S03 E07

Closing the Gap in Indigenous Health

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Dr. Rachel Asiniwasis

Dermatologist & Founder

Origins Dermatology Centre

In the seventh episode of our third season, Peter Brenders, CEO of the New Brunswick Health Research Foundation, talks with Dr. Rachel Asiniwasis, about her dermatological work servicing rural and remote Indigenous communities, Canada's first national Close the Gap Day and the Indigenous Skin Spectrum Summit.



From the National Pharmaceutical Congress, this is the NPC Podcast for March 17, 2021. Each week, we're all about discussing and considering the purpose, process and people of the pharma industry during the Age of Covid. Today, we are continuing the healthcare conversation by answering questions from listeners like you. 


The NPC Podcast is presented in cooperation with Impres, Impres best in class commercial solutions offer top line and bottom line growth with maximum sales force, flexibility, speed and efficiency. Learn more about their next generation commercial model at www.impres.com


On today's podcast, our guest is Dr. Rachel Asiniwasis of Regina, Saskatchewan on the topic of Indigenous health and Close the Gap Day in Canada. Your host is Peter Brenders but first, here is Mitch Shannon, CEO of Chronicle Companies.




Thanks Liona. Tomorrow, March 18 is the first Close the Gap Day in Canada. That refers to the gap between the health care provided to indigenous Canadians and the rest of the population. How big is the gap? Canada ranks 16th in the 2020 United Nations Human Development Index, Indigenous Canadians would rank 78th in the same index. Obviously, that's a gap it's going to take more than one day to close. But you've got to start somewhere. 


Dr. Rachel Asiniwasis is a dermatologist in Regina, who is an organizer of the Indigenous Skin Spectrum Summit which is going to be held in conjunction with Close the Gap Day starting tomorrow. 


Here's Dr. Asiniwasis in conversation with Peter.




Welcome to the NPC Podcast. I'm Peter Brenders, your host. In our continuing look at the purpose, process and people in pharma in Canada. This episode touches on the world of Indigenous health in Canada, and in particular, surprising challenges in dermatology. 


Joining us from Regina today we're delighted to have Dr. Rachel Asiniwasis, a dermatologist who in addition to her local practice also serves the rural and Indigenous communities throughout Saskatchewan. 


Welcome to the NPC Podcast, Dr. Asiniwasis.




Thank you very much, Peter. And I'm really happy to be here. And thank you for having me.




Terrific. We're excited to hear from you today. So but before we get into those specific healthcare challenges in Indigenous communities, I think our listeners would be interested in hearing your journey. Like how did you find yourself as a dermatologist in Regina serving communities across the province?




Sure. Well, I'm a Regina girl to begin with. I was born and raised here in Southern Saskatchewan. I finished my residency at the University of Toronto in 2014. And I moved back to Regina to work full time. And I just wanted to say that I've learned so much since then, because at that time, we didn't really have any like smooth running, well oiled dermatology clinics available to work here. So it really was truly the Wild West in a way being in an underserved area. 


And I was one of the first new full time dermatologist to join Regina in many, many years. And really what happened to me is I just got slammed with a two year waiting list well, less than a year into practice. But I'm going to spare you the long series of events and interesting experiences I've had, but I ended up opening my own clinic in 2016. And I think that that was kind of the best route for my overall needs. 


So my main clinic space is in Regina, and that's where I see the general population of Southern Saskatchewan. But in 2015, I expanded my clinics to a semi rural area in Saskatchewan called Fort Qu'Appelle, which is almost an hour away from Regina. It services both surrounding Indigenous reserves in a culturally sensitive way as well as the general population. So it's a mixture. 


You know, I'm half Indigenous on my father's side and my mom, she's an English immigrant. And given the mixed practice there, the Indigenous reserves and the general population. I just love working there. It's my most favorite clinic ever to be in. So not to mention my dad was born just across the lake from the hospital as well, it feels like home to me. So I ended up building, you know, a pretty big patient base out there. And that included more and more Indigenous patients as time went on. And I actually go there now, every two weeks. And so that's kind of where I started out. 


