On Dec. 9, 2021, Heather Winterstein, a 24-year-old Cayuga woman, went to the emergency department in St. Catharines, Ont., with severe back pain, was sent home with Tylenol and returned by ambulance the following day. After waiting more than two hours, she collapsed and died of septic shock. At the coroner’s inquest, clinicians testified they had not known she was Indigenous. The inquest issued 68 recommendations addressing cultural safety, clinical assessment and emergency department procedures.
For decades, Indigenous families and organizations have documented the consequences of racism in health care. Statistics Canada data cited by the Canadian Medical Association (CMA) show that approximately one in five Indigenous people reported unfair treatment, racism or discrimination from a health-care professional. British Columbia’s In Plain Sight report documented widespread anti-Indigenous racism in health care. Following a visit to Canada, United Nations Special Rapporteur Ashwini K.P. warned on Oct. 9 that “the severity and distinct historical and systemic dimensions of anti-Indigenous racism set it apart from other forms of racism in Canada.”
Over the past few months, three national initiatives have sought to strengthen accountability for anti-Indigenous racism in health care.
On Sept. 18, the CMA released a revised Code of Ethics and Professionalism. It explicitly prohibits racist and discriminatory conduct toward patients and directs physicians to address racism in their workplaces, including reporting it when appropriate. The Code is available in Anishinaabemowin, Michif, Northern Michif-Cree and Inuktitut.
On Oct. 9, The Health Standards Organization released CAN/HSO 75001:2026, the first national standard for cultural safety and humility in health and social services. Building on an earlier British Columbia standard developed with the First Nations Health Authority, it sets expectations for organizational governance, clinical services and reporting incidents of Indigenous-specific racism.
On Oct. 22, the four organizations that developed CanMEDS released the 2026 revision of the physician competency framework, which informs postgraduate medical training and assessment across Canada. The revision addresses racism and discrimination and is accompanied by an Indigenous Health Framework Guide developed by the Indigenous health committees of the Royal College of Physicians and Surgeons of Canada (RCPSC) and the College of Family Physicians of Canada. (CFPC) Taken together, these documents address physician conduct, medical education and the institutions where patients receive care.
What happens next depends on implementation.
Why new standards may not be enough
The Truth and Reconciliation Commission called on medical and nursing schools to require education on Indigenous health, including anti-racism, in 2015. British Columbia introduced a new cultural safety standard in 2022. At the time, Nel Wieman of the First Nations Health Authority warned that such standards have little force until they are tied to accreditation. In 2024, the CMA apologized for the medical profession’s past and ongoing harms to Indigenous Peoples. Commitments have accumulated faster than actions.
Training programs should assess the Guide
CanMEDS 2026 expects physicians to recognize racism and discrimination and respond appropriately when they encounter it. The accompanying Indigenous Health Guide goes further, calling on physicians to challenge culturally unsafe behaviour by colleagues and seek feedback from patients about whether the care they received was culturally safe.
Yet the guide’s recommendations will have limited influence if training programs treat them as supplementary reading. The RCPSC and the CFPC should explain how Indigenous health competencies must be incorporated into residency curricula, accreditation standards and assessments. Indigenous physicians and communities must have a meaningful role in determining what competent, culturally safe practice looks like and how it is evaluated. Residents should be assessed not only on identifying racism, but on how they respond when they encounter it in clinical practice.
Governments and regulators must make the standard enforceable
The new standard is designed to support formal assessment of health care organizations, but publishing a new standard does not make compliance mandatory. Governments and accrediting bodies must decide how it will be implemented.
Within the next year, every medical regulator should publicly explain whether it will adopt the revised Code, how its existing standards address racism, and what consequences physicians may face when they violate those standards.
Provincial and territorial governments should work with accreditors to make compliance an expectation for publicly funded health-care institutions. Hospitals should publicly report incidents of Indigenous-specific racism, the actions taken in response and whether those actions resulted in changes to practice, while protecting patient and staff confidentiality. Reporting must be accompanied by measures of patient experience, since the number of complaints alone cannot establish whether care is becoming safer. Indigenous health workers already know which emergency departments their patients avoid. A public reporting requirement could make it harder for institutions to dismiss those experiences as isolated complaints.
Meaningful implementation will also require Indigenous organizations to contribute time and expertise. Of the standard’s 67 criteria, 49 depend on collaboration with First Nations, Inuit and Métis partners. Hospitals will need resources to implement the standard, but Indigenous organizations should not be expected to provide the expertise required to make it work without compensation. Governments should fund Indigenous partners directly, rather than expecting them to absorb the cost of institutional reform.
Measuring whether care improves
We do not need to begin measuring progress from scratch. The Canadian Institute for Health Information has developed indicators with Indigenous partners to assess whether patients experience culturally safe care. Over time, successful implementation should be reflected in fewer Indigenous patients reporting racism, greater trust in health-care services and a narrowing of disparities in access to care. By 2028, medical regulators, the organizations responsible for CanMEDS and provincial and territorial governments should each publish an account of what they have implemented, what they have measured and what remains unfinished.
At Heather Winterstein’s inquest, clinicians acknowledged they did not know she was Indigenous, but patients should not have to disclose their identity to receive appropriate care, nor should they have to worry that doing so will expose them to discrimination. The revised Code, CanMEDS framework and national standard offer ways to address racism in Canadian healthcare. Whether they make a difference will depend on what regulators, educators and governments do next.
Competing interests: The author was part of a group consulted on the revision of the CMA Code of Ethics and Professionalism and on CanMEDS 2026. The author had no role in developing CAN/HSO 75001:2026.
