Surviving Hate is a multi-year investigation into how racism, hate, and discrimination affect Canadians — through the lens of public institutions. If you have experienced an incident involving racism or discrimination, you can also take the Surviving Hate survey.
For Jayelle Friesen-Enns, a fourth-year Indigenous student at the University of Manitoba, applying to medical school was one challenge after another.
"When I wrote the MCAT, I was working nearly full time," says Friesen-Enns, adding that, unlike their more privileged peers, they couldn't afford prep courses or new textbooks. "That's the position a lot of Indigenous people are in."
Those lucky enough to make it often face a hostile admissions process, Friesen-Enns says: “Even if you do get an interview, the traditional admissions format isn’t looking for an Indigenous person. They don’t want to hear your experiences in an honest way, that you have a negative view of medicine or care work. But, as an Indigenous person, a lot of us have seen the worst of it.”
That Indigenous students like Friesen-Enns can struggle to pursue a post-secondary health education is no surprise.
In 2015, the Truth and Reconciliation Commission published 94 Calls to Action — policy recommendations designed to “redress the legacy of residential schools and advance the process of Canadian reconciliation.”
Six of these Calls to Action (18 to 24) covered health disparities between Indigenous and non-Indigenous peoples and recommended implementing Indigenous healing practices and increasing the number of Indigenous health professionals within their communities and the system at large.
The 24th Call to Action urged Canadian medical and nursing schools to develop a course addressing Indigenous health issues, teachings and practices, and the legacy of residential schools.
Eight years after the Calls to Action were published, Surviving Hate contacted all 17 medical schools and 44 nursing programs in Canada to see what progress they’d made in their efforts toward reconciliation.
How Canadian medical schools are tackling the Calls to Action
Of the 17 medical schools contacted by Surviving Hate, 16 replied to our questions regarding the inclusion of a dedicated course on Indigenous health, coursework on traditional Indigenous medicine, and experiential learning opportunities within Indigenous communities.
Here are some key findings from the responses we received:
Six of the 16 schools have a dedicated course in Indigenous health, while nine have committed to embedding Indigenous-health content throughout their four-year curriculum. Some schools, such as the University of Alberta, require students to complete self-directed online courses, such as the Indigenous Canada Massive Open Online Course, in the summer before their first year of classes.
Eleven of out 16 schools provide students with the opportunity to complete placements in Indigenous communities, though the length of these placements varies between institutions. Only the Northern Ontario School of Medicine requires all students to complete a mandatory four-week placement in their first year, with a focus on cultural immersion.
Nine of out 16 schools mentioned Indigenous faculty leading curriculum design. At the University of Saskatchewan, for example, Dr. Veronica McKinney, the director of Northern Medical Services at the College of Medicine, is in charge of “incorporating Indigenous health content broadly across the curriculum.”
At least six out of 16 schools have recently created a leadership position for an Indigenous health expert to lead reform efforts at their school. At the University of Calgary, for example, Pamela Roach was appointed director of Indigenous Health Education in May 2021.
Spurred by the TRC Calls to Action, the Association of Faculties of Medicine of Canada — an “academic partnership” between the 17 faculties of medicine — released a “Joint Commitment to Action on Indigenous Health” in 2019. It proposed the implementation of a “longitudinal” Indigenous health curriculum that would see material about the history of colonization, residential schools, and other topics relevant to understanding the present-day condition of Indigenous health embedded throughout the MD curriculum.
Wayne Clark, executive director of the Indigenous Health Program at the University of Alberta, says this helps students build on their understanding of Indigenous health over the course of their studies.
“With longitudinal themes in medicine, we have a chance to introduce some concepts and then reintroduce them where the knowledge can be applied,” he says. “There’s only four years of medical school, so we have to work really hard to ensure they’re going to have enough knowledge to practise on the ward. With the shift in the curriculum, we are seeing resident doctors going to sweat ceremonies so they can understand what healing looks like. We never would have done that 10 years ago.”
“If we don’t take this on, then we’re not going to make improvements to the system,” says Wayne Clark, the executive director of the Indigenous Health Program at the University of Alberta. “We have to make these changes to support Indigenous communities to heal and access care in a different way than we’re currently providing.” (Danielle Orr)
The Joint Commitment also listed 10 actions beyond curricular change to advance reconciliation in Canadian medical education. These actions included developing a “critical mass of Indigenous Faculty and Staff,” creating “meaningful relationships” with the Indigenous communities served by these schools, and establishing “robust policies and processes for identifying and addressing anti-Indigenous racism.”
