Indigenous health in Canada

Indigenous peoples in Canada encompass First Nations, Inuit, and Métis. Indigenous populations face profound health disparities compared to non-Indigenous populations; contributing factors include colonial policies (e.g., residential schools, the Sixties Scoop). Understanding Canadian historical context, health care policies, and legal frameworks is essential for providing equitable care.

Canada recognizes three main groups of Indigenous peoples, whose rights are affirmed in the Canadian constitution. As of the 2021 Census, over 1.8 million people identified as Indigenous, representing 5.0% of Canada's total population. The population is relatively young compared to the non-Indigenous Canadian population and is growing rapidly. ^[1]

First Nations

• Demographics: the largest group of Indigenous peoples in Canada, comprising over one million individuals
• Culture and language
  • Comprises over 630 unique First Nations communities with distinct traditions
  • Regional language families include:
    • Algonquian (e.g., Cree, Mi'kmaq, Ojibwe, Blackfoot)
    • Athapaskan/Dene (e.g., Slavey, Chipewyan, Dene Tha')
    • Iroquoian (e.g., Mohawk, Huron)
    • Salishan (e.g., Squamish, Shuswap)
    • Siouan (e.g., Stoney, Assiniboine)
• Legal definitions
  • Status First Nations: individuals formally registered with the federal government under the Indian Act; entitled to certain benefits and rights
  • Non-status First Nations: individuals of First Nations descent who are not formally registered; variable access to federal benefits
• Geography
  • ∼ 40% of First Nations individuals live on federally recognized Indian reserves.
  • ∼ 60% live off reserve, in urban centers or rural areas.
• Governance: Structures are highly localized and diverse across the communities, ranging from traditional hereditary leadership systems to Indian Act elected band councils and modern, independent self-government agreements.

Inuit

• Definition: Indigenous peoples of the Arctic and subarctic regions with distinct languages (e.g., Inuktitut) and cultural practices
• Geography: primarily inhabit Inuit Nunangat, comprising Nunavut, Inuvialuit Settlement Region, Nunavik, and Nunatsiavut
• Health context: unique barriers to care due to climate and extreme geographic isolation

Métis

• Definition: people of mixed Indigenous and European ancestry who identify as Métis and are accepted by the Métis Nation
• Culture: distinct collective identity, languages (e.g., Michif), and governance structures arising from the fur trade era
• Geography: historically located in the Red River Valley, stretching across the Prairies (Western Canada) and parts of Ontario
• Rights: historic hunting and harvesting rights; generally no access to federally administered reserves or the full Non-Insured Health Benefits (NIHB) program

Although the term "Aboriginal" appears in the 1982 Constitution of Canada, "Indigenous" is the preferred contemporary term. "First Nations" has largely replaced the term "Indian," except in specific legal contexts related to the Indian Act.

Indigenous identity in a clinical and data context is based on voluntary self-identification. Many Indigenous people do not possess "status" under the Indian Act but identify strongly with their community and culture. Clinicians should rely on patient self-identification rather than legal documentation or physical appearance.

Current Indigenous health disparities are structurally linked to historical legislation (e.g., colonization, the residential school system). The longitudinal impact of these systemic interventions includes intergenerational trauma and established mistrust of health care institutions. Consequently, public health frameworks require historical competency as a standard for providing effective clinical care.

Colonization and early legislation ^[2]

• Ecological disruption: Seizure of traditional territories disrupted food systems (e.g., hunting, fishing), leading to a loss of nutritional sovereignty.
• Infectious disease: Introduction of smallpox, measles, and tuberculosis (TB) caused catastrophic population collapse.
• The Indian Act (1876): federal legislation that strictly controlled Indigenous life
  • Pass system: restricted movement off-reserve
  • Potlatch ban: criminalized cultural ceremonies and governance
  • Dependency: created a structural economic dependency on the federal state

The Residential school system (1870s–1996) ^[2]

• Scope
  • Over 150,000 First Nations, Inuit, and Métis children were placed in the government-funded (typically church-operated) residential school system.
  • Although enrollment paths varied, the system fundamentally relied on compulsory attendance laws and the systemic separation of children from their homes.
  • Institutional rules strictly prohibited children from speaking their Indigenous languages or practicing their cultures, while communication and contact with their families were heavily restricted.
• Intent: assimilation through cultural genocide ("kill the Indian in the child" )
• Health impacts
  • Abuse: widespread physical, sexual, and psychological abuse
  • Malnutrition experiments: documented biomedical research involving controlled malnutrition (1940s–1950s) ^[3]
  • Mortality: more than 4100 documented deaths (actual number likely higher) due to TB outbreaks, malnutrition, and overcrowding; mortality rates as high as 47% ^[2]
• Clinical sequel: intergenerational trauma (residential school syndrome)

Indian hospitals (1920s–1980s) ^[4]

• Segregation: racially segregated facilities established primarily for TB management and to mitigate the "perceived threat" Indigenous people posed to the non-Indigenous population
• Conditions: chronically underfunded and overcrowded; frequent use of physical restraints and medical treatment without consent
• Continuum of care: Children often moved in a cycle of institutionalization between residential schools and Indian hospitals.
• Legacy: contributed to deep-seated mistrust of the health care system among Indigenous Elders

Indian day schools (1860–2000) ^[5]

• Scope
  • An estimated 200,000 Indigenous children attended the federal Indian day school system over its history.
  • In 1920, an amendment to the Indian Act made attendance legally compulsory.
• Health impact and settlement
  • Many students experienced physical, verbal, and sexual abuse.
  • Although excluded from the original Residential Schools Settlement Agreement, survivors launched a national class-action lawsuit.
  • In 2019, the McLean Day Schools settlement recognized these harms and established a compensation framework for the estimated 120,000 to 140,000 living survivors.

