It is no secret that colonial structures put in place through the Indian Act have shaped modern treatment of Indigenous health, including the perpetuation of social inequity, greater (negative) impact of health determinants, and limited access to and provision of culturally appropriate services (Earle, 2011; Richmond & Cook, 2016; Taylor et al., 2020; Truth and Reconciliation Commission of Canada [TRC], 2015). Despite recognition of injustice and its impact on past and present treatment of this population, health services provided to Indigenous persons continue to demonstrate notions of Western superiority, influences of structural discrimination and a lack of respect for human and inherent rights (Beavis et al., 2015; Demystifying Medicine, 2018; Richmond & Cook, 2016; TRC, 2015).
Such oppression is further entrenched through use of deficit-based research, which highlights the poorer health outcomes of Indigenous communities relative to other, less-marginalized groups, and (unintentionally) confirms stereotypes and perpetuates stigmatization (Hyett et al., 2019). This form of research is especially detrimental as it risks further deterring Indigenous persons from accessing care and contributes to the provision of poorer care overall, due to the conscious or unconscious biases of health providers (Hyett et al., 2019).
Western approaches to health, while useful in addressing the physical side of illness, do not account for the emotional, intellectual, and spiritual elements of holistic well-being, important in Indigenous views of wellness (Earle, 2011; Taylor et al., 2020). Further, Western approaches fail to account for the importance of intergenerational knowledge transmission, and its use in healing, nor the importance of the institutions of family and community (Earle, 2011). Critical examinations of white privilege and colonial impact are lacking in health care institutions and care provision; evident in the continued “othering” of Indigenous and other marginalized populations by health providers (Beavis et al., 2015).
In many previous forums, peers have identified the well-studied, health disparities and disproportionate impact of the social determinants of health on Indigenous populations. Unfortunately, it is evident that awareness of this in research, has not translated into meaningful action at a community, organizational, or policy level (Taylor et al., 2020). Instead, adherence to existing policy, loosely enforced organizational standards of cultural competence, and relative government neglect of Indigenous communities continues to promote institutional racism and poor treatment across sectors (Clifford et al., 2015; Demystifying Medicine, 2018; Richmond & Cook. 2016; Taylor et al., 2020). If Indigenous health is to improve, action must be urgently undertaken to develop cultural competence, re-educate the public and spur organizational change; fostering a better understanding of the impact and enormity of transgenerational trauma, the need for competent and equitable treatment of Indigenous persons and communities in health and other sectors, and the creation of healthy organizational and public policy that seeks to recognize the experiences of the Indigenous population, and dismantle oppressive structures and barriers to care (Beavis et al., 2015; Demystifying Medicine, 2018; Richmond & Cook. 2016; Van Sickle, 2019).
In its Calls to Action the Truth and Reconciliation Commission of Canada (2015) clearly identifies priorities for all levels of government and Canadian institutions in addressing current Indigenous (health) challenges and reconciling past injustices that perpetuate current treatment (TRC, 2015). Unfortunately, progress on these initiatives remains slow, while risks to Indigenous health continue to climb; especially in the wake of the global pandemic, and unfathomable discovery of thousands of unmarked graves of Indigenous children on the sites of now defunct residential schools. There exists much to be done to move from rhetoric to real change including, most notably, working collaboratively with Indigenous communities to break down barriers and create culturally safe and appropriate care (Beavis et al., 2015).
Speaking to the profession of social work specifically, recognition of the history of Indigenous persons is an important first step (of many) in improving practice. Historical and personal experiences of Indigenous persons can shape views of the social work profession, and willingness to engage in service, as social work is often synonymous in these populations with “the theft of children, the destruction of families, and the deliberate oppression of…communities” (Van Sickle, 2019). In recognition of this, and in keeping with the values and ethics of the profession (including acting in the best interests of the client, respecting intrinsic worth, right to self-determination, and advocacy), social workers are encouraged to be aware of Indigenous clients’ past experiences and the socio-cultural context of these, and partner with Indigenous persons to determine an appropriate path to improvement (Van Sickle, 2019). It is encouraged that practice be done through a lens of cultural humility, which views social workers as learners rather than experts, and includes “commitment to self-evaluation and self-critique … desire to fix power imbalances; and develop[ment of] partnerships with people and groups who advocate for others” rather than one of (strictly) cultural competence (Van Sickle, 2019). The TRC (2015) specifically address these challenges, calling on all levels of government, as well as social work and other child welfare professionals to ensure that they are trained in cultural competence, as well as “properly educated…about the potential for Aboriginal communities and families to provide more appropriate solutions to family healing”. The Canadian Association of Social Workers has committed through statements and practice to continue the “ongoing work of allyship, taking the lead of Indigenous people and communities and using [the United Nations Declaration of the Rights of Indigenous Persons] as a guide” in service provision (Canadian Association of Social Workers, 2021). Social workers in Ontario, as an example, are encouraged to annually review the TRC Calls to Action, as well as reflect on their own inherent biases when formulating goals related to continuing competence and personal and professional improvement.
