The following is a , by Amy Shawanda, Ph.D., who will be joining us at the Department of Family Medicine in August as a tenure track Assistant Professor and Indigenous Scholar.
Abstract
In Canada, there is evidence that Indigenous Peoples have experienced systemic and medical racism directly or indirectly. This commentary discusses the prejudice and racism evident in healthcare throughout history. The narrative then shifts to address medical professionals who do not provide quality treatment, and a guideline is provided for Indigenous patients and clients to enable them to file complaints with licensing boards. The intention is for healthcare professionals to incorporate cultural competency, cultural safety and cultural humility into their practices and, if possible, create a structure that will allow Indigenous patients to voice their concerns.
Introduction
The medical racism that Indigenous Peoples experience is well documented in plenty of research articles, studies and news reports. Moreover, persistent health disparities and systemic racism still exist within healthcare. Indigenous patients often share their stories with their families and friends about the mistreatment and neglect that they have encountered. These stories are cautionary tales, causing other Indigenous Peoples to be less likely to seek healthcare for illnesses from healthcare workers. Also, when they seek treatment, they are often subjected to discrimination and stereotypes that either place them under surveillance or lead to them being ignored. Because of this, a significant number of Indigenous patients with treatable and preventable conditions have received no treatment or below average healthcare or have died at the hands of medical professionals. If Indigenous patients had not been dehumanized, their conditions would have prevented their deaths. This is the crux of the problem: Indigenous Peoples have a hard time coming forward about the harm they have experienced or a family member’s wrongful death within the healthcare system. It is one of the many challenges that Indigenous Peoples often face when interacting with healthcare professionals. This resolution should not only transform our experiences with healthcare but also bring about systemic changes that result in better policies, education and training for healthcare providers. As Indigenous Peoples, we need to start holding healthcare practitioners accountable so that we can have better access to healthcare.
Addressing the Challenges
The arrival of settlers coincided with the introduction of new diseases and illnesses. First Nations and Inuit Peoples lacked immunity to these new pathogens, which increased their mortality risk. Furthermore, with the western expansion came famine because of the intentional depletion of food sources. The First Nations have encountered difficulties in providing primary care for settler diseases and conditions. The first written call to address health issues came from Treaty No. 6 (1876), which included the “Medicine Chest†that has two clauses. The first clause is as follows:
That in the event hereafter of the Indians comprised within this treaty being overtaken by any pestilence, or by a general famine, the Queen, on being satisfied and certified thereof by Her Indian Agent or Agents, will grant to the Indians assistance of such character and to such extent as Her Chief Superintendent of Indian Affairs shall deem necessary and sufficient to relieve the Indians from the calamity that shall have befallen them. (Duhame 1964: para. 23)
In general, the terms “pestilence†and “general famine†are not often spoken of in relation to Indigenous Peoples, unless the greater Canadian population is at risk. The second clause has been written about in many reports and other Indigenous health literature. It is as follows:
That a medicine chest shall be kept at the house of each Indian Agent for the use and benefit of the Indians at the discretion of such Agent. (Duhame 1964: para. 25)
Both of these clauses apply to all First Nations Peoples as they are the treaty signatories. It is important to note that when this treaty was signed, it gave control and discretion to Indian agents who could administer medicines in times of pestilence or general outbreaks such as smallpox, scarlet fever and tuberculosis. To many, this is regarded as one of the earliest forms of healthcare discrimination. Since then, it is well documented that Indigenous Peoples have been mistreated, discriminated and stereotyped in healthcare settings. This was identified in several publications, including the Bryce (1922) report, the report by the Royal Commission on Aboriginal Peoples (1996) and, most recently, those by the Truth and Reconciliation Commission of Canada (2015) and the National Inquiry into Missing and Murdered Indigenous Women and Girls (2019). Each of these reports identified the following: the need for improving healthcare policies and practices for Indigenous Peoples, such as attracting and training more Indigenous Peoples to enter the health field; to allow for more Indigenous traditional healing to be integrated into western healthcare practices; and to protect Indigenous healthcare rights. Each of these reports provided recommendations or made calls to action, which are still perpetuating the same discrimination against and marginalization of Indigenous Peoples within healthcare.