The Sixties Scoop (1950s–1980s) ^[6]

• 1951 Indian Act amendments granted provincial agencies reserve jurisdiction.
• Applying Eurocentric standards, social workers routinely conflated systemic poverty, traditional diets, and communal child-rearing practices with neglect, driving mass apprehensions without consent.
• Roughly 20,000 Indigenous children were removed and placed in non-Indigenous homes, sometimes internationally, permanently severing children's ties to their birth families, languages, and heritage.
• By the late 1970s, Indigenous children comprised 20% of all children in care nationally (up to 60% in some provinces), despite making up less than 5% of the youth population.

Policy shift and closure of residential schools (1950s–1996)

• Integration policy (1951–1969)
  • The federal government shifted from segregation to integration, moving Indigenous children from residential schools into public schools and provincial foster care (see "Sixties Scoop").
  • A 1969 white paper that proposed the abolishment of Indian status was rejected by Indigenous leaders.
• Indigenous control (1973)
  • The National Indian Brotherhood's 1972 paper "Indian Control of Indian Education" asserted parental responsibility and local control over education and successfully challenged federal jurisdiction.
  • The government began gradually transferring school administration to local Indigenous governments.
• Final closure (1996)
  • The last federally run school, Gordon Residential School in Punnichy, Saskatchewan, closed in 1996.
  • That same year, the Royal Commission on Aboriginal Peoples (RCAP) released its final report, which found that the residential school system was "a national crime" and a primary driver of health disparities. ^[2]

Legal resolution: Indian Residential School Settlement Agreement (implemented in 2007) ^[7]

• The Indian Residential Schools Settlement Agreement (IRSSA) is the largest class-action settlement in Canadian history.
• Purpose: established the Truth and Reconciliation Commission, provided for reparations, and funded the Aboriginal Healing Foundation
• Compensation models
  • Common Experience Payment (CEP): financial compensation for all eligible students based on the number of years of residency
  • Independent Assessment Process (IAP): an out-of-court adjudication process to resolve claims of sexual abuse and serious physical abuse

Truth and Reconciliation Commission (TRC) ^[8]

• Mandate: to document the history and impacts of the system on Indigenous students and their families
• Findings (2015): The final TRC report defined the system as "cultural genocide."
• Calls to action: The report included 94 recommendations (calls to action).
• Health care (Calls 18–24): These specific mandates call on the government to recognize the value of Indigenous healing practices, increase the number of Indigenous health care professionals, and provide cultural competency training for all health care professionals and students.
  • Call 18 (acknowledgment of impact): Governments must officially acknowledge that current Indigenous health inequities are the direct result of previous policies (including residential schools) and recognize Indigenous health rights under international and constitutional law.
  • Call 19 (closing health gaps): The federal government must collaborate with Indigenous peoples to set measurable goals and publish annual progress reports on closing gaps in key health indicators, such as infant mortality, suicide rates, and life expectancy.
  • Call 20 (addressing jurisdictional disputes): The federal government must resolve jurisdictional disputes regarding the health needs of Métis, Inuit, and First Nations individuals living off-reserve to ensure patients are not denied care due to funding disagreements between federal and provincial governments.
  • Call 21 (funding for healing centers): The federal government must provide sustainable funding for Indigenous healing centers (particularly in Nunavut and the Northwest Territories) to address the physical, mental, emotional, and spiritual harms of residential schools.
  • Call 22 (integration of traditional healing): Health care systems and providers must recognize the value of Indigenous healing practices and, at the patient’s request, collaborate respectfully with Elders and traditional healers as part of the treatment plan.
  • Call 23 (workforce and training): All levels of government must increase the recruitment and retention of Indigenous health care professionals and mandate cultural competency training for all providers to ensure a culturally safe workforce.
  • Call 24 (medical and nursing education curriculum): Medical and nursing schools must implement a mandatory curriculum covering the history of residential schools, treaties, and Indigenous rights, while training students in intercultural competency, conflict resolution, and anti-racism.

United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) ^[9]

• Adoption: incorporated into Canadian law in June 2021 (Bill C-15) ^[10]
• Article 24: asserts that Indigenous individuals have an equal right to the "highest attainable standard of physical and mental health" and to their own traditional medicines and health practices

Missing and murdered Indigenous women, girls, and 2SLGBTQI+ people (MMIWG2S+) ^{[11] [12][13]}

The MMIWG2S+ crisis is an ongoing emergency in Canada and the US, characterized by disproportionate rates of violence and systemic neglect.

• Epidemiology
  • Indigenous women and girls are up to 16 times more likely to be murdered or go missing than non-Indigenous women and girls.
  • Indigenous women and girls comprise ∼ 5% of the female Canadian population but represent > 50% of female human trafficking victims.
• Contributing factors
  • Systemic racism: Deep-seated colonial legacies and settler colonialism result in the failure of protective systems.
  • Institutional neglect: documented history of police neglect in investigating disappearances and instances of state-sanctioned brutality
  • Intersectional vulnerability: 2SLGBTQI+ individuals (e.g., Two-Spirit, Indigiqueer) face compounded risks due to intersecting transphobia, homophobia, and anti-Indigenous racism.
• Health care implications
  • Barriers to care: Ongoing violence and systemic distrust (e.g., of police and hospitals) discourage individuals from seeking routine health care, screenings, or acute medical attention.
  • Trauma-informed care is a crucial part of recognition that the MMIWG2S+ crisis is a significant source of intergenerational and ongoing trauma that impacts patient engagement and health outcomes.

