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The gestures stem not only from the country's growing diversity, but a generally more patient-focused system - and a recognition treating solely physical ailments is not always enough. "If we don't engage in the (cultural) discussion, we won't fully understand their health needs and they won't get met," says Marie Serdynska, who heads a pioneering project in the field, the Montreal Children's Hospital's socio-cultural consultation and interpretation services.

So ultimately they will get sicker and be a greater cost to the health-care system." But with the topic being featured at national pediatric and bioethics conferences recently, medical professionals are debating a difficult question: is there is a point at which catering to cultural preferences crosses a moral - or even legal - line? While a physician in the neonatal intensive care unit at Toronto's SickKids hospital, Dr. Jonathan Hellman was sometimes asked by fathers from "patriarchal" cultures not to discuss a child's condition with the mother unless the husband was also present.

Some Halifax hospitals have convinced the fire marshal to allow smudging, aboriginal purification rituals in which sweetgrass is burned. Sometimes, this means adjusting the smoke detector in a patient's room temporarily so it doesn't set off an alarm, says Christy Simpson, a bioethicist at Dalhousie University in Halifax. Randi Zlotnik Shaul, director of bioethics at SickKids, said she's aware of a request for a drumming circle in a neonatal intensive care unit, a normally very quiet environment. Steps were taken to comply with the proposal - and not interfere with other tiny patients - but the need for an open fire eventually made it impossible, she said.

And it recently emerged that a Vancouver-area intensive-care unit was asked to keep a braindead patient on life support for days until he could be flown to his country of origin, the family's culture rejecting the concept of neurological death. Still, for every demanding request, there are dozens of positive incidents - even if they involve once-unheard-of accommodation, say ethicists, doctors and patient advocates.

Agreeing to such a request not only raises ethical and practical questions, he says, but might even violate Ontario's Health-Care Consent Act - unless the mother explicitly agreed to the arrangement. "It's challenging to the caregivers in that situation, when the mother is at the bedside and the father is able to visit only in the evenings," says Hellman. "And we believe that both equally have decision-making power, both should have information." Even hospitals that try to be sensitive to specific cultural groups, like Ontario's Hamilton Health Sciences Centre, with its aboriginal patient "navigator," can face vexing dilemmas. When two First Nations girls with leukemia decided to withdraw from chemotherapy at the facility and try native remedies, an emotional courtroom battle followed.

Yet fulfilling such appeals, often made for dying patients, can be a question simply of innovation and compromise, like when someone asks that a patient's bed face Mecca, she says. "Some might respond very categorically, 'Nope, in this place all beds face the same way,' "she says. "Someone oriented another way might say, 'Yeah, they are all faced that way, but maybe if we got an extension cord, there is actually something we can do.' " Serdynska says she knows of hospitals providing "mementos" of births to new mothers whose cultures traditionally require them to bury their placenta. Dr. Tara Kiran, a Toronto family physician, was taken aback when she first encountered patients from Bangladesh and Pakistan at an inner-city clinic who insisted on fasting between sunrise and sunset during Ramadan, despite health issues like diabetes that normally require strict regulation of diet and medication.

Her patients, however, happily embraced what they saw as the experience's beneficial, spiritual benefits. "It was an interesting challenge to my assumptions," says Kiran. "My gut reaction was that fasting has negative impacts on health." In London, Ont., St. Joseph's Health Centre runs a special clinic during Ramadan to help the city's estimated 3,000 diabetic Muslims. Muslim needs, including heightened privacy for female hospital patients instead of the usual, unannounced arrival of staff at the bedside, were once given short shrift, says Khadija Haffajee, spokeswoman for the National Council of Canadian Muslims. But the system has generally made great strides, adds Haffajee, who has addressed classes of nursing students on her faith's practices. "It's about reasonable accommodation and understanding," she says. "When people are ill, you're dealing with very vulnerable people, so empathy goes a long way."

Accommodation can sometimes simply be a case of bridging the cultural divide, says Montreal's Serdynska. Medical teams at her hospital once saw Vietnamese patients with unexplained bruising and immediately suspected child abuse. Further inquiry revealed the marks were the result of "capping," or "coining," a traditional southeast Asian treatment that involves scraping a smooth edge across the body in the belief it releases unhealthy elements. Her service now has cultural interpreters who will talk to immigrant parents when, for instance, drug treatment is not working. Sometimes, it relates to the side effects and contraindications spelled out on unfamiliar packaging, she says. "For some cultures who do not generally take pharmaceutical medication, this is very frightening." The institutional, impersonal nature of a hospital alone makes it a daunting place for aboriginal people, especially if they attended residential schools, says Margo Greenwood, academic leader at the National Collaborating Centre for Aboriginal Health in Prince George, B.C. Hanging indigenous art, providing culturally appropriate prayer space and consulting local native communities all help alleviate that anxiety, as does being open to other forms of treatment.