Read:
Analysis of anti-Indigenous racism in hospitals reveals pattern of harm, no tracking mechanism
We tracked hate at Canadian schools and found a growing problem
Confronting medical colonialism in Canada
Understanding medical colonialism is key to creating culturally safe interactions between health-care professionals and Indigenous patients, says Samir Shaheen-Hussain, a pediatric physician and professor at McGill University and author of Fighting for a Hand to Hold: Medical Colonialism Against Indigenous Children in Canada.
“Only with an understanding of colonialism can you address the social and structural determinants of health that may be impacting your [Indigenous] patients.” says Samir Shaheen-Hussain. “It also forces us, as health-care providers, to recognize our role in colonial structures, including residential schools. We played an active role in that apparatus.” (Nazila Bettache)
“We can’t just talk about medical education now without recognizing that the Canadian medical system was never intended to actually provide dignified care for Indigenous peoples,” he says. “The medical-education system explicitly excluded Indigenous peoples.”
For much of the 20th century, Indigenous patients were forced to seek medical care in segregated so-called Indian hospitals, many of which began as makeshift sanitoriums onsite at residential schools. The Indian Act, first introduced in 1876, stipulated that First Nations students who completed a university degree would be stripped of their status. For these students, graduating from medical school meant losing the only federally recognized form of Indigenous identity and relinquishing all rights and protections afforded by this status.
Nurses feed Indigenous children at Charles Camsell Indian Hospital in Edmonton. First built as a school by the Jesuits in 1914, Charles Camsell was transformed into a tuberculosis hospital for Indigenous patients after the Second World War. Patients who were forcibly removed from their communities to isolate in the hospital suffered forced sterilizations, experimental surgeries, and drug testing. (Source: RG53/Library and Archives Canada/e010933401)
The systematic disenfranchisement of Indigenous patients and medical practitioners over the late 19th and 20th centuries formed the basis for the health inequities faced by Indigenous peoples today. In Canada, the average life expectancy for an Indigenous person is still a decade less than it is for a non-Indigenous person. While most Canadian medical schools have created admissions streams tailored to recruiting Indigenous medical students, those who make it to medical school continue to face significant challenges.
Read: Juliette Tapaquon's tragic story exposes health-care inequality
The TRC Report Card Group, a student-led initiative by the University of British Columbia and the Indigenous Physicians Association of Canada, published its findings from a survey of Indigenous medical students across the country in 2021.
It found that “nearly 70% of students felt that their educators were minimally educated or not educated at all on the issues facing Indigenous peoples in Canada” and that “less than 40% of respondents felt satisfied with the amount of cultural support offered by their program.” Less than a third of students surveyed reported having faculty support or protected time to attend cultural activities, conferences, or events.
The same year this survey was released, Friesen-Enns co-founded the Indigenous Medical Students Association of Canada after their first year in medical school.
“When I started meeting Indigenous students from different schools across the country, I was saddened to discover we were all facing the same problems. There’s a huge lack of academic support. Indigenous students have people telling them repeatedly that they don’t deserve to be here,” Friesen-Enns says.
“Then you’re hit with the crazy workload, the exams that are harder than what you’re used to. You do poorly on one, and you just start spiralling a lot of the time. You feel like you’re letting down your community, because it was such a win for you to get in ... and now you’re realizing you’re not good enough.”
How nursing schools have responded to the TRC Calls to Action
According to the Canadian Association of Schools of Nursing, the accreditation body for nursing programs in Canada, there are 100 accredited nursing programs in the country.
In February 2023, the CASN amended its “National Nursing Education Framework” to include training on cultural safety and cultural humility for bachelor’s students and training on Indigenous data sovereignty for master’s students. Going forward, nursing programs will be required to implement this training in order to achieve accreditation.
Surviving Hate contacted nursing programs at 44 schools with questions about the institutional and curricular changes they have made in response to the TRC Calls to Action. Twenty-six supplied a response.
Here is what we learned:
Thirteen out of 26 nursing programs have a dedicated course in Indigenous health, while 17 have Indigenous-health content woven throughout the curriculum. At the Université de Moncton's School of Nursing, for example, Indigenous-health content is embedded within “several existing courses in the third and fourth year of the program. These additions represent approximately 36 hours or more of theoretical instruction, the equivalent of one course.”
Twenty-two out of 26 programs offer placements in Indigenous communities, though all of them are optional and of varying lengths. At Trent University, nursing students have the option of practising in three Indigenous communities locally; a small group of students also visited Totonicapán, Guatemala, in the fall of 2022 to work with K’iche midwives.
Thirteen out of 26 schools mentioned Indigenous faculty leading curriculum design. At the University of Northern British Columbia, graduate students take a mandatory six-week course totalling 36 hours designed by Tina Fraser, a Māori scholar from Aotearoa (New Zealand).
