Racism in Inuit experiences in healthcare: findings from an environmental scan

ABSTRACT

While the category of “race” has no scientific foundation, race and subsequent racism continue to be determinants of access to health for Indigenous communities globally, including for Inuit in Canada. This scan raised concerns from community members voicing racial inequities in healthcare. The aim of this review was to scan Canadian Inuit experiences of racism in healthcare. To date, no such work has been done, and contemporary Inuit experiences of racism in the healthcare context have not been systematically documented. We hope that this review will serve as a foundation for scholars, policy makers and/or Inuit-community-based organisations to engage with this issue further. We conducted an environmental scan from 2000 to 2024 of peer-reviewed and grey literature to explore Canadian Inuit experiences of racism in healthcare. Our scan identified 16 sources. We analysed sources using the following: systemic or interpersonal racism, and then distinguishing if racism was explicitly mentioned or inferred by the authors. We found medical evacuation, women’s health issues, cancer care and postoperative outcomes to be places where racism in healthcare has been documented. Overall, we hope that this review draws much-needed attention to this issue and contributes to the imagination of a new way of practice.

Introduction

In Canada, advances in its public health, medicine and social welfare now deliver a preferential quality of life to Canadians compared to other countries. For example, in 2021, Canada ranked within the top eleven countries for healthcare (measured through access to care, the care process, administrative efficiency, equity and healthcare outcomes) [1]. However, Inuit in Canada face numerous adverse health outcomes: e.g. life expectancy approximately ten years lower than that of their Canadian counterparts [2], higher rates of chronic illness [3], tuberculosis [4] and infant mortality [5]. The suicide rates of youth are termed a “public health emergency”, being up to ten times higher than those of their non-Indigenous counterparts [6]. From our research efforts to support Inuit health and well-being in Winnipeg, community members have frequently suggested that these health outcomes are in part due to experiences of racism faced in healthcare settings. However, to our knowledge, Inuit experiences of racism in healthcare have not been mapped.

Harding states that Canadians often believe that the publicly funded healthcare system is available to all citizens equally, and that Indigenous peoples’ challenges in accessing healthcare are not widely known [7]. This lack of awareness perpetuates health-race inequities, reinforcing Canadian “settler-identity”, where, namely, those of white settler ancestry can be unaware of the privilege and biases that they carry, thus upholding the colonial cycle and perpetuating harms onto Indigenous peoples [8,9]. The absence of awareness or self-reflection of one’s position is particularly problematic in healthcare settings where practitioners’ judgments can be clouded by stereotypes, termed “deficit thinking”. This may lead providers to see patients as the sole source of their problems (bad choices, self-indulgent lifestyle) rather than as a result of multiple contextual factors, often leading to inadequate or unsafe care [9,10]. In 2012, the Health Council of Canada reported that Indigenous peoples were less likely to access health support and that interpersonal and systemic racism were identified as an obstacle to receiving adequate healthcare [7]. While research has been undertaken to document Indigenous experiences of racism in Canada, it often takes a First Nations or Pan-Indigenous approach where the specific experiences of Inuit are not identified [7,11,12]. The purpose of this paper is to report on an environmental scan of Inuit’s experience of racism in the Canadian healthcare system, as well as the provision of the necessary context to understand this issue.

Race and the link to colonialism

“Race” is an imagined category with no scientific basis. For example, there are more genetic differences among racial categories than variances between races [7]; nonetheless, these distinctions have become a social construct widely used to inform power-based relationships [13]. Racism is defined as a “belief or doctrine that inherent differences among the various human racial groups determine cultural or individual achievement, usually involving the idea that one’s own race is superior and has the right to dominate others” [[7], p. 1]. This doctrine is maintained through prejudice, stereotyping and biases and disrupts access to a variety of social goods and benefits, including healthcare services. Resulting health inequities are then “rationalised” through prejudice and stereotypes, and used to explain “why some groups have lower status than others” [[14], p. 17], leading to the creation of “racial” hierarchies where the racial category of whiteness has been positioned at the top [13,15]. These hierarchies and imagined categories have fuelled “settler colonial science​​” [16] to literally create “structures of indifference” for Indigenous peoples in Canada [17].

Colonialism is linked to race through maintaining these hierarchies, and racism is described as the “legitimising ideology of colonialism” [[13], p. 6]. Stereotypes of Indigenous peoples are upheld from these beliefs, in turn distorting interactions and undermining the provision of responsive healthcare. This interaction has been called a “circulatory system” whereby “colonial beliefs and stereotypes about Indigenous peoples flow in a cycle throughout systems to influence attitudes that can lead to discriminatory actions” [[7], p. 10]. The “circulatory system” in this context is informed by the belief that Indigenous peoples were and continue to be biologically weaker and thus more susceptible to diseases or illnesses, an ideology described as “scientific racism” which is used to justify imperialist and colonialist actions where “lesser races” were and continue to be subjugated [12]. This belief has carried through to the present, where healthcare wants to find the biological answers to the high rates of ailments (e.g. chronic disease, mental health) rather than looking at the structural issues of the problems, i.e. the “colonial and racist roots of modern medicine and general inequities” [[12], p. 21]. Therefore, health inequities are upheld by colonial actions and enacted through racism. Lavallee and Harding call this an “inextricable intertwining” [18]. Hantke sums up the link between whiteness, racism and healthcare in this context: “during Canada’s first hundred years of nationhood, it developed labour and health policies that wove together a social safety net designed to protect the well-being of the desired national subjects: the white settler population” [[10], p. 178].

