Treating Root Causes, Not Symptoms

History of colonialism and systemic racism looms over Indigenous health disparities

By Stuart Foxman

When teaching medical trainees, Dr. Sarah Funnell asks them to name an Indigenous health inequity. Then she starts peeling back the layers.

“We go back to root causes,” says Dr. Funnell, Associate Medical Officer of Health at Ottawa Public Health.

There’s no shortage of examples. Indigenous people have the worst health outcomes of any population group in Canada. Compared to non-Indigenous Canadians, that includes:

• Infant mortality rates 2-4 times higher. 
• Diabetes rates nearly twice as high overall, and 4 times higher on reserve.
• Opioid-related deaths up to 3 times higher.
• Suicide rates about twice as high, and 5-6 times as high for youth ages 10-29 living on reserve.
• Heart disease rates as much as 50% higher, and double the death rates from strokes.
• Much heavier infectious disease burdens.
• Overall life expectancy up to 15 years shorter.

Dr. Funnell understands the toll. She is Director of Indigenous Health in the Department of Family Medicine at Queen’s University and has provided primary care in the Akwesasne First Nation. For her cause analysis exercise, she has the trainees keep answering the same question: “Why?”

With diabetes, why are rates so high? If an answer is unhealthy food habits, why does that happen? Maybe low income plays a part. Why is a population disadvantaged that way? If a community can’t practise its traditional way of harvesting food, why is that? Was the process disrupted at some point? If so, why?

Ask enough “why” questions, Dr. Funnell says, and the discussion lands on one truth: power and control over Indigenous people and their rich traditional territories.

You can’t avoid it. Look at limited food choices, inadequate housing, poverty, the legacy of residential schools, a forced disruption of Indigenous culture, and substandard health care. All can be traced in some way to colonial policies and systemic racism. “There’s only one explanation,” says Dr. Funnell.

How does anti-Indigenous racism come into play in health care? What biases might emerge? And how can doctors make a meaningful impact on health care equity? Five Indigenous doctors share their thoughts with Dialogue.

Common trauma

The Indigenous people are made up of three distinct Indigenous groups: First Nations, Inuit and Metis. Within those three groups are a diversity of language, culture and traditions. All three groups share common trauma: colonialism.

The Truth and Reconciliation Commission detailed Canada’s original sin: “States that engage in cultural genocide set out to destroy the political and social institutions of the targeted group. Land is seized, populations are forcibly transferred, and their movement is restricted. Languages are banned. Spiritual practices are forbidden. Families are disrupted to prevent the transmission of cultural values and identity from one generation to the next. In dealing with Aboriginal people, Canada did all these things.”

The damage is deep. A Wellesley Institute report, “First Peoples, Second Class Treatment,” said: “Policies and practices emerging from colonial ideologies have been extremely destructive to the health and well-being of Indigenous peoples, cutting across the broad spectrum of social determinants of health.”

What’s the lasting impact? “The historical and contemporary contexts of racism continue to negatively shape the life choices and chances of Indigenous peoples in this country,” the report stated. “Racism fundamentally contributes to the alarming disparities in health between Indigenous and non-Indigenous peoples.”

Racism is a determinant itself. “Living with racism, you have constant stress. It affects your whole body chemistry and wellness,” says Dr. Jason Pennington, a staff surgeon at Scarborough Health Network, an assistant professor at University of Toronto, and Regional Indigenous Cancer Lead at the Central East Regional Cancer Program.

Everyone was fooled

Do Canadians, as a whole, understand these inequities? Do doctors?

“A big portion don’t think it’s an actual issue,” says Dr. Chase McMurren, Indigenous Medical Education Theme Lead, MD Program, University of Toronto.

Dr. Funnell mentions her own upbringing on the Alderville First Nation Reserve. “I was taught in school that Canada was a cultural mosaic. I believed we were based on that. We were the global peacekeepers. We freed the Black slaves. I was appalled by the Holocaust and South Africa. I didn’t realize that my own country was founded on the oppression of the racial group I was a member of. If I was fooled, then everyone else was fooled.”

That goes for her peers in medicine too.

