Social Determinants of Health
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“This is what is means to be born Indigenous, in Canada, in the 21st century: You are twice as likely to die in infancy. You will be nine times more likely to be sexually assaulted as a child and three times more likely to drop out of school. You will be twice as likely to lose your job. If you have a job, you will earn 60 per cent less.” Scott Gilmore, Maclean’s Magazine, December 19, 2016, page 12.
The term ‘Aboriginal’ (meaning 'from the origins') was used in the 1982 Canadian Constitution to designate the First Nations, Inuit and Métis peoples of Canada. According to the United Nations, ‘Indigenous’ relates to the description of self-identified peoples who have historically inhabited the lands where they currently reside, before and after contact or colonization, with distinct cultures, societal functions, languages, beliefs and connection with the land and its resources. Although they are the non-dominant society, these Indigenous peoples continue to keep their cultures, traditions, lifestyles, history and identity distinct and thriving. Currently, the preferred term is ‘Indigenous’, or in French, ‘autochtones’. Avoid the term ‘indigène’ in French, which has negative connotations. (Allan B, Smylie J. First Peoples. Second Class Treatment. The Well Living House Action Research Center Canada: 2015)
Reported Aboriginal population and percentage of Aboriginal people in Canada
(Statistics Canada 2011 National Household Survey)
Percentage of region population
Newfoundland and Labrador
Prince Edward Island
- The Assembly of First Nations of Canada
- Congress of Aboriginal Peoples
- Tapirrit Kanatami
- Métis National Council of Canada
- National Collaborating Centre for Aboriginal Health (NCCAH)
- A nice comparison of Aboriginal and Western values was provided by the Aboriginal Human Resource Council
- Indigenous and Northern Affairs Canada
- Journal of Indigenous and Aboriginal Community Health
- Pimatisiwin; A Journal of Aboriginal and Indigenous Community Health
- International Journal of Indigenous Health
- 2011 National Household survey
- Health Professional Working with First Nations, Inuit and Métis Consensus Guidelines
- Indian Act
- Health Canada; Non-Insured Health Benefits
- There is a film, "The Invisible Nation", by Richard Desjardins and Robert Monderie, that describes the history of the Algonquin people from their initial displacement in the 16th century by the early European settlers to modern times.
- University of Ottawa Library; Aboriginal Health Research Guide
Virtually every health indicator suggests that the health of Indigenous peoples in Canada is significantly poorer than that of the remainder population, although the gap in life expectancy between Indigenous and non-Indigenous Canadians has been narrowing.
Education and Employment
Access to Health Services
Housing and Culture
Birth and Mortality rates
For more information regarding health and social determinants of health for the First Nations, Inuit and Métis:
- Health Canada; First Nation Determinants of Health 2006 to 2010
- Health Canada; Health of First Nations vital statistics for Atlantic and Western Canada, 2001-2002
- An Overview of Aboriginal Health in Canada
- 2011 Census Program
- Stats Canada projection for Indigenous population from 2006 census to 2031
- Stats Canada; Aboriginal Peoples Survey, 2012
- First Nations and Inuit Health
- Stats Canada; Inuit Health
- Stats Canada; Métis Health
- The Aboriginal Healing Foundation has a publication series that cover a variety of health topics
- Report on First Nations, Métis, and Inuit Health Indicators in Canada.
- Statistics Canada resources on Indigenous health
- Federal government Indian & Northern Affairs home page
- Dr Alvarez's slides on Inuit pulmonary health
Within the Indigenous culture, the term Two-Spirit encompasses a wide range of sexual and gender identities. The Two-Spirit refers both to individuals who embody male and female spirits as well as Indigenous people who identify as lesbian, gay, bisexual or transgender. (Hunt S. An introduction to the health of two-spirit people: Historical, contemporary and emergent issues. NCCAH: 2016). The Native Youth Sexual Health Network notes that “not all Indigenous people identify as Two-Spirit and have other ways and words to express their gender and sexual identity.”
Colonization and its Impact
The First Nations, Inuit and Métis people have endured several events in Canadian history that continue to affect their health and well-being. Colonization, residential schools and racism are widely felt by Indigenous scholars to impact the daily lives of Indigenous persons, families and communities. These three factors are interrelated and contribute to the pervasive health and social problems that we see today. In moving forward for reconciliation, Canadians must learn and appreciate these factors to truly understand this negative impact and collaborate to find solutions for better health overall for Indigenous peoples.
"The concept of historical trauma and grief was first identified in the context of providing “culturally safe” care for Maori people in New Zealand. It has been defined as “cumulative, emotional and psychological wounding across generations, including the life span, which emanates from massive group trauma …
This trauma has affected Indigenous attitudes, beliefs and behaviors, and forms a crucial social determinant of Indigenous health. Colonization is not just a historical process, but must be recognized as a contemporary reality and an ongoing part of Indigenous life. The present day effects of colonization include a lack of cultural understanding between Indigenous and non-Indigenous Canada and strong feelings of distrust between the two."
(Dodgson J. Indigenous women's voices. J Transcultural Nursing 2005; 16(4):339)
Cultural safety is fundamental for providing adequate and safe care for the Indigenous population. This first begins with respect for the Indigenous people, their culture and practices. It is also very important to understand the impacts colonization, trauma and grief as they are a key step in understanding and providing culturally safe care.