Provincial and territorial governments

• Core responsibility: constitutionally responsible for the administration and delivery of health care for all residents, including Indigenous peoples
• Services covered: the exact scope varies by province/territory but includes physician services, acute hospital care, and standard diagnostics
• Public health: sanitation and disease surveillance in all urban, rural, and southern regions

Indigenous Services Canada (ISC)

• Role: the primary federal service provider and funder
• Target population
  • Primarily status First Nations and Inuit
  • Métis health care is generally provincial, although ISC provides some project-based funding
• Mandate: to improve access to high-quality services and to transfer control to Indigenous governments
• Key duties
  • Health benefits: administers NIHB and the Indian Residential Schools Resolution Health Support Program and coordinates Jordan’s Principle funding
  • Direct care: operates or funds nursing stations and health centers in remote and/or isolated First Nations communities
  • Public health: management of TB, HIV, and AIDS; vaccine administration, environmental health, and emergency response
  • Services beyond health care (e.g., education)

The First Nations and Inuit Health Branch (FNIHB) was transferred from Health Canada to ISC in 2017 to integrate health with other social determinants (e.g., water, housing). Pre-2017 clinical guidelines may refer to "Health Canada" regarding NIHB or nursing stations, but ISC is now responsible for these services.

Health Canada ^[15]

• Role: the federal regulator and policy lead (not a service provider)
• Key duties
  • Approving and regulating pharmaceuticals, medical devices, and vaccines to ensure safety
  • Enforcing the Canada Health Act to ensure provinces maintain standards (universality, portability, etc.)
  • Managing national funding programs (e.g., Substance Use and Addictions Program)

Indigenous Health Authorities

• Goal: fulfill the federal legal mandate to replace the federal health administration with Indigenous-led authorities that design and deliver culturally appropriate care
• The British Columbia Model ^[16]
  • In British Columbia, federal health responsibilities were transferred to the First Nations Health Authority (FNHA) in 2013.
  • Significance: While other First Nations communities and regional tribal councils manage local health services and clinics, the FNHA is the only provincial-level First Nations health authority to have taken over federal health service delivery for Indigenous populations.
  • Clinical impact: Physicians coordinate with the FNHA rather than ISC.

Non-Insured Health Benefits (NIHB) ^[17]

Definition and eligibility

• A national program that provides coverage for a specified range of medically necessary items and services not covered by provincial or territorial health plans or by private insurance
• Administered largely by ISC
• Applies to registered First Nations individuals and Inuit recognized by an Inuit land claim organization (all ages)
• Métis individuals are not eligible for NIHB unless they are also registered status First Nations.
• Treaty context
  • For many First Nations, NIHB is considered the fulfillment of treaty rights from the 19th and 20th centuries rather than merely a social program.
  • Treaty 6 included a "Medicine Chest Clause" promising access to medicine.
  • The federal government historically classifies NIHB as a matter of "social policy" rather than a treaty obligation.

Clinical guidance

• NIHB provides coverage for medically necessary items and services not funded by provincial or territorial plans or private insurance, based on the standard of care and at the lowest cost-effective rate (e.g., generic drug versions).
• Services are listed on the NIHB benefit list and categorized as:
  • Open benefit: no prior approval required
  • Limited use: specific clinical criteria to be met
  • Exceptions: require special case review
• Requirements for health care professionals
  • Check the NIHB benefit list to verify coverage before prescribing medications or ordering medical supplies and equipment.
  • Provide a valid prescription or medical requisition.
  • Open benefit items: For most medications and dental services, clinicians bill NIHB directly using the client's status card number.
  • Limited use items
    • For items requiring prior approval (e.g., certain medical supplies and equipment, specialized dental and orthodontic procedures, clinicians must submit a prior approval request with medical justification to the regional NIHB office before the service is provided.
    • This request should include the patient's clinical history, why alternative treatments are unsuitable, and the medical necessity of the requested item or service.
  • Exception requests: If an item is not listed on the benefit list, clinicians can submit a request for exception with clinical justification.
  • Appeals: If a request is denied, clients have the right to three levels of appeal; clinicians can provide additional clinical evidence or letters of support to justify the exception.
  • Inquiries: Clinicians can contact the NIHB provider claims processing center (Express Scripts Canada) for real-time eligibility checks.
• NIHB is the payer of last resort; if a patient has private insurance (e.g., through a spouse or employer), that plan must be billed before NIHB covers the balance.

Coverage scope

• Pharmacy benefits, including prescription drugs and some over-the-counter medications listed on the NIHB drug benefit list
• Dental care, including diagnostic, restorative, and orthodontic services (with strict clinical scoring)
• Vision care, including eye examinations and eyeglasses or contact lenses
• Medical supplies and equipment, including diabetic supplies, mobility aids, oxygen, ostomy supplies, hearing aids, and prosthetics
• Mental health counseling, including short-term crisis intervention and therapy with NIHB-registered providers
• Medical transportation, including travel and accommodation costs for medical appointments not available locally

Jordan’s Principle ^[18]

Definition and eligibility

• A child-first principle that ensures First Nations children can access all government-funded public services (e.g., health care, speech therapy, medical equipment, educational supports) without delays caused by jurisdictional disputes between federal and provincial governments
• Named after Jordan River Anderson, a First Nations child from Manitoba who died in hospital at 5 years of age while governments disputed who should pay for his at-home care
• Eligibility
  • Children under the age of majority who permanently live in Canada and meet ≥ 1 of the following criteria:
    • Recognized by their Nation for the purposes of Jordan's Principle
    • Registered under the Indian Act as Status First Nations or are eligible to register
    • A parent or guardian is registered under the Indian Act as Status First Nations or is eligible to register
    • Ordinarily live on a reserve
  • Inuit children are covered under a parallel stream called the Inuit Child First Initiative, which offers virtually identical protection and funding.
• Goal: achieve substantive equity with non-Indigenous children
• Legal status: mandated by the Canadian Human Rights Tribunal in 2016; binding for the federal government

