Serving vulnerable communities

One of the goals of the CFPC strategic plan is to “Meet the evolving health care needs of our communities.”¹ A specific objective of this goal is to “Advocate for equitable health outcomes for vulnerable/marginalized groups, including ... Indigenous, rural, and remote populations.”¹ Why this focus? It is because family physicians recognize that some lives are less healthy and are cut short due to social determinants of health that overwhelm treatment efforts.² Many determinants, such as poverty, lack of education, unemployment, and racism, are overrepresented in Indigenous, rural, and remote populations.

My interest in rural and Indigenous health began during medical training, when I undertook electives in small northern Ontario communities. My first job as a physician was with the University of Toronto Sioux Lookout Project. Working in a small hospital devoted to the Indigenous population, and flying in to remote communities with nurse practitioners and local Indigenous health workers, I was keen to use my new knowledge to serve people who were most in need. It became evident that my skills, medications, and advice were at best Band-Aids for important health issues such as alcohol abuse, suicide, self-harm, gasoline sniffing, and widespread infections. At that time, in the late 1970s and early 1980s, the devastating effects of residential schools, lack of clean water, exorbitant food costs, and racism were just beginning to be recognized. It was only decades later that I learned, to my horror, that one of Canada’s most prolific pedophiles was abusing boys in the very communities that I visited.^3,4

The College’s commitment to addressing the needs of vulnerable populations is founded on a strong track record. Poverty: A Clinical Tool for Primary Care Providers was developed in Ontario and launched nationally by the CFPC and the Centre for Effective Practice in 2016.⁵ That same year the Indigenous Health Working Group produced a fact sheet on systemic racism.⁶ This year’s Rural Road Map for Action⁷ provides 20 clear actions for improving the health of rural, remote, and Indigenous populations.

Family physicians are making meaningful contributions. As President, I have visited Aboriginal health centres and leaders in both urban settings and First Nations communities. In June, Dr Darlene Kitty invited me to her home community, the Cree Nation of Chisasibi, on the eastern shore of James Bay in Quebec. With her, I attended rounds, toured the hospital, visited community sites, and saw the beautiful surrounding territory. She organized a health forum for the visit that included the Deputy Chief, the Chair of the Cree Health Board, leaders of the Chisasibi Hospital, and long-serving family physicians. The meeting revealed a deep understanding of the issues affecting the health of the community and a strong sense of commitment and engagement to addressing the problems. Daisy House-Lameboy, the Deputy Chief, spoke of quarterly meetings where schooling and health were important agenda items. Physicians and nurses noted the limited resources but also emphasized the value of the traditional diet and how the sense of connectedness to the land was integral to health. They stressed the importance of preparing health professionals to work in Indigenous communities and to be responsive to communities’ needs, giving examples such as recognizing that it is not traditional to talk of feelings. Maternity services were lost from Chisasibi in 2001; several spoke of the need to return the cries of birth to their communities.

Governance has a greater effect on health than we sometimes realize. Dr Kitty and Bella Moses Petawabano, the elected Chair of the Cree Health Board, described the importance of the James Bay and Northern Quebec Agreement, approved in 1975 by the Cree and Inuit of northern Quebec.⁸ Subsequent to this treaty—the first modern one—the Cree Health Board was created in 1978 and now serves 9 communities and 20 000 people with 43 health facilities, an annual budget of $223 million, and 2500 employees. Dr Kitty recently advocated successfully for the preservation of the health benefits flowing from this treaty at hearings with the Quebec Minister of Health.

The visit vividly illustrated socially accountable care at the individual, community, and policy levels⁹—and how family physicians are working with communities and decision makers at multiple echelons to enhance health.

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