Residential schools were created and initially run by the federal government through legislated acts to assimilate Indigenous children and youth and remove their cultural identity. Later, the churches operated schools in the early 19th century, feeling that education was the best way to turn Indigenous children into Christians who would also respect white settler lifestyle, values and customs.
There were 11 church-run boarding schools in 1880, rising to 45 by 1896 and eventually over 130 in all. Indigenous and Northern Affairs Canada created a map noting the location of all the Indian residential schools in Canada. Approximately 150,000 indigenous children were taken from their families and sent to these schools. The schools were badly under funded and poorly built; inadequate ventilation increased the spread of tuberculosis and other infections. In many of the schools children were physically, emotionally and sexually abused.
(Link to original map that you can enlarge for greater clarity: https://www.aadnc-aandc.gc.ca/DAM/DAM-INTER-HQ-AI/STAGING/texte-text/irs_cep_institutions_map_1336653954617_eng.pdf)
Children were removed from their homes at five or six years of age. They were kept at school, separated from their family and even their siblings who attended the same school, for 10 months of the year. Some never returned to their family or community. They were prohibited from speaking their traditional languages and carrying out their customs, such as hunting and fishing. These Indigenous children and youth were given minimal academic instruction as they had to work to clean and maintain the schools and were subjected to religious and cultural indoctrination. They had their names changed or were simply identified by a number.
Compliance with attending such schools was very poor and the government tried various tactics to raise enrolment. Revisions to the Indian Act in 1884 gave powers to arrest, transport and detain children at school. Families were also threatened they would not receive supplies and money unless they sent their children to school. In 1894, regulations made residential school attendance voluntary, but the justice of the peace or an Indian agent was still able to send Indian children between the ages of six and sixteen to the residential schools if they felt the child was not properly cared for or educated, or if the parents/guardians were seen as unfit.
The Truth and Reconciliation Commission documented the deaths of more than 6,000 residential school students in the system, with many of the deaths being due to preventable causes. Deaths were highest in the early twentieth century. In 1902, the mortality rate among children in residential schools was 2.74%. The government was well aware of this, but ignored complaints brought forward by the Medical Officer of Health in the Department of Indian Affairs Dr. Peter Henderson Bryce. Note that the residential school experience in Canada meets the UN criteria for genocide.
In the 1960’s many Indigenous children were taken from their families and communities by child-welfare agencies and placed in non-Indigenous homes. This is commonly referred to the “60’s Scoop”, which endeavored to assimilate children by different means since the residential school system was unhealthy and ineffective in doing so. The Indigenous families and communities often had no knowledge that this was happening to their children. Thousands of children were sent into non-Indigenous homes across Canada, the United States and even overseas. This continued until the mid to late 1980’s.
By 1970, the government turned over management of all the residential schools to the provincial and territorial governments, and some bands also began to run their own local school; the influence of the churches was reduced. However, the negative impact of acculturation, isolation and abuses remained engrained in the memory of its survivors and their families, resulting in multi-generational trauma, psychological effects and social problems seen today.
In 1998, the government founded the Aboriginal Healing Foundation and committed over $350M to address the legacy of physical and sexual abuse suffered by individuals who attended the residential schools. Roughly 13% of Indigenous people self-identify as survivors of the residential school system. There were approximately 86,000 survivors, and their families as intergenerational survivors, compiling about 287,000 members, who collectively number about 373,000 persons today who are affected by the residential school experience. (TRC Final Report)
Residential school students attempted to adapt to their circumstances using the following coping strategies:
- Detachment (shutting down, not participating in the group)
- Reinterpretation (living out fantasies about the future or present, idolizing those who ran away from school, etc)
- Accommodation (currying favor with those in power; this may have led to exposure to sexual abuse out of a desire to obtain protection)
- Resistance (defending younger children, stealing food, running away)
Since the residential schools continued for several generations, the effects have been devastating and pervasive for survivors and their families, including;
- Loss of cultural identity and self-esteem
- Loss of indigenous languages, traditions and lifestyle
- Loss of parenting skills and sense of responsibility for caring and teaching children
- The hierarchical institutions discouraged the development of decision-making skills, autonomy and initiative.
- A high incidence of abuse and violence affecting Indigenous people, families and communities, reflecting the sexual, physical and emotional abuse in the residential schools.
- Extensive consequent alcohol and substance abuse and high rates of mental health problems, including suicide.
“Sadness, anger, or indifference in our First Nations patients may represent the struggles of generations before them and be linked to a history that has not been resolved.” (Dr. Nadine Caron, General Surgeon, Sagamok Anishnawbek First Nation).
Truth and Reconciliation Commission of Canada (TRC)
By 2001, a large number of abuse claims had been filed by former students against the federal government. A negotiated Indian Residential Schools Settlement Agreement (IRRSSA) was approved and implemented in 2007 as a result of advocacy by survivors, supported by the Assembly of First Nations, for a holistic, fair and lasting resolution to the legacy of the schools. The IRSSA included financial compensation, an assessment process for claims of sexual and serious physical abuse, funding for healing and commemoration activities and the establishment of the Truth and Reconciliation Commission.
