Course:GEOG350/2024/Accessibility to Healthcare

Chapter 2 - Place, Placelessness, Spatial Inequality Pertaining to Accessibility to Healthcare

Introduction

Second only to Sweden, Canada is ranked second in the world for having a “well-developed public health system” as determined by U.S. News out of 87 countries. Despite Canada being recognized for having one of the best healthcare in the world, there is noticeable healthcare disparities amongst the Canadian population as healthcare is not equally or universally accessible by all, with the Indigenous people notably experiencing healthcare despairingly as compared to Canadians overall.  

The Indigenous people’s ancestors first settled in Vancouver over 10,000 years ago; today, Indigenous people only account for 2.3% of the population in Vancouver according to Statistics Canada 2021. It is worth noting that Indigenous people account for 5.9% of the Province of British Columbia, and that the distribution of the Indigenous people is much larger in rural and small population centers as opposed to metropolitan areas such as Vancouver.

Medical technology has been advancing at an exponential rate; medicines and procedures providing better efficacy and treating previously untreatable ailments is being invented at a faster rate than we are able to adopt, fund and implement. Whereas in the past it could be said Vancouver offers the state-of-the-art healthcare, this may no longer be the case given the plethora of new procedures technically possible but not offered. It is important to see how the relative decline of healthcare affect those who have once felt safe in Vancouver, in their chosen environment and surroundings.

In this chapter, the focus will first be on Vancouver’s Indigenous people and the place they call home – their established community consisting of vast amounts of productive land for hunting, gathering, and practicing traditional healing – and how subsequent urbanization altered their lands with modern infrastructures, a crisscross of roads, pipe and buildings rendering the land no longer supportive to their way of life. Undoubtedly, these changes affect the Indigenous people and their view of their sacred land.  The second focus will be on placelessness as pertains to healthcare, exploring the transition of the Indigenous people from their traditional healing, a cultural practice passed on from generation to generation, to modern western medicine. What practices, if any, do they continue to use and continue to pass on to future generations? Has medical technological advancement left them feeling their sacred land and their community have lost their identity?  Finally, the focus will be on spatial inequality pertaining to the accessibility of healthcare, exploring the accessibility to healthcare for the Indigenous people and how the inaccessibility of access negatively impacts this particular group in the population. How are their mental health and wellbeing impacted in Vancouver given the constraining factors such as limited resources, systemic racism and healthcare discrimination of the Indigenous people.  It is important to look at the healthcare system, recognize the flaws, and provide a solution that not only improves the mental health and well being of Indigenous people but at the same time respect their culture and incorporate their practices with modern medicine.

Overview of issue/focus

It has been documented that the Indigenous people first came to Vancouver as early as 500 BC.  Being one of the earliest settlers in the region, retaining their culture – their way of life – against the constant nag of modern progress and urbanization has been an ongoing struggle.  In the late 1860s, Joseph Trutch who was the governor of BC at the time, decreased the land size of the reserves.  While he thought there was too much unproductive reserve land, the Indigenous people felt they were left with too little of their land, approximately 20 acres per family. Modified reserves brought with them less-than-ideal locations. Methods of reallocating reserves were based on who needed access to waterways, some form of consultation, or simply just placed in a reserve that had no traditional value altogether for the Indigenous people.  This led to challenges in obtaining sufficient resources to care for their family. Access to their traditional foods were diminishing as their sacred lands were taken away; nutritional foods and previously dependable sustenance became more difficult to obtain, impoverishing the reserve communities.

It has been documented that the Indigenous people first came to Vancouver as early as 500 BC.  Being one of the earliest settlers in the region, retaining their culture – their way of life – against the constant nag of modern progress and urbanization has been an ongoing struggle.  In the late 1860s, Joseph Trutch who was the governor of BC at the time, decreased the land size of the reserves.  While he thought there was too much unproductive reserve land, the Indigenous people felt they were left with too little of their land, approximately 20 acres per family. Modified reserves brought with them less-than-ideal locations. Methods of reallocating reserves were based on who needed access to waterways, some form of consultation, or simply just placed in a reserve that had no traditional value altogether for the Indigenous people.  This led to challenges in obtaining sufficient resources to care for their family. Access to their traditional foods were diminishing as their sacred lands were taken away; nutritional foods and previously dependable sustenance became more difficult to obtain, impoverishing the reserve communities.

