Truths and Reconciliation: Peer navigation in Indigenous contexts Part 2.1 (Reconciliation): Poisoning the spirit of peer

Questing for system change in HIV and hepatitis C healthcare

Indigenous people resist Indigenous-specific racism.^1,2 This type of racism is rooted in the history of settler colonialism and it continues the injustices experienced by Indigenous people.^1,2 In healthcare, the doing of Indigenous-specific racism includes the tokenization of peer navigators.² It also involves the discrimination against Indigenous cisgender and transgender women with lived and living experiences (IWLE) of HIV and/or hepatitis C.² This has been leading to healthcare historic trauma— the perpetuation by healthcare of the intergenerational colonial harming of Indigenous people in Canada and globally (i.e., historic trauma).^2,3 Because of this trauma, peer navigators and IWLE face unsafe healthcare environments.²

In response, the Peers4Wellness community (see below) asked and answered two questions: Why does healthcare continue to expose peer navigators and IWLE to Indigenous-specific racism and historic trauma? And what needs to change to stop this?

This is the first of three articles in a story about reconciliation. The story is about the poisoning and reawakening of the spirit of peer (representing a group that includes IWLE and peer navigators), who is the main character. The story unravels the language and relational drivers of Indigenous-specific racism and historic trauma in healthcare (part 2.1). It also sets a path for healthcare system change (in parts 2.2 and 2.3). 

Braiding Voices of reconciliation

This series of articles aims to respond to the Truth and Reconciliation Commission’s Calls to Action and the Calls for Justice of the National Inquiry into Missing and Murdered Indigenous Women and Girls. The series shares learnings from the Peers4Wellnesss project.² Peers4Wellness is an Indigenous- and peer-led community-based research study in British Columbia (B.C.) on the unceded territory of the Coast Salish peoples. The knowledge shared in the article was gathered during a needs assessment (2017–2021) with the Peers4Wellness community (referred to as the community in this article). The assessment explored the need for Indigenous-centred peer navigation programs in B.C. 

This article applies the methodology Braiding Voices, which is influenced by Indigenous storytelling.^2–4 The primary storytellers are members of the community. The first and senior authors are the story stewards. Using quotations, the story is written primarily in the first-person voices of the community and Indigenous scholars. The audience is invited to connect with and gain their own interpretation of the quotes. The unquoted text reflects the first and senior authors’ learnings from the community and literature. Braiding Voices honours and privileges the ideas and expressions of the community and Indigenous people.

Teachings 

1. Indigenous-specific racism is a product of the coloniality of being. This is a mentality and a relationship, which transforms diversity into divisiveness. The coloniality of being involves beliefs and attitudes that separate people on the basis of “race,” class or gender. This mentality manifests in an unequal relation, where select people are singled out as being unworthy and undeserving of human rights.
2. The coloniality of being is embodied in how healthcare defines and relates to peer (representing a group that includes IWLE and peer navigators). 
3. Peer has become constructed as a second-class identity. The classification criteria are having lived experiences of HIV and/or hepatitis C and/or lay healthcare roles. 
4. Peer (second class) and others (“better” class) in healthcare have unequal standing. Healthcare does not recognize that peer has the same worth and basic rights as everyone else. Healthcare acts accordingly. It does not practise equality of treatment, equality of dignity, equality of opportunity, equality of interaction and equality of outcome.
5. Equality is tied to human rights. Relational equality is the principle that people have the same societal status (i.e., moral, political, social value) and hence the same human rights. Distributive equality is the use of the latter principle; it is achieved when everyone can enjoy their rights.
6. Healthcare fails to see and engage with peers (i.e., members of the peer class) as equals. As a result, peers are deprived of universal healthcare rights (i.e., basic standards of care and work in healthcare, which all Canadians are equally entitled to enjoy). This is a violation of public policy on human rights. 
7. Healthcare’s alienation of public policy is attributed to the social environment. The coloniality of being erodes social connectedness, which is necessary to protect human rights.
8. The disenfranchisement of peer continues healthcare historic trauma because of what it does and what it represents. What it does is deny peer the opportunity to enjoy basic standards of care and work in healthcare. This results in negative health outcomes for people with HIV and/or hepatitis C. What it represents is the rejection of peer as an equal citizen. This deepens the soul wounding from the rejection of Indigenous people by the settler state.
9. The coloniality of being is a hidden force of domination. This force has different faces including class and the notion of race. Class is what is at play in the healthcare experiences of peer, yet it’s perceived as Indigenous-specific racism. For IWLE and peer navigators, all faces of all colonial domination hurt the same.
10. Healthcare system change entails overturning the coloniality of being. This can be achieved by reclaiming peer’s identity, equality and universal healthcare rights. A goal is to broaden the scope of change beyond the blatant acts and visible harms of Indigenous-specific racism, chasing Indigenous healthcare equity and race-based discourse and action. System change should also attend to root causes and harms, securing Indigenous healthcare equality and attending to class-based ideologies and relationships.