“There is an emerging and compelling desire to put the events of the past behind us so that we can work towards a stronger and healthier future. The truth telling and reconciliation process as part of an overall holistic and comprehensive response to the Indian Residential School legacy is a sincere indication and acknowledgement of the injustices and harms experienced by Aboriginal people and the need for continued healing. This is a profound commitment to establishing new relationships embedded in mutual recognition and respect that will forge a brighter future. The truth of our common experiences will help set our spirits free and pave the way to reconciliation.”(TRC Mandate).
The TRC funded and hosted seven national events across Canada in order to engage and educate the Canadian population about the history and experiences of the Indian residential schools. The events took place in Winnipeg, Inuvik, Halifax, Saskatoon, Montreal, Vancouver and Edmonton between 2010 and 2014.13 In 2015 the TRC released a comprehensive report that outlined the history, the legacy, the challenge of reconciliation and calls to action of the residential schools in Canada. Within the calls to action are two very important statements related to the health care education;
- First, the importance of increasing the number of Indigenous professionals in the health care field.
- Second, the requirement of all medical and nursing students to learn about Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. (TRC Calls to Action)
The central conclusions made from the TRC include:
- The recognition of the Indigenous right of self-determination
- More appropriate funding allocation for services from the government
- Systematic tracking of the progress made since the TRC
- Aiding in the long process of reconciliation.
It is important to note that the TRC did not have any subpoena powers and was not a criminal tribunal. Its purpose was to listen to individuals who had been impacted by the Indian residential school system and record their stories. As of December 2015, the TRC has transferred its work to the National Centre for Truth and Reconciliation at the University of Manitoba in Winnipeg and is completely accessible to the public.
What is Racism?
In order to understand racism it is first imperative to understand the idea of race. ’Race’ is a relatively recent concept that was constructed in western societies, based on physical characteristics and geographic origin. By the 1800’s the idea of classification by race was common and as a result created a social hierarchy. Prior to this, individuals were identified primarily by their religion and by their language. (Smedley A, Smedley B. Race as biology is fiction, racism as a social problem is real: Anthropological and historical perspectives on the social construction of race. American Psychologist. 2005; 60(1): 16-26.)
Unfortunately this socially constructed idea of race still exists in the 21st century.
Racism takes the idea of race one step further; it is the belief that one’s race is superior to another. This belief can lead to discrimination, intolerance or even hatred of other races based on physical appearance and artificially constructed ideas and stereotypes of other races. As a result of racism, certain groups of people receive unfair treatment and even diminished opportunities in life simply due to their race. Racism has unjust impacts on individuals, families, communities and entire nations. (National Collaborating Center for Aboriginal Health. Understanding Racism: 2013).
Racism exists in many different forms which include; structural or systemic racism, relational racism, embodied racism, symbolic racism, and social exclusion.17 Structural or systemic racism refers to social, political and economic constructs that result in the exclusion or promotion of certain groups within society (Bonilla-Silva E. Rethinking racism: Toward a structural interpretation. American Sociological Review. 1997; 62(3): 465-480).
Relational racism refers to racism that occurs in the context of everyday life. Examples of relational racism include: being followed in stores by employees, being ignored in a line when your turn comes, being passed for a promotion, and abuse (verbal, physical, or sexual). (Levin J. The violence of hate: Confronting racism, anti-semitism, and other forms of bigotry. Boston: 2011, Allyn & Bacon).
Embodied racism refers to the physical and psychological responses an individual who has been discriminated may experience. Symbolic racism is a more recent term that is a more subtle form of racism. It is typically present in the dominant group who are not labeled as racist in terms of relational racism, but they have negative attitude or stereotypes towards another racial group. For example, an individual who holds the belief that Indigenous people should not be given ‘special’ treatment is a form of symbolic racism. Finally, social exclusion is a type of racism that acts to physically and socially exclude a group from having the equal opportunity to participate in educational, political, health care and economic systems that should be equally available to everyone in society. (Wallis M., Sunseri W., & Galabuzi G. Social exclusion. Colonialism and racism in Canada: Historical traces and contemporary issues: 2010. pp227-245. Toronto, ON: Nelson Education Ltd.)
Racism in Canada
The Indigenous peoples of Canada continue to experience the impacts of racism. This began as a result of the Europeans arriving in Canada and exploiting the Indigenous population and lands for economic and social gain. Throughout history, colonization by the Europeans has negatively affected the Indigenous populations and communities, resulting in oppression, disadvantage and loss of cultures and traditions. In Canada and globally, racism towards the Indigenous peoples is still present, in the form of negative stereotypes and stigmatization, violence and the persistence of many structures in society that label Indigenous people as second class citizens and unfortunately enables segregation. (de Leeuw S, Kobayashi A, Cameron E. Difference. In: Del Casino VJ, Thomas ME, Cloke P, Panelli R (eds). A companion to social geography. Oxford, UK: Wiley-Blackwell, 2010 pp17-37)
Stereotyping is dangerous and damaging as it unfairly characterizes an entire group of people. This occurs frequently towards the Indigenous population. Some examples of negative stereotypes include: the dependence of Indigenous people on governmental funding, alcohol and drug addiction, unemployment, and violence. (Harding R. Historical representations of Aboriginal people in the Canadian news media. Discourse & Society. 2006; 17(2): 205-235).