And then it was a year later, you know, in 2015 when I had gotten in contact with Dr. Veronica McKinney. She's an Indigenous physician from B.C. originally, she's the head of Northern Medical Services. And she's also a speaker at our Skin Summit, which I'll touch on. But we talked about starting like some fly in dermatology clinics at a northern remote area called Stony Rapids and Black Lake which is just at the border of the Northwest Territories. So what I did for those is I didn't realize how much of a long day that it would be but what I did you know was I drove up to Saskatoon from Regina, after work. I'd stay overnight, I'd catch a plane through, you know, West Winds, which is a northern service, just small planes, get up early, and the fly up community was almost three hours one way. So I knew that this was kind of getting really remote. 


What happened was, I was shocked at the level of comorbidities and chronicity, and complex skin disease that I was seeing in all ages. But I just learned that it was a lot of work, like I'd work all day, I'd barely have time to go to the bathroom, and then the plane would come, there might still be patients waiting. It's like, "oh, Rachel, you got to go, the pilots have to go". So I come back to Saskatoon tonight, drive back to Regina and I was tired. But I knew that this was an area that I really wanted to work further in just from the experience that I had after being up there a few times periodically. And the pandemic has thrown a fork in that, obviously, but we're restarting the remote clinics now. 


So as time went on, you know, I expanded to more clinics, to Pelican Narrows, which is North Eastern Saskatchewan, it's a drive up community. And then La Loche and Île-à-la-Crosse as well, which are kind of more north but not as far as Stony Rapids. And so I also ended up picking up remote communities in Southern Saskatchewan as well, I guess it just kind of the way that things happened. And there's a group called Wellness Wheel of physicians and nurses, both specialist physicians and family doctors, like we have infectious disease, general internal medicine, and they service four areas, four reserves, part of the Touchwood Agency Tribal Council in Southern Saskatchewan. And so I picked up those clinics along with them. So I became a part of that team. And it just kind of been, you know, basically snowballing from there.




Sounds like you got an incredibly busy life. So it gives us some some depth on I mean, you're seeing firsthand insight into those health challenges in these communities. Tell us about that.




For sure. First and foremost, you know, I just want to mention that the skin, you know, is a fascinating organ in the sense that it's a reflection of both internal and external health. We see a lot of that in these communities. And we know that Canadian Indigenous communities, they face unique health determinants, and that they're often complex and interlinked, related to historical and social context. But we see many challenges, some documented, and some not. The areas are quite underserviced, you know, with locums, often flying in, and sometimes it's a nurse themselves just running the station. 


I just remember once being up at Pelican Narrows and the nurse practitioner there who was supposed to be helping us with the dermatology clinic. I mean, she started running a trauma code and had to run out of the room during our clinic. And I just know that the staff they're often burnt out themselves, like you can just kind of see it in their faces. But we know that other things, you know, like and I know I'm kind of getting into a spiel here because there's so much I could say, but travel times, you know, are kind of a barrier, especially if the communities are very remote or fly in, seasonal road access that kind of thing. 


Not to mention, you know, especially the cost of basic skincare and hygiene products in those really Northern and remote communities, they can be quite inflated due to transportation and so forth. Water access issues that have come up, crowded housing and communicable disease. But putting all these things together, I think that we're starting to see some unique dermatological challenges in these communities. There are top conditions that we're starting to see in literature, media, and just practitioner experience, the little we know about that is that there are themes, and that the top condition that my belief is from all of these things put together, including my own experience, you know, is eczema, uncontrolled eczema, or atopic dermatitis. 


It's all age groups, but many of these are children. And this can come with a whole host of you know, physical and psychological and even economic impact that I think needs to be recognized. Those with eczema, their baseline increased risk for secondary skin infection, and that's based on their primary immune dysfunction and skin barrier dysfunction. So if you throw in kind of all of these other issues like crowded housing or lack of access to certain basic skin care, hygiene products or concerns about water, you know, I just see a lot of chronic infections. It's quite shocking. 


I haven't really seen it in the urban centers as much especially even training in Toronto, like I didn't really even see it there in that much better serviced region. But it's not uncommon to see children you know, having things like uncontrolled eczema mixed with impetigo or MRSA and scabies and lice sometimes all at the same time.




You're listening to the NPC Podcast, I'm Peter Brenders your host. 


