Canadian Public Health Policy: Addressing Systemic Anti Indigenous Racism

Abstract

?Throughout Canada, there are examples in the Canadian Healthcare system of Indigenous peoples being “Ignored to death”[1] as Gunn and Hall put it. These examples can be found in every province. Brian Sinclair in Winnipeg, Manitoba, was sent to the emergency room of Winnipeg's Health Center, one of the most well-equipped hospitals in the province, at the recommendation of his family doctor. Brian sat in the waiting room for 36 hours, unattended and uncared for, before succumbing to a very treatable bladder infection. There is also the case of Joyce Echaquan, who told those attending to her in a Quebec hospital that due to her pacemaker, she could not handle morphine. Some of her last moments were live-streamed to Facebook as she called for help, and the nurses responded with derogatory and abusive language.[2] In B.C. there were accusations of Nurses playing a "Price is Right" style guessing game with the blood alcohol levels of Indigenous patients. While a review did not find strong evidence of this game being played and organized, there was still evidence of other activities that resembled this one. [3]The harmful racial stereotype of the “drunken Indian” is still very much prevalent today in the minds of front-line staff and policymakers alike. These negative racist views and stereotypes have real effects on the attitudes of staff who are meant to make decisions on triage, decisions on who is most deserving of care next. All this to say that the accusations were indicative of the culture of racial profiling prevalent in healthcare. Indigenous peoples in Canada live with widespread healthcare inequalities due to lower social and economic status and lack of quality and accessible healthcare in their communities. Because of this, Indigenous peoples in Canada have lower health outcomes than non-Indigenous Canadians. The healthcare system in Canada is rife with structural and sometimes overt forms of racism. Structural racism exists in the Canadian public health system and other sectors, with severe repercussions for access to health care and health inequalities.

Canadian Public Health Policy

?Canada’s public health system is a complicated and intricate mosaic of legislation, policies, and even relationships. To add to the complexity is the fact that health services come under the jurisdiction of a multitude of authorities, from the federal government to provincial governments, municipal governments, and even a variety of Indigenous authorities.[4] This multi-layer governance structure allows flexibility but leaves no formal or direct methods of accountability to Indigenous peoples.[5] The Canada Health Act (CHA), a piece of Federal Legislation that was cemented in law in 1985, sets out Canada’s primary objective in terms of health care policy, which is "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers."[6] To ensure this goal is met, the CHA established a set of criteria related to health services. Should a province or territory meet the criteria, they are then eligible to receive the complete Canada Health Transfer (CHT), which is federal funding allocated to help cover healthcare costs for Canadian citizens. As outlined in the British North America Act of 1867, health services fall under provincial jurisdiction; however, Indigenous affairs fall under Federal jurisdiction, as outlined by the very same act. Federal responsibility to Indigenous peoples was further cemented by the Indian Act in 1876, which included sections around health. The First Nations and Inuit Health Branch (FNIHB) of the federal government offer services to registered Indians living “on-reserve” and Inuit’s “living in their traditional territories."[7] First Nations and Inuit have their own health transfer policy through the FNIHB, yet, for decades, the healthcare budgets of most reserve communities have been capped.[8] This framework, however, fails to meet the needs of the Metis or the Inuit and Indigenous who are not registered or living on reserve/traditional territory. The failures of this framework are very apparent in the story of Jordan Anderson. Jordan Anderson was born in Manitoba in 1999 with a rare but treatable disorder. He lived shortly and soon died in the hospital because the Federal and Provincial governments were disputing over whose jurisdiction the child falls under and, therefore, who needed to cough up the cash to pay for his treatment. This incident sparked the creation of the private member's motion (M-296), commonly referred to as Jordan's Principle, which outlines how to respond in the event of a jurisdictional disagreement. It states that the first government in contact with the case will pay for the services with the option to seek “cost-sharing” later on. This principle became a legal requirement in 2016 rather than a policy or program, which was in line with the 3rd call to action from the Truth and Reconciliation Commission of Canada (TRC).[9] Another call to action from the Truth and Reconciliation Commission of Canada was implementing the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) into Canadian law.[10] On June 21st, 2021, the United Nations Declaration on the Rights of Indigenous Peoples Act received Royal Assent and was made into law. This Act is meant to provide a path for the Government of Canada to work with Indigenous peoples on implementing the articles from the United Nations Declaration on the Rights of Indigenous Peoples into Canadian Society so that we can move forward with Reconciliation in a wholesome way.