The media plays a vital role in the perception of Indigenous people in Canada: reporting often focuses on negative social and economic problems facing the Indigenous population rather than positive and successful aspects of their cultures, lives and communities. (Harding R. Historical representations of Aboriginal people in the Canadian news media. Discourse & Society. 2006; 17(2): 205-235) Though this is slowly improving in recent years, Indigenous leaders continue to advocate and teach others to increase general knowledge of Indigenous peoples, cultures and communities across Canada. There remains, particularly in health care, an urgent need for health professionals to increase their knowledge and experience in working with Indigenous populations to give culturally safe care.
The most significant example of systemic racism was the establishment of the Indian residential school system that tore generations of indigenous families and communities apart in the name of assimilation. Another example was the creation of Indian reserves through historic and modern day treaties. Insufficient and delayed federal investments in housing has lead to overcrowding in substandard homes, lack of adequate water and sewage systems, increasing the risk of exposure to infectious diseases and mold. This combination results in living conditions that are comparable to those in developing countries, though some Indigenous communities fare better than others. (de Leeuw S, Kobayashi A, Cameron E. Difference. in: Del Casino VJ, Thomas ME, Cloke P, Panelli R (eds). A companion to social geography. Oxford, UK: Wiley-Blackwell, 2010 pp17-37).
The establishment of the Indian Act in 1876, along with the creation of the Department of Indian Affairs in 1880, gave the federal government authority to regulate and manage the Indian population and their communities. The federal government controlled the Indigenous rights to land, resources, languages and cultural practices, leaving the Indigenous people with little autonomy over their lives and communities. Since 1876 there have been changes to the Indian Act, but many of the inequalities it imposed remain. Today, Indigenous leaders debate its value and significance, as well as the historic treaties whereas modern day treaties are more protective of Indigenous rights.
Indigenous people experience systemic racism within the justice and health care systems. In the justice system, an Indigenous individual is more likely to be imprisoned for a crime; an Indigenous victim may not be seen as credible; and, proper justice may not be served. (Martel J, Brassard R. Painting the prison ‘red’: Constructing and experiencing Aboriginal identities in prison. British Journal of Social Work. 2008; 38(2): 340-361). In the health care system, implicit racial bias can be seen in the form of under funding and understaffing of services in Indigenous communities, longer wait times, fewer referrals and a lack of understanding or respect for Indigenous peoples and their cultures. As a result, some Indigenous individuals have lost trust in a system that was created to look after their health, even though provision of health services is often the responsibility of the government. (Narine S. Racism, mistrust keep aboriginal people from health care. Windspeaker. 2011; 30(11)). This leads to less screening for infections, cancer, and chronic diseases in the Indigenous population, which may help explain why the burden of disease is higher and the life expectancy is lower in the Indigenous population.
An unfortunate example of racism in the health care system is the story of Brian Sinclair. Mr. Sinclair was a 45 year old Indigenous man who was sent to the ER by a community physician for a bladder infection. Mr. Sinclair died in the waiting room of the ER 34 hours after arriving even after several people pleaded with nurses and other health care workers to see Mr. Sinclair. According to Brian Sinclair’s brother Robert Sinclair, the “Hospital staff assumed Brian Sinclair was drunk or homeless rather than a person in need of medical care — assumptions based solely on visual observations of a poor aboriginal double-amputee in a wheelchair". (CBC News; December 12, 2014).
This pattern of systemic racism and stereotyping resulted in unfair treatment and ultimately his death. The Sinclair family and the local Indigenous community wanted answers. They requested a coroner’s inquest as they felt that Mr. Sinclair’s race as well as his disability resulted in unfair treatment. The 2014 inquest report contained 63 recommendations to improve the emergency departments, though ultimately it did not find Sinclair’s death to be homicide, nor call for a public inquiry. The Sinclair family was not satisfied with the results of the inquest, which failed to address racism as a cause for Mr. Sinclair’s death. (Provincial Court of Manitoba report; December 12, 2014).
Violence towards the Indigenous population is also present in our society. Indigenous men and women are more likely to experience harassment or violence from authorities or other individuals as compared to the non-Indigenous population. Examples include the 724-kilometer length of British Columbia’s Highway 16; now commonly referred to as the Highway of Tears where many Indigenous women went missing and were found murdered, the disappearance of more than 60 women from the Downtown Eastside of Vancouver and the Robert Pickton murders, many of whom were Indigenous women. Missing and murdered Indigenous women (MMIW) is now recognized by the federal government as a prioritized social issue that will be addressed through a national inquiry to support the victims’ families and communities in finding answers to this complex issue.
What has been done?
As previously mentioned, the media plays a very influential role in the perception of Indigenous peoples; therefore the media has a significant role in addressing racism. The Canadian Broadcasting Act was created to ensure all broadcasts reflect the cultural diversity of Canada. There are also specific television networks, such as APTN, that focus primarily on Indigenous content. In 2012, CBC presented “8th Fire,” a series that focused on the relationship between Indigenous and non-Indigenous people in Canada. (National Collaborating Center for Aboriginal Health. Policies, programs and strategies to address aboriginal racism: A Canadian perspective: 2014) This series engaged Indigenous filmmakers to help the audience move past prejudice, stereotypes and misunderstandings, to encounters with a new generation of Indigenous community members who are reclaiming both their culture and their confidence.
In some provinces, Indigenous content has been incorporated into the curriculum so that all students will learn about the history and culture of the Indigenous population. Unfortunately this has not been integrated across the country and may account for why there is such a large number of Canadians who do not have a full understanding of Indigenous history and culture.28 However, one recommendation by the TRC advised that schools must increase Indigenous content in curricula, which will hopefully be improved through reconciliation efforts.
