Québec’s Minister Responsible for Relations with the First Nations and the Inuit, Ian Lafrenière, recently introduced Bill 32, which aims to “establish the cultural safety approach within the health and social services network.”
The intent of the bill is for health and social service networks in Québec to adopt a cultural safety approach towards Indigenous people, taking into account cultural and historical realities.
In November 2020, in the aftermath of the death of Joyce Echaquan at the Centre hospitalier de Lanaudière in Joliette, the Québec government introduced 90-minute mandatory Indigenous cultural awareness training for all employees of the province’s ministry of health and social services.
The goal of this training was to quickly sensitize health-care personnel to Indigenous cultures in order to improve the care provided for First Nations and Inuit Peoples in the Québec health and social services system.
It also aims to deconstruct myths and prejudices regarding Indigenous Peoples, to foster effective intercultural communication and to allow employees to better work with members of Indigenous communities.
However, since the training program was launched, Indigenous leaders and health professionals have said it fails to improve cultural safety and poses safety risks to Indigenous Peoples.
Legislating individuals and systems to shift behaviours and attitudes is useless without well-developed cultural safety programs developed and delivered by Indigenous Peoples.
Cultural safety
In April, we attended a round table on cultural safety organized by the Québe Network Environment for Indigenous Health Research on cultural safety alongside Indigenous scholars, patient partners and other community members in Montréal. Participants at the round table arrived to the same conclusions and supported concerns that the content of the mandatory training is inadequate and contains inaccuracies.
In addition, important results and calls to actions from the Truth and Reconciliation Commission, the Viens Commission Report, and the National Inquiry into Missing and Murdered Indigenous Women and Girls are not mentioned during the training. Glaringly absent are also any references to the concept of cultural safety, cultural humility, systemic racism and Joyce’s Principle — which “aims to guarantee to all Indigenous people the right of equitable access, without any discrimination, to all social and health services.”
In this article, we assert that Québec’s training falls short of its objectives because it is based on three flawed assumptions about the problem at hand.
1. Racism is an individual problem.
The focus on mandatory training as a solution to a systemic issue misrepresents the problem of racism as an individual problem of bias, attitudes and knowledge. Discrimination by health-care professionals should not be viewed only as individual acts, but as part of broader patterns of institutional and systemic racism.
Researchers and scholars in this field assert that racism in health care needs to be understood in the context of past and current colonialism.
It is a fact that colonial policies of assimilation were based on a racist ideology that presupposed inferiority of Indigenous Peoples. These policies have imprinted racist structures and stereotypes across institutions.
For instance, when analyzing the case of Echaquan, coroner Géhane Kamel revealed her mistreatment took place in an environment that lacked culturally appropriate resources, was characterized by inequitable practices and tolerated racist attitudes and comments.
Understanding the problem of racial discrimination in health care means we must frankly and openly discuss contemporary colonialist and racist realities. To address systemic racism and its influence on health, we need to go beyond individual racial bias and address structural power inequalities. Systemic racism needs systemic solutions, not individual ones.
2. Racism, bias and stereotypes can be addressed through cultural sensitivity training.
The educational strategies that underlie the awareness training are insufficient to countering racism and fostering cultural safety. This is because the training program is based on a cultural sensitivity approach. However, numerous studies suggest this kind of training may reinforce negative stereotypes of the concerned groups.
Cultural sensitivity tends to focus on having knowledge of a patient’s culture and reducing their experience of the health-care system to a matter of overcoming cultural differences.
Research shows that cultural safety is a better way to foster change. It compels us to examine the power imbalances and racial inequities underlying the health-care system. Cultural safety promotes an approach to foster change that moves away from simply learning about a culture. Instead, it aims to help staff examine their own beliefs and how these manifest in their interactions with Indigenous patients.
Scholars propose a conception of cultural safety as a systemic approach to health-care transformation, one that goes beyond individual training but engages organizations and society as a whole towards the principles of cultural safety, equity, social justice and decolonization. As such, comprehensive Indigenous cultural safety training programs should explicitly integrate notions of power, privilege, colonialism and racism.
3. Cultural safety can’t be developed without involving the concerned groups.
The lack of meaningful involvement by Indigenous stakeholders is a critical weakness of the awareness training. However, cultural safety privileges the autonomy and self-determination of Indigenous Peoples in relation to their health services, and as such, promotes their empowerment.
The current awareness training does not significantly involve Indigenous stakeholders. It relies on few Indigenous perspectives and voices compared to non-Indigenous professors for instance. This is contrary to the very concept of cultural safety. It also contradicts all the declarations, protocols and principles established by Indigenous groups in the last decades, which are based on the rallying cry “nothing about us without us.”
Cultural safety should be guided by the people it concerns. They are the only ones with the lived experience to share on the topic of safety and on the nature of the desired care.
This approach to health-care transformation recognizes Indigenous expertise in designing solutions relevant to their needs. Cultural safety is aligned with principles that promote empowerment and rely on values such as respect, equity and reciprocity.
In addition to failing to address the problems Indigenous people face, the training risks further marginalization and continued discrimination, as well as increased distrust of government and institutions among Indigenous populations.
For these reasons, this training should be immediately discontinued. To create a more equal health-care system, Indigenous people, organizations and health-care professionals — Indigenous or not — must have space to develop solutions based on cultural knowledge, lived experiences and their collective expertise.
The authors of this piece would like to acknowledge the significant contributions made to the article by the members of the Indigenous patient partner circles of the Unité de Soutien SSA Québec.