Indigenous and Northern Affairs Committee on May 3rd, 2022

[Dr. James A. Makokis]

One, it's important, when we look at the provision of medical care and medicine, that we follow medical practices that are keeping up with the current times. If we look at the processes that exist within the NIHB system, there are flow charts of multiple steps that patients have to jump through. The clearest example is rheumatoid arthritis. People should not end up in wheelchairs with amputations, disabled, because they're not provided with the proper medication that exists today in the form of biologic and immunological agents—things like Humira. Instead, those patients have to take older medication, and their joints are completely destroyed by that time. They end up disabled and dying. We should not be seeing that in a country like Canada. We need to follow medical advice and recommendations that keep up with the fast pace of medicine.

Two, if we look at our original agreement within the medicine chest clause, which is a symbol of health care that would evolve into the future, it was all-encompassing. It included medicine as it would evolve—the pharmaceutical drugs that would come, and medical equipment and supplies that would come. Again, there are very rigid parameters as to how people can access this. If we look at diabetes and foot ulcers.... The basic principles of wound care include VAC or having patients wear Aircasts to off-load pressure. None of those are provided. Then we see that the rate of amputation among indigenous peoples is the highest in this country.

We actually need to provide care that reflects the needs of the state of health of indigenous peoples, which is the worst among any group across this country. That is not something our ancestors agreed to when we agreed to share this country in peace and friendship. Ultimately, 150 years later, we're in worse condition than when our relatives arrived on the shores of this country.

[The Chair, Liberal, Marc Garneau]

Thank you, Doctor.

Go ahead, Dr. Adams.

[Dr. Evan Adams]

Yes, and I hope we have talked about UNDRIP and decisions being made about indigenous health without indigenous people at the table.

That time should be over for a couple of reasons. Indigenous decision-making is more than making a system faster so that more indigenous people can have more drugs faster. That is not the point.

With indigenous consultation, we can decide which parts of the system need to be addressed. We need to look upstream and downstream, of course, as well. We take the criticism at first nations and Inuit health branch.

We need to stop people from falling off the bridge rather than trying to help them once they're in the water. Upstream investments in our peoples means spending money on children and on prevention in the social determinants of health. If FNIHB cures your cancer, but we return you to homelessness, unemployment and poverty, have we really done our job?

We really need to be holistic. Indigenous people are very holistic in their approach and they're very clear on what improvements need to made. If they're at the table, we simply have to talk to them. If they're at the table, they will point in many directions where we can invest time and make improvements.

Thanks.

[The Chair, Liberal, Marc Garneau]

Thank you.

Mr. Morrice, I'm afraid we've run out of time, but perhaps in a quick second round you might get in there.

We now go to Ms. Idlout.

Ms. Idlout, you have six minutes.

[Lori Idlout, NDP, Nunavut, NU]

[Member spoke in Inuktitut as follows:]

ᖁᔭᓐᓇᒦᒃ ᐅᕙᑦᑎᓐᓄᑦ ᐅᓂᒃᑳᓵᕋᔅᓯ. ᐅᑉᐱᕈᓱᓗᐊᑦᓯᐊᙱᓐᓇᒪ ᐃᓘᓐᓇᓯ ᓄᓇᖃᖅᑳᖅᓯᒪᔪᓂᒃ, ᐊᓪᓚᓄᑦ, ᐊᓪᓚᖓᔪᓄᑦ ᐃᓄᖕᓄᑦ ᐱᔨᑦᑎᕋᑦᑎᐊᙱᓲᖑᒐᔅᓯ ᐊᐃᑦᑖᖑᒐᓗᐊᖅ ᑭᓯᐊᓂ ᑖᓐᓇ ᓘᑦᑖᖅ ᒪᑰᑲᔅᒧᑦ ᐊᐱᕆᔪᒪᕗᖓ ᑖᓐᓇ ᐅᑉᐱᕆᑦᓯᐊᕋᒃᑯ ᐅᐱᒋᓪᓗᒍ ᓄᓇᖃᖅᑳᖅᓯᒪᓪᓗᓂᓪᓗ ᓘᑦᑖᖑᒻᒪᑦ ᑐᑭᓯᔪᒪᒋᕙᒋᑦ ᐃᒪᓐᓇ. ᖃᓄᑎᒋ ᑖᒃᑯᐊ ᓇᓪᓕᐅᒃᑯᒫᓕᕆᔩᑦ ᓄᓇᖃᖅᑳᖅᓯᒪᔪᓄᑦ ᐃᑲᔫᓯᐊᑦ ᑮᓇᐅᔭᐃᑦ ᐃᑲᔪᕐᓂᖃᓲᖑᒻᒪᖔᑦ ᑕᒪᒃᑮᑦ ᓄᓇᖃᖅᑳᖅᓯᒪᔪᐃᑦ ᐱᖅᑯᓯᖏᓐᓂᑦ ᐊᒻᒪᓗ ᖃᓪᓗᓈᑎᑐᑦ ᑖᒃᑯᐊ ᓘᑦᑖᖃᕐᓂᓕᕆᓂᕐᒧᑦ ᒥᒃᓵᓄᑦ ᐊᑦᑐᐊᓂᖃᓲᖑᒻᒪᖔᑕ ᓄᓇᖃᖅᑳᖅᓯᒪᔪᓄᑦ

