'Cultural safety' tackles racism in aboriginal health care February 03, 2009 | Wendy Glauser

The movement is known as “cultural safety” and its driving force is the current crisis in aboriginal health care.

“The health disparities for Inuit, Métis and First Nations people are extreme and persistent,” says Dr. Barry Lavallee, a family doctor in Winnipeg and vice-president of the Indigenous Physicians Association of Canada. “We can’t afford not to make aboriginal health a priority.”

Aboriginal people suffer from type 2 diabetes at a rate three to five times above the Canadian average. One-third of native Canadians die violent deaths. They’re also three times more likely to be hospitalized for a preventable reason.

Cultural safety, first coined in the 1990s by a Maori nurse in New Zealand, attempts to ingrain within all health-care workers a critical understanding of how power imbalances in society affect health, particularly aboriginal health.

Delving into a past Canadians rarely discuss, that of colonialism, genocide and residential schools, cultural safety rejects superficial “do’s and don’ts” and vague notions of respect for practical resolutions.

Reflect on prejudices
Under a cultural safety framework, for example, health-care workers will be expected to conscientiously reflect on their own racial prejudices while doctors will spend more time with aboriginal patients than they currently do.

Already, several hospitals in British Columbia routinely hold cultural safety sessions for staff. One of them, the Vernon Jubilee Hospital, recently designated a room to accommodate ceremonial burnings—a rite aboriginal people believe eases the passage of a recently deceased person’s spirit.

Medical schools at the University of Calgary and the University of Manitoba have incorporated cultural safety into their core medical curriculum, and within five years all medical students will have to pass cultural safety examinations in order to graduate, says Dr. Evan Adams, a physician and the aboriginal adviser to the B.C. premier.

“Physicians are products of society. We’re just as prone as anyone to classism and racism,” says Dr. Lavallee.

Lawrence Berg, a Canada research chair in human rights, diversity in identity, said he has heard case after case of an aboriginal patient suffering a diabetic attack being told to “sober up” in his research with the Okanagan Urban Aboriginal Health Research Collective.

Other commonly held misconceptions include that most aboriginals live on a reserve and that aboriginals are uneducated or don’t live modern lifestyles, says Berg.

Such misguided stereotypes not only skew diagnostic decisions, but the assumptions also affect doctor-patient communication. “When I visit my doctor, my health care is very much a partnership,” says Berg. “But with aboriginals, there’s often the assumption that they’re not capable of making complex decisions about their health and it’s necessary to talk in short sentences with small words.”

Cultural safety stresses that aboriginal communities in Canada are by no means homogenous. At the same time, however, cultural safety recognizes that aboriginal people may have needs that Canada’s health-care system, by setting “whiteness” as the standard, has completely overlooked.

Aboriginal Canadians often seek out health advice and counselling sessions from traditional sources, for instance, and “doctors don’t acknowledge that or what that means for the patient,” Dr. Lavallee says.

Cultural safety standards call for doctors to ask patients questions about spirituality and to understand the basic beliefs and rites around child bearing, morality, and practices around death and dying.

“Canadians are beginning to recognize that the agreed upon standard of health care may not actually work for everyone,” says Dr. Adams.
“Cultural safety provides a space for cultural difference.”

Indeed, says Berg, studies have shown that cultural safety, by raising awareness of how religion, culture, socioeconomic status and racism affect health, results in improved care for all minorities.

The particular focus on aboriginal health care, however, is justified given the modern legacy of colonialism in Canadian society, Berg argues.

In a survey of patients in Vancouver’s downtown, Dr. Adams discovered one-quarter of his aboriginal patients had been to residential schools. The statistic was a major eye-opener: “If I don’t screen my patients for residential schools, then I’m missing a huge component of their trauma issues,” he says.

Understanding the continuing marginalization of aboriginal people in Canadian society will help counter the erroneous mindset that aboriginals “get everything,” a pervasive view here, says Dr.
Lavallee. “That is the most destructive thing to feel toward someone who doesn’t feel empowered at all.”

To exemplify the continuing cycle of how Canada’s violent colonial past affects aboriginal health today, Dr. Lavallee talks about a 37-year-old alcoholic native patient who, on their first meeting, showed him the scars on his back from the times his mother, likely a product of a residential school herself, beat him for being “too dark.”

More than anything, however, cultural safety is about bringing attention to structural racism and to issues in aboriginal communities that are largely invisible in mainstream society.

The death of Brian Sinclair, a native man, after 34 hours in a Winnipeg ER epitomizes this invisibility, according to Berg.

“An internal review into his death . . . says that nobody did anything wrong, and they probably didn’t in stripped, technical definitions of the current policies, but that says something about the policy.

“So we’ve got to look at the policies, the system and ask, ‘How does that happen?’”

MEDICAL POST