Shaheen-Hussain notes that types of racism, e.g. systemic, institutional, and structural, are used interchangeably and often without clarity [19]. To avoid confusion and to allow for a comprehensive discussion of the sources identified in this review, we have distinguished between systemic and interpersonal racism. Systemic racism is defined as relating to structural issues, e.g. in institutions, and interpersonal racism is defined as relational, i.e. occurring between individuals [19,20]. Further, Shaheen-Hussain highlights the link between systemic and interpersonal racism, which exists due to aspects of structural power, i.e. the power that certain individuals in society hold, e.g. a doctor, government office or teacher [19]. Owing to the ongoing impacts of colonialism, the term “coloniality” [21] should be used, as it emphasises the continued ramifications of past actions. Harding suggests that it is only with a “critical anti-Indigenous racism lens” that health inequities can become visible [7]. Overall, Indigenous-specific racism is derived from coloniality and maintained through power imbalances, discrimination, stereotyping and prejudice, resulting in “othering”, fed by what Henry and Tator call “historical amnesia”:

“Canada suffers from historical amnesia. Its citizens and institutions function in a state of collective denial. Canadians have obliterated from their collective memory the racist laws, policies, and practices that have shaped their major social, cultural, political and economic institutions for three hundred years. Racist beliefs and practices, although widespread and persistent, are frequently invisible to everyone but those who suffer from them. White Canadians tend to dismiss evidence of their racial prejudice and their differential treatment of minorities.” [[22], p.1]

A prime example of this amnesia is Prime Minister of Canada Stephen Harper’s 2009 statement during a G20 press conference: “we [Canada] also have no history of colonialism” [[12], p. 20]. These words aptly demonstrate the historical amnesia that has been perpetuated by settler Canadians, in part by governing figures. Words such as these reinforce the settler colonialism state, or coloniality, that exists today in Canada.

Context: tuberculosis and sterilisation

Medical transportation via small planes is still commonly used for routine healthcare issues for Inuit living in Northern Canada, e.g. childbirth, x-rays. While physical geographical considerations are a barrier towards provision of care in remote communities, in the past and present, systemic and systematic underfunding, colonial legacies, workforce shortages and aspects related to social determinants of health, e.g. overcrowding and food insecurity, are also significant contributing factors in the delivery of comprehensive care in Northern Canada [23–25]. This results in Inuit, who require care beyond the level of primary care available locally, flying to cities located outside Inuit’s traditional territory to access care: while transportation and care are paid for by a publicly funded health care system, the care provided is unlikely to be culturally and contextually informed, echoing past experiences. The remainder of this section highlights of the harms of historical tuberculosis treatment and forced/coerced sterilisation (both still in living memory of many), which continue to shape Inuit emotionally, culturally and psychologically, as well as current health-seeking behaviour [26].

Budgell argues that the continuation of medical transportation as a default, starting with forced removal for tuberculosis (TB) care, shows that the Canadian government is stuck in an outdated, harmful paradigm that is medically inappropriate, culturally unsafe, and avoidable; this practice laid the foundations for contemporary medical care out of territory [24,27]. In the past, it could be argued that care away from remote communities was pragmatic to prevent a TB epidemic and subsequent deaths. However, TB rates in Northern Canada remain one of the highest globally [28]. Inuit in Alaska, who faced similar contextual issues when TB rates rose, lower rates were maintained, suggesting that these different outcomes might be attributed to a local approach that was originally taken rather than evacuation [24]. In an “Eye on the Arctic” news publication, Nancy Anilniliak’s (Pangnirtung) personal narrative of past TB treatment highlights the cultural dislocation that resulted from accessing TB treatment in an urban-based sanatorium:

“Sixty-five years ago, tuberculosis left Nancy Anilniliak with an invisible scar. Taken from her family at the age of five to the sanatorium in Hamilton via the C.D. Howe (Canadian Arctic patrol ship) [she]– describes it as ‘robb[ing] her of part of her childhood and, nearly of her language… [her] older brother was on the ship, but on a different floor, when they got to Hamilton the men women and children were separated, she didn’t see him again until she eventually made it back to the community”. Nancy recalls that the trip ‘probably took about a month or more because they had to go to different places…communities in the Baffin and the Nunavik regions’ and her face is described as ‘sombre’ when she recalls ‘the long hours physically confined to her bed or the day when staff forcibly cut her hair.’ Nancy had to later relearn Inuktitut and expressed regret at the time she lost while at the sanatorium as when she returned to Pangnirtung her mother soon passed” [[29], no pagination].

It is generally accepted that TB was brought to the Canadian Arctic during the 1800s by Europeans, although archaeological research has unearthed evidence of TB existing on the American continent prior to contact [30]. In the Canadian 1940–1980 context, TB among Inuit was addressed through medical evacuation via ship to sanatoriums in southern Canada [24]. Treatment impacted both adults and children; from 1953 to 1964, it was approximated that half of the Inuit population was institutionalised in TB sanatoria [31]. Individuals often had no opportunity to say goodbye to their family, as they boarded the ship for diagnosis (via X-ray), and those found to be infected were not allowed to leave the ship. Some did not return to their home communities, either because records of their home community were not kept, or because they were too young when they left for treatment and did not know where they came from [29]. This treatment tore families apart and led to the loss of cultural knowledge, which is in the living memory of people today, suggested to be linked to current apprehension in treatment, as well as issues around treatment protocols not being explained but rather enforcing adherence despite continued high TB rates [24,26].

The official Canadian narrative of Inuit TB treatment is one of compassion and kindness [32]. However, forced removal and transportation of Inuit took place against medical advice, as demonstrated by a physician advisor to the federal government stating: “the removal of northern natives to southern institutions is not good practice…the patients…become lonesome, decline and sometimes die” [[33], p. 62]. Alternatives to removal and transportation to southern sanatoria, offered at the time by medical professionals or government staff, are outlined in Grygier’s comprehensive volume [33]. Further lack of treating patients with dignity is exemplified by the following practices: being given numbers to be referred to rather than names, no translators to assist with the language divide, children and adults released post-treatment to find their own way home, some children placed in foster care without permission, individuals plaster-casted to prevent leaving the sanatoria, families not informed of TB deaths or burial places of those who had died away from home [31,33]. Stevenson states that this approach lost sight of Inuit being “anything other than bodies needing care” and that use of the numbering system instead of names shows the degree to which “Inuit bodies actually became statistics in the eyes of the Canadian state” [[31], p. 29]. Specifically, Inuit culture is an important link to cultural beliefs, connecting individuals to their ancestors, and the loss of one’s name to numbers has been likened to the loss of identity [31,34].

