Indigenous health research and reconciliation
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* Marcia Anderson

KEY POINTS
*   Indigenous health research can support reconciliation if it responds to the Truth and Reconciliation Commission of Canada’s calls to action and uses the United Nations Declaration on the Rights of Indigenous Peoples as its framework for relationships.

*   As gaps in Indigenous health outcomes are rooted in racism and colonization, Indigenous health research must be explicitly antiracist and anticolonial in order to contribute to closing these gaps.

*   There is a role for non-Indigenous researchers in Indigenous health research, particularly if they are willing to understand their positionality and become active disrupters of systems of whiteness and racism that are the roots of historic and current harms to the health of Indigenous Peoples.

The role played by non-Indigenous researchers involved in Indigenous health research can be complicated and contentious. Kilian and colleagues1 discuss some of the reasons for this in their qualitative study of the approaches of non-Indigenous researchers to Indigenous research, published in *CMAJ Open*. These reasons include that non-Indigenous researchers carry out most Indigenous health research (with ensuing academic and career benefits), and the relative lack of benefits and sometimes harms to Indigenous communities. One theme identified in their study is researchers’ personal journeys of “growth and reconciliation,” which raises important questions about how research can support or hamper reconciliation. How should non-Indigenous researchers engage in Indigenous health research to contribute to positive outcomes for Indigenous communities?

The Truth and Reconciliation Commission of Canada described reconciliation as “establishing and maintaining a mutually respectful relationship between Aboriginal and non-Aboriginal peoples in this country. In order for that to happen, there has to be awareness of the past, acknowledgement of the harm that has been inflicted, atonement for the causes, and action to change behaviour.”2 Kilian and colleagues1 briefly mention the ethical requirement for Indigenous communities to benefit from research, yet the need for research to benefit communities did not emerge as a dominant theme in their analysis, and discussion of potential harms was lacking.

For research to be supportive of reconciliation, it should respond to the Truth and Reconciliation Commission’s calls to action, particularly item 19, which calls on us to close the gaps in Indigenous health outcomes.3 It should follow the commission’s principles of reconciliation, which state that the United Nations Declaration on the Rights of Indigenous Peoples is the framework for reconciliation.4

The type of research that is being done matters. One action that supports reconciliation and respects the equal right of Indigenous Peoples to the highest attainable standard of health (as articulated in the Declaration on the Rights of Indigenous Peoples) is to increase the proportion of Indigenous health research that is well-designed, high-quality interventional research affecting population health outcomes. Studies across Canada, the United States, Australia and New Zealand have shown that up to 92% of Indigenous health research is descriptive and no more than 18% is interventional.5 Of the interventional research that is done, much fails to meet acceptable standards of scientific rigour or quality.6,7 Research, particularly interventional research, is recognized as one necessary part of closing the gaps in Indigenous health outcomes, but in some situations these gaps are actually widening.8

The Truth and Reconciliation Commission calls on us to understand gaps in Indigenous health outcomes as a result of colonization, and there is a wealth of evidence on the impact of racism on the health of Indigenous Peoples.9 Studies such as that by Kilian and colleagues1 must thus reflect meaningfully on racism and colonialism. The fourth theme identified by the study’s authors is the continued existence of academic institutional structures that act as barriers to the ethical conduct of research among Indigenous communities, but this was not named or discussed as an example of institutional racism. Although there is a superficial reference to privilege, the authors would have done well to discuss more in depth how the power relationships inherent in our colonial state and institutions perpetuate practices that are racist and antithetical to reconciliation, and to advance discussion about why the non-Indigenous researchers in their study sample did not discuss these core factors. For research to support reconciliation as rights-based relationships of mutual respect, non-Indigenous researchers must understand and self-reflect on the concept of white fragility.10 They will then need to take the next step and identify the ways in which they participate in systems of whiteness from which they disproportionately benefit11 at the same time as those systems create the gaps in Indigenous health outcomes their research is trying to close.

These concepts are embedded within the vision and strategic plan of the Canadian Institutes of Health Research’s Institute of Indigenous Peoples’ Health (particularly strategic priority #3).12 Research will be transformative at the structural level to benefit Indigenous Peoples only if it is explicitly antiracist and anticolonial. A reconciliation-based research paradigm will require non- Indigenous researchers to move beyond beneficent notions of allyship to become active disrupters of the systems of whiteness and racism that continue to harm Indigenous Peoples today. This includes moving beyond mentorship to giving up places of power and privilege to Indigenous researchers, in academic or community settings, as a fundamental step to the realization of the right of Indigenous self-determination. The intentions of non-Indigenous researchers are not relevant to reconciliation — only their impacts and outcomes are.

