For Indigenous people, cultural safety means medical safety

A history of colonialism and mistreatment in Quebec's medical system demands a new approach.

Joyce Echaquan was surrounded by all the familiar features of a healthcare environment. She lay in a motorized bed wearing a teal gown, the walls were a soft beige, and the beeps of medical machinery faintly filled the air.

The racist phrases said by staff in Echaquan’s hospital room were familiar too.

She would die in that room on Sept. 28, 2020, at 37 years old, and leave behind seven children.

The circumstances of her death at the Centre Hospitalier de Lanaudière in Joliette, Q.C. are still being investigated by the Quebec government. However, Echaquan put the hostility and contempt she experienced in the moments before her death on direct display through a Facebook Live video.

“She’s only good for sex,” a nurse said off-camera. “You made bad choices, my dear.”

This racism towards Echaquan echoes the experiences of many other Indigenous people treated in hospitals across Quebec.


Mourners hold up photos of Echaquan at a candlelight vigil held for her in Ottawa. Photo by: Spencer Colby

Marjolaine Siouï, executive director for the First Nations of Quebec and Labrador Health and Social Services Commission, told The Pigeon in an interview that Echaquan wasn’t alone in her mistreatment by healthcare professionals.

“Joyce’s case is not an isolated case,” she explained. “Sometimes, it’s a lack of knowledge, understanding, or comprehension.”

“In other ways, it’s about pure racism.”

Indeed, the cultural reckoning that swept across the country in 2020 quickly amplified Echaquan’s video, with some drawing parallels between her death and the death of George Floyd in the US this past May.

In early October, thousands marched through Montréal and held vigils in Ottawa demanding action against systemic racism in healthcare.

Siouï compares this recent public outcry to the Idle No More movement, which started in 2012 and campaigns to protect both First Nations territory and sovereignty.

“[Echaquan’s death] kind of re-enacted that movement in a different way,” she said. “We can no longer lose that momentum. We need to make sure that real changes in the system are going to be made.”

Quebec leaders have so far denied the existence of systemic racism in healthcare—a position they doubled down on while simultaneously rejecting a series of recommendations to improve health care in Echaquan’s name.

Despite this fact, they announced that they will provide $15 million over five years to train hospital staff in cultural sensitivity and hire workers who can help Indigenous patients navigate the Quebec health system.

Is this enough?


At L’Université de Laval, Christopher Fletcher is an anthropologist and public health researcher who runs a program to train First Nations and Inuit doctors.

“The role of the Quebec government in Indigenous health is very dependent on [what population] we’re talking about and where they are,” he told The Pigeon. “The right to healthcare is dependent on the geography they live in.”

Indeed, on a more granular level, health services for Indigenous people in Quebec tend to vary depending on geographic location.

Many First Nations, for example, have their own means of providing care to the community. Just over 100 km north of Montréal, for example, the Abénaki First Nation has a health centre that provides preventative medicine, nursing services, and mental health consultations.

For critical care, however, residents must rely on Quebec’s health system. Echaquan herself travelled about 185 km south from her home in Manawan to Joliette to treat her stomach pains.

This kind of distance can put a person at increased risk. According to a study from Concordia University, in an emergency situation, “every additional kilometre [to a hospital] decreases a person’s probability of survival because it causes an injured individual to become a more serious case.”

“The solution to many of these problems is to make sure that the people who need the services run the services,” said Fletcher. “It’s not going to be perfect, but it’s one step on the road to making things more effective.”

Better care for Indigenous people comes down to increased decision-making powers for First Nations communities and organizations over Indigenous health services, according to a 2019 report by the First Nations of Quebec and Labrador Health and Social Services Commission. It also means building a more robust partnership between First Nations and the Quebec provincial government to expand services in their communities.

Fletcher also added that Quebec needs more Indigenous doctors and nurses. This can help build trust between a person and their healthcare provider, which can, in turn, increase a person’s likelihood to go back to that doctor for regular check-ups.

This creates continuity of care, which is well-established as an important part of care delivery—it is linked to lower hospitalization rates, improved patient satisfaction, and can help to avoid preventable deaths.

Fletcher went on to describe the importance of sharing culture with your care provider.

“It’s all the stuff that never has to be said because everybody already knows it,” he explained.

“When people already understand each other and approach others as brothers and sisters, it makes for a trusting relationship. It makes for fewer errors [and] less misunderstandings.”

As it stands, according to a 2016 Statistics Canada census found that Indigenous people make up less than one per cent of doctors in the country, despite comprising 4.5 per cent of the population.

From cultural sensitivity training to wider structural reforms, these changes must be understood in relation to Canada and Quebec’s history with Indigenous peoples.

