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That question dominated the recent Public Health 2016 conference in Toronto. Speakers described persistent inequity and inaction across the health system, from research to medical training to hospital care. “The common response is to deny that the problem lies in the structures,” said Charlotte Loppie, director of the Centre for Indigenous Research and Community-led Engagement at the University of Victoria in British Columbia.

She argued that it’s a mistake to see “colonization” as something that happened in the past. “It’s about the control that some people have over other people, which obviously continues today in the health policies and programs that are developed and expanded on indigenous communities, rather than with those communities.”

Research Loppie spoke at a panel hosted by the Canadian Institutes of Health Research (CIHR), which faced criticism in February for awarding less than 1% of funding to Aboriginal health projects in its first major competition since restructuring. “We know we have to work to get this right and get this better and I think we’re learning as we go,” said Nancy Edwards, scientific director of the Institute of Population and Public Health at CIHR.

According to Edwards, Aboriginal health is now a “standing item” at science council meetings, which bring together CIHR top brass every four to six weeks. There has also been “a lot of consultation” with indigenous researchers and communities. There isn’t a single barrier standing in the way. “It’s not that simple,” she said.

Speakers at the Canadian Public Health Association’s annual conference urged structural change to improve indigenous health.

Loppie said she considers Edwards an ally, but noted that CIHR has “a long way to go” to correct the disadvantage to Aboriginal health research under the new funding structure. “Change is a difficult point,” particularly at the most senior levels of administration, she said.

Medical education Australia’s experience integrating indi genous health education into medical training shows how change at that level can help transform a system. Australia’s version of a Truth and Reconciliation Commission recommended compulsory courses for all health professionals in 1989. But this didn’t become reality for doctors until 2006, when the Australian Medical Council set standards that the indigenous health training schools must provide.

With accreditation on the line, change was rapid and meaningful, said Janie Smith, a professor of innovations in medical education at Bond University in Australia. “If you don’t meet the standards, you can’t run your program, so it’s very powerful.” Bond’s medical program overhauled its case-based curriculum to include indigenous examples to teach core concepts. Students also complete a two-day cultural immersion workshop in first year and a remote clinical placement in fifth year.

“It’s a really important principle that this is the normal program and it’s funded out of the normal budget,” Smith said. Integration in core curriculum teaches students that cultural sensitivity is fundamental to being a good doctor, like understanding anatomy. It also protects indigenous health education from “toe cutters” when budgets are tight. Although Canadian medical schools are expanding their indigenous health content, some educators noted that it’s still peripheral to core training.

Lloy Wylie teaches medical students as an assistant professor of public health at Western University in London, Ontario. She recalled one indigenous health session that only a third of students attended. “When it’s voluntary, only the people who don’t need the training show up.”

Hospital care Wylie said she encountered the same indifference among some medical colleagues at Victoria Hospital in London, Ont., where she is appointed to the psychiatry department. “There are still some very unsettling things that I see going on in our hospital system.” She shared stories of “huge jurisdictional gaps” between the hospital and reserve, of patients with cancer denied adequate pain medication because of assumptions about addiction, and of health workers “woefully unaware” of indigenous culture and services.

People in the hospital weren’t even aware of the Aboriginal patient liaison that was in the hospital,” Wylie said. There are some recent bright spots; for example, British Columbia and Ontario are boosting cultural sensitivity training for health workers. But Wylie noted that the same workers “go back to institutions that are very culturally unsafe, so we need to look at changing those institutions as a whole.”

Brock Pitawanakwat, an assistant professor of indigenous studies at the University of Sudbury in Ontario, cited the importance of creating space for traditional healing alongside clinical care. In some cases, it’s a physical space: Health Sciences North in Sudbury has an on-site medicine lodge that provides traditional ceremonies and medicines.

These services are as much about healing mistrust as any physical remedy, Pitawanakwat said. “Going into a hospital after attending a residential school, there’s still that negative emotion,” he explained. “If you look at these buildings in archival photos, they’re almost identical.”

