Indigenous cultural safety: Necessary for Indigenous health
Image: Mi'kmaw Elder Dorene Bernard leads a Water Walk in Antigonish, NS, on October 28, 2017.
In this blog post, Jaime Stief unpacks some of the concepts discussed in a recent NCCDH-hosted webinar on Indigenous health promotion, tying them to ideas brought up in a workshop on Indigenous cultural safety at TOPHC 2018. The author is a White settler who lives and works in Waterloo, Ontario, on the Haldimand Tract, the traditional territory of the Neutral, Anishnaabeg and Haudenosauonee peoples.
In the 2018 edition of Health Promotion in Canada,  Dr. Charlotte Loppie (University of Victoria, NCCAH advisory committee member), discusses the diversity of Indigenous communities in Canada while highlighting the determinants that, despite this diversity, collectively influence Indigenous health outcomes. Writing about the considerations that health promoters should make when addressing health inequities faced by Indigenous peoples, she makes a case for the importance of centring cultural safety in these efforts:
Health promotion professionals who have established respectful relationships with Indigenous partners take the time to learn about local, regional and national distinctions and similarities. … It is critical that health professionals and policy-makers gain a comprehensive appreciation of how historical and current political intrusions have shaped social inequities as well as the health promotion needs of Indigenous communities. Otherwise, health promotion programs might duplicate disrespectful practices and represent a form of colonial oppression. [1p186] [Emphasis added.]
Loppie’s explanation (and subsequent case examples) explores the importance of recognizing how Indigenous communities are directly and indirectly impacted by the legacy and contemporary reality of European colonization. As Loppie explains, recognizing the impact of colonialism on present inequities is a crucial step in preventing the duplication of previously harmful practices and promoting the dismantling of opressive systems.[1p187]
Establishing respectful relationships
The cultivation of respectful relationships with Indigenous partners as Loppie describes above is an ongoing process requiring consistent reexamination of policies, assumptions and impact. Loppie’s work on this topic is particularly relevant to the NCCDH because, since 2016, we have been making efforts as a team and organization to better understand how to promote racial equity from within. In addition, the Calls to Action in the 2015 Truth and Reconciliation Commission of Canada report  set standards for NCCDH work. Many of the Calls relate to improving determinants of health, and Call No. 23 [ii] requires all levels of government to “provide cultural competency training for all healthcare professionals.”  This challenges organizations like the NCCDH to create resources that speak to Indigenous health issues.
Unpacking cultural safety
In the July 24, 2018, webinar, Loppie addressed the political and social contexts of Indigenous health promotion, unpacking some of the social determinants of Indigenous health. She referenced the World Health Organization’s definition of the social determinants of health  that, she pointed out, emphasizes the “political decisions about resources and power or control that shape inequity.”  This assessment is key in rooting social inequities within larger structures, such as the health implications of waste disposal near Indigenous or African-Canadian communities,  or the negative mental health outcomes of racialized people in areas with fewer social and economic resources. 
Dr. Marcia Anderson (University of Manitoba and Winnipeg Regional Health Authority) made a similar observation in a 2018 workshop on Indigenous cultural safety she contributed to at The Ontario Public Health Convention in Toronto.  Drawing on the work of Camara Phyllis Jones,  Anderson highlighted “inaction in the face of need” as a key expression of institutional racism, which impacts both Indigenous peoples and other racialized peoples. Loppie’s and the Anderson’s observations highlight systems in which the needs of racialized groups are deprioritized and the conditions that contribute to this marginalization remain unquestioned.
As the root cause of institutional racism towards Indigenous peoples in Canada (and elsewhere),  the ongoing legacy of colonialism is what necessitates conversations about Indigenous cultural safety today. In the same TOPHC workshop where Anderson presented, members of the Ontario Indigenous Cultural Safety Program (OICSP) discussed  the Cultural Safety Continuum,  a framework Cheryl Ward adapted from the work of Terry Cross.  The model offers examples of how non-Indigenous practitioners may articulate their level of Indigenous cultural competence, spanning cultural destructiveness [iii] to cultural safety. [i] It is important to note that, in this model, practitioner attitudes and behaviours are a determinant of Indigenous cultural safety: non-Indigenous practitioners — some of whom are subject to institutional racism themselves — must take responsibility and initiative for making public health spaces, policies and leadership receptive to Indigenous experiences and knowledge if they wish to promote Indigenous health. Taking on the mantle of anticolonial practice is especially crucial for White settlers, who benefit the most from the colonial system and from institutional racism in general.
