MANAWAN, Quebec — As Joyce Echaquan, a 37-year-old Indigenous mother of seven, moaned in pain at a hospital in Quebec, in the final hours of her life, the torrent of insults began.
“You’re stupid as hell,” good only at having sex, and “better off dead,” a nurse at Joliette Hospital in Quebec berated Ms. Echaquan, who only minutes earlier had begun recording a Facebook Live video, asking her husband to come get her because, she said, the hospital was overmedicating her.
By the time Ms. Echaquan, who suffered from heart problems, died — about two hours later on a Monday in late September 2020 — the video was beginning to incite indignation across Canada. It eventually reverberated around the world, becoming a potent symbol of how differently Canada’s vaunted universal health care system treats Indigenous people.
Indigenous leaders and health experts say Canada’s 1.7 million Indigenous citizens are being buffeted by a health care crisis, fueled in part by racial bias, that is shortening life spans, exacerbating chronic diseases and undermining their quality of life.
A 2019 report by a retired Quebec Superior Court justice, Jacques Viens, concluded that prejudice in the health care system in Quebec was having “dire consequences” for Indigenous people, including delayed diagnoses and doctors who in some cases refused to do medical evaluations or to prescribe necessary diagnostic exams and tests as well as “proper medication.”
According to a 2019 federal public health agency report, Indigenous people in Canada have an average life expectancy of about 70 to 75 years compared with 82 years for non-Indigenous people, while infant mortality rates are at least two times higher. They also suffer from a higher incidence of diseases such as diabetes, asthma and obesity, the report said.
“Imagine having to explain to your children that they no longer have a mother,” Carol Dubé, Ms. Echaquan’s husband, said in an interview from the Atikamekw First Nations reserve in Manawan, about 150 miles north of Montreal.
Amid a national outcry over the video, Prime Minister Justin Trudeau told the House of Commons that it captured “the worst form of racism at a time when someone was most in need of help.”
“This is another example of systemic racism, which is, quite simply, unacceptable in Canada,” he said.
Following the dissemination of Ms. Echaquan’s video, the nurse was fired. A public coroner’s inquiry in Quebec is examining the events that led to her death on Sept. 28, 2020, and the findings are expected to be released in the coming weeks.
During the inquiry, the nurse in the video apologized to Ms. Echaquan’s family and testified that she had hit a breaking point, exacerbated by the pandemic. She insisted she didn’t insult Ms. Echaquan because she was Indigenous.
Maryse Poupart, who in April became chief executive of the regional health authority responsible for Joliette Hospital, in southwest Quebec, said in an interview that what had happened to Ms. Echaquan was “unacceptable.” She would not comment on the specifics of her case but stressed recent efforts to build bridges, including hiring a member of Ms. Echaquan’s Atikamekw group as a senior deputy and beefing up cultural sensitivity training for medical staff.
But the broader changes that Indigenous people have sought have been elusive.
On the day of her death, barely breathing and likely in a coma, Ms. Echaquan was left for at least 11 minutes without being properly monitored, before going into cardiac arrest, Dr. Alain Vadeboncoeur, an emergency physician at the Montreal Heart Institute, wrote in an expert report filed to the inquiry.
Prejudices are so endemic in the health care system, said Alisha Tukkiapik, an Inuk social worker from Nunavik, a remote area in northern Quebec, that she tried to “pass for white” on trips to the doctor. Before hospital checkups, she said, she removed her beaded traditional earrings.
She recalled that when she was pregnant with her daughter, doctors would stereotype her as a drug or an alcohol abuser, asking her five times during the same visit if she had a problem with substance abuse. “When I reply ‘no,’ they then will ask me, ‘Are you sure. Not even a little bit?’”
Disguising her Indigenous identity, she said, “can be the difference between getting or not receiving treatment, between life and death.”
Canada’s Indigenous citizens often live on remote reserves with inadequate access to clean drinking water, medical treatment or emergency services.
Exacerbating the health care challenge, Indigenous leaders say, is the intergenerational trauma suffered by Indigenous people.
Dr. Samir Shaheen-Hussain, an assistant professor of medicine at McGill University in Montreal, who wrote a book on the colonial policies against Indigenous children, said agonizing experiences, including the forced sterilization of Indigenous girls and women between 1920 and the 1970s, had fomented “deep distrust” of the health care system among Indigenous communities.
Manawan, the Atikamekw First Nations reserve, where Ms. Echaquan lived, is at the end of a 50-mile unpaved dirt road on the shores of Lake Métabeskéga.
Ms. Echaquan’s image is ubiquitous on the reserve — on hats, on posters, on paintings — often accompanied by the words, “Justice for Joyce.” Mourners pay homage at her grave, which is marked by a simple wooden cross covered with necklaces and purple ribbons.
Sipi Flamand, vice chief of the Atikamekw First Nations community, said there had been several Covid-19 outbreaks since the pandemic began, with about 39 cases and two Covid-related deaths.
