Evidence of meeting #17 for Indigenous and Northern Affairs in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was care.

A video is available from Parliament.

On the agenda

MPs speaking

Also speaking

John Main  Minister of Health, Government of Nunavut
Clerk of the Committee  Ms. Vanessa Davies
Julie Green  Minister of Health and Social Services, Government of the Northwest Territories
Tracy-Anne McPhee  Minister of Health and Social Services, Government of Yukon
Alika Lafontaine  President-Elect, Canadian Medical Association
James A. Makokis  Plains Cree Family Physician, Kinokamasihk Nehiyawak Nation, Treaty Number Six Territory, As an Individual
Evan Adams  Vice President, Indigenous Physicians Association of Canada

4:35 p.m.

Liberal

The Chair Liberal Marc Garneau

Okay.

Thank you very much.

Dr. Lafontaine, apparently you don't have the normal headset that we use for our interpreters.

I would ask you to conclude, but speak a little more slowly.

4:35 p.m.

President-Elect, Canadian Medical Association

Dr. Alika Lafontaine

Sure. I'm sorry about that.

In conclusion, the CMA recommends that this initiative be coupled with sustained investments to address the ongoing structural inequities that marginalize indigenous peoples. That's the inclusion of indigenous peoples in societal systems and sectors and a commitment to collaborative and respectful relationships with indigenous patients and communities.

Thank you, Mr. Chair.

4:35 p.m.

Liberal

The Chair Liberal Marc Garneau

Thank you, Dr. Lafontaine.

We'll now go to Dr. James Makokis.

Doctor, you have five minutes.

4:35 p.m.

Dr. James A. Makokis Plains Cree Family Physician, Kinokamasihk Nehiyawak Nation, Treaty Number Six Territory, As an Individual

[Witness spoke in Cree]

[English]

I'm from the Saddle Lake Cree Nation and am a descendant of signatories of Treaty No. 6. I'm one of the few indigenous physicians who grew up with their people and who work with their own people. Presently I work on Kinokamasihk. I am testifying as a user of the current NIHB program and as a Nehiyawak physician who treats Nehiyawak, also users of the NIHB program, on a daily basis.

I greet you today in the language of my people, Nehiyawewin, which comes from these lands upon which your people now sit, welcomed by my ancestors nearly 500 years ago, a language imbued with sacred teachings of natural law that governs our people, with laws that roughly translate to kindness, love, honesty, sharing, respect, family, trust, reciprocity, fairness, equity, care, longevity and, above all, honour for our mother, the earth, and all of its inhabitants.

The same language was used to agree to a treaty that allowed for your ancestors to respectfully share these lands in exchange for peace and friendship, mutual understanding and the promise of health and health care, also know as the medicine chest clause, to be honoured for as long as the sun shines, the grass grows and the rivers flow and as long as there are native peoples. In English legalese, this would be represented by the phrase “in perpetuity throughout the universe”.

If the promises of the treaty had been truly honoured, I'd speak to you in my own language, and all of you would fully understand what I am saying. We'd sit around a fire, begin our conversation in ceremony with a prayer and the guidance of a pipe, the keeper of our laws. We would sit and discuss these matters until the matter at hand was resolved.

Yet, I sit here and speak to you in English, a foreign language, with much too short a time limit to articulate the shortcomings of a program that shouldn't even be an issue because everything I'm going to discuss was already promised to us over 150 years ago when your ancestors agreed to a treaty.

To discuss these matters as an indigenous physician is insulting because not only are our health and health care guaranteed by our treaty, which continues to be in full force and effect, but the Government of Canada ushered in the era of truth and reconciliation in an attempt to correct the reality of what is actually happening to our people, which is genocide. Yet I still have to sit here and point out the ways in which NIHB not only continues to fail to provide adequate health measures for our people in the most basic ways, for example by giving patients an insufficient number of catheters while NIHB bureaucrats instruct these same patients to wash and reuse their catheters, which goes against medical standards, but also does so in communities with boil water advisories, as was the case when I practised in my own nation, Saddle Lake, in 2013.

We wonder why indigenous peoples have higher rates of kidney disease and dialysis. We wonder why, when ISC nurses asked me to assess a 17-year-old Cree person from my community who had suffered a spinal cord injury, I found a stage 4 sacral ulcer. For those of you who don't know what that means, the ulcer was so deep I could press on her tail bone. Why did she have this? NIHB would provide her with a new wheelchair at only limited intervals, but children grow and she outgrew her wheelchair, causing these pressure ulcers. Jordan's principle was passed in an effort to address these issues, but still they persist.