In the health care field, it has been found that many health services offered to Indigenous people are not culturally safe and that some health care professionals are influenced by racial stereotypes when serving the Indigenous population. (Fontaine L, Health Council of Canada. Empathy, dignity, and respect: Creating cultural safety for Aboriginal people in urban health care. Toronto, ON: Health Council of Canada, 2012.) Proportionate to their population, there is a large shortage of Indigenous health care providers, but many educational institutions are now are now creating programs to recruit and train Indigenous students to become health care professionals. The TRC also recommended that health professionals learn about residential schools and other relevant factors that currently affect the health and well-being of Indigenous populations.
The federal and provincial governments have established numerous anti-discriminatory laws in order to begin to address the problem of racism. The Criminal Code of Canada is a law that protects against violence and hate crimes. The Canadian Human Rights Act provides an avenue for individuals to report incidents of racism or discrimination; the Canadian Rights Commission will investigate the claim. The Ontario Human Rights Commission performs the same role at the provincial level. The Canadian Charter of Rights and Freedoms states that every individual is equal regardless of race, national or ethnic origin, religion, sex, age or disability.28 The Truth and Reconciliation Commission focused on revealing the truth, acknowledging the residential school experiences and moving forward towards reconciliation, Indigenous and non-Indigenous Canadians together.
What you can do
Racism is not routinely addressed, especially by people of a dominant group who may not be directly impacted by it. It is very important to try and change this by starting to have open conversations about what is really happening in order to begin to control the discrimination and oppression that has been occurring in the Indigenous population. Once this conversation has started it is important as stated by Bernard Guerin (2003) to first identify racism and acknowledge its extent. Then begin to understand the experience of racism and finally demonstrate a suitable response to racist incidents that have occurred. (Guerin B. Combatting everyday racial discrimination without assuming racist or racism: new intervention ideas from a contextual analysis. Behavior and Social Issues. 2005; 14: 46-70.)
- Understanding Racism
- Aboriginal experiences with racism and its impacts
- Policies, program and strategies to address Aboriginal Racism
- Bernard Guerin; Combating everyday racial discrimination
- Robert Sinclair additional information and article
There are substantial housing shortages in many of the Indigenous communities, leading to homelessness and overcrowding. Many of the homes lack ventilation, an adequate water supply and sewage system, particularly in remote communities. The overcrowding and poor living conditions contribute to high rates of infection and mental health issues. (Reading C; Wien F. Health Inequalities and social determinant of aboriginal health (NCCAH: 2013).)
Inadequate levels of secondary and post-secondary education and high drop-out rates result in less specialized skills to offer in the labor market, typically resulting in lower paying jobs. An important reason for this is the lack of funding provided by Indigenous and Northern Affairs Canada (INAC) for First Nations education. Low funding has left many communities struggling for quality schooling or access to post secondary training. In 2005, almost 50% of Indigenous individuals over 15 years of age had not completed secondary school. Within the Indigenous population the Inuit are the most disadvantaged due to low numbers of teachers, crowded living spaces that make studying difficult and high rates of unemployment. (Coryse C, Scott K. The determinants of employment among Aboriginal peoples; 2006). The number of Indigenous individuals attaining post secondary education is increasing, especially among Indigenous women, but still falls far below the non-Indigenous population.
Within the Indigenous population there are higher levels of unemployment and lower levels of income as compared to the non-Indigenous population resulting in more Indigenous families that must rely on social assistance from the government as compared to non- Indigenous families.
Poverty (compounded by more single-parent families and lower incomes) has an immense impact on the types of food an individual or family can afford. The combination of food insecurity, encroachments on land and pollution have begun to limit the ability of Indigenous people to obtain traditional food by means of hunting, trapping and fishing. Processed food is often cheaper and more available than healthy food such as fruits and vegetables in Indigenous communities. This is especially true in remote and rural communities as the high cost of transport makes fresh food very expensive. Food insecurity and unhealthy eating habits are stressors that can lead to depression, distress and obesity.
More detail on food insecurity
Within the Indigenous population there are higher rates of alcohol, substance abuse, and smoking, inadequate levels of exercise and unhealthy diet choices. All these choices represent a significant determinant of health within the Indigenous population. (Tjepkema M, Wilkins R, Senécal S, Guimond É, Penney C. Mortality of urban Aboriginal adults in Canada, 1991- 2001. Chronic Diseases in Canada. 2010; 31(1))
The impact of colonization still has an immense impact on the physical, emotional and mental health of the Indigenous population. Being aware of the Indigenous social determinants of health is paramount in providing adequate and culturally safe care to the Indigenous people.
Efforts are being made in public health and clinical services to improve the social determinants of health at the patient, family and community levels through patient education, healthy lifestyle campaigns and community engagement. Local, regional and government partners are beginning to engage and collaborate with Indigenous peoples and communities, building upon their resiliency and cultural resources to achieve improved health together.
For more information on Indigenous social determinants of health see links provided below.