Hands-on truths and system change 

“I believe that we suffer needlessly” because “there’s so much racism” in healthcare, stressed members (member(s) is used in this article as shorthand for member(s) of the Peers4Wellness community).² These truths demand healthcare system change.² 

“Even though there have been changes, there is still need for more,” said a member. Although there have been relentless efforts to address Indigenous-specific racism, it is still pervasive.^1,2,5–7 Often, the spotlight is on addressing healthcare’s ways of doing, which is warranted. These ways of doing refer to the blatantly Indigenous-racist harmful acts of healthcare including — but not limited to — the murdering of Jordan River Anderson, Brian Sinclair, Joyce Echaquan and other Indigenous people.^1,2,5–7 

Out of sight are healthcare’s ways of being, which involve hidden beliefs, attitudes and relationships.⁸ These are root causes of Indigenous-racist acts and of the invisible “soul sicknesses” that healthcare inflicts on Indigenous communities as put by a member.^2,9 Left intact, these unseen dimensions of healthcare can prevent change. “It is like a rotten cesspool that you’re trying to grow something out of a nutrient impoverished environment; in fact, it’s poisoned” at the roots, said a member. The community responded by exposing this poison and setting it as the bullseye of system change.

Bullseye on coloniality 

Healthcare “has an entirely different way of being,” than Indigenous systems, said a member. The scholar Nelson Maldonado-Torres describes it as “the coloniality of being” (referred to as coloniality in this article).¹⁰ 

Coloniality refers to an “us versus them” mentality and relationship, which has been “separating people out into their little spheres,” lent [1] a member (10). Coloniality involves language that exploits diversity (e.g., ethnic, health and social differences among people) to impose symbolic “segregation,” lent a member.^10–12 The segregation refers to dividing people into groups (e.g., “races, classes” or genders), which are assigned different societal status (i.e., moral, political, social value).^10–12 The result is relational unequality, [2] where select people are singled out as being unworthy and undeserving of human rights.¹³

Coloniality creates “the feeding grounds for hepatitis; [HIV]; for addiction; for all of the maladies we see in my people,” said a member. It seeds the ideological and relational foundations that promote the doing of Indigenous-specific racism. Therefore, upending coloniality is a necessary step toward transformative system change.⁸ 

This story is intended to raise awareness about coloniality. The plot shows that coloniality is embodied in the meaning and standing of peer (representing a group that includes IWLE and peer navigators) in healthcare. The story also reveals how coloniality enables healthcare to operate as “a system that is hostile” to peers (members of the peer group), lent a member. 

Synopsis: poisoning the spirit of peer

Peer is the main character of this healthcare story. The spirit of peer is free and equal. But coloniality poisoned this spirit. Because of colonial beliefs and attitudes, peer is assigned a second-class identity. Consequently, peer and others are given unequal standing in terms of worth and rights. Healthcare acts in accordance with its beliefs, attitudes and relations. It deprives peer of human rights. The spirit of peer is confined and oppressed. The segregation and disenfranchisement poison peer in visible and invisible ways. Peer experiences being (re)traumatized by Indigenous-specific racism. 

While bleak, peer’s story is telling. It exposes the works of the hidden ideological and relational generators of Indigenous-specific racism in healthcare. In article part 2.2, peer draws on this knowledge to reclaim identity. Then in part 2.3, peer shows a way for healthcare to heal from this racism. 

Manufacturing the second class 

According to the community, peer refers to a group in HIV and hepatitis C care that includes IWLE as care recipients or patients and peer navigators as care providers. Peer is framed as a second-class identity. Peer can mean that “you are not good enough,” lent a member. This identity (i.e., peer as second class) is the product of colonial healthcare beliefs and attitudes, which split (group, label, mark and rank) people into a hierarchy of societal status.^10–12 

The community explained that people with (a) disease and those with lay roles are grouped and labelled as peer.^2,14–25 One member explained by saying that “peer can mean a lot of things. In our HIV/hepatitis C world, peer tends to mean HIV or hepatitis C positive, or current or former drug user.” It also denotes having healthcare roles that are “based off life experiences, as opposed to professional” expertise, added another member. This grouping is not neutral because the peer label is marked with stigma and is associated with lack of expertise.^{2,14,16,18,26} According to the community, “having HIV/hepatitis C leads to the stigma.” Also stigmatizing is the notion that “Oh, you’re a drug user.” Further, people with lived experiences are not “seen as the experts in the community.” These marks translate into ranks, wherein peer (as a group) is seen as less deserving of healthcare than others.^{10–12,27–32} Classed as peer, I am being told that other people “are so much better than me,” said a member. 

