6.2 Anti-Indigenous Racism, Truth and Reconciliation & Trauma-Informed Care

6.2 Anti-Indigenous Racism, Truth and Reconciliation & Trauma-Informed Care

Systemic and Anti-Indigenous Racism in Canadian Healthcare

Anti-Indigenous racism within the Canadian healthcare system is not a collection of isolated interpersonal incidents, but an entrenched, structural reality rooted in centuries of colonial policy. Under the Canadian Paramedic Competence Framework (CPCF Areas F2 and F3), primary care paramedics must recognize how historical and ongoing colonial legislation—specifically the Indian Act of 1876, the forced displacement of communities onto reserves, the establishment of racially segregated "Indian Hospitals," and unauthorized nutritional and medical experimentation on Indigenous children—laid the groundwork for deep institutional inequities and widespread mistrust of medical authorities.

Contemporary independent investigations and coroners' inquests have decisively exposed the ongoing reality of anti-Indigenous racism across Canadian emergency and acute care services:

• The In Plain Sight Report (2020): Led by Dr. Mary Ellen Turpel-Lafond, this landmark investigation into British Columbia’s healthcare system documented widespread, systemic racism, stereotyping, and discriminatory profiling against Indigenous patients. The report revealed that Indigenous peoples routinely experience delayed care, denial of service, racist slurs, and substandard clinical treatment due to healthcare providers presuming they are "intoxicated," "drug-seeking," or "unfit parents."
• Joyce's Principle and the Death of Joyce Echaquan (2020): Joyce Echaquan, an Atikamekw woman and mother of seven, died in a Joliette, Quebec hospital while hospital staff subjected her to degrading racial insults as she cried out in pain. Her courageous act of live-streaming the abuse galvanized international condemnation. Joyce’s Principle asserts that all Indigenous peoples have an equal right to access highest-quality physical, mental, emotional, and spiritual healthcare, free from all forms of discrimination, with full respect for their traditional knowledge and medicines.
• The Brian Sinclair Inquest (Winnipeg, Manitoba): Brian Sinclair, an Indigenous double-amputee, was referred to a Winnipeg emergency department for an easily treatable blocked catheter. He was ignored by staff for 34 consecutive hours, vomiting and deteriorating in his wheelchair, because healthcare workers assumed he was "sleeping off" intoxication or homeless. He died of preventable acute peritonitis and septic shock.

In prehospital paramedicine, anti-Indigenous racism frequently manifests when paramedics dismiss acute presentations—such as altered mental status, hypoglycemia, stroke, closed head injuries, or septic shock—as simple alcohol intoxication or drug use based solely on the patient's Indigenous ancestry. Overcoming systemic racism requires paramedics to actively confront their own implicit biases, challenge derogatory commentary from colleagues, and adhere to uncompromising clinical assessment standards for every patient.

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The Truth and Reconciliation Commission (TRC) Call to Action #24

The Truth and Reconciliation Commission of Canada (TRC) was established to uncover the truth regarding the history and devastating impacts of the Indian Residential School system. In its 2015 Final Report, the TRC published 94 Calls to Action. Among these, Call to Action #24 stands as a direct, foundational mandate for Canadian healthcare education and professional regulation:

TRC Call to Action #24

"We call upon medical and nursing schools in Canada to require all students to take a course dealing with Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices. This will require skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism."

For prehospital clinicians, Call to Action #24 establishes that knowledge of colonial history, treaty relationships, constitutional protections (Section 35 of the Constitution Act, 1982), the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), and anti-racism is a mandatory clinical competence. Paramedics must recognize that Indigenous health disparities—including elevated rates of chronic metabolic disease, cardiovascular disease, tuberculosis, and suicide—are not biological or cultural traits, but direct consequences of social dispossession, colonial policy, and ongoing systemic inequity.

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Intergenerational Trauma: Colonial Roots and Prehospital Manifestations

Intergenerational trauma refers to the cumulative, collective psychological and biological wounding transmitted across generations within a family or cultural group following massive, systemic trauma. The primary drivers of intergenerational trauma among Indigenous populations in Canada include:

1. The Indian Residential School (IRS) System (1883–1996): More than 150,000 First Nations, Inuit, and Métis children were forcibly removed from their families, homes, and cultures under federal law and placed into church-run institutions designed to "kill the Indian in the child." Children experienced rampant physical, emotional, and sexual abuse, malnutrition, and cultural suppression, severing familial bonding and parenting knowledge across multiple generations.
2. The Sixties Scoop (1950s–1980s): The mass removal of Indigenous children from their families by child welfare agencies, placing them into non-Indigenous foster and adoptive homes across Canada, the United States, and Europe, continuing the trauma of family separation.
3. The Contemporary Millennium Scoop: The ongoing, extreme overrepresentation of Indigenous children within provincial child welfare systems, driven by poverty, inadequate housing, and systemic discrimination rather than parental neglect.

