Indigenous children have a greater than twofold increase in 30-day and long-term postoperative mortality compared to non-Indigenous children: study

MD student Rachel Livergant. Photo supplied.

Some people know what they want to do with their lives from childhood. Others, like graduating University of Alberta medical student Rachel Livergant, follow their passions over time, building a collection of impressive skills and experiences that perfectly position them to make a difference in the world.  

With an interest in surgery and a passion for equity, Livergant is currently completing medical school at the U of A while simultaneously working toward a graduate certificate in global surgical care at the University of British Columbia. But her academic career began with a wide variety of studies that reflected her broad interests in travel, languages and culture. 

Livergant studied life sciences, world languages and international studies at Queen’s University and spent six months in France learning about international law and discovering the disparities and inequities that exist globally, and the work that still needs to be done in this area. 

She went on to study biomedical technology at the University of Calgary’s Cumming School of Medicine, where she learned how to get meaningful biomedical innovations to the people who need them. She used this knowledge in social entrepreneurship in East Africa, working on projects such as a water filtration system, a digital IT platform for blood transfusion and blood product management, and a solar-powered oxygen concentrator. 

During her time as an MD student she was appointed head of the U of A Global Health Education and Advocacy program and created a global and population health certificate, which is currently being considered for approval. She also served as co-president for the Edmonton chapter and is currently the Western Canada regional rep for the Canadian Global Surgery Trainees’ Alliance. 

Livergant has since turned her attention toward local surgical inequities. “I had been doing some research in global surgery and global health for a while and we were mainly focusing on international populations,” she says. “Then the more I got into working clinically in Canada, the more I realized that there’s a lot of disparities and inequities and health issues at home, and particularly in Indigenous, northern and rural communities.” 

While not Indigenous herself, “Part of the reason that I do this work is I’m actually from a Jewish background,” says Livergant. With family having been in Auschwitz during the Holocaust and others escaping the Russian pogroms, she says, “It’s understanding how intergenerational trauma affects someone and wanting to use the privilege I have now to bring about change in my own system and not have it be a constant rhetoric of us versus them, and really trying to build up people who don’t have that privilege or that equity.” 

Livergant spearheaded a scoping review and meta-analysis of postoperative morbidity and mortality in pediatric Indigenous populations. She and her research team, including Indigenous lead and valued mentor Tracey Hillier looked at studies done in the Americas and Oceania, representing 88,385 patients, 5.4 per cent of whom were Indigenous. Hillier says, “The work and approach of Livergant and this team is so important in that they are taking a global lens to gather comparative data from the literature but plan to engage with communities to understand the community perspective on challenges and possible solutions.”

The results of the study were sobering. 

The review showed that Indigenous pediatric patients have a greater than twofold overall postoperative mortality than non-Indigenous populations. And they face greater hospital readmission rates, lower rates of reoperation for failed surgeries, and lower rates of graft survival following renal transplantation. “And that’s despite multiple calls to action to have more equitable health outcomes for that population,” says Livergant.

The review also revealed that current data on postoperative outcomes in pediatric Indigenous patients remain limited and of poor quality. “There's been lots of talk about having a focus in Indigenous health and Indigenous equity when it comes to research programs or health-care programs and things like that,” says Livergant. “But that’s not really shown in the current research and that hasn’t really translated.”

“We’re looking at a new generation and right now, we’re not seeing the steps being made to show a healthier future for Indigenous populations,” says Livergant, adding that pediatric outcomes are currently similar to that seen in adults. “So it’s really important to look at the health of the children and then, how that translates to longer-term health, wellness, and other social determinants of health later down the line.”

When asked what might be behind the disparity in postoperative outcomes, Livergant has several answers: “There’s greater mistrust in the health-care system and lower ability to access the health-care system, especially if you compound remote and rural factors. And then there’s systemic racism that is still present in the health system.” She adds that there may also be gaps in preventative screening and surgical followup.

Livergant has recently completed a project as part of her program in global surgical care at UBC. It focuses on patient navigation in pediatric surgery for Indigenous populations in the Western Arctic and Inuvik region and explores how to support families in a culturally sensitive, community-focused and respectful way to promote healthy outcomes.

“How do you support people through the pipeline of surgery?” Livergant asks. “It can be very confusing and difficult. These children come down for surgery for two or three months, but what are their parents supposed to do? They can have a parent with them, but then that parent is not working. They have other kids at home and it’s just not feasible. And it’s the same with dental work.”  Livergant’s project looks at creating a community health-navigator program to support and advocate for pediatric patients — someone from the community to be with them, help lead them through the process, and support them in post-operative care such as attending appointments and taking required medications.

After graduating with her MD from the U of A, Livergant will be starting a general surgical residency with UBC this July, where she hopes to work toward implementing the patient-navigation program. She is also writing a paper that focuses on current postoperative outcomes in adult Indigenous populations. Perfectly positioned for the next challenge, she adds, “and then we’ll look at how to work with communities to solve these issues.”