“The physicians of my generation have the same Euro-centric education,” Dr. Funnell says. “Then we go on to have other educational experiences and work in institutions founded on a colonial mindset, and on traditional land whose stories aren’t told.”

Dr. Pennington agrees the medical community doesn’t fully grasp the scope of Indigenous health issues and anti-Indigenous racism, and the link between them.

“People don’t want to think it’s racism, so will say all other reasons why outcomes are poorer,” says Dr. Pennington.

He says to think of the proximal, intermediate and distant social determinants of health, just as you’d think of any ailment. If a patient gets a foot ulcer, you can use antibiotics and a dressing. But you must treat the underlying diabetes. With Indigenous health, says Dr. Pennington, the symptoms will always return unless we treat the disease at the root. 

Beyond all the social determinants, consider how health care is conceptualized. Is it always about the mind, body and spirit? Many Indigenous people require wraparound care, partly because of direct or residual trauma, says Dr. Lisa Richardson, Vice-Chair, Culture & Inclusion at the University of Toronto’s Department of Medicine.

“When we don’t provide care in a holistic way, that can disadvantage our people,” says Dr. Richardson, who is also Strategic Lead in Indigenous Health for Temerty Faculty of Medicine. Along with Dr. Pennington, she worked to develop the Office of Indigenous Medical Education within the MD program.

Dr. Richardson notes too how often it’s non-Indigenous leaders who have to approve programs or policies relating to Indigenous people. “That’s a classic example of how institutional racism plays out, and undermines self-determination,” Dr. Richardson says.

Stretched thin

Access is a huge impediment for Indigenous communities in more remote locations. Dr. Jonathan Fiddler sees it all the time. He has worked as a physician in the Oji-Cree community of Kitchenuhmaykoosib Inninuwug since 2015.

Known as KI for short, or Big Trout Lake First Nation, the community is about 580 km north of Thunder Bay. Three or four doctors come to KI regularly, and hand off to each other.

“The refrain we hear from patients is that the health-care system doesn’t do anything for us. Not because of any practitioner, but because resources are stretched thin,” says Dr. Fiddler.

Demands can be high. For one, KI has faced an opioid epidemic. When Dialogue reported on it last year (Issue 3, 2019), about 1 in 12 people were in a suboxone program. Everyone knows someone affected. Sometimes, opioid (and other substance abuse) is linked to intergenerational trauma in the community. The effect on identity and health is huge. In fact, some populations need to deal with substance abuse disorders with a trauma-informed approach.

Dr. Fiddler alternates 2-3 weeks at a time in KI (pulling 12-16-hour days) with four weeks in his home base of Toronto. One physician at a time covers a community of almost 2,000 people. “And not an average population, but 2,000 people with complex health needs,” he says.

“When you look at the care that’s often delivered in northern contexts, it’s 100% inferior,” says Dr. Fiddler. “We’re aware of it, and the community is aware of it.”

The health-care system becomes a target too for the frustration the people have overall. About government policies, and inertia around lingering issues. About boil-water advisories that never end, like the one that has been in effect since 1995 in Neskantaga First Nation Reserve, along the shore of Attawapiskat Lake. And about food.

Dr. Fiddler says health care is actually one of the least efficient areas to drive change around personal health. Supporting Indigenous-led efforts to achieve food security would reap more rewards.

“The dispossession of land had huge impacts on changing the foods that are available,” says Dr. Fiddler. “Low-nutritional foods started to be dumped on reserves as part of treaty commitments. Go to any store in the remote north and what do you see? Low quality. Maybe some apples, very questionable looking bananas, a head of lettuce and some tomatoes, if you’re lucky.”

What’s stocked instead? “Goods that can be trucked in on a winter road and kept in storage for long periods. Kraft dinner, frozen pizzas, soda pop — things that have an incredibly long shelf life, but that aren’t particular nutritious.”

Do they see me, do they care?

Access isn’t just a northern or remote issue. Of course, Indigenous people live all over Canada. In health care, a lack of access can relate to resources in a community, financial barriers to a service, wait times, and, significantly, a fear of being stereotyped or marginalized.

