CHAPTER | Structural Determinants of Aboriginal Peoples’ Health Charlotte Reading ‘The Oxford relations betw ionary (nd. defines “structure” as “the arrangement of and n the parts or clements of somethi g complex.” In order tounderstand the challenging realities of Aboriginal health—specifically, the persistent disparities between the health of Aboriginal peoples and. that of non-Aboriginal people in Canada—itis necessary to examine the interrelated features and relationships of the structural (historical, polit nic) determinants that shape Al “There is increasing consensus that the oppre ical, societal, and original health, olonial structure thin which Aboriginal peop material ine« ities chat result in health d (Waldram, Herring, & You arities that persist over several generations 2006), Diminished life expectan: n of chronic disease and communicable i disproportional bus : addictions, and social violence have all been linked to an colonial structure (Butler-Jones, 2008) Th influence the observable health burden experienced by Aboriginal in Can: health before moving to a chapter explores this structure and how its “movi ida, T be jn with an overview of structural determinants of scussion of how the historical structure of colonialism is connected to disproportionate rates of disease, disabil nce, and early death experienced by Aboriginal peoples. I also examine contemporary ideological and political structures in otrace the pathways through which they exert control over the determ: nants of Aboriginal health. Although it is challenging to establish an empirical connection between the ideological, political, economic, and ures of Canadian society and the h Ith inequities experi enced by Aboriginal peoples, this undertaking is essential in order to create lasting change in the health trajectories of Aboriginal children, youth, and future generations. STRUCTURAL DETERMINANTS OF HEALTH Understanding the intricacies and interconnections between proximal intermediate, and distal determinants of Aboriginal health (Loppie Reading & Wien, 2009) is a critical first step in appreciating how these determinants influence the socio-economic trajectories for children and youth that often predict their health status during adulthood, Within an Indigenous paradigm, the metaphor of a tree is perhaps most appropriate for exploring the social determinants of health. Similarly, and within the context of diverse cultures, the teee is a familiar part of the natural world. We typically think of ees as possessing three interconnected elements: the crown (leaves and branches), the trunk, and the roots. Each part of the tree is dependent not only upon the other pacts for sustenance and support, but also upon the environment that nourishes and sometimes damages them. Like the crown of a tree, proximal determinants influence health in the most obvious and direct ways, Within a eterminants of he ‘model, proximal determinants include eaely child development, income and social status, education and literacy, social support networks, nal health, the physical der (Krieger, 2008). The evidence that disadvantage and inequity within this stratum (e.g, pov employment, working conditions and occup ‘environment, culture, and ges whelming, erty, discrimination, lack of education, unemployment, poor working conditions, and inadequate or harmful physical environments) give rise to all manner of phy challenges (Marmot, 2005). Like the trunk or core of a tree, intermediate determinants facili- al, emotional, mental, spiritual, and social tate or hinder health through systems that connect proximal and distal eerminants, These determinants inchide health promotion and health ae, education and justice, social supports, labour markets, as well as sveonment and private enterprise (Loppie Reading & Wien, 2009) {Wichin an Indigenous framework, in snelude kinship networks, mediate determinants might also lationship to the land, language, ceremonies, 009. of knowle: gavel 25 sharing (Loppie Reading & Wien, iat this stratum, determina s have a less direct impact on the health ofindivideals, yet profoundly influence proximal determinants. For jstance, we know the following: there are inadequate federal/provincial resources available €0 support healthy development for all Aboriginal childeen (Blackstock & Trocmé, 2005); lack of economic develop- sent opportunities leads to poverty in many Aboriginal communities @ Nations peoples living on-reser Ichouse, 1999); inaccessibility of health care services for many First ¢ leads to diminished screenin, diagnosis, and negative health outcomes (Cardinal, 2004), a problem that is compounded when many of the health care programs and se that are accessible to these communities fail to consi .