On first glance, there’s not much in common between 10-ply tires for a diesel-engine, 4 ×4 Super Duty Ford F-350 and a recently released national report entitled “First Peoples, Second Class Treatment.”1
Ask Dr John Pawlovich about the two, however, and you will receive an eloquent answer about transforming the way medicine is delivered to isolated northern First Nations communities, communities with some of the worst health conditions in our country. “I often feel horrified that there are people in this country living in the conditions we still see on reserves. It is shameful that in such a rich country, such disparities persist. Spend a week on a reserve. It will change the way you think.”
According to Pawlovich, if there’s any hope for changing a medical system that evidence increasingly documents is neither meeting the needs of indigenous peoples nor substantially lessening the health disparities between indigenous and non-indigenous peoples, physicians have to radically rethink how and where medicine is delivered.
And that likely involves big trucks with tires ready to navigate the roughest of gravel logging roads.
It also involves reimagining our understandings about indigenous peoples and communities, foregrounding the resiliencies and strengths of peoples who are, in Pawlovich’s words, “the fabric of this country. Canada is founded on a relationship with aboriginal peoples. We have so much to learn.”
“We have to deliver health care in the places where it’s needed most,” observes Pawlovich, “because people need to have their family physician where they live.” For Pawlovich, who’s been in practice for more than 2 decades, if health care in Canada is ever going to genuinely affect the health inequalities lived by the country’s First Peoples, a wholesale change must occur in the way indigenous peoples are seen and understood. “Traditional boundaries between people are not the same on reserves, with aboriginal peoples, so health care has to look different there too.”
Pawlovich reflects carefully on the more critical evaluations about how indigenous peoples are treated in Canada’s health care system, agreeing “we do still see those condescending questions being asked to aboriginal patients, we do witness the eye rolling, the impatience—and so our medical students mirror that.” Change, according to Pawlovich, is about building relationships with indigenous peoples and communities, from coast to coast to coast: “We have to see aboriginal peoples in a different light; we have to spend time with them, in their own homes, in their communities, where they are presenting with their symptoms. By participating in the lives of our patients, by focusing on longitudinal relationships, we understand and are understood in a different light, and we can practise differently.”
Participating differently in the lives of isolated First Nations in northern British Columbia means practising medicine differently too. Pawlovich spends 1 week a month in the communities he serves. The rest of his practice is done by telehealth, a way of working that, as Pawlovich explains it, is about “texting, phoning, video-conferencing, allowing patients to talk with a physician they trust, no matter where they are. The mainstream still wants to ‘do’ medicine within the boundaries of what’s always been traditional. Our work is about changing the actual delivery of health care. Telehealth has to be part of that spectrum of care.”
Sceptics about Pawlovich’s work certainly exist: those who worry patients might be missed or, even worse, mistreated, resulting in others having to “pick up the slack” that could result from a family physician who delivers much of his care virtually. Anything is possible, admits Pawlovich, but right now “we are meeting people where they are, and that equals social accountability, which means services for them. If an elder is sick, people in the community know who they can reach out to, and it’s someone they know and trust.”
There was no defining moment when Dr John—which is what folks call him in the 5 tiny isolated reserves scattered across the 200 000 km2 of north-central British Columbia where Pawlovich practises—decided to practise family medicine differently, decided to fully dedicate his practice to marginalized First Nations communities, working with everything from teams of nurse practitioners to Skype, from specialists who ride in his 4 × 4 trucks to medical students who fly in helicopters through fog and snow to see the communities where he likes to play basketball.
“Somewhere along the way, a seed got planted. As I matured, I realized medicine really is about making a difference. I used to care more about the ‘sexy stuff,’ about lots of procedures. Now I feel my compass turning towards things like [social determinants of health], relationships with patients, improving the access point of care, towards making small differences in the big lives of peoples in the isolated places of our country.”
BACKGROUND PHOTO
Old Fort in summer.PHOTOS (TOP, LEFT TO RIGHT)
Dr Pawlovich with a Takla Lake lake trout.
Takla youth with young doctors in training: (left to right) Kenlynn West (front), Noah Abraham, Elissa Abraham, Nathan Teegee, Tamica West, and Dr Peter Eppinga.
Dr Pawlovich with Jason Balczer Jr and Gentry Balczer on BC Rivers Day 2015 in Fort Babine.
PHOTOS (BOTTOM, LEFT TO RIGHT)
Young “MD” Trista Joseph from the Yekooche First Nation.
Dr Erin Knight, Cynthia Munger, and Dr Pawlovich in the Stellaquo community garden.
Dr Pawlovich at a Takla elder’s cabin in Hogum, BC.
Dr Pawlovich with Julie Jacques and fresh bannock.
PHOTOS (TOP TO BOTTOM)
Dr Pawlovich and Dr Bria Sharkey with Tachet drummers and dancers: Vaughan Michell, Summer Michell, Christian Issack, Jordan Johnson, Anthony George, Harley George, and Caroline Michell.
Gloria Michell in the Tachet smokehouse, and Victor Tom using the telehealth equipment.
Babine Lake Road.
PHOTOS (RIGHT)
Takla Landing in winter.
The Yekooche Health Centre.
PHOTOGRAPHER
Cover photo by Dr Bria Sharkey.
Other photos submitted by Dr Pawlovich with the generous assistance of many students and residents. Dr Pawlovich wishes to thank everyone in these pictures for generously adding to the richness of the story.
Footnotes
The Cover Project The Faces of Family Medicine project has evolved from individual faces of family medicine in Canada to portraits of communities across the country grappling with some of the inequities and challenges pervading society. It is our hope that over time this collection of covers and stories will help us to enhance our relationships with our patients in our own communities.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de janvier 2016 à la page e44.
Dr Pawlovich works in British Columbia’s Northern Health Authority, supported by Carrier Sekani Family Services, an organization guided by elders and committed to healing and empowerment of aboriginal families residing in Carrier and Sekani territory.
- Copyright© the College of Family Physicians of Canada
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