Defining Medical Racism
Paradies (2018) explained that racism can be thought of as discrepancies in authority, as well as imbalances that are both unequal and preventable in resources, capacities or opportunities, which are “centered on ethnic, racial, religious or cultural differences… [that] can manifest through cognitive beliefs (e.g., stereotypes), feelings (e.g., prejudice) or practices and behaviors that are discriminatory†(p. 2). There are preconceived biases about who Indigenous Peoples are, and they are often boxed into stereotypes of being alcoholics, addicts, dirty, homeless, promiscuous, uneducated and a burden to the medical system. These stereotypes, prejudices and unconscious biases all factor into medical racism. Medical racism is frequently used in the context of anti-Black racism. Similar forms of racism that are rooted in the medical and healthcare system may also be directed toward Indigenous Peoples. The national cases of Brian Sinclair, Joyce Echaquan and many others that have not been made public knowledge are examples of medical racism. The Encyclopedia.com (2020) defines medical racism as “prejudice and discrimination in medicine and the medical/healthcare system based upon perceived raceâ€.
[U]nderstanding racial disparities in medical care requires an appreciation of the ways in which racism has operated and continues to operate in society. The term “racism†refers to an organized system, rooted in an ideology of inferiority that categorizes, ranks and differentially allocates societal resources to human population groups. (Williams and Rucker 2000: 76)
Medical racism is the systemic wide-spread racism against people of colour within the medical system. It includes … the racism in our society that makes Black People [and Indigenous Peoples] less healthy, the disparity in health coverage by race, and the biases held by healthcare workers against people of colour in their care. (Bronson 2020)
Indigenous Peoples have shared many medical horror stories about inequality, unsafe, mistreatment, blatant racism and/or stereotypes from medical practitioners. Examples include forced sterilization of Indigenous women (Dossey 2015; Native Women's Association of Canada 2023); misdiagnosis of ailments (Phillips-Beck et al. 2020); not conducting proper assessments (Mahabir et al. 2021); birth alerts of Indigenous babies (Malone 2022); healthcare providers belittling the patients' concerns (Mahabir et al. 2021); and unequal healthcare access for fly-in communities to urban Indigenous populations (Allan 2013; Reading and Wien 2009). I would like to align the above-mentioned definitions about medical racism and avoid using systemic racism because systemic racism is not only within healthcare but also in educational, government and other institutions.
So what can the healthcare system do about medical racism?
The Canadian healthcare system has not done much to date in terms of addressing the racist and discriminatory actions, which does not align itself with culturally safe care. Indigenous Peoples will share their experiences with their family members and friends, soon alerting the community of certain healthcare providers. Once this happens, Indigenous Peoples will try to avoid going to that healthcare facility despite their ill health or visit the facility with mental stress. Indigenous Peoples have not lodged complaints against healthcare professionals with healthcare administrators so the system is unable to address racism or those who perpetuate it. In rare instances where a complaint was lodged internally, it was not properly addressed or was dismissed. Consequently, it is crucial for Indigenous patients to submit complaints with licensing bodies. These licensing bodies enable individuals with professional degrees to register with their respective college, board, bar or association, which grants these individuals with a license to practise in their respective profession.
In Ontario, Indigenous patients can file complaints about the mistreatments or the inadequate care to the College of Physicians and Surgeons of Ontario, College of Nurses of Ontario, College of Psychologists of Ontario and the Ontario College of Social Workers, among others. When it comes to administrators and other staff, Indigenous Peoples can file independent complaints to the healthcare facilities. If none of these complaints are resolved, it can be taken to the patient's ombudsman. For many Indigenous Peoples, these complaints can prevent harm or even deaths of family members. These healthcare professionals when left unreported tend to cause further harm to Indigenous Peoples, preventing them from obtaining care and creating distrust within the Indigenous communities (Bains 2022). This is a healthcare challenge.
How does healthcare continue to improve?
