Although she can recall a number of occasions when she witnessed cultural misunderstandings and mistreatment, Patricia Farrugia remembers one particular moment that crystallized things, one experience that made it abundantly clear what she needed to do. Practising as a registered nurse on the oncology floor of an Ontario hospital, Ms. Farrugia was caring for a patient who had been diagnosed with metastatic brain cancer. The patient and his family, who were aboriginal, wanted to perform a traditional cleansing ceremony, smudging the room and burning tobacco. Hospital authorities frowned on this – they cited the no-smoking policy, among other things – and questioned whether the ceremony was necessary.
“As that patient’s nurse, I tried to facilitate it, but I just came across barrier after barrier after barrier. And I felt really bad, because I knew that it was very important to the patient, and I couldn’t meet his needs,” she says, her face turning serious at the recollection.
Determined to do something about these situations, Ms. Farrugia – of Ojibway descent and a member of the Chippewas of Nawash First Nation – went to medical school. It wasn’t easy; she was 29 years old, married, with twin little girls. Now, having completed her third and final year at McMaster University’s Michael G. DeGroote School of Medicine (and president of the graduating class), Dr. Farrugia is poised to begin a residency in orthopedic surgery.
That fact is an obvious point of satisfaction for Alan Neville, assistant dean of the undergraduate medical program at DeGroote. “I’ll bet you there are very few female, aboriginal orthopedic surgeons in Canada,” says Dr. Neville, a smile sneaking through his buttoned-down, vaguely British demeanor.
Dr. Neville’s satisfaction is that of a man who is seeing his efforts, and those of many others, bear fruit.
For Dr. Neville, the effort started in earnest five-and-a-half years ago, during a one-day forum that followed the 2004 annual conference of the Association of Faculties of Medicine of Canada in Halifax. The agenda was open; no papers were presented. Instead, representatives from various parts of the healthcare sector broke into small groups to address a relatively simple question: How can medical schools better serve their communities?
At Dr. Neville’s table, “a lot of fairly impassioned discussion took place around aboriginal health,” he recalls. “People had seen and read about the huge disparities in terms of aboriginal health needs, which were unmet because of the small number of resources being applied to them.”
Delegates recognized that the ratio of indigenous physicians to indigenous population was woefully inadequate, that the health needs of this underserved population were staggering, and that the grim statistics – on infectious diseases, circulatory conditions, preventable deaths – were undeniable.
At the same time, the condition of Canada’s indigenous peoples, revealed through rankings and reports by international organizations such as the World Health Organization, was becoming something of a national embarrassment – with statistics like tuberculosis rates in the indigenous population that are six times the national average or suicide rates for indigenous youths seven times the national average.
“When you separate out the indigenous health care indicators from those of the rest of Canada, aboriginal people would rank as one of the poorer countries in Africa,” says Barry Lavallée, a professor of medical education at the University of Manitoba. “We don’t do well in this really rich country – and medical people have a very powerful way to change that.”
At the end of the day in Halifax, aboriginal health became one of two national priorities for Canada’s faculties of medicine (the other is public health).
De Groote medical school already had an aboriginal leader on its faculty – Karen Hill, coordinator of the aboriginal students’ health sciences office and herself a DeGroote graduate and family doctor at the nearby Six Nations of the Grand River community. As Dr. Neville watched the efforts and inroads she was making with very little help, he was provoked to read and learn more about aboriginal health.
Similar things were happening all across the country. Indigenous medical leaders were emerging and, although few in number, were making a big impact on their colleagues. Several of them formed the Indigenous Physicians Association of Canada, also in 2004. This turned out to be a critical development, notes Dr. Lavallée, now the association’s vice-president. The Indigenous Physicians Association formed a partnership with the newly focused Association of Faculties of Medicine of Canada with goals to increase aboriginal recruitment and transform the curriculum in Canada’s
17 medical schools.
Five years later, the changes have been nothing short of dramatic. Preliminary data from the first few years of this new push (2005 to 2008) show that the number of medical students who identify themselves as aboriginal has grown by more than 60 percent. McMaster is now a national leader, with 28 aboriginal students spread across its three-year program. Ten years ago, it had just three aboriginal medical students. This year, 56 aboriginal medical graduates accepted positions across Canada, expanding the ranks of indigenous physicians by 25 percent in one fell swoop. Some 25 years ago, an informal survey revealed just four indigenous physicians in the entire country, says Dr. Lavallée.
While opening the door to more indigenous students is an effective strategy, medical schools aren’t simply staying home to do that. At the University of British Columbia’s medical school – a national leader, with 13 seats reserved for aboriginal students and 28 students enrolled, 12 of them in first year – the coordinator of aboriginal programs, James Andrew, travels to colleges and universities around the province to hold information sessions for indigenous students, and he gives presentations at career fairs. Mr. Andrew, a member of B.C.’s Lil’wat Nation, also oversees a program of pre-admissions workshops, teaching prospective indigenous students how to prepare for the medical school entrance exam, how to put together an application and how to perform in an interview. Meals and accommodations to attend the workshop are paid for by UBC for those coming from outside Vancouver.