At least five out of 26 schools have recently created a position for Indigenous scholars to lead reform efforts at the school. The University of Prince Edward Island went one step further and established the Indigenous-led Faculty of Indigenous Knowledge, Education, Research, and Applied Studies in November 2022 to provide “all UPEI graduates with the value of Indigenous knowledge systems and history.”
Veronica McKinney is the chair of the Indigenous Health Committee at the University of Saskatchewan. When it comes to changes at universities, she says, “our communities are involved, and we’re looking at things through a much more Indigenous lens. It’s not just the curriculum. It’s also residency training and faculty development … I think that’s the brilliant part.” (Courtesy of the University of Saskatchewan)
“It’s actually quite astounding to me what shifts we’re already seeing in terms of what students are aware of and what questions they’re asking,” says Veronica McKinney, chair of the Indigenous Health Committee at the University of Saskatchewan.
“They’re well aware of the TRC and residential schools. We’re not spending our energy trying to convince people anymore; we’re actually thinking about how this affects access to health care.”
McKinney says schools could do more to support and retain Indigenous leadership.
“If you look at universities, there are very few Indigenous scholars, and they certainly don’t hold much in the way of positions,” she says.
“I think it is telling of the system, which is set up in a way that is very competitive. Those values don’t fit in with many Indigenous populations. I think we’re starting to look at some of these pieces, but we’re not quite there yet.”
Indigenous health in a global context
Similar efforts to reform Indigenous health programming at medical and nursing schools are underway in countries like New Zealand, Australia, and the United States, all of which have significant Indigenous populations.
In New Zealand, where a quarter of the population identifies as Māori or Pasifika, just over 6 per cent of doctors identify as the same. However, according to the Medical Council of New Zealand, Māori and Pasifika medical students made up a quarter of their cohorts between 2015 and 2019. A 2018 study of 302 medical students in New Zealand found that “medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Māori.”
In Australia, an Indigenous Health Curriculum Framework for medical schools was developed back in 2004. By 2012, a review of this framework highlighted the benefits of integrating Indigenous health content across the medical curriculum and providing experiential learning opportunities for students in “rural clinical schools.” Today, the Committee of Deans of Australian Medical Schools, which developed this framework, stresses the importance of integrating Indigenous leadership throughout the governance structure of medical schools, building relationships with Indigenous communities, and designing Indigenous-led curriculum.
In 1973, a year after its founding, the University of Minnesota launched its first premedical program for Indigenous students, in collaboration with the local Indigenous community. It became the first university in the US to make Indigenous health education mandatory for all medical students in 2014. (TEMP)
In the United States, 90 per cent of medical schools have three or fewer Indigenous students, according to the Association of American Medical Colleges. It found that, while Indigenous students are more likely to serve their communities after graduation, they are also disproportionately saddled with pre-medical debt and face numerous barriers to higher education, including a lack of institutional support and access to academic counsellors. Forty per cent of Indigenous medical students attend just six schools: the universities of Arizona, Minnesota, New Mexico, North Dakota, Oklahoma, and Washington. In 2014, the University of Minnesota became the first medical school in the U.S. to institute a mandatory Indigenous health curriculum for all medical students.
Back at home, only 1 per cent of all physicians and specialists identify as Indigenous, according to the 2016 census, compared to 4.5 per cent of the population. Canadian medical and nursing schools are working to bridge that gap.
Jayelle Friesen-Enns graduated from the University of Manitoba this year. “It’s really great to see all these programs adopting an Indigenous curriculum and cultural-safety training,” they say. “I hope that it shows we have the capacity to change.” (Nikolas Friesen-Enns)
This year, Friesen-Enns graduated from medical school.
In July, they will begin a residency in emergency medicine at the University of Calgary. Reflecting on their undergraduate experience as a medical student, Jayelle recalls their time attending clinical placements in northern communities with significant Indigenous populations.
“Patients constantly looked at me and asked, ‘Where are you from? You’re Indigenous, right?’” Jayelle says. “They got so excited and said, ‘We need more people like you. Come back when you’re a full doctor because I’d like you to be my doctor.”
About Surviving Hate
Surviving Hate is a collaborative journalism project, co-ordinated by Humber College's StoryLab and the University of Toronto's Investigative Journalism Bureau, that seeks to fill the data gap on the reporting of hate crimes in Canada. Academic partners include Algonquin College, Trent University, the University of King’s College, Toronto Metropolitan University, Carleton University, and the Centre for Human Rights Research at the University of Manitoba. Our media partners are Canada’s National Observer, the Toronto Star, TVO Today, and J-Source. Surviving Hate is supported by the Inspirit Foundation, Google News Initiative, Journalists for Human Rights, and Humber College’s Office of Research and Innovation and Faculty of Media and Creative Arts.
Research credit: Martha Troian, Danielle Orr, Janice Saji
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