Across Canada, syphilis continues to mostly affect men who have sex with men, but on the Prairies, rates are also high among heterosexual women. In this conversation, the second in a series for the National Collaborating Centre for Infectious Diseases in conjunction with the National Collaborating Centre for Aboriginal Health, we’ll hear from Dr. Marcia Anderson, a medical officer of health and medical lead for the Winnipeg Regional Health Authority. She’ll discuss the determinants of syphilis transmission for Indigenous women and what public health and primary care providers can do to slow or stop its progression. Dr. Anderson spoke with NCCID’s Jami Neufeld.
Jami Neufeld: What is your understanding of the circumstances that are contributing to syphilis outbreaks among Indigenous women in Winnipeg and Manitoba?
Dr. Marcia Anderson: I think it’s important that we think about the increase in syphilis rates right now the way we think about any Indigenous health outcome and specifically that we think about TRC [Truth & Reconciliation Commission] Call to Action number 18 which says we should think about the current state of Indigenous health as a result of previous government policies. So to frame that a little bit, some of the factors – and the first one I would say is that it’s nothing inherent to Indigenous women that are putting them at higher risk, it’s not a genetic factor, it’s not an immune system deficiency, it is the structures of society that are putting a group of Indigenous women at higher risk for negative health outcomes. Some of the other factors that are associated with the higher rates right now amongst Indigenous women in Winnipeg are things like crystal meth use and are things like survival sex or sexual exploitation or trading sex to meet basic needs.
So I think it’s important that we understand what puts Indigenous women at higher rates of being in those circumstances. And specifically we need to think about how colonization has led to higher rates of poverty amongst Indigenous people and how the very specifically gendered impacts of colonization through who was recognized as an Indian through impacts of the Church and patriarchal systems that put women more at risk or at the margins of society. I think we need to think about how inequitable education opportunities puts Indigenous women at higher risk and so it’s these types of structural impacts that lead to downstream health outcomes. Some of the other things that we really need to be cognisant of is that many of these women report not having strong connections or any connections with organizations or services that they would need. One hypothesis I would have around that is that they have probably had negative interactions in the past and probably a low level of trust for mainstream organizations.
So there may have been family experiences in residential school, with the 60s Scoop or with child welfare which have all been well described to put women at higher risk, leads to marginalization and then have downstream impacts like drug use or poor mental health. So those are some of the surface answers that I think we need to be thinking of when we’re trying to understand these higher rates.
Neufeld: What factors do primary healthcare practitioners and public health personnel need to know and understand about Indigenous women’s risks of syphilis in the communities that you work with?
Dr. Anderson: I think one of most important things is that health and social service practitioners who may encounter these women need to be able to approach them with respect, with kindness and without any type of discrimination, stigma or judgement. I think we need to recognize that these women are doing the best they can, that they’ve been heavily disadvantaged by society and they are bearing kind of an individual or personal cost of multiple layers of disadvantaged both historically and in the current context. I think that in any encounter, it’s really important that service providers work at rebuilding some trust or trying to establish some trust and one thing that I’ve often said is the relationship is the first outcome. So likely these are women who are going to require multiple different types of services so they may not have stable housing and they may need assistance with stable housing. They may not have employment; they may need assistance with finding employment.
They may be in very food insecure settings, they may have children involved in the CFS system and they clearly need healthcare since we’re talking about women who have syphilis. If the first interaction trying to get treatment for the syphilis is negative, they are going to further disengage, right? So I think it’s really important that providers don’t approach this thinking about individual level blame or individual actions like the single sex act that maybe was unprotected and led to an STBBI (sexually transmitted and blood borne infection) like syphilis, but instead are able to see these women in their whole context. And really are able to use the knowledge and tools and resources they have to support the women and, like I mentioned, in kind, respectful, non-judgemental ways.
Jami Neufeld: In considering the current syphilis outbreak among Indigenous women in Winnipeg and in Manitoba, what role do Ka Ni Kanichihk and other Indigenous organizations play in providing care, services or information?
Dr. Anderson: You know, Ka Ni Kanichihk has this funding from Public Health Agency of Canada looking at developing a culturally safe model of STBBI care. They are a community organization; they’re not a health services organization so I wouldn’t say that they have a role at this point in providing direct testing and treatment but I think that there are several really valuable roles that Indigenous organizations can play. And the first thing that I would say is – because I’ve been supporting that project development with them, I’ve been reviewing a lot of the literature. It’s really clear that Indigenous people prefer to access services when they are led and developed by other Indigenous people and when they can see themselves in them. They feel culturally safe; they feel like they belong. They don’t feel foreign when they’re going to receive care for something that can be pretty vulnerable to talk about. Ka Ni Kanichihk or other Indigenous community organizations can be really important brokers. They are more likely to be trusted by Indigenous people in the community than mainstream organizations like the WRHA (Winnipeg Regional Health Authority) are going to be.
