Ending violence against Indigenous peoples in Canada: a healthcare responsibility.

There is growing interest in the pursuit of reconciliation with Indigenous peoples in Canada, specifically by indigenizing public policy areas related to health, education, child welfare, and criminal justice. Medical and health sciences faculties, departments, and programs in universities are charting out strategic priorities related to equity for Indigenous health in education, research, and clinical services. In 2019, the Association of Faculties of Medicine of Canada (AFMC) launched its Joint Commitment to Action on Indigenous Health to respond to the Truth and Reconciliation Commission of Canada 's Calls to Action . The concept of reconciliation has since been shaping a commonly articulated goal in health research: to close the Indigenous health gap. 33 In its document, What We Heard: Principles of Truth and Reconciliation , the Commission details its fifth principle: “Reconciliation must create a more equitable and inclusive society by closing the gaps in social, health, and economic outcomes that exist between Aboriginal and non-Aboriginal Canadians.” 34 While much of the Final Report emphasises Indigenous sovereignty, rights, and respectful relations between nations, public institutions have tended to zero in on the nebulous goal of bellying up health outcomes while abstracting this goal from the colonial violence that continues to produce health inequities. This is a missed opportunity given that Indigenous peoples cannot be enduringly well until chronic violence is stopped. Reconciliation talk limits healthcare to focus on “closing the Indigenous health gap” at the expense of “ending colonial violence.” As an analytical framework, “closing the Indigenous health gap” is limited by its deficit-based assumptions, which stymy the ability to name and address the colonial relations of violence that continue to shape Indigenous life and death as well as healthcare institutions’ role in producing, sustaining, and extending them. Given that institutional reconciliation efforts have typically been at the exclusion of the Calls for Justice , attention to colonial violence has not oriented the policies shaping indigenisation efforts in universities, which train clinicians and policy makers for adjacent healthcare institutions. The conceptual ordering of the National Inquiry , which contrasts health and wellness with harm, effectively reorients medical discourse so that it takes violence seriously as a critical matter of health facing Indigenous peoples in Canada. The framing of health and wellness against harm rather than entrenched medical binaries that define health as the absence of disease or disorder invites us to identify ways that Indigenous peoples are targeted for violence rather than situating Indigenous people as always being the source of their poor health outcomes. It invites reflection on the individual and institutional perpetrators and systems of violence rather than focusing on behavioural or lifestyle interventions for patients. Ending violence and improving health and wellness for Indigenous peoples is not a matter of reconciliatory imperative alone. Ending colonial violence is required by the unique legal and political relationships Canada and its citizens have with Indigenous peoples. The provision of healthcare to Indigenous peoples as an act of charity and moral obligation, rather than a matter of treaties, relationships, and sovereignty, is unfortunately entrenched in healthcare fields and requires critical questioning. 35 Indigenous peoples are not simply one more group among Canada's multicultural mosaic. They are sovereign nations with inherent, constitutional, treaty, and international rights and legal agreements with the nation-state and its citizens that continue to live in Indigenous homelands. As such, healthcare systems and institutions have a responsibility to additionally implement the Calls for Justice and contribute to ending colonial violence.

