We recently caught up with Dr. Alika Lafontaine, an Indigenous physician of Cree and Anishinaabe heritage. Dr. Lafontaine is the President of the Indigenous Physicians Association of Canada and lectures across the country about the impact of bias, discrimination and racism on patient care, and why addressing these issues lie at the core of improving the health of First Nations, Metis and Inuit Peoples.
Q: What is the current health situation in Indigenous communities in Canada?
A: The state of Indigenous health in Canada is dire. It’s been generally accepted that the level of access and the state of health outcomes is somehow normal for Indigenous Peoples. Relative to that is the idea that somehow we have time to catch up.
The idea that you go into a clinic in the middle of a city – or even in a remote town in Alberta, or any of our provinces – and receive a different level of base service is something that I really think Canadians take for granted. With Indigenous communities, you might have services and programs that are non-existent, and there isn’t that base level of health care access. Even the programs that do exist community to community – things like non-insured health benefits, medical transportation and other core programs that Health Canada administers — aren’t always consistent. It’s no wonder that we run into the health outcomes that we have.
Q: What are some of the biggest challenges that you see for improving the way health care is delivered for First Nations?
A: We were chatting in Alberta in the Aboriginal Health Program, which I’m a part of, and one of the things that we shared was back in the early 1990s there was an actual director from the Ministry of Health in Alberta that said “we should just stop providing care on Reserve.” Even though that policy directive has now evolved, and that’s no longer the position, the idea persists. There is a corporate memory of not providing services to First Nations People, and just leaving them to the Federal Government to provide that base level of care. That’s one of the reasons that we’re in the situation that we’re in today.
Another challenge I think health-related institutions, organizations, and First Nations have is charting clear map of where exactly we need to go. This is a question we’ve never really had to ask in the mainstream healthcare system – “what do we need to provide as a core basket of services?” Whenever we need something in the mainstream healthcare system, we advocate and then it gets swallowed into the core set of services. Then it becomes an expectation that if you go to get a diagnosis for diabetes – or going in for something that’s a new accountability like assisted dying – that the system should just provide it.
On the other hand, we have the system in Indigenous health which is very “a la carte”, offering only time-limited programming. So even if you have a program that has a real impact in a community, it still only has a 1, 2 or 3-year funding cycle. There is a very small proportion of programs that actually have sustained core funding.
It’s also necessary to shift out of the mindset – but also realize that the mindset exists – that a community somehow needs to justify a diabetes prevention program by showing that it has high rates of diabetes. You know, diabetes prevention exists in every community in Canada because it should exist in every community in Canada as part of the core programming. A community should not have to apply to the health system in order to have programming that we know should be part of the core basket. I think the discussion is starting, and that there’s a lot of optimism. I also think that the discussion will continue but at the moment we need to clarify what exactly goes into those core services for First Nations, and work towards an agreement from both sides.
Q: What about efforts to improve health care within First Nations communities? What sort of initiatives have you seen that are helping fill the gap?
A: I think you do see things at different levels. There is an option for First Nations to create their own program and then apply to Health Canada as part of a proposal. The number one challenge is that it’s a proposal so you’re immediately going in with the possibility that it will be turned down. But there is also programming that has come up – successful, past Health Canada programs – that are no longer qualified for funding. So you have physicians that are going to communities here in Alberta and other parts of the country where they’ve created really novel ways of funding, either through fundraising or through negotiating with the mainstream system to extend services on to First Nations.
They’ve had the same sort of outcomes as the work Dignitas has been doing in Northern Ontario with the diabetes program that was initiated. But what really needs to change is very organization or provider-motivated programs. If suddenly Dignitas disappeared, or for whatever reason couldn’t maintain the program in Northern Ontario, the question I would ask is: “Would the program continue?” The same with these physician or health-practitioner programming in Alberta and elsewhere. If suddenly these individuals retired or had to move or for whatever reason couldn’t provide the services, because of a change in their clinical practices or personal circumstances, what would happen to those patients?
I think in the mainstream system there are mechanisms in place to ensure that continuity exists that’s non-provider specific, and it doesn’t depend on the leadership at your hospital whether or not that service is provided. I think in the transition we’re now experiencing, it is important to think through ways to move from proposal-based funding to some sort of negotiated base level of funding. We already know this is happening – this is what lead to the creation of the First Nations Health Authority. People recognize that this challenge is out there. But what’s preventing many of these programs from making a big impact is how we make that transition.
Q: What are some of the positive transformations you’re seeing in First Nations’ health in Canada?
A: I think we have an amazing opportunity – not only understand the reality of communities, but also to change the way the system works structurally and the perceptions that people have about what Indigenous communities get versus what they really have.
One of the exciting things now – and it’s a mixture of the evolution of the Truth and Reconciliation Commission, and the fact that you can tell a patient’s story over social media without having it sanitized to the level that it doesn’t have the same sort of honesty that it had at the beginning, I think we’re starting to see people stand up and say those things.
We have a Minster of Health for the Federal Government who has said that we have to provide a minimum standard of care – that is the only thing that is acceptable. With her history working as a physician she understands the circle of care and what the expectations should be. And so I do think we’re seeing changes, but we’re still working though provincial and federal jurisdictional arguments, which even at the beginning, never had a legal underpinning.
I am also seeing a difference in tone. Every time that I’ve talked to people from Health Canada, Indigenous and Northern Development, there’s an open willingness to change, and a desire to better understand where we need to go.
Q: How can people outside of First Nations communities support First Nations’ health initiatives?
A: One of the things Canadians can do in general is accept the reality of what Indigenous patients go through, even though it is so far removed from their experience. To hear that a patient in a northern community only gets doctor coverage two days out of the month – or a week out of the month – is something that is so far removed from their experience that it’s almost unbelievable to most Canadians.
The same sort of parallel can be made to the residential school experience. I remember sitting down with my dad, and he used to tell a story about my grandmother, who was taken out to watch a group of men get hanged while she was in grade school. After the men had been hung, the teacher turned to them and said: “Never forget the power of the Queen.” And then they were shuttled back to class. I remember sharing that story with a friend who was on a leadership taskforce looking at food security in Nunavut. The response from the taskforce was that this would never happen. Not so long after, I started to question whether or not it actually happened.
It wasn’t until the Truth and Reconciliation report came out and I saw that story in print that I realized that I was questioning my own family members’ experience. I think that’s one of the stresses that Indigenous patients face in coming out and actually talking about the reality of what’s going on. Whenever you challenge a patient that’s already placed in a position of trauma, and you don’t validate what they’ve gone through as real lived experience, you just won’t hear about the stories.
I think Canadians need to take these almost unbelievable experiences as truthful from the point of the patient, and not try to reframe them as story that isn’t as bad as it sounds. That’s something Indigenous people urgently need Canadians to do: to accept their experience as real. I think that if we can work towards that, the same way we’ve done with the Truth and Reconciliation Commission and its work over the past few years, you’re going to start to see the pace of Indigenous health transformation really speed up, and things really start to change.
This interview has been edited for brevity and clarity