Wylie suggested that the fee-for-service model could also be changed to support physicians building better relationships with patients. “Anything we do to make our hospitals more welcoming places for Aboriginal people will be good for everybody,” she said. “Right now, they’re really alienating for everybody.”

Address prejudice among health workers

Provide benefits for Indigenous people not recognized by the Indian Act

Put less addictive pharmaceutical options on the formulary

Collaborate more across service providers

Make trauma-informed care the standard of care

Address smoking rates in Indigenous communities

Implement basic standards for supplies in nursing stations in remote, Indigenous communities

CIHR’s decision-making style, which resulted in it going ahead with changes to funding despite objections from Indigenous and non-Indigenous researchers, “is not consistent with the recommendations of the Truth and Reconciliation Commission,” says Rod McCormick, a Mohawk researcher and co-chair of the Aboriginal Health Research Steering Committee.

There is no recognition or provision for the fact that systemic policies, when applied across the board, can have damaging impacts for groups that are different,” McCormick told an emotionally charged meeting at the Wabano Centre for Aboriginal Health in Ottawa on Jan. 25.

In 2014/15, funding for Aboriginal health research was $31 million, down from $34 million at its annual peak 2004–2008, the Aboriginal Health Research Steering Committee reported.

McCormick and co-chair Frederic Wien, the principal investigator for the Atlantic Aboriginal Health Research Program, urged CIHR to revisit its changes and rebuild what Wien called “a respectful relationship with First Nations, Métis and Inuit people.” Given the crisis in the health and well-being of many of these communities, the researchers want CIHR to prioritize Aboriginal health research.

We have gone through major changes at CIHR. I do not deny that,” Beaudet said. “But I would deny ... that these changes are affecting particularly the Aboriginal community.”

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples, believes CIHR is out of step with the Truth and Reconciliation Commission’s recommendations.

Beaudet made the remarks just three days after the shootings at La Loche, Saskatchewan. The murder of two teenagers, a teacher and a teacher’s aide in the largely Dene community underscored for some attendees the crises in suicide, lack of mental health support and poverty that affect many Aboriginal youth and families.

Beaudet said Aboriginal health research is “extremely important” for CIHR, and its strategic investments will reflect that. CIHR has been working with the Aboriginal Health Research Steering Committee for 14 months and, according to the institute’s media specialist David Coulombe, is committed to “co-building research initiatives” that “will improve the health of Canada’s First Nations, Inuit and Métis peoples.”

While Beaudet acknowledged both the magnitude of the recent changes and the fact that the Aboriginal health research budget has “flatlined,” he said it has done so parallel to CIHR’s overall budget. CIHR’s billion-dollar annual federal budget has not increased since 2009, meaning that its spending power has declined by roughly 25% since then.

CIHR’s president denied any need for the federal agency to engage in reconciliation. “I would like to bring my personal views, not only those of CIHR, about the stormy weather we have been experiencing lately,” Dr. Alain Beaudet told attendees at the January meeting. “But not in the spirit of reconciliation, because I don’t think anything has been broken.”

The Aboriginal Health Research Steering Committee contends that CIHR disadvantages researchers working in Aboriginal health through recent changes such as scrapping an Aboriginal-specific peer review process, requiring matching funds for several granting programs, and reallocating almost half the open competition funding for stellar emerging and establishing scholars.

But Beaudet said the changes promote more “out-of-the-box” research that will enable Canada to achieve more international success. He also suggested that those critical of the new system are afraid of change, and advised researchers that “looking back doesn’t work.” Learning from the past is a critical Indigenous value. CIHR is starting to analyze the

results of its initial investments, but it will take seven years for the new system to take full effect and before “meaningful” figures result, Beaudet said. “We’ll work as quickly as we can, but we need the data. I’m saying ‘Yes, trust us,’ because if you look at CIHR’s record, we’ve done a lot, and we’ve done it in good faith.”