The literature argues that, in this context, the management of TB was political [27,35]. Stevenson likens the approach towards TB treatment for Inuit as a “biopolitical form of care” imbued with notions of governmentality, where the form of care and governance was concerned with the maintenance of life itself, directed at a population-level approach rather than taking into consideration the needs of the community [31]. Furthermore, the impact and ramifications of the colonial public health measures of TB treatment are linked to the high Inuit youth suicide rates in the Canadian North: “the irony of course, is that by the 1980s, after Inuit health had undergone increasing surveillance, when fewer Inuit were dying in childbirth, of starvation and tuberculosis, a suicide epidemic among Inuit youth erupted” – that biopolitics here has taken on a “psychic life” [[31], p. 70, 73], i.e. that biopolitical power not only governs people externally, but also shapes individuals internally, e.g. their identity and sense of self.

While still a form of biopolitical control and governmentality, but not concerned with the maintenance of life, forced/coerced sterilisation of Indigenous peoples, including Inuit, demonstrates the approach of the government towards these groups. Official policies of sterilisation for Indigenous peoples emerged in the 1920s and are argued to be part of a eugenic and genocidal movement in Canada [36,37]. For example, in 1928, Alberta passed legislation to sterilise those classified as “mentally challenged” or belonging to “disadvantaged groups” – many Indigenous women were included; the legislation was repealed in 1972; however, an estimated 2,800 sterilisations occurred [37]. For Inuit, an inquiry ¹ from the 1970s estimated that 1,150 sterilisations of women took place in Northern Canada, as well as reports of men being vasectomised without knowledge/consent; however, these are only documented cases, and testimony suggests that more cases occurred [36]. In recent years, this issue has gained traction in news outlets through women sharing their experiences – both of those in living memory, and in more recent cases [19,37,38].

Methods

As the aim of this paper was to identify Inuit experiences of racism in healthcare settings in Canada, an environmental scan was chosen as the preferred methodology [39,40], inclusive of grey literature along with peer-reviewed publications. It was thought that this would be valuable, as outlets not covered by peer-reviewed literature could be included, e.g. non-government organisations and news reports. Further, environmental scans are useful in health settings, as they are a “needs-assessment tool”, allowing for action-based recommendations that can contribute to implementing change [[41], p. 528]. Since there is a lack of consensus in the literature on the definition and methodology of an environmental scan [41,42], to mitigate confusion, the specific methodological process for the scan is outlined below.

Search strategy and data extraction

Scopus and Google Advanced were used to identify Inuit experiences of racism in healthcare, where the search focused on Canada from 2000 to 2024. Scopus includes Medline records and Embase records, other journal articles and scholarly publications. Google Scholar was used to search for grey literature to allow for the inclusion of material that may be overlooked in a Scopus search. Publications in French were not reviewed due to language limitations, time and funding constraints of the lead author. The search terms input to Scopus and Google Scholar were:

(TITLE-ABS-KEY (inuit* OR nunavut* OR iqaluit OR circumpolar) AND TITLE-ABS-KEY (racis* OR barrier* OR discriminat* OR stigma* OR stereotyp*) AND TITLE-ABS-KEY (health* OR hospital* OR medical OR nurs* OR physician* OR doctor* OR patient*) AND TITLE-ABS-KEY (care OR service* OR healthcare))

The searches conducted by Indigenous health librarian at the University of Manitoba, retrieved 174 articles. In the first screening by the librarian, 37 articles were identified as relevant. From this pool, 15 sources were identified by the lead author, and one relevant source was identified from the literature already included, leading to a total of 16 sources included using the following criteria:

• Covering Inuit experiences of racism (implicitly or explicitly) in healthcare.

• Canada based.

• From the years 2000–2024.

Data analysis

We analysed the 16 identified sources’ format (peer reviewed, grey literature, news articles), jurisdiction and whether systemic or interpersonal racism were investigated explicitly or inferred by the authors (see supplementary material, Table 1). This analysis, along with thematic analysis [43], yielded a series of themes related to medical evacuation, aspects of women’s health, cancer care and post-operative outcomes as areas where Inuit experiences of systematic and interpersonal racism in healthcare were documented.

Results

Figure 1 visually shows the steps used to identify and analyze sources for this scan. It should be noted that due to the limited healthcare infrastructure in Northern Canada, a large proportion of the literature refers to race-related/racism experiences of individuals coming from the North to urban settings to receive care. This highlights a few issues: the lack of exploration of this topic from an Inuit urban perspective, which is concerning given the rise of the urban Inuit population (56.2% from the 2016 census [44]), the ongoing healthcare provision issues in the North, and the lack of documented Inuit experience of healthcare in Northern Canada.

Figure 1.

Source identification and analysis.

From the identified 16 sources, nine were from peer-reviewed literature, four from news articles and three from the grey literature. Medical evacuation was identified in four sources [19,45–47], women’s health in five sources [36,48–51], cancer care in six sources [52–57], and one source covered post-operative outcomes [58]. All 16 sources identified aspects of systemic racism, with nine explicitly calling out systemic racism [19,36,46–49,51,54,55] and seven inferring it [45,50,52,53,56–58]. Ten sources discussed interpersonal racism, with seven explicitly referring to this type of racism [19,36,46,47,51,54,55] and three inferring it [45,56,57]. In terms of the geographical location/jurisdiction of the identified sources, four were located in Nunavik/Quebec [19,45–47], two in Nunavik [56,57], three in Nunavut/Ontario [51,52,58], one in Nunavut/Manitoba [50], one in Nunavut [53], one in Inuit-Nunangat (unspecified)/Ontario [55] and four in unspecified or numerous locations of Canada [36,48,49,54]. In addition to presenting instances of systemic or interpersonal racism from the identified sources, context-specific information for each of the identified thematic health areas will also be briefly presented, allowing the reader to gain a greater appreciation of the data presented.

