Calls for cultural safety training for health-care staff renewed after Joyce Echaquan's death

Indigenous health professionals say the recent death of an Atikamekw woman in a Quebec hospital reiterates the need for governments to implement longstanding calls to action to combat racism in health care.

Joyce Echaquan, a 37-year-old woman from the Atikamekw community of Manawan, Que., died in a hospital in Joliette, Que., last week after recording medical staff hurling racial slurs. A nurse and an orderly have since been fired, and a number of investigations have been launched.

The Canadian Indigenous Nurses Association (CINA) and Canadian Nurses Association denounced the treatment Echaquan received, stating that it is a clear example of the need for a mandatory cultural competency and humility training program for health-care professions.

It's one of the 94 calls to action that the Truth and Reconciliation Commission (TRC) released in its 2015 final report.

"It will help in addressing systemic barriers, challenges and the outcomes that all of us must deal with," said Marilee Nowgesic, chief executive officer at CINA.

"It's amazing to think that in this date and time in Canada that there are a lot of people who don't know about Indian residential schools, don't know about Indian day schools, don't know about missing, murdered indigenous women and girls."

The TRC also called for medical and nursing schools in Canada to require all students to take a course dealing with Indigenous health issues. While several medical schools across Canada offer courses on Indigenous health issues, not all are mandatory.

"These should not be elective courses," said Nowgesic.

"At some point everyone is going to have an encounter with an Indigenous person in their health profession. Let's give them the tools to make that treatment or that treatment plan with their clients a positive outcome."

She said her organization has been working with the Canadian Association of Schools of Nursing on revising nursing curriculum and is trying to co-ordinate with all levels of government responsible for curriculum modifications.

"The deans within the universities in Quebec have accepted the challenge to say we need to address this better," she said.

"It won't happen overnight, but at least the steps are being done to address it."

Need for government implementation

Dr. Samir Shaheen-Hussain, a Montreal physician and assistant professor in the Faculty of Medicine at McGill University, wrote the book Fighting for a Hand to Hold: Confronting Medical Colonialism against Indigenous Children in Canada. 

For the 2019-2020 academic year, he said, none of Quebec's four faculties of medicine exceeded 20 compulsory hours dedicated to Indigenous health and health care issues in their medical undergraduate programs.

"We're not talking about issues tied to cultural safety, and as far as I know none of the medical schools discuss the establishments' own role in medical violence," he said.

Shaheen-Hussain said one of the cornerstones of cultural safety is recognizing the history of colonialism in producing the inequalities and inequities in health care. He said some faculties are doing their best to address the issue but the kind of change needed requires policies and practices that are government-implemented.

"It's not enough for one faculty of medicine or of nursing in the province to implement practices… It has to be across the board," he said.

"The issue is that the recommendations are never fully or properly implemented. In Quebec, one of the most infuriating situations is that the premier of Quebec, Francois Legault, consistently denies the very existence of systemic racism."

The Viens Commission, which looked into the treatment of First Nations and Inuit in Quebec by the public service and issued its report last year, echoed many of the calls to action from the TRC including adding a component, developed with Indigenous authorities, on First Nations and Inuit in professional programs at colleges and universities.

The commission also called for an amendment to the province's health act to enshrine the concept of cultural safeguards.

Legualt said in the National Assembly last week that his government is taking action on the training of public service personnel to combat prejudice, and Quebec's minister responsible for Indigenous Affairs minister Sylvie D'Amours said many of the 142 calls to action from the Viens Commission are being worked on.

"Implementing such a comprehensive and voluminous report is a gradual process," she said in a statement last week.

"What matters is that we continue to move forward in constant respect of our commitment to walk hand in hand with First Nations and Inuit. Implementing the Calls to Action and Justice remains my priority, and I look forward to being able to report good news to you in the near future."

Targeting anti-Indigenous racism

Similar to the TRC and Viens Commission, the national inquiry into missing and murdered Indigenous women and girls called for ongoing anti-bias and anti-racism training, education on local Indigenous languages and culture, and awareness about history of colonialism for everyone involved in the provision of health services to Indigenous people.

Citing a report on violence from the Quebec public health institute, the inquiry's final report stated that language barriers, mistrust, and "lack of cultural skills" contribute to the inadequacy of the services provided to Indigenous people in the province, including how some workers may "take approaches that perpetuate victim-blaming or judgmental attitudes regarding certain behaviours, such as alcohol consumption."

Dr. Barry Lavallee, the medical advisor for Manitoba Keewatinowi Okimakanak, which represents First Nations in northern Manitoba, testified to the inquiry as an expert witness about discrimination Indigenous women often face when accessing health services.

Echaquan's story did not surprise him.

"We know that stereotyping proxy to racism kills, it maims, and it increases levels of sickness through a variety of ways," he said.

"You're going to have people who say they've made progress but that progress does not translate, in Manitoba, to improved health outcomes."

Lavallee said clear and distinct laws, processes and consequences for Indigenous-specific racism must be targeted. 

"It sounds like it's a radical thing because the discourse in medicine and nursing is the concept of cultural competency, sensitivity, humility, and safety but that is a non-progressive, stepwise fashion to address hard drive racism against Indigenous people," said Lavallee.

"Policies are fine — it will take you five years to pull them together. I don't have time for five years, so I want action now."