Biological and Clinical Manifestations in Prehospital Care

From a neurobiological standpoint, severe historical trauma results in chronic dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system. This state of sustained allostatic load causes elevated cortisol and inflammatory markers, contributing to premature cardiovascular illness, diabetes, and complex post-traumatic stress disorder (C-PTSD).

When responding to emergencies involving Indigenous patients or communities, paramedics must recognize how the prehospital environment can trigger traumatic stress:

• The Paramedic Uniform and Authority: Dark uniforms, epaulets, badges, radios, high-visibility tactical vests, and heavy boots closely resemble law enforcement and historical colonial officials (such as the RCMP and "Indian Agents") who forcibly removed children from their homes.
• Hypervigilance and Defensive Responses: An Indigenous patient experiencing acute distress may display heightened suspicion, emotional withdrawal, flat affect, or verbal defensiveness. These behaviors are not signs of "hostility" or "uncooperativeness," but adaptive survival responses rooted in historical medical trauma and institutional abuse.
• Fear of Child Apprehension: Indigenous mothers and parents frequently avoid seeking emergency medical care out of intense, historically justified fear that healthcare providers will contact child welfare services to seize their children.

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The Four Pillars of Trauma-Informed Care (TIC)

Trauma-Informed Care (TIC) is a strengths-based clinical delivery framework that acknowledges the pervasive prevalence of trauma and centers healing. TIC fundamentally shifts the clinical perspective from a judgmental question ("What is wrong with you?") to an empathetic, inquiry-based question ("What happened to you?").

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Culturally Safe Clinical Communication with Indigenous Patients

Effective clinical communication requires honoring the unique cultural heritage, governance, and spiritual traditions of First Nations, Inuit, and Métis peoples, avoiding "pan-Indigenous" generalizations:

Traditional Sacred Medicines and Medicine Bundles

• The Four Sacred Medicines: In many First Nations traditions, sweetgrass, sage, cedar, and tobacco are sacred gifts from the Creator utilized for prayer, cleansing, healing, and gratitude.
• Sacred Medicine Bundles and Pouches: A medicine bundle or pouch is a sacred, consecrated object containing spiritual medicines, animal totems, or stones personal to the wearer. It represents spiritual identity, protection, and connection to ancestors.
• Clinical Protocol for Handling Sacred Items:
  • Never touch, open, handle, or cut a sacred medicine bundle or necklace without explicit permission from the patient, family, or Elder.
  • If placing ECG electrodes, defibrillator pads, or performing chest compressions, gently move the pouch to the side while keeping the cord intact.
  • If clothing must be cut during critical trauma resuscitation, cut around the sacred item. Never discard, confiscate, or place sacred items in trash or biohazard receptacles. Ensure the item remains physically with the patient throughout transport and handoff.

Smudging Ceremonies in the Healthcare Environment

A smudge is an Indigenous ceremonial practice of burning sacred plants (commonly sage or sweetgrass) in an abalone shell or cast-iron pot, gently directing the smoke over the body to cleanse the mind, heart, and spirit of negative energy. Paramedics encountering smudge smoke in a home or community lodge must:

• Recognize that smudge smoke is an act of prayer and spiritual healing, not a house fire or hazardous toxic inhalation.
• If concentrated medical oxygen is in use, manage flammability safely by asking respectfully to relocate the burning embers away from pressurized oxygen tanks without denigrating the ceremony.

Two-Eyed Seeing (Etuaptmumk)

Introduced by revered Mi'kmaq Elder Albert Marshall, Two-Eyed Seeing (Etuaptmumk) is the practice of learning to see from one eye with the strengths of Indigenous ways of knowing, and from the other eye with the strengths of Western sciences, and learning to use both eyes together for the benefit of all. In paramedicine, Two-Eyed Seeing means integrating advanced prehospital diagnostics and pharmacological protocols with traditional Indigenous healing practices, Elder counsel, and holistic community support.