Colonialism profoundly shapes the health and life chances of Indigenous peoples in Canada and around the world. 1 , 2 Operating through violent force, including the dispossession of Indigenous peoples from land, life/ways, and governance, colonialism is not simply a determinant of health among other variables. Dispossession refers to the translation of Indigenous homelands to property and the manifestation of legal and political power over those lands by an existing or new nation-state. 3 Modern colonialism is exercised through and reproduced by a Westphalian form of sovereignty, whereby the nation-state, through its juridical system, claims possession, exclusive governing authority, and the use of legitimate force over its boundaries, resources, wards, and citizens. 4 Public institutions, like healthcare systems, remain constitutive of Canadian sovereignty and governance as manifested through race-based legislation and the separation of healthcare jurisdiction to what Canada constitutionally defines as three Aboriginal peoples: Indian, Inuit, and Métis. 5 Since the Truth and Reconciliation Commission of Canada concluded its mandate in 2015, reconciliation has now become a dominant and, arguably, taken-for-granted way of framing the relationship between Indigenous peoples and Canadian society. Health equity for Indigenous populations has also become a matter of reconciliation. This Viewpoint explores how reconciliation limits possibilities, particularly in healthcare, to closing statistical gaps at the expense of addressing harm and ending colonial violence. ᒪᓂᒎᐢ manicôs . ᒪᓂᒎᐢ manicôs imagines a glitchy Mycobacterium Tuberculosis cell lodged in the lungs of our Indigenous kin. The buggy visual artifacts here open onto a transcendent space, gesturing to the emergence of something new that nonetheless draws from ancestral power. Fireweed sprouts first after fires; here, it overruns the bacterium, blazing a path for Indigenous futures in health/care. ᒪᓂᒎᐢ manicôs . ᒪᓂᒎᐢ manicôs imagines a glitchy Mycobacterium Tuberculosis cell lodged in the lungs of our Indigenous kin. The buggy visual artifacts here open onto a transcendent space, gesturing to the emergence of something new that nonetheless draws from ancestral power. Fireweed sprouts first after fires; here, it overruns the bacterium, blazing a path for Indigenous futures in health/care. The concept of indigeneity, in its various re/iterations (e.g. “Indian” defined by the Indian Act , “Aboriginal” defined by the Constitution Act , or “population” used in health research and policy), mobilises racial logics that epistemologically and materially distort and reorder the richness, diversity, and contingency that constitute Indigenous peoplehoods—the first peoples and their relations to place and each other. Indigeneity is produced through scientific and political ideas that have conditioned histories of territorial and political invasion and dispossession as being natural and just. 6 Colonial dispossession, therefore, involves the violent categorisation and regulation of bodies deemed, for instance, Aboriginal , Native American , Indian, or Indigenous population insofar as formalisations of nation-state citizenship, legal personhood, healthiness, and biological variation have been predicated on how those subjects deemed possessive and exceptional (i.e. typically white) differ from those ascribed to (an) iteration(s) of indigeneity. That Canada has defined and governed Indigenous peoples and governed them/us differently has resulted in distinct experiences with healthcare quality and access for First Nations, Inuit, and Métis peoples. Therefore, Indigenous health researchers often advocate for a distinctions-based approach to addressing health matters. In Canada, the publicly funded healthcare system is Medicare. While the federal government provides healthcare funding to the provinces and territories, “provincial and territorial governments are responsible for the management, organisation and delivery of healthcare services for their residents." 7 While the provision of healthcare services is a matter of provincial jurisdiction, the Government of Canada claims jurisdiction over “Indians and lands reserved for Indians” in section 91(24) of its Constitution Act , 1867. As a result, the federal government directly delivers healthcare services to Inuit and First Nations people living on reserve, but not, for instance, to Métis and off-reserve First Nations people. The separation between provincial and federal jurisdictions means that some Indigenous peoples are considered a provincial responsibility, and others a federal one. This separation has caused disparities in access to healthcare services for Indigenous peoples and is considered a significant social determinant of health. 8 In the face of existing barriers and challenges, Indigenous peoples have successfully engaged in health activism and research. The First Nations Health Authority, an example of Indigenous governance and leadership, partners with First Nations in British Columbia to close service gaps and provide services formerly delivered by the federal government. Jurisdictional differences in health policy and services can be analysed as a form of colonial violence predicated on the nation-state categorisation and governance of “Aboriginal peoples.” However, it is also the result of Indigenous resistance and insistence on recognition and distinctions-based health research and services. Colonial dispossession extends beyond the loss of land and through legal authority, which becomes a mechanism through which Indigenous peoplehoods and relationalities are translated into and governed through administrative categories like Indian, Inuit, and Métis. Dispossession is materially felt on bodies and organised through logics of racism, white and human supremacy, patriarchy, ableism, and heteronormativity. Dispossession is, therefore, always an embodied experience, and violence against bodies by these logics is also an assault on Indigenous peoples' existence in place. Further, colonial violence is experienced through one's confluence of subject positionings. 