They clearly can have a role in upstream education, absolutely can help overall in the provision of harm reduction services, prevention. So, whether that’s education or direct distribution of condoms or sterile needles or whatever other harm reduction supplies can be. I think we also need to think about how they can bridge or broker individual clinical interactions. So part of the project we’re working on right now is around developing this model and then providing education and training and really walking alongside clinics to implement a more culturally safe model that will include a feedback or evaluation loop that allows people who are receiving the services to actually evaluate it as culturally safe or not. So those are some of the roles that I think they can play. And I think really importantly, as we think about public health and how we provide public health moving forward, many of these small Indigenous community organizations have been doing upstream work of public health for years already as part of the non-profit or community organization sector.
I think those of us who are in the mainstream organizations need to think more about how we distribute our resources; whether that’s our knowledge or our financial resources or our tools to more broadly empower and resource these community organizations to do that public facing frontline work.
Jami Neufeld: So what should or can public health personnel and primary care providers do or learn to work with agencies such as Ka Ni Kanichihk to slow or stop the progression of syphilis among women and in the community?
Dr. Anderson: So the first thing that I would say about that, and to be really clear, is – with syphilis we’re seeing a rise right now. But Indigenous women have always had higher rates of STBBI whether that’s chlamydia or gonorrhea. We’ve had the highest incidents of new HIV infections for several years now. So it just happens to be syphilis, but the factors that perpetually keep Indigenous women at higher risk haven’t actually changed. So the exact disease is a little bit of a red herring, the real focus needs to be on those upstream factors that put Indigenous women at higher risk. I think we really need to look at those structural determinants and really focus on our roles in health equity and advocacy as public health personnel to try to remove or address those structural factors that are putting Indigenous women at higher risk. So I’d mentioned housing before; depending on what context you live in, it may make sense to be more involved in advocating for more affordable public housing, right?
Other upstream factors like basic income, food security, education and employment opportunities. Things that pull women from their margins to where they can actually be resourced, autonomous and then are in the best position to be self-determining about their own health. So whether it’s syphilis or HIV or diabetes, the action for us is really the same and it’s working at those upstream factors that are putting women at higher risk for downstream negative health impacts.
Jami Neufeld: What do you think are the ways to support Indigenous women who have or are at risk for syphilis and what supports do they need?
Dr. Anderson: So it’s still a combination of answers, right? If it’s a service provision context, it’s treating people with respect and dignity and really doing the most you can to meet their needs where they are at as opposed to whatever the minimum you can do. So I think that’s one thing. I think we all need to be democratically engaged; so there is a series of municipal elections going on right now, provincial and federal elections are kind of on the horizon in the next couple of years also. So I think another thing is to be educated about the type of social policies that put Indigenous women at higher risk or would help mitigate some of the structural disadvantage that are faced by women right now and ensure that you’re asking candidates where they stand on those types of policies. Then holding governments accountable through the actions of voting and being civically engaged. I also think it’s really important that we’re all participating in shifting the public discourse around Indigenous women.
So there’s this whole social media thing going on right now about this one store in the United States called the Spunky Squaw. Squaw, of course, being a racial slur that has been used to hypersexualize Indigenous women and also has a connotation of women as being disposable. So when you think about the national inquiry into missing and murdered Indigenous women, Indigenous women being at higher risk than any other population in Canada of going missing and being murdered and similarly in the United States. Those discourses are really dangerous and that’s been compounded by things like unequal protection under the law which is why the Winnipeg police service recently apologised to women for not taking those cases seriously. So we all need to contribute to shifting those discourses, to changing names of mascots, of stores that hypersexualize Indigenous women because that also contributes to our risk. And as long as we have a public discourse that treats Indigenous women as inferior, as squaws, as hypersexual, as disposable, then we’re going to continue to see policies that don’t actually afford equal protection or equal opportunity for Indigenous women. So I think that’s the other thing that we all have a responsibility to be shifting.
That concludes our conversation with Dr Marcia Anderson, an Indigenous physician based in Winnipeg, the second in our series on syphilis and public health. A production of the National Collaborating Centre for Infectious Diseases in conjunction with the National Collaborating Centre for Aboriginal Health, this content has been made possible in part through a financial contribution from the Public Health Agency of Canada. Note that the views expressed here do not necessarily represent those of the Agency. The host organization of the NCCID is the University of Manitoba. Learn more at nccid.ca.