Medical evacuation

Medical evacuation (medevac) refers to the use of unscheduled or emergency flights to transport a critically ill/injured patient in need of urgent specialised care not available in their community. Medevacs are used throughout Northern Canada, e.g. the territories and the provincial north, to transport patients to southern hospitals for treatment. Patients may be accompanied by a family member whose travel is subsidised in certain instances; however, this depends on the health issue and the jurisdiction. In Quebec, children are not allowed to be accompanied by a parent/caregiver if they are medevacked. To meet their child at the place of treatment, parents had to take a commercial flight and pay the costs [19]. This practice has been criticised for not being based on written policy [19]. The four sources identified referred to the application of this unwritten rule as a mixture of interpersonal and systemic racism [19,45–47] – two of these sources are peer-reviewed, and the other two are news articles.

The book “Fighting for a Hand to Hold” comprehensively outlines how colonial structures persist in the Canadian healthcare system, particularly focusing on the treatment of Inuit children needing to be medevacked from Northern Quebec. Systemic racism is challenged multiple times in this volume in relation to this issue; for example: “highlighting how anti-Indigenous systemic racism and medical colonialism have tainted the government’s actions” (p. 5); “the root cause unfortunately is systemic racism” (p. 10); “the ‘causes of the causes’ that allowed such a practice to persist for so long soon became obvious: systemic racism and colonial policies rooted in capitalism” (p. 62); and “throughout the #aHand2Hold campaign, the intention was never to point fingers at specific individuals, but rather to understand the issue as being rooted in colonialism and racism, deeply embedded…a system that we’ve inherited and that will continue to perpetuate itself unless we choose to confront it” [[19], p. 77]. Interpersonal racism is also suggested through: “demonstrating that relational (or interpersonal) racism was at play: the health minister’s comments in June 2018 explicitly perpetuating anti-Indigenous racist stereotypes” [[19], p. 74]. This refers to Quebec’s former Health Minister Gaétan Barrette evoking the stereotype of the “drunken Indian” as justification for non-accompaniment: “I guarantee you that there will be at least one instance in the next six months where someone will not be allowed to get on the plane. Why? Because no one – agitated, drugged, under whatever influence – would get on the plane at any cost. That will not happen. And [individuals who are agitated, drugged, under whatever influence wanting to board the plane] happen[s] all the time” [[59], no pagination].

A news article called the separation of caregivers/parents and children “medical colonialism” and questioned whether the length of time to change the non-accompaniment would be the same if the families primarily being impacted weren’t Indigenous/Inuit [45]. While “racism” is not explicitly used in this article, we have interpreted this as an implicit reference to both systemic and interpersonal racism because of the explicit reference to Indigenous identity. Both this news article and the volume mentioned above outline the harm caused to children by this practice to further solidify their claim that these practices are informed by racism. They further underscore that the practice undermines the provision of adequate medical care in a number of ways, including, (a) the possible absence of interpretation in the Inuktut dialect of the patient, possibly resulting in the inability to treat the patient as symptoms may not be understood; (b) an incomplete medical history or allergies; and (c) patients being severely upset, as they may not know what was happening – leading to emotional and psychological damage [19,45]. Another news article explicitly reported this practice as racism: “Another Nunavik mother, whose young child was transported alone by air ambulance…[said] ‘we’ve been so de-humanized, we accept it…we are stressed enough as a society, these policies just add to it. But when you strip it all down, it’s racism’” [[46], no pagination].

Furthermore, systemic and interpersonal racism were criticised in a news article recounting two incidents of delayed treatment in relation to needing medical evacuation. Siasi Kumarluk from Kuujjuarapik believes that racism and structural issues within the healthcare system contributed to her brother’s death, and states that “if he was qallunaaq [white] then he would still be alive” – her brother was told that he was a “strong hunter” and did not need immediate treatment, instead he died in severe pain from a punctured lung waiting for an X-ray in Puvirnituq [[47], no pagination]. This source reports another incident where a woman from Inukjuak died because “the nursing staff failed to send her out of the community for tests [believing that she] just want[ed] to go to Montreal” – despite also being in severe pain; over a year later, she was diagnosed with colon cancer [[47], no pagination].

Women’s health

In comparison to non-Indigenous women, Indigenous women in Canada, including Inuit, have worse overall physical and mental health, higher rates of chronic diseases and morbidity and have to wait longer times for regular primary care services in urban and non-urban settings. As a result, there is higher use of hospitals for “non-urgent” care, and fewer consultations with dentists are also noted [60]. Even with adjustments for income and education, Indigenous women are still at a disadvantage in healthcare services compared to non-Indigenous women [61]. Further, in Northern Canada, language barriers have been reported in healthcare, as providers often do not speak Inuktut. In this section, one source relates to experiences of forced/coerced sterilisation [36] and four to birthing [48–51].

In 2019, the Senate Committee on Human Rights investigated forced and coerced sterilisation in Canada and concluded that “forced and coerced sterilisation is clearly continuing in Canada today, and is both underreported and underestimated”, where Indigenous women, including Inuit, were primarily impacted, as well as those with “intersecting vulnerabilities” [[36], p. 8, 7]. The investigation found that consent was not obtained for procedures such as tubal ligation; women were misinformed about procedures, e.g. not knowing the permanent nature of such procedures, they felt threatened by receiving procedures, and medical professionals negotiated consent at inappropriate times, for example, during the birthing process [36]. The impact of these actions has led to women going into early menopause, finding out they can’t have children, as well as an overall lack of trust in healthcare [36]. Systemic racism is specifically mentioned in the report’s findings: “forced and coerced sterilization is an act of sexism, racism and cultural genocide, rooted in colonization and paternalism” (p. 10); “survivors confirmed this [racism in Canada’s healthcare system], and further explained how racism and discrimination have hampered efforts to raise awareness about the issue of forced and coerced sterilization” (p. 19). These examples could also pertain to interpersonal racism, as this treatment is forced/coerced onto bodies deemed not valuable enough to have autonomy over their reproductive rights. Further, interpersonal racism is specifically mentioned through the backlash that survivors endured when speaking about their experiences: “several survivors… informed the Committee of discriminatory comments they received when attempting to raise awareness of the issue…[one] explained that interviews she participated in the topic of forced and coerced sterilisation have incited violent and racist comments” [[36], p. 21].

