Positionality statement

During my first year of medical school at the University of British Columbia, an Indigenous youth went missing on the streets of Amiskwaciy Waskahikan (Edmonton). As a Nehiyaw (Cree) and Otipemisiwak (Métis) Indigenous youth worker, I worked as an Indigenous liaison in an Edmonton school district by creating spaces and opportunities for our sacred Indigenous youth, and I worked with this particular missing youth for an extended time as a traditional “auntie,” advocating for them in their education while providing cultural and spiritual experiences. Upon their disappearance, we—their community and their family—were at a complete loss as to their well-being. After a taxing series of search parties, posters, fundraising, and media coverage (and lack thereof), our sacred youth was found living but not well. What resulted for them and their family was a multiyear process of custody, ownership, financial burden, and ultimately failing and fractured health. My role throughout the experience was that of distressed and helpless bystander; throughout the search and the subsequent consequences, I was terrified for the lives of those involved. I struggled with the threat not only that the youth might become a statistic of the missing and murdered Indigenous women and girls (MMIWG) (and men and boys) tragedies, but that their family would fall victim to the mental, emotional, physical, and spiritual harm that I have witnessed during the fallout of these tragedies. Since then, this youth and their family truly have become statistics of tragedy, their health marred by the trauma of the situation and its proceedings.

As I continued to integrate into the world of Western medicine in the UBC Southern Medical Program, I was strongly compelled by my experience to advocate for the wellness of victims such as my sacred youth and their family. I saw a gap in the intended holistic care we provide for Indigenous patients and their families. I witnessed several health concerns in my Indigenous community members that directly stemmed from their MMIWG tragedy experience, including posttraumatic stress disorder, suicidality, depression, and eating disorders.

After careful review of the literature and guidance from my ever-growing mentorship from Indigenous physicians and allied health care workers, recommendations for physicians were born [Box 1]. These recommendations invite physicians to enrich their care and enhance their approach to providing necessary health services to the Indigenous population that has been affected by the MMIWG tragedies. The recommendations are actionable and direct, and they are accompanied by a list of relevant terms [Box 2] and patient resources [Box 3] designed to provide physicians with a supplement to the care they provide to Indigenous people in British Columbia.

As I near the end of my training as a medical student, I see a need for cultural support for our fellow BC physicians as the pressures of providing care for more and more patients with increasingly complex needs rise. I hope this article supports you in your goals to provide more deeply informed and holistic care to my Indigenous brothers and sisters.

Two reports on Indigenous health issues: Problems and solutions

Two reports—Reclaiming Power and Place: The Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls and In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in BC Health Care—make it clear that there is a great need for strategies to address the specific health needs of Indigenous people affected by the MMIWG tragedies.[1,2] It is important to note that it is not only women and girls that are affected by the MMIWG tragedies; men, boys, and nonbinary, queer, trans, Two Spirit, and gender-nonconforming people are affected as well. The health outcomes of Indigenous people affected by these tragedies are undermined by a combination of a violent systemic colonial history and suboptimal cultural-safety education. Indigenous needs may be better served by improving health care providers’ understanding of how to safely and efficiently provide care.[1] As the number of both documented and undocumented missing and murdered Indigenous people climbs through the thousands, it is crucial that physicians have necessary resources available.

Many Indigenous patients are affected by the MMIWG tragedies because of the structure and function of traditional Indigenous kinship and communities. Although a patient may not be directly tied to a victim, these tragedies affect whole Indigenous communities. Special care may also be extended to survivors who were once a missing person themselves and are in need of trauma-informed, safe medical care.

Reclaiming Power and Place report and recommendations

The Reclaiming Power and Place report focuses on testimonies from families and friends of missing individuals in Canada by sharing the findings of the truth-gathering process.[2] Section 2 of the report addresses encountering oppression and proposes an approach that defines a right to culture, a right to health, a right to security, and a right to justice. It describes how the federal government’s approach to health programs and services for Indigenous people does not enforce any statutory or treaty obligations to provide health services for First Nations or Métis people.[2] Based on several Indigenous witnesses’ descriptions of the failings of Canadian health care,[2] I believe that health care providers’ unfamiliarity with traditional and holistic elements of Indigenous well-being plays an instrumental role in the discrepancies in health outcomes for families.

