9.2 Indigenous Health, Cultural Safety, and Humility

9.2 Indigenous Health, Cultural Safety, and Humility

Exam Focus: The PEBC Evaluating Examination requires pharmacy practitioners to demonstrate deep knowledge of Indigenous health determinants in Canada. Candidates must understand the impacts of colonialism, the Truth and Reconciliation Commission (TRC) Calls to Action, the continuum from cultural competence to cultural safety, billing and navigation under the Non-Insured Health Benefits (NIHB) program, Jordan's Principle, and safe integration of traditional Indigenous medicines.

---

Historical Context, Colonialism, and Health Inequities

Under Section 35 of the Constitution Act, 1982, the Aboriginal peoples of Canada comprise three distinct groups with unique cultural identities, governance structures, and legal rights: First Nations, Inuit, and Métis.

Disparities in health outcomes between Indigenous and non-Indigenous populations in Canada—including lower life expectancy, elevated infant mortality, and disproportionate rates of type 2 diabetes, cardiovascular disease, tuberculosis, substance use disorders, and suicide—are not caused by genetic or biological predispositions. Instead, they represent the direct, cumulative consequences of colonial policies, land dispossession, structural racism, and intergenerational trauma.

+-------------------------------------------------------------------------+
|                   COLONIAL DRIVERS OF INDIGENOUS HEALTH INEQUITIES      |
+-------------------------------------------------------------------------+
|  1. The Indian Act (1876):                                              |
|     Paternalistic federal legislation enforcing assimilation, band      |
|     membership controls, and systemic loss of self-determination        |
|                                |                                        |
|                                v                                        |
|  2. Indian Residential School System (IRSS) & Sixties Scoop:            |
|     Forced separation of children from families, systemic emotional,    |
|     physical, and sexual abuse; cultural disruption; epigenetic trauma  |
|                                |                                        |
|                                v                                        |
|  3. Segregated "Indian Hospitals" & Medical Experimentation:            |
|     Substandard racially segregated healthcare, unconsented clinical    |
|     nutritional experiments, and forced sterilization of Indigenous women|
|                                |                                        |
|                                v                                        |
|  4. Ongoing Systemic Racism in Contemporary Healthcare:                 |
|     Interpersonal stereotyping, neglect, and diagnostic delays          |
|     (e.g., Brian Sinclair inquiry, Joyce Echaquan coroner's report)     |
+-------------------------------------------------------------------------+

Intergenerational and Epigenetic Trauma

Intergenerational trauma refers to the transmission of trauma effects across generations following catastrophic collective experiences. The physiological stress resulting from residential schools, family separation during the Sixties Scoop, and ongoing systemic discrimination alters neuroendocrine regulatory systems (the hypothalamic-pituitary-adrenal [HPA] axis), predisposing subsequent generations to elevated cardiometabolic and psychiatric morbidity.

---

The Truth and Reconciliation Commission (TRC) and UNDRIP

The Truth and Reconciliation Commission of Canada (TRC) issued 94 Calls to Action in 2015 to redress the legacy of residential schools and advance national reconciliation. Calls to Action 18 through 24 specifically address health:

• Call 18: Acknowledge that the current state of Indigenous health in Canada is a direct result of previous Canadian government policies, including residential schools.
• Call 19: Establish measurable goals to identify and close the gaps in health outcomes between Indigenous and non-Indigenous communities.
• Call 20: Recognize, respect, and address the distinct health needs of First Nations, Inuit, and Métis, including off-reserve populations.
• Call 21: Provide sustainable long-term funding for existing and new Aboriginal healing centres to address the physical, mental, emotional, and spiritual harms of residential schools.
• Call 22: Recognize the value of Indigenous healing practices and use them in the treatment of Indigenous patients in collaboration with Indigenous healers and Elders.
• Call 23: Increase the number of Indigenous healthcare professionals and provide cultural competency training for all healthcare professionals.
• Call 24: Require medical, nursing, and healthcare professional programs to deliver mandatory curriculum on Indigenous health issues, including the history and legacy of residential schools, UNDRIP, Treaties, and Indigenous rights.

In 2021, the Canadian federal government enacted the United Nations Declaration on the Rights of Indigenous Peoples Act (UNDRIP Act), legally committing federal laws to align with UNDRIP's minimum standards for the survival, dignity, and well-being of Indigenous peoples, including rights to traditional medicines and health practices (Article 24).

