The featured image for this story is reproduced with permission from the Health Council of Canada. Illustrator: Leah Fontaine
Canada’s First Nations, Inuit and Métis peoples have, on average, much poorer health than other Canadians.
Chronic diseases like diabetes are significantly more common among Aboriginal peoples, and they have a substantially shorter life expectancy than the general population. Mental illness is also alarmingly common in Aboriginal communities, where suicide rates are often five to six times the national average. Suicide rates among Inuit youth are among the highest in the world: 11 times the national average.
There are many factors that contribute to these differences in health, which are rooted in Canada’s history of colonization. In addition to the health challenges all Canadians face, Aboriginal peoples are more likely to live in crowded homes, are more likely to smoke, and less likely to have stable access to an appropriate diet, all of which contribute to poorer health.
In addition, survivors of Canada’s residential school system frequently suffer from trauma inflicted by residential schools. In addition to loss of culture, language and parenting skills, survivors and their families frequently suffer from post-traumatic stress disorder, and unresolved trauma can lead to further mental illness and re-victimization of new generations.
Beyond these social contributors, Aboriginal peoples also tend to have less access to health care services than other Canadians. This is particularly true in northern Aboriginal communities, many of which have very limited access to doctors and other health care providers. Even when Aboriginal peoples do have access to health services, they often face discrimination and a lack of culturally appropriate care. For these reasons, the recruitment of more Aboriginal doctors has become a priority for many of Canada’s medical schools.
The need for more Aboriginal doctors
Canada’s medical schools have recognized that they must become more proactive in recruiting Aboriginal doctors and training non-Aboriginal doctors to be culturally competent and safe, says Nick Busing, President of the Association of Faculties of Medicine in Canada. “Medical schools must be socially accountable to Canadians,” he says, “and an important part of this is making sure that the doctors we train will meet society’s needs.”
Aboriginal doctors are often best equipped to provide culturally competent and safe care to other Aboriginal people, according to Darlene Kitty, President of the Indigenous Physicians Association of Canada. “Aboriginal doctors already know the culture and the history… they’re already sensitive to the issues in their community,” she says. “Many people in our communities have trauma,” she continues, “and other Aboriginal people often understand that trauma a lot better than non-Aboriginal people.”
Aboriginal students also contribute to the cultural diversity of medical schools, and this diversity helps all medical students, both Aboriginal and non-Aboriginal, become more culturally competent and culturally safe, says Kitty. This is echoed in Canada’s accreditation standards for medical schools, which stress that doctors will be best prepared to deliver health care to a diverse population if they are educated in a diverse environment where they are exposed to other cultures.
Evidence also indicates that one of the best predictors for where future doctors will practice medicine is where they went to high school. “If all of our medical students are from the big cities, then that’s where all our doctors will want to practice,” says Busing. The expectation is that if medical schools can recruit medical trainees from underserved Aboriginal communities, then there is a good chance that some of them will return to their communities once they have completed their training.
But the need for more Aboriginal doctors goes beyond just the needs of rural and remote communities. More than half of Canada’s 1.3 million Aboriginal people live in urban areas, and they too can benefit from more culturally competent doctors.
Challenges in recruiting Aboriginal medical students
Recruiting more Aboriginal medical students, however, is not easy. In addition to the substantial challenges all applicants to medical school face, Aboriginal applicants often face additional barriers, some of which can continue throughout medical school and residency.
The pool of potential Aboriginal applicants to medical schools is small, since less than 4% of Canada’s population is Aboriginal.
However, the biggest factor restricting the number of potential applications is the much lower rates of post-secondary education (a pre-requisite for medical school) among Aboriginal people. Only 12% of Aboriginal Canadians complete a post-secondary degree, compared to 33% of non-Aboriginal Canadians. The rate is even lower (5%) for Aboriginal youth living on reserves.
These lower rates of post-secondary education are rooted in many of the same social determinants and multi-generational trauma that contribute to the poor health of many Aboriginal peoples. In addition, funding for schools on reserves is rarely comparable to that provided to other Canadian schools.
Even for Aboriginal applicants who obtain post-secondary education, medical school admission remains a challenge due to academic requirements and/or cost. The cost of medical school has increased steadily in recent decades, and medical students are graduating with record levels of debt, factors that have likely contributed to the disproportionately low enrollment of students of lower socioeconomic status in Canada’s medical schools. Since Aboriginal Canadians are more likely than other Canadians to be of lower socioeconomic status, the sheer cost of medical school is likely a deterrent for many potential Aboriginal applicants.
Furthermore, the location of the vast majority of medical schools means many Aboriginal students must leave their community for new settings for at least the length of medical school and their post-graduate training.
“Culture shock” for many Aboriginal medical students
For those Aboriginal applicants who are accepted to medical school, the challenges often continue. “I experienced huge culture shock when I got to medical school,” says Doris Mitchell, a graduate of the Northern Ontario Medical School who practices in Chapleau, Ontario.
“Age can be a big thing,” says Mitchell, who worked as a nurse for 15 years before going to medical school. “Many of us [Aboriginal medical students] were coming in as adult learners. We had families already, and there are challenges with caring for them while at school.” The difference in age compared with most medical students can create a sense of isolation from the rest of the class, she says, “it can make you feel very different.”