Four identified sources related to the broader context of birthing: two explicitly mentioned systemic racism (one peer-reviewed, the other grey literature) [48,49], while another news article inferred systemic racism [50], and one piece of grey literature explicitly mentioned systemic and interpersonal racism [51]. Lehman stated that “given access to maternal healthcare, [Inuit] mothers have consistently experienced marginalisation through systemic racism endemic in medical environments” [[48], p. 116]. This source unpacked the link between systemic racism through the medicalisation ² of childbirth for Inuit women, highlighting that this approach undermined cultural preferences and “interfered with the transmission of insular midwifery knowledge, the autonomy of Inuit women and the mental health of entire communities” [[48], p. 112].

Another source outlined Silatik Qavvik’s experience of coming to Winnipeg from Sanikiluaq where she contracted COVID-19 and passed away after giving birth, inferring systemic racism in birthing procedures for Inuit who have to travel to southern cities to give birth through outlining the structural issues that women are faced with – primarily not knowing the city and where is safe, no access to traditional food, the language barriers and not having family with them [50]. A report from Pauktuutit explicitly referenced this case as “systemic racism in healthcare” and called this death “preventable” [[49], p. 3]. Finally, another piece of grey literature explicitly mentions interpersonal and systemic racism in outlining Alookie Otuk’s experience of a birth complication in Iqaluit, meaning that she had to visit Ottawa (2,000 km away), during the COVID-19 pandemic [51]. The source states: “We have to battle racism the minute that we come into a hospital…pregnant Indigenous women have faced racism and been denied pain medicine; stereotyped as drug addicts and thieves” and “institutional racism and stereotyping has kept people from getting the care they need” [[51], no pagination]. In Ottawa, Otuk and her newborn stayed in a small room in a boarding house for two months without any postnatal care or assistance to recover from her gallbladder procedure, with no access to hot meals or laundry, and were denied accompaniment from her husband (she was considered the escort for the newborn); a further 14 days of quarantine were required before returning home [51].

Cancer care

Globally, Inuit have high mortality rates from cancer [52,54,55], with rates that are also significantly higher than those of their non-Indigenous Canadian counterparts [62,63]. For Inuit, cancer is identified as one of the main causes of premature death [64], with lung cancer being the most common cause for both men and women; rates are reported to be three to five times higher than the Canadian average [52,54,65]. Cervical cancer provides the next highest mortality and incidence rate among Inuit, with a mortality rate approximately three times higher than that of their non-Indigenous Canadian counterparts [56]. The literature identified from the scan pertaining to cancer care included six peer-reviewed papers: two inferring systemic racism [52,53], two explicitly mentioning systemic and interpersonal racism [54,55], and two inferring systemic as well as interpersonal racism [56,57].

In relation to experiences of Inuit travelling from remote areas to cities in southern Canada, systemic racism was inferred in this context from the findings of a 2021 study by Jull and colleagues where the themes from participant interviews were summed up as being “hard to take part in decisions about getting healthcare; no one explain[ing] the decisions you will need to make; [lack of consideration of] mak[ing] decisions that support family and community; the lack of knowledge impact[ing] opportunities to engage in decision making…participants described themselves as directed, with little or no support…” [[52], no pagination]. The study concludes that there is a need to “build capacity in the health care system to support Inuit’s participation in decisions related to their cancer care… that uphold and incorporate Inuit knowledge” [[52], no pagination]. This need to “build capacity” in relation to the stated context that Inuit are “at risk for poor health and…barriers to health care access” is also suggestive of systemic racism [[52], no pagination]. The other paper inferring systemic racism related to the exploration of the perspectives of patients from Nunavut on cancer care [53]: “difficulties associated with extensive medical travel; preference for care within the community and for family involvement in care; challenges with communication; challenges with culturally appropriate care; and the value of service providers with strong ties to the community” and through highlighting that these findings “emphasises the importance of health service capacity building in Nunavut…emphasis [on] Inuit language and cultural knowledge…[need] to improve the quality and consistency of communication among health service providers working in both community and southern referral settings and between service providers and the patients and the families they serve” [[53], no pagination].

Another paper exploring the factors influencing cancer care for Inuit explicitly mentioned aspects of systemic and interpersonal racism. Here, systemic racism was exemplified through the mention of “structural barriers”: “results highlight interconnections between racism and colonialism, the lack of health service information on urban Inuit, as well as the need for system-wide efforts to address the structural barriers in cancer care…disparities are exacerbated by socioeconomic disadvantages and systemic racism, compounded by the historical and ongoing marginalization by mainstream health services” [[54], no pagination]. Interpersonal racism, which also intersecting with systemic racism, was specifically mentioned through the following: “institutional racism against Inuit patients led to feelings of intimidation and fear of being stigmatised” and through highlighting that “two themes [that] emerged…limited culturally and linguistically appropriate cancer information and racism” [[54], no pagination]. The other paper to explicitly mention systemic and interpersonal racism did so through the following: “we assert that colonial Western practices must be actively identified and expunged as efforts to improve a system that is fundamentally steeped in systemic racism perpetuates a colonial approach to health and wellness”; “geographic remoteness of Inuit communities requires Inuit to travel vast distances to urban centres to receive cancer care. Once they arrive, they are subjugated to systemic racism resulting from the legacy of colonialism within the Canadian healthcare system and thus denied the experiences of culturally safe care” and “Inuit communication was discussed as extending beyond simply words that are spoken to include different forms that should be understood by healthcare providers working with Inuit. Clear communication between patients and their healthcare providers is an essential aspect of cultural safety; clear communication leads to services that are free of racism and discrimination and helps build trust and support providers” [[55], no pagination].