[Inuktitut text interpreted as follows:]

Thank you.

First of all, I wish to thank you three for coming to give us this presentation.

I know that when it comes to first nations, Métis and Inuit, you may be limited with some of the Inuit and other aboriginal groups. The one I can relate to is Dr. Makokis. As you are in direct [Inaudible—Editor] and you are a care provider, I admire that very much.

I wish to ask you this now, Dr. Makokis. In what ways do shortfalls in NIHB funding for both traditional indigenous medical systems and western clinical services impact indigenous people?

[English]

[Dr. James A. Makokis]

Thank you so much for your question, MP Idlout.

This is all a very long answer. When we look at the state of indigenous people's health in this country, it's directly proportional to the systemic dismantling that has occurred through federal policies and laws.

Our people had our own health systems, method of health, healing and medicines that helped to keep our people strong, well and healthy well into the ages that we're currently living with all of the advance of Western medicine technology and pharmaceutical drugs.

We know that the federal government, from 1884 to 1951, banned ceremonies, including potlatches, indigenous medicines and ways of being that formed the fabric of our medical system. We're seeing the direct results of that in the high rates of chronic disease, infectious disease, suicide and mental health issues that Dr. Adams mentioned.

For there to be a dramatic transformation in all of these health statistics, we need to systematically rebuild indigenous health systems. That starts with funding indigenous healers, elders, medicine people and young people who can train in their footsteps. We're at the verge of the possible extinction of our knowledge as it relates to indigenous medicines when it comes to how to keep our people healthy and well.

We know, when we look at research from the Aboriginal Healing Foundation, that indigenous peoples routinely rated our own medicines and access to our healers and medicine people higher and more important than accessing Western medicine, physicians and Western allied health professionals.

When we look at the non-insured health program, as Dr. Adams mentioned, yes, travel to see elders and traditional medicine people is covered, but the compensation to them as practitioners within our own health system, which has been decimated by Canadian law, is not covered. It's left up to the patient to cover themselves. We stopped paying for physician services when the Canada Health Act was implemented back in the 1980s and funding was provided by the federal government to provinces and territories to help pay for physician services.

We also have to pay for indigenous health services practised by our own people for our own people. We know that it works the best. We've had Western medicine for the past—I don't know how many—decades, and we haven't seen a transformation in indigenous mental, physical or spiritual health. What we need is our own medicine supported in a systematic way that has longevity and that our people can access. That's what they're looking for. We haven't seen any funding or resources put towards this.

Indigenous physicians who work with our own elders and healers would be a tremendous resource to help to guide this process, working in conjunction with our own people and our own leaders within our own communities. Unfortunately, there are very few indigenous physicians with that background, but there are some who would be willing to provide this help and guidance.