Clinical guidance

• Jordan's Principle ensures funding for services that exceed standard provincial coverage if deemed medically necessary (e.g., specialized equipment, home nursing or respite care for medically fragile children, medical transportation).
• An application requires a written recommendation or prescription from a licensed health care professional.
• Clinicians act as advocates by documenting medical necessity.
• Application process
  • Applications are processed through ISC (FNHA in British Columbia).
  • Jordan's Principle service coordinators assist families with the application process and follow-up.
  • Urgent requests must receive a response within 12 hours.
  • Nonurgent requests must receive a response within 48 hours.
  • Timelines are mandated by the Canadian Human Rights Tribunal and are legally binding, but systemic delays are common.

Indian Residential Schools Resolution Health Support Program (IRS-RHSP) ^[19]

Overview

• Definition: a national program established under the Indian Residential Schools Settlement Agreement to provide mental health, emotional, and cultural support services to former students and their families
• The health supports under the original Settlement Agreement formally concluded in 2021, but their funding has been extended indefinitely and restructured into the Trauma-Informed Health and Cultural Support Program.
• The expanded program now includes survivors of Federal Indian Day Schools and those affected by the MMIWG2S+ crisis.
• Administered by ISC (FNHA in British Columbia for status and non-status First Nations survivors)
• Applies to all former students (individuals listed in the 2006 Settlement Agreement, regardless of status or residence) and intergenerational survivors (e.g., spouses, partners, and children) affected by the intergenerational trauma of a relative's residential school experience
• Goal: address the ongoing trauma and health impacts of the residential school system

Clinical guidance

• Clinician role: actively refer eligible patients to the regional IRS-RHSP coordinator (contact the ISC regional office, FNHA in British Columbia)
• Refer Indigenous patients with a personal or family history of residential or day schools and/or MMIWG2S+ trauma if they:
  • Present with complex PTSD, depression, substance use disorder, and/or suicidal ideation
  • Struggle to engage with mainstream health care due to mistrust and/or discrimination
  • Request culturally specific mental health services

Services provided

• Cultural support
  • Coordination of services with Elders or traditional healers
  • Ceremonies, prayers, and traditional healing practices
• Emotional support: provided by Resolution Health Support Workers (RHSWs)
  • Assistance during medical or legal appointments related to residential school claims
  • Accompaniment to triggering or difficult medical procedures
• Professional counseling
  • Access to psychologists, social workers, and/or therapists registered with the program
  • Individual, family, or group therapy for trauma, PTSD, depression, and substance use
• Transportation assistance: financial support for travel to counseling or cultural support services if not available locally

Joyce’s Principle ^[20]

Overview

• A framework developed following the death of Joyce Echaquan, an Atikamekw woman who died in a Quebec hospital in 2020 while being subjected to racist remarks by health care staff
• Aims to guarantee the right of all Indigenous people to equitable access to health care and social services without discrimination
• Legal status: Endorsed by various professional bodies (e.g., the Canadian Medical Association) but has not yet been fully adopted into federal or Quebec provincial law due to political disputes regarding the definition of systemic racism

Clinical guidance

• Right to health: The framework asserts that Indigenous people have the right to the highest attainable standard of physical and mental health.
• Clinician role
  • Actively dismantle systemic racism within the clinical encounter
  • Recognize and correct implicit biases that lead to undertreatment, misdiagnosis, or dismissal of Indigenous patients' concerns
  • Avoid stereotyping (e.g., assuming substance use, noncompliance, or exaggeration of symptoms)
  • Treat all patients with dignity and respect, regardless of appearance, behavior, or social circumstances
  • Include Indigenous patient navigators and family members in the circle of care when appropriate
  • Ensure the patient's voice and autonomy are respected in clinical decision-making
  • Challenge discriminatory comments or behaviors by colleagues
  • Advocate for resources that address the social determinants of health (e.g., housing, clean water) as part of a comprehensive treatment plan

Mitigating systemic bias

• Indigenous populations in Canada face significant health disparities, illustrated by a life expectancy gap of up to 13.5 years for First Nations people living on-reserve and infant mortality rates among Inuit that are 3.2 times higher than rates in the non-Indigenous population.
• These outcomes are predominantly driven by systemic determinants (e.g., poverty, overcrowded housing, barriers to health care, racism, organizational neglect) rather than individual choices or biology.
• Clinicians must recognize these structural root causes to avoid stigmatization when managing conditions with higher prevalence.
• Understanding disease patterns, genetic predispositions, and environmental factors specific to individual Indigenous people remains essential for accurate diagnosis and management.

Life expectancy and infant mortality ^[21][22]

Available data for life expectancy and infant mortality vary significantly by province, territory, and population group, and national data often lags behind provincial reports. Provincial data may show gaps significantly wider than the national average (e.g., due to the toxic drug crisis).