Healthcare’s colonial mentality manufactures peer as second class, which is a devalued and deprivileged identity. But “that’s not who I am,” insisted members. We “are a vital part” of healthcare. Because the peer label can carry belittling connotations, “some [peers] don’t like to call us peers,” added members (the word “peers” refers to members of the peer group). Also, healthcare is not a privilege, which can be denied to peer but granted to the “better” class. Therefore, “it’s my hope that we can change that [attitude],” lent members. Otherwise, we will continue to endure the lack of healthcare equality. 

Delivering unequal healthcare 

Because of the second-class identity they have been given, “peers are not an integral part of the basket of healthcare,” lent a member. Instead, peer (as a group) and others are assigned unequal standing in healthcare. This relationship conditions behaviour.^13,33 Therefore, “people are getting treated as less than for being peers,” said a member. IWLE and peer navigators outlined the evidence and asked healthcare to reflect on it.

Healthcare is biased against peer. Because of being classed as a peer, “I was completely treated differently” than others in healthcare. For example, “I [felt] absolutely illegal [i.e., unwelcomed], right there, as soon as I walked in the [hospital] door.” Once, a doctor “was supposed to up my Kadian dose, and she made me wait a week for that. So, now you’re making me suffer” with no medical justification. Question: Where is equality of treatment?

Peer is disrespected. We endure “unacceptable behaviour from healthcare professionals.” I can’t believe that “the pharmacist called me a stupid bitch.” Question: Where is equality of dignity?

Peer is excluded from meaningful participation in healthcare. For example, the physician “was making decisions without seeing me.” Also, “there is a fine line between staff, and volunteer and peers.” For peers, “you just ignore what they say” and you pay them less. “Because when you start paying the peers a lot, technically they’re an employee” and some people feel that healthcare and perhaps peers may not be ready for that. Question: Where is equality of opportunity? 

Communication occurs in one direction and is dismissive of peer. Healthcare “is not having the adequate conversations with the peers, [keeping] in mind that they become informed. But they’re also informants.” For example, “the healthcare providers that I encountered didn’t understand me, as a person” and “they were speaking a language I didn’t even understand.” Question: Where is equality of interaction?

The “Do No Harm” principle is peer-blind^.9,34–36 Healthcare is “filling but not fulfilling the need.” Consequently, “Indigenous women are scared to go into the healthcare system.” Peer navigators “get home, they cry and they’re hurt.” “Trauma plays so much havoc in our lives.” Therefore, we can interpret unmet needs as an abandonment; this is harmful to us. Question: Where is equality of outcome? 

Overall, said a member, “I just can hardly believe” that the answer to all five questions is negative. This is a violation of human rights. 

Violating human rights  

Equality and human rights are intertwined. Relational equality is the principle that people have the same value and hence the same human rights.³³ Distributive equality is the enactment of the latter principle; it is achieved when everyone can enjoy their rights.³⁷ Some of the instituting policies include the United Nations Universal Declaration of Human Rights (UNDHR) (Article 1, Article 23, Article 25), the Canada Health Act and B.C.’s Human Rights Code (Section 8). 

According to public policy, peer and others have the same universal healthcare rights. These rights signify basic standards of care and work that all Canadians are entitled to enjoy. To honour these rights, healthcare must deliver on two fronts. First is to uphold relational equality, which means that “we have got to be seen as equals,” said a member. Second is to act accordingly by guaranteeing equality of treatment, equality of dignity, equality of opportunity, equality of interaction and equality of outcome.^{27,33,37–39} 

Healthcare fails on both fronts and in turn it breaches human rights. “It’s totally unacceptable what’s going on with peers,” said a member. What enables healthcare to violate policy and deprive peers of their rights?

Turning back on public policy on human rights

The alienation of public policy is common in practice.^40,41 According to the community, the disregard of human rights can be attributed to the social environment that coloniality creates. 

Indigenous ways foster social connectedness.^42–46 “We’re willing to sit in a circle together” with “no one above the other,” explained members. This way of being together is an expression of relational equality. It also comes with relational accountability, which means that “you are answering to all your relations,” wrote Indigenous scholar Shawn Wilson⁴³ (p. 177). This togetherness encourages people to be protective of each other’s rights.^33,43–46

“Now with colonization, that connection has been cut off,” a member pointed out. Coloniality imposed a disharmonious way of being, which alienates peer as second class and an unequal. It segregates and hierarchizes people (peer and others) on the basis of HIV and hepatitis C circumstances and healthcare roles. ^{11,14,18,32,47} It is almost like “all sit way over here in the corner…then way on this side is all the Native women” and the peer navigators, lent a member. Healthcare breaks the circle; hence, it absolves itself from answering to human rights.³³ 