The Indigenous peoples of Canada share a rich history, yet diverse languages and traditions that represent important historical, social, political and cultural aspects of Canadian society. First Nations, Inuit and Métis populations, whether urban, rural or remote, face many challenges in their health and well-being, including the provision of health care services. It is clear that the social determinants of health (such as housing, education, gender and income), the historical and current context of colonization and the residential schools experiences have negatively impacted health. Recently, systemic racism also plays a role in how well Indigenous peoples receive care. As a result, the epidemiology of health issues demonstrates the significant disparities that exist. To improve health outcomes, health care professionals must aim for and provide culturally safe care by learning about Indigenous health and social issues and the factors that affect their health, lifestyle and communities. This includes the residential school experiences and multigenerational sequelae that must be appreciated so that health providers and Indigenous patients, families and communities can move forward together in reconciliation.
- TRC “Final Report”
- TRC “The Survivors Speak”
- TRC Survivors page
- TRC “What We Have Learned”
- TRC “Calls to Action”
- Violence in Aboriginal Communities
- A CBC web site contains a number of film clips of residential schools, some clearly government propaganda showing happy children enjoying their school experience.
- The Aboriginal Healing Foundation offers materials on residential schools; Final Report.
- The Residential School Experience; Syndrome or Historic Trauma
- First Peoples, Second Class Treatment
- Two-Spirit and Native Youth Sexual Health Network
- Social Determinants of Health; The Canadian Facts
- Health Inequalities and Social determinants of Aboriginal Health
Every treatment has a cultural component. Western medicine is founded on science, but we must recognize that this holds no inherent guarantee of quality or efficacy. We teach the importance of evidence-based medicine, but there are many therapies for which we have not yet accumulated evidence of effectiveness, so should you dismiss all therapies that are not yet proven? One suggestion is to proceed with an open but enquiring mind – be skeptical (i.e. question things), but not cynical (i.e. dismiss ideas and find fault with them). Western medicine places diagnosis as a central goal, whereas other approaches, including Indigenous medicine, see it as less central and pay more attention to finding a safe environment in which the patient may recover. For conditions such as mental disorders, this latter approach may prove more effective than struggling to fit a label to the disorder.
Here are some background notes to make you aware of some common Indigenous healing practices that your Indigenous patients may mention. You should at least have a general understanding of what these involve.
- Indigenous medicine contains innumerable folk remedies based on plants, many of which have formed the basis for pharmaceutical treatments that we use routinely in Western medicine
- Traditional approaches to healing are holistic and consider mind, body and spirit. Medicine is distinguished from healing, which goes beyond mere treatment of sickness. As Donald Warne points out, it is somewhat ironic that modern physicians say they provide health care when they really treat diseases. (Warne D: Traditional perspectives on child and family health. Paediatr Child Health 2005;10:542)
- The healing relationship is based on a series of virtues: respect; humility; compassion; honesty; truth, sharing, hospitality and divine love.
- Traditional Indigenous care recognizes many routes to healing. Seven routes are commonly mentioned: Talking, Crying, Laughing, Dancing, Sweating, Yawning, and Yelling (giving vent to your feelings, not yelling at someone!)
- Much traditional healing centers around group ceremonies, including prayers, the sharing of a meal, the use of traditional medicines and practices such as sweat lodges. Healing also involves feeling part of a shared culture, of being outdoors and in connection with the land and with nature. The Cree of James Bay, for example, emphasize the interconnections of people and animals; hunters feel respect and love for the animals; a feast is a communal way to express this respect. The traditional lifestyle naturally encourages healthy eating and exercise. (The biophylia hypothesis and ecopsychology hold that humans have an instinct to connect emotionally with nature and that dissociation from nature has caused disease and social pathologies). This has led to the idea of land-based healing programs that seek to put people back in touch with nature.
The Medicine Wheel
The medicine wheel symbolizes the interconnection of all life, the various cycles of nature, and how life represents a circular journey. The number four is sacred to the many Indigenous peoples of North America and can represent many things: the four seasons, the four parts of a person (physical, mental, emotional and spiritual); the four kingdoms (animal, mineral, plant and human); the four sacred medicines (sweetgrass, tobacco, cedar and sage). Hence, you may see the medicine wheel presented in several different ways:
- The four points of the compass, each with a guiding spirit, symbolize stages in the life journey. The East, direction of the daily birth of the sun, represents a person's birth and early years. The South relates to childhood and intellectual growth. The West symbolizes adulthood and introspection, while the North represents the old age, wisdom and the spiritual aspects of life. The centre of the wheel is symbolic of Mother Earth and the Creator, and their role in the beginning and continuation of life.
- The four points can also represent the balance between spiritual (East), mental (North), physical (West) and emotional (South) aspects of health.
- The wheel can also represent values and decisions. Here, values (drawn in the East, where the sun rises) influence decisions taken in the mental realm (drawn in the North, at the top). Then, decisions are implemented in the physical realm (West), and actions produce reactions in the emotional realm (South). Finally, these reactions provide feedback into the value system, completing the circle of value - action - evaluation.
- The quadrants of the wheel are often colored red, yellow, black, white or green.
For a traditional healer, an imbalance (e.g., the loss of traditional values, perhaps resulting from experiences in residential schools) may affect health decisions (e.g., leading to alcoholism). Here is an article on the medicine wheel in healing.
The Four Sacred Medicines
1. Sweetgrass (the North) is used by almost all Indigenous peoples in North America for ritual cleansing. When Sweetgrass is walked on, it bends but does not break. Hence, it has been associated with virtue: an injustice can be returned by a kindness, by bending, not breaking.