This sense of difference was amplified by the competitive culture of medical school. “Coming from an Aboriginal nursing background, I was used to an environment that was very nurturing, very non-judgmental, very non-competitive,” she says. “You learn to be very comfortable talking about your struggles, what you need to work on to become a stronger person or a better caregiver. Medical school was very different. It was a very competitive environment… people keep their cards close to their chest… they don’t want to reveal themselves; what they see as weaknesses. I found this very difficult. My colleagues didn’t understand. When asked to self-evaluate, my colleagues thought I was putting myself down. I think my ability to talk about myself is a huge strength, it lets me improve as a doctor and as a person, but my colleagues didn’t see it that way. I found this very difficult.”
“Isolation is a big thing,” says James Andrew, Aboriginal Student Initiatives Coordinator at the University of British Columbia. “For students coming from really small communities where they’ve known everyone for their whole lives, it’s really hard on them to come to university where they know no one. It’s a big shock to the system.”
Progress is slow, but real
“Medical schools are doing a lot more now to recruit Aboriginal students,” says Kitty. When she went to medical school at the University of Ottawa from 1998 to 2002, she was the only Aboriginal student for those four years. Since she finished in 2002, she says, the University of Ottawa has admitted 40 Aboriginal students to the program.
The University of Alberta was the first school in Canada to make recruiting Aboriginal medical students a priority, by setting aside seats specifically for Aboriginal applicants. Aboriginal applicants must still meet the rigorous academic requirements as all other medical students, so not all of these seats are filled every year.
Canada’s other medical schools have followed suit, with nearly all now setting aside a small number of seats for Aboriginal students, says Kitty. While the University of Calgary does not reserve seats for Aboriginal students, in 2010 it began to evaluate MCAT scores from Aboriginal applicants against historic data on Aboriginal applicants’ scores, rather than against the general applicant pool. Since then it has nearly doubled the Aboriginal students it accepts each year.
The University of British Columbia (UBC) now reserves 14 seats for Aboriginal applicants. But Andrew stresses that filling those seats (this year UBC filled only 5 seats from 23 applications) takes a lot more than “just putting up a welcoming banner.”
In order to encourage Aboriginal youth to consider applying to medical school, UBC has run an outreach program for the last 10 years aimed at undergraduate and high school students. “We do workshops about the admissions process: how to fill out your application, how to prepare for the MCAT, and mock interviews… We also connect them with some of our current Aboriginal medical students who mentor them during the program, which is a big help to them.”
The University of Alberta runs a similar program called Health Horizon Days in collaboration with Alberta’s First Nations under treaties 6, 7 and 8, where selected students go to Edmonton for two days to visit the campus and take part in hands-on workshops on medical science, medicine & dentistry. Many outreach programs like these are supported through Health Canada’s Aboriginal Health Human Resources Initiative, which was launched in 2004 to improve the recruitment and retention of Aboriginal health care workers across the country.
Medical schools have also begun to do more to provide financial support for Aboriginal medical students. Students at the Northern Ontario School of Medicine (NOSM) can access special grants and bursaries to help with the financial burden of medical school says Lisa Graves, Associate Dean of Undergraduate Medical Education at NOSM.
Aboriginal health slowly becoming part of the curriculum
In order to facilitate greater uptake of Aboriginal health in medical school curricula, the Indigenous Physicians Association of Canada (IPAC) partnered with the Association of Faculties of Medicine of Canada (AFMC) to develop a curriculum framework and implementation toolkit for core competencies in Aboriginal health for undergraduate medical education.
Schools like UBC have significantly increased the amount of the curriculum devoted to Aboriginal health. “When I started, Aboriginal health was a single hour and a half lecture,” says Andrew, “now it’s much more integrated; there’s a lot more.”
In addition to more focus on Aboriginal health in the classroom, NOSM has an Aboriginal elder on each campus, says Graves. Any student, faculty or staff can go talk to the elders to get their perspective or advice, but it’s especially helpful I think for our Aboriginal students to have them there,” she says.
NOSM has also adopted an unusual orientation. Rather than go through orientation at one of the campuses in Thunder Bay or Sudbury, NOSM tours its students through Northern Ontario, to introduce them to the kinds of communities that they are being trained to serve in.
This past year, students stayed in the Aboriginal community of Obishikokaang and heard from community members about their challenges, including experiences in residential schools and living in a community that does not have safe drinking water. “This had a profound effect on all our students,” says Graves, “and we heard from our Aboriginal students that it made them feel welcomed by the medical school.”
“We could be doing more”
While Kitty is pleased with the progress many of Canada’s medical schools have made in both recruiting and retaining Aboriginal medical students, she says “we could be doing more.”
Busing also believes more could be done to bring Aboriginal health into medical education. While he is proud of the Aboriginal curriculum framework developed by IPAC and AFMC, he notes that not all of Canada’s medical schools have embraced this framework equally. “There’s no doubt that medical faculties, to one degree or another, teach to the test,” he says. He believes that if cultural competency and safety start to appear on the licensing exams for physicians, Canadian medical schools would quickly make it a larger focus.
Mitchell agrees, but is clear that unless the social barriers for Aboriginal students are addressed, reserved seats at medical schools and curriculum changes can only do so much. “There are so many challenges Aboriginal people face today,” she says, “whether it’s isolation, substandard education, poor preparation, lack of role modeling… unless you’re willing to talk about and tackle these issues, things aren’t going to get better.”