Finally, two papers explored perspectives of cervical cancer screening among Inuit women in Nunavik, and inferred both systemic and interpersonal racism. Systemic racism is inferred from the statement, “the most influential factor in using health services was the cultural awareness of the healthcare provider. A significant barrier to screening was the patient’s lack of information” and interpersonal racism through patient-provider communications, “the principal vector of change – the factor most likely to influence other factors – was the means of communication between the healthcare provider and the patient” [[56], no pagination]. Here, “means of communication” refers to the ways in which aspects such as medical information, interpersonal communications and treatment plans are conveyed to patients. Finally, Santella and colleagues suggest a mix of interpersonal and systemic racism through highlighting barriers to cancer care related to a “healthcare system founded on Western values and practices…culture barrier, language barrier…communication challenges also [arising] from the common use of medical jargon” [[57], no pagination].

Postoperative outcomes

One peer-reviewed source covering experiences of postoperative outcomes pertaining to Inuit referred from Nunavut to Ottawa’s main hospital found in comparison to non-Inuit, that post-surgery Inuit had a 25% relative increased chance of morbidity and death post-surgery, increased rates of further adverse health-related outcomes, and despite 20% more being spent per patient, outcomes were 20% less promising [58]. These differences were observed to a higher degree in cancer patients [58]. This source implicitly links systemic racism to these findings, concluding that: “this may be due to systemic barriers in accessing timely and culturally appropriate surgical care…leading to presentations with more advanced disease and thereby risk of postoperative adverse events” and that there is a need to “examine the upstream and downstream factors that influence surgical outcomes…such as the impacts of the social determinants of health, access to healthcare, cancer screening programs and systemic racism” [[58], no pagination].

Discussion

The data presented here shows that Inuit experience a mix of systemic and interpersonal instances of racism, either explicitly or inferred from the identified sources, which have often been explicitly linked to coloniality. The sources show that Inuit experiences of racism impact adults, children, youth, men and women – although there was a lack of specifically reported experiences from men. There was a notable lack of literature specifically focusing on the experience of Inuit living in urban environments (possibly due to search terms), as well as experiences of healthcare in the Canadian Arctic: the literature is largely related to the experiences of those travelling from the northern to southern cities to receive care. While the latter is expected, given the lack of local healthcare services in Northern Canada, the other two findings are somewhat surprising: firstly, owing to the documented growing urban Inuit population [66] , secondly, owing to findings from the lead author’s doctoral work where feelings of contempt, discrimination, racism, lack of clear communication as well as language barriers, and health concerns not being taken seriously (often leading to more severe health outcomes than when first presented) being voiced by Inuit in Nunavut and Winnipeg [67]. Furthermore, none of the identified health aspects in the scan related to mental health. This is also somewhat surprising given the high rates of youth suicide in this population [68] as well as concerns voiced by youth participants in recent investigations [67]. Finally, despite the range of searched publications being from 2000 to 2024, all identified publications fell within the period between 2018 and 2023.

Overall, the identified sources have raised the following common issues: underlying mistrust in the healthcare system due to past experiences and population histories, a biomedical approach (and associated communications) that does not align with Inuit epistemologies or realities, a lack of culturally appropriate care and issues with having to travel long distances for basic care. Ultimately, these factors perpetuate systemic and interpersonal experiences of racism. The remainder of this section explores issues related to distinguishing between interpersonal and systemic racism and relates the thematic categories identified to the wider literature, to build upon the data to provide comprehensive recommendations for this topic. We also unpack the limitations of this scan.

Limitations

While this environmental scan has mapped out areas where Inuit experiences racism in healthcare, the following issues limit this work. It has been challenging to distinguish between interpersonal and systemic racism, along with implicit and explicit racism (often due to a lack of provided definitions in the identified literature), and personal judgment has made these decisions. To provide a comprehensive in-depth exploration of this topic, we suggest further work to include search terms related to capturing solutions/recommendations (e.g. healthcare reconciliation), explicitly naming the regions in Inuit Nunangat, as well as search terms related to “urban”. Further, search terms should capture a wider pool of medical professionals, e.g. midwives, dentists, community health workers, as well as terms related to illness/injury. Moreover, some sources may have been missed, particularly those in the grey literature/news categories. For example, the 2018 Nunatsiaq News article sharing the case of her young child being transported to a southern hospital was cited in “A Hand to Hold”, but this article did not included in our grey literature search. We are also mindful of engaging with anecdotal evidence through presentation in news articles. Nevertheless, we believe that this environmental scan provides a seminal perspective on documented instances of racism experienced by Inuit accessing healthcare services. As such, this study’s contribution remains unique, and as such, valuable.

Interpersonal versus systemic racism

While there are differences between systemic and interpersonal racism, the literature notes that they are linked, can intersect and, at times, distinguishing between them is difficult [19]. We found this to be true in this exploration. For example, only three of the sixteen sources explicitly titled their pieces to relate to racism and healthcare, one of which is a news article [47] and the other two gray literature sources [49,51]. This could be due to the purposes and/or formats of the different types of literature identified; often, news article titles are meant to be shocking to pull readers in, whereas the grey literature is advocating for change and peer-reviewed literature needs to stay within the parameters of the evidence collected. Here, it is the news articles or grey literature that primarily explicitly speak of systemic or interpersonal racism.

