Introduction

Recent events in Canada surrounding the tragic death of Ms. Joyce Echaquan in Quebec, and the decade-long investigation into the death of Mr. Brian Sinclair in Manitoba, have catalyzed attention to Indigenous-specific racism and the ways it characterizes, deepens, and perpetuates inequities and poor health outcomes for Indigenous peoples. Against this backdrop are repeated calls for identifying and addressing anti-Indigenous racism in Canadian healthcare systems (see for example, Brian Sinclair Working Group, 2017; McCallum & Perry, 2018; National Inquiry into Missing and Murdered Indigenous Women and Girls, 2019; Public Health Agency of Canada, 2020). In the wake of Ms. Echaquan’s death and widespread public outrage, Ottawa hosted a series of meetings in 2020–2021 for federal, provincial, and territorial governments; First Nations Inuit and Métis political and service delivery organizations; and health system partners, to discuss racism in healthcare. These discussions focused on short- and long-term concrete actions to eliminate anti-Indigenous racism in healthcare systems and encourage organizations to continue developing and implementing response strategies. As members of the Brian Sinclair Working Group, we note that the recommendations emanating from these discussions focused on:

  • Launching engagements to support the co-development of distinctions-based (First Nations, Inuit, and Métis) Indigenous health legislation.

  • $2 million to the First Nations governing authorities of Manawan Atikamekw Council and Atikamekw Nation Tribal Council in Quebec for training and education on the right to equitable access to social and health services, as stated in Joyce’s Principle (Council of the Atikamekw of Manawan and the Council of the Atikamekw Nation, 2020).

  • $4 million for the creation of a National Consortium on Indigenous Medical Education led by the Indigenous Physicians Association of Canada, tasked to provide leadership and implement Indigenous-led projects to reform and update the education of physicians.

In this commentary, we propose additional strategies, areas for consideration, and recommendations for embedding anti-racism into Canada’s health sector. Our aim is to intensify the dialogue in Canada regarding the need for multi-tiered, system-level efforts to address anti-Indigenous racism with the explicit aim of transforming healthcare cultures, policies, and practices in support of health equity.

Reflection on proposed responses

The development of a distinction-based Indigenous health legislation has been called for decades, as a way to clarify areas of jurisdictional confusion documented as key structural barriers to equity since 1969 (Booz-Allen & Hamilton Canada Ltd., 1969). The federal government provides and funds health services for First Nations and Inuit outside of any legislative framework. To date, the federal government has repeatedly side-stepped demands to itemize the obligations it recognizes as its own, and as a result refuses to be held accountable for poor outcomes. Federal-provincial-territorial jurisdictional confusion continues to result in delays in access to healthcare and perpetuates inequities (Lavoie, 2018). On April 14, 2016, the Supreme Court of Canada ruled that the Federal Government has Constitutional responsibility for Métis and non-Status Indians: this decision has yet to impact policy. While the proposed distinction-based legislation, to be co-developed by federal and Indigenous governments, may reduce instances of systemic racism resulting from jurisdictional confusion, it will not hold provincial and territorial governments accountable to address systemic racism in their respective systems, which is the key issue at hand here.

Providing $2 million to the Manawan Atikamekw Council and Atikamekw Nation Tribal Council in Quebec for the implementation of Joyce’s Principle is commendable: this commitment aims to guarantee that all Indigenous peoples have “the right of equitable access, without any discrimination, to all social and health services, as well as the right to enjoy the best possible physical, mental, emotional and spiritual health” (Council of the Atikamekw of Manawan and the Council of the Atikamekw Nation, 2020). These funds will be spent on training and education for non-Indigenous people, and is a step in the right direction. Too often, Indigenous-centric resources are produced in English, but remain more limited in French. The emerging dialogue on systemic racism in Quebec’s healthcare system is more likely to be fruitful if the Atikamekw and other First Nations are resourced to fully participate. However, it is unlikely that this initiative will have a significant impact on other provincial and territorial healthcare systems. Additionally, and arguably, the cost and labour for this now clearly identified gap in health-profession education and training should not fall on First Nations people and governments; nor does $2 million seem adequate if training and education are viewed as part of wider system changes.

Across Canada, calls are mounting for governments and health authorities to address the ongoing health inequities affecting Indigenous peoples—including specific calls to address anti-Indigenous systemic racism (Kétéskwēw Dion Stout et al., 2021; McCallum & Perry, 2018; Turpel-Lafond, 2020). The resources designated to support improved physician training are laudable. However, directing funding only to physician training overlooks the evidence showing the extent to which all types and levels of healthcare staff, including physicians, nurses, social workers, security guards, healthcare aides, intake workers, and triage staff, among others, can (often unintentionally) become caught up in perpetuating systemic racism. Given the extent to which healthcare is delivered by interprofessional teams, efforts toward supporting anti-racism education would need to include all healthcare staff. Furthermore, research continues to show that training and education on the right to equitable access to health and social services, while valuable, are insufficient without broader structural transformation in conjunction with accountability mechanisms, policy directives, and organizational change (Hansen et al., 2019).