Indigenous Rights

Canada’s Constitution and Charter of Rights and freedoms hold special sections regarding the rights of Indigenous peoples. Rights guaranteed by the Charter cannot infringe upon Aboriginal Peoples' rights, according to Section 25. In addition to section 25 of the Charter, section 35 of the Constitution Act, 1982, Part II - Aboriginal Peoples of Canada, declares that the Indigenous Peoples of Canada retain existing Aboriginal and treaty rights, which are recognized?and affirmed.[11] The Supreme Court of Canada has ruled that section 35 of the Constitution Act, 1982 protects Indigenous rights under treaties and other legislation. On the subject of rights, the Canada Health Act is vague, saying that each province's healthcare plan "must entitle" all insured individuals in the jurisdiction to healthcare?services supplied on standard conditions.[12] Since the 1960s, the Government of Canada has held the position that health services for Indigenous peoples “as a matter of policy only for humanitarian reasons and not due to any Aboriginal or Treaty rights."[13]. However, with the implementation of UNDRIP into Canadian law, that position will need to change. The United Nations Declaration on the Rights of Indigenous Peoples contains many articles outlining the rights of Indigenous peoples around the world to constitute the minimum standards for the survival, dignity and well-being of the Indigenous peoples, and one of them, in particular, is tied to health and healthcare. Article 24 of UNDRIP reads as

?“1. Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of their vital medicinal plants, animals and minerals. Indigenous individuals also have the right to access, without any discrimination, to all social and health services.

2. Indigenous individuals have an equal right to the enjoyment of the highest attainable standard of physical and mental health. States shall take the necessary steps with a view to achieving progressively the full realization of this right.”[14]

As Canada moves towards implementing the United Nations Declaration on the Rights of Indigenous Peoples into law, the cultural and inherent rights of Indigenous peoples will hopefully begin to see improvement. Stephen Wilmot, in his paper “Cultural Rights and First Nations Health Care in Canada," uses UNDRIP and Will Kymlicka’s theory of Indigenous cultural rights to form the argument that Indigenous peoples have the right to culturally appropriate healthcare, which is, in my opinion, a fundamental right that would help to alleviate the social determinants of Indigenous health. Indigenous public health must be self-determined?at its core: adapted to the needs of specific nations and grounded in local Indigenous language, culture, and ways of knowing; developed, implemented, and led by Indigenous Peoples.[15] Calls to Action 18 to 24 within the TRC all pertain to the Health of Indigenous peoples or healthcare in Canada. The 18th call to action from the TRC reads as

“We call upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies, including residential schools, and to recognize and implement the healthcare rights of Aboriginal people as identified in international law, constitutional law, and under the Treaties.”[16]

?The acknowledgment by the multiple levels of government is essential in moving forward with Reconciliation and ensuring good health for Indigenous peoples. Too many non-Indigenous Canadians view poor health, injury, disease, addiction, and even death as the fault of the casualty, with little understanding or regard for the social determinants of health and the enormous role that colonization, discrimination, oppression, and continued racism have on an Indigenous person health. For the benefits of an advanced healthcare system to reach individuals, they must have political, physical, and social access to said healthcare. For Indigenous peoples, this is unfortunately not the case.

Determinants of Health

?Access to universal health services that is reasonable and equitable allows for early diagnosis, decreases mortality and comorbidity rates, and improves physical, mental, emotional, and social outcomes.[17] Part two of article 24 in UNDRIP, which is listed above, is particularly relevant to this section. Health is experienced on many levels, from spiritual and physical, to emotional and mental. Indigenous peoples face disparities in health at all levels. As Naomi Adelson puts it in her paper “The Embodiment of Inequity: Health Disparities in Aboriginal Canada." - “Health disparities are directly and indirectly associated with or related to social, economic, cultural and political inequities; the end result of which is a disproportionate burden of ill health and social suffering on the aboriginal populations of Canada.” [18] These health disparities can also be referred to as Social Determinants of Health[19], a common term used in the field of Sociology. Decades of statistics and census data show a regular social and economic status gap between Indigenous and non-Indigenous Canadians.[20] Metis peoples feel these socioeconomic impacts to a lesser extent and even have a marginally socioeconomic status than First Nations peoples, and First Nations marginally better than Inuit. Indigenous peoples in Canada struggle with lower median incomes than non-Indigenous Canadians, but also higher rates of poverty, lower education rates, household overcrowding, poor housing conditions, and in too many cases, lack access to essential utilities such as clean running water. There is often a lack of access to quality medical care on reserves. Harlen Laboucan was a six-year-old from Fox Lake who died after waiting hours for the nursing station to open.[21] ?Indigenous Services Canada, which is part of the federal government, is meant to be primarily responsible for providing health?services to on-reserve First Nations in Canada. However, the fact is that funding and management come from a mix of the federal, provincial, and First Nations governments. This funding model is a total disorganized mess that has led to a lack of equitable access to health services for reservations and the tragic and infuriating death of Harlen Laboucan. Racism is a factor that plays into all of these things, from structural racism in the political and economic institutions to overt racism and biases affecting Indigenous people’s social well-being. These things all affect a person’s health, and the build-up of these factors is seen clearly in the lower physical, emotional, and mental health of the Indigenous peoples of Canada. Poverty, substance use, HIV, and other stigmatizing health issues all intersect with race, increasing an individual’s experiences of racism and negatively impacting their ability to seek out medical care.