[Lori Idlout, NDP, Nunavut, NU]

[Member spoke in Inuktitut as follows:]

ᖁᔭᓐᓇᒦᒃ. ᑭᖑᓪᓕᖅ ᐊᐱᕆᑲᐅᖅᑐᑐᐃᓐᓇᕐᓂᐊᖅᑕᕋ. ᐅᓂᒃᑳᕈᓐᓇᖅᐲᑦ ᖃᐅᔨᒪᔭᓐᓂᑦ ᓲᕐᓗ ᑕᑯᓯᒪᔭᓐᓂᑦ ᐋᓐᓂᐊᕐᓇᖅᑐᓕᕆᓂᐅᑉ ᒥᒃᓵᓄᑦ ᑐᓂᔭᐅᓯᒪᔪᓄᑦ ᓄᓇᖃᖅᑳᖅᓯᒪᔪᓄᑦ ᑎᒥᖏᓐᓄᑦ.

[Inuktitut text interpreted as follows:]

Thank you.

I will make this last question short. Can you give an example of a transfer of health services to indigenous nations? Would you provide an example of what you've seen in transferring to indigenous people?

[English]

[Dr. James A. Makokis]

I know that Dr. Adams mentioned the First Nations Health Authority, which is constantly referred to as the example across the country of what should be done.

I know that, in the province of Alberta, for example, which has Treaty 6, 7 and 8, some nations within Treaty 8, like the Bigstone Cree nation, have taken over their NIHB program. I have patients who access that; I see them as a frontline provider.

What I and other indigenous physicians who work with that program have found with that particular program is that it's even more difficult to get pharmaceutical drugs, medications, equipment and supplies covered. What I observe happening is that the restrictions that were under NIHB are exacerbated. I'm not sure if, in this transfer of funds to the nations and communities themselves, the funding is further restricted so that communities and nations are then administering their own poverty with funds that are given and transferred from federal programs and things like that.

[The Chair, Liberal, Marc Garneau]

Thank you very much, Ms. Idlout.

Colleagues, we have a little bit of time left. I'm going to make a proposal that we start the second round with three minutes to each of the first two speakers and then one question each for the third and fourth speakers. That way, we can probably finish on time.

I'm going to start with the Conservatives. I'm not exactly sure who would be the speaker, but they would have three minutes.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Thank you, Chair.

I'll just pick up from where Dr. Makokis was in our last conversation, and I will go to Dr. Lafontaine.

When you're talking about the costs, it seems that, as was mentioned, instead of having three people decide you have to sign off on something before you actually see some movement, there could be some real efficiencies by changing those dollars from funding bureaucrats to actually going to the care of individuals.

[Dr. Alika Lafontaine]

I do agree with that statement. I think in exploring the workflows we do have to be careful that we don't assume that those costs can be immediately transferred to patients, but I do believe that, yes, your comment is correct.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Dr. Makokis.

[Dr. James A. Makokis]

I'm sorry, but can you just repeat your question?

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

I was just talking about costs, where we have, in some cases, excess bureaucracy and how, if we improved, as Dr. Lafontaine said, the workflow to ensure that things were getting done in a timely and efficient manner, we might be able to hopefully move some of those dollars into actually funding the care that's needed.

[Dr. James A. Makokis]

Yes. If you look at Onion Lake Cree Nation, they're looking at having treaty-based funding given directly to the nation to administer and look after its own health agreements and look after the priorities of their own nation in terms of health.

As we know, if we look at the bureaucracy of Indigenous Services Canada, the money that's provided for indigenous people is actually siphoned off by this large bureaucracy, and a very small amount actually ends up getting to the people who require it the most.

So I do agree that, yes, the bureaucracy does take a lot of this money when it's actually required by indigenous peoples who, again, have the worst health outcomes of this country. Nations like Onion Lake Cree Nation, which are leading in this area, would be examples to learn from.

[Jamie Schmale, Conservative, Haliburton—Kawartha Lakes—Brock, ON]

Dr. Makokis, just out of curiosity, in those painful stories that you presented here to committee, when you had to basically, as I mentioned before, hit the panic button before you saw any movement, was the person on the other end of the line actually somebody from the department who had medical experience or was it just somebody who happened to pick up the phone that day?

[Dr. James A. Makokis]

The people in NIHB who are trained to answer the phone are non-medical professionals. Sometimes they do hire medical professionals, as I mentioned, such as the national pharmacist, and there are regulated health professionals who are a part of that program, but largely it's just regular people without a medical background who follow the flow charts and decision-making processes given to them by Health Canada under NIHB. I have to advocate to these non-health professionals about somebody's personal health history and try to get across to them my medical decision-making process when they don't have any background or understanding about that.

