Canada has been criticized for underlying and overt racism in governing legislation and public policy (Richmond & Cook, 2016). Since the early day of colonialism, Canada's policies have not prioritized the rights of Aboriginal peoples and has contributed to health inequity (Richmond & Cook, 2016). An example is the the Indian Act of 1876, which gave the federal government of Canada authority to determine who can identify as an "Indian" (Allan & Smylie, 2015). Moreover, the Indian Act made First Nations peoples move from their homelands onto "reserve lands" (Allan & Smylie, 2015). A pass card system was used to govern the movement of "Indians" on and off reserves, thereby restricting the activities and movement of Indigenous peoples (Allan & Smylie, 2015). Mobility restrictions resulted in a dependence on government rations of European foods since traditional hunting and gathering processes were disrupted (Allan & Smylie, 2015). The previously matriarchal communities were harmed by undermining the roles of women and preventing the transmission of traditional knowledge (Allan & Smylie, 2015).
Compared to non-Indigenous Canadians, Indigenous peoples fair far worse in many health measures. For instance, Indigenous communities have significantly higher rates of infant mortality, suicide among youth and teens, and diabetes (Richmond & Cook, 2016). This burden is highly influenced by social determinants of health such as sub-standard living conditions, low income, unemployment, and low educational attainment (Richmond & Cook, 2016). Worse health outcomes in this vulnerable population highlights Canada's failure in terms of meeting the health care needs of Indigenous peoples (Richmond & Cook, 2016).
Racism in Healthcare
Historically, First Nations people were portrayed as mentally inferior, child-like, unpredictable, untrustworthy, and violent as a way to justify colonial policies (Allan & Smylie, 2015). The goal of assimilation, including residential schools, was to “civilize” Indigenous children by removing them from their “savage” families (Allan & Smylie, 2015). Their communities were viewed as inferior and their traditional knowledge or practices were not valued (Allan & Smylie, 2015). The reputation of leaders from First Nations communities have often been tarnished, with media portrayals making them seem inept or corrupt (Allan & Smylie, 2015). Harmful stereotypes impact how Indigenous people are treated and have consequences on health and wellbeing. Despite the expectation of professionalism from healthcare providers including physicians, unintentional anti-Indigenous racism is still pervasive in Canada (Leyland et al, 2016). The main manifestations of this are assumptions and stereotyping regarding a patient’s diagnosis or health behaviours (Leyland et al., 2016). Profiling of Indigenous patients based on stereotypes about addiction can harm health outcomes, and sometimes lead to death (Stewart, 2020; Allan & Smylie, 2015). For example, Brian Lloyd Sinclair died in hospital following a sequence of racist events when he tried to receive health care but was ignored (Allan & Smylie, 2015).
Reports of hospital emergency staff in British Columbia playing a “game” that involved guessing the blood-alcohol content of Indigenous patients resulted in an investigation lead by Turpel-Lafond (Stewart, 2020). The findings of this investigation, “In Plain Sight”, and examples of discrimination in healthcare against Indigenous people are highlighted in Video 1 from CBC news (Stewart, 2020). Although the allegations regarding the “game” were not substantiated, the investigation revealed how stereotypes can lead to discriminatory care (Stewart, 2020). “In Plaint Sight” surveyed 9000 participants about racism, including patients, witnesses, and healthcare workers (Stewart, 2020). According to the findings, 52% of Indigenous healthcare workers experienced racism at work and an overwhelming 84% of Indigenous patients reported discrimination in the provincial healthcare system (Stewart, 2020). Moreover, fear of racism was a big enough deterrent for many Indigenous people to avoid seeking medical attention altogether (Stewart, 2020)
Video 1. Racism against Indigenous peoples within B.C. health care (Stewart, 2020)
Systemic racism exists in the Canadian healthcare system, especially against Indigenous peoples (Boyer, 2017; Leyland et al., 2016). Health care systems are designed with a power imbalance between non-Indigenous health care providers and Indigenous patients, which Boyer (2017) compares to the colonial perspectives of superiority with racist policies in residential schools. Health inequities for First Nations communities have roots in racism and colonization (Allan & Smylie, 2015). According to Boyer (2017), research studies typically align with a colonial framework, thereby preventing health equity. Leyland et al., (2016) argue that access to power and resources disproportionately favour one social group, leaving Indigenous people with substandard health care, inadequate living conditions, and limited healthy food choices.