Immigrants continued to arrive in BC, bringing with them their lived experiences and cultures, slowly but surely reducing the relative population of Indigenous people whilst slowly eroding the Indigenous people’s way of life. Set against the continuous waves of immigration, Indigenous people continued to lose their lands and customs, negatively impacting their nutrition and their ways of healing which leads many Indigenous people to deign to accept many of the Canadian’s modern way of life, from foodstuff to medicines and medical procedures, losing much of their own cultural identity along the way.

Despite having adopted some of Canadian’s modern way of life, Canadian society’s general ignorance of the history of the unceded territories has led to Indigenous people often finding themselves alienated from the rest of the society as they struggle with retaining their culture.  With alienation comes disparities in resources from a of lack of funding and systemic racism and discrimination.  Poor healthcare in particular is a result of lack of funding. Amidst the exponential growth of advanced medical technologies that inundates modern life, the disparity of healthcare afforded to the Indigenous people is stark.

Healthcare, for one, is not easily accessible in remote communities, leading to underreported mental well-being and chronic health conditions such as asthma and diabetes.  A study conducted by Statistics Canada in 2017-2020 found that 85.5% of Indigenous people across Canada did not have a regular healthcare provider, predominantly men and young adults ages 18 to 34 years old.  In an independent study in British Columbia by Mary Ellen Turpel-Lafond, it was quite evident that Indigenous people do not have as much access to physicians. Further, their connection with their healthcare providers when compared to the non-Indigenous people is tenuous. A survey was completed and found that accessibility to physicians were difficult because of long wait times and limited access to a care facility.  The same study found that Indigenous peoples could not form a connection with their healthcare providers because it was difficult or unable to access them.  In another study found those that lived in rural communities had challenges with travelling to and from healthcare facilities due to the distance. It was also noted there was a shortage of services and medical professionals, and few accessibilities to culturally safe services. With disparities in accessibility to a regular healthcare provider, it is evident life expectancy is lower than non-Indigenous people.

Systemic racism and discrimination are best exemplified by the residential schools established in the 1880s. Mandatory attendance was fervently enforced on all Indigenous children. Despite assimilation of Indigenous children being the goal, they were not provided the same resources that Canadian society would provide to their own. On the contrary, healthcare, amongst other resources, was deeply deficient as the schools were severely underfunded.  Despite the lack of proper healthcare resources, access to traditional medicine and healing practices were forbidden to the Indigenous children.  This proved to be fatal for many of the children.  In 1907, medical inspector P.H. Bryce reported that 24% of the Indigenous children were dying in the residential schools. This 24% figure significantly underreports the total percentage of children dying as a result of attending the residential schools because severely ill children are typically sent home, where they often (47% to 75%) succumb to their illness and die shortly after returning home. Treatment of illnesses such as tuberculosis were often provided in inferior and racially segregated healthcare facilities. Systemic racism and discrimination are still ongoing and present today.  This discourages Indigenous peoples from seeking medical treatment and has impacted them by building mistrust for today’s healthcare system and the medical professionals.

Understanding the history is important because it helps those that reside in Vancouver, the government and the non-Indigenous people, be more inclusive during decision making and adoption of new policies that affect the Indigenous people.

The scale and scope of this particular issue is far and wide; while it affects Indigenous people of Vancouver, this is a similar situation for Indigenous people province wide – broad strokes, it could be said for Indigenous people worldwide, where old Indigenous cultures are faded out by new immigrants and the resulting sea change of the Indigenous way of life.

Case Study of the issue

Vancouver, BC is proud to be a multicultural city, with its citizen hailing from dozens of countries worldwide. Interestingly, Vancouver’s citizens whose entire lineage originates from Vancouver are sparse in number and are arguably treated amongst the worst as a group. Despite being proud of our multiculturalism, we apparently still segregate the Indigenous people according to a number of recent studies and interviews conducted. Bluntly, Indigenous people are not being treated equally in many areas, one of which is access to resources.  In particular, healthcare resources are specifically lacking for the Indigenous people, and it remains a challenge to provide the necessary treatments, and to a lesser extent for Indigenous Vancouverites, physical access to medical facilities.