To improve health and wellness for Indigenous Peoples, there should not be any barriers to high-quality healthcare. While Indigenous Peoples wait for an improvement in the quality of care they receive, there need to be more Indigenous liaisons within hospitals and clinics. Indigenous patients should have someone to advocate on their behalf and to attend medical appointments with them. This information should be made public knowledge. These navigators should guide Indigenous patients to appointments and, when warranted, assist with the complaint process because it is emotionally taxing on Indigenous Peoples. Also, there can be language and culture barriers, mental health issues such as anxiety, ongoing addictions, trust issues with the healthcare system and the living memories and stories about the mistreatment that prevent Indigenous Peoples from filing complaints.
A healthcare challenge is to change the narrative around Indigenous health. This includes the recruitment of Indigenous students into all healthcare programs. Also, this requires reducing the barriers to entry into professional healthcare programs. In healthcare education, there must also be an Indigenous faculty-led component emphasizing the cultural needs of Indigenous students and educating non-Indigenous students about the same. Existing non-Indigenous practitioners may require additional training and education in how they care for Indigenous Peoples. Indigenous patients can benefit from both western and traditional models of care in order to shift their focus to their health and well-being and not have their fight-or-flight responses triggered. This has been done successfully by several Indigenous primary healthcare organizations. Other healthcare centres can reach out to these organizations to learn more about incorporating traditional practices and knowledge into all levels of their institutions.
Resolution
How to document your incident
If possible, always bring a witness with you to an appointment. Try to be on the lookout for teenagers and our Elderly as they can be the most vulnerable in these situations and we should be providing them with someone whom they can trust to accompany them to any medical services. Alternatively, if this is not an available option, we need to teach our vulnerable population about how to document incidents when they begin to feel unsafe, mistreated or frightened. Similarly, we need to teach them how to use their phones (if they do not know how) to capture any incident. If you do not have a phone, carry a pen and paper. If you have a phone, begin recording the scene to capture an immediate unjust action, make notes and/or send an e-mail. This is an excellent way to document the incident, as well as collect the evidence needed to establish the chain of events of mistreatment. My recommendation is this: consult with your trusted colleagues, friends and family. If they agree there is a wrongdoing that occurred, then report it. The caution I spread here is about malicious intent because misconduct and not liking someone are two different things. Although, when trying to decipher the difference, a personal issue and a racial discrimination-driven experience can be a hard line to journey.
How to report it?
When an Indigenous patient enters a medical setting, they are strongly encouraged to have their questions regarding health and well-being written down beforehand and to bring a trusted source as a witness – if possible. This way they can ensure that they are getting the proper care they need. In the event that an incident transpires, the Indigenous patient will need to report it. The documentation for the same should include the following:
- Date and time: Note if it was an emergency visit or an appointment.
- Name of the healthcare facility, address and phone number.
- Name of the specialist, doctor and/or nurse.
- Write down your experience like you were telling your story to a trusted source:
- What happened? Who was there and when and where did it happen?
- Were there any witnesses (try to get their names if possible)?
- Try to provide as many details as possible.
Try your best to make notes during or soon after the incident occurs. This way you do not have to put yourself through the emotional anguish of recalling the upsetting experience later.
Conclusion
This article is not out to criticize medical practitioners. This is an opportunity for our healthcare teams to deliver culturally competent care that is accessible to all Indigenous Peoples, regardless of where they receive medical treatment. As an Anishinaabe Kwe who is visibly Indigenous, I know how exhausting it can be to face racism but also the emotional harm it brings to relive the appalling experiences to write a complaint. However, I believe we have a collective voice while holding healthcare professionals accountable for their actions and behaviours. By doing so, we contribute to the evolution of policies, training modules and safety practices for our Indigenous vulnerable populations and for our Nations. When we work together to file our concerns and complaints, we can build a movement by declaring that we will no longer tolerate racism and abuse. Above all, we refuse to allow another person to die in a waiting room or on a hospital bed because the nurse/doctor did not take our illnesses seriously. We want to be treated with dignity and respect. I hope this paper gives you the courage you need to fight for a better healthcare system that cares for our future generations. I hope this paper serves healthcare practitioners to aim for culturally safe care.
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About the Author(s)
Amy Shawanda, PhD, Provost Post-Doctoral Fellow, Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
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