Elisa Levi is an MD Candidate at the Michael G. DeGroote School of Medicine, member of Chippewas of Nawash, and Yellowhead Institute Research Fellow.

While some Canadians are anxiously awaiting their chance to get vaccinated against COVID-19, others are expressing reluctance. There may be several reasons for this vaccine hesitancy — defined by the World Health Organization as purposefully delaying receiving available vaccines — but the issue is particularly complicated when it comes to Indigenous communities.

As public health authorities roll out vaccination programs regionally across Canada, it is important that Indigenous peoples are part of vaccination uptake. Their high degree of socio-economic marginalization results in disproportionate risk in public health emergencies, which may increase their vulnerability to COVID-19. Increased vaccination uptake will help individuals protect themselves, as well as build community immunity (also called “herd immunity.”)

But it is equally important that they are given all the information necessary to make an informed decision and that their concerns are respected. Some members of Indigenous communities have legitimate concerns around medical treatments, rooted in historical trauma. “We have to be honest about where the fear comes from,” Grand Chief Arlen Dumas of the Assembly of Manitoba Chiefs told the CBC.

Historical trauma and vaccine hesitancy

Indigenous people have good reason to distrust government. While younger generations may not have experienced the segregated “Indian Hospitals” that were established in the early 20th century, we have certainly heard about it and experienced the intergenerational trauma that comes along with it. These hospitals focused on tuberculosis treatment, including testing of tuberculosis vaccines in the 1940-50s, but advances in treating the disease were not extended to Indigenous patients, who instead languished in the hospitals. Furthermore, in the 1940s, government scientists performed nutrition experiments on Indigenous people without consent in some of these hospitals, as they did with children in residential schools.

If the vaccine is rolled out in a community without information that an individual understands, they may reject it, and this could trigger historical trauma based on previous experiences. Historical trauma, when triggered, can result in dissociation.

While there have been many improvements in the areas of ethical health research and culturally safe health care, historical trauma continues to present itself in health disparities. Colonization has left us with devastating inequities, including high rates of infectious disease and non-communicable disease such as diabetes, and a health-care system in which Indigenous people such as Joyce Echaquan fall victim to systemic racism. Shortly before her death this past September, Echaquan broadcast a video on Facebook Live showing her crying out for help in her hospital bed while two nurses at the Quebec hospital insulted her. Following this tragedy, the Council of the Atikamekw Nation and the Council of the Atikamekw of Manawan delivered to the federal and provincial governments Joyce’s Principle, which demands that all Indigenous people have an equal right to the highest standards of physical and mental health care, and that the government recognize Indigenous rights to autonomy and self-determination in matters of health and social services. The Quebec government rejected the proposal.

It has been said that vaccines don’t save lives: vaccinations do. But the right to health for all people, including autonomy in decision-making, must remain at the core of vaccination rollout, for this pandemic and beyond.

First-wave resilience, second-wave concerns

We knew that the consequences of colonization, including pre-existing health conditions, would put Indigenous people at a higher risk of severe illness and death from COVID-19. Therefore governments, including Indigenous communities, have been preparing for this pandemic since the H1N1 flu outbreak in 2009. Most communities had community emergency plans ready to implement.

Dr. Evan Adams, Deputy Chief Medical Officer of Public Health for Indigenous Services Canada (ISC), said that in spite of the social determinants of health and underlying health issues that could put First Nations at a disadvantage, COVID-19 incidence and fatality rates there were one-quarter of the national rate in the first wave of the pandemic. He attributed this to cultural veneration of the elderly and the swift action of leadership to shut the borders of their communities to control movement, and therefore COVID-19 incidence.

But now the number of COVID-19 cases reported in First Nations communities across the country is rising at what an ISC public health official calls an “alarming” rate. ISC reported 5,571 active cases in First Nations communities this week, the highest number so far. Case counts have been increasing by 1,753 to 2,046 a week so far this year, with Western Canada being hardest hit. We are witnessing outbreaks now in what would be considered the “second wave” of the pandemic.

An equity-based approach to immunization

The National Advisory Committee on Immunization (NACI) is an external advisory body to the Public Health Agency of Canada that provides medical, scientific and public health advice on the use of vaccines. As it develops its recommendations on delivering the COVID-19 vaccine, one of the factors it must consider is equity. Equity seeks to increase access to immunization services to reduce health inequities without further stigmatization or discrimination. As such, the key populations NACI identified for early vaccination include those whose living or working conditions put them at elevated risk of infection and where infection could have disproportionate consequences, including Indigenous communities.

Equity also means engaging systematically marginalized and racialized populations in immunization program planning. As NACI recognizes, any immunization program should consider the needs of diverse population groups, based on health status, ethnicity and culture, ability and other socioeconomic and demographic factors that may place individuals in vulnerable circumstances.

An equitable approach should integrate the values and preferences of these populations in vaccine program planning, and build capacity to ensure convenient access to immunization services. As Caroline Lidstone-Jones, chief executive officer of the Indigenous Primary Health Care Council, told the Toronto Star, “If you engage with us effectively and appropriately, there are real ways that we can get better uptake and engagement of our population.”

There has been some progress here when it comes to Indigenous communities. Federal and provincial bodies have committed to work together on vaccination efforts with Indigenous, First Nations, Metis and Inuit communities to ensure efforts reach the most vulnerable, including the most northern communities. In Ontario, Chiefs of Ontario Regional Chief RoseAnne Archibald was appointed to the COVID-19 Vaccine Distribution Task Force. In addition, a separate sub-table was created by Indigenous Affairs Ontario and the Indigenous Primary Health Care Council, and other Indigenous organizations were invited to participate.

Nishnawbe Aski Nation, which represents 49 First Nations in northern Ontario, has been working with the ORNGE air ambulance service and the provincial government to develop a plan for the distribution of vaccines to First Nations, including 31 remote First Nations in NAN. And the Indigenous Primary Health Care Council has united with Ontario’s primary care organizations to help ensure Indigenous inclusion in the vaccination rollout, and to educate health system providers about Indigenous concerns like systemic racism.

One example of an Indigenous-led vaccination initiative was a community-focused rollout day in Toronto, led by Anishnawbe Health Mobile Healing Unit in partnership with Women’s College Hospital. It resulted in approximately 74 per cent uptake of Indigenous seniors at a retirement residence. With a vaccine that is 95 per cent effective, it has been projected that 70 per cent uptake is needed for community immunity.

It has been said that vaccines don’t save lives: vaccinations do. But the right to health for all people, including autonomy in decision-making, must remain at the core of vaccination rollout, for this pandemic and beyond. Respectful communication that is transparent, empathetic and proactive about curiosity, risks and vaccine availability will contribute to building trust in the science.

In the months ahead, we will see the outcomes of a conscious effort to not repeat history by working with Indigenous leadership and Indigenous organizations in the rollout of the COVID-19 vaccination.