May 17, 2022

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Stalled progress on reconciliation in health care

For award-winning Anishinaabe artist and activist Waawaate Fobister (they/them), accessing care in health systems that weren’t designed for or by Indigenous people can require an “exhausting” performance to be taken seriously.

“I hate that I have to turn it on in every single institution,” Fobister says.

Fobister comes from Asubpeeschosee-wagong First Nation, also known as Grassy Narrows. The isolated reserve about an hour north of Kenora, Ontario, has been grappling with the health fallout of one of the worst environmental disasters in Canadian history.

Like an estimated 90% of the community, Fobister lives with symptoms of mercury poisoning from exposure to pollution that a nearby paper mill dumped in the English-Wabigoon River system decades ago and never cleaned up.

Mercury poisoning can permanently damage the nervous system, brain and kidneys, and the tremors, impaired speech and muscle weakness associated with the condition can look like intoxication — symptoms that Fobister says some health workers treat with disdain.

Once, when Fobister sought care for a broken arm, hospital workers repeatedly questioned if Fobister was sober and refused to provide pain medication until an x-ray proved the break. A paramedic even tossed Fobister’s flip-flops onto the injured arm.

Alone, scared, and in terrible pain, “I had no energy to fight,” Fobister recalls. Drawing from their years of stage experience, they asked questions instead: No, I’m not an alcoholic, but why does it matter? No, I haven’t been out partying, but how does that factor into my treatment? Why can’t I be treated with respect and care?

Two steps forward, one step back

Now, seven years after the Truth and Reconciliation Commission (TRC), Fobister and others say the needle hasn’t moved much on reconciliation in health care.

Slow progress on redressing the poisonings at Grassy Narrows is just one example. A hunger strike by former Treaty 3 Grand Chief Steve Fobister in 2014 spurred a review of compensation for those affected, as well as federal commitments to build a specialized treatment centre. Yet, most claims for compensation have been denied and Ontario hasn’t completed a promised cleanup of the contamination. When Steve Fobister died in 2018, neither the federal nor provincial government recognized mercury poisoning as a factor.

Every year, Eva Jewell (she/her) and her colleagues at the Yellowhead Institute measure progress on the TRC’s 94 calls to action. In the past two years, they’ve found no progress on any of the seven calls to action related to health.

Indeed, a federal website created to track progress on the health calls to action was last updated in 2019 and mostly lists spending and programs announced in 2018. A government spokesperson was not immediately available to comment.

Since then, “we don’t see any clear messaging on the part of the government of how they are addressing the health gaps [and] poor health outcomes [resulting from] colonial legacy and things like jurisdictional disputes,” says Jewell, who is an Anishinaabekwe from Deshkan Ziibiing, or Chippewa of the Thames First Nation.

Meanwhile, Jewell says, 2021 saw the federal government “actively fighting” against a human rights tribunal order to expand Jordan’s Principle — a principle that governments should not delay or deny public services for First Nations children while they sort out who should foot the bill.

The COVID-19 pandemic has brought new disparities. After early success keeping SARS-CoV-2 out of their communities, Indigenous people have since reported some of the highest infection rates and lowest vaccination rates in Canada.

According to Jewell and her colleagues, prioritizing vaccines for Indigenous people without tailoring the rollout to their needs may have contributed to hesitancy among those wary of medical racism and experimentation.

Vaccine clinics like the one run by Saskatoon Tribal Council were an exception. There, patients were greeted with smudging as well as hand sanitizer, and most of the staff and helpers were Indigenous.

But according to the Yellowhead Institute report, “it was Indigenous peoples, communities, and organizations doing the heavy lifting to create this kind of Indigenous-centred health care delivery — not the federal or provincial governments.”

Paternalism, structural discrimination, and insufficient resources remain longstanding barriers to meaningful action on reconciliation, the report concluded.

“Many Canadians think that Indigenous people are worse off by our own doing,” Jewell says. She points to the mistreatment of Joyce Echaquan, who was mocked by Quebec hospital workers on her deathbed, as a “very poignant” example of the abuse and neglect Indigenous people encounter in health care.

Correcting the narrative

“Canada has barely scratched the surface of the TRC health calls to action,” says Renée Monchalin (she/her), an Anishinaabe and Métis assistant professor in the School of Public Health and Social Policy at the University of Victoria.

Among other recommendations, the TRC called for officials to recognize the direct link between government policies and health inequities, and to set goals for closing those gaps. They also called for sustainable funding for Indigenous healing centres, the recognition of Aboriginal healing practices, efforts to boost the numbers of Indigenous professionals, and cultural education for health professionals and trainees.

While cultural safety training is becoming a norm in health care settings and medical education, Monchalin worries that’s where reconciliation efforts begin and end.

“Many health service providers have been treating cultural safety training as just a checkbox on their to-do list,” she says. “But hanging up a painting by an Indigenous artist in your clinic is far from being enough. Health services and programs need to be Indigenous-led and Indigenous-informed if we want to see any real change.”

According to Dr. Nel Wieman of the First Nation Health Authority in British Columbia, reconciliation requires health workers to have a “clear and accurate understanding” of the ongoing harms of generations of colonial rule.

Despite thousands of adult survivors of the residential school system testifying to the TRC, two-thirds of Canadians reported little or no knowledge about the system prior to the recovery of the remains of 215 children last year from an unmarked gravesite at a former residential school in Kamloops.

“The educational system has not taught people the correct history,” Wieman says. “It was about genocide, and it was about assimilation. And we need to get people comfortable, including physicians, saying words like genocide [and] racism, knowing what they mean, and believing that is the truth.”

There were more than 130 known residential schools across Canada, and investigations into deaths at the schools are ongoing.

Dr. Kona Williams (she/her), a First Nations forensic pathologist and coroner, hopes that the recovery of remains will bring a new reckoning — including in health care. “Canada has to come to terms with the truth and that’s going to change a lot [in terms of medical education] about how we understand and better treat Indigenous people,” she says.

Williams’ father is Cree, and her mother is Mohawk. Both attended residential and day schools and had relatives who were forced to attend. Williams learned about the schools from family conversations around the kitchen table, but not in her medical training.

“When it comes to First Nations people, in particular, you can see the trauma written all over their lives,” she says. “You’re dealing with suicide, addictions, mental health issues, incarceration, homelessness, and all that trauma that’s built up over generations.”

Numerous reports since the TRC have documented how flawed, inequitable systems contribute to worse health outcomes for Indigenous people, yet denial persists. Williams cites Quebec Premier François Legault’s refusal to acknowledge systemic racism in health care, even after a coroner ruled it was a factor in Joyce Echaquan’s death.

From calls to mandates

British Columbia led the charge on cultural safety training in Canada more than a decade ago. But an investigation into anti-Indigenous racism in 2020 found “little to no change at the front line, due to a lack of a systemic, coherent approach underpinned by accountability.”

According to Wieman, who heads the Indigenous Physicians Association of Canada, the organization is working on making cultural safety training mandatory in B.C.

“We created a provincial standard on cultural safety and humility and anti-Indigenous racism,” she explains. “Once that standard is adopted, then health organizations, including academic institutions, will be held to that standard for accreditation purposes.”

Last year, the Royal College of Physicians and Surgeons of Canada announced it would require all residency programs to provide Indigenous health and cultural safety training.

Wieman says that putting some teeth in the TRC health calls to action is the next step to ensuring accountability for healing and change.

“We can ask that doctors take cultural safety training. We can ask them to be more aware. We can ask them to read the TRC calls to action,” she says. “But at a certain point, we get tired of asking nicely, and we have to make people aware that we’re now moving into accountability.”

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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