This February, it took two months to get an appropriate nutritional formula for a four-month-old Cree baby at a time in their life when their brain was developing the most. We wonder why indigenous youth do not graduate from high school.

To get anything covered through NIHB requires extensive and exhaustive advocacy. I once required post-exposure prophylactic antiretroviral HIV drugs after I performed a procedure in my clinic. The ID specialist recommended I take two drugs within 72 hours of the incident. NIHB denied the claim. I then had to get on the phone myself and speak with the NIHB bureaucrat, who then directed me to the national pharmacist of the NIHB program. I had to tell the national NIHB pharmacist, “If you do not give me these anti-HIV medications, I will be at Canada Place on Monday morning with the Grand Chief of the Confederacy of Treaty Six stating that your policies have possibly caused one of the few indigenous physicians in this country to contract HIV, and it will be in the media. Is that what you want?” Only then was this medication provided. How would a regular person be expected to know how to navigate and advocate through this bureaucratic mess? And we wonder why indigenous peoples have the highest rates of HIV infections.

On April 25, our home care nurse stated that NIHB would not cover wound supplies for a 65-year-old Cree woman who was palliative, dying at home, with metastatic cancer. She required daily dressing changes and NIHB would only give one dressing every three days. I had to spend 60 minutes on the phone with the NIHB bureaucrats and speak with a supervisor to explain that if the patient died of sepsis, I would record how their actions contributed to her untimely death.

It is only when physicians make drastic statements that supplies, equipment and medication are covered. We should not have to do this. Family physicians, specialists and allied health professionals repeatedly state how difficult it is to work within this program and to attain appropriate coverage for indigenous peoples and they ask how this can be improved.

I recommend that the NIHB program be evaluated by indigenous scholars, allies and users of the program and then changed to create an inclusive, responsive and comprehensive program that actually meets the real health needs of indigenous peoples. The current NIHB system only further contributes to our early morbidity and mortality, and its use is a risk factor for our early death.

Hiy hiy.

4:40 p.m.

Liberal

The Chair Liberal Marc Garneau

Thank you, Dr. Makokis.

We're now ready for Dr. Evans.

You have five minutes.

4:40 p.m.

Dr. Evan Adams Vice President, Indigenous Physicians Association of Canada

Thank you very much.

I am here as a dual representative: as the deputy chief medical officer at first nations and Inuit health branch headquarters in Ottawa, but also as the vice president of the Indigenous Physicians Association of Canada.

The Indigenous Physicians Association of Canada is invested in supporting indigenous physicians across the country, indigenous patients and clients and indigenous health and transforming the system. We understand that the colonial experience and the “health interrupted” of indigenous peoples are major factors in their unwellness. We advocate for self-determination and governance, or indigenous control over indigenous health services, recognizing that health services, access to health services and health services as a determinant of health are in a spectrum of the social determinants of indigenous health, which I'm sure you have heard about quite often here.

There are a few items that the Indigenous Physicians Association of Canada would like to touch upon, such as the need for good, distinctions-based first nations, Inuit and Métis public health data—or, really, just health data—so that we get a clearer picture of where we're working and how our clients are doing, which will point us in a direction of wellness.

There are many areas where indigenous peoples need help and support, but here are a few. One is communicable diseases. Also, mental health and wellness have been identified quite early as a need, particularly by the chiefs of Canada. Others are social determinants of health, such as housing, and, of course, the areas where we work: in communities, or within the territories of first nations, Inuit and Métis, and within our clinics and hospitals.

You've probably heard by now about a number of aspects of the non-insured health benefits program, but I wanted to touch upon a few areas where we often complain or hear complaints.

One is the NIHB program appeals process. If coverage for a benefit through the health benefits program is denied, clients, parents, legal guardians or a representative of a client may appeal the decisions. There are three levels of appeal available. Appeals are assessed by a different program official at each appeal level. The NIHB program aims to send clients a written explanation of the decision for an appeal within 30 business days 80% of the time under normal circumstances after receiving completed appeal documents.

The First Nations Health Authority of B.C. understood that the timeliness of the appeals program was difficult and endeavoured to do quality improvement so that the period of time for response and for appeals was considerably shortened.

Next is medical transportation to access traditional healers. The non-insured health benefits also support access to traditional healing services through the medical transportation benefit, which provides eligible clients with coverage for transportation to access health services not available locally, including traditional healing services.

