Indigenous Peoples and Cultural Safety in Public Health

There is a growing consciousness in the United States regarding the need to address structural root causes of health inequities for marginalized populations.¹ Addressing structural root causes are particularly imperative for Indigenous Peoples in the United States, who experience some of the highest rates of health inequities of any ethnic or racial group.² Public health (PH) literature has echoed the need for structural change, with calls for antiracist and transformative PH practices centered on and in the pursuit of equity.³ There has also been increasing and urgent calls for health equity to be more firmly centered in PH education and practice.

Cultural safety is an applied equity concept that has received little attention in the PH field in the United States despite its uptake in other international contexts. “Cultural safety can be viewed on a continuum” that moves from cultural awareness to cultural sensitivity to cultural safety; it “is inherently reflexive as a practice” and requires health care providers to identify and understand their own sets of values and norms while considering how these values and norms might influence how their patients receive health care services.^4(p2) Indigenous Peoples in the United States may benefit from the operationalizing of cultural safety within PH education and practice as it steers its focus from cultural othering to the clear recognition of the power and privilege of the PH field in relation to tribal communities. PH professionals in the United States, however, require cultural safety frameworks and tools for transformation toward true equity for Indigenous Peoples.

In this article, we propose that such frameworks and tools should not seek to create only awareness of or perceptions of being competent with the cultural norms and practices of marginalized communities. We have seen the harm of falsely embodied cultural competence and exotic othering that occurs within many Indigenous PH spaces, instead of providing PH professionals the resources to look at themselves with the intent to move forward toward true equity.⁵ We premise that an internal assessment of dominant cultural beliefs and practices is necessary to create a transformation toward equity.⁵

POSITIONALITY

Because this article discusses cultural safety as it applies to Indigenous Peoples, it is appropriate and expected to provide insight into the contexts and structures influencing the authors.⁶ The first author (M. C.) grew up in a White, middle-class, agricultural family within a community of strong Protestant and Catholic traditions and political conservatism. She moved to a metropolitan community in Alaska, where for the first time she lived within a diverse community with a significant Indigenous community presence. The senior author (N. R.) is an enrolled member of the Deninu K’ue First Nation, an Indigenous public health scholar, and former clinician. As authors, we embody within this article the words of renowned Indigenous PH physician and scholar Donald Warne, MD, MPH, who states if “we are ever going to get to equity, we have to walk through truth, even when it’s unpleasant. Even when it makes us uncomfortable.”⁷

BACKGROUND

Two primary documents, the 10 Essential Public Health Services and the Public Health Code of Ethics, guide PH professional aspirations, key functions, and roles in the United States. Both the Code of Ethics and the 10 Essential Services have recently been revised (in 2019 and 2020, respectively) after extensive input from PH professionals.^3,8 Within the most recent revision to the 10 Essential Services, which are framed within a circle, a significant edit resulted in the centering of “equity” within the circle (ph.phnci.net/10ephs). The revision also updated language to reflect the embedding of equity into each respective essential service. Additional edits included a call to “correct historical injustices,” build a skilled and diverse workforce encompassing “cultural competencies,” and place an emphasis on the role of PH in the development or reformation of infrastructures and systems as opposed to the previous focus on innovation and research.³

Updates to the Code of Ethics also reflect more explicit identification of the need to address health equity, inclusivity, and justice.⁸ Although the Code of Ethics is not a checklist or rulebook, it does lay out guidance for organizational and individual reflection as well as for the professional development necessary to correct the structural and cultural factors adversely affecting PH services and population health outcomes.⁹ The equity calls within the core PH documents echo a national trend to recognize the structural factors, or determinants of health, integral to addressing health inequities within the United States.¹ Other PH-specific literature notes that health inequities can only be corrected by addressing root structural issues underlying population health.¹⁰

Indigenous Peoples

Indigenous Peoples experience notable health inequities in the United States and associated territories. Globally, Indigenous Peoples are identified as distinct social, cultural, and political groups or nations who were the original residents and stewards within a region long before settler colonization and modern-day political boundaries.¹¹ For the purposes of this article, “Indigenous Peoples” refers to the original residents of the United States and associated territories, including persons commonly identified as American Indian, Alaska Native, Native Hawaiian, Chamorro, Samoan, or other Pacific Islanders. However, it must be noted that these identifiers (e.g., Pacific Islanders, Alaska Native) were created for the purpose and convenience of racist and colonial policies rather than directed by Indigenous Peoples themselves.¹²