9 For example, it has been statistically known for decades that Indigenous women, girls, Two Spirit, and trans people experience the highest rates of physical and sexual violence compared to others in Canada. The healthcare system has itself produced violence. Indigenous women, for example, continue to be targeted for forced and coerced sterilisation while accessing health services. 10 Nevertheless, statistical knowledge regarding rates of violence in and beyond the healthcare system has never dismantled a colonially violent society. Changing the colonial state of things requires far more than reconciling the numerical expression of the effects of colonial violence that quantitatively cite gaps in health outcomes between Indigenous and non-Indigenous populations. I do not cite such numbers here. Instead, I depart from a norm in health research that assumes and produces Indigenous health as being in a deficit. While there is a violence gap in Canada, the goal to address it ought not be to “close the gap” and for Indigenous women, girls, Two Spirit, and trans people to experience the same rates of violence as non-Indigenous groups. This approach would normalise acceptable rates of gendered violence as a standard to reach. Basing representations of, and action against colonial violence on the pre-existing standards of non-Indigenous society alone will not lead to transformative change for all. Why, then, should conceptions of health and well-being also remain limited to non-Indigenous standards? Methodologically, my goal is not to deny health inequity, but to model a unique way of representing it by offering critical Indigenous theory to guide future health research and inform policy-making and clinical practice. 11 After all, if colonialism is an ongoing and violent process which re/orders relations between Indigenous peoples, governance, and health, then analysing the conditions that produce Indigenous health requires attention to harm. In theorizing relations of colonial violence, this Viewpoint understands that the healthcare system in Canada is a perpetrator of colonial violence, not least of all through, for example, its history of segregated health services, medical experimentation on Indigenous children, and deadly forms of anti-Indigenous racism in emergency rooms and doctors' offices; and, as such, bears a responsibility to recognise, and end colonial violence. 12 , 13 , 14 , 15 This responsibility must be taken up in partnership with Indigenous peoples and sovereignties and by following Indigenous leadership. Analysing multiple relations of violence against Indigenous women in and from Winnipeg, Manitoba, I suggest that the healthcare system (including provincial and federal health services, health research and institutions, and health policy) can begin contributing to the address of colonial violence by implementing the Calls for Justice under Section 7 (7.1–7.7) related to “Health and Wellness” laid out in the Final Report of the National Inquiry into Missing and Murdered Indigenous Women and Girls (the National Inquiry or Inquiry hereafter). 16 In 2019, the National Inquiry bore witness to the genocidal scale of gendered and racialised violence experienced by Indigenous peoples in Canada. The Inquiry was structured around four pillars, one of which was the “Right to Health,” and made 231 Calls for Justice that squarely identified the healthcare system's role in producing and responsibility for addressing this genocide. After four years, there has been no movement on six of the seven calls under Health and Wellness. 17 The language of the National Inquiry 's Final Report contrasts health and wellness with harm; language that directs attention to colonial violence–a necessary redirection from medical discourses and health research that overwhelmingly position Indigenous peoples, and by extension, the concept of indigeneity, as being in a deficit state. By referencing the Final Report , I reconstitute the righteously imbued discourse of reconciliation in healthcare by bringing into focus ongoing colonial violence.

Indigenous researchers fight for life and that of our loved ones and communities, just as we struggle for our justified existence and that of our knowledge, methodologies, and practices in universities and healthcare institutions. This reality informs critical Indigenous theorising and has given rise to the discipline of critical Indigenous studies, which includes methodologies shaped by Indigenous onto-epistemologies and embodied knowledges. 18 Critical Indigenous theory positions Indigenous peoples primarily as producers of knowledge, not as research subjects or participants to be engaged. For Indigenous peoples, there is a positive correlation between self-determination and health outcomes. 19 , 20 Self-determination includes being formative of and representing ourselves within the capacities of knowledge production. Indigenous expertise, leadership, and governance of health research are connected to the material wellness of Indigenous people and peoplehoods. However, critical Indigenous studies theoretical frameworks rarely shape health research and even less common are theories and methods developed by Indigenous women. 21 , 22 As Keira Loukes and colleagues write: “Vital to decolonial health and well-being research is Indigenous women's understandings, ethics, leadership, and knowledge systems that uphold our well-being”. 21 The sharing of the stories of ourselves, our families, and our homes serves as powerful evidence of the accumulative affective force that personal yet shared experiences among Indigenous peoples reveal about the relations of violence shaping health in the present. 23 From this framing, the density rather than deficit of Indigenous health outcomes can be represented. 