¢ cultural safety of Aboriginal peoples (Smye & Browne, 2002) Although there is an undeniable need to explore the processes and. health impacts of inequitable proximal and intermediate determinants, the focus of this chapter ison the distal or root (or structural) determi- nants of Aboriginal peoples’ health, Like the roots of a tree, these deeply embedded determinants represent the historical, political, ideological, economical, and social foundations (which includes Indigenous world, views, spirituality, and self-determination) from waich all other deter minants evolve. Just as maladies obse red in the leaves are generally not uently result corruption or deficiencies in the unseen but critical root system. In much the same way that all domains of health (physical, mental, emotional, and spiritual) are intimately interconnected, so too are the proximal, intermediate, and distal determinants of health Similarly, within each of these strata of determinants, elements of in- fluence combine to create synergies of advantage and/or disadvanta, In the sections that follow, | discuss the historical and contempor- ary structures that have formed the distal determinants of health for Aboriginal peoples.6 Pert 1 Setting the Contest: Beyr HISTORICAL STRUCTURES, Inorderto fully appreciate the current health disparities facing Aboriginal peoples, we must first explore the historical roots upon which current ved. Over the past 400 y across North America have experienced similar patterns of cofonial 15, Indigenous societies le the details of distinct historical colonial encounters oppression. Wh may have differed, the impacts of colonization, conquest, and attempted. cor successful assimilation into the dominant society are nearly univer- pen spared the dramatic alteration sal. Few Indigenous groups ha sures, or the drastic changes in cconomie, political, and social stru disease patterns and general health, brought about by colonialism (Klein & Ackerman, 1995). Given that engagement in subsistence activities represents aeritical determinant of health (Macmot, 2005), itis ctear that interrupted access to land, food, and waters intimately linked to the drastic post-colonial changes in health among Indigenous peoples in Canada and elsewhere Prior to colonization, many Indigenous groups travelled regularly to access resources and maintain social networks. Through the Indian Act the imposition of a reserve system in Canada prevented seasonal ‘migration of small family groups, that instead became confined to one location year-round (Kelm, 1998). In general, reserve lands were, and ough either continue to be, insufficient to sustain food production th riculture or ranchi Further, these relatively small tracts of land are frequen remote and lack access to potable water (Waldram, Herring, 8 Young, 2006). Historically, water rights and services were developed to meet Euro-Canadian needs with litter ence to Aboriginal communities. As a result, when combined spread water con tamination resulting from colonial development of surrounding lands, lack of access to clean water facilitated the spread of communicable illness on many reserves. Ironically, although decisions about resource allocation were primarily made by federal and provincial governments, high rates of illness in Aborigina perceived as the healthy” (i.e, We en) modes of liv result of resistance to adopt (Waldram et al, 1995). The intrusion of European settlers and the conversion of trad: jsional hunting tersitories to pasture land severely restricted Indigenous ieand increas peoples’ access to food and other resources. Encroachm while unscrupulous trappers pulous trapp. steipped traditional lands of fur-bearing animals. Fuct ing mechanization frightened game away, many forms indigenous hunting and fishing were banned in the interests of 1 3 ig were banned in the interests of expand apitalist ventures ‘Waldram et al., 1995). In fact, most government ed to support industry at the “The dem pense of Indigenous self-sufficiency c of the fur trade and ever-increasing restrictions to reserve land compelled many Indigenous eoples to engage in wage labour, However, racially di atory hiring and wage practices meant that they operated on th 2 margins of Euro-Canadian society, often resulting in widespread poverty (Kelm, 1998; Lemchuk-Favel, 1995; Waldram et al., 1995) Prior to and during the processes described above, Euro, an dis- ceases devastated Indigenous populations. According to Kunitz, “Contact induced diseases were as much a prelude as an aftermath of European domination” (1994, p. 8). Indigenous peoples h Euro ‘ diseases such as smallpox, 1 losis, diphthes wasles, whooping cough, tubercu- a, typhus, yellow er, influenza, and dysentery, leaving ch either immunological or medical means. Epidemics decimated entire populations, spreading through trade routes ried by people f or in advance of the colonizers, often c them (Oakes et al, 2000; Kunitz, 1994) Early Western medical ng before to Indigenous peaples was immersed in an agenda that sought to justify and sustain Canada’s colonial activities ‘Kelm, 1998). ‘The Indian Act directed the minister of Indian Affairs to enforce regulations regarding the suppression of communic: ble disease sanitation, and the provision of medical treatment and health services, However, the Act was more permissive than directive with Indian agents to appoint doctors or the federal gov nent assume financial esponsibility fr health services Tn fat the government refused to accep leg obligation to provide health care to First Nations peoples, despite the widespread, albeit capricious and substandard, practice of providing on-reserve care by government doctors (Waldram et al., 1995). -8 Port 1 Setting he Context Beyond Western