The entanglement of systemic and interpersonal racism is exemplified by the fact that ten of the sixteen sources were identified to include, either explicitly or implicitly, both types of racism. Further, in some sources where racism was inferred, they still pointed to the entanglement of these types of racism through highlighting institutional (i.e. systemic) barriers, originating from colonial structural legacies and interpersonal aspects through communication-related issues, e.g. language barriers without translators available, issues not being explained appropriately to be understood and having to travel long distances for care, or general patient treatment at the personal level [45,50,52,53,56–58]. While we have identified communication-related barriers in healthcare settings as interpersonal, this could be seen as both personal and systemic issue – e.g. if the practitioner conducts themselves in a specific way, it could also be considered a wider systemic issue if this is due to how they were trained. This level of detail of “communication” barriers identified in the literature was not available [52,53,56,57]. Moreover, we classified reported incidences of fear in health-seeking/stereotyping in health settings as implicit interpersonal racism; however, in these incidences, there was a lack of unpacking what this meant in practice [19,51,54]. Overall, despite these entanglements and clarity-related issues, we argue that all these points towards the existence of a perpetuating “circulatory system” where systemic and interpersonal incidents feed into each other. McCallum and Perry suggest that these distinctions are arbitrary, that settler colonialism and structures of indifference cause these inequities, where they are always a mix of interpersonal and systemic issues [17].

Medical evacuation

Medical evacuation to access healthcare is needed owing to geographical complexities and issues with economies of scale for the provision of complex care to those living in scarcely populated areas. A rise in telehealth services, as seen during and after the COVID-19 pandemic, can partially address this issue; however, the effectiveness of this service is contested due to connectivity issues, technology accessibility (due to the cost or age of patients), consistent practitioner provision, practitioners still being unaware of contextual considerations and the overall lack of cultural appropriateness that this approach takes [69–72]. A barrier for practitioner retention could be related to the fact that many providers are not from the communities they serve [73]. However, there are multiple barriers for Inuit to enter the healthcare professions, e.g. not being able to study science subjects in their home high school and having to stay long-term away from home for post-secondary education [67,74]. Finally, the literature questions the long-term costs of medical evacuation versus investment in Northern healthcare infrastructure [24].

Women’s health

In relation to women’s health issues, the literature reviewed has demonstrated that Inuit lack access to culturally appropriate birthing services and have faced incidents of forced/coerced sterilisation until relatively recently [36]. Forced/coerced sterilisation directly contradicts Section Seven of the Canadian Charter of Rights and Freedoms and Human Rights Frameworks from the United Nations, which Canada has ratified [36]. Forced/coerced sterilisation is also included in international definitions of genocide [75]. Despite this, the practice is not technically criminalised in Canadian law. Senator Boyer has been working on Bill S-250/S-228 to criminalise forced sterilisation, which is still working its way through the legislative process [76–78]. The literature also notes that those subjected to forced/coerced sterilisation should have adequate culturally appropriate support [36]. Canadian Inuit are not unique to this issue; recent investigations have found Greenlandic Inuit to have faced similar practices at the hands of Danish doctors [79].

In relation to childbirth, the literature argues that the medicalisation of and current birthing practices can be emotionally and financially harmful to the mother, isolating and not culturally appropriate [48,50,80–82]. Lehman specifically highlighted the link between the medicalisation of birthing for Inuit and a decline in overall community health [48]. The birthing out of territory practice was justified through the claim that Inuit women had higher adverse birthing outcomes due to a lack of medical support [48]. However, this has been debunked through the comparison of Inuit women’s birth outcomes in southern and northern Quebec from 1991 to 2000, where the results showed that there was equal risk for infants and women in both locations [83].

Traditional birthing practices allowed for women’s autonomy and the support of an ikajurti (Inuit midwife) [84]. The Inuulitsivik Health Centre (Puvirnituq, Quebec) shows that culturally-based birthing is possible in the North, with Inuit leadership, values and an interdisciplinary approach to care cited as the reasons for success [85]. However, in Rankin Inlet, two qualified Inuit midwives from the birthing centre (now closed) stopped working owing to reported mistreatment and burnout, in part owing to microaggressions faced from the Nunavut Department of Health, where hiring practices favoured those with southern credentials who often came with preconceived and prejudicial ideas [86]. As summarised by Lee and colleagues, resolving this issue is not simple, and multiple factors need to be addressed: the structure of the Nunavut medical system, the lack of high turnover of medical staff, the medicalisation of childbirth and professionalisation of the midwife [84].

Cancer care and postoperative outcomes

In relation to experiences of cancer care, the literature we reviewed showed that the biggest issues were in relation to barriers to communication between patients and practitioners, the patient and the larger structural procedures around treatment, and the lack of culturally appropriate care [52–55]. “Shared decision making” is a way that patients can actively be involved in their treatment plans, and this type of dialogue relates to one of the core principles of Inuit Qaujimajatuqangit (Inuit knowledge), aajiiqatigiinniq – decision-making through discussion and reaching consensus [52]. Further aligning with cultural preferences and in turn contributing to cultural safety, visual and oral communication is a way to convey medical information and procedure protocols [26,56,57]. Furthermore, it is essential for practitioners to have an adequate contextual understanding of this population and be able to adapt to suit the needs of patients. For example, a pathway to increase cervical cancer screening would be to adopt self-screening rather than having a gynaecological exam, thus easing pressures on a scarce workforce, and increasing a sense of control and agency for women, some of whom might be particularly reluctant because of histories of abuse [57]. In relation to tackling structural issues for patients travelling to urban settings for care, the following have been recommended: provision of pre-arranged transport, medical escorts and a case manager to help co-ordinate treatment and appointments [52,54].

Limited literature exists documenting Inuit postoperative experiences, however the hypothesis that there are obstacles to accessing cancer care (access to providers, distrust) resulting in Inuit typically presenting further alongside cancer progression is supported by the wider literature [87,88]. Overall, to allow for “healthcare reconciliation” for Inuit, care needs to be culturally relevant, aligning with Inuit values, principles, understandings and language – these aspects are unpacked further in the next section.

