Closing the health gap: Advocating for Indigenous health equity
New consortium aims to improve culturally safe health care by improving Indigenous medical education
In the six years since the Truth and Reconciliation Commission (TRC) issued its Calls to Action for Health Care, Canadian faculties of medicine and health sciences have begun gearing up to improve Indigenous medical education.
Some are considerably further along than others.
The National Consortium on Indigenous Medical Education (NCIME) was established earlier this year to help speed up the process. The consortium’s aim is to share practices and policies, collaborate across schools and organizations, and “bring everyone along,” says Lisa Richardson, MD, FRCPC, one of the eight-member NCIME executive committee.
She notes that while some medical faculties in the country are still struggling to recruit a cohort of Indigenous leaders to help with programs and curricula, and to support learners; others, like the University of Manitoba (long committed to Indigenous medical education) have specific institutes dedicated to Indigenous health and healing.
The overarching goal of the TRC’s Health Care Calls to Action is to close the health gap between Indigenous Peoples and non-Indigenous people in Canada. That, of course, requires work by all sectors of Canadian society, observes Marcia Anderson, MD, FRCPC, executive director of Indigenous Academic Affairs at Ongomiizwin and chair of the NCIME executive committee. A key task for medical schools, the TRC states, is to improve culturally safe health care through the education of medical professionals.
Individually, the five national medical organizations that partnered to establish the NCIME had already committed to work on the Calls to Action: the Royal College, the Indigenous Physicians Association of Canada, the Association of Faculties of Medicine of Canada, the College of Family Physicians of Canada and the Medical Council of Canada.
Supporting Indigenous physicians
Indigenous physician leaders have carried much of the load of advising medical organizations about Indigenous issues and the need to improve care.
“It is emotional labour to work in an unsafe system to make it more safe, but as Indigenous medical leaders we agree to do this, knowing that some conversations can be harmful,” says Dr. Anderson.
The six Indigenous physicians on the NCIME executive committee had already been working with national organizations; the NCIME, funded by a $4-million federal grant, provides more infrastructure support for the work.
“Indigenous physicians are often overstretched in their work for many reasons – because of systemic racism, because of lack of infrastructure locally to support the work and because of being pulled in so many directions,” says Dr. Richardson.
So, while one of the NCIME’s mandates is to improve the recruitment and retention of Indigenous medical students and physicians, another is a focus on promoting “physician wellness and joy in work.” The Indigenous Physicians Association of Canada, with its history of providing mentorship, is taking a lead in that area.
Kinship is another source of support. The members of the self-proclaimed Indigenous “medical matriarchy” (including the five female physicians on the NCIME executive) work together to make change.
“And when there are bumps in the road, we help each other; we understand how hard things can be,” Dr. Richardson says.
Anti-racism work challenges meritocracy
Anti-racism work is another key focus for the NCIME. The Max Rady Faculty of Health Sciences at the University of Manitoba spent two years developing its ground-breaking Disruption of all Forms of Racism policy, approved in 2020. It is already being shared with other medical faculties as a model that could be adapted locally.
Dr. Anderson led the work on the policy and she points out that anti-racism work is difficult and emotional. It involves conversations about privilege — who has the opportunity to acquire it and who doesn’t — and what knowledge and skills are really valued.
She says anti-racism work challenges the idea of meritocracy, the long-held assumption that medical schools admit only the best and brightest, and reveals how there are gaps and structural racism.
“Conversations about this are often experienced as a real threat to one’s social or professional identity. We ask people to recognize how they are upholding an unfair system so that we can create a more fair system that will be better prepared to serve the Indigenous community.”
Advocating for Indigenous health equity
The NCIME’s Knowledge Keeper Leslie Spillett, who is Cree/Métis, knows all too well the devastating impacts of racism in the Canadian health care system. Ms. Spillett worked with a Winnipeg community organization (Ka Ni Kanichihk) for whom she presented at the inquest into the death, 13 years ago, of Brian Sinclair. An Indigenous wheelchair-bound double-amputee with a catheter, Mr. Sinclair died from a treatable bladder infection after he was left sitting for 34 hours in the waiting room of a Winnipeg hospital emergency ward.
While various witnesses spoke to the role that racism played in the treatment of Mr. Sinclair, Ms. Spillett says their testimony was based in racialized assumptions that they did not view as racism. She also notes that the recommendations in the inquest report didn’t speak to the role that racism played in Mr. Sinclair’s death. Indeed, most of the 63 recommendations spoke to the organization of emergency departments; the very last one recommended that health care staff have mandatory cultural safety training.
Ms. Spillett says she likes to think that there is much more awareness today of the role that racism often plays in how Indigenous patients are treated but she is not entirely sure how that awareness translates into the treatment of Indigenous patients. She will continue to advocate for Indigenous health equity through the NCIME.
“Indigenous 101”: the need to understand the impact of colonialism
Meanwhile, many students enter medical school lacking knowledge of the colonial history that affects the health and well-being of Indigenous Peoples.
“I was just on the phone with the vice-dean of a medical school who said that many medical students do not have any foundational knowledge about Indigenous Peoples in Canada. So often, we have to play catch up about basic history and policies like the Indian Act,” says Dr. Richardson. “I call this Indigenous 101.”
Classroom learning is vital, but so is anti-racism work with professional colleges and health delivery organizations, Dr. Anderson adds. Much of medical education takes part in clinical settings and so “to reach the outcomes that we want, we need to see changes in the clinical learning environments that parallel what is taking place in classrooms.”
Local implementation key
The biggest impact of national-level work happens when it is implemented locally, says Dr. Anderson.
“There is a huge opportunity, even a responsibility, for Royal College members who are affiliated with medical schools or clinical environments to get involved in local implementation that will lead to system-level change to produce Indigenous health equity.”
Dr. Richardson is hopeful that she is witnessing “a kind of racial reckoning” — an awakening to the impact of racism because of the social and economic inequities that the COVID-19 pandemic has underscored, as well as the Black Lives Matter movement.