Indigenous health

Indigenous health care in urban settings

In Clyde’s story, we have seen the impact that a remote setting can have on the delivery of health care. However, at least half of Canada’s Indigenous people live in towns and, especially in cities. They primarily leave the reserve to find work or because of social problems on the reserve. In a large city, Indigenous people might be cut off from the reserve culture and feel like immigrants in their own country. They may be marginalized by prevailing stereotyping and bias. Some may no longer have treaty status, and thus fall under a different level of health care. Physicians who have Indigenous patients may not even know that their patients are Indigenous.

To illustrate some of these points, here are several stories told by physicians who work with Indigenous patients in a large city. There is also a story told by an Indigenous person describing what it is like to be an “Indian in the city.”

The complexity of Indigenous health care

In this story you learn about the complexity of Indigenous health care and the involvement of different levels of government.

  • One of the first cases that I remember involving an Aboriginal, who was one of my patients, was an older lady who was in her 60s who I had done a bone mineral density as part of her physical and she was osteoporotic. So, to treat the osteoporosis I had initially given her Didrocal which was covered, and she tried but she had a lot of stomach upset with it so in her follow-up visit, I changed her, I think, to Phosomax.

    So, I had sent her with the prescription and I usually tend to give a years’ worth of prescription because it takes a while for the medication to actually show its effect. I had gotten a call back from the pharmacy saying: “This medication isn’t covered, you need to fill out a form.” So, I had thought that I had simply forgotten that, through Ontario drug benefit coverage, you needed to put a limited use form into play. So, I filled out a limited use form, and I faxed it to the pharmacy, and that was the last I heard of it. The patient didn’t contact me. There wasn’t a follow-up from the pharmacy.

    I see her again, essentially a year later, ask her about the medication, because I’m about to do a follow-up bone mineral density to see, you know, I guess it was more than a year later. And she says to me “Oh, I haven’t been taking it after I last saw you.” And I said: “But I gave you the prescription.” but she said: “Yes, but it wasn’t covered.” But I said: “I filled out the limited use form.” I could see in the chart that I had sent it. And she said “But I’m not with the Ontario drug benefit program. I’m a status Indian, so the medication is covered through a different branch.”

    I had needed to fill out a completely different form. The pharmacy hadn’t told me. I wasn’t aware of it. And so, this patient who didn’t get her medication had simply just assumed, ah yes, another situation where I’m not going to get my medication, and had shrugged about it and just assumed she was just going to get suboptimal health care and had accepted it.

    It was my not having the knowledge of which forms and how to navigate, and my lack of understanding, that because she was a status Indian, her medication was not covered by the province but rather by the federal government through Health Canada, so it’s a different system to navigate. I wasn’t aware of that. And because of that, she didn’t get the health care that she deserved.

    I couldn’t understand why she didn’t get back to me about why she didn’t get the medicine. And she said, “Well I took the prescription to the pharmacy. The pharmacy said you hadn’t filled out the form and that they were going to contact you. And when I went back, and they said they still hadn’t gotten permission, I just assumed that it was too much bother.”

    She sort of accepted it, it was sort of like … resignation. And I see that sometimes in that age group, that sort of resignation of “Well, what else is new” sort of thing. They’ve been whacked by the system and so they expect to get whacked by the system, and so when the system fails them, they are not surprised at the failure. It’s not apathy, it’s more resignation.

Assumptions about ethnicity of patients

In this story the physician describes her gradual realization of the assumptions she was making about the ethnicity of her patients.

  • I started to be more aware that many of my patients were Aboriginals, that they weren’t on the reserve, they were here, in an urban area. And they didn’t necessarily volunteer to me unless I asked them that they were Aboriginal. But because I had made assumptions and because I hadn’t asked, I sometimes didn’t know what I could do for them.

    Probably the biggest thing that happened was that I stopped making, or I tried to stop making assumptions about my patients that, whether they look Aboriginal or not, or if they look mainstream Canadian or not, or if they look like an obvious visible minority, I don’t make assumptions as to who they are. I actually try to be, I think the catch phrase is “culturally sensitive” and actually ask them what their home environment is.

View on urban Indigenous people

In this story the physician describes the life of her Indigenous patients in the city, and how it differs from those on reserve.

  • Most of them moved for work or because the living conditions or the situation there were poor. It doesn’t mean that things were wonderful here either although most of them have … have had, most of the Aboriginal patients I see have all the same health problems as everybody else but there is an increase, particularly in diabetes, that I see it’s a higher frequency. And coronary artery disease is probably at a higher level too.