Social determinants of health ^[23]

• Income and economic opportunity
  • Income gap: significantly lower median income for Indigenous people (especially women and those living on reserves or in Inuit Nunangat) than the non-Indigenous average
  • Child poverty: disproportionately high rates in Indigenous populations (especially those living on reserves) compared to non-Indigenous populations ^[24]
  • High cost of living: The impact of lower income is exacerbated by the extremely high cost of living in remote and Northern communities (e.g., Nunavut), where fuel and perishable foods are substantially more expensive than in southern Canada.
  • Unemployment: unemployment rates 2–3 times higher than the national average, often due to educational barriers and a lack of local economic infrastructure ^[25]
• Housing and infrastructure
  • Overcrowding: a primary driver for the high rates of TB and respiratory infections (e.g., RSV) in Inuit and First Nations communities
  • Poor ventilation: exacerbates mold growth
  • Wood smoke exposure: Many homes use wood stoves; inadequate ventilation leads to chronic smoke exposure.
  • Lack of clean water ^[26]
    • Long-term boil water advisories for drinking water on some reserves
    • Increased MRSA risk due to insufficient hand hygiene
    • Baby formula cannot be mixed safely.
• Food security and access
  • Loss of access to traditional foods (loss of hunting and fishing territories, environmental contamination)
  • High cost of perishable food in remote fly-in communities
  • Reliance on cheap, processed, calorie-dense, shelf-stable foods (a major contributor to obesity, cardiovascular disease, and type 2 diabetes)
• Access to health care
  • Geographic barriers: Remote communities often rely on nursing stations with itinerant physicians; medevacs are required for tertiary care.
  • Lack of access to properly trained mental health and addictions counselors and facilities (and related biases therein)
• Discrimination, racism, and historical trauma
  • Colonial legacies and state intervention
    • Residential schools: intergenerational trauma affecting parenting and mental health; higher prevalence of adverse childhood experiences (ACEs)
    • The child welfare system: overrepresentation of Indigenous children in foster care, reflecting a continuation of historical trauma (the "Millennium Scoop"); perpetuates family fragmentation ^[27]
    • Reproductive coercion: mistrust in reproductive health settings due to state-sanctioned forced sterilization of Indigenous women throughout the 20th century
  • Systemic violence and public safety
    • MMIWG2S+ crisis: high rates of sexual and gender-based violence
    • Institutional neglect: cycle of under-policing (failed investigations) and over-policing (disproportionate arrests) that fuels systemic distrust and leads to avoidance of medical or legal care
    • Health care racism: documented bias in emergency departments (e.g., assuming a patient is intoxicated rather than ruling out hypoglycemia, sepsis, or traumatic brain injury) leads to delayed diagnosis and death (e.g., Brian Sinclair )

Environmental determinants of health

• Cold exposure and frostbite: higher rates in northern communities due to extreme cold and outdoor activities (hunting, fishing, travel)
• Mercury exposure: methylmercury in certain fish and marine mammals (seal, whale, walrus) from Arctic waters
• Lead exposure: lead shot in hunted game, contaminated drinking water (old infrastructure, lead pipes), lead-based paint

Conditions with an increased prevalence in Indigenous individuals due to social determinants

The increased prevalence of the conditions below is primarily driven by inequitable social determinants of health and the legacy of colonization. These conditions are disproportionately common due to environmental factors (e.g., overcrowding, food insecurity, barriers to care).

Infectious diseases

• Tuberculosis ^[28]
  • Significantly higher rates in Inuit Nunangat and some First Nations communities compared to non-Indigenous populations
  • Driver: overcrowded housing and poor ventilation facilitate transmission
• Respiratory infections (RSV, bronchiolitis, chronic otitis media)
  • High rates of severe infection in infants
  • Driver: overcrowding, wood smoke exposure, and mold
• H. pylori infection ^[29]
  • Higher prevalence of H. pylori infection leads to increased rates of gastric cancer.
  • Driver: inadequate water infrastructure and housing conditions
• Rheumatic fever and rheumatic heart disease ^[30]
  • Remnants of disparities in primary care access
  • Especially common in remote northern communities
• Skin and soft tissue infections ^[31]
  • Increased rates of community-acquired MRSA in communities with boil water advisories
  • Driver: lack of clean running water for hand hygiene

Chronic and metabolic conditions

• Type 2 diabetes ^[32]
  • Onset is often observed earlier (20–39 years of age) compared to non-Indigenous populations.
  • Driver: food insecurity, loss of traditional food sources, and reliance on affordable, processed foods ("nutrition transition")
• Cardiovascular disease ^[33]
  • Events often occur 10–15 years earlier than in the general population.
  • Driver: allostatic load (chronic stress), commercial tobacco use, and metabolic risk factors
• Chronic kidney disease ^[34]
  • Higher baseline rates of renal disease relative to the general population
  • The "Indigenous race" coefficient in risk calculators (e.g., KFRE) is controversial; it acts as a statistical proxy for unmeasured social determinants and lower baseline kidney health rather than reflecting a biological difference.

Oncology

• Cervical cancer ^[35]
  • Higher incidence and mortality rates compared to non-Indigenous women in Canada
  • Driver: barriers to screening (Pap and HPV tests), including lack of local providers and history of medical trauma (e.g., coerced sterilization, sexual violence)
  • Management: Some provinces offer HPV self-collection to bypass pelvic examinations and reduce retraumatization.
• Lung cancer: linked to commercial tobacco use (distinct from traditional ceremonial tobacco) ^[36]

Nutrition

• Vitamin D deficiency: high prevalence in northern populations due to limited sunlight, especially in winter
• Iron deficiency anemia
  • Common in individuals who can become pregnant, children, and pregnant individuals
  • Driver: high cost of perishable fresh foods in fly-in communities
• Folate deficiency: common in individuals who can become pregnant due to limited access to fortified grains and fresh vegetables