Healthcare reconciliation

Healthcare reconciliation is defined as “confronting and interrupting how implicit biases or racist stereotypes can influence the care we provide to Indigenous patients and understanding how current health inequities for Indigenous peoples are linked to previous government policies” [[89], p. 826]. While this scan has drawn attention to complex issues that need addressing, ultimately continuation of the “status quo” denies Inuit health sovereignty and demonstrates that reconciliation is “purely rhetorical, and that colonial practices die hard” [[45], no pagination]. Further, harms created from current practices are not just individual, but also collective, and addressing the gaps in care would allow for collective healing [37]. We first unpack recommendations for healthcare reconciliation from Inuit-centric organisations, as well as addressing the need for cultural safety training in healthcare and the dearth of Inuit-specific data on this topic.

Pauktuutit, the national representative organisation for Inuit women in Canada, states that taking an anti-racism approach in healthcare, firstly, it is essential for the existence of racism to be recognised and understood, allowing for structural changes that perpetuate these inequities to be addressed, where all levels of government work together to tackle the systemic nature of this issue [49]. They provide the following recommendations to address racism in healthcare: improvement and expansion of healthcare in Inuit Nunangat, which is culturally appropriate – using Inuit engagement and knowledge from the outset; fostering the growth of Inuit healthcare providers and traditional midwifery practices; and ensuring that practitioners undertake comprehensive cultural competency training [49]. Furthermore, Inuit Tapiriit Kanatami, the national representative organisation for Inuit residing in the land-claims agreement regions, states that to tackle systemic discrimination in healthcare, the adoption of an “Inuit Nunangat Policy”​​​​​​ ³ is needed to allow healthcare provision in Inuktitut, creation of a national data system, specific Inuit health legislation, authority over federal spending in healthcare, and fostering Inuit in healthcare positions [90].

Cultural safety training for healthcare practitioners can be an effective way to tackle racism in healthcare through making practitioners aware of specific needs, and contextual understanding of the community they serve, as well as the ability to critically reflect upon and address their own biases [12,91–93]. For example, Inuit patients from Nunavik receiving healthcare in Montreal reported that being informed about the medical process throughout the course of treatment allowed a sense of culturally sensitive treatment [94]. Further, Inuit in an urban city in Ontario stated that the following contributed to culturally safe care: the integration of traditional ways of life in the healthcare process, communication throughout the treatment process and the involvement of the patient’s family in the healthcare process [55]. Despite the establishment of this approach, to our knowledge, an Inuit-specific cultural safety training does not exist; rather, training exists with a pan-Indigenous approach or by targeting other Indigenous groups in Canada [95].

To appropriately address instances of racism in healthcare, a study of Inuit-specific experiences of healthcare needs to take place to allow a comprehensive understanding of manifestations and impacts of unsafe care [89,96]. The following studies have been fruitful in identifying and being able to address Indigenous experiences of racism in Canada – however, they are limited to certain locations and take a pan-Indigenous approach:

1. “What’s the Harm: Examining the Stereotyping of Indigenous Peoples in Health Systems” (British Columbia) [7].

2. “In Plain Sight: Addressing Indigenous-specific Racism and Discrimination in British Columbia Health Care” (British Columbia) [11]; to caveat, the lead author’s representation as Cree is contested [97].

3. “Share Your Story: Indigenous-Specific Racism in Health Care Across the Champlain Region” (Champlain, Quebec) [12].

This information could then be used to develop training material for healthcare providers.

Further, the literature notes that healthcare systems and/or providers in Canada do not regularly collect ethnic data and where collected, it is not consistent between organisations/provinces – this contributes to the lack of data available to improve the provision of appropriate care [96]. However, this can only be done if individuals are comfortable disclosing this information. In Toronto, Kiran and colleagues found that patients were open to the routine collection of ethnicity if the patient trusted the person collecting the data and if sufficient explanation was given for its collection; however, this study did not specifically cover Indigenous perspectives [98]. Moreover, if such data are to be collected, Inuit data governance and sovereignty needs to be guaranteed; smaller Inuit-based organisations have begun to do this; however, it is difficult to sustain collection and analysis [96].

Recommendations

Building upon the data presented as well as the literature drawn upon in the discussion, we provide a synthesis of recommendations. Firstly, a more comprehensive review and data collection needs to occur on this topic, as well as the inclusion of literature in French. The routine collection of Inuit-specific healthcare data, as well as the implementation of an Inuit-specific cultural safety programme for practitioners, should be considered. Moreover, co-exploration of ways in which specific aspects of healthcare procedures and protocols can be based on Inuit traditional practices and language should be conducted. Finally, attention and remedies to the lack of healthcare infrastructure in northern Canada needs to be addressed, as well as the consideration of racism as a prominent social and/or structural determinant of health and accountability for those that perpetuate the “circulatory system”.

Conclusion

Healthcare is not just about doctors; other actors, such as nurses and midwives are essential. In particular, nurse practitioners in the North often provide primary care services and have a distinct scope of practice, responsibilities and accountabilities beyond those of registered nurses in southern Canada. While the Hippocratic oath “above all do no harm” [[19], p. 9] is largely taken by physicians/doctors, this review shows that this practice among medical professionals is not always upheld. This environmental scan has shown that Inuit experiences racism in the healthcare systemically or interpersonally, explicitly or implicitly through medical evacuation, aspects of women’s health, cancer care and postoperative outcomes. The review has highlighted the integral need for contextual comprehension to appropriately unpack a topic such as this, as demonstrated through parallels between past biopolitical, paternalistic and culturally insensitive healthcare experiences and contemporary patient experiences. Furthermore, the review, as well as the literature discussed, highlights that racism in healthcare is rooted in settler colonialism and shows how systemic racism operates at a societal level to create structural indifference. It is only when the issues identified are addressed that there will be a move towards Inuit healthcare reconciliation, where reverence for life can be upheld. We end with Kovach’s sentiment of “imagining a new way”, with the hope that this paper inspires, and contributes to healing of the “colonial wound” [[99], p. 255–256].

Supplementary Material

Supplementary Material

Supplementary Material Experiences racism paper FINAL1.pdf

Funding Statement

This study was supported by the Canadian Institutes of Health (461824).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed at https://doi.org/10.1080/22423982.2026.2726014.