At best, colonists viewed Indigenous people as child-like and incapable of managing their own affairs. At worst, they viewed them as “savages” and separated Indigenous children from their families in an attempt to erase their culture.

Quebec’s approach to health echoes these colonial frameworks. As documented in the Viens Commission report—the result of a public inquiry launched by the Quebec provincial government—religious groups were primarily responsible for healthcare delivery to Indigenous peoples until the late 1940s. These groups operated “with the support of patrons and doctors, whose profession was then essentially unregulated.”

While the report does not indicate these religious health services’ effectiveness, it does say that Christian missions often worked towards erasing traditional Indigenous spiritual practices.

Then, during the mid-20th century, polio and tuberculosis broke out in First Nation communities and Inuit villages. Health teams responded by evacuating patients to health centres in the southern regions of the province. The problem, however, is that patients were separated from their families, culture, and support systems. As stated in the Viens report, “[patients] were isolated and far from their families.”

Quebec healthcare providers also often failed to notify families when Indigenous patients died on their watch. Examples of this occurred until as recently as the 1970s, when eight Indigenous children died in a hospital in Blanc-Sablon, and their parents weren’t notified until 2015.


One of Echaquan’s 7 children attends an Ottawa vigil in her memory. Photo by: Spencer Colby.

Siouï said that cultural sensitivity training for medical staff is a good first step, but politicians should receive this training, too.

“Training is part of the solution, but it has to be more global than that,” she explained. “When deputies are elected—and you have the election of the premier and other ministers—they need to have that training.”

She said this training should be provided by Indigenous communities and should include education about the differences between First Nations and about important treaties such as the James Bay Agreement.

Dr. Lisa Richardson, the strategic lead in Indigenous Health at the Women’s College Hospital in Toronto, agrees that cultural training can help prevent racist incidents in healthcare, but there are some potential limitations.

“The problem is that people think they can take a single course and then ‘tick,’ it’s done,” she explained. “But it’s really about that ongoing reflexive work.”

The board of directors for the Women’s College Hospital is chaired by Tammy Brown, a member of the Shawanaga First Nation and the first female Indigenous board chair for a hospital in Canada. The hospital is also home to the Centre for Wise Practices in Indigenous Health, which offers resources on how health care professionals can do better when working with Indigenous patients.

Dr. Richardson explained that training should encourage people to reflect on their biases and question whether they are reproducing colonial structures and stereotypes through their actions.

“It’s about training a way of existing, to bring that lens of being able to see the world from a different perspective,” she added.

Indeed, Fletcher explained that ongoing cultural awareness is the first step to building trust between non-Indigenous care providers and Indigenous patients.

“The path to trust is really in self-awareness first,” he said. “You need to be aware of how you are as a service provider, as a person, as a cultural being, as somebody who has a particular way of understanding themselves and the world around them.”

Richardson also said that, while education is good, health systems need safe reporting systems for when racist incidents occur and that organizations must identify these incidents after they happen so that they can be dealt with internally or by an external body.

“There needs to be accountability for when clinicians are treating people this way,” she said. “It’s really not acceptable if you treat someone this way that you can continue to practice without repercussions.”


 Indigenous people in Quebec also experience health inequities that extend beyond racism at the point of care.

According to a report from the Public Health Agency of Canada, Indigenous people have, on average, a life expectancy that’s five years shorter than non-Indigenous people.

In Quebec specifically, only half of the surveyed Indigenous people living off-reserve rated their health as “good” or “excellent.” This is nine per cent lower than the non-Indigenous people surveyed.

Siouï explained that a recognition of these historical practices is important when helping an Indigenous person.

An Indigenous person presenting to the hospital may have experienced residential schools in their childhood, resulting in long-term trauma and distrust of government institutions. This feeling can be amplified if the person had to travel far from their family, culture, and language to receive treatment—effectively losing their support system.

“If staff are aware of that, then maybe the approach would be different,” Siouï explained. “They would understand the behaviour of that person and the fear that [they] may have, and to build that relationship with them and try to make them feel safe and understand where [they’re] coming from.”

Siouï also emphasized that cultural and structural changes in healthcare delivery are everyone’s responsibility, from Indigenous doctors to non-Indigenous doctors, from citizens to political leaders.

“It’s something we need to do together,” she said.

“From that, we’ll see great changes.”


Eric Dicaire is an aspiring health reporter in Montreal, Q.C. He holds a master’s degree in Communication from the University of Ottawa and has previously worked in the health sector for three years. He is now taking a break to study journalism at Concordia University, looking for ways to amplify voices and make a difference in the world.

When he’s not at his desk, he can usually be found in the kitchen cooking, with headphones on, taking in the podcasts of the week or listening to one of his favourite bands.

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