medicine played a key sole in the colonization of Indigenous peoples by virtue of the rationale given for its involvement in their lives and its intrusion into their bodies (Kelm, 1998). For the most part, carly Indigenous health policy was based on notions of “white” racial superiority, assimilation goals, and an irrational fear of “interracial” contagion, Disease prevention initiatives sought only to minimize the colonial burden of sick Indigenous peoples and to contain disease, thereby protecting Buro-Canadians (Kelm, 1998) ‘Medicine was instrumental not only in shaping ideas about d- 1em as inherently pathological, making Indi ical discourse that desc :nous peoples and the bed ¢ the provision of health care a colonial obligation, ‘The prevailing belief -ommunities but in perpetuating Indi (Kelm, 1998), Medicine was seen as “one of the most effective a in spreading the glorious Gospel ofthe Blessed God” (Thomas Crosby, health could only be guaranteed through assimilation meant that nous bodies became sites of colonization by missionary doctors nineteenth-century Methodist missionary; cited in Waldram et al., 1995, p. 104). Moralizing and humanitarianism became the framework in which the colonial project was fashioned and missionaries were granted the right to rule through good deeds, with medicine symbolizing humanitarian domination (Keim, 1998). The color malized in 18 al partnership between religion and government was for~ 7, when churches were given control over education and. residential schools became the primary instrument of assimilation. The racist ideology that rationalized these schools also promoted the notion that Indigenous peoples required phy well as spiritual healing, d social transformation as well as eradicate Indigenous family and kinship structures (Kelm, 1998; Miller & Churchryk, 1996). Children were Colonial education was designed to facilitate and support economic forcibly removed from their ho} ‘communities for time, thereby disrupting social networks and cultural learning. Attempts ‘were made to indoctrinate them into a system that stripped them of their 1 into second-class Canadiar 1998) exceptions, residential schools were underfunded Indigenous identity and transformed a citizens and lows With fe and understaffed, which meant that children were often poorly fed, labourers tended periods of ce Sieh nants Aborginol Peoples’ Heohh 9 jll-clothed, and overworked. Tuberculosis (TB) was rampant in many schools, its spread often facilitated by overcrowding. Children frequently returned to their home communities infected with TB, reading the d fairs (DIA) repo 35 percent of stu cto others. In 1907, the Department of Indian fed that in the previous 15 years, between 25 and sin residential .ools had died, mostly from TB .n DIA Deputy Minister Duncan Scott admitted that 50 percent of Indian students never lived to “be ived. Whi objected to the absence of their children from home (sometim as long as 10 months a y (Waldram et al,, 1995). In the early 1900s, t” from the education they many parents and the harsh conditions child subjected to in residential schools, they risked imprisonment if they attempted to withhold their children from school (Assembly of First Nations, 1994; Kelm, 1998), Within the walls of residential ools, Indigenous languag customs, and dress were forbidden and children often paid a terrible price in the form of harsh physical punishment for small or unwitting afractions. ‘The legacy of sexual abuse still impacts many Aboriginal men and women who were fore to attend residential school as children, This federal effort to re-educate, convert, and assimilate Aboriginal children caused unimaginable physical, em ional, mental, spiritual, and sexual harm to thousands of Aboriginal peoples,» years (Assembly of First Nations, 1994), Perhaps the gre entire Indigenous cult: anning 100 oss was to languages, stories, and spiritualities—some are lost forever, but many 1998; Knockwood, 199% Aboriginal childre and learnin, xe in the process of being restored (Kelm, Unfortunately, the practice o prehending -n and placing them within non-Aboriginal living Wironments did not end with the gradual closing of ‘most residential schools. Rather, the practice continued with the “sixties scoop" (Johnston, 1983) and the current o child presentation of Aboriginal n who are apprehended and placed in the child welfare system in which no distinction is made between negl +t due to parental pov- rd (Tz0emé, Knoke, 8 erty and neglect resulting from parental disee Blackstock, 2004).the Socal CONTEMPORARY STRUCTURES Ideally, the structures (social, political, economic) of any given soci ety facilitate cohesion among its members, as well as create systems rich all pet opportunities. Instead, Canadian society has, by and large, engaged through ple can access resources and derive benefit from in systemic discrimination against Aboriginal peoples, manifested as ith families, communities, and nation-states. inequitable structural de srminants that detrimentally impact t and well-being of individu Contemporary relations bet and the n Aboriginal peo} Canadian state are founded on a racialized ideology, which continues to support the tenets of colonialism. The historical rec ds of