That becomes a safety issue, says Dr. McMurren: “Do people see me? Do they care?”

Many Indigenous people hesitate to seek care because they don’t think it’s designed for them. “It’s more than just a feeling — it’s real,” Dr. Funnell says.

Maybe you hold off on going to the doctor until your problem is more acute or advanced. Maybe you don’t go to the hospital. That’s a safe space for most people, but not for all.

“I’ve seen people who just can’t walk into western health care institutions,” says Dr. Pennington. “For some, it’s very traumatic.”

“When you look at the care that’s often delivered in northern contexts, it’s 100% inferior”

All of that also affects your outcomes. But it’s understandable, says Dr. Pennington. He compares the feeling to that of a bullied child who doesn’t want to go to school anymore.

Stereotypes can kill

Negative feelings towards health care by Indigenous people (or towards the justice, policing, child welfare, education and government systems) shouldn’t be surprising.

As the Wellesley Institute’s report stated: “Stereotypes of the ‘drunken Indian’ or the hyper-sexualized ‘squaw’, the casting of Indigenous parents as perpetual ‘bad mothers’ or ‘deadbeat dads’, or media portrayals of Indigenous leadership as corrupt and/or inept, all serve to justify acts of belittlement, exclusion, maltreatment or violence at the interpersonal, societal and systemic levels.”

The report said that has shaped how Indigenous peoples are received and treated by, among others, health-care providers. Stereotypes can be used to marginalize — and, at worst, can be fatal.

Consider Brian Sinclair. He was 45 in 2008 when he went to a community health clinic in Winnipeg, after experiencing abdominal pain and an inability to urinate for 24 hours. The doctor referred him to the ED at the Winnipeg Health Sciences Centre. Sinclair went right away. He registered. And then waited. And waited. And waited.

He stayed in the waiting room for 34 hours, in pain. No staff attended to or spoke to him. Sinclair died sitting there. The cause: acute peritonitis due to severe acute cystitis caused by neurogenic bladder. By the time staff noticed him, he had been dead for hours. An inquest found hospital staff made certain assumptions about Sinclair, that he was intoxicated and sleeping it off, or homeless.

“He was stereotyped because he was Indigenous and presumed to be drunk,” says Dr. Funnell.

Sinclair’s ailment could have been treated. His death was preventable. As many have said, Brian Sinclair was ignored to death.

Just this past September, Joyce Echaquan, a 37-year-old mother of seven, went to a hospital in Joliette, Quebec, after experiencing stomach pain. From her bed, she went live on Facebook.

As Echaquan moaned, multiple health-care workers made comments: “Are you done acting stupid?” “You made bad choices, my dear.” “What are your children going to think, seeing you like this?” “She’s good at screwing, more than anything else. And we’re paying for this.”

Echaquan ended up recording what were the last moments of her life.

“Why do Indigenous people fear going to hospital? Just look at that,” Dr. Pennington says. “We completely failed.”

Egregious cases get headlines, but people move on. “They soon forget it, and it’s out of sight, out of mind,” Dr. Pennington says. In the meantime, everyday inequities continue.

Check your biases

In society and the practice of medicine, outright discrimination and explicit bias are easier to identify. But implicit bias has significant impacts too. What assumptions might you make about an Indigenous patient’s lifestyle? How often might you wonder, maybe just fleetingly, if a patient brought a problem on themselves?

As another article in this issue describes, you may not even realize you have these implicit biases. But many, including Dr. Funnell dislike the term. “It’s actually racism,” she says. “It’s not excusable in medicine.”

The notion of biases being implicit or unconscious can let you off the hook for certain actions or attitudes, says Dr. Funnell. One remedy: make efforts to know better.