Cheryl Ward’s Cultural Safety Continuum,  adapted from the work of Terry Cross  and presented by the Ontario Indigenous Cultural Safety Program (with permission) at TOPHC 2018. The top level of the Cultural Safety Continuum ladder represents a system in which Indigenous peoples feel comfortable and welcome accessing public health services.
Action initiated by non-Indigenous people
Reflecting on her experience of working with non-Indigenous practitioners wishing to promote Indigenous health, Loppie made the following observation:
People often say “I want to understand Indigenous people so I can do good work.” It’s just as important to understand yourself and the context of that work as it is to understand the forces that have shaped indigenous peoples’ health. 
Her explanation highlights the idea that, for non-Indigenous practitioners, acknowledging the determinants of Indigenous health, such as employment, environmental stewardship and self-determination,  is not enough. In order to fully understand how these determinants function in relation to Indigenous world views (of which there are many), non-Indigenous practitioners must also become more aware of their own world views, including how the dominance of these views contributes to their own sense of cultural safety. By developing a sense of the conditions that contribute to non-Indigenous cultural safety (i.e., systems that cater to our larger world views), non-Indigenous people like myself can hopefully gain perspective on how draining it would be to navigate a system that contradicts — and has actively sought to eradicate — Indigenous world views. As Loppie explained, “It’s not about doing for [Indigenous peoples] or even sometimes doing with; it’s about giving over resources [and] power, and working in service of community.”
Loppie’s presentation was complemented by a segment hosted by Mariette Sutherland,  the manager of Indigenous engagement at Public Health Sudbury & Districts (PHSD). Providing an example of change at the institutional level, Sutherland described her health authority’s process of enacting an Indigenous Engagement Strategy (see diagram below), which started in 2016 and is ongoing.
Diagram from Mariette Sutherland’s webinar presentation on July 24, 2018.  These diagrams describe the process Public Health Sudbury & Districts has taken to enact an Indigenous Engagement Strategy, starting in 2016.
The PHSD process has included the following measures:
- A board motion signaling “formal expression of commitment”
- The establishment of an external advisory committee with Indigenous voices to draw in ‘culturally appropriate and community-driven guidance’
- Staff development opportunities, such as training on the Truth and Reconciliation Commission findings, knowledge exchange with those who have worked on similar projects in the past, and a Relationship Principles and Values workshop to find common ground among project participants
When describing the project’s key learnings so far, Sutherland recognized the importance of Indigenous self-determination, an essential element of Indigenous cultural safety.
Centring cultural safety
Loppie’s, Anderson’s and the OICSP’s emphasis on Indigenous cultural safety is echoed by the work of the San'yas Indigenous Cultural Safety Training Program, a BC-based organization offering introductory training designed for those working at health authorities. [iv] As a follow-up to the NCCDH’s two-part webinar series titled “Racing” the Social Determinants of Health and Health Equity (Part 1; Part 2), we are excited to collaborate with San’yas on an upcoming webinar that will highlight anti-Indigenous racism in relation to health equity. The date of the webinar will be announced in our e-newsletter and on Twitter.
Photo credit: Jaime Stief
[ii] Call to Action 23: “We call upon all levels of government to: i. Increase the number of Aboriginal professionals working in the health-care field. ii. Ensure the retention of Aboriginal health-care providers in Aboriginal communities. iii. Provide cultural competency training for all healthcare professionals.” 
[iii] In his original publication, Terry Cross defines cultural destructiveness as the “attitudes, policies and practices which are destructive to cultures and consequently to the individuals within the culture.” [13p1-2]
[iv] The OICSP’s presentation at TOPHC 2018 was based on teaching materials provided (with permission) by the San’yas Indigenous Cultural Safety Training Program.