Mr. Flamand said the lack of access to health care in Manawan has long been a problem. The nearest public hospital — the Joliette hospital where Ms. Echaquan died — is at least two and half hours away by car. After two decades of lobbying the provincial government, the reserve got its first ambulance but not until 2018, two years after an 8-year-old girl drowned while her parents waited in vain for an ambulance to arrive.
Francine Moart, a nurse who is director of health services for the reserve, said the community had nursing services 24 hours a day and family doctors did rotations there three days a month. But she lamented that there was no full-time doctor, no gynecologist and no radiology services.
Indigenous Children Vanished in Canada
The remains of what are presumed to be Indigenous children have been discovered at the sites of defunct boarding schools in Canada. Here’s what you should know:
- Background: Around 1883, Indigenous children in many parts of Canada were forced to attend residential schools in a forced assimilation program. Most of these schools were operated by churches, and all of them banned the use of Indigenous languages and Indigenous cultural practices, often through violence. Disease, as well as sexual, physical and emotional abuse were widespread. An estimated 150,000 children passed through the schools between their opening and their closing in 1996.
- The Missing Children: A National Truth and Reconciliation Commission, set up as part of a government apology and settlement over the schools, concluded that at least 4,100 students died while attending them, many from mistreatment or neglect, others from disease or accident. In many cases, families never learned the fate of their offspring, who are now known as “the missing children.”
- The Discoveries: In May, members of the Tk’emlups te Secwepemc First Nation found 215 bodies at the Kamloops school — which was operated by the Roman Catholic Church until 1969 — after bringing in ground-penetrating radar. In June, an Indigenous group said the remains of as many as 751 people, mainly children, had been found in unmarked graves on the site of a former boarding school in Saskatchewan.
- Cultural Genocide: In a 2015 report, the commission concluded that the system was a form of “cultural genocide.” Murray Sinclair, a former judge and senator who headed the commission, recently said he now believed the number of disappeared children was “well beyond 10,000.”
- Apologies and Next Steps: The commission called for an apology from the pope for the Roman Catholic church’s role. Pope Francis stopped short of one, but the archbishop of Vancouver apologized on behalf of his archdiocese. Canada has formally apologized and offered financial and other search support, but Indigenous leaders believe the government still has a long way to go.
Budgets were also stretched to the limit, she said, with the federal and provincial governments squabbling over who was responsible for paying the bills. While the health care of Canadians is the responsibility of provinces or territories, 19th-century laws that still govern the lives of Indigenous people stipulate that their health care is a federal responsibility. As a result, she said, both governments tried to “pass the buck.”
In 2007, Jordan River Anderson, a 5-year-old Cree boy from Manitoba with a rare muscle disorder, died in a hospital after his discharge was delayed by two years because the federal and provincial governments couldn’t agree on who would finance his home care. In response, Parliament passed a 2007 law requiring that helping a child be prioritized over who paid the bill.
Mr. Dubé said Ms. Echaquan, one of seven siblings, was a devoted mother who liked to make moose meat stew for their family and adored nature and fishing. She was so enamored of animals, he said, that he avoided hunting in her presence.
There were also struggles. People who know the family said the couple were under severe financial strain. Mr. Dubé had quit his job as a firefighter to help care for the children. After Ms. Echaquan’s brother drowned in 2012, they said, she had become depressed and turned to amphetamines, but had overcome her addiction.
Ms. Echaquan had been afraid of Joliette Hospital, where she had previously faced prejudice, including being pressured to have abortions in 2013 and 2017, Mr. Dubé said. Patrick Martin-Ménard, the family’s lawyer, said that, following a pregnancy, she had been sterilized at a different hospital in 2020, without free and informed consent, further fanning her mistrust of hospitals.
Mr. Dubé said he hadn’t been able to accompany his wife to the hospital because of pandemic restrictions, and learned of her now viral video from a neighbor. As news of the video spread across the reserve, he said one of his teenage sons saw it while at school. Then, his 20-year-old daughter, Marie-Wasianna, rushed to Joliette hospital, where, he said, the receptionist refused to help her.
When she eventually found her mother after frantically searching the emergency room, she was pale and unresponsive, and under the charge of a student nurse, according to Mr. Martin-Ménard.
He said that under Quebec health regulations, a nursing student shouldn’t have been responsible for an unstable patient.
Following Ms. Echaquan’s death, Indigenous community leaders called on the province to adopt policies promoting equitable access to health care for Indigenous people, which they detailed in a document, “Joyce’s Principle.” But the government of Quebec’s premiere, François Legault, has rejected the document because it explicitly mentions “systemic racism.”
Ewan Sauves, a spokesman for Mr. Legault, said the government was committed to fighting racism and, among other measures, had invested $15 million to train health care workers to assure Indigenous people felt “culturally safe.”
He said the government did not believe systemic racism existed in the province.
Vjosa Isai contributed reporting from Toronto.