The outreach efforts have been matched by a major shift in medical school curriculum. Dr. Neville admits that five years ago he had never heard of a concept called “cultural safety;” it means that a doctor’s understanding of the culture of a First Nations patient and the accompanying awareness of colonial power relationships is an integral part of treatment. Cultural safety is now one of the guiding principles in a set of core competencies, developed jointly by the indigenous physicians’ association and the association of medical faculties. Now, each of Canada’s 17 medical faculties is in the process of grafting these core competencies into its curriculum.
At the Association of Faculties of Medicine of Canada’s most recent annual conference this past April in Edmonton, a panel of three indigenous health professionals, including Dr. Lavallée of U of Manitoba, gave a presentation about burdens borne by aboriginal people, the structural issues affecting their health and the concept of cultural safety.
Dr. Lavallée, who is the son of a Métis father and an aboriginal mother from the Interlake region of Manitoba, says that the presentation “had a profound impact on a lot of the people in the audience.
“Profound. People were wiping their eyes. Out of all the talks I’ve given in my whole career, this was the most amazing. I couldn’t imagine this happening even three years ago, and I’ve been one of the leaders in the forefront for the last 15 years.”
In addition to dramatic growth in numbers of aboriginal medical students, the changes to medical curriculum are also having an influence. At McMaster, Dr. Hill has worked hard to expose all students in the program to aboriginal people and culture, by taking students for visits to the Six Nations community, about half an hour west of Hamilton, Ontario. The talks she gives routinely to first-year medical classes have had a noticeable impact. Naheed Dosani, a non-aboriginal second-year student, remembers the passion Dr. Hill had for the topic and the awareness it raised in him and his classmates. These experiences, plus the additional indigenous health elements woven into the curriculum, had such an effect that Mr. Dosani now wants to complete a placement in a First Nations community.
“I’m an example of a non-aboriginal student who has come to this curriculum and is already thinking about, how can I have an impact on aboriginal health?” says Mr. Dosani, who is the second-year class president.
Other medical schools, too, are using the new “core competencies” to integrate examples and create modules and electives that will better acquaint students with aboriginal health issues. Some are making the hiring of indigenous faculty a priority. The University of Alberta has added to its faculty a traditional aboriginal healer named Clifford Cardinal (he also has a master of science degree and a background in public health). Students have the opportunity to shadow him while he practises traditional healing, and he teaches courses focused on indigenous medicine.
Some schools are offering placements that give students intimate exposure to the needs of an aboriginal community. None are doing more along these lines than the Northern Ontario School of Medicine, which opened in 2005 with campuses at both Lakehead and Laurentian universities. It says it is the first medical school in the world that requires students to spend at least four weeks living and working in an indigenous community.
“The focus is on the students learning about the community, about the history, about the tradition, about the culture, about the social and health issues,” says Roger Strasser, the school’s founding dean (and previously head of rural health at Monash University in Australia).
“For many of the students, this is a life-transforming experience,” he says. “They come back with a different view of themselves and of aboriginal people and culture.”
Surely, making these kinds of curriculum changes and recruiting and retaining more indigenous medical students is a worthy goal in itself. But a debate roils over the question: where will these graduates have the greatest positive impact on health care delivery for indigenous peoples? Even with the infusion of 56 new aboriginal doctors this year, the number of indigenous physicians in Canada – about 250 – is still well short of 2,000, a target that, if met, would bring the ratio of aboriginal physicians to aboriginal people in line with the situation for the rest of Canadians.
One view is that securing more aboriginal doctors for First Nations communities should be the top priority, given their unique pairing of skills with an intimate knowledge of the culture and needs of their community. Others argue that having aboriginal doctors in senior positions where they can dispel stereotypes, work in advocacy and serve as role models for those coming through the system is more important.
Evan Adams is one who resists picking a side. A member of the Sliammon First Nation who trained as an MD at the University of Calgary, Dr. Adams serves as aboriginal health physician adviser for B.C.’s Ministry of Healthy Living and Sport. He says aboriginal doctors are needed in all sectors.
“Some of us are going into clinical service, which is what we’re trained to do. Some of us are going into public health, and some of us are going into research. We’re needed in all those areas. And we’re really, really needed in simple advocacy roles, speaking up for ourselves and our patients, to say, look, we really need to do more for them.”
Dr. Farrugia won’t be returning to her First Nations community, even though she feels the pull. And she’s already feeling a special burden.
“I’m sure people expect me to solve a lot of their problems, or solve every problem that exists with aboriginal health care.”
But, she says, she can only focus on one area – orthopedic surgery, her chosen specialty. As an orthopedic surgeon, she says she can help both aboriginal Canadians – particularly children and obese adults requiring hip and joint replacements – and non-aboriginal patients.
Her career goals reflect the dual focus that’s inherent in being both a medical doctor and an indigenous person in Canada today. “I want to gain a reputation as an approachable, well-engaged physician who gives a special amount of care to my patients, whether they’re aboriginal or not,” says Dr. Farrugia.
Her face knits into a look of resolve. “And I want to be known as a person who is always up for a fight, that I’m not going to back down, that I’m going to continuously advocate for aboriginal people – and for the health of Canadians.”