It is important to recognize however, that intermittent awareness and one-time training alone, are not enough to wholly transform behaviours and attitudes impacting the provision of service to Indigenous persons and communities (Clifford et al., 2015). Consistent education is needed; beginning with an understanding of the history of Aboriginal communities in Canada as result of colonialism and building over time towards an understanding of how structures, rooted in colonization continue to impact behaviours and attitudes related to Aboriginal health care and the perpetuation of inequity (Beavis et al., 2015). Advocacy must be undertaken to influence change at organizational and systemic levels – including demonstrated commitment from leadership to develop and promote a culture of respect towards Indigenous persons which recognizes their resilience rather than placing blame, active recruitment and retention of Indigenous practitioners and implementation of a post-colonial and culturally safe approach to practice, and the valued involvement of Indigenous perspectives on multidisciplinary teams (Beavis et al., 2015; Taylor et al., 2020).
In recognition of this, and in a continued effort to move towards reconciliation, health research, program development and implementation should be collaborative, community-based, and community-led where possible. This will restore Indigenous voices, integrate knowledge, history, and diverse perspectives, and encourage health promoting behaviours within the population (Clifford et al., 2015; Earle, 2011; Hyett et al., 2019; Richmond & Cook, 2016; Taylor et al., 2020; Van Sickle, 2019). Researchers and (health) organizations wishing to work with Indigenous populations should engage stakeholders to first determine if the work in question seeks to help, or risk harming the community (through further stigmatization, marginalization, and oppression) and allow Indigenous leaders to ensure that research, organizational, and political interests align with community goals, concerns, and cultural norms (Hyett et al., 2019). Indigenous-led initiatives allow for knowledge production and responsiveness that is meaningful in an Indigenous context and recognizes that non-Indigenous persons can never be experts on the lived experience, health challenges, and resultant health deficits present in the Indigenous population. Further, the creation of culturally appropriate services serves to increase Indigenous access, compliance to treatment, and motivation to participate in health reform (Clifford et al., 2015; Earle, 2011; Taylor et al., 2020). Active and prioritized recruitment of Indigenous health practitioners and patient liaisons is an additional, and invaluable step, as their knowledge and presence has been identified as creating a safe space for care through an understanding of and respect for Indigenous patient priorities and cultural norms (Beavis et al., 2015; Clifford et al., 2015; Taylor et al., 2020; TRC, 2015).
To counteract the negative impact of deficit-based research, an important forward step would be the use of a strength-based approach, which focuses on positive aspects of health and positive approaches to negative health issues. Such an approach respects Indigenous knowledge, perspectives, and traditions, and amplifies the capacities of Indigenous individuals and communities to cope, manage, and address health challenges (Beavis et al., 2015; Hyett et al., 2019). Regardless of approach however, research presented on these populations and programs designed to care for them should clearly identify the influence of colonization and Westernization in creating health inequity, and the impacts of these on past and present health challenges, access to care, and management of health conditions. Doing so will generate greater understanding in the general population as well as organizational buy-in towards wider, sustained improvement (Beavis et al., 2015; Hyett et al., 2019).
Below is a diagram from the Canadian Coalition for Global Health Research (taken from Hyett et al., 2019) demonstrating principles for global health research that, I feel, are applicable and would be of benefit to an Indigenous research and health provision context:
References
Beavis, A. W., Hojjati, A., Kassam, A., Choudhury, D., Fraser, M., Masching, R., & Nixon, S. A. (2015). What all students in healthcare training programs should learn to increase health equity: Perspectives on postcolonialism and the health of Aboriginal peoples in Canada. BMC Medical Education, 15(1). https://doi.org/10.1186/s12909-015-0442-y
Canadian Association of Social Workers (2021, June 29). The United Nations Declaration on the Rights of Indigenous Peoples becomes law – but the journey is far from over. https://www.casw-acts.ca/en/united-nations-declaration-rights-indigenous-peoples-becomes-law-journey-far-over
Clifford, A., McCalman, J., Bainbridge, R., & Tsey, K. (2015). Interventions to improve cultural competency in health care for Indigenous peoples of Australia, New Zealand, Canada and the USA: A systematic review. International Journal for Quality in Health Care, 27(2), 89–98. https://doi.org/10.1093/intqhc/mzv010
Demystifying Medicine (2018, April 02). Indigenous health in Canada [Video]. YouTube. https://youtu.be/QeLwBDdbEJc
Earle, L. (2011). Understanding chronic disease and the role for traditional approaches in Aboriginal communities. National Collaborating Centre for Aboriginal Health. https://www.nccih.ca/495/Understanding_chronic_disease_and_the_role_for_traditional_approaches_in_Aboriginal_communities_.nccih?id=45
Hyett, S., Gabel, C., Marjerrison, S., & Schwartz, L. (2019). Deficit-based Indigenous health research and the stereotyping of Indigenous peoples. Canadian Journal of Bioethics, 2(2), 102–109. https://doi.org/10.7202/1065690ar
Richmond, C. M., & Cook, C. (2016). Creating conditions for Canadian Aboriginal health equity: The promise of healthy public policy. Public Health Reviews, 37(1). https://doi.org/10.1186/s40985-016-0016-5
Taylor, E. V., Lyford, M., Mason, T., Sabesan, S., & Thompson, S. C. (2020). “We’re very much part of the team here”: A culture of respect for Indigenous health workforce transforms Indigenous health care. PLOS ONE, 15(9), Article e0239207. https://doi.org/10.1371/journal. pone.0239207
Truth and Reconciliation Commission of Canada (2015). Truth and Reconciliation Commission of Canada: Calls to action. National Centre for Truth and Reconciliation. http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf
Van Sickle, C. (2019). Practice notes: Cultural humility: A commitment to lifelong learning. Perspectives.
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