Most of the researchers and representatives of Aboriginal political organizations at the meeting did not seem inclined to trust Beaudet’s reassurances.

You’re really saying to this group, ‘Trust us.’ And I just want to remind you that there’s very little basis for trust,” said Scott Serson, a former deputy minister of Indian Affairs and Northern Development, now with Canadians for a New Partnership, a group working for a new relationship between Indigenous and other Canadians.

The Aboriginal Health Research Steering Committee asked CIHR to set aside half a day at the June meeting of its governing council to address these issues. In an online statement, Beaudet acknowledged the request for an in-depth discussion at “a future meeting” of the governing council. He also urged Indigenous health researchers and community members to apply as members of the new Institutes Advisory Board on Indigenous People’s Health and a new College of Reviewers.

Marlene Brant Castellano, co-director of research for the Royal Commission on Aboriginal Peoples and the Mohawk elder who closed the meeting, described Beaudet and CIHR’s response to the committee’s requests as “disconnected” from the prevailing political environment.

Castellano, who is revered as the first Aboriginal full professor at a Canadian university, brought many in the audience to tears. Instead of recognizing the need for a new relationship between Canada and its Indigenous peoples, Beaudet’s remarks echoed a too-familiar demand that Aboriginal researchers “get with” CIHR’s program because, eventually, they would discover it was good for them, Castellano said.

“We have 400 years as Indigenous people trying to make things work in other people’s agendas, and that is where we’ve gotten to the place now, where we still are, of watching our children dying,” she said, tears streaming down her cheeks.

Beaudet had already left the meeting before Castellano went to the podium, and the two CIHR vice-presidents who had stayed for most of the discussion left as she began to speak, citing prior commitments. Only Malcolm King, scientific director of CIHR’s Institute of Aboriginal Peoples’ Health and a member of the Mississaugas of the New Credit First Nation, remained for the duration of the meeting.

According to Coulombe, Beaudet had a phone conversation with Castellano on Jan. 29, and “agreed to continue working collaboratively with community representatives and leaders in the future.”

Corresponding to the devolution process have been revisions to the Indian Act as it relates to Indian status. From the "honorary white man" policy of the 1850s, Canadian legislation has intended to unmake Indians in the legal sense. Much of this strategy has focused on attacking women, removing their status if they marry a non-status Indian, which resulted in the disenrollment of tens of thousands of individuals who rightfully belonged within their nations. In post-Charter Canada, the Indian Act was successfully challenged and amendments in 1985 and 2011 partly ended the discrimination, precipitating a surge in the "official" First Nation population.

While much has been made of the "marry out, get out" provision at Kahnawake, the membership law, as well as many other First Nation membership laws, is more complex. The objective is to separate Indian status from band membership and take control of the latter from the federal government. "Membership" in this sense includes residency qualifications, electoral rules and treaty rights, eligibility guidelines on business operations and even burial plot designation. In reserve politics, or "reserve nationalism" as Audra Simpson calls it, this might be described as citizenship and even immigration policy. In a general sense, it is about who belongs.

There are two extremes in this conversation. The "exclusive" membership perspective views lineage as the crucial qualification to belonging. Citizens must be descended from indigenous peoples, inculcated in indigenous culture. They exclude those with weak lineage or none at all, especially if taking up land or resources. Of course, communities today have increasing numbers of both groups. About three-dozen of those who share this conservative approach to membership at Kahnawake are responsible for taking the initiative to evict non-indigenous people from the community.

The "inclusive" perspective advocates for a more open community not necessarily delimited by strict ancestral connection but inter-community relationships. It is the far more common practice among indigenous peoples (extending the rafters of the longhouse, the ever-expanding circle, etc.). Non-indigenous people who can make a contribution to the community while reflecting indigenous values should be welcome. In the case of Kahnawake, a handful of these inclusive proponents are appealing to the Quebec Superior Court to protect this view. In many ways, the debate revolves around claims of authenticity: a contentious notion after 150 years of Indian policies that have cultivated artificial governments and islands of reserved lands, imposed patriarchy and domesticated sovereignty.

