Shifting Power to Improve First Nation Peoples’ Access and Outcomes in Kidney Care

Related article, p 896

In this internationally important systematic review¹ identified and given voice by a First Nation-led multidisciplinary group in Canada and amplified internationally in this issue of Kidney Medicine, readers are invited to engage with Indigenous peoples’ perspectives about Cultural Safety in kidney care. Smith et al¹ posit 2 knowledge systems: the Eurocentric academic process and a process that centers on Indigenous peoples and storytelling.¹ The review identified 2,232 articles, of which 15 relevant articles addressed the research question on Cultural Safety within the context of Indigenous kidney health care. The review focused on research from New Zealand, Australia, Canada, and the United States, dating back to 2002, when Cultural Safety as a term was proposed by Ramsden² and gained academic acceptance.

Smith et al¹ introduce the academic knowledge system in the methodology of the paper, but first comes the story of Indigenous peoples lost, missing, and dying in care systems that fail them. Indigenous people seek access to health care as well as optimal health care interactions and outcomes, just as non-Indigenous people do. The reader is challenged to consider Cultural Safety in kidney care for Indigenous peoples, with a prompt to readers to recognize “triggered unease” as expected experiences when engaging “issues of racism.” Racism has persisted in health systems and continues to harm Indigenous peoples in Canada, the United States, New Zealand, and Australia.³

This paper is a timely exploration of the depth and breadth of knowing of Cultural Safety, with its source material harvested from academic knowledge repositories. The 15 articles that Smith et al¹ identified expose the differing assumptions of academic knowledge systems, in which academic repositories archive materials whose evidence ratings have been developed without the knowledge or values of Indigenous peoples. Nevertheless, this repository is used for purposes that fundamentally affect the nature of care provided to Indigenous peoples, including the teaching curricula of kidney health practitioners, designing health care systems, and accreditation of hospital practices.⁴ In the area of kidney disease, the voices of Indigenous people have been largely absent from this repository, either as authors, researchers, or storytellers.

Smith et al¹ invite readers to reflect on sustained legacies of colonialism when considering the body of Cultural Safety in kidney care publications deposited in academic archives. Processes that intentionally make space (through shifting power) for Indigenous peoples’ self-determination in health care and those that promote improved health outcomes need research funding prioritization and the editorial commitment of assigning editors and journal reviewers to support research archiving. Utilization by editorial teams of research quality appraisal tools, which are designed by First Nations people,^5,6 can systematically promote the epistemic publication value of research produced from and by First Nation communities. Important power shifts and process shifts are occurring in international journals, such as Kidney Medicine, to amplify Indigenous peoples’ knowledge.

The kidney health writing collaboration of Smith et al¹ was First Nation-led and multidisciplinary. Through this lens, readers are invited to witness the profound cultural strength of Indigenous peoples. These were revealed in the clustered identification of Cultural Safety concepts of relationality, engagement, and health care self-determination. These profound strengths occur among systemic issues (barriers and access) that are an ongoing legacy of colonialism and resonate with Australian experiences among Indigenous peoples as health care users.

Smith et al¹ advocate that Cultural Safety in kidney care within Indigenous communities requires further understanding and delineation. We agree but also provide an Australian example of Indigenous leadership in transforming kidney care. Australian processes that enable access to specialized kidney treatments, specifically to kidney transplantation, have only recently invited engagement of Aboriginal and Torres Strait Islander people.^7,8 In early 2019, the Transplant Society of Australia and New Zealand secured federal government funding to establish a National Indigenous Kidney Transplant Taskforce, the first in more than 50 years of Australian transplantation. This Taskforce was formed to improve Aboriginal and Torres Strait Islander peoples’ access to kidney transplantation, recognizing the inequity of being a minoritized population (3% of the Australian population), with a 4-5 times higher incidence of end-stage kidney disease than other Australians, yet with lower access to kidney transplantation.⁹ The Taskforce champions, who were Indigenous and non-Indigenous clinicians and transplantation leaders, met with the federal Minister of Indigenous Health, Hon Ken Wyatt AM, MP, in the preceding year, and all parties supported the Aboriginal and Torres Strait Islander peoples’ self-determination for equitable kidney transplant care⁸ and recognized that systemic cultural bias contributed to lower access to transplantation.¹⁰ This work has been shared in community meetings, conferences, and a recent publication.¹¹

With 3 years of funding (2019-2022), the Taskforce includes 25 members from the Aboriginal Community Controlled Health Sector, primary and tertiary health care, transplant units and medical, nursing and allied health professionals, and patient leaders. We committed to 4 principal activities:¹¹ (1) convening an Aboriginal and Torres Strait Islander Consumer community network; (2) defining data variables and data capture to define barriers to access transplant workup; (3) Access and Equity Sponsorships, which provisioned $1 million across 7 pilot projects to support regionally defined initiatives to improving access to transplant waitlisting, and which privileged community-led and or community-health care partnerships; and (4) a review of Cultural Bias initiatives in Australian renal units. For this activity, the Taskforce commissioned the Lowitja Institute to review the depth of publications describing Cultural Bias initiatives in kidney transplantation in Aboriginal and Torres Strait Islander peoples in Australia.¹² Consistent with Smith et al¹, there is a critical need for Indigenous peoples to self-determine Culturally Safe Kidney Care as well as a critical need for research documentation that supports Indigenous academic, clinical, and methodological leadership and authorship.

In conclusion, Smith et al¹ entreat us in their systematic review, advocating for shifting power differentials so that all people (health providers and Indigenous recipients of health care) feel safe and respected in the health care system. There is a critical need to improve Cultural Safety in all health care interactions and for Indigenous peoples’ kidney care. Creating a body of knowledge within the academic repositories is crucial – we look forward to the day when systematic reviews can find hundreds, not a dozen, reports supporting programs that address these issues. Indigenous peoples’ self-determination in improved kidney health outcomes is critical; engagement, involvement and leadership in research, and design and service improvement of health care systems will be required to ensure that kidney health care is fit for this purpose.