Reclaiming Power and Place also identifies that implicit discrimination violates one of the fundamental principles of human rights and often lies at the root of poor health status;[2] it then urges that barriers to health and well-being, such as lack of trauma-informed care for Indigenous people, should never be considered normal.[2] Because there are not enough financial supports and sustainable funding models to encourage Indigenous individuals to enter into health and wellness fields,[2] non-Indigenous physicians may respond to these deficits by practising informed and compassionate care. Although non-Indigenous physicians practising informed care may not replace the need for Indigenous physicians, I believe it is instrumental in easing the implicit discrimination that exists in the current standard of Indigenous care in Canada.

In Plain Sight report and recommendations

The In Plain Sight report conducted an Indigenous Peoples’ survey that examined stereotyping and racism, discrimination at the point of care, decreased access to health care, and poor outcomes in British Columbia hospitals.[1] In total, 2780 Indigenous people responded to the survey;[1] 20% of all respondents “do not trust health care workers,”[1] and 19% “always receive poorer service than others.”[1] Only 27% “always felt like their needs were taken seriously,” as compared to the 59% of non-Indigenous respondents who “felt that their needs were always taken seriously.”[1] The report references specific poor outcomes that Indigenous people face in BC, including higher suicidation, higher levels of stress, reduced life expectancy, increased rates of chronic disease, and higher infant mortality.[1] Suicidation is a term used in the report; it encompasses suicidal ideation, suicidal thoughts, and suicide attempts. I believe these findings may be extrapolated to the context of family, friends, and communities affected by the MMIWG tragedy, a group of individuals who are undoubtedly faced with a high burden of stress and mental health comorbidities. The recommendations included in Box 1 may be used by physicians to improve the reliability and trustworthiness experienced by their patients by fostering an environment of care and understanding.

The recommendations of the In Plain Sight report almost exclusively call for administrative and governing systems to make changes that will trickle down to individualized care provided by specialists and primary care physicians.[1] Until these higher-level recommendations are enacted, physicians are left to their own devices to initiate change and begin to challenge their workspaces. Many physicians may feel compelled to transform their practices to even further facilitate the unique needs of their Indigenous patients affected by the MMIWG tragedies.

A word of hope

Physicians may feel discouraged that so many of the implicit issues in the health care system depend on redesigning system-level approaches to Indigenous health care. I hope these recommendations instead serve as a starting point for those who are motivated by the inequities and driven by the need to provide trauma-informed, safe, and directed care for a systemically disadvantaged group.

Acknowledgments

The author thanks Dr Michael Dumont, CCFP, for his supervision of the Flexible and Enhanced Learning research project that yielded these recommendations, as well as Dr Kala Draney, PGY1, Dr Randi George, PGY3, and Ms Jenna Burke, MS13, for reading and providing feedback on these recommendations.

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This article has been peer reviewed.

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

References

1.    Turpel-Lafond ME. In plain sight: Addressing Indigenous-specific racism and discrimination in BC health care. Addressing racism review summary report. November 2020. Accessed 15 December 2021. https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf.

2.    National Inquiry into Missing and Murdered Indigenous Women and Girls. Reclaiming power and place: The final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. Vol 1a. 2019. Accessed 14 December 2021. www.mmiwg-ffada.ca/wp-content/uploads/2019/06/Final_Report_Vol_1a-1.pdf.

3.    UNHCR. Gender-based violence. Accessed 15 December 2021. www.unhcr.org/gender-based-violence.html.

4.    Menzies P. Intergenerational trauma and residential schools. The Canadian Encyclopedia. Topic last updated 25 March 2020. Accessed 15 December 2021. https://thecanadianencyclopedia.ca/en/article/intergenerational-trauma-and-residential-schools.

5.    BC Mental Health and Substance Use Services. Trauma-informed practice. Accessed 15 December 2021. www.bcmhsus.ca/health-professionals/clinical-professional-resources/trauma-informed-practice.

6.    Wells VS. Transgender. The Canadian Encyclopedia. Topic last updated 16 September 2022. Accessed 15 December 2021. www.thecanadianencyclopedia.ca/en/article/transgender.

7.    Institute for Integrative Science and Health. Two-Eyed Seeing. Accessed 15 December 2021. www.integrativescience.ca/Principles/TwoEyedSeeing.

8.    Filice M. Two-Spirit. The Canadian Encyclopedia. Topic last updated 2 February 2023. Accessed 15 December 2021. www.thecanadianencyclopedia.ca/en/article/two-spirit.

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Samantha Erron Gibbon is a Nehiyaw (Cree) and Otipemisiwak (Métis) iskwew who hails from Edmonton, Alberta. She completed her undergraduate degree at the University of Alberta and is currently completing the third year of her medical degree in the UBC Southern Medical Program. She enjoys spending time with her daughter and participating in traditional crafting and dance.