early explorers and clergy America as, firstand foremost, not white (Red Mer adjectiv acrally describe the Indigenous peoples of North often preceded by nd thus intellectually, morally, cof ins was reconstructed through such as “primitive” or “savag and socially inferior to white Europeans. The generosity and tole y Indi the colonial gaze into racialized stereotypes of apathy and submissiveness, th lands, generalized violence, and the exploita nus peoples toward Europ providing a rationale for discriminatory policies, :ppropriation of on of Indigenous women, ‘These groundless stereotypes also provided the ideological foundation upon which the Indian Act was written into Canadian law. The Indian Act includes several sections that define the identity of In harvest food} gov igenous peoples; the lands upon waich they can live, fish, hunt, and ‘nance over community decision making; services and resources available to community: nbers; and the political relationship they have with the Canadian state. ‘The health elated, systems-level determinants resulting from this policy document are far-reaching and influence almost every aspect of First Natio peoples’ lives. Ironically, the exclusion of Métis and Inuit peoples from the colonial identity of “Indian” created a separate but similarly pernicious trajectory of health for these groups (Royal Commission on Aboriginal Peoples, 1996). Within the context of social justice, systematic discrimination from resources and opportunities may well be interpreted as a form of struc- tural violence. Examples can be found in the exclusion of Aboriginal t Nation peoples from social goods, such as inadequate housing on Fi Chepter | SircrwalDeterminants of Aboriginal Peoples’ Heoth 11 reserves or insufficient funding for Aboriginal programs and services, in addition to improper infrastructure in Aboriginal communities and al to provide prompt and adequate care (Reading & Halseth, 2013). The exclusion of Aboriginal peoples from social repro~ health systems tha duction? is manifest in an historical record that neglects to accurately or fully eport the colonial chall iges they continue to fice, inthe failure to acknowledge the important cultural contributions made by Aborigin: peoples, and in the denial of opportunities for them to activ in Canadian society (Galabuei, 2004). Bconomie exchsion is ikewise ed when Abo employment opportunities, particularly in remote communi economic developm and Social Devel Aborig’ Research dating ba nal peoples are denied equitable educational and , where tis crucial to community health (Human Resources pment Corporation, 1999 } Standing Committee on al Affairs and Northern Development, 2007), o the Whitehall study of 1966 clearly links health status to a socio-economic gradient across populations (van Rossum, van de Mheen, Grobbee, & Marmot, 2000). Moreove ntage has cumulative effects, not only over the life of an individual, but al 0 across generations (Reading, 2009), Socio-economic stratification creates a gradient of disparities in health-promoting conditions, which contribute to health damage among those who are releg to increasingly disadvantageous iderichsen, Evans, & Whitehead, 2001). ‘The 1996 Report of the Royal Commission on Aborigis living conditions ( | Peoples concluded that “Aboriginal people are at the bottom of almost index of so ery available cioeconomic well being, whether [we] are measuring edu- cational levels, employment opportunities, housing conditions, 1on-Aboriginal of the highest standards of living in the world” (n In describing the influence of structural determinants on health, apa ineom any of the other conditions that gi Canadians o1 Gehlert et al. (2008) employ a descending causal model that describes Structural determinants as “upstream” forces, creating conditions that flow down to affect ;pulation health. Within the tr metaphor, how- ever, resources from the surrounding environment are taken up by the roots (distal determinants) and travel up throu, the systems of the trunk (intermediate determinants) and into the crown (proximal determinant).12 Pact 1 Seting the Context: Beyond the Soca Two excellent examples of the “trickle-up" effect of structural determi nants on Aboriginal health can be found in diabetes and HIV, Few Canadians ate una dc re of the widespre of diabetes among Aboriginal peoples, with rates between d five times those of non-Aboriginal Canadians (Oster et al, 2011). If we hope to appro- priately address diabetes, we must first understand what determinants ig the development and persistence of this debilitating ind life-threatening illness. Yet, if we limit our analysis to its proxi= imal determinants, as is often the case, we will continue to focus our attention on obesity, poor diet, and sedentary lifestyle, If, however, we explore further, we will likely encounter additional determinants such as economic (lack of resoure to afford healthy food) and/or geographic (remote locations with expensive shipping costs) barriers to accessing healthy market or country foods, as well as physical environments that do not always support health-promoting exercise (crowded housing, lack of sidewalks or walking trails, cold weather, lack of accessible recreational Butler-Jones, 2008), If