Abundant evidence has demonstrated that historic and present-day colonialism has disrupted the health and well-being of Indigenous peoples in Canada. Decades of federal policies with the sole purpose of eradicating Indigenous identities, families, communities, culture, and traditional ways of life have resulted in intergenerational trauma, racism, and discrimination.39-41 These factors manifest as an overall increased risk of premature morbidity and mortality among Indigenous peoples in Canada relative to non-Indigenous people in Canada.42-44 Epidemiological data that show higher prevalence rates of high-risk substance use, substance use disorders, and substance-related harms among Indigenous peoples42,45 must also be interpreted within this broader context. More specifically, it is emphasized that Indigenous peoples are not, by nature of their genetic background and cultural identity, a “high-risk” population; rather, the settler state’s approach of erasure, displacement, and assimilation of Indigenous peoples has led to significant health and social inequities and created conditions where some individuals use alcohol and other substances to cope.46,47 Racism and harmful stereotypes about Indigenous peoples, particularly around substance use,48-50 persist within the health care system in BC and can act as a deterrent to seeking out and remaining engaged in care in this population.51-54 

If the mainstream health care system is to be effective in addressing health and social inequities experienced by Indigenous peoples, health care providers must commit to the principles of culturally safe and anti-racist care and exercise cultural humility.55 Cultural safety is achieved when the person receiving care or accessing a service feels safe and perceives their environment as a space free from racism and discrimination. Achieving this outcome depends on respectful engagement that seeks to address power imbalances inherent in the health care system. Cultural humility is a self-reflection process undertaken to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust; it requires humbly acknowledging oneself as a learner when attempting to understand another person’s experience.  These processes move beyond the concept of cultural sensitivity  to consider how social and historical contexts, institutional discrimination, structural and interpersonal power imbalances, and past, current, and ongoing colonization shape health and health care experiences of Indigenous peoples.56 It requires health care providers to be knowledgeable of the colonial history of Canada and the roots of historical, ongoing, and intergenerational trauma among Indigenous peoples, and to practice cultural humility: to be continually self-reflective of personal biases and aware of their position of power and the effects that this power dynamic may have on their Indigenous patients.57 

Specific approaches and understandings have been identified as necessary to provide culturally safe and  appropriate care to Indigenous peoples,58 these include: 

• Understanding the importance of local history and the lasting and multigenerational impacts of colonization and the residential school system 
• Examining, understanding, and acknowledging how health care providers’ own values impact the healthcare environment and healthcare encounters 
• Understanding health as encompassing physical, mental, emotional, and spiritual wellness
• Understanding the impacts of disparities in the social determinants of health 
• Respecting local traditions, traditional beliefs, and healing practices, and offering to incorporate them in the patient’s care plan when available and appropriate
• Recognizing and respecting differences in communication styles, which may be influenced by power imbalances as well as culturally-specific behaviours  
• Understanding that whole communities may be impacted by what happens to one community member, that the family unit may be a large, extended family, and that hostile healthcare experiences can influence entire communities’ healthcare seeking attitudes 
• Understanding that cultural healing practices may require that families be involved in the care of clients
• Approaching patient relationships with respectful curiosity 
• Challenging personal assumptions, being flexible, and being open to changing how things are commonly done
• Recognizing and accommodating the need for a translator for those whose primary language is not English 

As a starting point, all health care professionals and staff should undertake Indigenous cultural safety training to improve their ability to establish safe, positive partnerships with Indigenous patients and families. Care teams and staff are also encouraged to familiarize themselves with the Truth and Reconciliation Commission Reports, specifically the Calls to Action, which outline necessary actions to address the legacy of colonialism in a range of domains including health care. There are several Indigenous cultural safety training programs available to health care providers and staff in BC. PHSA hosts an online Indigenous Cultural Safety Learning Series in partnership with the Southwest Ontario Aboriginal Health Access Centre, which is guided by an advisory council of national and international Indigenous and non-Indigenous leaders. Information on this monthly webinar can be found here: http://www.icscollaborative.com/. First Nations Health Authority and the BC Patient Safety & Quality Council offer a cultural safety and cultural humility webinar series, in addition to several policies and resources that can be accessed on the FNHA website. Care providers are also encouraged to seek out resources that may be available in local health authorities. For example, the Vancouver Coastal Health (VCH) Indigenous Health program offers Foundational Indigenous Cultural Safety (ICS) Training, an in-person interactive and self-reflective group training session, to VCH staff. Additional resources and guidance on working with Indigenous populations can be found in Section 4.0.