While the healthcare plight of the Indigenous people has been well documented and are now gaining wider attention, historical repressions have left many suffering from depression and substance abuse. While more western medical treatments and facilities are needed for the indigenous community, what is also needed is support for indigenous traditional medicinal practices. The Indigenous people’s trust in the Canadian government has understandably been long since eroded; by supporting and including indigenous traditional medicinal practices in prescribed treatments, a modicum of trust could be rebuilt over time. By accommodating the traditional medical needs of Indigenous people, such as providing spaces for smudging or sweat lodges, they could better rediscover their identity which could have a lasting positive impact on their health and wellbeing.

By providing the Indigenous people space in the medical facilities for smudging, sweat lodges or healing circles, it not only provides them the physical space for their own medicinal treatments, but it also provides them a sense of place.   ‘Place’ to most people provides a sense of security and a sense of belonging. Unfortunately, ‘place’ for the Indigenous people is much harder to define. Lands that formed their place has long since disappeared; swaths had been taken away by the government without their consultation and that which has not been taken has been since significantly altered by modern development.  Their culture, identity, and their way of life was lost to roads and powerlines, mining and logging, infrastructure and buildings.

Once a vibrant forest, full of game for hunting and with fish aplenty, Vancouver easily supported the Indigenous way of life. Today, hunting and gathering is no longer possible, making it virtually impossible to continue their way of life and very difficult to maintain their culture. Rather than hunt and gather, they now must find other means to provide for their families.  Their sense of belonging is fast fading given the rapid pace of change and the stark changes to their lands.  With the loss of much of their lands, not only do they lose their way of life, but they even had to curtail space dedicated for their traditional practices and traditional healing.

Today, the Indigenous way of life in Vancouver is all but gone and their traditional practices have been relegated to museums and tourist destinations. The relative obscurity of the Indigenous culture and traditions, gives rise to ignorance and a general lack of understanding from the wider Canadian society. This ignorance and lack of understanding forms stereotypes, racism, discrimination and biases, which ultimately spreads into all aspects of society including the healthcare setting.  Discrimination is bad, discrimination in the healthcare system can be dangerous, as illustrated in ‘The Case of Brian Sinclair.’

In September 2008 Brian Sinclair, a 45-year-old man, wheeled himself into the emergency waiting room of Winnipeg’s Health Sciences Centre with a note from a walk-in clinic explaining his condition: a bladder infection caused by a blocked catheter.  He was not triaged and was left sitting in the waiting room unattended.  Despite efforts made by security staff and other patients in the waiting room, Brian Sinclair was left neglected by medical professionals.  After 34 hours in the waiting room, Brian Sinclair was pronounced dead.  His condition was treatable, and his death was preventable had a medical professional attended to him in a timely manner.

The pervasive stereotyping of the Indigenous people had led the medical professionals present at the time to assume that Brian Sinclair was just merely intoxicated and possibly homeless, waiting for a bed. This case was acknowledged in 2017 with doctors across Canada acknowledging that racism was present.

Many Indigenous people still face ongoing systemic racism, discrimination and bias today in  the healthcare system.  Another case, “Price is Right”, demonstrates racism remains pervasive in the health care setting in the lower mainland. In 2020, many Indigenous people have reported that medical professionals in hospitals in BC were playing a game of guessing the blood alcohol level in their patient before providing treatment. Although there was not enough supporting evidence to prove if this game occurred, a review of the system was conducted. Analyzing data gathered from surveys, interviews and direct submissions, it established that widespread systemic racism was indeed ubiquitous throughout the BC health care system.  To combat the systemic racism, Indigenous people are provided equal opportunity in decision and policy making in the health care system. Further, efforts were since put in place to raise awareness of the racism faced by the Indigenous people in the healthcare setting; also, medical professionals were educated in the Indigenous practices, so they are able to accommodate their traditions.  The result of the awareness and education campaign is to foster understanding and empathy in the healthcare professionals while building up the Indigenous people’s confidence in the healthcare system.

The Indigenous people is Placelessness made manifest.  Financially, Indigenous people are struggling to keep up with the rest of Vancouver society. Most Indigenous people are in poverty and suffer chronic health conditions. As a result, it’s often a difficult trade off for the youth: to stay in school or to drop out to seek income. Amidst this struggle, the Indigenous people continue to lose most of their land to development and the construction of infrastructure.  Many are displaced from their homes to other reserves, reserves that has no traditional meaning to them.  Places allocated for traditional healing and cultural practices have been take over by medical facilities.  Many feel they no longer belong and move outwards in hopes to find a new “safe” place but only find racism and discrimination.  To fight placelessness would be to provide place; educating our society on their traditions is a good first step, as this will engender understanding and empathy. Further, a safe environment for Indigenous people to practice their traditional healing and traditional practices should be provided, which in time could perhaps become their place.