24 Indigenous peoples are, after all, far more than victims of health inequity. In 2022, the Winnipeg police service announced that the remains of two Indigenous women, Marcedes Myran and Morgan Harris, both from Long Plain First Nation and victims of a white male serial killer, were believed to be in the Prairie Green Landfill north of Winnipeg, Manitoba. The loss of these women and two others, Rebecca Contois and an unidentified woman that community members have named, Mashkode Bizhiki'ikwe (Buffalo Woman), at the hands of this self-identified racially and gender motivated killer is beyond disturbing and devastating. These murders were made worse by the killer's legal defense in which the deployment of mental illness was used to rationalise his hateful actions—actions linked to a pre-existing genocidal pattern of colonial violence in the country. I am myself an Indigenous woman from Winnipeg. On my mother's side, my family is from Peguis First Nation, whose shared territories include land adjacent to the Winnipeg landfill. The landfill now sits east of our First Nation's first reserve and just north of “Little Peguis”—a colloquial term for a Winnipeg suburb where many Peguis families live. Most of our people were forcibly removed from the lands north of Winnipeg after an illegal land surrender involving our nation and the federal government in 1907. Multi- and inter-generational experiences of Indian Day and Residential Schools, the 60s Scoop, gender-based interpersonal violence, racism in the healthcare system, racist-sexism from police, and undelivered justice in Canadian courts worsened our nation's land-based dispossession. These experiences have left marks on all our bodies, contributing to a variety of harms such as endometriosis, autoimmune disorders, self-harm, and post-traumatic stress disorder, among others. In 2022, like many women in my family, I (a now middle-class, suburban-dwelling professional) was also violently assaulted by a stranger. In Canada, Indigenous women are more likely than other populations to be beset by physical and sexual violence from someone they do not know. 25 It is important to understand the relations of colonial power linking different forms and manifestations of violence. The murder of Indigenous women, assaults that could easily lead to the same outcome, or the removal of a people from their homeland are all forms of colonial violence that stem ontologically from a white patriarchal system of sovereignty, governance, and relationality. However, we should not fall into the deficit trap of referring to Indigenous women as being a vulnerable population. Instead, perpetrators of colonial violence target our bodies for place-based and embodied dispossessions. 26 , 27 , 28 , 29 The deficit is not our own. Whether experiencing it, supporting loved ones through it, or witnessing it against others in our communities, colonial violence is felt on our bodies in resounding ways, which evidences the entanglement of its land-based, representational, institutional, and interpersonal relations. Colonial violence is a public health issue. The municipal and provincial decision not to perform a state-funded search of the Winnipeg landfill for the remains of Myran and Harris reached international attention. 30 Former Manitoba Premier Heather Stefanson backed the Winnipeg Police Service's decision not to search. The policy rationalisation not to search the landfill extended the colonial governance of lands and bodies that historically transformed peoples into Indians, their Indigenous homeland into a Canadian province and then a privately owned landfill designed to metabolise the waste of a city—now including, apparently, the bodies of Indigenous women. In October 2023, the Federal Government committed $740 k to expand a feasibility study that concluded that the search could happen safely if mitigating protocols were taken; in the same month, the newly elected and first First Nations Premier, Wab Kinew , indicated that his administration would prioritise the search. Yet, people in Manitoba remain divided on their support for the search according to a privately commissioned poll with 47 per cent of respondents in favour of searching the landfill, 45 per cent opposed, and 8 percent undecided. 31 The genocidal-level of violence experienced by Indigenous people, the treatment of Indigenous bodies as disposable, and the province's assertion under Stefanson that bringing women home to their families was not worth the financial expenditure or risk have shaken and wounded Indigenous peoples in and far beyond Winnipeg. For many of us, it is yet another reminder of the ongoing threat of colonial violence in our daily lives, which includes both the violence against our bodies and the societal reluctance to care about it. Searching the landfill is a gendered and racialised health issue as much as it is an issue about the tensions between federal, provincial, municipal, and Indigenous governance. Critical Indigenous studies scholarship lays bare the precariousness of life, embodiment, and reproduction for Indigenous peoples and how shifts in colonial governance, including through health research and healthcare institutions, sustain such precariousness. Like other Indigenous health researchers, I confront these themes among the cross-cutting planes of mortal survival and disciplinary knowledge production. Sharing personal context is meant to affectively convey the immediacy of what is a shared experience of violence among Indigenous peoples and, therefore, the multiple and interdependent relations of a health issue in Canada that it presents. 32 Our Indigenous lives (and deaths) are the evidence of critical Indigenous theory, and the ways that we narrate them, including the conceptual orders articulating our experiences strategically, involve high politico-material stakes—the words representing our struggles and power matter for building more liveable worlds.

All contributions were made by the corresponding author. The image was created by SJ Okemow .

The author has no conflicts of interest to declare.