Non-Verbal Communication and Pacing

• Eye Contact: In many Indigenous cultures, prolonged, unbroken direct eye contact is perceived as confrontational, aggressive, or disrespectful. Paramedics should use soft, intermittent eye contact and match the patient’s conversational rhythm.
• Silence and Pacing: Silence during conversation is a sign of respect, contemplation, and careful listening. Paramedics should resist the urge to interrupt or rush responses, allowing the patient ample time to process questions and articulate their needs.

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Community-Level Advocacy and Systemic Transformation

Paramedics have an ethical duty under the CPCF to advocate for structural change within their services and regions:

• Challenging Peer Racism: Refusing to tolerate racist jokes, derogatory slurs, or stereotyping in crew rooms, ambulances, or emergency department transfer bays.
• Collaborating with Indigenous Health Navigators: Partnering with hospital-based Indigenous liaisons, Friendship Centres, band health directors, and community health representatives to ensure continuum of care.
• Reporting Systemic Inequities: Documenting instances of discriminatory triage or delayed hospital handoffs experienced by Indigenous patients to EMS leadership and institutional ombudspersons.

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Clinical Scenario: Trauma-Informed Assessment of Acute Chest Pain

Prehospital Encounter: Respecting Identity in Cardiac Crisis

A paramedic crew responds to an urban residence for a 58-year-old First Nations woman experiencing acute substernal chest discomfort and diaphoresis. Upon arrival, the crew finds the patient sitting on a couch, breathing rapidly, clenching her hands, visibly trembling, and clutching a small leather pouch worn around her neck.

Recognizing Trauma Triggers:
As the paramedics enter the room in uniform carrying heavy equipment bags, the patient’s heart rate accelerates to 118 bpm, and she pulls back defensively, whispering, "Please don't take me away. I just need to pray." Recognizing the signs of traumatic activation and fear of institutionalization, the lead paramedic immediately implements Trauma-Informed Care:

1. Establishing Safety: The paramedic steps back, removes their duty hat and sunglasses, crouches down at eye level several feet away, and speaks in a calm, gentle tone: "Hello, my name is Alex, and this is Jordan. We are here to support you. You are completely safe with us, and we will not do anything without your permission."
2. Offering Choice & Restoring Autonomy: The paramedic asks: "Would it be alright if Jordan checks your blood pressure while I listen to your chest? You are in complete control." The patient nods consent.
3. Honoring Cultural Safety: When preparing to perform a 12-lead ECG, the paramedic notices the sacred medicine pouch. Instead of reaching for surgical shears, the paramedic respectfully explains: "I need to place some small sticky pads on your chest to check your heart. I see your sacred bundle. May I gently slide the cord to the side so it doesn't get tangled, or would you prefer to move it yourself?" The patient touches the pouch, slides it slightly toward her shoulder, and visibly relaxes.

Clinical Resolution:
The 12-lead ECG reveals ST-segment elevation in leads II, III, and aVF with reciprocal depressions in leads I and aVL, confirming an acute inferior STEMI. The paramedic explains the findings clearly, administers 162 mg chewed ASA, establishes IV access, transmits the ECG, and initiates Code STEMI bypass to the catheterization lab. The patient's chosen support person is invited to ride in the front seat of the ambulance, ensuring emotional continuity and trust.

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Exam Pitfalls & High-Yield Pearls

• TRC Call to Action #24: Exam questions frequently test the specific mandate of TRC #24. It requires education for healthcare professionals on residential school history, UNDRIP, treaties, Indigenous rights, teachings, and anti-racism.
• Joyce's Principle: Understand that Joyce's Principle demands equitable, discrimination-free healthcare access for Indigenous people and guarantees their right to enjoy traditional knowledge and medicines.
• Handling Sacred Medicine Bundles: Never cut, open, or confiscate a medicine bundle. Explain clinical needs transparently and gently move the item aside only if required for cardiac monitoring or defibrillation.
• Two-Eyed Seeing (Etuaptmumk): Coined by Elder Albert Marshall, this principle harmonizes Indigenous ways of knowing with Western medical science to enrich patient care.
• Four Pillars of TIC: Remember: Trauma Awareness, Safety/Trustworthiness, Choice/Collaboration, and Empowerment/Strengths-Based Care. Reframing patient agitation from "What is wrong with you?" to "What happened to you?" is the foundational paradigm shift.