In terms of catheters, they were a topic of discussion a couple of years ago, but this bears reiterating. Items covered under the NIHB program's medical supplies and equipment benefit are intended to address our clients' medical needs in relation to basic activities of daily living, such as eating, bathing, dressing, toileting and transferring. In 2017, NIHB increased coverage for disposable intermittent urinary catheters to four per day and removed the prior approval requirement.

The non-insured health benefits program reviews its services and coverage regularly. We have a non-insured health benefits oral health advisory committee, which is made up of several dentists. Their bios are available on our website.

Our drugs and therapeutics advisory committee includes seven physicians and a few lay people and is chaired by Dr. Derek Jorgenson and vice-chaired by Dr. Marlyn Cook, an indigenous physician from Manitoba.

We also have a medical supplies and equipment advisory committee, which includes vision care experts, a registered nurse, a family physician, a public health physician, a health economist, an ophthalmologist, a podiatrist, etc.

As a side note, I absolutely understand that quality control and the improvement of the quality of services for first nations, Inuit and Métis are an important aspect of system transformation. We take that transformation seriously and understand that consultation with health experts and health leaders, like the indigenous physicians here, is extremely important. This is beside speaking to indigenous clients and indigenous leaders, like chiefs.

I'll end my statement there. I'm happy for discussion.

Thanks very much.

4:50 p.m.

Liberal

The Chair Liberal Marc Garneau

Thank you very much, Dr. Adams.

We'll proceed to a round of questions, and we'll start with Mr. Vidal.

You have six minutes.

4:50 p.m.

Conservative

Gary Vidal Conservative Desnethé—Missinippi—Churchill River, SK

Mr. Schmale is going to take our first slot, Mr. Chair.

4:50 p.m.

Liberal

The Chair Liberal Marc Garneau

Very good.

4:50 p.m.

Conservative

Jamie Schmale Conservative Haliburton—Kawartha Lakes—Brock, ON

Thank you very much, Chair.

Thank you to our witnesses for that testimony. A lot of the common theme we've heard, especially from our first two witnesses, revolved around bureaucracy and the slowdowns that can occur when a government department gets too big and too bureaucratic. As it was pointed out, it costs lives in some cases. We've heard testimony in the veterans committee where veterans have to reapply to prove that their limbs are still missing. This seems to be a common theme.

I'll start with Dr. Makokis, if I can, and then maybe Dr. Lafontaine can jump in. As you pointed out in your testimony, it seems that bureaucracy only moved when you hit the panic button and shocked the department into doing its job. This must be extremely frustrating for you, as was very clear in your testimony.

How would you go about, as some people have suggested, restructuring the department as a whole so that it functions properly?

4:50 p.m.

Plains Cree Family Physician, Kinokamasihk Nehiyawak Nation, Treaty Number Six Territory, As an Individual

Dr. James A. Makokis

It's a complex question with complex solutions. I used to work in a first nations and Inuit health branch as a university student, so sometimes I walked by the NIHB employees and staff and had a listen to the conversations that they were having with our people. Some of them were around medical transportation, which was mentioned previously, and they would ask, “Why can't you just walk to the health centre?” There's no public transportation on reserves, as people know.

What I find is that the bureaucrats who work under the program are completely out of touch with the reality of the lived experiences of people on the reserve and the communities that they're supposed to provide care for. They act as an extreme barrier to the provision of basic, standard care. They don't have any training about indigenous peoples, about indigenous peoples' health, about our treaty promise to health and the provision of health care, medical services and supplies. That is a huge issue.

You mentioned a second piece, which is the tremendous advocacy that physicians or health providers have to do to navigate and get items covered under that program. As indigenous physicians, other indigenous colleagues and I, who work with our own people, routinely have to get people's names and supervisors and document them in the medical chart. We literally say, “You will cause the death of this patient. I'm documenting this and your name will be on the death record as, potentially, one of the contributing causes.” Only then are items covered under this program.

It shouldn't take that level of advocacy. Most health professionals don't even know how to navigate through this system, because they're not taught about it within their professional schools, whether that's in medicine or pharmacy. It's only when we are forced to work within this system that we have to figure out which buttons to press to ensure that something is covered.

When we compare that to any other extended health benefits, whether that's Blue Cross, Manulife or any of the other ones in this country, providers routinely say that the NIHB program is the most difficult and causes the most harm to patients when they want to access it. It is also the most humiliating for patients to access, when they're at the provider's, looking to have their pharmaceutical or their medical equipment covered and having to stand there and advocate for themselves to great lengths to ensure that they receive proper care.

4:50 p.m.

Conservative

Jamie Schmale Conservative Haliburton—Kawartha Lakes—Brock, ON

Dr. Makokis, thank you. That was great. It actually answered my second question, which was about how it compared with other programs.