“We flowed. And now all of a sudden colonization beat it out of us,” said a member. Peer and healthcare are not “being part of a circle,” to paraphrase a member’s comment. The severing of social connectedness is what enables healthcare to ignore policy on human rights.³³ Consequently, “a lot of people are suffering, down here, right now,” said another member.^2,9

Disenfranchisement is a twofold assault

Depriving peers of universal healthcare rights (i.e., disenfranchisement) harms IWLE and peer navigators because of what it does and what it represents.^39,48 It deters IWLE and peer navigators from accessing supports to meet their basic health and occupational needs, leading to negative healthcare outcomes for people with HIV and/or hepatitis C.² What it represents strikes deep and harms a lot more than meets the eye. This section of the story aims to heighten healthcare’s awareness of these invisible harms. 

Can you imagine “the hurt and the pain of trying to reach out and receive help only to be given a slap; an emotional slap or a rejection?” asked a member. “Those feelings damage the soul,” said another member.^{2,9,34,49–52} The damage is often invisible, yet it is at the core of how we experience historic trauma.^9,49–51 

Universal healthcare rights are tied to “our sense of ourselves as equal citizens,” to paraphrase the scholar Weinstock³⁹ (p. 429). Therefore, the disenfranchisement of peer strips away IWLEs’ and peer navigators’ sense of belonging as citizens. These experiences can be (re)traumatizing because they remind peer of how colonial institutions have been marginalizing Indigenous people.^{2,9,34,50–52} When denying my rights, healthcare “is rejecting me like that teacher did in residential school and she’s saying I’m a dirty Indian,” said a member. Both healthcare and the school are not recognizing the equal political standing of peers as Canadian citizens and/or as Indigenous people in Canada. 

When healthcare withholds a person’s rights, it traumatizes them twice. For example, “when a doctor doesn’t hear me, I will take it hard” because it can be a reminder of my experiences with other institutions “that’s neglected me, abandoned me and forgotten me,” concluded a member.^39,48

All colonial roads lead to racism 

Peers (as a group) have negative healthcare experiences because of their second-class status, which is assigned based on health circumstances and healthcare roles. Therefore, the (re)traumatization of peer (as a group) in healthcare is not purely “race” based. But “because we’ve been hurt, we might interpret that [traumatization] as racism,” said a member. The community unpacked this association, marking it as a consideration for healthcare system change. 

“I remember reading an article about when the settlers came here, equally when they went to Africa and elsewhere. How they take out big game. So, our bison, lions, bears and whatnot. And, for us, many of these animals have spiritual connotations, symbolism. And so, part of the colonizing process is that if you can so easily kill something that we uphold and respect, it’s an indirect form of domination if you will. It really is a colonizing of the brain, of values, of dreams,” said a member. 

This experience continues in healthcare. Notably, peer  “were seen so differently. Yeah, like 10 years ago in the community, people were really proud of the title of peer. At least within our little community. [We] really valued and respected people’s lived experiences. And because the community had this shift in treating peers as less than, it affected how our team now views that as well,” said a member. While not driven by the notion of race, the shift is a form of colonial domination. 

Irrespective of whether it is related to race or class, colonial domination applies a common set of tactics and is perceived as Indigenous-specific racism. Coloniality relies on symbolism (the slaughter of big game, the semantics of peer) to dismantle the equal standing (moral, political, social) of the dominated group (Indigenous people in Canada, peer in healthcare).^10,11,32 This relationship enables the disenfranchisement of people. The violation of our human rights hurts the same regardless of the specific grounds for the colonial assault. It is like “being attacked at residential school” once again, lent a member. 

The point is that “if you have experienced [colonial domination], you have a heightened alertness, where you have interpreted something to be racist when in fact maybe it wasn’t,” to paraphrase a member’s comment. Therefore, the community alerted healthcare to change its mentality around and relationship with peer. The reason is that healing class-based ways in healthcare can alleviate experiences of Indigenous-specific racism. 

Invoking the reflexive spirit 

The spirit of peer (i.e., the essence of what the word peer means and what peer relationships represent and invite) guided healthcare on a reflexive journey. The community responded to the need for reflexive practice, which is a vital undertaking when seeking Indigenous-responsive system change.⁵³ We understand reflexive practice as a visioning process, which reveals unseen ways of being (beliefs, attitudes, relations) that generate seen ways of doing (behaviours, actions). Reflexive practice can identify necessary targets for transformative system change; these targets might otherwise be left unseen and untouched, hence preventing reform.^8,53 

This story practised reflexivity by unearthing coloniality as a root cause of Indigenous-specific racism in health. It revealed the works of coloniality, which involve a classist mentality and relationships that promote healthcare unequality. The story illuminated the invisible harms of healthcare unequality, which can be as deeply traumatizing as the visible harms. The story taught that IWLE and peer navigators can experience healthcare to be Indigenous racist, even when the trauma they endure is not all “race” based. The moral of this story is that healthcare needs a different way of being. 