---

The Cultural Safety and Humility Continuum

Delivering equitable healthcare to Indigenous patients requires progressing along the cultural safety continuum. Cultural competence is an important step, but it is not the endpoint of professional development.

+-------------------------------------------------------------------------+
|                     THE CULTURAL SAFETY CONTINUUM                       |
+-------------------------------------------------------------------------+
|  CULTURAL AWARENESS                                                     |
|  - Acknowledging difference and diversity exists                        |
|                                |                                        |
|                                v                                        |
|  CULTURAL SENSITIVITY                                                   |
|  - Recognizing that differences must be respected without judgment      |
|                                |                                        |
|                                v                                        |
|  CULTURAL COMPETENCE                                                    |
|  - Acquiring knowledge, communication skills, and clinical behaviors    |
|                                |                                        |
|                                v                                        |
|  CULTURAL SAFETY (The Ultimate Practice Goal)                           |
|  - An environment free of racism, where the patient feels secure,       |
|    respected, and heard. DEFINED EXCLUSIVELY BY THE RECIPIENT OF CARE   |
+-------------------------------------------------------------------------+

Cultural Humility

Cultural humility is a lifelong commitment to self-reflection, self-critique, and learning. It requires healthcare providers to:

1. Examine their own personal and systemic biases, assumptions, and privileges.
2. Acknowledge and actively address the power imbalances inherent in the patient-provider dynamic.
3. Approach every patient encounter with openness, humility, and willingness to learn from the patient as the expert in their own lived experience.

Two-Eyed Seeing (Etuaptmumk)

Coined by Mi'kmaq Elder Albert Marshall, Two-Eyed Seeing is the guiding principle of learning to see from one eye with the strengths of Indigenous knowledges and ways of knowing, and from the other eye with the strengths of Western sciences, and using both eyes together for the benefit of all. In pharmacy, Two-Eyed Seeing encourages integrating evidence-based pharmacotherapy alongside traditional medicines, ceremonies, and holistic healing circles without creating false hierarchies.

---

The Non-Insured Health Benefits (NIHB) Program

The Non-Insured Health Benefits (NIHB) program is a federally funded program administered by Indigenous Services Canada (ISC) that provides coverage to eligible First Nations and Inuit clients for specified medically necessary health goods and services not covered by provincial, territorial, or private health plans.

+-------------------------------------------------------------------------+
|                   NIHB PHARMACY BENEFIT SUMMARY                         |
+-------------------------------------------------------------------------+
|  ELIGIBLE CLIENTS:                                                      |
|  - Registered First Nations individuals (Status under Indian Act)       |
|  - Recognized Inuit beneficiaries of land claim agreements              |
|  - Note: Métis are NOT covered under NIHB (unless registered Status)    |
|                                                                         |
|  BENEFIT TIERS ON DRUG BENEFIT LIST (DBL):                              |
|  - Open Benefit: Automatically reimbursed without prior approval        |
|  - Limited Use (LU): Specific clinical criteria or prescriber specialty |
|  - Prior Approval / Exception: Requires formal clinical case submission |
|                                                                         |
|  BILLING & PAYMENT RULES:                                               |
|  - Point-of-sale electronic adjudication via Express Scripts Canada     |
|  - Strictly 100% covered: ZERO copayments, deductibles, or user fees    |
|  - BALANCE BILLING IS STRICTLY PROHIBITED BY NIHB PROVIDER AGREEMENT    |
+-------------------------------------------------------------------------+

Core NIHB Operational and Dispensing Rules

1. Client Identification: Verified using the client's 10-digit Indian Status registration number (Treaty number) or Inuit beneficiary identification.
2. Payer of Last Resort vs. Provincial Coordination:
   • If a client has private commercial insurance (e.g., through an employer), private insurance is billed first; NIHB acts as the secondary payer of last resort for remaining balances.
   • However, for registered First Nations and Inuit clients, NIHB provides comprehensive primary coverage relative to provincial public drug programs (with specific provincial coordination agreements in certain jurisdictions such as BC's First Nations Health Authority [FNHA]).
3. Prohibition of Balance Billing:
   • Pharmacists participating in NIHB agree to accept the NIHB-negotiated dispensing fee and reimbursement schedule. Pharmacists are strictly prohibited from charging extra fees, co-payments, or balance-billing the patient for the difference between pharmacy retail prices and NIHB reimbursement.
4. Emergency Dispensing Policy:
   • If a client requires an urgent medication on the Limited Use or Prior Approval list outside business hours or before prior approval is processed, pharmacists can dispense an emergency supply (typically up to a 7-day supply) to prevent treatment interruptions.
5. Short-Term Dispensing Policy:
   • For stable chronic medications, NIHB covers up to a 100-day supply to optimize convenience and reduce dispensing fee overhead. For unstable, newly initiated, or acute therapies, shorter intervals (e.g., 30-day fills) are standard.

