On Nov. 2, Dr. Evan Adams, MD, MPH, the Deputy Chief Medical Officer for Indigenous Services Canada,spoke to a virtual audience as part of MEDiveristy Week 2022: Securing health equity for all. Dr. Adams, a member of the Tla’amin (Sliammon) First Nation, has worked extensively with First Nations health programs in Canada. He served as deputy provincial health officer with the British Columbia Ministry of Health, and wasappointed the first-ever Aboriginal Health Physician Advisor for the province of British Columbia. Dr. Adams spoke about Indigenous health and wellbeing, which goes beyond the physical health of an individual. To improve health outcomes today, Dr. Adams shared that Canada must address their country’s violent past—and present—towards Indigenous Peoples. Below are highlights of some of his lecture that have been edited for length and clarity.

The Great Reckoning

Some of you may have heard of the Great Reckoning, that thousands of Indigenous child graves have been found in dozens of former residential schools. They called them residential because Indigenous students came and lived there, though they were not quite schools. They were more like prisons, and the education that they gave to all the children was very rudimentary. And this experience, which lasted for a number of generations in Canada, apparently killed thousands of our children. Rediscovering these graves has caused quite a lot of self-reflection amongst Canadians. How could a civilized country like Canada, or the United States—and the the United States had lots of schools—do this to a particular ethnic group, particularly to their children? In what was state-sanctioned and church-sanctioned violence against the most vulnerable, against our children, who are now adults. What does this mean?

Indigenous peoples are original peoples. We’ve been here since, well, many thousands of years. Mesopotamia was 5,000 years ago. Indigenous peoples in the Americas have been here for at least 10,000 years, more like 20,000 or 30,000 years. We have a long history here on this continent. We used to own everything, and now we own hardly anything. And we have the worst health of any ethnic group in this country. And is that by accident or is that by possibly design?

Health of the people is connected to the past

I want to talk about the health of the people—that’s my job.  The health of the people is not just their physical bodies—it’s their mind and their body and their spirit. And they would say that our health and wellbeing is connected to our peace of mind, to access to justice, access to opportunities, access to our own wealth, to fairness, to duty, and to culture. Social determinants of Indigenous health are shown over and over again to be directly related to community health. When we put it in another way, if I could cure your cancer, but I return you to homelessness, have I done all that I can for your health and wellbeing? It’s no accident that those who are wealthier are generally healthy, and that those who are poorer, suffer and die more frequently…

I think some of us forget what a long history we’ve had in these countries, in our own homelands. In Utah, you are very close to settlements that still exist, or at least used to exist, of Indigenous Peoples, who’ve been there for a very, very, very long time. And we still exist. I live in my home territory where generations of my ancestors are here, just right here. And I remember the story that I was told when I was a child. My great-grandfather was born in 1860. In 1862, a smallpox epidemic began in San Francisco, it whipped south, down into the Central/South America, and whipped north, from San Francisco all the way up to Alaska. And amongst all the coastal Indigenous people, about a third of them died. A third of my village died. About 5% to 10% of them were blinded by smallpox, including my great-grandfather. But we have stories of him being a woodcutter. His daughters would lead him into the forest and he’d feel around for wood, and he’d cut them by hand. And at the end of the day, his daughters would come get him, and they would take the wood that he would cut, and they’d sell it on the road. Whenever I think I’m having a hard life, I remember my great-grandfather.

My mother was in a residential school from grade two until grade 12. My father went for only one year. His mother had my father in 1936. She had tuberculosis and she died when he was 16 months old, so he was raised in our way, which is that he was raised by his grandmother to follow the ways of his people. He had to do cold water baths, or cold-water cleanse, which we’re just learning now in sports medicine is a really good way to build endurance. He grew up with our knowledge, which was… well, we never called it traditional knowledge, it was just called knowledge. If you live here, you should know where the food is, you should know where the deer are, you should know where the water is.  And with that physicality and that formal training, he could do sports very, easily. And probably he had some good genetics, but I think that most of it’s because that’s just the way that he grew up.

Political power to fight against racism

For us, as Indigenous people, it is a new day. In the old days, let’s say the 1960s, we had much less political might than we do now. And we refuse to be second-class citizens in our own country, in our own territories. We would like to have a say in our future. That can be hard for settlers to hear, because they’re accustomed to not sharing power.

Here in this country a couple of years ago, we had a woman named Joyce Echaquan. A First Nations woman in Quebec, the French-speaking area of our country. This young woman recorded a video while she was being degraded by a hospital staff. The nurses were yelling at her as she lay dying. And those were broadcast via Facebook live. So, she managed to capture these racist acts against her while she was in the health care system. And this resulted in quite a strong response from all over the country. We essentially asked ourselves, how racist is our health care system? How safe is our health care system? How common is everyday workplace racism? And if racism is happening in our workplaces and in health environments, what does it mean for the health outcomes of Indigenous Peoples?

