Power Relations

1. POWER RELATIONS

Patients identified one aspect of power relations that requires special mention and discussion outside of the context of discrimination and marginalization.

➤ Categorization and hierarchy

According to the Newfoundland and Labrador Indigenous Administrative Data Identifier Standard (2017), there is a “need to identify the records of Indigenous persons within regional, provincial, territorial and national health information systems” (pg. 1). According to the Standard, the rationale for implementing an Indigenous identifier data standard is that having a record of Indigenous persons within various health information systems is beneficial for the health of these populations. From the perspective of health decision-makers, having an identifier on MCP cards to flag patients as Indigenous is seen as a positive move, in terms of mobilizing resources for increased programming. However, Indigenous knowledge holders describe important downsides to the health care system identifying and categorizing Indigenous patients.

This practice has the feel of perpetuating colonialist methods of surveillance, and there are nuances to this sentiment that are important to learn about in further discussions with Inuit, Southern Inuit, Innu, and Mi’kmaq leaders, elders, and community members. The politics of recognition in terms of Indigenous group identity get played out in patients’ perceptions of injustice with respect to who gets access to what through the APNs. At the time the research was conducted, the two APNs were both Inuit, something that was apparent to the APNs and to EH decision makers as occasionally problematic in terms of the perception of injustice. (And in fact, plans to hire an Innu APN were in progress at the time of data collection).

➤ Second escort support perceived as example of settler stratification of Indigeneity

Typically, only one patient escort is paid for by Nunatsiavut Government or Health Canada via the Band Council. However, at the discretion of the decision maker (that is, Nunatsiavut Government or the Band Council), a second patient escort could be approved.

"For the Aboriginal there is no benefit [to labelling medical card with Indigenous identifier], none whatsoever and that’s bluntly putting it. Because we’re Aboriginal. We’re just numbers to them. They [health care decision makers] don’t care. We’re not a person that we’re considered to sit up and talk to ... When you’re put down and being picked on or categorized they [Indigenous patients] don’t want to do it [engage in the health care system] – they’d sooner die. They’d sooner let their self go, because, and I see it every day, every day they’re categorized and they don’t want it. [Indigenous patient 3: Inuit woman – patient and patient supporter]

An Inuit patient supporter explains why it is so important to have a second escort in some cases:

"You know, like if you’re out there for a long time it’s gets really tiring ... Being in the hospital going back and forth to where you’re staying, going back to the hospital, and it really gets tiring and really drains you out as the escort. Then sometimes this escort needs some help, you know, like needs some support, maybe taking turns being with the person who is in the hospital who may be in critical condition or whatever ... I was spending a lot of time at the hospital and by the time I would get home, like late in the night, I would be drained, exhausted and then the next thing I would get up early in the morning and go back up there again; like it’s almost like you need two people you know especially if there’s critical conditions." [Indigenous patient 6: Inuit woman – patient, patient supporter, and interpreter]

Advance Education and Skills [AES] (“income support”) clients are not given a choice of accommodations, but rather are booked into one of the other cheaper hostels or motels. If the patient happens to also be a beneficiary of Nunatsiavut, then their expenses are first paid by AES, and only afterward does Nunatsiavut Government support begin. Patients in this category have difficulty understanding the unfairness of them staying in cheaper accommodations with no choice, whereas as a patient under Nunatsiavut Government they would have had a choice of a variety of accommodations.

Most often differences in services provided by the APNs are related to how proximate or distant to the St. John’s site a patient is in terms of geography, social and cultural context, and English-speaking ability:

Various factors contribute to perceptions of unfairness between the supports offered to different Indigenous groups. On the other hand, many people experienced the assumption that all Indigenous peoples are the same.

➤ Assuming all Indigenous patients are the same

Categorizing and labelling on the basis of community identity poses challenges of exacerbating already problematic perceptions of a hierarchy of care. Yet there are equally grave problems with lumping together all communities as if they are one homogeneous group (“Indigenous”) sharing identical values, beliefs and experiences with respect to health and health care.

In summary, while adopting the Indigenous Administrative Data Identifier Standard (2017), introduced earlier in this section has obvious benefits from the perspective of health decision-makers and administrators, judging the appropriateness of this system requires further consultation from Indigenous knowledge holders to assess the community implications of using a “blanket” Indigenous identification system.

"Yeah, if it’s from the [northeast] coast it’s usually ... the whole nine yards. Like we have to meet patients sometimes at the airport, they’re often scared ... We can go meet them at the airport. Take them to their accommodations and then discuss meeting with them the next day about their appointments and then we’ll just go from there .... As compared to somebody coming from Stephenville, they’re pretty well on their own or just looking for help with paperwork." [APN]

"They think that we’re all one people. That we all speak one language ... Like I went to the emergency room yesterday and they said 'Oh, you’re the interpreter'. I said 'No, I’m not an interpreter'. She said 'Oh, well we’re looking for one', and I said 'Well, I’m trying to find you an Innu interpreter ... Ours is not available'and she said 'Oh no, I thought you were the interpreter”’. I said “No”. So, she thought I was able to speak a hundred languages because I’m Aboriginal .... [This came from an assumption of] thinking that we’re one people." [APN]