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As the University of Toronto marks Orange Shirt Day and the first National Day for Truth and Reconciliation on Sept. 30, faculty members in the department of family and community medicine (DFCM) in the Temerty Faculty of Medicine are working to address the disproportionate impact of infectious diseases on Indigenous communities and dismantle systemic barriers that can prevent them from accessing care.

Toronto is home to more than 95,000 First Nations, Métis and Inuit – the largest population of Indigenous Peoples anywhere in the province. Only one in three of these individuals has a primary care provider, while 38 per cent live with two or more chronic diseases (compared to 15 per cent of adults in Canada) and 87 per cent live below the low-income cutoff.

Facing systemic inequities and ongoing discrimination that prevent access to care, the city’s Indigenous residents have also suffered from higher rates of severe illness from COVID-19 – with hospitalization rates as much as 40 to 80 per cent higher than for Torontonians generally, and twice as high as the general Ontario population.

“COVID-19 has exposed long-standing unequal distribution of health and social resources in our communities,” says Professor Janet Smylie, Indigenous health research lead in family and community medicine who is cross-appointed to the Dalla Lana School of Public Health and a scientist at Unity Health. “We need to address these inequities in concrete, tangible ways. But to do this we need to witness and track the scale of the issues. What’s counted, counts.”

With limited resources, Smylie, who is also a scientist at Unity Health, and Suzanne Shoush,  and a physician at St. Michael’s Hospital, have been working with community organizations to build trust in the health system, support COVID-19 testing and vaccination, and collect data to inform research and policy changes.

The  opened in October 2020 to provide integrated testing and case management, contact tracing, outreach supports and referrals. The Indigenous community-led centre is a collaboration between Na-Me-Res, Seventh Generation Midwives Toronto, Well Living House at St. Michael’s Hospital and the Centre for Wise Practices in Indigenous Health at Women’s College Hospital.

Meaning “Place of Healthy Breathing” in the Anishinaabe language, the Auduzhe Mino Nesewinong team has conducted more than 1,100 COVID-19 tests and administered over 6,800 COVID-19 vaccinations at Auduzhe and partnered clinics.

“We knew at the beginning of the pandemic that there was dire need to have a for-Indigenous by-Indigenous comprehensive COVID-19 response,” says Steve Teekens, executive director of Na-Me-Res, an emergency shelter and housing organization. “Our team has been able to provide culturally safe services in a warm inviting space, while providing quality services to our community members.”

Auduzhe Mino Nesewinong runs in tandem to , an Indigenous community-owned database about First Nations, Inuit and Métis COVID-19 spread led by Smylie, who is also the director of Well Living House.

“Community is the foundation of both the clinic and our research,” says Smylie. “The clinic is a critical part of the COVID-19 response. But looking ahead, we need the research component to challenge the policies that have led us to this point and make lasting change. The two go hand-in-hand.”

Given historic and ongoing abuse and discrimination that Indigenous Peoples experience within the Canadian health system, creating safe spaces with trusted partners has been key.

“The importance of this project is profound, in particular because it is a combination of service and research that is community-led. All systems are informed by the urban Indigenous community and designed specifically for that community – and the outreach and supports are based on Indigenous kinship systems of inclusion, care and self-determination,” said Cheryllee Bourgeois, exemption Métis midwife at Seventh Generation Midwives Toronto, .

“To date, 50 per cent of Toronto’s First Nations, Métis and Inuit population has had two doses of a COVID-19 vaccine, leaving 50 per cent vulnerable to the disease,” says Smylie, who is Canada Research Chair in Indigenous Health. “Some days feel overwhelming, but other days I feel hugely optimistic – especially when I see colleagues across DFCM stepping up to staff our swabbing and vaccination clinics.”

Beyond COVID-19 and throughout the Canadian health-care system, Smylie and colleagues say there is significant work needed to eradicate anti-Indigenous discrimination, work to which we can all contribute.

“We need to recognize and fight [anti-Indigenous discrimination in hospitals] the same way we do infection,” they . “We need leaders who label it as a preventable and life-threatening organizational challenge, and who promote cross-system extermination, ongoing vigilance and prevention. We need action, including co-ordinated systems-level responses that hold individuals and institutions accountable.”