[The Chair, Liberal, Marc Garneau]

Thank you very much.

We'll now go to a Liberal, Mr. Badawey.

[Vance Badawey, Liberal, Niagara Centre, ON]

Thank you, Mr. Chairman.

I'll be splitting my time with Ms. Atwin, but I do have one question. I appreciate the time split with me.

With respect to Dr. Makokis' comments, as the PS for Indigenous Services Canada, I'm very much interested to work with you, Doctor, as well as with Dr. Lafontaine and Dr. Adams, to establish a direction for community health and a more formalized community health plan.

To all three of you, is there or has there been established—I'll use these words—“a strategic plan” with respect to overall community health within indigenous communities, on reserve in rural areas, in smaller communities and in other on-reserve communities as well? Has there been a strategic plan that's been consistent or that the three of you wish would be implemented on reserve?

[The Chair, Liberal, Marc Garneau]

In the interest of time, I'll direct that first to Dr. Adams, if you want to comment, then Dr. Makokis and then Dr. Lafontaine.

[Dr. Evan Adams]

Sure.

B.C. has a tripartite first nations health plan. The first document was quite slim—I think under 10 pages. The next plan after they finished their initial mandate was much longer. I think first nations, Inuit and Métis have actually described well where they would like to invest and where their priorities are. I think it would be very welcome to just have them lead those kinds of directions and investment. It doesn't make sense to enact care that hasn't been asked for, and from a distant location. It really needs to involve local peoples.

Thanks.

[The Chair, Liberal, Marc Garneau]

Thank you.

Dr. Makokis.

[Dr. James A. Makokis]

I think one of the issues that we routinely see as indigenous physicians who work in the community—there are very few of us who do that—is that we are left out of the decision-making process, and we're actually not asked about our routine experiences that we have as we interface with these programs.

When I talk with other allied health professionals like pharmacists, optometrists, opticians and nurses, they have the same experiences when it comes to these programs. I think that's one of the biggest challenges. We actually need to speak with, dialogue and have conversations with the users of these programs, who then can articulate these types of experiences that are real world and real time with real people of what they routinely go through on a regular basis.

I know that in the previous panel the importance of having chaperones was raised. Chaperones can be life-saving for individuals who routinely face systemic racism within the health care system, because they're going to be the ones who advocate and see that in real time. We know what happened with Joyce Echaquan, as well as many others within the health care system of Canada, where people are dying because of systemic racism.

We actually need to have conversations with the users of the program, with the bureaucrats who are often forced to sign non-disclosure agreements that they can't talk about the injustices they see within the program. You can talk with some of the Indigenous Services Canada nurses I interface with routinely who see the injustices but are unable to bring them to the attention of media because of these NDAs that they're forced to sign. Under their own regulatory profession and advocacy as nurses, they're not able to bring that forward.

I think there are many issues. Those are just the tip of the iceberg, and I think this conversation needs to be expanded to include more people.

[Vance Badawey, Liberal, Niagara Centre, ON]

Let's do that.

Dr. Lafontaine.

[Dr. Alika Lafontaine]

I was part of an alliance called the Indigenous Health Alliance from 2013 to 2017. It had more than 150 first nations across three provinces participating in it. There was Nishnawbe Aski Nation in northern Ontario, Keewatinowi Okimakanak in northern Manitoba and the Federation of Sovereign Indigenous Nations. We had the support of AFN. We were meeting with ministers, and at the time I gained a real insight into the question that you just asked.

If you use the example of cooking, what I think we often ask communities to do is walk into a kitchen with foreign ingredients and cook what they want. I think that's how it is with health care for many people who aren't in health care or have been through a past patient experience. They don't really know what they don't know, and they don't know how the pieces fit together.

The most valuable thing that we did with that alliance, and something that we try to do here at the CMA, is give people examples of what to cook. We teach them what the different ingredients are and how they mix together. I think if you're looking at scaling different approaches, it's giving first nations, Inuit and Métis communities across the country the ability to pick and choose what they want to eat, but then understand about nutrition, about cooking, the ingredients, etc.

The question is not if people can cook; it's if they can cook with what we give them. I think we have to change our orientation from asking if communities have capacity, to assuming that they have capacity but do they have the supports they need to make better decisions?