I will get back to you in two seconds. I just want Dr. Lafontaine to quickly chime in.

4:55 p.m.

President-Elect, Canadian Medical Association

Dr. Alika Lafontaine

Thank you for that question.

For the interpreters, if my headset is causing problems, let me know and I will switch it out to something different.

When we look at bureaucracy, I think it's sometimes an easy target when things fall apart. I'm not saying that bureaucracies need to be big, but we do need people whose job it is to measure metrics, follow costs, make sure that workflows get followed through, audit and do all those other things. This takes people time and effort. Otherwise, that responsibility falls onto whoever else is left within the system. We know that one of the major causes of burnout among physicians is actual administrative work, so I will try to temper some of that criticism of bureaucracy in my answer.

I think the challenge is workflows, actually. The federal government is not a provincial or territorial medical system. ISC has gone through an evolution. They've changed from a program that's usually based on grant funding or other things to a more sustainable program where they are trying to design and create health systems in partnership with first nations and Inuit and Métis nations across the country. Along the way, they're revisiting those workflows and asking questions. Do three people have to approve this? Can just one person sign off on this? Could the responsibility for signing off actually go to the physician?

These are the same struggles we have within our provincial and territorial medical systems. Me having to phone an administrator to get permission to do a surgery at one in the morning, say, could create adverse problems for a person who needs an open fracture fixed in the middle of the night. I think the redesign could be leaning towards understanding what the workflows are trying to get out of the system and lining that up with the needs of patients—right care, right person, right time, and in a place that's as convenient to them as possible.

In your last panel, there was a comment from one of the panellists that sometimes we can't create these systems because of the cost or limited resources. We know that health human resources are at a critical point right now. Trying to work through what's best for the patient, and trying to line up those approvals and auditing processes to make sure that we're compliant with workflows that work in their best interest, I think is our recommendation from the CMA—to explore this type of program redesign.

4:55 p.m.

Liberal

The Chair Liberal Marc Garneau

Thank you.

We will now go to Mr. Hanley, who is sharing his time with Ms. Atwin.

You have six minutes.

4:55 p.m.

Liberal

Brendan Hanley Liberal Yukon, YT

Thank you very much.

Thanks to all three panellists for a really fascinating discourse. Certainly, a common theme is incorporating first nations indigenous leadership and patient experience into program design but also maintaining that public accountability of running what needs to be a publicly funded institution. I appreciate that there is a balance.

Dr. Adams, you and I have known each other in many different roles over the years. When I look back at your experience with the First Nations Health Authority, you were one of the instrumental people, I think, in helping to design the First Nations Health Authority. I think it's a really good example of incorporating first nations leadership into program design.

I wonder if you could comment briefly on what you learned from that and how you might apply that to how we can address some of the inefficiencies, perhaps, that have been witnessed in talking about NIHB.

4:55 p.m.

Vice President, Indigenous Physicians Association of Canada

Dr. Evan Adams

That's great. This is a subject area that I can talk about for a while.

The First Nations Health Authority has been evolving for many years and now is a first nations health organization that has close to 1,000 employees helping about 160,000 first nations people in B.C.

There are a few themes. One is self-determination. It doesn't make sense for first nations health to be run from Vancouver or from Ottawa. Perhaps more local workers and local knowledge could be incorporated.

We've understood that sometimes our workers, who are meant to be helpful and not hurtful, are not well versed in our communities and community needs, and that a clerk in an office in Vancouver making health decisions that supersede those of an indigenous physician who's on the ground—or any physician or health care worker on the ground—is completely inappropriate, and we had to change the way that business was practised.

As many of you know, with quality improvements, making changes—just very simple business practices like how quickly you can get a scalpel to an operating room—requires quite a lot of co-operation and an admission by those workers in that chain that they can do better.

In B.C., that was the beginning of that transformation, and we made quite rigorous commitments through first nations leadership, but also at a tripartite level. Since I've arrived on the call, I haven't heard a mention of the responsibility of provincial services, which is the lion's share of services. They employ doctors and nurses and run hospitals and clinics, so it's the co-operation of the province, the federal partners, the first nations and particularly the first nations health leaders, not just leaders. Chiefs can make some change, but health leaders like Dr. Lafontaine and Dr. Makokis absolutely need to be a part of that process and part of the rigour of making change. They hold the moral high ground in order to ask for those quality changes.

Thanks.

5 p.m.

Liberal

Brendan Hanley Liberal Yukon, YT

I'll let Ms. Atwin continue for the six minutes.