You're dealing with two different systems of knowledge: one is what I learned when I went to university and one is what I learned in my community," she says. "People (are) saying ... 'I want the two to work together.' "But what are health-care providers to do when the request stemming from an ethnic or religious practice appears to breach their own ethical boundaries? Reports in 2013 of doctors in Quebec issuing virginity certificates earned a swift response from the province's medical regulatory body. Physicians must refuse to comply, insisted the College des Médecins, and explain such a service has nothing to do with health care. Less black-and-white, perhaps, is the patient asking for a doctor of a particular sex or, less commonly, of a specific race. On the surface, at least, the idea is a repudiation of fundamental human-rights principles, yet for some patients it could be a religious imperative or a fallout from past abuse.

Some hospitals say they will try as much as possible to provide a female doctor for Muslim women, for instance, when asked. In Montreal, about half the obstetrician-gynecologists are women, so supplying a female one is usually quite feasible, said Togas Tulandi, interim head of the McGill University medical school's obstetrics and gynecology department. More troublesome, say ethicists and physicians, are patients who insist they not be treated by a doctor or nurse of a certain race - typically Caucasians rejecting non-white workers in today's multi-hued medical workforce - or want one of their own colour. Ethicists at Toronto's University Health Network (UHN) published a nine-page paper on how to tackle "discriminatory" requests of this sort, suggesting the affected health-care worker should often have the final say.

"It's ugly, it's unfair," says Linda Wright, a bioethicist at UHN, of the potential impact on medical staff. "To ... have someone say you're not good enough because of the colour of your skin is offensive." How often Canadian hospitals have to deal with the dilemma is unclear. A 2010 U.S. study of emergency doctors, though, concluded the scenario is common, with hospitals frequently accommodating requests for race-specific practitioners. And that is not such a bad thing, argued U.S. law professor Kimani Paul-Emile in a provocative 2012 article. He cited evidence that having a "race-concordant" doctor can bring health benefits, especially for blacks and others who have historically faced prejudice. In the meantime, hospitals here are still more likely to encounter less-contentious culturally based issues, such as whether to loosen age-old restrictions on the number of well-wishers in a patient's room.

"In some cultures ... you have everybody there. You have all the aunts and all the uncles, and all the family members and friends," says Dalhousie's Simpson. "For me, that's been one of the really interesting changes. Why did we say it only had to be two? Why did we limit it so much? Because clearly there's value to having your loved ones around you."

We need to stabilize the situation in Attawapiskat in terms of making sure they have the health support they need,” Mr. Angus (Timmins-James-Bay, Ont.) told The Hill Times last week. “We need a plan to get people who are needing help in any of the communities to get that help.”

A rash of attempted suicides prompted Mr. Angus, who’s also the NDP critic for indigenous and northern affairs, to call for an emergency debate on the ongoing suicide crisis in the James Bay community of about 2,000. As a result, the House of Commons convened until midnight last Tuesday for an emotionally charged discussion on mental health services following a string of incidents in northern reserves in recent months. Several MPs choked up during their statements, recounting suicide incidents in their ridings and personal lives.

Sometimes partisan politics need to be put aside and members need to come together to find solutions to prevent another unnecessary loss of life,” Conservative MP Todd Doherty (Cariboo-Prince George, B.C.) said during the debate. NDP MP Georgina Jolibois (Desnethé-Missinippi-Churchill River, Sask.) said the suicide rate went up in her home community of La Loche in northern Saskatchewan after a shooting spree that killed four people last January.

Liberal MP Robert-Falcon Ouellette (Winnipeg Centre, Man.) recalled visiting the northern Manitoba Pimicikamak Cree Nation, which declared a state of emergency over a series of suicide attempts last month.

Mr. Angus made an emotional appeal to action in his opening remarks during the emergency debate. “We have to end the culture of deniability whereby children and young people are denied mental health services on a routine basis, as a matter of course, by the federal government,” he said. Eleven people attempted to take their lives in Attawapiskat two Saturdays ago, prompting the First Nation to declare a state of emergency—the fourth one since 2006. There has been more than 100 suicide attempts in the reserve since the month of September, many of which involved children. The community has been plagued by flooding and several housing crises in recent years.