First Nations Perspective on Health and Wellness
Physical, mental, emotional, and spiritual aspects of health are all important from a holistic point of view (First Nations Health Authority, 2012). The First Nations' perspective values a "healthy mind, body and spirit." (First Nations Health Authority, 2021c). The First Nations Health Authority (2012) consulted with members of BC First Nations communities and researched other models before developing an illustration that visually depicts the First Nations perspective on health and wellness, shown in Figure 1. Respect, wisdom, responsibility, and relationships are the overarching values that support and uphold wellness according to the First Nations' perspective (First Nations Health Authority, 2012).
Figure 1. First Nations perspective on health and wellness (First Nations Health Authority, 2012)
The First Nations Health Authority (2021a; 2021b; 2021c) have identified four key components to health which are called wellness streams.
1) Being Active
(First Nations Health Authority, 2021a)
The benefits of staying active are felt to be physical, mental, emotional, and spiritual. For example, going on a walk is a great way to spend time with family and friends. It is also an opportunity to reconnect to the land. Exercising increases energy levels during the day and results in better sleep at night. Walking not only reduces body fat and increases muscle tone, but it also help increase bone density to prevent osteoporosis. Moreover, walking helps increase flexibility and coordination. The First Nations Health Authority encourages people to wear a pedometer to track steps, and to aim for at least 10,000 steps per day. It is also recommended that hand weights are placed near the television or phone as a way to encourage mild exercise during these activities. Also, having a pair of walking shoes at work or workout clothes in the car allow for someone to be ready to exercise more easily. Several fitness programs and physical activity resources are listed on this website.
2) Eating Healthy
(First Nations Health Authority, 2021b)
Indigenous Peoples traditionally eat seafood, wild meats, berries, roots, and plants. Salmon, eulachon, and herring are particularly important seafood to First Nations communities. Other commonly eaten seafood include crab, shrimp, and bivalves such as clams, mussels and oysters. Small mammals like beavers, squirrels, and rabbits are also traditional foods. Moose and deer are good sources of protein, niacin, iron, riboflavin, and vitamin C. Traditionally eaten birds include wild ducks, ptarmigan, and geese. It is recommended to eat vegetables with every meal and drink 6-8 glasses of water per day. It is best to avoid sugary drinks, hydrogenated and trans-fats as well as reduced saturated fats. The main tips according to the First Nations Health Authority are to eat in moderation a variety of foods with a balance between all nutrient groups, choosing foods close to nature with as little processing as possible. Healthy eating also requires mindful eating; this involves sitting for meals, focusing on eating, and chewing food.
3) Nurturing Spirit
(First Nations Health Authority, 2021c)
Connections to others, Mother Nature, and yourself are all improved by nurturing your spirit. For example, building self-esteem is a way to care for the spirit. It is important to provide a space for spirituality and activities such as drumming and dancing are encouraged. Another recommendation is to manage stress through healthy outlets including yoga and meditation. Learning a new hobby can help a person decompress and become happier. Healing the spirit is often ignored. However, according to the First Nations perspective, supporting a healthy spirit is a key component to achieving wellness.
4) Respecting Tobacco
(Alberta Health Services, 2016)
Tobacco companies add harmful chemicals to their products, which is dangerous. For example, smoking cigarettes increases the chances of developing lung cancer. On the contrary, traditional use of tobacco in Aboriginal customs is not dangerous. The tobacco leaves are dried and may be mixed with other natural ingredients, without the addition of hazardous toxins. When tobacco is burned, the smoke is waved in each of the four directions, up towards the sky, down towards the earth, and around people or objects. Tobacco leaves can be smoked in a pipe, burned on coals, or thrown in a fire. The smoke itself is not inhaled. Tobacco leaves can also be used as offerings without burning them. Giving tobacco to an elder, medicine person, or spiritual leader is a gesture of appreciation and a way to ask for protection or assistance. This gift initiates a contract with the hopes of receiving medicine, knowledge, or a ceremony in return. Wearing tobacco leaves or hanging them around the house keeps away bad spirits. Leaders in Indigenous communities want tobacco to remain sacred. Tobacco can be used respectfully in prayer for healing, giving thanks to the Creator and Mother Earth, purifying the mind, and communicating with the spirits. This video describes the spiritual benefits of traditional tobacco use.