So why children, why do you think children are particularly at risk here?




So I will tell you my thought on that which is my own opinion. I think that the issue boils down to eczema, because the cases that we're seeing both in my own personal experience and in the literature, you know, we know that 90% of eczema starts before age five, and many people can improve with time. But that's what we tend to see though those kinds of presentations, not only can eczema I have a hereditary component, it's an impaired skin barrier. So we often think about eczema as being a condition that we see in children. 


So I think that that's the common underlying link and the vast majority of children I've been seeing, I mean, nearly all of them have eczema. So I think that those are the children that are at risk. But there are problems in adults too, like a retrospective chart review done in 2020 of several reserves across Canada, showing that there's a very high prevalence of skin and soft tissue infections and antibiotic use, in which many of those are MRSA, so we know that there's something going on.




So what is going on? Why is there so much more eczema going on in especially in a pediatric population, and then, like what you've seen elsewhere, like, what's unique that's happening in these Indigenous communities?




We know that there's a hereditary component, often things like filaggrin deficiency or other, you know, genetic predispositions and the epidermal differentiation complex that may be passed on, you know, this is all in the literature I've been reading about. And I'll spare you details on that. 


But what I do know is, and I'm doing this in my chart review, is that we have, I've seen many, many patients, and I always ask them about their family history. And many of them have atopic dermatitis or eczema in their family. And not just that, we know that according to the First Nations Regional Health Survey from 2010, that eczema comes with other atopic conditions, right, like we call that the atopic triad. So asthma, eczema and allergies. And those are actually top chronic conditions that we're seeing in the literature as well. So I personally think that there's a genetic component. And then if you compound all the other barriers, because we know eczema is a common common condition, it affects up to 10% of adults and 20% of children, depending on the resource that you read. Right? 


So my theory is, if you're missing the lack of basic access to healthcare practitioners or moisturizers, right, or skin products, or it's too expensive, I mean, I don't know I've been to the northern strip, I'm like, why is this so expensive, like even I wouldn't buy this as a dermatologist and it just crowded housing, if you compound all of those things together, right, or people are afraid of using the water, the first line treatment for eczema is bathing, moisturizing, hypoallergenic skincare and washing, you know, and that if they cannot access that basic care, then that's when the disease gets out of control. And then the infection comes in kind of on top of that.




So it's fascinating. So you listen to this, like those whole determinants of health come into play. And so instead to your point, instead of seeing 10 to 20% of the population, you're seeing what a majority of the population suffering from these conditions, because of all those other factors.




Right. So I think that my practice is in a sense that I'm going to see all these things because I'm a dermatologist, right? So we don't have any per se epidemiologic prevalence studies saying I mean, there are some case series, but you know, that's what I'm seeing. And it's a trend. It's a trend, and it's repeating itself in the media. It's repeating itself in the literature, and it's repeating itself in healthcare practitioners. So it's time to start the conversation.




In many of the earlier episodes in our podcast series, we talked about the impact of the pandemic, and you mentioned a little bit about this at the start a little bit earlier in terms of that some clinics are slowing down, but how has the pandemic hurt, you know, health care delivery and in the various Indigenous populations?




I think that there are many challenges that the pandemic has placed both on the communities and the healthcare practitioners. Many practitioners have switched to virtual care and some remote communities, you know, they don't necessarily have the best access to internet right? Or virtual care in general. I mean, I do have some patients that literally don't have a phone and have a woodstove. Like I see, I actually see that, not common, but it's usually the older generation. 


So virtual care thing can have positives and negatives. It's sometimes hard to manage or diagnose some conditions without seeing the patient in person, right. Another thing is, let's say the community is on pandemic restrictions, and that they're only allowed to repeat their labs on certain times, right, like the lab is not as accessible. So if I'm using something like a traditional systemic immunosuppressant, such as methotrexate or cyclosporin, right for severe eczema, or severe psoriasis, we're not able to get that safety lab work done as soon as we would. 