Mental health

• Suicide and nonsuicidal self harm and injury: Rates are critically high among Inuit youth. ^[37]
• Substance use disorders
  • The toxic drug crisis has profoundly affected Indigenous communities, resulting in overdose rates that far exceed the national average.
  • Should be viewed through a trauma-informed lens; may be "self-medication" for intergenerational trauma or complex PTSD ^[38]
• Residential school syndrome ^[39]
  • Residential school survivors and their descendants experience ongoing psychological, social, and health impacts as a result of personal or intergenerational trauma.
  • Increased rates of PTSD, depression, substance use disorders, suicide, and chronic disease
  • Disrupted parenting and family structures due to a lack of positive role models
  • Mistrust of institutions, including health care systems
  • Continues beyond the era of residential schools and should be documented in patient assessments
• Interpersonal violence ^[40]
  • Rooted in intergenerational trauma, systemic inequities, and colonial legacies (e.g., residential school system)
  • Disproportionately affects women and 2SLGBTQI+ individuals; rates significantly exceed national averages
  • Increased prevalence of lifetime violence, severe physical injury, femicide, and homicide
  • Significant distrust of legal and social systems (e.g., fear of child welfare intervention and possible removal of children), which often precludes reporting
  • Remote and northern communities face acute shortages of emergency shelters and crisis services, often forcing victims into prolonged proximity with their abusers.
  • Polyvictimization: frequent co-occurrence of childhood maltreatment, domestic abuse, and systemic violence; compounds psychological morbidity

Cultural safety

Cultural safety is an outcome based on a patient's experience. It moves beyond "competency" to actively address institutional racism, discrimination, and colonial history. Cultural safety is defined by the following core principles:

• Power dynamics: actively recognizing and mitigating the inherent power held by the health care provider and the institution over the patient
• Addressing racism: acknowledging that systemic, Indigenous-specific racism and discrimination are widespread ^[42]

Cultural safety is aligned with the TRC calls to action (18–24) in the following ways:

• Acknowledgement of current health inequities
• Establishment of measurable goals to close the gap in health outcomes
• Mandatory cultural training for all health care professionals

Cultural humility

Cultural humility focuses on the process of the practitioner. It involves an ongoing commitment to reflection, recognition of power imbalances, and treating the patient as an expert on their own experience.

• Self-reflection and critique: engaging in continuous introspection to understand one's own worldview and limitations
• Addressing biases: actively learning about and challenging one's own biases
• Understanding power history: committing to learning the history of power relationships in health care and how they impact current patient interactions
• Patient as expert: relinquishing the role of "expert" regarding the patient’s culture and instead listening to the patient's lived experience as the primary source of truth
• Institutional accountability: holding oneself and one's organization accountable for creating inclusive and equitable spaces
• Common biases toward Indigenous patients include:
  • Assuming substance use or addiction without evidence
  • Dismissing pain reports as drug-seeking behavior
  • Expecting noncompliance or missed appointments
  • Attributing health problems to personal choices rather than systemic factors
• Strategies to address bias include:
  • Engaging in regular self-reflection and anti-racism training
  • Challenging assumptions before making clinical decisions
  • Inquiring about past experiences of discrimination in health care settings
  • Acknowledging possible harm done by health care systems

Cultural competence

• Overview
  • Focuses on the health care provider acquiring a specific set of knowledge, skills, and attitudes to work effectively with cross-cultural populations
  • Often treats cultural knowledge as a checklist or a static level of expertise that can be mastered
• Considered a necessary foundation but insufficient on its own because of:
  • Finite endpoint: implies that one can eventually become fully competent in another person's culture, ignoring the dynamic nature of culture
  • Power imbalance: reinforces the provider as the expert (even on the patient's life) rather than the learner
  • Stereotyping: often creates generalizations (e.g., "All Indigenous patients believe X") rather than treating the patient as an individual
  • Ignores systemic issues: focuses on individual provider skills rather than addressing institutional racism or power imbalances

Mitigating systemic bias

• Effective clinical care for Indigenous patients requires balancing a high index of suspicion for specific disease patterns with a commitment to individualized, nonjudgmental care that avoids stereotyping.
• A trauma-informed approach involves validating traditional healing practices, using harm-reduction strategies for substance use, and explicitly asking about barriers like inadequate access to clean water or refrigeration.
• When communicating, providers should prioritize building trust, avoiding "lifestyle" lectures in favor of harm reduction, and offering culturally safe referrals (e.g., to Indigenous-led programs).
• Clinicians should act as advocates by using mechanisms like Jordan’s Principle to bypass bureaucratic delays for pediatric services.

Establishing rapport

• Introduce yourself and your role clearly.
• Use a warm, respectful tone; avoid rushing.
• Allow time for storytelling and holistic health discussion.
• Ask about preferred name, pronouns, and cultural background.
• Invite family members or support persons to participate if the patient desires.

Allow the patient to self-identify their ancestry rather than making assumptions based on appearance or geography.

Always explain that you are asking about Indigenous self-identification to improve access to care, not to label the patient. Use a normalizing lead-in: "We ask all our patients about their cultural background so we can offer the most appropriate resources, benefits, and supports available to you."

Assessing social context

• Check records, advocates, or public notices for known challenges (e.g., boil water advisories) before asking the patient; asking patients to verify widely known crises conveys ignorance and damages trust.
• Avoid identity-based assumptions; ask about social determinants only when context is missing or specific clinical risks exist.
• When appropriate, explore housing, food, and income security, alongside environmental exposures (e.g., mold, lead, water quality).
• Inquire about distance to facilities, transportation barriers, and medical transit funding (e.g., NIHB).
• Recognize cultural identity and community ties as protective factors, while remaining sensitive to past health care or institutional discrimination.
• Document systemic findings as direct contributors to current health, and connect patients with resources (e.g., social workers, community groups, Indigenous Services Canada programs).