2. Tobacco (the East) is held as a scared plant by most First Nations peoples. Tobacco connects us to the spirit world; it absorbs prayers and carries them to the spirit world. If a request is accompanied by an offer of tobacco that is accepted, the promise must be honored. Tobacco can also be used to thank the Creator for his gifts: if you enjoyed good weather, you could leave some tobacco on the ground, and say thank you for the gift. Tobacco is generally not smoked, except on special ceremonial occasions.
3. Cedar (the South) is used for purification and (taken as a tea) to attract positive energy, feelings, emotions and for balance. Its vitamin C content helped prevent scurvy when fruits and vegetables were unavailable during the winter months.
4. Sage (the West) is a women's medicine, conferring strength, wisdom, and clarity of purpose. It is a powerful purifying medicine that drives away negative energies. Sage can be found braided and hung in people’s homes, perhaps tied with a ribbon in one of the colors of the medicine wheel. The threefold braid represents body, mind and spirit.
A 'smudge' is smoke used for ritual cleansing. Smudging is a ceremony traditionally practiced by some Indigenous cultures to purify or cleanse negative energy, feelings or thoughts from a place or a person. Sacred medicines such as cedar, sage, sweetgrass or tobacco are burned in an abalone shell. The shell represents water, the first of four elements of life; the medicines represent gifts from mother earth and the burning represents fire, the next two elements. The person puts their hands in the smoke and carries it to their body, especially to areas that need spiritual healing (mind, heart, body). The smoke represents air, the final element. Perhaps the smell of the burning medicines stimulates the brain to produce beta-endorphins and promote healing processes.
Meetings held to heal physical, emotional and spiritual wounds. A symbolic object, often an eagle feather, may be given to a person who wishes to speak, and then it is passed around the circle in sequence to others who wish to speak. Shamans may conduct the ceremony.
A ceremonial sauna used for healing and cleansing. It made of a wooden framework covered by blankets or skins, usually igloo-shaped, about 1.5 metres high and large enough for eight people to sit in a circle on the ground. Hot stones are placed in a shallow hole in the centre of the lodge. A medicine man pours water on the stones to produce steam and participants may spend an hour sweating in the lodge. The lodge combines the four elements of fire, water, air and earth. Ceremonies include offerings, prayers, and reverence. At times, excessive exposure to the heat of the lodge may have health effects; also toxins can be released if grasses that have been exposed to pesticides are placed on the rocks. Further information.
Sun Dance (a.k.a. Rain Dance, Thirst Dance, Medicine Dance)
A ritual that celebrates the harmony between man and nature, and spiritual dedication. Originally practiced at the summer solstice, the sun dance represents continuity between life, death, and regeneration. The symbolism often involved the buffalo, on which plains Indian groups depended, so deserving reverence, but which they also had to kill. Four days before the ceremony, the dancers prepare by purifying themselves, at times in a sweat lodge, by meditating and collecting ceremonial items of dress to use in the sun dance. The sun dance itself takes another four days, and generally involves drumming, singing, and dancing, but also fasting and, in some cases, self-inflicted pain. This symbolized rebirth and often involved piercing the skin and attaching cords that the person had to tear out. This element led governments to suppress the sun dance around 1880, but it has been re-introduced.
The pipe is used individually and in groups for prayer and ceremonial purposes. Participants gather in a circle. A braid of sweetgrass is burned to purify the area and those present, to make a sacred place for the spirits to visit. Tobacco or kinnickkinnick, a traditional mixture of bearberry and wild herbs or red willow shavings, is smoked so that prayers can be made to the Great Spirit or requests made of the spirits. The pipe may also be smoked to open other meetings or ceremonies. When not in use, the bowl and stem are separated and carried by one individual, the pipe holder. Further information
A ceremonial feast among northwest Pacific coast Native peoples held to celebrate major family events such as a marriage or birth. The host distributes gifts according to the status of each guest; reinforcing the perceived hierarchical relations between groups. At times the gift-giving became competitive, the host giving away personal possessions in anticipation that others would reciprocate in their turn. Such largesse enhanced the host’s prestige. Missionaries encouraged government to outlaw the potlach around 1885; it is now common. Further information
- Review of Aboriginal health systems in Canada (pdf article from J Aboriginal Health, 2004)
- NAHO has an overview document on traditional knowledge and medicine
- Comparison between Aboriginal and Western medical traditions
- Basic facts and figures on the Health status of Aboriginal peoples in Canada
- An Australian web site on Aboriginal healing
Nadine Caron. MD, MPH, offered some helpful comments on treating Indigenous patients:
- Non-verbal communication (intended or unintentional) is extremely challenging as there are so many different cultural expectations. For example:
- In some Indigenous cultures it is disrespectful to look into a person’s eyes as the eyes are the window to the soul. In North American culture, of course, looking into a person’s eyes suggests interest, honesty and concern. So an Indigenous patient who avoids looking into your eyes may be showing you respect – not that they are not interested in what you are saying.
- An Indigenous patient who uses a soft voice may also be signaling respect. In turn, use a soft tone back to them.
- Sometimes an Indigenous patient will respond to your question with what seems a long-winded story. Be patient: the reply may contain both the information you want and also an indication of their feelings. You may prefer brevity, but if you cut the patient off you will be regarded as “the doctor who didn’t care.”