And the other thing too, is, you know, and I know that this might be for a broad audience and not necessarily just dermatologists, but things like PASI scores, which is psoriasis area severity index or EASI scores for eczema. It's really hard to do that virtually without bringing them and doing proper skin exam. So it's creating challenges for all sorts of things like getting their meds covered, such as biologics, and also the resource burden on the staff and admin just like consenting people for virtual care, chasing them down right, the picture is blurry or you can't reach them, I think that the admin burden has increased as well. And that it you know, it can be difficult from that end.




Let's come to the Indigenous Skin Spectrum Summit that you've mentioned is coming up. I understand it's coming up fairly soon. I also don't understand that the third Thursday in March, is the annual National Close the Gap Day, a day of action in support of achieving Indigenous health equality, can you give us a little more insight in terms of the Close the Gap Day or the Indigenous Skin Spectrum Summit? What's happening?




So this is the first national summit and you know, might be the first international summit on Indigenous health with a focus on the big picture. So culturally sensitive care and optimizing treatment strategies for Indigenous patients with skin disease, with a focus on the northern and remote communities. So we deliver the conference in a holistic way, we have a combination of both Indigenous and non-Indigenous speakers who come from different areas of expertise. Many of them are my mentors. In fact, I know most of those from my past life. 


And we are holding the summit, alongside Close the Gap Day in Australia on March 18, and 20th, which is an initiative involving a pledge by health oriented groups and organizations to take action to close the gap between lower life expectancies and health determinants and Indigenous patients compared to the general population. We see a lot of commonalities with the Australian Indigenous population that we do in Canada based on similar historical and social reasons and health determinants. And I'm not an expert on that, but my dad is an historian, and he talks to me about that. So I think that we can join the fight internationally. And I think we all need to come together to close that gap. And I think that skin is a very unique way to approach that. 


We're going to talk a little bit about an overview on Indigenous history. So how did we get to where we are today that is done by Dr. Blair Stonechild, a historian who's also my father. We're going to have Dr. Carrie Bourrassa, a prominent Métis researcher, speak about culturally safe care for Indigenous peoples and addressing systemic racism. She's also been working in Saskatchewan, Ontario, as well. And she's a mentor of mine as well. And we're going to have Dr. Veronica McKinney, on listening to the Indigenous patient, talking about comorbidities and the overall impact on that. So like I said, the big picture, we have Dr. Alika Lafontaine, a Indigenous physician who was recently the the CMA President Elect. So congratulations to Alika. And he'll be speaking about environmental sustainability and considerations from an Indigenous perspective, we're going to have Tara-Rose Farrell, who is a child and youth care worker and a Master's has an MA. And she'll be speaking about strategies on working with Indigenous children and engaging them. And we have Dr. Gary Sibbald, a prominent dermatologist speaking about wound healing, and Hidradenitis Suppurativa. And we're also going to review what's new in research as well. And I'm going to be babbling about skin problems. And my and my cat,




Wow, it's always important to bring up the photos of the cat, so.




I'm a little bit obsessed with her. She's my girl. 


But I'm going to be speaking on kind of a structured approach to what we're seeing in these communities, based on what we know, from the limited literature, we have the media and healthcare practitioner experiences. I'm also going to be reviewing case based discussions on some of my own experience in northern and remote communities. Those are the main points. Yeah, I'm really excited for this summit.




You're listening to Dr. Rachel Asiniwasis on the NPC Podcast. 


I find it interesting. I love how, what you said that sort of the summit is positioned to seek to improve health care practitioners' cultural competence. So, help us understand what are the biggest gaps in this cultural competence?




I guess my general view on that would be that the general public, you know, including Canadian healthcare practitioners, they come from like diverse backgrounds, they have different levels of understanding, like I've met people who know a lot about Indigenous health. And you know, I'm really impressed on history, right. And then I've met a lot of people who also seem to not know very much, and they've literally asked if my dad has lived in a teepee. Like I've never had that question before, and didn't know that the last residential school only closed in 1996, which is barely one generation away, and my dad also attended for nine years. 


So I think that that's a hard question for me to answer where the gaps are, because I think it's there's so much diversity across Canada on that end, but what I can say is, I think there needs to be use of accredited learning modules. There are some that are very, extremely well done out of the University of Alberta and the University of Saskatchewan that I think could be put to use I do recommend it to healthcare practitioners. But I know that there are a lot of programs like nursing and medicine that do include this, but I do think that we need to add Indigenous cultural competency program to our dermatology residency programs. Just coming from that perspective, myself and my career so.




