential School in Manitoba, makes the connection between his inadequate residential school diet and later health issues explicit in his 2011 memoir:

For years after leaving school, I gorged almost every day on bacon, sausage, ham, bologna and eggs. I'd cut long slices into my toast and insert tracks of butter into them, and I routinely laid a piece of bread or bannock in the pan where I'd just fried bacon and let it soak up the grease, unaware of the health risks associated with eating this treat. I'd acquired a taste for a high-fat, low nutrient diet, which later contributed to my clogged arteries and need for open-heart surgery.

(Fontaine 2010: 126–7)

While more research still needs to be done examining the intergenerational effects of residential schools on the food cultures and dietary practices of Indigenous communities, it is nonetheless clear that the residential school experience often had a devastating effect on Indigenous diets and health even well after students left the schools.

Conclusion

Reynaldo Martorell (1999) once observed that malnutrition is often overlooked as a significant cause of childhood illness. There is strong evidence that nutritional deprivation, with its concomitant effects on growth, body size, and metabolism, sets an individual on a path toward lifelong risk of obesity and chronic disease. Growing evidence of intergenerational effects associated with these processes should lead us to consider current health patterns among Indigenous peoples in Canada from an intergenerational perspective, following the suggestion of Hoke and McDade to consider the ways in which biology and poverty interact temporally to produce 'ever-widening disparities in contemporary society' (2015: 195).

Residential school survivors from every part of the country have long testified that hunger and malnutrition defined their residential school experiences, yet there have been few studies of the long-term health effects of this hunger and malnutrition. In attempting to take the testimony of survivors seriously and to investigate the nature and extent of hunger and malnutrition in residential schools, the present research indicates that the high pattern of low birthweight, childhood and adult obesity, early-onset insulin resistance, and diabetes observed among Indigenous peoples in Canada may, in some part, be attributable to the prolonged caloric restriction experienced by those who attended residential schools. This knowledge introduces into both the health research and practice communities the very real possibility that much of our evidence base overlooks a significant driver of Indigenous health in Canada: malnutrition in childhood. That this malnutrition arises from state-sponsored intervention in the lives of Indigenous families whose intent, according to the Truth and Reconciliation Commission, was nothing short of an attempted cultural genocide (TRC 2015a) is a fact that will hopefully mobilise collective action to address these health disparities. As in Russia, the Netherlands, and China, there is also an opportunity here to develop research that examines the intergenerational effects of malnutrition on health patterns among Indigenous peoples in Canada–one that not only remediates the harms arising from this legacy, but also promotes healing and reconciliation for survivors and their families.

In the meantime, primary health care providers need to be aware that these nutritional processes likely underlie high prevalence of metabolic and cardiovascular disease among Indigenous peoples, and that current therapies and approaches may be insufficient to address the biological changes associated with chronic disease in Indigenous patients. Behavioural and pharmacological interventions cannot reverse biology formed by intergenerational exposures. Comprehensive, culturally appropr iate, and community-driven interventions are therefore necessary to support improvements in health and nutrition for the survivors and intergenerational survivors of residential schools. Results will, undoubtedly, be slow and incremental. The good news, however, is that these changes also have both individual and intergenerational effects, shifting the trajectories of growth and health in positive directions for current and future generations of Indigenous children.