Dr. Funnell was among the authors of a fact sheet for the College of Family Physicians of Canada on Indigenous people, health care and systemic racism. It outlined what doctors can do to build solid relationships with Indigenous patients. Ask yourself:

• Do you understand culturally safe care, and are you committed to providing it?
• Is the patient’s way of knowing and being respected as valid?
• Is the patient a partner in the health care decision-making process?
• Has the patient determined whether the care received is culturally safe? 
• What is the perception of Indigenous peoples where you currently live/work? Where did you get this information? 
• Can you identify potential biases or stereotypes in the source of this information? 
• Have you reached out to local Indigenous organizations to learn more? 
• Have you learned about Indigenous-specific effects of colonial policies, and how they are linked to historic and current medical services for Indigenous people?
• Have you learned about anti-racism and anti-oppression, health inequities, and the social determinants of health?

It’s ultimately your responsibility to fill in the gaps in your education and, more fundamentally, to know your patient.

“There are a few instances where you need to make quick decisions using an algorithm. Otherwise, risk factors are important, but it’s more important to understand, in a patient-centred way, someone’s experience, and what it means to them to be well,” says Dr. Funnell.

At least, remind yourself that the possibility of bias exists, so you can do something about it.

“We’ll never be entirely free of internalized racism,” says Dr. Fiddler. “At best, we can hope to achieve a commitment to address bias within ourselves. No matter how progressive and free of the constructs of racism and bias you think you are, there will always be things encoded within you.”

What can doctors do?

What impact can doctors make on what is a societal problem?

At an institutional level, work with your clinic or hospital on initiatives that enhance care experiences, ease barriers to access, and illuminate inequities, biases and stereotypes.

And at the provincial or national levels, get involved in efforts that advocate for improvements in health care for Indigenous populations, and all the determinants that support it (like better food security and housing).

Dr. Fiddler says that no one person can dramatically change government policy around Indigenous affairs. But you can’t use that as a pretext to wash your hands of the issue.

“Doctors need to remain committed to the process of political change and encourage others to do so. Health is inherently a political outcome. Many things aren’t amenable to change through medicine alone,” says Dr. Fiddler.

Structural and societal changes aren’t under your immediate control. But something else is. “At the individual level, you can become the most culturally safe physician possible,” says Dr. Funnell.

Strive to have the tools to be introspective about your interactions. But be mindful that taking the right course doesn’t make you perfectly, culturally safe.

Dr. McMurren says related terms like cultural competency and cultural sensitivity can be problematic. “The intention can be positive, but the impact can be dangerous,” he says.

Why? It can lead to false confidence, and generalizations about Indigenous people (or any group) that themselves can be racist.

Dr. McMurren prefers the term cultural humility — know that you don’t know. Doctors know a lot about medicine, and maybe something about the challenges that different populations face, but they don’t know it all. And until they probe, they don’t know a thing about the individual patient before them.

“It starts with ourselves. An awareness of what we’re ignorant about, and that our view isn’t complete,” says Dr. McMurren, who is also a medical director and psychotherapist at the Artists’ Health Centre at Toronto Western Hospital. “Genuine curiosity goes a long way. We have a duty of curiosity.”

A seat at the table

What else can affect change? Within medicine, there’s an under-representation and, often, a marginalization of Indigenous doctors. Increased representation would have an impact, in serving the Indigenous community and changing the culture in the system.

That’s true for seats at the leadership table in government, health-care facilities and agencies, professional bodies, and regulators like CPSO.

“The care, programs, policies and pathways for Indigenous people must be developed by Indigenous communities. That’s much more likely to happen when you have Indigenous leadership within these institutions,” says Dr. Richardson.

“We’re not in for token positions, or to make numbers look good. We’re looking to participate and be equals,” says Dr. Pennington.

“Our medical system is also based on a paternalistic model — the saviour complex,” he adds. “The doctors are the healers, and the Indigenous people are the sick community. That’s not the way we envision ourselves. A better question is what should we do together?” All the commissions and reports are talking about this new relationship.”

If he could wave a magic wand, Dr. Pennington would wish that Indigenous patients (and by extension, all patients) have easy access to the type of health care where they feel comfortable, safe and empowered.

More than that, he wishes that such care would meet all of their physical, mental, spiritual and emotional needs while trying to recognize, acknowledge and address the social determinants of Indigenous health.

The distant determinants: colonialism, racism and loss of self-determination must also be acknowledged. “Without addressing these,” says Dr. Pennington, “true health equity will never be attained.”