Racial Discrimination

?Whether directly or indirectly, in individual interactions or as a group, Indigenous people are frequently blamed for their illnesses and medical issues. Racial discrimination towards Indigenous peoples has many direct physiological effects on our health. The stress that comes from actions we perceive as racist, the way we internalize those negative stigmas, the stress of being constantly vigilant expecting racist treatment, and most horribly, being denied access to healthcare that fits our needs.[22] These are all ways in which racism and discrimination in Canada can affect our health. I have shared the story of Brian Sinclair, Joyce Echaquan, Jordan Anderson, and even Harlen Laboucan. There are numerous other examples, such as Lillian Vanasse, an Ojibway woman in Alberta. She was not given oxygen upon arriving at a hospital for difficulty breathing under the excuse that she was likely suffering from methadone withdrawal after finishing her prescription 3 days early, the day before. Lillian was instead given "breathing exercises" and several blood tests looking for drugs and or alcohol in her system. Lillian passed away that same night, unable to breathe, and denied oxygen from hospital staff.[23] Rocky Whitford was a 37-year-old Cree man from Alexander First Nation here in Central Alberta. While on a family trip to Quesnel, B.C., Rocky Whitford’s mental health came to an all-time low. He insisted on being taken to the hospital. Rocky was assured he would be looked after at the hospital but was denied any medication to calm his emotional state. After hours of being left unattended, Rocky left the hospital and returned after his partner convinced him to do so. Upon returning for the 3rd time, Rocky went into a hospital bathroom and took his own life. Rocky took the bravest step a person can take when contemplating suicide and reached out for help, only to have his please not taken seriously by hospital staff.[24] Stote records 580 sterilizations at Indian hospitals across Canada between 1970 and 1975 in her book An Act of Genocide: Colonialism and the Sterilization of Aboriginal Women.[25] The practice of sterilizing Indigenous women without their consent is known as coerced sterilization. Sexual Sterilization Acts were passed in Alberta (1928 to 1972) and British Columbia (1933 to 1973) based on eugenics principles and practices; these Acts were not repealed until the 1970s.[26]

?Indigenous peoples are treated far too often by the healthcare system as if they don’t belong. Despite a large amount of evidence that clearly proves that Indigenous peoples are inadequately served, healthcare staff and the doctors, nurses, receptionists, and even social workers will often deny whether racial discrimination plays a role in the social determinants of Indigenous peoples’ health. [27]

Indigenous Health and Covid-19

?“For many years, Indigenous communities have experienced social and economic inequalities due to colonialism and face health inequities such as a high burden of cardiovascular disease, food insecurity, lack of clean water, etc. These circumstances leave many communities disproportionately unprepared for the COVID-19 pandemic.” (Public Health Agency of Canada, What we heard, 2021 Report, p.2) Because of issues about the availability of clean water, First Nations communities cannot completely follow public health practices such as regular hand washing, nor can they physically distance or isolate themselves because many homes are overcrowded. The disadvantages that Indigenous?peoples?confront on a daily basis are exacerbated?due to the pandemic,?potentially increasing the number of cases and fatalities.?However, despite these inequalities, many Indigenous communities demonstrated self-determination during COVID-19 by enforcing regulations on who can access their communities, frequently using significantly harsher restrictions?than those adopted by local governments, such as closures and checkpoints.[28] Because of this use of self-determination, on-reserve First Nations have a COVID-19 case rate that is four times lower than the general Canadian population, with three times fewer deaths and a thirty percent greater recovery rate.[29] Indigenous ways of knowing and health are some critical factors in the lower rates of Indigenous Covid-19 cases. This leads back to the argument for access to culturally appropriate healthcare and self-determination in Indigenous public health.