w still for the determinants responsible for shaping these infrastructure or programs) arch deeper -onditions, we fashioned from discover the root ofthe problem—a colonial structure th communities and ntralization of Aboriginal peoples into remo reserves, the oppressive ure of the Indian Act, the damaging legacy of residential schools, racial diserimi environments and ation in soci and lack of public or private investment in ¢co- the labour marke nomic development for Aboriginal communities (Royal Commission con Aboriginal Peoples, 1996) HIV provides anot linked to current health issues facing Aboriginal peoples. Although Abor tion, in 2008 they accounted for 12.5 percent of all new HIV infectior example of how structural determinants are al peoples represent just over 4 percent of the Canadian popula- and 8 percent of its prevalence in Canada, with women repr ng half of all Aboriginal peoples infected (Public Health Agency of Canada, 2010), We also know that the majority of Aboriginal peoples with HIV this epidemic, most health promotion progeams look for w come infected through injection drug use. In addressing to reduce drug use or the harms associated with it. In attempting to understand HIV among Aboriginal peoples, several researchers have explored the CChopter 1 Structural Determinants of Aborginol Peoples He 8 experiences of people who contracted HIV through injecting drugs Most of them report a personal history of violence and abuse, which js often intergenerational in nature and frequently began in foster care and/or resulted from the residential school experiences of their parents and/or grandparents. Once again, structural determinants are revealed ss the foundation upon which successive trauma, sometimes over gen- erations, leads to coping through drug use and the epidemic of HIV among Aboriginal peoples. CONCLUSION Research exploring the relationship between stress and health has clearly demonstrated that individuals experience increased stress when they are exposed to systemic disadvantage, when they face bartiers to control over their lives, and when they encounter dehumanizing treatment (Clask, Anderson, Clark, & Williams, 1999). Beyond the acute stress ought about by overt personal discrimination, chronic stress in this case linked to systemic oppression, has ben shown to diminish immunity and resiliency to disease (Avitsur, Powell, Padget, & Sheridan, 2009). Likewise, social problems such as interpersonal violence and substance misuse represent reactions to and a means of coping with unrelent- ing stress (Walters, Simoni, & Evans-Campbell, 2002), Perhaps most importantly, physical, emotional, mental, and spiritual harm caused by cumulative stress can decrease one’s capacity to address health problems ney (Roddenberry & Reak, 2010) Disparities in Aboriginal health cannot be understood in isolation by diminishing one's sense of ag sminants such as historical and contemporary political es, and resource distribution. Despite a plethora apporting a structural approach to redressing inequities in Aboriginal peoples’ health, policy-makers continue to focus on proximal determinants. This is clearly irrational and counterproduetive. Instead, policy should be aimed at (1) ensuring that no Aboriginal child is denied the basic resources for healthy development; (2) creating fai employment opportunities and work environments for Aboriginal peoples; (3) support ing Aboriginal peoples to maximize their capacities and self determination; ) facilitating the development of healthy and sustainable Aboriginal14 Pout 1 Setting the Cantent: Beyond the Soca communities; (5) decreasing exposure of Aboriginal communities to nts; (6) ensuring that policy ati industrial toxins and development pollut cisions are based on balane social tion; and (7) preventing the consequences of differential exposure to harmful environments, If we neglect to consider the most profoundly influential deter~ minants of Aboriginal health, we are not only ignoring what is now a critical mass of evidence (Commission on Social Determinants of Health, 2008), but are complicit in the perpetuation of structural inequities that will impact the health and well-being of future generations of Aboriginal peoples. In a country that distinguishes itself on ps ples of equity and social justice, this lack of attention to the root determinants of Aboriginal health is conspicuous and suspect. NOTES 1. Enacted by the Parloment of Conadein|876, the Indian Act grants the federal government authority over First Nation lands, First Notion governance, and First Notion identity (Constitution Acts, 1867) 2. Processes that sustain the characteristics ofa given socio structure or radon REFERENCES Adelson, N, (2005) The embodiment of inequality: Health disparities in Aboriginal Canad Health, 96, S4S-S61 Assembly of First Nations. (1994), Brea Canadian Journal of Pub ig the silence: An interpretive study of First Nations residential shoo! impact and healing as illustrated by individual, Ottawa, ON: Native Tribal Health Con Avitsus, R, Powell, N., Padgett, D., 8 Sheridan, J. (2009), stress and immunity Backhouse, C. (1999). Toronto, ON: The Osgoode Blackstock, C., & Troemé, N. (2005). 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