- Many Indigenous cultures do not perceive status as deriving from education, titles or income. Although it is important that patients hear your opinions, you may anticipate that they will also expect you to hear theirs.
- Treat the patient, not the illness. Try to learn about the whole person; they may view health in terms of overall balance so it is important that you assess more than just the physical.
- Avoid generalizations and make no assumptions about your patients.
- “Background knowledge of a culture is valuable, but simply observing and asking questions can clarify uncertainties”
- Indigenous patients expect health care professionals to respect them as persons.
(Nadine Caron, MD MPh. Caring for Aboriginal patients: the culturally competent physician” Royal College Outlook Fall 2006;3(2):19-23)
From the introduction to cultural awareness, here are some ideas to bear in mind when caring for Indigenous patients.
1. Moral codes. There is huge variation between different Indigenous groups, but you should be aware of several common values held by many groups. Taken together, they form a beautiful approach to living:
- The Earth has intrinsic value and humans must care for it as its custodian.
- Prayers of thanks or blessings should be made to the Creator every day for all living things.
- All living things and objects have a spirit. When taking the life of a plant or animal of the Earth, a person should pay respect to its spirit. Gifts of sacred plants such as tobacco should be made to the plant or animal spirits when such a life is taken for use or consumption.
- Families are valued greatly, including extended families and other individuals who may be considered family. Respect must be shown to every individual, especially adults and children.
- Gifts should be given to show respect or to seal an agreement.
- While individuals control their own behavior, they should do so in consideration of the community in which they live.
- A person should strive to be good, and this can be achieved in part through participation in ceremonies
- All sacred objects must be treated as such by anyone touching them.
2. In some traditions, values are linked to directions:
Up; Father sky
Down; Mother earth
Centre; within yourself
(From: Warne D: Traditional perspectives on child and family health. Paediatr Child Health 2005;10:542)
3. The Many Hands, One Dream declaration offers some powerful resolutions on child health.
Self determination: whose community is it?
It really does take a community to raise a child, but whose community? Since colonization, Indigenous ideas of health were put aside by mainstream ideas, which were presumed to be a better way of caring for Indigenous children …
Intergenerational: a healthy world across the generations
We have inherited the world as our ancestors left it to us. Their decisions, actions and beliefs have had a direct impact on our lived experience, just as our decisions will affect generations to come …
Non-discrimination: equitable access for all children
Indigenous children and youth face serious discrepancies in their experience of health and health care …
Holism: the whole child
The health of Indigenous children is a balance between the physical, spiritual, emotional and cognitive senses of self and how these interrelate with family, community, world and the environment, in the past, present and future. . .
Respect for culture and language
Culture shapes concepts of health and health care, defining what is considered legitimate health care practice and what is not. (…) The health care system that currently serves Indigenous children and youth is assumed to be culturally neutral when in fact it is infused with mainstream culture that does not necessarily make room for the world view of Indigenous peoples …
Shared responsibility for health: the best of both worlds
Indigenous children need the best that Indigenous and non- Indigenous systems have to offer. For that to happen, the mainstream needs to make space for Indigenous concepts of health. It needs to improve its capacity to work with Indigenous children and families. One way is to improve the links between professionals working in child and youth health and communities, increasing their understanding of Indigenous perspectives of health. (…) These new relationships would be characterized by reciprocity, respect and a balance of power
4. Here are some common health practices you may encounter
Medicine pouches may be worn when an individual wishes to call on the protection of the spirits of the four cardinal directions. An elder prescribes the contents of the pouch, which may include the four sacred plants, or items such as diamond willow fungus, dried or powdered beaver testicles, and buffalo droppings. They will usually be burned when the owner wishes to invoke the power of the spirits. A sacred pouch must not be touched by anyone but the person wearing it or the elder, for doing so would be a violation of the religious sensibilities of the wearer and a desecration of the contents. The sacred herbs are sometimes worn pinned to clothing.
Fasting (both food and drink) over one or several days is sometimes used as a spiritual experience. An elder may provide guidelines for the fast and ensure that the health of the individual is adequate for fasting conditions. A physician may also be asked to assess the person’s health.
Certain rituals or celebrations may require specific foods that have a symbolic importance for the ritual or ceremony. These foods vary between tribal traditions. At times of sickness, rattles may be used to call the spirit of life to assist in healing the affected individual. A sick person may wish to burn tobacco, sweetgrass or other sacred herbs as an aid to healing.
Death and Burial. Funeral and mourning practices vary among different Nations and individual families. Most First Nations people who are Christian usually prefer the funeral and burial practices particular to their church. Those who follow native spiritual traditions may observe a variety of practices that can include burying the person’s possessions with them; keeping a sacred fire burning on the grave for a period of days; a mourning period of week or more (sometimes up to a year); holding a feast after the period of mourning. Further information.
Long, uncut hair is common and is considered sacred by some First Nations. Hair may be braided; three braided strands signify the body, mind and spirit. Braids or uncut hair generally signify that the style worn is of spiritual and cultural importance to the individual and reinforces his or her sense of identity as a member of a particular First Nation.
- Janet Smylie: A Guide for Health Professionals working with Aboriginal peoples. This contains a set of recommendations (see foot of page 5) covering the awareness of physicians practicing among Aboriginal populations.
Updated December 1, 2017