Be mindful of systemic barriers (e.g., food insecurity, lack of potable water) and avoid offering patronizing and/or impractical health advice. Recognizing these barriers as primary drivers of health status is essential for maintaining a therapeutic alliance and delivering relevant clinical interventions.

Screening for historical trauma ^[44]

• Ask if the patient or their family has been affected by the residential school system; normalize the question as part of routine social history.
• Document residential school impact as a valid social determinant of health.
• Assess for symptoms of complex PTSD, depression, or substance use related to trauma.
• Refer to IRS-RHSP (for residential school survivors), helplines (e.g., Hope for Wellness Helpline), or culturally safe mental health services.

Integrating traditional healing

• Ask if patients are interested in using traditional medicines or healing practices and if they would like to involve a traditional healer or Elder in their care.
• Indigenous Patient Navigators are available in many tertiary hospitals to help patients navigate the health care system, facilitate discharge planning, and coordinate access to traditional supports.
• Respect traditional healing as valid and complementary.
• Collaborate with traditional healers or Elders when requested.
• If working within an inpatient, residential, or clinic facility, proactively verify local policies regarding smudging or other traditional ceremonies.
• Assess for potential herb-drug interactions without dismissing traditional practices.
• Document the use of traditional healing in a supportive manner.

Promoting health literacy

• Establish a baseline: Start by asking the patient what they already know or have been told about their condition.
• Use plain language: Avoid medical jargon; explain terms clearly; use storytelling or metaphors that resonate with the patient's background.
• Assess understanding: Use the teach-back method.
• Provide visual aids (diagrams, models, or pictures to illustrate conditions or procedures).
• Offer interpreter services if language barriers exist.
• Give written materials in the patient's preferred language and at an appropriate literacy level.
• Let patients know that they can bring a family or support person to appointments.

Acknowledge that a patient's hesitation might be a result of cultural differences in communication styles (e.g., direct eye contact or immediate questioning) rather than a lack of understanding.

Coordinating benefits and coverage

• Verify eligibility for NIHB, Jordan's Principle (for pediatric patients), and/or IRS-RHSP.
• Assist with navigating jurisdictional barriers between federal and provincial systems.
• Provide written prescriptions or recommendations to support access to services.
• Connect patients with service coordinators or patient navigators.
• Advocate for patient needs when facing administrative delays or denials.

Consider modified screening strategies for conditions with a high prevalence

• Indigenous populations experience higher rates of chronic and infectious diseases, often with earlier onset.
• Standard screening guidelines (e.g., cancer, diabetes) apply but should be offered rather than enforced, with explicit informed consent to avoid triggering trauma related to historical forced medical procedures.
• There are no mandatory screening programs that apply to all Indigenous people in Canada.
• The concept of "general screening" carries significant historical trauma for many Indigenous communities because of aggressive, mandatory screening programs in the mid-20th century, through which people were forcibly removed from their families.
• Consider individual needs; e.g., an Inuit patient from a northern community (higher risk of TB) will have a different clinical profile than an urban First Nations patient (higher risk of diabetes and mental health challenges).

Compounded discrimination against members of Indigenous populations

• Patients may face multiple layers of systemic barriers and discrimination based on:
  • Gender and sexuality
    • 2SLGBTQI+ individuals and Indigenous women
    • Two-Spirit (2S): a culturally specific identity for individuals embodying both masculine and feminine qualities; 2S individuals often hold significant roles as healers or mediators
  • Age and ability: young adults, older adults, and individuals with disabilities
  • Geography: off-reserve and urban populations (often fall between jurisdictional gaps)

Urban Indigenous populations

• Context: Approximately 60% of Indigenous people in Canada live in urban areas yet remain underserved by health care systems. ^[45]
• Clinical approach
  • Avoid assumptions of cultural disconnection; identity is not defined by residence.
  • Use voluntary self-identification rather than making assumptions.
  • Screen for housing instability and food insecurity (high prevalence).
  • Refer to friendship centers or urban Indigenous health clinics for culturally safe wrap-around care.

Northern and remote communities

• Barriers: geographic isolation (e.g., fly-in communities), limited local resources (e.g., nursing stations only), infrastructure gaps (e.g., overcrowded housing, boil water advisories, high food costs)
• Climate: extreme cold, prolonged darkness, weather delays for evacuations
• Evacuation: routine for emergencies and childbirth (36–38 weeks' gestation); causes cultural disconnection and financial strain
• Clinical approach
  • Use telemedicine to reduce unnecessary travel.
  • Leverage NIHB medical transportation for essential travel.
  • Prescribe medications available in the local formulary to prevent delays.

Indigenous youth

• Mental health: significantly higher suicide rates than the national average
  • Evalaute for signs of depression, suicidal ideation, and protective factors.
  • Protective factors include connection to Elders, cultural pride, and land-based activities (e.g., traditional hunting, fishing, medicine harvesting, or hide tanning).
• Substance use: Use motivational interviewing and harm reduction; address underlying intergenerational trauma rather than stigmatizing use.

Elders

• Role: custodians of wisdom and culture; central to community decision-making
• Clinical approach
  • Respect: Use titles (e.g., "Grandmother," "Elder") and allow time for storytelling.
  • Care planning: Involve Elders in family meetings; facilitate access to traditional healers.
  • Polypharmacy: Review medications frequently (high risk of chronic comorbidities).
  • End-of-life: Elders often provide spiritual guidance at bedside; document cultural preferences.