Video 2. Traditional tobacco use (Alberta Health Services, 2016)
Cultural Safety
Indigenous cultural safety requires an environment that is not judgmental and does not assault or deny their identity. Healthcare organizations and its staff must pursue continuous education on how to be culturally sensitive (Vancouver Coastal Health, 2014). Culturally competent care is a basic desire of First Nations peoples described in Video 3 (Vancouver Coastal Health, 2014). This quality assurance measure requires changes at the individual and organizational levels (Vancouver Coastal Health, 2014). This results in modifications to attitudes and behaviours. Considering Canada’s multiculturalism, Video 3 stresses the relevance of cultural competence among caregivers and the importance of recognizing similarities and differences between cultures (Vancouver Coastal Health, 2014). There are hundreds of Aboriginal cultures within Canada; therefore, it is unrealistic to have extensive knowledge about each one (Vancouver Coastal Health, 2014). However, it is an expectation that healthcare providers attempt to learn about their local First Nations communities through experience and study (Vancouver Coastal Health, 2014). Self-reflection is one of the steps in committing to provide culturally competent care (Vancouver Coastal Health, 2014). Healthcare workers are encouraged to recognize their own thoughts and behaviours in regards to their clients (Vancouver Coastal Health, 2014). Understanding one’s cultural world view and attitudes towards cultural differences are important (Vancouver Coastal Health, 2014). These attitudes influence value systems, capacity for learning, and behavioural changes (Vancouver Coastal Health, 2014).
Video 3. Cultural competency (Vancouver Coastal Health, 2014)
Improving Access to Health Care
Healthcare spending in the Northwest Territories is more than double the Canadian average per capita, $12,791 versus $6,069 (Redvers et al., 2019). Approximately 50% of the population in the Northwest Territories are Indigenous, which includes First Nations, Inuit, and Métis (Redvers et al., 2019). Although healthcare spending is very high in this region, these residents have one of the lowest life expectancies in the country (Redvers et al., 2019). This is attributable to social, economic, geographic, and colonial factors (Redvers et al., 2019). The Truth and Reconciliation Commission's calls to action highlight the need for policy reform and culturally competent care (Redvers et al., 2019; Richmond & Cook, 2016). Improving clinical skills to respect different cultures is considered to be a lifelong learning experience (Leyland et al., 2016). Self-reflection is encouraged to identify biases and misconceptions regarding Indigenous people (Leyland et al., 2016). There are many barriers that Indigenous peoples face when trying to access culturally sensitive healthcare in Canada (Nguyen et al., 2020):
1) Proximal barriers (eg. geography, education, and negative bias among healthcare professionals)
2) Intermediate barriers (eg. employment, income inequities, and inaccessible health systems)
3) Distal barriers (eg. lack of involvement of Indigenous people in policy making, colonialism, racism, and social exclusions)
Mitigating strategies to minimize barriers must involve improving the services that are offered, providing better cultural safety training for healthcare providers, and strengthening Indigenous communities (Nguyen et al., 2020). For example, building capacity within Indigenous communities includes infrastructure development, increases in employment and academic achievement (Nguyen et al., 2020). As a part of the continuum of medical care, Indigenous patients should have access to traditional medicine and traditional practices (Redvers et al,. 2019). Interdisciplinary teamwork results in optimal operationalization (Browne et al., 2016). Organizations and healthcare providers should follow guidelines that target the key dimensions of equity-oriented health services (Browne et al., 2016). According to Browne et al. (2016) these four key dimensions needed to support Indigenous communities are:
1) Inequity-responsive care
2) Culturally safe care
3) Trauma- and violence-informed care
4) Contextually tailored care
Abolishing systemic racism requires structural changes in order to address failures. For example, new policies need to be created with a commitment to investigate complaints filed by Indigenous patients or witnesses of anti-Indigenous racism (Boyer, 2017; Stewart, 2020). The recruitment of Indigenous students into healthcare programs is also necessary (Stewart, 2020). Another way to minimize barriers is to involve Indigenous peoples in the development and implementation of policy (Redvers et al., 2019; Nguyen et al, 2020; Leyland et al., 2016). Indigenous communities and elders need to be involved in decision-making processes and the creation of policies (Nguyen et al., 2020; Leyland et al., 2016).
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