To achieve that, healthcare can commit to the following: 

First is mending how healthcare defines peer and relates to peers. Instead of second-classing peers, healthcare needs to “put their arms around them” and focus on “just bringing people together,” explained members. The goal is to foster social connectedness, which is an expression of relational equality and accountability to respecting people’s rights. 

Second is to set healthcare equality as a primary goal for healthcare system change. This goal is important because change makers have been causing Indigenous healthcare equity.^1,6,54–56 However, the community demanded equality first. Equality ensures the same start line, so that everyone in healthcare can attain the care and work they need. Equity ensures the same finish line, so that healthcare can close the gaps in health outcomes between Indigenous and non-Indigenous people.^1,6,54–56 For the community, delivering healthcare equality is the priority because it is a matter of honouring human rights; the denial of these rights is at the core of Indigenous-specific racism in healthcare. 

Third is to adopt a 360⁰ focus. This includes healthcare plans for “dealing with the need for multi-dimensional healing” from Indigenous-specific racism. Healthcare should also attend to “race-” and class-based ideologues and relationships that generate this racism. 

“I say we need All My Relations for everybody,” said a member. This way of being is awakened in the next articles of this story (parts 2.2 and 2.3). 

Definitions 

Indigenous-specific racism in healthcare²: A distinct type of racism that perpetuates colonization (i.e., domination and oppression by settler institutions) in healthcare. It is experienced as discrimination against Indigenous people, undervaluing lived/living experience, little focus on community-based care and the under-representation of Indigenous healing practices, Indigenous care providers and Indigenous healthcare spaces.

Historic trauma^2,9: The ongoing and intergenerational harming of Indigenous people as a group. The word “historic” acknowledges the colonial origins of this lingering trauma. In Canada, historic trauma is the result of colonization and subsequent policies and practices including the dispositions of Indigenous lands, Indian Residential Schools, the Sixties Scoop, child welfare, the correctional system, racism, social exclusion and violence against Indigenous women. On an individual level, historic trauma causes cumulative stress. This stress leads to physical, mental, emotional and spiritual harm. To cope with these harms, some individuals resort to undesirable practices such as substance use or the avoidance of traumatizing places including healthcare centres.

Peer navigation²: Health navigation that is provided by peer workers. Health navigation involves supporting care recipients to overcome barriers to healthcare. Peer workers are caregivers whose leading qualification is having lived/living experiences that are similar to those of care recipients. 

Healthcare⁵⁷: The services aimed at improving or maintaining health. The scope of healthcare is policy driven and dependent on the definition of health. The functions of healthcare fall anywhere under a continuum from public health to medical care.

Wellness^2,9: A concept that includes the physical, social, emotional, cultural and spiritual, for both the individual and the community. 

Historic trauma-safe healthcare^2,9: An emerging concept that describes healthcare environments that do not perpetuate historic trauma. This entails preventing the traumatization and retraumatization of Indigenous people and their allies (e.g., peer navigators) in healthcare. The concept emphasizes proactivity and the safety principle of historic trauma-informed care. 

Universal healthcare rights: Basic standards of care and work that all Canadians are entitled to enjoy. The standards apply to treatment, dignity, opportunity, interaction and outcomes in healthcare. Some of the instituting policies include the United Nations Universal Declaration of Human Rights (UNDHR) (Article 1, Article 23, Article 25), the Canada Health Act and B.C.’s Human Rights Code (Section 8). 

Healthcare equality^33,37: A way of being (relational equality) and doing (distributive equality) that is protective of universal healthcare rights. Relational equality is the principle that people have the same societal status (moral, political and/or social value) and hence the same human rights. Distributive equality is the enactment of the latter principle; it is achieved when everyone can enjoy their rights. 