Embedding anti-racism in the Canada Health Act

Although the Charter of Rights and Freedoms guarantees that every Canadian is entitled to constitutional and human rights protections against discrimination, the ongoing harms and poor health outcomes affecting Indigenous peoples within healthcare systems demonstrate an ongoing denial of basic human dignity that is deeply rooted in Canada’s history of colonialism. Lawyers advocating for the Sinclair family’s position regarding the death of Mr. Brian Sinclair are continuing to argue for system-level changes. Indigenous peoples are rights holders, yet human rights breaches continue to occur—as was so tragically rendered visible in the case of Ms. Joyce Echaquan. As the Chief Commissioner of the Ontario Human Rights Commission recently observed, one-off legal responses to racist incidents in healthcare are not an effective way to address racism as an inherently structural issue (Chadha, 2020).

Medicare, the healthcare system created by the adoption of the Canada Health Act, is widely recognized by Canadians as part of their national identity. The adoption of the Canada Health Act created a nationally articulated healthcare system by linking, and to a limited extent, harmonizing the 10 provincial and more recently, three territorial healthcare systems, while allowing for considerable adaptation at the provincial and territorial levels (Lavoie, 2018). For the past several decades, many Canadians have consistently rated the Canadian healthcare system as one of the leading symbols of Canadian identity (Tuohy, 2018). However, the Canada Health Act was also built and is maintained without consultation with Indigenous peoples in Canada.

We contend that adding anti-racism to the Canada Health Act will prompt a national dialogue, trigger the development of universal policies and programs to interrupt systemic and interpersonal racism in health systems, and be sustainable over time despite changes in governments and political ideologies. To date, more than 2000 individuals and organizations have signed our open letter calling on the federal government to adopt anti-racism as a pillar of the Canada Health Act. On Nov. 5, 2020, Senator Mary Jane McCallum tabled a motion to call on the government to adopt anti-racism as the sixth pillar of the Canada Health Act, stating that “concerted action at the highest levels of influence and authority in Canada is required to disrupt racism in the Canadian health-care system” (Sen. Mary Jane McCallum becomes 1st Indigenous woman chancellor of Brandon University, 2021). While the federal Indigenous Services Minister at the time did not officially rule out this approach, the department maintains a “carrots over sticks” (education, not law) approach to addressing racism in Canada. We do not think this will go far enough to effect change. Rather, enshrining anti-racism as a sixth core principle would acknowledge the transformative changes needed within Canada’s health system to foster health equity, prevent further deaths and harm to Indigenous peoples and other groups, and set benchmark expectations and minimum requirements for provincial, territorial, and healthcare organizations and institutions.

Until this is achieved, we are calling for all healthcare institutions and organizations to continue to operationalize plans for accountability, and consider how accountability measures can be built in as organizational aspirations (see for example, Johansen et al., 2021; University of Manitoba Rady Faculty of Health Sciences, 2020). This call intersects directly with the recently released report from the Quebec coroner’s inquiry into the death of Ms. Joyce Echaquan, which identifies, as the top recommendation, for the province to acknowledge that systemic racism exists and “make the commitment to contribute to its elimination” (Bureau du Coroner du Québec, 2021, p. 20, our translation).

Conversations that challenge the status quo will be required to reconsider how, for example, complaints or concerns about racism or other forms of discrimination are handled, how apologies are offered, and what kinds of locally relevant transformative actions can ensue. In collaboration with, and taking guidance from local communities and leaders, processes for addressing complaints might include, for example, restorative justice processes or healing circles. Importantly, accountability mechanisms aimed at redressing anti-Indigenous racism will require organizations and institutions to set minimum requirements for engaging people and communities with lived experiences of racism and other forms of discrimination, both in advisory capacities and as full partners, to work toward the ideals of reconciliation.

We applaud the leadership of the federal government in hosting a national conversation following the death of Ms. Echaquan. We also recall the deafening silence of the federal government following the death of Mr. Brian Sinclair (Brian Sinclair Working Group, 2017; McCallum & Perry, 2018). Still, and despite the best of intentions, we remain concerned that current plans will fall short, that other tragedies will occur, and that another generation of tepid actions will lead to insufficient actions that eventually lose momentum.

The time to act is now.