Although distinctive and autonomous, Indigenous Peoples do share overlapping experiences of colonization.^12,13 Colonization refers to the forced process and worldview in which so-called “superior” or “universal” cultural norms, expectations, and teachings are imposed by non-Indigenous settlers to a region.¹⁴ Colonization established—often violently—new conditions for Indigenous Peoples within a White, male, and human supremacy–orientated society, often labeling them either explicitly or implicitly as an inferior “other” with consequential experiences of genocide, exploitation, racism, and historical trauma.¹⁴

Colonization’s outcomes of genocide, exploitation, racism, and historical trauma have reverberating effects on current-day health inequities for Indigenous Peoples.¹⁴ Compared with non-Hispanic Whites in the United States, Indigenous Peoples have increased rates of chronic conditions, including cancer, diabetes, and heart disease.² Indigenous Peoples also have lower educational attainment and are much more likely to be low-income or impoverished.² These health inequities are not the result of individual, community, biological, or genetic predispositions but are the direct result of the cumulative impacts of colonization and racism as key determinants of health.¹⁵

Colonization creates conditions that undermine fundamental determinants of health within Indigenous communities. For instance, the United States has demonstrated historically poor adherence to treaties with Indigenous Peoples, leading to significant gaps and underfunding within educational and health care systems.^2,13 One contributing factor to underfunding can be traced to undercounting within the US Census,¹⁶ which plays an integral role in funding allocation and resource planning. Undercounting of Indigenous Peoples in health monitoring and surveillance systems was powerfully demonstrated during the COVID-19 pandemic.¹⁷ Indigenous Peoples’ case counts and mortality reports were underreported because of arbitrary aggregation thresholds requiring grassroots efforts to identify and track case and mortality inequities to ensure equitable distribution of vaccines.¹⁷

There are additional policy factors contributing to the data obfuscation of Indigenous Peoples beyond the Census, including those facilitating diaspora. Many Indigenous Peoples have been forcibly removed from their traditional homelands, with later relocation to urban centers,¹⁸ or have had other treaty rights allowing relocation for educational or economic purposes.¹³ PH professionals work in communities with Indigenous Peoples and may be unaware that they do so. PH professionals need to be aware not only of the presence and histories of Indigenous Peoples in their communities but also of the systems and power dynamics affecting the Indigenous determinants of health. The existing PH literature and developed interventions often continue to neglect many of the root causes of the determinants of Indigenous Peoples’ health (e.g., colonialism as a determinant of health), prioritizing individual or interpersonal interventions rather than addressing the systems creating health inequities.¹⁰

Cultural Safety

Cultural safety is one applied equity concept that may support the improvement of health outcomes and the relationship between Indigenous Peoples and PH. Cultural safety was originally conceptualized by nurses in response to the inequities experienced by Māori Peoples of Aotearoa (New Zealand) that needed to be addressed by examining the power imbalance between patients and providers.¹⁹ Although there is no singular definition or operationalization of cultural safety,²⁰ a consistent element that separates cultural safety from cultural competency or humility is the individual and organizational responsibility to recognize and examine the structural relationships of power in every context.²¹ Anderson et al.²¹ additionally stated that

[r]ather than focusing on exotic belief systems of people from different ethnocultural backgrounds and treating each group as a distinct entity, we are challenged, instead, to examine the unequal relations of power that are the legacy of the colonial past and neocolonial present.^{21(pp196–197)}

The recent increase in cultural safety literature has paralleled the increase in literature on the need to recognize and address biases, prejudice, and racism.²² Cultural safety, however, has had less traction within the United States compared with the international context to date. There is some speculation that this has roots in the United States’ identity as an independent nation rather than a Commonwealth country as well as difficulty in acknowledging existing structures as inequitable.²³

Cultural safety requires more than acknowledgment of implicit or internalized biases or racism. Cultural safety demands recognition of and action upon the relationships of racism, colonization, and power at the institutional levels of society where immense privileges and power are conferred to the select few.^19,21 Cultural safety shifts the solution of power imbalances and health inequities from Indigenous Peoples to the non-Indigenous culture, as the latter is the main contributor to the problem and therefore is also key to any solutions.⁵

As colonization is the imposition of practices and worldviews creating conditions of superiority or universal cultural norms, decolonization may therefore be described as the process of countering Western-imposed ideals of superiority and homogeneity. Decolonization respects the rights and autonomy of Indigenous Peoples to develop and practice social and organizational structures (i.e., family, health, governance, education) embedded within cultural values as equal to those within Western or European systems of thought and practice.¹⁴ Supporting Indigenous Peoples’ decolonization alongside Western-based PH system transformation toward true equity requires ongoing acknowledgment, key actions, and adjustments made to the existing relationships of unbalanced power between Indigenous Nations and the PH profession.