The incident prompted a report called In Plain Sight that addressed Indigenous-specific racism and discrimination in British Columbia health care. In what was an extraordinary, but very simple gathering of stories of racism in health care in BC, my province that I live in, tens of thousands of people came forward and said, “Yes, I had a racist experience while I was very vulnerable and seeking help within the BC, or British Columbia, health care system.” And those were logged, analyzed, and many recommendations came from that report. I suggest you have a look at it and ask yourself the question: How safe is my system? And what would people say if I asked, “Have you had a racist encounter within my health care system?” What would that report point you towards? What action do you need to be looking at the most?

For us, as Indigenous people, one of the things that helps me the most to imagine a new and improved system that’s much more fair, egalitarian, much more safe and accessible, is to imagine that there is a circle of care around people. Including Indigenous people, including minorities, including People of Color.

So when you look at the circle of care, or the health care system, my thoughts are not necessarily just around getting those within the circle of care to do better, but to expand that circle of care so that there are more of us who should be there. Let’s expand the circle. Let’s open the door. Let’s invite people in. Let’s expand our idea of who’s helpful, and let’s have a circle, not a hierarchy, but a circle. And as many of you know, it’s not just doctors and nurses who give us wellbeing. It can be family members. It can be those who help our elderly. It can be educators. It can even be a coach who helps our younger family members. So, I’ve talked about the social determinants of Indigenous health, and how we’re not just looking at physical bodies and diseases. We’re looking at community health.

Reckoning with the violence of the past

Canada’s Truth and Reconciliation Commission collected bodies of children who died at the residential schools and discovered many thousands of graves…and I think this will change our country in that we are forced to examine our own history to reflect on how we find ourselves today. How do we deal with situations where we know settlers committed violence against us in order to obtain our land? And that we find ourselves now in this time of uneasy peace between us, where we can’t make up stories about crimes in the past, we have to say what really happened.

And part of that is anger. I definitely feel angry. Even though I’m what’s called an intergenerational survivor, a descendant of two residential school survivors, even though I was a formal honorary witness to the Truth and Reconciliation Commission and talked about residential schools and what happened in Canada. The Pope met with the chiefs of Canada to apologize for what happened in residential schools. And this had a lot of meaning in Canada and sparked a lot of discussion in the States. What does it mean? How do we make this right?

The way forward, to me, is clear. We need to sit down and have conversation and make sure students are learning the truth of what happened. Another part of the answer is to create cultural safety and what I call cultural humility, which is for health care professionals to know your community that you work in. Don’t go in and say, “Oh, I’m a really self-important health care professional, and I’m going to be the boss of you, the insignificant patient or community member.” I’m going to come in with humility and say, ” I’m trained in our way. I want to be helpful. I have biases, so for instance, I don’t know what it’s like to have a baby as a man. As a cis-gender man, I have no idea what it’s like to actually physically have a baby. But I have empathy, and so let’s work together on this issue. That’s a humble tradition, but that’s cultural humility.

There needs to be accountability in the healthcare system to say whar are appropriate and inappropriate actions, what are the quality of our actions, and how can we improve. And you can’t improve the quality of our service unless we admit we can improve the quality of our service. But it’s amazing to me just how many health care professionals don’t admit that they can do better.

Improving healthcare for Indigenous Peoples

Luckily for us in Canada, we have our very first Indigenous president of the Canadian Medical Association, and he’s promoting policy and systems change, and engaging the Indigenous communities for more inclusion. And that does in fact bring up then the concept of allyship. So allyship to me is really the addition of an anti-racist stance, which includes not just individual racism. Way too many people think racism is individual racism, when really it’s institutional and structural racism. Through the National Consortium for Indigenous Medical Education, we asked Indigenous people what they want, what they think is important. They said that it’s important for us to be strong as Indigenous people, not just smart. So, not just be the person with the fanciest degree, but the one who is knowledgeable in our philosophies and ways…

Sometimes wellbeing is related to resistance. And so, I think when we’re trying to understand equity and trying to lift everyone up, that anger is sometimes present. It’s a very normal and a very healthy part of resistance. So even something simple as collecting data about Indigenous people, which isn’t done. I sometimes have to feel anger or take an angry stance, in order to ensure change. It doesn’t mean being destructive. It doesn’t mean being aggressive. But to say that I am frustrated with a colonial system that doesn’t collect data about Indigenous People is necessary to change it.