Recent years have not been kind to the reputation of the health care system in Canada. Its image as a pinnacle of public systems, a place wherein care is freely offered to all comers, an unmitigated social good, has suffered. Much of this decline is attributable to the way in which the Canadian health care system has been enacted as a tool of oppression, from research exposing genocidal experimenta- tion enacted upon the bodies of Indigenous children to the deadly mistreatment of Indigenous patients in contemporary hospitals and clinics. Always held up against the American private disaster to the south, the Canadian health care system has sustained itself on a mythology that has, over the last several years, become increasingly scrutinized and critiqued both from those standing outside of its doors and from those on the other side of the threshold. For many professional organizations and governing bodies within medicine, the years following the 2015 Truth and Reconciliation Commission Report were ones of great reckoning. Like exposed roots in upturned soil, the colonial foundations of Canadian medical practice are all too painfully visible. And while those outside the system call out its injustices and rattle its foundations demanding change, they are joined by people working within the system, who every day confront the policies that perpetuate and embed the racist practices therein. Health care workers committed to decolonial struggle are forcing a reckoning with the past and present violence of the Canadian health care system. In Samir Shaheen-Hussain’s important new book, some of these histories and contemporary struggles are put into print.
The title of Shaheen-Hussain’s book, Fighting for a Hand to Hold: Confronting Medical Colonialism against Indigenous Children in Canada, hints at the target of his argument. But the book and its title are deceptive: it is both the story of a campaign to decolonize one tiny piece of the health care system in one province and an overarching historical retelling of some of the great myths and mythical figures of Canadian medicine. Shaheen-Hussain, a pediatric emergency physician in Tio’tia:ke (Montréal), attained some prominence in recent years as one of the faces of the #AHandToHold campaign. The campaign appeared to be a modest struggle, seemingly a fight to ensure that the Québec goverment ceases the decades-long practice of separating sick children from their caregivers on MedEvac (Medical Evacuation) flights from remote parts of Northern Québec to tertiary care centres in the south. But as I noted, Shaheen-Hussain’s was not a singular struggle; rather, it was a node in the network of larger struggles against the colonial and genocidal logics that underpin the medical system in Canada, both in its history and its present. He shares his modest victory in challenging the ongoing colonial policies that govern modern health care while at the same time charting the massive undertaking that we face in decolonizing a system that was so thoroughly a part of the theft of land and genocide of Indigenous peoples across this vast terrain.
The book begins with a foreword by the inimitable Cindy Blackstock, whose own work defending Indigenous children is legendary. She has won cases alleging that the Canadian state discriminates against Indigenous children by consistently under-funding child welfare on reserves and is indefatigable in the face of persistent appeals and challenges by that same state. In the short foreword, she asks, “How could any government think that putting sick Indigenous children on a MedEvac flight without a parent or caregiver’s ‘hand to hold’ was a good idea, let alone an idea worth defending?”: a question worth asking of the many colonial policies that Shaheen-Hussain later outlines. But despite the various tragedies Blackstock notes in this foreword—the violence and abuse in the residential school system, missing and murdered Indigenous women and girls, toxic water on numerous reserves—her work is always, like Shaheen-Hussain’s, shot through with hope. She ends her foreword by noting that “rinsing Canadian society from the ravages of the colonial/savage dichotomy can happen” if people make it a priority and if the decolonial struggle is generalized across all sectors, everywhere. It is books like this one that make those hopeful words believable, not only because of the horrors they expose, but because of the possibilities they present. In his book, Shaheen-Hussain gives us a template for thinking about, and organizing a struggle against, the institutions of colonial society that callously and often blindly continue the genocidal project from within which they were born.
The book proper begins with a timeline of Shaheen-Hussain’s involvement in the struggle against unaccompanied minors being moved on MedEvac flights from Québec’s Northern communities. His campaign started in the summer of 2017 and ended just over a year later with the victory of #AHandToHold. The Ministry of Health and representatives of the MedEvac flight company confirmed that children would be allowed caregiver accompaniment on emergency medical flights. It is a complicated tale, with many sad attempts to justify racist policies with more racism and many promises broken. But it is Shaheen-Hussain’s deep involvement in the struggle that makes this story compelling. He is able to speak from the perspective of someone who has worked to treat young children: seen the fear in their eyes and the inability to communicate in the colonial language of French. He shares not only the injustice of a child with a possible head injury being flown to a major city alone, but also the ways in which this impacted the quality of care this child received. How could he know, Shaheen-Hussain asks, whether the child he was treating had suddenly burst into inconsolable tears because he had a sudden onset headache, because he had rapidly become disoriented, or because he was simply scared and alone? In laying out this and other examples, he is able to reveal the lie at the heart of the four pillars of medical ethics— autonomy, beneficence, non-malevolence, and justice—as it pertains to the treatment of Indigenous people in the health care system in Canada.