## Footnotes

*   See *CMAJ Open* article, [www.cmajopen.ca/content/7/3/E504](http://www.cmajopen.ca/content/7/3/E504).

*   **Competing interests:** None declared.

*   This article was solicited and has not been peer reviewed.

## References

1.  Kilian A, Fellows TK, Giroux R, et al. Exploring the approaches of non-Indigenous researchers to Indigenous research: a qualitative study. CMAJ Open 2019;7: E504–9.
    
    

2.  Honouring the truth, reconciling for the future: summary of the final report of the Truth and Reconciliation Commission of Canada. Winnipeg: Truth and Reconciliation Commission of Canada; 2015. Available: [www.trc.ca/assets/pdf/Honouring\_the\_Truth\_Reconciling\_for\_the\_Future\_July\_23\_2015.pdf](http://www.trc.ca/assets/pdf/Honouring\_the\_Truth\_Reconciling\_for\_the\_Future_July_23_2015.pdf) (accessed 2019 July 25).
    
    

3.  Truth and Reconciliation Commission of Canada: calls to action. Winnipeg: Truth and Reconciliation Commission of Canada; 2015. Available: [http://trc.ca/assets/pdf/Calls\_to\_Action\_English2.pdf](http://trc.ca/assets/pdf/Calls_to_Action_English2.pdf) (accessed 2019 July 26).
    
    

4.  What we have learned: principles of truth and reconciliation. Winnipeg: Truth and Reconciliation Commission of Canada; 2015. Available: [www.trc.ca/assets/pdf/Principles20of20Truth20and20Reconciliation.pdf](http://www.trc.ca/assets/pdf/Principles20of20Truth20and20Reconciliation.pdf) (accessed 2019 July 26).
    
    

5.  Sanson-Fisher RW, Campbell EM, Perkins JJ, et al. Indigenous health research: a critical review of outputs over time. Med J Aust 2006;184:502–5.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=16719748&link_type=MED&atom=%2Fcmaj%2F191%2F34%2FE930.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000238071800007&link_type=ISI) 

6.  Paul CL, Sanson-Fisher R, Stewart J, et al. Being sorry is not enough: the sorry state of the evidence base for improving the health of Indigenous populations. Am J Prev Med 2010;38:566–8.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1016/j.amepre.2010.02.001&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=20409504&link_type=MED&atom=%2Fcmaj%2F191%2F34%2FE930.atom) 

7.  McNamara BJ, Sanson-Fisher R, D’Este C, et al. Type 2 diabetes in Indigenous populations: quality of intervention research over 20 years. Prev Med 2011;52: 3–9.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=21070804&link_type=MED&atom=%2Fcmaj%2F191%2F34%2FE930.atom) 

8.  Stanley LR, Swaim RC, Kaholokulu JK, et al. The imperative for research to promote health equity in Indigenous communities. Prev Sci 2017 Nov. 6 [Epub ahead of print]. doi:10.1007/s11121-017-0850-9.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1007/s11121-017-0850-9&link_type=DOI) 

9.  Allan B, Smylie J. First Peoples, second class treatment: the role of racism in the health and well-being of Indigenous peoples in Canada. Toronto: The Wellesley Institute; 2015. Available: [www.wellesleyinstitute.com/wp-content/uploads/2015/02/Full-Report-FPSCT-Updated.pdf](http://www.wellesleyinstitute.com/wp-content/uploads/2015/02/Full-Report-FPSCT-Updated.pdf) (accessed 2019 July 26).
    
    

10. DiAngelo R. White fragility. Int J Crit Pedagogy 2011;3:54–70.
    
    

11. Hesse B. *The Student Union Lecture Series 5: unsettling whiteness* [speech]. London (UK): SOAS Radio, University of London; 2015 Nov. 13. Available: [https://soasradio.org/speech/episodes/studen-union-lecture-series-5-unsettling-whiteness](https://soasradio.org/speech/episodes/studen-union-lecture-series-5-unsettling-whiteness) (accessed 2019 July 26).
    
    

12. IIPH strategic priorities. In IIPH strategic plan 2019–2024. Saskatoon: Institute for Indigenous Peoples’ Health, Canadian Institutes of Health Research; modified 2019 June 27. Available: [www.cihr-irsc.gc.ca/e/51559.html#7.2](http://www.cihr-irsc.gc.ca/e/51559.html#7.2) (accessed 2019 July 26).