References 

1. Turpel-Lafond ME, Johnson H. In plain sight: Addressing Indigenous-specific racism and discrimination in BC health care. Victoria (BC): Ministry of Health; 2020 Dec. p. 240. Available from: https://engage.gov.bc.ca/addressingracism/
2. Fayed S, Peers4Wellness Community, King A. Truths and reconciliation: Peer navigation in Indigenous contexts - Part 1 (Truths). Navigating historic trauma in HIV and hepatitis C healthcare. Toronto (ON): CATIE; 2023 Feb [cited 2023 Feb 10]. Available from: https://www.catie.ca/prevention-in-focus/truths-and-reconciliation-peer-navigation-in-indigenous-contexts-part-1-truths
3. Xiiem J-AAQQ, Lee-Morgan JBJ, Santolo JD. Decolonizing research: Indigenous storywork as methodology. London (UK): Bloomsbury Publishing; 2019. 
4. Archibald JA. Indigenous storywork: Educating the heart, mind, body, and spirit. 1st ed. Vancouver (BC): UBC Press; 2008. 
5. Jewell E, Mosby I. Calls to Action accountability: A 2022 status update on reconciliation. Toronto (ON): Yellow Head Institute; 2021 Dec [cited 2023 Mar 25]. p. 32. Available from: https://yellowheadinstitute.org/trc/
6. Council of the Atikamekw of Manawan, Council de la Nation Atikamekw. Joyce’s Principle. Brief presented by the Council of the Atikamekw of Manawan and the Council de la Nation Atikamekw. Council of the Atikamekw of Manawan, Council de la Nation Atikamekw; 2022. Available from: https://principedejoyce.com/sn_uploads/principe/Joyce_s_Principle_brief___Eng.pdf
7. National Inquiry into Missing and Murdered Indigenous Women and Girls, editor. Reclaiming power and place: The final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. National Inquiry into Missing and Murdered Indigenous Women and Girls; 2019. 
8. Kania J, Kramer M, Senge P. The water of systems change. Boston (MA): FSG; 2018. p. 20. Available from: https://www.fsg.org/resource/water_of_systems_change/
9. Fayed ST, King A, King M et al. In the eyes of Indigenous people in Canada: exposing the underlying colonial etiology of hepatitis C and the imperative for trauma-informed care. Canadian Living Journal. 2018 Oct;1(3):115-29. 
10. Maldonado-Torres N. On the coloniality of being. Cultural Studies. 2007 Mar 1;21(2-3):240-70. 
11. Bourdieu P, Wacquant LJD. An invitation to reflexive sociology. Chicago (IL): University of Chicago Press; 1992. 
12. Allan B, Smylie J. First Peoples, second class treatment: The role of racism in the healthcare and well-being of Indigenous People in Canada. Toronto (ON): Wellesley Institute; 2015 [cited 2022 Sep 12]. Available from: https://www.wellesleyinstitute.com/publications/first-peoples-second-class-treatment/
13. Ridgeway CL. Why status matters for inequality. Los Angeles (CA): SAGE Publications; 2013. 
14. Kipping M, Bühlmann F, David T. Professionalization through symbolic and social capital: Evidence from the careers of elite consultants. Journal of Professions and Organization. 2019 Oct 24;6(3):265-85. 
15. Castro EM, Van Regenmortel T, Sermeus W et al. Patients’ experiential knowledge and expertise in health care: A hybrid concept analysis. Social Theory and Health. 2019;17(3):307-30. 
16. Williamson C. Combining professional and lay knowledge to improve patient care. British Journal of General Practice. 2018 Jan;68(666):39-40. 
17. Lewin SA, Dick J, Pond P et al. Lay health workers in primary and community health care. Cochrane Database of Systematic Reviews. 2005 Jan 25;(1):CD004015.
18. Schinkel W, Noordegraaf M. Professionalism as symbolic capital: Materials for a Bourdieusian theory of professionalism. Comparative Sociology. 2011 Jan 1;10:67-96. 
19. Dennis CL. Peer support within a health care context: a concept analysis. International Journal of Nursing Studies. 2003;40(3):321-32. 
20. Broeckaert L. Practice guidelines in peer health navigation for people living with HIV. Toronto (ON): CATIE; 2018 [cited 2022 Jan 6]. Available from: http://epe.lac-bac.gc.ca/100/200/300/catie/practice_guidelines-e/practice-guidelines-peer-nav-en-02082018.pdf
21. Øgård-Repål A, Berg RC, Fossum M. Peer support for people living with HIV: A scoping review. Health Promotion Practice. 2023 Jan 1;24(1):172-90. 
22. Øgård-Repål A, Berg RC, Fossum M. A scoping review of the empirical literature on peer support for people living with HIV. Journal of the International Association of Providers of AIDS Care. 2021 Jan 1;20:23259582211066401. 
23. Crawford S, Bath N. Peer support models for people with a history of injecting drug use undertaking assessment and treatment for hepatitis C virus infection. Clinical Infectious Diseases. 2013 Aug;57 Suppl 2:S75-9. 
24. Mead S, Hilton D, Curtis L. Peer support: A theoretical perspective. Psychiatric Rehabilitation Journal. 2001 Feb 1;25:134-41. 
25. Penney D. Defining “peer support”: Implications for policy, practice, and research. Sudbury (MA): Advocates for Human Potential; 2018. 
26. Stangl AL, Earnshaw VA, Logie CH et al. The Health Stigma and Discrimination Framework: A global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Medicine. 2019 Feb 15;17(1):31. 
27. Sangiuliano AR. Substantive equality as equal recognition: A new theory of section 15 of the Charter. Osgoode Hall Law Journal. 2015;52(2):601. 