Conclusion and Solutions

??Indigenous health in Canada is a complex, multifaceted network of issues involving policy, laws, rights, regulations, socioeconomic conditions, and attitudes. Addressing these issues is no simple feat and would require a tremendous amount of effort on behalf of all levels of government with a strong emphasis on taking direction from Indigenous peoples. As I stated in the section on Indigenous rights, Indigenous public health must be self-determined at its core: adapted to the needs of specific nations and grounded in local Indigenous language, culture, and ways of knowing; developed, implemented, and led by Indigenous Peoples.[30] This effort demands the creation of anti-racism programs and strategies, along with anti-racism education for all healthcare?workers and students. Call to action number 24 from the TRC, which calls upon nursing and medical schools to require students to learn about Indigenous peoples and their history, and all the factors that are involved in the social determinants of health will be instrumental in reducing racist attitudes in future healthcare professionals. However, that does not help with the racism that Indigenous peoples experience right now; therefore, I would suggest that all currently working healthcare professionals be required to take a similar course to keep their license up to date. I will also borrow from Gunn and Hall, stating that Indigenous knowledge and worldviews must be included in any efforts to enhance Indigenous peoples' health outcomes, such as measurements that target all levels of well-being, including spiritual, emotional, physical, and social well-being.[31] To further address some of the health disparities among Indigenous peoples, improved access to Indigenous health systems, including traditional medicines, is required, in addition to access to the Canadian health care system. This, again, falls in line with another call to action from the TRC. Call to action number 22 calls upon anyone in healthcare who can help affect change to recognize the value of traditional Indigenous medicines and allow Indigenous patients to receive such medicines in collaboration with Elders and Healers.

?The government of Canada says that they acknowledge the effects that colonialism and residential schools have had on Indigenous health, and have even stated that they are committed to investing to provide high-quality healthcare for Indigenous peoples. The Fall Economic Statement for 2020 included a two-year investment of $15.6 million to support the co-development of distinctions-based health legislation. The Budget 2021 allocates $1.4 billion over five years, as well as $40.6 million annually, to continue basic health care services for Indigenous peoples and to continue efforts to improve Indigenous health systems. The Government of Canada, specifically Indigenous services Canada, has been hosting round tables with various Indigenous health groups and Indigenous healthcare professionals to discuss the next steps on addressing Anti-Indigenous racism in healthcare. The Minister of Indigenous affairs acknowledged some of the recommendations coming out of these round tables and announced investments from the 2021 budget to go towards addressing the recommendations. [32]The Government of Canada is, only in recent years, begun putting in the work to address the TRC calls to action and make improvements for Indigenous health. In the coming years, I believe we will see many policy shifts within Canada’s Public Health Policy to address the determinants of health and history with Indigenous peoples.

?Ultimately, improving Indigenous peoples' health will also need to resolve other social determinants of health beyond Canadian public health policy that adds to the lower health outcomes among Indigenous peoples. To achieve this, I believe that the TRC and UNDRIP are great places to start. The Government of Canada has begun the work to address the calls to action, years after they were published and so it will likely be some time before we see any fruit bear from these efforts, but I believe we are on the way. It would be my recommendation that everyone in Canada, no matter who you are, read the calls to action and help us move forward in addressing them so that we can genuinely achieve Reconciliation.

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[1] Gunn and Hall, "Ignored to Death."

[2] Kirkup and Ha, " Indigenous Woman Records Slurs."

[3] “In Plain Sight.”

[4] Lavoie, " Aboriginal Health Legislation and Policy Framework."

[5] Wilmot, "Cultural Rights.” 291

[6] “Canada Health Act.”

[7] Health Canada, “Closing the Gaps.”

[8] Lavoie, “Evaluation of the First Nations and Inuit Health Transfer.”

[9] " TRC Calls to Action."

[10] “UNDRIP Act.”

[11] “The Constitution Act of 1982”

[12] Wilmot, "Cultural Rights.”

[13] Lavoie, " Responding to health inequities," 8.

[14] U.N. General Assembly, "UNDRIP."

[15] Richardson and Crawford, " COVID-19 and the decolonization of Indigenous public health."

[16] " TRC Calls to Action."

[17] National Collaborating Centre for Indigenous Health, " Access to Health Services as a Social Determinant."

[18] Adelson, " The Embodiment of Inequity," 545.

[19] Symbaluk and Bereska, Sociology in Action, 251.

[20] Reading and Wien, " Health Inequalities and Social Determinants."

[21] Robb, " Death of Harlen Laboucan."

[22] Gunn and Hall, " Ignored to Death," 1.

[23] Pimental, " Investigation underway into how Ojibway woman died."

[24] Silva, " He Just Felt Hopeless."

[25] Stote, “An Act of Genocide

[26] Marshal and Robertson, " Eugenics in Canada."

[27] Gunn and Hall, " Ignored to Death."

[28] Zavaleta, " COVID-19: review Indigenous peoples," 185.

[29] Indigenous Services Canada, " Update on COVID-19 in Indigenous Communities."

[30] Richardson and Crawford, " COVID-19 and the decolonization of Indigenous public health."

[31] Gunn and Hall, "Ignored to Death."

[32] "Delivering on Truth and Reconciliation Commission Calls to Action."