Indeed, indigenous peoples would be justified in evicting white people from the little land we have left if that were the case. But this is a crude simplification.

Despite the opinions of pundits or politicians on the allegedly racist law at Kahnawake (or elsewhere), this is fundamentally about people passionately and earnestly working towards visions of community well-being amid very real, long-standing and external constraints. This is about striving to be Kanien'keha:ka or Anishinaabe in a place traditionally hostile to that very proposition. Hayden King is Anishinaabe from Beausoleil First Nation. He is the director of the Centre for Indigenous Governance at Ryerson University. Jessica Deer is a Kanien'keha:ka from Kahnawake. She is a reporter for The Eastern Door.

Traditional medicine is a system of medicine in the same way that Western medicine is a system, in the same way naturopathic medicine is a system,” says Dr. Karen Hill, who shares a practice with traditional healer Elva Jamieson on the Six Nations of the Grand River First Nation in Ohsweken, Ont. “Because it doesn’t look the same, I think physicians don’t know how to receive it.”

Hill, who is Mohawk, believes a clash of cultures influenced the decision of doctors at the McMaster Children’s Hospital in Hamilton, Ont., to ask Judge Gethin Edward of the Ontario Court of Justice to compel cancer treatment for J.J, an 11-year-old Mohawk girl who has acute lymphoblastic leukemia. Although Hill neither confirmed nor denied that she and Jamieson are treating J.J., Hill did testify in the case. Edward ruled in November 2014 that J.J.’s mother, the girl’s substitute decision-maker, had a constitutionally guaranteed right to practise traditional medicine.

On Jan. 19, 2015, Makayla Sault, another 11-year-old Aboriginal girl with leukemia, died following a stroke. Makayla and her family, who are from the neighbouring Mississaugas of the New Credit First Nation, had also stopped chemotherapy at McMaster. Makayla’s death has drawn international attention to the issue of consent to treatment and whether Aboriginal rights may potentially clash with a child’s best interests and right to life.

Both cases have also raised the question of how doctors should respond to an Aboriginal patient’s desire to pursue traditional or other types of medicine over Western medical treatment. “The big message is that this is not just about medical choice,” Hill told CMAJ. “This is about indigenous people reclaiming their wholeness as people. This isn’t about religion; it isn’t about choice. It’s about being who we are.”

Choosing one type of treatment over the other is not the only option, say Hill and Dr. Veronica McKinney, a Cree/Métis woman who is on the executive of the Indigenous Physicians Association of Canada.

“More and more people are coming to understand that you can have a blend (of treatments),” says McKinney, who is the director of Northern Medical Services at the University of Saskatchewan. “I have a number of patients where this is the case, and I support that.”

Hill, who graduated from McMaster University medical school, and Jamieson, who apprenticed with her mother on Six Nations, often work together with patients to plan a combination of traditional and Western medical treatment.

In J.J.’s case, McMaster made an effort to permit the family to pursue its traditional practices, says Daphne Jarvis, McMaster’s lawyer. “There was a ceremony that took place in the hospital that the family arranged and they seemed very appreciative of that,” she told CMAJ. “With respect to the use of traditional medicines, I think the caveat was: ‘as long as it doesn’t interfere with the chemotherapy’ — so that was perceived to be hierarchical, which it wasn’t intended to be.”

Practitioners need a trusting relationship with their patients that includes self-reflection, respect for other world views, and reciprocity that acknowledges the patient’s contribution to healing, says McKinney. “When you are the one making all the decisions aside from the patient, you’re going off-track. It doesn’t matter whether we’re talking cancer or high blood pressure ... that completely does not match patient-centred care.”

There are few medical institutions in Canada, McKinney says, that support the positive contributions of traditional medicine, which includes plant-based medicines, ritual and ceremonies, alongside efforts to establish mental, spiritual, emotional and physical balance.