5 p.m.

Liberal

Jenica Atwin Liberal Fredericton, NB

Thank you so much, MP Hanley.

With my brief time, there's so much I could say, but I would first like to acknowledge that I'm speaking on the unceded territory of the Wolastoqiyik here in New Brunswick.

Again, with my limited time, I want to thank you, Dr. Makokis, for your testimony today. In particular, the honesty is really going to help inform our work in moving forward.

As well, for Dr. Lafontaine, congratulations on your election. Actually, the previous chair, Dr. Ann Collins, happened to be from Fredericton.

My question is for Dr. Adams. I'm a big fan, by the way. I have to say that.

In some of the themes that have been coming up, we've talked about the need for this to be indigenous-led—absolutely—the need to address systemic racism within the system and informed advocacy and all these pieces.

I know that a big piece of the Indigenous Physicians Association of Canada is looking for that capacity building. How can provinces, territories and communities recruit and support indigenous doctors and medical professionals to help deal with some of these issues?

5 p.m.

Vice President, Indigenous Physicians Association of Canada

Dr. Evan Adams

That's an excellent question. I hope you will keep asking that question of a number of professionals.

Really quickly, absolutely, I'm getting learners ready so that they're eligible to apply to medical school, and that's in undergraduate and even high school programs.

Admissions is another area. Also, then, there's the area of support for indigenous learners who are in medical school, because they are quite unique. They are like those who are here. They have phenomenal responsibilities within their communities as community leaders, cultural leaders and keepers of indigenous knowledge, besides going to medical school. Also, many of them are older and many of them already have families, so they need support. They're a different kind of learner than the average medical student. Last of all, they need jobs.

It's wonderful that we can be working in hospitals and clinics alongside our non-indigenous colleagues, but really, indigenous physicians need to be able to ascend. They need to sit alongside chiefs, as their medical officers. Indigenous people can have their own medical officers as their senior health advisers, and we need indigenous physicians and other health care professionals at the highest levels to ask for accountabilities and change.

Thanks.

5 p.m.

Liberal

Jenica Atwin Liberal Fredericton, NB

Is there more time, Mr. Chair?

5 p.m.

Liberal

The Chair Liberal Marc Garneau

No. I'm afraid that has just run out the clock. Thank you, Ms. Atwin.

We will now go to Mrs. Gill and Mr. Morrice.

Mrs. Gill, you have the floor for six minutes.

May 3rd, 2022 / 5 p.m.

Bloc

Marilène Gill Bloc Manicouagan, QC

Thank you, Mr. Chair.

I would like to thank all the witnesses again, Mr. Lafontaine, Mr. Adams and Mr. Makokis.

Thank you for your testimony, which is varied.

Moreover, you work on the ground. You really see the reality in its most concrete and certainly most difficult way as well.

I would have liked to hear you make recommendations to shed light on all the difficulties you are facing. I've heard about the paperwork, in fact. I know that back home in Quebec, the Assembly of First Nations of Quebec and Labrador often comes back to this issue, which is very problematic for them. It prevents people from receiving care. If you can enlighten us, please do so.

My question is for all three of you.

5 p.m.

Liberal

The Chair Liberal Marc Garneau

Dr. Lafontaine, would you get us going on that one?

5 p.m.

President-Elect, Canadian Medical Association

Dr. Alika Lafontaine

I think that's a really good question: What do you recommend to fix some of these problems?

I'll keep my comments focused.

First, you need people to provide the services. I think we have to look at that need the same way we do with respect to an integrated, pan-Canadian health human resources plan. Just as Dr. Adams and Dr. Makokis mentioned, it is a struggle to recruit indigenous physicians into indigenous communities to provide care to indigenous patients. That's extremely important.

Second, it's not just about comparing costs internally against the NIHB program. We also have to look at relative care between provincial and federal systems. The goal of the CMA is advocating for equitable care. This means that, when you come through a door, whether you're indigenous or non-indigenous, you receive the same care, the same sort of access and the same type of timely service.

Finally, as we look toward making changes, there are things we can learn from indigenous health systems, and there are things we can learn from medicare. We're introducing pharmacare and dental care, hopefully, into our national medicare regime. We have decades of experience on how that has worked and not worked within indigenous communities, which we can learn from. We have decades of experience on how to fix other problems that indigenous communities are going through within medicare.

Thank you.

5:05 p.m.

Liberal

The Chair Liberal Marc Garneau

Thank you, Dr. Lafontaine.

Go ahead, Dr. Makokis.