Eighteen mental health workers were dispatched to Attawapiskat on Tuesday, including two counsellors, one crisis worker, two youth support workers, and one psychologist. While there is no set timeline, they’re not expected to leave for at least two weeks, said Health Canada assistant deputy minister Keith Conn during a teleconference last week.

Some of the people treated for mental health problems last week had previously been airlifted out of the community for assessment before being sent back after their examination, according to Mr. Conn. This past Tuesday, at least 13 people, including a nine-year-old child, had made plans to overdose on prescription pills as part of a suicide pact. The Nishnawbe-Aski Police Service apprehended them before sending them to the local hospital for a mental health assessment.

Mr. Conn said he’s heard criticism of the mental health assessment process from Attawapiskat First Nation Chief Bruce Shisheesh. Individuals who are identified as likely to commit suicide are typically sent to a hospital in Moose Factory, Ont., to be psychologically evaluated by a psychologist or psychiatrist. They are then discharged and sent back to the community, where some try to take their life again. Mr. Conn said Health Canada does not “control the process,” but he personally committed to review the mental health assessment effectiveness.

No federally funded psychiatrists were present in the region prior to the crisis, despite reserve health-care falling under the purview of the federal government. Mr. Conn said the Weeneebayko Area Health Authority (WAHA), a provincial health unit servicing communities on the James Bay coastline, is usually responsible for the Attawapiskat First Nation following an agreement struck with the federal government about 10 years ago.

A mental health worker position for the reserve has been vacant since last summer, in part because there’s a lack of housing for such staff. The community has been left without permanent, on-site mental health care services. Since then, the position has been filled by someone already living on reserve. During the emergency debate in the House last week, Health Minister Jane Philpott (Markham-Stouffville, Ont.) emphasized the need for short- and long-term responses to the crisis.

We need to address the socio-economic conditions that will improve indigenous people’s wellness in addition to ensuring that First Nations and Inuit have the health care they need and deserve,” she said. Ms. Philpott pointed to the Liberal government’s budget, which includes $8.4-billion for “better schools and housing, cleaner water, and improvements for nursing stations.”

“Our department and our government are ensuring that all the necessary services and programs are in place,” she said during the debate. “We are currently investing over $300-million per year in mental wellness programs in these communities.” Yet, Mr. Angus said the budget includes “no new mental health dollars” for First Nations communities. In addition to allocating more funds for mental health services to indigenous communities, Mr. Angus said there needs to be a concerted effort to bring in the aboriginal youth in the conversation.

We need to bring a special youth council together,” he told The Hill Times on Wednesday. “We need to have them be able to come and talk to Parliament about their concerns, so we’re looking at those options now.” Emotion was audible in Mr. Angus’ voice when he read letters he received from Aboriginal youth during the emergency debate, which expressed a desire to work with the federal government to solve the crisis.

The greatest resource we have in this country is not the gold and it is not the oil; it is the children,” he said. “The day we recognize that is the day that we will be the nation we were meant to be.” Mr. Angus met with Indigenous and Northern Affairs Minister Carolyn Bennett (Toronto—St. Paul’s, Ont.) earlier in the week to discuss potential long-term solutions to the suicide crisis. “I’ve always had an excellent relationship with Carolyn Bennett, and as minister we’re trying to find ways to work together on this, to take the tension down, to start finding solutions,” Mr. Angus said. Mr. Angus criticized “Band-Aid” solutions that have been thrown at First Nations issues over the years and said there needs to be a “transformative change” this time.

That’s where we have to move beyond the positive language to actually the brass tacks,” he said. During the emergency debate, Mr. Angus supported the idea of giving more resources to frontline workers such as on-reserve police, and health and treatment centres. 0eMr. Angus’ riding sprawls from shores of the Hudson Bay to the Timiskaming district on the border with Quebec, an area roughly equivalent in land size to that of Guinea. He holds two constituency offices in Timmins and Kirkland Lake.

She and her colleagues released a report earlier this month that highlights some of these problems. It found that first-nations people living in Hamilton were more than twice as likely to visit an emergency room, and 25 times more likely to live in crowded conditions, than were the rest of the city’s population. First-nations people were also much more likely to have a child with asthma.

Part of the remedy is creating health services that take into account local knowledge and traditions and the needs of the specific population