Dr. James Makokis is a Nehiyô (Plains Cree) two-spirit family physician. He is an assistant clinical professor in family medicine at the University of Alberta and medical director of the Indigenous wellness centre, Shkaabe Makwa, at the Centre for Addiction and Mental Health.
When Joyce Echaquan, a 37-year-old Atikamekw woman, filmed the final moments of her life at a hospital in Joliette, Que., Canadians and the world experienced the entrenched racism and substandard care Indigenous Peoples know all too well. The autopsy report for Ms. Echaquan identifies the cause of death as pulmonary edema precipitated by underlying rheumatic heart valvular disease. The pathologist who did the autopsy, Richard Fraser, said this was the first time he’d seen this cause of death in the 3,500 autopsies performed during his career. If Dr. Fraser performed more autopsies on Indigenous People, he would see rheumatic heart disease frequently.
Rheumatic heart disease is a condition of poverty and lack of access to health care that can occur when strep throat is untreated, an illness that is easily cured with a short course of antibiotics. Yet, all too often strep throat is not diagnosed in Indigenous communities simply because they don’t have access to primary care. So instead of suffering with a sore throat and fever for a short period of time, the untreated consequences of strep throat can result in streptococcal glomerulonephritis, rheumatic heart disease and death, all of which I have seen in my patients.
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Even in my own family, two of my uncles have suffered from rheumatic heart disease. In fact, one of them was hospitalized in rural Alberta during my second year of medical residency, and my family asked for me to check on him. Their call was not unwarranted because it’s common for First Nations to experience racism both at the small-town hospitals near reserves and at major hospitals in urban areas. It is no wonder we frequently hear within the Indigenous community that you only go to certain hospitals if you want to die or “get your baby snatched” after delivery. This is how the medical system discriminates against Indigenous People – by not appropriately responding to their needs, resulting in poor care and premature death.
When I arrived at the hospital to see my uncle, stethoscope in hand, I was prepared for the worst. As I entered his room I was shocked to see him sitting in a chair, hunched over, gasping for air. Using my own stethoscope, I listened to his chest and heard crackles at the base of both lungs, indicating the presence of fluid. His heart was malfunctioning and blood was starting to flow backward. Like Ms. Echaquan, my uncle’s lungs were filling with fluid, as his heart was no longer able to pump the blood forward and he was essentially drowning in his own body. He had no cardiac monitors, no oxygen, no cardiac medications, in a room far away from the nursing station. All they had given him was a low dose of Tylenol, and he had been sitting that way for a week.
I asked the nurse to page the physician on call and was told that she “would decide when the physician needed to be called.” The morning came and went and the on call physician never made his rounds. My uncle needed to be transferred to a cardiac unit at a tertiary care centre or he would die. This required a cardiologist at the receiving hospital to accept his transfer. Since he had already been in the rural hospital for one week, I didn’t trust them to make the referral and took matters into my own hands.
I called a cardiologist friend in England to discuss my uncle’s case and he was quick to agree that my uncle was experiencing heart failure. Immediately, he contacted one of his cardiology colleagues in Alberta, who agreed to accept the transfer. By this point it was late afternoon and I was finally able to speak with the on call physician. He explained that my uncle’s shortness of breath was caused by anxiety – but anxiety does not cause fluid to crackle in the lungs. When my uncle finally arrived at the cardiac unit in Edmonton, he was experiencing congestive heart failure and liver failure. Had I not taken the extraordinary steps to get him transferred, he likely would have died.
Racism and systemic bias disproportionately affect Indigenous Peoples in Canada, resulting in higher levels of negative health outcomes and unnecessary deaths. Racism is experienced by both Indigenous patients and Indigenous health care providers. This pattern of abuse is consistent with the long history of systemic oppression perpetuated by Canada and its institutions against First Nations Peoples. This is a violation of the treaty agreements on health, which continue to be in full force and effect.
Extraordinary measures should not have to be taken by Indigenous Peoples to receive basic standards of care. It is clear that the current health care system needs to change: complaints procedures need to be culturally safe and trauma informed and most importantly, restorative actions need to occur when adverse events are reported. To improve Indigenous health, adequate financial resources and investments must be made to develop health care infrastructure, including rebuilding the Indigenous health systems decimated by federal legislation since Confederation.
Leaving health care provision to the provinces and territories without proper quality control measures will only lead to more of the same. When will enough be enough? Our collective treaty agreements allowed for us to live together in peace and friendship and to take care of one another as members of the human family. We started out in this way, and First Nations are still waiting for our treaty partners to remember this.
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