 I Rootman, A Pederson, K Frohlich, S Dupéré, editors. Health promotion in Canada. 4th ed. Toronto (ON): Canadian Scholars' Press Inc; 2017.
 D Wilson, S Ronde, S Brascoupé, A Nicole Apale, L Barney, B Guthrie, . . . S Wolfe. Health professionals working with First Nations, Inuit, and Métis - consensus guidelines. J of Obstetrics and Gynaecology Canada. 2013;35(6),550-553.
 Truth and Reconciliation Commission of Canada. Truth and reconciliation commission of Canada: calls to action [Internet]. Winnipeg (MB): The Commission; 2015 [cited 2018 Sep 22]. p 2. Available from: http://www.trc.ca/websites/trcinstitution/File/2015/Findings/Calls_to_Action_English2.pdf.
 C Loppie. Indigenous health promotion. Presentation delivered digitally as part of Promising practices in Indigenous community health promotion webinar; 2018 Jul 24. Available at: https://youtu.be/JT81cH-LDE0.
 World Health Organization [Internet]. [Location unknown]: The Organization; c2018. Social determinants of health [cited 2018 Sep 22];[1 screen]. Available from: http://www.who.int/gender-equity-rights/understanding/sdh-definition/en/.
 I Waldron. Environmental racism and the politics of waste [Internet]. Waterloo (ON): Waterloo Global Science Initiative; 2018 Apr 25 [cited 2018 Sep 22]. Video: 1 hour. Available from: http://wgsi.org/video/ingrid-waldron-environmental-racism-politics-waste-generationsdg.
 S Nestel. Colour coded health care: the impact of race and racism on Canadians’ health [Internet]. Toronto (ON): Wellesley Institute; 2012 [cited 2018 Sep 22]. 30 p. Available from: http://www.wellesleyinstitute.com/wp-content/uploads/2012/02/Colour-Coded-Health-Care-Sheryl-Nestel.pdf.
 M Anderson. Grounding public health in the colonial context. Workshop presentation at: The Ontario Public Health Convention; 2018 Mar 21-23; Toronto (ON).
 Camara Phyllis Jones. Levels of racism: a theoretic framework and a gardener’s tale [Internet]. American Journal of Public Health; 2000 Aug;90(8):1212. Available from: https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.90.8.1212.
 C Reading. Understanding racism [Internet]. Prince George (BC): National Collaborating Centre for Aboriginal Health; 2013 [cited 2018 Sep 22]. 8 p. Available from: https://www.ccnsa-nccah.ca/docs/determinants/FS-UnderstandingRacism-Reading-EN.pdf.
 R Ray, D Wesley. Getting to the roots of tolerance: transformation in public health settings. Workshop presented at: The Ontario Public Health Conference; 2018 Mar 23; Toronto (ON).
 C Ward. Cultural safety continuum [figure]. 2015 Feb 19 [cited 2018 Sep 22]. In: C Ward, San’yas Indigenous Cultural Safety Training. Beyond good intentions: moving to Indigenous cultural safety. Presentation at: Journey to safety: creating a place of belonging. 2015 Feb 19; Ottawa (ON). Available from: http://www.wabano.com/wp-content/uploads/2015/03/Beyond-Good-Intentions-Moving-to-Indigenous-Cultural-Safety-Cheryl-Ward.pdf.
 T Cross. Services to minority populations. Cultural competence continuum. Focal Point; 1988;3,1-9.
 M Greenwood, S de Leeuw. Web of being: social determinants and aboriginal people’s health [figure]. [Date unknown];[cited 2019 Sep 22]. In: Social determinants of health and the future well-being of Aboriginal children in Canada [Internet]. Paediatr Child Health; 2012 Aug-Sep:17(7),381-384. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3448539/figure/f1-pch17381/?report=objectonly.
 M Sutherland. Promising practices in Indigenous community at Public Health Sudbury and Districts. Presentation delivered digitally as part of Promising practices in Indigenous community health promotion webinar; 2018 Jul 24. Available at: https://youtu.be/uYk1xHL8slI.