28. Tang SY, Browne AJ, Mussell B et al. ‘Underclassism’ and access to healthcare in urban centres. Sociology of Health & Illness. 2015;37(5):698-714. 
29. Gopal DP, Chetty U, O’Donnell P et al. Implicit bias in healthcare: Clinical practice, research and decision making. Future Healthcare Journal. 2021 Mar;8(1):40-8. 
30. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: A systematic review. BMC Medical Ethics. 2017 Mar 1;18:19. 
31. Vela MB, Erondu AI, Smith NA et al. Eliminating explicit and implicit biases in health care: Evidence and research needs. Annual Review of Public Health. 2022;43(1):477-501. 
32. Bourdieu P. What makes a social class?: On the theoretical and practical existence of groups. Berkeley Journal of Sociology. 1987;32:1-17. 
33. Joyce KE. Relational equality: A conceptual and normative analysis. San Diego (CA): UC San Diego; 2020 [cited 2023 Aug 18]. Available from: https://escholarship.org/uc/item/2x58v87x
34. Fayed S, King A. CATIE Blog. In the eyes of Indigenous people: The link between colonialism and hepatitis C, and the need for historic trauma-informed care. 2019 [cited 2022 Feb 19]. Available from: https://blog.catie.ca/2019/04/15/in-the-eyes-of-indigenous-people-the-link-between-colonialism-and-hepatitis-c-and-the-need-for-historic-trauma-informed-care/
35. Ghaly RF, Knezevic NN. What happened to “Patient first” and “Do no harm” medical principles? Surgical Neurology International. 2018;9:176 [cited 2023 Mar 17]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6130150/
36. Luxford K. ‘First, do no harm’: shifting the paradigm towards a culture of health. Patient Experience Journal. 2016 Nov 3;3(2):5-8. 
37. Schemmel C. Distributive and relational equality. Politics, Philosophy & Economics. 2012 May 1;11(2):123-48. 
38. Hajdin M, editor. The notion of equality. London (UK): Routledge; 2017. 
39. Voigt K, Wester G. Relational equality and health. Social Philosophy and Policy. 2015 Mar 1;31:204-29. 
40. Tummers L. Explaining the willingness of public professionals to implement new policies: A policy alienation framework. International Review of Administrative Sciences. 2011 Sep 1;77(3):555-81. 
41. Tummers L. Policy alienation of public professionals: The construct and its measurement. Public Administration Review. 2012;72(4):516-25. 
42. Jinkerson-Brass S. Creating oneness—ceremonial research. Journal of the Association of Nurses in AIDS Care. 2022 Dec;33(6):646-56. 
43. Wilson S. Research is ceremony: Indigenous research methods. Halifax (NS): Fernwood Publishing; 2008. 
44. Absolon KE. Kaandossiwin: How we come to know. Halifax (NS): Fernwood Publishing; 2011. 
45. Hawe P, Shiell A. Social capital and health promotion: a review. Social Science & Medicine. 2000 Sep;51(6):871-85. 
46. Hart M. Seeking Mino-Pimatisiwin: An Aboriginal approach to helping. Halifax (NS): Fernwood Publishing; 2020. 
47. Schneider-Kamp A. Health capital: Toward a conceptual framework for understanding the construction of individual health. Social Theory and Health. 2021;19(3):205-19. 
48. Weinstock DM. How should political philosophers think of health? Journal of Medicine and Philosophy. 2011 Aug;36(4):424-35. 
49. Whitbeck LB, Adams GW, Hoyt DR et al. Conceptualizing and measuring historical trauma among American Indian people. American Journal of Community Psychology. 2004 Jun;33(3-4):119-30. 
50. Les Whitbeck B, Chen X, Hoyt DR, et al. Discrimination, historical loss and enculturation: Culturally specific risk and resiliency factors for alcohol abuse among American Indians. Journal of Studies on Alcohol. 2004 Jul;65(4):409-18. 
51. Brave Heart MYH, Chase J, Elkins J et al. Historical trauma among Indigenous Peoples of the Americas: Concepts, research, and clinical considerations. Journal of Psychoactive Drugs. 2011 Oct;43(4):282–90. 
52. Truth and Reconciliation Commission of Canada. Truth and Reconciliation Commission of Canada: Calls to Action. 2015 [cited 2022 Sep 11]. Available from: https://crc-canada.org/en/ressources/calls-to-action-truth-reconciliation-commission-canada/
53. Dawson J, Laccos-Barrett K, Hammond C et al. Reflexive practice as an approach to improve healthcare delivery for Indigenous Peoples: A systematic critical synthesis and exploration of the cultural safety education literature. International Journal of Environmental Research and Public Health. 2022 May 30;19(11):6691. 
54. Browne AJ, Varcoe C, Lavoie J et al. Enhancing health care equity with Indigenous populations: Evidence-based strategies from an ethnographic study. BMC Health Services Research. 2016 Oct 4;16(1):544. 
55. Browne AJ, Varcoe CM, Wong ST et al. Closing the health equity gap: Evidence-based strategies for primary health care organizations. International Journal for Equity in Health. 2012 Oct 13;11:59. 
56. Blanchet Garneau A, Bélisle M, Lavoie P et al. Integrating equity and social justice for indigenous peoples in undergraduate health professions education in Canada: A framework from a critical review of literature. International Journal for Equity in Health. 2021 May 21;20(1):123. 
57. Deber R. Treating health care: How the Canadian system works and how it could work better. Toronto (ON): University of Toronto Press; 2017.