---

Jordan's Principle and the Inuit Child First Initiative

Jordan's Principle

Jordan's Principle is a child-first, human-rights principle established in memory of Jordan River Anderson, a young First Nations child from Norway House Cree Nation in Manitoba who was born with complex medical needs. Jordan spent years needlessly hospitalized while federal and provincial governments argued over who was responsible for paying for his home care equipment; he died in the hospital at age five before the dispute was resolved.

+-------------------------------------------------------------------------+
|                    JORDAN'S PRINCIPLE: WORKFLOW                         |
+-------------------------------------------------------------------------+
|  First Nations child (0-18 years) requires health, social, or           |
|  educational product / service (e.g., specialized medical formula,      |
|  non-formulary compounded medication, sensory therapy, mobility aid)     |
|                                |                                        |
|                                v                                        |
|  Request submitted to Jordan's Principle Focal Point                    |
|                                |                                        |
|                                v                                        |
|  MANDATORY FIRST-CONTACT RULE:                                          |
|  The government department of first contact MUST PAY FOR THE SERVICE    |
|  IMMEDIATELY without delays or denials                                  |
|                                |                                        |
|                                v                                        |
|  Intergovernmental jurisdictional disputes are resolved AFTER payment   |
+-------------------------------------------------------------------------+

• Legal Scope: Applies to all First Nations children living on or off reserve.
• Scope of Coverage: Encompasses all health products, pharmaceuticals, medical compounding, medical devices, educational aids, and mental health supports required to meet substantive equality.
• Inuit Child First Initiative: Extends the exact same legal principle and child-first mandate to all Inuit children across Canada.

---

Indigenous Traditional Medicines and Culturally Safe Pharmacotherapy

Indigenous healing systems are holistic, viewing health as a dynamic balance between physical, mental, emotional, and spiritual dimensions represented within the Medicine Wheel.

+-------------------------------------------------------------------------+
|                  THE FOUR SACRED MEDICINES & PHARMACY                   |
+-------------------------------------------------------------------------+
|  1. TOBACCO (East): First medicine; used for prayer, giving thanks,     |
|     and offering respect to Elders and healers. (Distinct from commercial|
|     recreational tobacco).                                              |
|                                                                         |
|  2. SWEETGRASS (South): Used for cleansing, kindness, and smudging.     |
|     Contains coumarin derivatives (assess if patient uses high internal |
|     concentrations alongside anticoagulants like warfarin).             |
|                                                                         |
|  3. SAGE (West): Used for purification, spiritual protection, and tea.  |
|     Contains volatile thujones; non-judgmental inquiry for safety.      |
|                                                                         |
|  4. CEDAR (North): Used for cleansing, restorative tea (rich in vitamin |
|     C), and protection. Safe integration with conventional medicines.   |
+-------------------------------------------------------------------------+

Pharmacist Clinical Assessment of Traditional Botanicals

• Non-Judgmental Clinical Inquiry: Inquire about the use of traditional teas, plant medicines, and ceremonies during medication reconciliations using open, respectful language.
• Pharmacological Interactions:
  • Bearberry / Uva Ursi (Arctostaphylos uva-ursi): Contains arbutin, used historically for urinary tract health; requires an alkaline urinary pH to generate active hydroquinone (avoid combining with urinary acidifiers).
  • Willow Bark (Salix spp.): Contains salicin (metabolized to salicylic acid); assess additive bleeding risks when combined with NSAIDs, aspirin, or antiplatelets.
  • Sweetgrass (Hierochloe odorata): Contains natural coumarins; monitor international normalized ratio (INR) if consumed in large medicinal quantities by patients taking warfarin.