Women's health and 2SLGBTQI+ inclusion

• Cervical cancer screening
  • High rates of cervical cancer due to barriers in accessing Pap smears (e.g., geographic isolation, lack of female providers, and history of medical trauma)
  • Approach: Advocate for self-sampling HPV kits, which provide increased privacy and comfort for those with past medical trauma.
• Contraceptive choice
  • The history of coerced sterilization in Canada has created deep-seated mistrust of long-acting reversible contraceptives like IUDs or implants.
  • Approach: Ensure counseling is entirely patient-led and free of paternalistic pressure.
• Gender-based violence (MMIWG2S+): Assume a history of trauma for all patients to avoid retraumatization during physical and pelvic examinations.
• Two-Spirit and Indigiqueer inclusion
  • Prioritize the patient’s specific tribal or chosen term.
  • When possible, advocate for open-ended gender and sexuality fields on intake forms to avoid "othering" Indigenous identities.
  • Practice radical consent: Remind patients directly that they may stop the examination at any time and for any reason.
  • Screen for "double-marginalization" stressors (housing, food security) while also assessing for cultural strengths (connection to land, language, and ceremony).
  • Facilitate referrals to Two-Spirit-led peer support groups or Elders who are Two-Spirit-affirming.

Maternal health

• Prenatal care
  • Engage early to build trust.
  • Address barriers like geographic isolation and fear of child apprehension (historical trauma).
  • Engage with Indigenous doulas.
• Perinatal care
  • Obstetric evacuation
    • In remote communities lacking local birthing facilities, federal practice guidelines mandate transferring pregnant individuals to regional medical centers at 36–38 weeks' gestation to await labor and delivery.
    • Associated harms: This policy often results in forced separation from family and support systems, unexpected accommodation costs, cultural disconnection, and negative mental health impacts.
  • Community advocacy: Many communities advocate for the return of local birthing services, and birth centers are now available in some communities to support closer-to-home care.
  • Support community birth when safe, respect placenta practices, and facilitate traditional ceremonies.
• Breastfeeding support
  • Importance: optimal nutrition; free (critical in food-insecure communities); culturally traditional
  • Barriers: intergenerational loss of knowledge (e.g., due to residential schools), formula marketing, water contamination
  • Clinical approach: Strongly promote breastfeeding, provide lactation support, and educate on safe formula preparation if needed.

Child health

• Elevated rates of respiratory infections (RSV, TB), otitis media, and SIDS relative to the general Canadian child population
• Fetal alcohol spectrum disorder (FASD)
  • Screen children with developmental delays nonjudgmentally
  • Refer to multidisciplinary FASD clinics
  • Use Jordan’s Principle for funding interventions.
• Clinical approach
  • Encourage well-child visits.
  • Promote breastfeeding.
  • Ensure rigorous hearing screening.
  • Educate on safe sleep.

Indigenous perspectives on wellness

• Holistic framework: health viewed as a balance of physical, mental, emotional, and spiritual quadrants (e.g., medicine wheel); contrast to Western biomedical reductionism
• Relationality: Wellness is inextricably linked to land (ecology), family, community, and ancestral lineage; individual health is inseparable from collective health.
• Land-based healing: Natural environments and traditional practices (e.g., harvesting, ceremony) are considered primary therapeutic interventions, not "alternative" therapies.
• Clinical alienation: Individualistic or "self-help" philosophies often fail; interventions must involve family and/or community engagement to be effective and culturally safe.
• Self-determination: Health outcomes improve when care is Indigenous-led and respects tribal sovereignty and traditional knowledge systems.

Common traditional healing practices

• Practices vary significantly among First Nations, Inuit, and Métis communities; avoid generalizations.
• Two-Eyed Seeing
  • A principle that views Western medical treatments and Indigenous traditional healing not as competitors, but as complementary strengths.
  • Always ask about traditional practices; unless there is immediate biological toxicity or interaction, accommodate and integrate them into the care plan.
  • Culture is a social determinant of health; connection to culture improves outcomes.

Smudging

• Description: burning sacred plants (e.g., sage, sweetgrass, cedar, tobacco) to cleanse and purify
• Purpose: spiritual cleansing, prayer, preparation for ceremonies or important events
• Clinical considerations
  • May be requested before medical procedures or in hospital settings
  • Ensure hospital policies accommodate smudging or provide alternative spaces.
  • Assess for respiratory conditions that may be exacerbated by smoke (accommodate smokeless alternatives if needed).

Sweat lodge ceremonies

• Description: purification ceremony conducted in a heated, enclosed structure
• Purpose: physical, mental, emotional, and spiritual cleansing
• Clinical considerations
  • May be used for healing from trauma, addiction, or illness
  • Assess cardiovascular and respiratory fitness if the patient plans to participate.
  • Respect the patient's decision to participate as part of their healing journey.

Traditional medicines (herbal remedies)

• Examples: sweetgrass, cedar, sage, tobacco, Labrador tea (Rhododendron groenlandicum), devil's club
• Uses: vary by plant and tradition (e.g., used for respiratory conditions, pain, mental health, spiritual purposes)
• Clinical considerations
  • Ask about use in a nonjudgmental manner.
  • Assess for potential herb-drug interactions (consult pharmacist or Indigenous health resources).
  • Document use in the patient chart.
  • Educate about risks without dismissing traditional practices.

Traditional healers and Elders

• Roles
  • Provide guidance, counseling, and spiritual support
  • Administer traditional medicines and perform ceremonies
  • Support intergenerational knowledge transmission
• Clinical collaboration
  • Facilitate communication between traditional healers and the medical team.
  • Allow hospital access for traditional healers when requested by the patient.
  • Coordinate the timing of traditional and Western treatments to avoid conflicts.
  • Respect the confidentiality of traditional healing practices.

Herb-drug interactions

Always approach discussions of traditional medicine with respect and curiosity. Ask if the patient can tell you more about what they're taking and how it is helping them. Document use without judgment and consult resources for interaction risks.