Doctors continue to have a responsibility to report similar situations to child welfare authorities, says Jarvis. Those authorities should conduct sufficient investigation to satisfy themselves that families are pursuing a sincerely held practice of indigenous medicine, she adds. It’s up to child welfare authorities, not doctors, to determine how sincerely held are the beliefs in traditional medicine, she cautions.

It was clear during the hearing that J.J’s mother is a traditional Mohawk woman accessing indigenous medicines within the Six Nations community, Jarvis says. She calls media reports about the alternative treatment the family was pursuing at the Hippocrates Health Institute in Florida, “a red herring.” J.J.’s care in Florida was in addition to the traditional treatment she was getting on Six Nations, not instead of it, Jarvis says. Hill also visited the institute to help re-establish a connection to plant-based food, which is an important part of traditional healing.

Indigenous physicians can bridge the gap in understanding between the traditional and Western medical systems, says Hill. She hopes to help design a protocol for physicians about beginning that dialogue with patients and traditional healers.

Hill understands the angst both Makayla and J.J.’s cases have caused. But she hopes the medical community will understand that Makayla’s choice was about more than just medical treatment.

“It is about living and being Indigenous people, trusting our own medicines in the way we did for centuries before Western medicine. Behaving as indigenous people is what the mainstream finds difficult to understand and what the medical community needs to start working out in relationship with our people.”

However, we should avoid diagnosing this problem merely as a failure of law enforcement. Murders represent the tip of an iceberg of problems related to endemic violence in communities. Many Aboriginal women and girls, and indeed men and boys, live each day under the threat of interpersonal violence and its myriad consequences.

Initial statements from the three federal ministers tasked with leading the forthcoming inquiry — the ministers of Indigenous and Northern Affairs, Justice and Status of Women — suggest that its purpose is to achieve justice, to renew trust between indigenous communities and the Canadian government and law enforcement bodies, and to start a process of healing.

The inquiry surely must also endeavour to lay the groundwork for a clear plan to address the broader problem of interpersonal violence, which, in turn, is rooted in several key determinants. Addressing interpersonal violence is not merely an issue of justice; it is also a public health concern.

Factors associated with both the experience and perpetration of interpersonal violence are manifold. They include but are not limited to mental health issues, drug and alcohol misuse, unemployment, social isolation, low income and a history of experiencing disrupted parenting and physical discipline as a child. The Truth and Reconciliation Commission’s report has highlighted that many of these factors are widespread in the Aboriginal populations of Canada.4 Many of the same factors contribute to disparities between Aboriginal and non-Aboriginal peoples in areas such as education, socioeconomic circumstances and justice. T

here is also substantial overlap with identified determinants of poor health in Aboriginal communities both in Canada and elsewhere.5,6 These are the factors associated with higher rates of youth suicide, adverse birth outcomes and tuberculosis, and poorer child health. It’s clear that a common web — woven of a legacy of colonization and cultural genocide, and a cumulative history of societal neglect, discrimination and injustice — underlies both endemic interpersonal violence and health disparities in Canada’s indigenous populations. There is no conversation to be had about one without a conversation about the other — if the aim is healing — because the root causes are the same.

The World Health Organization (WHO) is currently engaged in developing a global plan of action to strengthen the role of health systems in addressing interpersonal violence, particularly that involving women and girls.7 A draft report by the WHO acknowledges interpersonal violence as a strongly health-related issue that nevertheless requires a multisectoral response tailored to the specific context. Evidence from Aboriginal community models in Canada gives hope for healing.

A recent report from the Canadian Council on Social Determinants of Health highlighted important strides that some Aboriginal communities have made to address the root causes of, and to mitigate, inequities through efforts to restore the people’s connection with indigenous culture.8 Increasing community control over social, political and physical environments has been linked to improvements in health and health determinants.

The public health sector in many parts of Canada has embraced the need for strong community involvement in restoring Aboriginal people to the health that is their right. In many community-led projects over the past few decades, the health care sector has worked with others to address common proximal and distal determinants of disparities.