The book goes on to detail what MedEvac flights are and what the non-accompaniment rule looks like in Québec. Since 1981 the Government of Québec has mandated an arms-length organization, EVAQ, staffed by physicians from the Hôpital de l’Enfant Jésus in Québec City, to provide all of the medical airlift evacuations throughout the entirety of the province. Their fleet includes two planes that serve as air shuttles and two that serve as “flying hospitals.” Despite there being no written policy forbidding it, never in its history has EVAQ permitted family members or caregivers on their hospital planes. This has meant that children leaving remote Northern communities in perilous medical states must travel alone. Parents or caregivers must then make their own way down to southern hospitals, travelling either by road or by commercial flight, sometimes taking up to 18 hours to reach their destination. The health impacts, both mental and physical, are grave. Shaheen-Hussain quotes some of the parents who have struggled to send their vulnerable young people off alone into the dark of a Northern night with strangers on a plane, destined for a faceless institution in the south.
Importantly, Shaheen-Hussain makes it clear that the rules set out by EVAQ affect all Québecers living in Northern and remote communities, including the settler populations in places like the Magdalen Islands or the Abitibi-Temiscamingue. But the #AHandToHold campaign centred on the experiences of Eeyou and Inuit communities in particular, both because these communities are affected in greater proportion and because it allowed the campaign to make a larger, bolder, and more far-reaching claim: one about the history of medicine itself, the role it played in the genocidal foundations of Canada, and what that means for how we move forward and begin processes of decolonization within the medical system and beyond. Shaheen-Hussain is able to situate the struggle for accompaniment on MedEvac flights within broader Québec movements targeting the colonial foundations of the Canadian nation-state in general and the health care system in particular. Carefully, he notes that “health care inequalities follow the fault lines of societal injustices” (47). While the intention of the campaign was not to centre certain communities at the expense of others, changing the policy of non-accompaniment that disproportionately impacted Inuit and Eeyou communities would benefit all of the Indigenous and non-Indigenous communities who also have experiences of sending children alone into the air without a caregiver at their side. A trickle-down theory that actually makes sense.
The final quarter of Shaheen-Hussain’s book is a critique of the medical establishment, and he does some of this from the standpoint of medical education. He offers a particularly blistering denunciation of who gets access to professional programs and how that impacts the way colonial care is coordinated. Not only are classrooms in medical education largely grounds for the reproduction of privilege, but they lack both Indigenous students and attention within their curriculum to the “impacts of colonial policies—past or present—on the health and well-being of Indigenous Peoples in Canada” (85). Ultimately, Shaheen-Hussain reminds us, “anti-Indigenous systemic racism is tolerated, enabled, and perpetuated” by medical education and the medical culture in which it is very deeply ingrained. He details the problematic premises of medical education’s “meritocracy” myth and how the people who are permitted entry into medical schools are often serious contributors to the impossibility of the medical system achieving systemic and structural change. While a struggle to decolonize medicine must target the institution itself, as Shaheen-Hussain’s work demonstrates—and no doubt, changes must be made to the ways in which hospitals, clinics, health care systems, and the practitioners within them operate—as with all political projects that claim to be radical, the changes must also begin at the root. The root of medicine as it is co-constructed today—by states, institutions, health care workers, and patients—lies in medical education; changing medical education carries with it the possibility of truly effective projects of decolonization in medicine going forward. And to begin, efforts to decolonize health care must consider who is permitted entry: who is able to gain access to that education, and what do they bring with them?
Medical training is an immense undertaking. The demands are enormous both on one’s time and their physical and mental capacities. It is a grind, pushing people to their limits and then beyond. In this way, medicine as a discipline self-selects for privilege at every step in its process. Not only does it benefit one as a prospective student to be descended from doctors (or other professionals), but it is almost necessary to be able-bodied, without histories of mental health crises, without caregiving responsibilities, without commitments to community or family or life outside of the training. It demands sublimation to the field and the exclusion of the world outside that. Hours are long. Absences are unacceptable. Vacation time is minimal.
