Reconceptualizing determinants of health: Barriers to improving the health status of First Nations peoples

Abstract

T he health status of First Nations people in Canada is well below the national average. [1][2][3] Contact with Europeans brought outbreaks of infectious diseases (e.g., influenza, measles and smallpox) to which First Nations people had no immunity. 4 First Nations people lost traditional lands to settlements for trade relationships based on harvesting furs. 5 The shift from a seasonal economy based on traditional food gathering to the fur trade led to exploitation of wildlife and land. 5,6 Locating reserve lands in remote areas served to isolate First Nations, impoverishing their communities by limiting access to traditional resources. 6,7 The British North America Act of 1867 8 allowed Canada to pass laws that subjugated all First Nations people and their land, replacing their traditional governments and taking control of valuable resources on reserve lands. 7 It also disrupted First Nations culture and families by imposing European concepts of marriage, parenting and land ownership 7 in the belief that First Nations people were "savage" and less than human. 7,9,10 The Indian Act 11 restricted First Nations people from leaving reserve lands and prohibited outsiders from doing business with First Nations people, thus marginalizing them. 7 It also disrupted the transmission of culture from generation to generation, reinforcing learned helplessness among First Nations people in Canada by making participation in traditional cultural events (e.g., the potlatch and sun dance) a criminal offence. 7,11 The residential school system was designed to assimilate First Nations people into the culture of the white majority. 7,12 The needs of First Nations children were neglected, and many were physically, sexually and emotionally abused in the schools. 13,14 Over 500 years of domination, displacement and assimilation have prevented First Nations from nurturing a model of health determinants congruent with their culture. 12 Although Health Canada has selected the key determinants of health, developed by the Agency (Table 1), as the benchmark model to address the health status of all Canadians, a growing body of work suggests that these determinants of health are not suitable for most First Nations peoples. 9,[15][16][17] In response, the Four Worlds Institute developed 14 determinants of well-being and health (14 health determinants) (Table 1) relevant to First Nations people using their guiding principles: Development Comes from Within; No Vision, No Development; Individual and Community Transformations Must Go Hand in Hand; and Holistic Learning is the Key to Deep and Lasting Change. 9,18 To improve the overall health status of First Nations people in Canada, it is vital that Health Canada adopt a model of health determinants that incorporates the worldview of Indigenous peoples. 9,[19][20][21][22]

Taking stock of the social determinants of health: A scoping review

“…[ 30 ] Finally, examples of subjectivism from this review are apparent in the articles that incorporated Aboriginal understandings and experiences of SDOH, through recognition of important influential factors such as the dispossession of land, cultural resilience, self-determination, and legacy of residential schools. [ 18 , 66 , 84 , 108 , 111 – 113 ]…”

Indigenous perspectives on health: Integration with a Canadian model of practice

“…Experiences of stigma, hostile treatment, discrimination, disrespect, culturally inappropriate care, and lack of understanding in health care contexts (Browne & Fiske, 2001; Habjan, Prince, & Kelly, 2012; Nesdole, Voigts, Lepnurm, & Roberts, 2014; Richmond & Ross, 2008, 2009) lead many Indigenous people to avoid mainstream health care, where they do not feel safe or respected (Health Council of Canada, 2012). This contributes to the poorer health outcomes Indigenous peoples face on multiple fronts (Gionet & Roshanafshar, 2013; National Collaborating Centre for Aboriginal Health, 2012).…”

Salutogenesis and the Prevention of Social Death: Cross-Cultural Lessons from Genocide-Impacted Rwandans and Indigenous Youth in Canada

“…54 Indeed, trans-generational transmission of trauma associated with dispossession from traditional territories, destruction of language and culture, and child apprehensions all continue to contribute to poor Indigenous health. 55 Canada's Truth and Reconciliation Commission has called "upon the federal, provincial, territorial, and Aboriginal governments to acknowledge that the current state of Aboriginal health in Canada is a direct result of previous Canadian government policies." 56 Indeed, the presence of negative "social determinants of health" including high levels of incarceration, rampant suicide, and exposure to disproportionate levels of violence all converge to support the thesis that social death continues to be a genocidal threat to Indigenous peoples.…”