Indigenous Health

Introduction to Indigenous Health in Canada

For the MCCQE1 and the CanMEDS framework (specifically the Health Advocate and Communicator roles), understanding Indigenous Health is critical. It involves recognizing the unique historical, political, and social contexts that shape the health outcomes of Indigenous Peoples in Canada.

Indigenous Peoples in Canada are not a homogenous group. The Constitution Act of 1982 recognizes three distinct groups:

1. First Nations (Status and Non-Status)
2. Inuit
3. Métis

Historical Context and Social Determinants

To perform well on the PHELO (Population Health, Ethical, Legal, and Organizational) section of the MCCQE1, you must understand the root causes of health inequities.

The Impact of Colonialism

Current health disparities are directly linked to the history of colonization, including:

• Residential Schools: Forced assimilation, abuse, and loss of culture/language.
• The “Sixties Scoop”: Mass removal of Indigenous children from their families into the child welfare system.
• Indian Hospitals: Segregated healthcare facilities with substandard care.

Determinants of Health: The Tree Metaphor

Indigenous health is often explained using a “tree” metaphor to categorize determinants.

Cultural Safety and Competence

The MCCQE1 assesses your ability to practice in a culturally safe manner.

Epidemiology and Specific Health Concerns

While avoiding stereotypes, candidates must be aware of epidemiological trends for the MCCQE1 to formulate appropriate differential diagnoses.

1. Chronic Diseases

• Type 2 Diabetes: Prevalence is 3–5 times higher than the general population. Onset is often earlier (including in children).
• Renal Disease: Higher rates of end-stage renal disease (ESRD), often secondary to diabetes.

2. Infectious Diseases

• Tuberculosis (TB):
  • Rate is significantly higher in the Inuit population (up to 300x the rate of Canadian-born non-Indigenous people).
  • MCCQE1 Tip: Always consider TB in the differential for chronic cough in patients from Inuit Nunangat.
• H. pylori: Higher prevalence, leading to increased risks of gastritis and gastric cancer.
• MRSA: Community-associated MRSA is more prevalent in some communities due to overcrowding/housing issues.

3. Mental Health and Suicide

• Suicide rates are significantly higher, particularly among Inuit youth and First Nations men.
• Etiology is linked to intergenerational trauma and colonization, not inherent pathology.

4. Infant and Maternal Health

• Higher rates of infant mortality.
• Higher rates of sudden infant death syndrome (SIDS).
• Issues regarding evacuation for birth (women forced to leave remote communities to give birth in cities).

Canadian Guidelines and Principles

Familiarity with these reports and principles is essential for the Ethical and Legal aspects of the exam.

The Truth and Reconciliation Commission (TRC)

The TRC released 94 Calls to Action. Calls 18–24 specifically address health.

• Acknowledge that current health gaps are the result of government policies (residential schools).
• Recognize distinct health needs of Off-Reserve, Metis, and Inuit peoples.
• Provide sustainable funding for healing centers.
• Course work on Indigenous health for medical and nursing students.

Jordan’s Principle

• The Rule: The government of first contact must pay for the service without delay. Payment disputes between federal and provincial governments are resolved after the child receives care.
• Scope: Applies to all First Nations children (on and off-reserve).

Joyce’s Principle

Named after Joyce Echaquan, this principle aims to guarantee to all Indigenous people the right of equitable access, without any discrimination, to all social and health services, as well as the right to enjoy the best possible physical, mental, emotional, and spiritual health.

Clinical Approach: The CanMEDS Framework

How to approach a station or clinical scenario involving an Indigenous patient.

Key Points to Remember for MCCQE1

• Jurisdiction: Healthcare is generally provincial, but healthcare for First Nations on-reserve and Inuit is often a shared federal responsibility (Indigenous Services Canada).
• Consent: Standard consent rules apply, but be hyper-aware of historical coercion (e.g., forced sterilization). Ensure consent is truly informed and voluntary.
• Nutrition: Food insecurity is high in Northern Canada (Inuit Nunangat) due to high costs. Recommend realistic dietary changes (e.g., traditional country foods are often healthier and more culturally appropriate than expensive imported produce).
• Antibiotic Resistance: Be aware of high rates of CA-MRSA in some communities; follow local antibiograms.
• Vaccination: NACI guidelines often recommend specific schedules for Indigenous communities (e.g., earlier Pneumococcal vaccines, Hepatitis A vaccination in susceptible communities).

Sample Question

A 6-year-old First Nations boy presents to the clinic with severe dental caries requiring extensive extraction and restoration under general anesthesia. The boy lives on a reserve. The recommended pediatric dental surgeon is located in a city 400 km away. The family expresses concern that the procedure was cancelled previously because the provincial health authority and the federal government could not agree on who would fund the medical transport and the anesthesia costs. The child is in pain and has difficulty eating.

Which of the following is the most appropriate principle to cite to ensure this child receives immediate care?

• A. The Canada Health Act
• B. The Indian Act
• C. Jordan’s Principle
• D. The Good Samaritan Act
• E. Joyce’s Principle

Explanation

The correct answer is:

• C. Jordan’s Principle

Explanation: Jordan’s Principle is a child-first principle intended to ensure that First Nations children do not experience denials, delays, or disruptions of services due to jurisdictional disputes between the federal and provincial/territorial governments. It states that the government of first contact should pay for the service and resolve jurisdictional/payment disputes later. This scenario describes a classic jurisdictional dispute causing a delay in care for a First Nations child, which is exactly what Jordan’s Principle addresses.

• A. The Canada Health Act: Sets out the criteria for provincial health insurance plans (public administration, comprehensiveness, universality, portability, accessibility) but does not specifically address the federal/provincial payment disputes for First Nations children.
• B. The Indian Act: A federal law that governs matters pertaining to Indian status, bands, and Indian reserves. While it provides the legal framework for “Status,” it is not the specific mechanism used to resolve immediate care access disputes for children.
• D. The Good Samaritan Act: Protects individuals who voluntarily assist someone in an emergency from liability. It is irrelevant here.
• E. Joyce’s Principle: Focuses on equitable access without discrimination and eliminating systemic racism in healthcare, inspired by the death of Joyce Echaquan. While relevant to the broader context of Indigenous health, Jordan’s Principle is the specific legal mechanism addressing child service funding disputes.

References

1. Truth and Reconciliation Commission of Canada. (2015). Truth and Reconciliation Commission of Canada: Calls to Action. Link 
2. Indigenous Services Canada. (2023). Jordan’s Principle. Government of Canada. Link 
3. National Collaborating Centre for Indigenous Health (NCCIH). (2023). Social Determinants of Health. Link 
4. College of Family Physicians of Canada. (2023). Indigenous Health Resources.
5. Public Health Agency of Canada. (2022). Tuberculosis in Canada.
6. Medical Council of Canada. (2023). MCCQE Part I Objectives: Population Health. Link