This sort of dedication is largely possible for only a few who come with both the financial background to permit engaging in four years of (expensive) study with no earnings and also a lack of the kind of responsibilities that make one capable of such narrow-minded focus, which is all to say that medical learners largely mimic, in experiences if not in body, the myth of the settler that founded so many of the institutions in this country. Learners themselves become the personified terra nulius, unused and unclaimed land that can be worked and shaped into the civilized body of the physician. This myth of settlement is reproduced in medical education: both construct an idealization of unwavering strength, persistence, and courage; the capacity to work without end; and the lack of competing demands or commitments. The white male settler body—unattached to time, place, or struggle and unfettered by responsibility—is the subject that is idealized and adopted without ever being acknowledged. It is the foundation of medical education today, even with the recent turn to increasing equity, diversity, and inclusion. And this settlement myth personified is the foundation from which a profoundly colonial medical system arises. No amount of wellness consultants or free subscriptions to the Headspace app can undo this, only a project of decolonizing medicine beginning with its roots in education can.
In his book, Shaheen-Hussain intimates that the “who” in medical education can perhaps help us deal with the “what.” Within medical education, we are taught—often very poorly and in passing—about the social determinants of health. We are taught that along with individual biology and lifestyle or behaviours, people’s living conditions, workplaces, and social contexts also play a role in their health and health outcomes. Shaheen-Hussain takes apart the ways medical education understands and teaches about social determinants of health. He notes the limitations of this perspective: the social determinants of health look at how things that already exist impact the condition of the individual, but tell you nothing of how those conditions came to be, how they are often the result of purposeful decisions, the result of the past living actively in the present. He incisively reminds us that when we place undue focus on the material conditions that people are living in now, we miss the structural elements that produce them and strip concepts like the social determinants of health of their “potential for more substantive change,” and as a result “the very framework intended to expand our understanding and analysis of health determinants ironically ends up limiting both” (52). Further, he goes on to show how attempts to integrate social determinants of health into medical training have studiously avoided questions of “class power as well as gender, race, and national power” and “how power is produced and reproduced in political institutions” (64), meaning that the very systems that create and maintain injustice and misery, and those who benefit from them, are never named.
In this way, Shaheen-Hussain begins the remainder of his book, which situates the #AHandToHold campaign within the history of medicine. He details various colonial abuses, some better known than others, in which the medical establishment played key roles. He shows clearly and with historical evidence that many doctors knew precisely what they were doing was harmful to Indigenous children and adults, but continued to do it anyway. He charts the inequities that founded the Canadian health care system and that persist today. As the book continues, it moves away from its central focus on the #AHandToHold campaign and tries to place both the campaign itself and the practice of non-accompaniment on MedEvac flights in the historical context of Canadian colonialization. Within medical education, we are often taught about the higher moral calling of physicians. A well-remunerated job one chooses because they care. Historical figures in medicine are trotted out to demonstrate for us the altruism in medicine: that medicine is benevolence, that it is beyond the political, that it only acts for the benefit of the community and of the individual.
On my first day of medical school, not too long ago, each and every student was given a copy of William Osler: A Life in Medicine, about the famous Canadian physician after whom several hospitals and medical faculties are named. We were never told of his racist writings and presentations or how his racist views were central to the ways he practiced medicine. But Shaheen-Hussain pulls apart the benevolent legacy of Osler and other key elements of the history of medical practice in Canada, spending several chapters detailing not only the ways in which the health care system was a key partner in policies of genocidal colonialism, but also how some individuals within these systems struggled against them to give the lie to the myth that all of this was just a product of its time, and thus cannot be critiqued from a presentist view.
Together, these are the histories Shaheen-Hussain collates and decodes for the reader. The critiques he makes of present policies and structures are most valuable for radicals, especially those that work within large faceless bureaucratic systems like the health care system. Pulling back the mythology of benevolence and revealing the genocidal histories that are a very real part of the present structure of medicine allows us to better see both the sites where change must take place and the ways in which it must change. Some of the histories Shaheen-Hussain shares in the middle chapters are better known, and others were previously unknown to me and came as a surprise. They are all appalling and can be demoralizing for one working within medicine and trying to create spaces of safety for Indigenous patients. But Shaheen-Hussain is not—and this should be obvious from his work—a defeatist. His book joins critique with pragmatic challenges to the colonial system; he crafts a history with enduring relevance to the present and charts the precise spaces wherein these colonial practices can be targeted. He lays out in detail the campaign he co-constructed and how he was able to succeed in this modest but wildly important movement. Shaheen-Hussain’s book is that all-too-rare story of a victory against colonial policies and, as such, serves as an important roadmap for how we, as radical health care practitioners or as radicals outside of the system, might continue this struggle in other ways and with other means, but with the same ultimate goal. *