Last November, the death of Joyce Echaquan, a 37-year-old Atikamekw woman, exposed the continuous problems that Indigenous peoples face in accessing healthcare in Canada. In Joyce’s case, hospital workers degraded and swore at her before she died under their care. The racism and sexism endemic to Canada’s healthcare system blocked Echaquan from accessing the healthcare to which she was entitled. While public hearings on her death have been scheduled for May 2021, the fundamental problems with Indigenous access to Canadian healthcare are systemic. According to a report by Indigenous healthcare professionals, Indigenous peoples face “a more significant burden of infectious and noncommunicable diseases”, poor mental health, and shorter life expectancy than non-Indigenous peoples due to social and health inequalities from intergenerational legacies of colonization and displacement. The COVID-19 pandemic has further exacerbated these problems due to the health and social inequalities between Indigenous and non-Indigenous communities. Dismantling barriers and improving healthcare access will require a nation-to-nation relationship between the Canadian government and Indigenous peoples. 

COVID-19 and Challenges Facing Indigenous Communities 

As of February 15, 2021, there are 19,608 confirmed cases of COVID-19 on First Nations reserves, representing 2.3% of total cases in Canada. Due to underlying health issues, geographic location, lack of healthcare infrastructure, access to clean drinking water, and inadequate housing, Indigenous people are more susceptible to infectious diseases. Indigenous communities’ vulnerabilities due to COVID-19 are magnified from systemic health and social inequalities. For example, Indigenous peoples have a higher likelihood of having asthma, arthritis, and diabetes, which are comorbidities with COVID-19. In sum, this means that if an Indigenous person contracted COVID-19, they would face more complicated treatment plans, a higher risk factor for mortality and more, leading them to have a higher burden of illness. Furthermore, many Indigenous communities lack adequate healthcare infrastructure. For example, rural and remote reserve land often have no dedicated healthcare professional, but instead rely on healthcare professionals flying in on a short-term basis. Due to the government’s COVID-19 travel restrictions, timely access to reliable medical care has been even more difficult. As a result, despite being disproportionately affected by COVID-19 and requiring a greater need for healthcare, Indigenous peoples have less access to it. 

The COVID-19 pandemic also posed various other challenges for Indigenous communities, including food insecurity, financial instability, and increased violence. Indigenous communities asserted their authority in their communities to deal with COVID-19 by issuing public health orders and restricting travel. Despite these actions, the rate of reported cases of COVID-19 for First Nations living on reserve is 40% higher than the general Canadian population. The inter-regional travel checkpoints exacerbate food insecurity and further limit services to remote Indigenous communities by restricting travel to urban centers. Furthermore, Indigenous communities face increased economic and social challenges due to COVID-19 and the lockdown measures imposed. The pandemic has worsened already limited livelihood options by restricting tourism and interrupting Indigenous communities' abilities to participate in cultural activities, contributing to the heightened food insecurity. Finally, the pandemic has contributed to an increase in sexual assault and violence, to which Indigenous people are already at an increased risk, due to heightened economic, emotional, and physical pressures, proximity mandated by lockdowns, and reduced access to support systems. The challenges from COVID-19 facing Indigenous communities are not limited to inadequate healthcare access, but also disruptions to their way of life from lockdown measures, which can create different risks such as food insecurity, cultural interruptions, and home violence. 

Does a healthcare solution exist? 

For Indigenous peoples, the federal healthcare programs created specifically for Indigenous peoples to mirror provincial healthcare lead to gaps in access and quality of services. The scope of the insured health benefits provided to Indigenous people by provinces is narrow.  As such, the federal government maintains the funding and delivery of non-insured health benefits to Inuit and status Indians. This hide-and-seek game that the provincial and federal governments play in delivering healthcare obscures the accountability  required to fix issues of access and quality. To improve healthcare access, a clear delineation of jurisdictional responsibilities needs to be established so that provincial healthcare services and federal non-insured health benefits are clear, and federal and provincial governments can be held accountable for the services they deliver. Bettering healthcare should not only be about improving physical accessibility, but also the social relations healthcare establishes between patient and provider. In order to improve these social relations, the relationship between the Canadian government and Indigenous governance structures needs to be revised and somehow reconciled. Including Indigenous interests and representatives in planning jurisdictional collaborations would help improve the nation-to-nation relationship between First Nations and Canada. 

In order to create positive and lasting change in healthcare access for Indigenous peoples, the government of Canada should respect and incorporate its nation-to-nation relationship with Indigenous communities. Solutions such as transferring control of healthcare or increasing healthcare funding to Indigenous communities would contribute to improvements. However, if this is not accompanied by Indigenous leadership and input, it has its own pitfalls of paternalism and unsustainable change. Building on a nation-to-nation relationship can be implemented through the incorporation of Indigenous knowledge, leadership, and healing in order to overcome the colonial structure upon which healthcare is built. The Truth and Reconciliation Commission’s (TRC) Call to Action 22 calls for those who can effect change within the Canadian healthcare system to recognize and use Aboriginal healing practices in collaboration with Aboriginal healers and Elders. Integration of Indigenous knowledge can help fight against the racism that Indigenous peoples face as a barrier to healthcare, and help create a space that is physically and culturally safe. Additionally, recruiting more Indigenous healthcare  professionals and requiring cultural competency training for all healthcare professionals is a TRC plan that has seen moderate progress, according to the Assembly of First Nations. Despite this attempt to create a culturally safe space, cultural barriers to accessing healthcare still exist, because historical trauma associated with the healthcare system is not easily dismissed. Building a nation-to-nation relationship, in terms of healthcare access, will require more than just these suggestions in the Truth and Reconciliation Commission, as these suggestions are “band-aid” measures that don’t fully address the systemic racism and discrimination Indigenous people face within the healthcare system. 

Despite the death of Joyce Echaquan sparking public outrage, and a public inquest, the problems that Indigenous peoples face are more systemic than what a public hearing could uncover. In order to resolve the barriers that Indigenous peoples face in healthcare, there needs to be a complete reexamination of how the relationship between Indigenous peoples and the federal-provincial divide in healthcare currently functions in Canada. The proposal to follow a nation-to-nation relationship is not a new one; however, this relationship would be difficult to implement not only politically, but also because it would mandate that Canada commit itself to the extremely costly process of reworking almost every area of governance. Integrating Indigenous knowledge with Western knowledge, increasing Aboriginal representatives in healthcare, and aligning provincial, federal, and Indigenous governments on providing healthcare services are all possible but incremental remedies. Ultimately, the assertion of Indigenous autonomy during a public health emergency has reaffirmed the need for Indigenous inclusion and leadership in policymaking, and the importance of a nation-to-nation relationship for the removal of physical and cultural barriers in healthcare.