Spatial Inequality of the healthcare system particularly impacts Indigenous people since over 50% of their population lives in remote or rural communities.  Hospitals and medical facilities, by virtue of pragmatism, are located near urban centers where it’s easily accessible to most and is able to find skilled workers. Unfortunately, this reality results in healthcare being not easily available to remote communities.  “In 2017, 82% of Inuit in Inuit Nunangat reported that they did not have a family doctor.  In comparison, less than one in five Canadians do not have a family doctor.” This lack of treatment centers exacerbates the prevalent poor health and poor mental wellbeing of the Indigenous community. For resolution, proper funding, provide training opportunities to meet their own needs, and supply resources needed.

• How is the urban population of Vancouver directly or indirectly affected by the selected issue/focus?

The urbanization of Vancouver has impacted the Indigenous people in a host of ways, the most dramatic would be the upheaval of their lands so that it is no longer fruit bearing and can no longer be their hunting grounds. The way of life for Indigenous people cannot exist given the vast changes to the land and fauna.  On the flipside, the Indigenous people has directly affected the urban population of Vancouver. The Indigenous people remain to be an uncomfortable acknowledgement amongst the urban population of Vancouver, knowing that their displacement from their unceded territories and their way of life has left them vulnerable, often in poverty and without a safe space.

The urban population of Vancouver is indirectly affected as we are recognized globally as a multicultural city but fail to recognize we are losing an important historical identity of our first settlers, the Indigenous people.

Lesson learned

There are a number of positive steps undertaken by the provincial government to ensure the traditional values of the Indigenous peoples in Vancouver are respected and heard. Together, they collaborated on the following:

• In 2013, the First Nations Health Authority became responsible for the programs and services that was once provided by Health Canada.  Through this action, they were able to “address service gaps through new partnerships, closer collaboration, health systems innovation, reform and redesign of health programs and services for individuals, families, communities and Nations.” This also paved the way for federal funding.   Over a 10-year span, $2 billion will be provided to the Indigenous Health Equity Fund to help improve fair and equal access to culturally safe healthcare.

• In 2015, The Truth and Reconciliation Commission of Canada calls for 94 actions. Child welfare, education, health, justice, language and culture are some of the actions called.  Acknowledgement of the mistreatment in the past and present, recognize the impact on their health the residential schools had on the survivors and their families, and being inclusive by working alongside Indigenous people on reconciliation is important.

• In November 2019 the Declaration on the Rights of Indigenous Peoples Act was established by the provincial government. In accordance with the UN Declaration on the Rights of Indigenous People, this approach aims to rid racism of Indigenous people in the healthcare system.

• In March 2022, the Declaration Act Action Plan was introduced.  There are 89 actions aiming for progression of reconciliation. This includes self-determination and self-government, rights and title, end racism, and improve the social, cultural, and economic well-being of the Indigenous peoples in BC.
• First Nations-led Primary Care Initiative was formed in BC to improve accessibility to healthcare by:

(a)   developing more centers in rural and urban land.  These centers will incorporate culturally safe and primary health care for Indigenous people.

(b)  Introducing the First Nations Virtual Doctor of the Day Program.  Doctor Prescribes Information About New First Nations Virtual Doctor of the Day Service. This decreases wait times as it allows the option for setting an appointment online or in person.  Respecting their culture is important as medical professionals come with an indigenous ancestorial background, lived experience, experience with cultural safety practices and humility, or experience in the rural community. Appointment times are flexible, and no time limit is set per appointment allowing a more covered consultation with a medical professional at no charge.

(c)   Introducing the Virtual Substance Use and Psychiatry Service.  Through a referral, pathways such as the Addictions Medicine Pathway and the Psychiatry Pathway are provided by specialists.

• The Indigenous Health Strategic Plan 2017-2021 was created and updated consistently providing accessibility to information related to health that ranges from nutrition to care for the elderly.  A number of services are also available such as All Nations’ Healing Room at the Royal Jubilee Hospital, Indigenous Health Diabetes Nurse Educator, Indigenous Health Dietitians, Indigenous Liaison Nurses, and the Indigenous Nurse Practitioners.

Acknowledgement of the history and working together for ongoing support presently will pave a better and inclusive future for the Indigenous people in Vancouver, BC.

References

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