Indigenous people in Canada suffer far worse health outcomes than the national average. Rates of maternal and infant mortality, tuberculosis, hypertension, diabetes, and suicide are just a few of the most striking disparities.[1,2] The United Nations Human Development Index includes three basic dimensions of well-being: a long and healthy life, access to knowledge, and a decent standard of living.[3,4] In 2019, Canada ranked 13th out of 189 countries on the index. When that same ranking was applied to Canadian First Nations communities, they ranked 63rd.[5] These statistics, while tragic, are not new.

I think that physicians are well intentioned. We spend our lives trying to heal others. Why, then, are we failing so badly at our attempts to help Indigenous people? To better understand the issue, I spoke with Dr Terri Aldred, a family physician from Tl'azt'en Nation who lives on Lheidli T'enneh territory, in which Prince George is located.

Dr Aldred has seen countless grants and initiatives directed at “fixing those Indigenous people.” Unfortunately, she pointed out, “Indigenous people have been studied to death” by White saviors, and each generation wants to think that they have solved the problem. However, failure to appropriately consider the impact of intergenerational trauma remains a catastrophic shortcoming of many efforts to improve the lives of Indigenous people. Colonialism and the enduring harm of residential schools are two root causes of the health and social inequities that we see today.[6] Even when her patients die for natural reasons, Dr Aldred explained, they still die 10 years below the average Canadian life expectancy.

Her words reminded me of a phrase from White Fragility, Robin DiAngelo’s best-selling book on race relations in America: We don’t have an Indigenous problem; we have a White people problem.

Indigenous people are dying of racism

To DiAngelo, racism is not a matter of “simple intolerance.” She defines White supremacy as a “highly descriptive sociological term for the society we live in, a society in which White people are elevated as the ideal for humanity.”[7] Her book urges White people to have the “uncomfortable, awkward, and frustrating” conversations that confront their racist worldview and acknowledge that they hold disproportionate institutional power. “White fragility” is DiAngelo’s term for the “propensity of White people to fend off suggestions of racism, whether by absurd denials (‘I don’t see color’) or by overly emotional displays of defensiveness or solidarity.”[7]

Let’s be clear, DiAngelo (and I in quoting her) does not think that all White people are bad, or hateful, or intentionally discriminatory. When I asked Dr Aldred about White fragility, she understood why White people avoid talking about racism—because it makes us feel shame. I agreed, having experienced my own feelings of shame about the actions of my ancestors and the ways in which my life has been easier, just by being born White.

Ironically, racism is easy to ignore because it is ubiquitous. Dr Aldred likened it to “trying to get a fish to see water.” A racist worldview can be composed of habits and thoughts that are subtle, almost imperceptible.[7] She reassured me that acknowledging racism does not make one a bad person. Quite the opposite: “We can’t heal what we can’t name.”

So how do we be better? When I asked Dr Aldred that question, she could have called out my arrogance and oversimplification of the issue (and she would have been well within her right to do so). I know there is no easy solution. But what if readers genuinely want to improve the situation for Indigenous people in Canada? What then? Many of us feel that the institutional and governance changes required to address systemic racism are beyond our control. How can one person make a difference from the bottom up?

“It’s time to turn the mirror around,” said Dr Aldred. She believes that each of us can rebuild and re-create our worldview through self-reflection. Several tools have been developed for this purpose.[8-10] The CHARGE2 framework,[8] for example, is designed to equip health care workers to mitigate unconscious bias. It suggests that you:

• C—Change your context: Is there another perspective that is possible?
• H—Be Honest: With yourself, acknowledge and be aware.
• A—Avoid blaming yourself: Know that you can do something about it.
• R—Realize when you need to slow down.
• G—Get to know people you perceive as different from you.
• E—Engage: Remember why you are doing this.
• E—Empower patients and peers.

Dr Aldred encourages us to take time after a patient interaction, or a committee meeting, or a journal article reading, to consider the embedded biases or engrained racism. How does it make you feel? If the process is painful or difficult, you’re probably on the right track. Listen to your patients, reflect, repeat. “It’s like peeling back the layers of an onion,” she described. “Healing is a journey.”

Dr Aldred’s three favorite resources on this subject are:

1. The Secret Path, by Gord Downie (https://secretpath.ca)
2. Indigenous Knowledge to Close Gaps in Indigenous Health, TEDxUManitoba, by Dr Marcia Anderson-DeCoteau (www.youtube.com/watch?v=IpKjtujtEYI)
3. The Inconvenient Indian, by Thomas King (www.penguinrandomhouse.ca/books/93028/the-inconvenient-indian-by-thomas-king)

—Caitlin Dunne, MD, FRCSC

Acknowledgment

Thank you to Dr Terri Aldred, a Dakelh from Tl'azt'en and proud member of the Lysiloo. She is a family physician and the site director for the UBC Indigenous Family Medicine Residency program.

References

1.    Rammohan I. Why do Canada’s Indigenous people face worse health outcomes than non-Indigenous people? The Varsity. 15 September 2019. Accessed 27 July 2020. https://thevarsity.ca/2019/09/15/why-do-canadas-indigenous-people-face-worse-health-outcomes-than-non-indigenous-people.

2.    Ramraj C, Shahidi FV, Darity W, et al. Equally inequitable? A cross-national comparative study of racial health inequalities in the United States and Canada. Soc Sci Med 2016;161:19-26.

3.    United Nations Development Programme. Inequalities in human development in the 21st century. Accessed 27 July 2020. http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/CAN.pdf.

4.    United Nations Development Programme. 2019 Human Development Index ranking. Accessed 27 July 2020. http://hdr.undp.org/en/content/2019-human-development-index-ranking.

5.    Mackrael K. Close the gap between Canada and its Aboriginal people: AFN chief. The Globe and Mail. 13 May 2015. Accessed 27 July 2020. www.theglobeandmail.com/news/politics/close-the-gap-between-canada-and-its-aboriginal-people-afn-chief/article24430620.

6.    Wilson D, de la Ronde S, Brascoupé S, et al. Health professionals working with First Nations, Inuit, and Métis consensus guideline. J Obstet Gynaecol Can 2013;35:550-558.

7.    Bergner D. “White fragility” is everywhere. But does antiracism training work? The New York Times Magazine. 15 July 2020. Accessed 27 July 2020. www.nytimes.com/2020/07/15/magazine/white-fragility-robin-diangelo.html.

8.    DallaPiazza M, Padilla-Register M, Dwarakanath M, et al. Exploring racism and health: An intensive interactive session for medical students. MedEdPORTAL 2018;14:10783.

9.    Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. Am J Public Health 2015;105:e60-e76.

10.    Perdomo J, Tolliver D, Hsu H, et al. Health equity rounds: An interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. MedEdPORTAL 2019;15:10858.