We are presented with not just an opportunity for renewing trust between indigenous communities and the Government of Canada but also for extending the roles of public health and the health care sector in the facilitation of trust and healing. There is much that the health sector can contribute to the forthcoming inquiry. Health Canada should be involved from the start to ensure that public health is properly represented

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.

Dr. Alika Lafontaine, an anesthesiologist in northern Alberta and the president of the Indigenous Physicians Association of Canada, spoke with Lawrence Nayally of CBC Radio's Trail's End about the racism and discrimination Indigenous people face in Canada's health care system.

Why is this important to non-Indigenous Canadians working in the health system?

Philpott said one of the misconceptions about the future of health care is that demographics - a silver tsunami related to an aging population - is going to bankrupt government coffers. While she acknowledged that seven per cent of $1,000-a-day hospital beds are taken up by seniors and 14 per cent of beds are occupied by patients who should be in alternate levels of care, Philpott threw cold water on the "doom and gloom" forecasts that an aging population means "massive infusions of cash" are needed to sustain public health care. Sticking to the federal government's commitment to inject another $3 million over four years into home care, she noted it's not only cost effective but preferred by patients and their families.

Federal health minister Jane Philpott said Tuesday a national pharmacare program is likely years away because of more pressing priorities like primary care, improved health for indigenous people, better care for those with mental illness, and more home care for seniors. "I do not want to promise anything I don't know I can deliver on," she told about 600 delegates and observers at the annual Canadian Medical Association meeting in Vancouver.

The reality is I don't know how this is going to end up. A lot of this will come down to basic principles of fairness." While Canada spends more per capita than many other countries, Philpott said she's concerned about international rating systems that show Canada gets poorer outcomes compared to countries such as Australia, the United Kingdom, France and Germany. During a press scrum, a journalist noted that all those other countries have parallel public/private systems. But Philpott insisted the federal government is only interested in how those other countries deliver care within the publicly funded realm. "Our government is firmly committed to upholding the Canada Health Act. That act has principles around accessibility and universality and it means Canadians have access to care based on need, not on ability to pay," she said. "You cannot have a growing, thriving middle class unless you have a publicly funded universal health care system."

Philpott attempted to dissuade doctors of the notion that the federal role is merely to transfer money to the provinces ($36 billion this year), maintaining that the government and "this minister of health" is determined to be engaged in health system transformation. The provinces have begun the slow process of negotiations with the federal government on a renewal of the Canada Health Accord to be signed sometime next year. But some health ministers have complained that the feds have given no indication about how much money they can expect. It's been more than a decade since the provinces and the federal government negotiated transfer payments and Philpott said that while the last round led to improvements like shorter waiting times in some surgical areas, "it did not buy change. So we should use this opportunity to trigger innovation."

Philpott said real change will incorporate digital health records and the banishment of anachronisms like fax machines. Patients should be seamlessly connected, in real time, to their health care providers, hospital, home care, pharmacy and lab. "What is it going to take to get there? Pragmatism, persistence and partnership. Changes require courage and practicality." Doctors gave her enthusiastic applause for stating that low socioeconomic status represents one of the greatest barriers to good health and "that is why this government believes that the economy and jobs and a stronger middle class will reduce social inequity." She said in 2016, the federal government has earmarked $8.4 billion in spending on social and economic conditions for indigenous communities. Earlier Tuesday, on the second day of the three-day annual meeting, doctors passed numerous motions that will now go to their board for further discussion before becoming official policy.

Delegates passed a motion introduced by Ontario doctor Stephen Singh of the Canadian Society of Palliative Care Physicians that aims to distinguish between palliative care ("neither to hasten or postpone death") and medical assistance in dying. Most palliative care doctors don't want to serve as gatekeepers to doctor-assisted dying, but they do want to consult with patients who have life-limiting illnesses in order to help mitigate their suffering.