So what more can be done? If you think just even beyond dermatology.




We do propose some calls to action, you know, in our summit and the calls to action, I mean, I think first and foremost, we need to have educational sessions targeting healthcare practitioners. So not just on the cultural safety part, but on dermatology itself. And this is well acknowledged in dermatology that out of all the organ systems in healthcare education training, I've heard so many people tell me over and over again, that dermatology is generally not as well covered as other organ systems, right, like diabetes or hypertension. So I think that that needs to be addressed, right, because these cases are frequently complex, if that makes sense. 


So we need to do that and that could be done through focus groups on different health care practitioners in different areas that work in Indigenous communities. We need to educate them on the common dermatological conditions we're seeing like eczema, scabies, psoriasis, lice, right, how to treat those and manage those. And you know, that can go hand in hand with cultural sensitivity training. 


Like I said, I'm not a policymaker, I'm a dermatologist. But I really do think that we need to have some kind of national strategy, like a protocol or something that if there's, especially like a child or a family that's been identified as like an MRSA or scabies, lice household or impetigo flying around, like, we need to have some kind of trategy to treat that because these are communicable diseases, and they are treatable. And I realize that things like water and lack of access can compound into that. But at the end of the day, these are treatable conditions. 


I think that that it can become messy. I think we need to update NIHB coverage, you know, and just kind of look at those streamlines. I'll spare you on that discussion. There's a lot I could say about that, especially around biologic coverage or topicals, as well. I also call out to improve teledermatology and virtual care, because this can potentially be very helpful and effective if used correctly and reduce wait times. And there's some times in which teledermatology may not be appropriate, like pigmented lesion assessments and so forth. But in this community, the issue or the rashes, the infections, right, the eczema, the children, I think that this might be a really good way to go. And I also think that we've learned a lot from the pandemic and delivering like, it used to be a disaster on my office when the pandemic had started, it was just crazy. But now we're getting streamlined and things are kind of getting more smoother. I think this is a good way to go for these communities. 


There is some literature out of Australia, specifically on teledermatology and Indigenous communities. So I think that we can learn from them as well. But we need to improve research here as well to inform policy and decision makers that their issues, you know, the whole thing is complicated. 


So bullet points, we need to improve research in Indigenous communities on skin disease just to open up that conversation, because it's less represented than other organ systems such as diabetes. We need to also involve the communities in research. I think it's also important to know that the fee for service system is not always compatible with Indigenous health if there are complex issues, given that our overheads are often high things like rent utility and stuff, especially in dermatology. I think that that needs to be recognized.




So fantastic interview Rachel, I really appreciate your insights on this one just to give us some clarity in terms of that the health challenges are different. They're unique and the solutions that you're talking about are also different. We can't just apply what you might have learned in downtown Toronto to a rural community in Saskatchewan. 


You've been listening to Dr. Rachel Asiniwasis on the NPC podcast. Thank you for listening.


Mitch Shannon  23:38  

Thanks to Peter and Dr. Asiniwasis. 


If you'd like to show your support for closing the gap, post a message at www.closethegap.xyz or add the hashtag #CloseTheGap, that's one word, to your social media posts tomorrow. The Skin Spectrum conference website is skinspectrum.ca/isss2021. 


Speaking of social media, podcast listeners remember that you can direct message us on Twitter @2021NPC or send an email to health@chronicle.org. Don't forget our comment line at 647-873-6995. Past episodes are always available on Apple iTunes, Google Podcasts, Stitcher, pretty much anywhere you'd look for your podcasts, as well as at www.pharmcongres.info


The NPC Podcast is presented in cooperation with Impres, Canada's next generation commercial partner learn more at www.impres.com


In Toronto I'm Mitch Shannon of Chronicle Companies. This episode was produced by Jeremy Visser. Your announcer is Leona Kelly droid. The musical theme is performed in our studio by the NPC Podcast Orchestra under the direction of Maestro Zubin Millbrook. 


Have a great day St. Patrick's Day if you're celebrating. We'll talk to you again next Wednesday.