    The other thing that I see is sometimes is a supply of infectious diseases that maybe isn’t as common in the general Canadian population, specifically many of my patients have had TB. In the, sort of the 40-60 age group, some of whom who have experienced residential schools, there is, I’m just thinking of a couple of my patients, who I would say still do have some post-traumatic stress related to their experiences as children. A lot of them, I think, there is probably more who have had that experience and that might be one of the reasons for leaving the environment and moving to an urban area, but not all will. They will allude to it, but they don’t really want to focus on it.

    A lot of people return to the reserve, for example, when they’re older, because that is where the family is. Many have conflicts because their children are even less aware or involved in their heritage.

View on cultural differences

In this story the physician tells us about the cultural differences a young Indigenous patient encounters while in the city for treatment.

  • I think one of the biggest challenges to understand is the whole concept which for people coming from a western culture, of group cohesion or group unity, and the fact that the whole community sees themselves as one large family.

    I remember when I was first working with this community, I had a young girl who was in hospital and wanted me to call back to her community way up north and talk to the chief and let him know what was going on. And I, first of all, was a little perplexed and thought “You want me to talk to your chief? What about your family? Would that not be a little more appropriate?” And she said “Oh no, the chief will pass on the information to everybody else. That’s all you need to do.”

    So, I had a conversation with the chief and explained what was going on with her permission. At the end, he asked me a few questions, whatever, at the end of the telephone conversation he said, rather loudly I thought, “Any other questions? Oh, yes, you at the back of the hall.” To my horror I realized that we were on speaker phone and that this whole conversation was being broadcast to the community. And questions were coming from the back of the gym in the local school and they were all asking how she was, what was going on, what had happened. And I just about died! It thought “Oh my goodness! Confidentiality! I’m going to be sued! I’m going to have to call the college! I’m going to have to call my supervising chief! What am I going to do?”

    So, I went back to the patient, first of all and I said to her, “I don’t know how to tell you this, but I have to apologize. I thought I was talking to the chief, but I was talking to the whole community!” And she said: “Oh yes,” she said “They’re all family. That’s not a problem. That’s what I expected. I guess I should have warned you.”

View on Indigenous health practices

In this story the physician describes some of the Indigenous health practices and beliefs that she learned about in her work.

  • One of the things that I find very interesting was that the spiritual and medicine are very much more integrated in First Nations culture than they are in western medicine. There, the belief that you know sort of, that spiritual forces or other things that you have done in past lives and you’ve done in even this life, have an influence on the disease process.

    The belief that you are healing yourself with the help of the doctor is my concept of medicine. And that seems to fit in better with Aboriginal health practices than “I’m the doctor. I know what is going on and this is what you need to get better.”

    I’ve worked with Anishnawbe Health which is a centre, here in Toronto, and they look at many different modalities of healing and we try to integrate those with my First Nations patients. So, they may go to a sweat lodge as part of their treatment. They may see an herbalist as well as seeing me and they may have counselling sessions with an elder and they may have a counsellor who deals specifically with their parenting issues in a culturally appropriate setting.

    There are lots of different ways to integrate their care in a much more holistic way which is very interesting to me because I’ve had to learn about these different modalities that can complement the care they are getting at my office or in the hospital or wherever else they’re interacting with western medicine. And I find the most success is when those complementary medicines and western medicine come together because it gives the patient some sort of control over what they need at that particular time.

Indigenous view on urban Indigenous people

In this story an Ojibway Anishinaabe man talks about being a young Indigenous person in the city.

  • First Nations people in the city are probably looked upon as being the lowest class of citizen anywhere. Even when you are as educated as I am, you are first an Indian and that is the way it has always been in the city. And you can understand why people may want to stay on the reserve because they are with their own.

    Just take a walk around the city and see what you see when it comes to First Nations people. You know, it’s a sad commentary on our society that the original inhabitants are treated the worse out of any other class of citizen in this country.

An elder’s view on prejudice and racism

In this story an elder describes the prejudice and racism she has experienced.

  • They say we can’t learn, but we can. We are very, very smart people.

    One of the things I really had to work on was the shame, the shame of being this colour … the shame of being female. Basically, it not only came from the school, it comes from the whole community.

    If you were about that high, and your parents would say “Don’t play with them. They’re dirty Indians.” And you had no idea what a “dirty Indian” is. So, you would go, and then you would turn around and say to your friends “We’re not supposed to play with them because they are dirty Indians,” and your friend would say, “Well, how come?” “Because my parents said so.” So, we learn a lot by what our parents say.

    I have to admit that a person who sniffed up, or a drunk, doesn’t smell very good. You know, if you’ve got a good nose, it doesn’t smell … But the thing is, you have to get past the smell and see the soul or the spirit. That’s a human being and we are all connected, and it doesn’t matter what race we come from or what nationality we are. We are connected. Racism is a very powerful thing. It’s very, very subtle.


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