KEY CONCEPTS OF CULTURAL SAFETY

Although cultural safety does not have a universal definition or procedure, several elements are noted consistently within the literature. First, cultural safety is different from cultural competency or humility in its demands to both recognize and transform the existing power relationships within systems. The relationships of power between people and between people and institutions are consistently identified as key components of cultural safety.^20,21,23 Cultural safety goes beyond acknowledging or learning about other cultures, bias, or racism; it requires “personal recognition and then action”⁵ upon the imbalances of power that are the foundational root of health inequities. Cultural safety addresses the imbalances of power formed within colonization that are the structural underpinnings of health inequities, particularly for Indigenous Peoples.^20,23 Box 1 provides a summary comparison between key aspects of cultural competency and cultural safety.

BOX 1—

Comparison of Key Concepts Between Cultural Safety and Cultural Competency

Cultural Competency	Cultural Safety
•Ethnic or cultural knowledge •Skills and attitudes •Implies achievement •Checking boxes •Implies expertise •Individualized •Indigenous culture holds the solution •Asks: What knowledge do I have?	•Historical contexts •Reflexivity •Process •Power relationships and structures •Decolonization •Systemic and individual •Non-Indigenous culture created the problem and holds the solution •Asks: How was this knowledge produced?

Source. Adapted from information provided by references 5, 19–21, 23, and 24.

Reflexivity is another key element identified within the cultural safety literature.^4,23,24 Reflexivity as both a term and process has long-documented use in qualitative research areas, having a more recent presence in PH and health literature.²⁴ Reflexivity is the process of recognizing one’s position within a system’s context and translating that examination into systemic change of norms, values, and structures.^4,25 Reflexivity is an advancement beyond reflection because reflection ultimately focuses on internal, individualistic processes and outcomes rather than systems.²⁵ Reflexivity also challenges the implied neutrality or objectivity of reflection, as cultural norms and values are neither neutral or apolitical.²⁴

Another main element in cultural safety literature is the concept of space. Space has been described as the process of maintaining openings or opportunities for other perspectives, voices, and realities.²¹ Leaving space emphasizes a deliberate process of not knowing or not being an expert,¹⁹ which reduces the current privileging of Western (White) ways of knowing and doing. Many PH practitioners are trained in Western-based contexts, and space can open power sharing with those not grounded within Western or formalized academic ways of knowing or doing.²³ Space making removes the demands of expertise and provides the opportunity for PH professionals to be allies and share the work of cultural safety even when they are not Indigenous or another minority person.⁵

Finally, cultural safety is a process. Compared with the implied achievements or expertise within cultural competency, cultural safety has no checklist or arrival.¹⁹ It is instead the ongoing work and commitment of individuals and institutions toward health equity, power sharing, systems change, and decolonization.^19,24 Cultural safety develops from the cumulative impact of numerous small decisions or behaviors rather than a singular event, training, or workshop.^5,22

THE JOURNEY FORWARD

As noted in the section on “Cultural Safety,” the concept of cultural safety is not currently prevalent in US-based resources or literature; however, it seems well-suited for meeting the calls for equity within PH. Although gaps remain in cultural safety interventions and implementation,²⁰ cultural safety may be the equity framework that best parallels the calls in PH core documents to address population health inequities at their foundational levels.

Cultural safety differs from its two predecessors, cultural competency and cultural humility, in its key themes of power, reflexivity, space, and process.^19,20 Cultural safety places the onus on PH professionals and organizations to transform both themselves and the systems in which they work. PH services must move beyond individual and interpersonal levels and begin to address the structural and systemic foundations of health, particularly for Indigenous Peoples. Cultural safety is an embodied skill that all PH providers need to develop, as Indigenous Peoples live, work, and play in all parts of the United States and are therefore affected by PH policies and practices. PH professionals must be aware of how internal and professional power dynamics influence Indigenous health. Given indications that some PH organizations may be practicing cultural safety without realizing they do so,²³ research about cultural safety understanding and practice in the US context is important. It will also be important to further define and operationalize cultural safety as it applies to Indigenous Peoples themselves as copartners.²⁰ Evaluation is needed of both the process and the outcomes of how PH transforms individual and organizational practice toward decolonization and equity.

Indigenous health inequities will continue to flourish until PH addresses and corrects the privileged and inequitable systems of power and relationships innate within the field.^10,12 The ability of PH to practice cultural safety requires education, training, and resources to develop the necessary skills to support decolonized systems while also uplifting and acknowledging the inherent strengths within Indigenous Nations.