About the authors 

Sadeem Fayed 

My name is Sadeem Fayed. I am a woman and a newcomer to the traditional lands of the Indigenous people in Canada. I live on the unceded Coast Salish territory in Vancouver, British Columbia. I work with Pewaseskwan (the Indigenous Wellness Research Group). I am also a PhD student in the Faculty of Health Sciences, Simon Fraser University. I have been learning and working in the field of Indigenous health and wellness research since 2017. My focus is the Peers4Wellness project, where I position myself as an invited outsider to the community. My work with Peers4Wellness has been guided by the mentorship of Dr. Alexandra King and Prof. Malcolm King. I also have been practising in relation with Dr. Sharon Jinkerson-Brass, Candice Norris and Nicole Smith who are my Indigenous research partners — we call ourselves the Clan. As a first author, I bear the trust of the Kings, the Clan and the rest of the Peers4Wellness community. I take this responsibility seriously and courageously. Being in this role, I am not only accountable to the community but also to all my relations as a Muslim whose Creator “offered the Trust to the heavens and the earth and the mountains, and they declined to bear it and feared it” (Quran, Verse 33:73). 

I acknowledge that this series of articles is biased. It features the perspectives and needs of peer navigators and Indigenous women, but it is missing medical care providers’ side of the story. Also, the undertone of the series points at healthcare (as an institution) to do the heavy lifting of system change. I believe that this bias is justified for three reasons. First, the bias is inevitable because the article is driven by the voices of the Peers4Wellness community, where Indigenous women and peer navigators are overrepresented. Second, the bias is not against medical care providers. “It’s not entirely their fault,” as put by community, that healthcare perpetuates historic trauma. Echoing the community, we/I recognize that “the system is designed almost to burn everybody out: nurses, doctors, everybody” and that “we need wellness for everybody.” Finally, the bias is necessary because the responsibility for enacting reconciliation falls on colonial institutions such as healthcare. 

I heard Dr. Alexandra King tell me that she is concerned about losing medical providers as an audience because of this bias. I listened and sought guidance from Dr. Sharon Jinkerson-Brass, who is the Indigenous Knowledge Holder on the Peers4Welness project. Sharon wrote that “we all understand the penetrating and comforting heat from a fire on a cold winter’s night and the beauty of a cool bath on a hot day. If we could remember the sacred fire and holy water when we are dreaming a new relationality in the healthcare system.” Being accountable to community, responding to Alexandra’s point and learning from Sharon’s wisdom, I offered the above acknowledgement (water) with the hope of cooling off the bias (fire).

Peers4Wellness Community 

This article is guided by the voices of the Peers4Wellness community in British Columbia on the unceded territory of the Coast Salish People. The community includes 53 people: Indigenous women (cis- and trans-gender) who have lived and living experiences of HIV and hepatitis C; Indigenous and non-Indigenous peer navigators including frontline workers and community organizations and Indigenous matriarchs including Dr. Sharon Jinkerson-Brass, Knowledge Holder and community research associate; Candice Norris, culture support worker and peer research associate; Nicole Smith, community research associate and Dr. Alexandra King, internist physician and principal investigator. Dr. Alexandra King is also the senior author of this article. 

Dr. Alexandra King

My name is Alexandra King. At least that is the name recognized by the government and in day-to-day life. However, I have been gifted with two spirit names that truly connect me to my ancestors and all my relations. I am a member of Nipissing First Nation, which is located in what is now known as Ontario. My First Nation ancestry flows from my Mother’s bloodline, while my Father was of mixed European ancestry. I have been welcomed by the Mississaugas of the Credit First Nation, my husband’s community, where I have the privilege of living. I work, mostly virtually, on Treaty 6 territory and the Homeland of the Métis on what has become known as Saskatoon at the University of Saskatchewan. I am honoured to be the Cameco Chair in Indigenous Health and Wellness, which is primarily a research chair; I also do clinical work as an internal medicine specialist. I have always deeply admired lived and living experience and the wisdom that this potentially brings to a culturally safe and responsive healthcare system. I see the Peers4Wellness research (funded by CIHR) as a critical piece supporting this work.