Study design

The Cedar Project (Cedar) is an Indigenous-governed cohort initiated in 2003 and was established to explore the lived experiences of HIV/HCV among young Indigenous people who use criminalized substances in BC. Our Indigenous-governance, the Cedar Project Partnership, is an independent body of Indigenous Elders, knowledge keepers and health and social service experts. They govern all aspects of Cedar research and process. Our research offices are located on Lheidli T’enneh (Prince George) and Coast Salish territories (Vancouver). Cedar methods have previously been described in detail [27]. In brief, participants were enrolled, by non-probabilistic sampling, if they self-identified as Indigenous, smoked or injected criminalized substances other than cannabis (e.g., crystal methamphetamine, crack-cocaine, heroin, cocaine, or opioids) at least one month before enrollment, were between 14–30 years of age at baseline, and provided informed consent. We define “Indigenous” as referring to people who are descendants of the First peoples of North America, including Métis, Aboriginal, First Nations, Inuit, and Status and non-Status Indians. Participants returned every 6 months for follow-up. Honoraria were provided. This cross-sectional analysis included 296 participants who completed a follow-up questionnaire between 2015–2016, and the interviewer administered Measure of Indigenous Racism Experiences (MIRE) scale [28].

Outcome measure

The outcome variable, perceived racial discrimination, was indicated by the interpersonal racism score captured by the MIRE. Interpersonal racism is racism that occurs between individuals. Created in Australia, this is the first validated instrument to address the unique and multiple facets of racism experienced by Indigenous peoples and has been previously adopted in Canadian settings [28, 29]. Participants were asked about experiences of “being treated unfairly because they are Indigenous” across 9 settings on a 5-point Likert scale: “never”, “hardly ever”, “sometimes”, “often”, “very often”. Settings included interactions at work, at home, at school, while doing leisure activities, by the police, by doctors, by staff of government agencies such as the Ministry of Children and Family Development (MCFD), public spaces such as restaurants, shops and stores, and by other people on the street. Experiences of interpersonal racism were collapsed into 3 levels: none (all a-i item responses ’never’), low (average response of ’hardly ever’ for items a-i) and high (average response of ’sometimes’, ’often’, or ’very often’ for items a-i) [28, 30]. A total of 25 (7.8%) participants were missing a response for more than 2 items and excluded from regression analyses. Cronbach’s α was 0.91, indicating good internal consistency.

Exposure variables

We received direction from our Partnership to examine the relationships between racism and several variables measuring historical and ongoing colonial trauma, substance use, access to services and treatment, HIV/HCV infection, and cultural connection. Examined variables included: age (years), sex (male/female), city (Vancouver/Prince George), sexuality (heterosexual/Two-Spirit), education (<high school/≥high school), relationship status (relationship/single). Participants reported if their parents attended residential schools (no/unsure/yes), and if they had ever (no/yes) been taken into foster care, were sexually abused as a child, had ever slept outside >3 nights in a row, ever went to jail or detention, ever physically assaulted, ever sexually assaulted, ever attempted suicide, ever overdosed, ever injected drugs, ever tried to quit using alcohol and drugs, ever been paid for sex, ever been denied shelter, ever been denied any services, ever tried to access treatment but were unable to, ever left the emergency room without receiving treatment, and had probable post-traumatic stress, defined as scoring above 30 on the PTSD Checklist civilian version (PCL-C)(25). Finally, we measured impact of cultural connections, including whether participants (rarely-never/often-always) participated in traditional ceremonies, had a traditional language spoken at home growing up, and their family lived by traditional culture.

Statistical analysis

Responses to the MIRE were analyzed as simple univariate proportions. Associations with other factors were examined via Chi-square test or Fisher’s exact tests of association. Multinomial logistic regression models identified factors associated with severity (none/low/high) of interpersonal racism. Unadjusted and adjusted odds ratios with corresponding 95% confidence intervals were calculated using cumulative logit models with severity levels as ordinal categorical response variables. Variables significant at p<0.10 were included in a multivariable model adjusted for age, location, and gender. Gender-stratified results are also presented. Variables with cell counts less than five were excluded from regression analyses. Available case-analysis was undertaken for all participants with outcome data (n = 296) and no imputation was conducted for missing data.

Ethical considerations

We followed the Tri-Council Policy Statement: Ethical Conduct for Research Involving Humans, with attention to chapter 9, pertaining to research involving Indigenous peoples [31]. Since Cedar’s inception, it has been governed by the Cedar Project Partnership, a body of Indigenous leaders, Elders, community members and health and social services experts. UBC-Providence Health Care Research Ethics Board approved the study.

At enrolment, all participants met with an Indigenous Study Coordinator who described the study, confirmed eligibility, and requested informed consented after explaining potential benefits and harms associated with participation. After the age of 14, minors may consent for themselves regarding their own medical care, therefore consent is not sought from parents or guardians. All participants receive a copy of the consent form and staff verbally review the full consent form with participants. The consenting process may take from 10 to 60 minutes depending on the participant and the number of questions for staff about the study. It is vital for all staff to review the consent form with participants outlining participant rights throughout the research process and explaining what will occur at every stage. Nothing should come as a surprise to participants throughout the duration of their involvement with Cedar.

Criminal justice system

Police were the most common source of racism in this study, with 45% of participants reporting experiencing racism in their interactions. This is consistent with previous Cedar research revealing frequent and concerning interactions with police in both Prince George and Vancouver [18]. Implementation of Canada’s racist settler-colonial laws, including systems of incarceration (reserve system, prison system) and child apprehension (residential ‘schools’, child ‘welfare’ system) has been carried out by police forces across Canada [18]. Understanding this historic context is critical to acknowledging how in the present day, Indigenous peoples continue to be subjected to disproportionate discretionary street check and incarceration rates compared to non-Indigenous people [34–36] and experience disturbing disparities in years of life lost to incarceration [37]. Structural and systemic reforms are urgently needed, including an Indigenous-led police oversight body with investigative powers and authority. Racist policing also has profound health and safety implications for people who are racialized and use illicit drugs, especially those experiencing mental health issues [25, 38]. Calls to de-fund/de-task the police represent the life-and-death need to examine current police structures and responsibilities, particularly in the context of mental health and substance use [39].

Mental health & addictions system

Participants screened for PTSD were nearly three times more likely to experience high interpersonal racism; these associations were particularly strong among women. Previous research underscores the detrimental impact of racism on mental health, leading to higher psychological distress and substance use [14, 40, 41]. Conversely, participants who tried to quit using substances were four times more likely to experience high interpersonal racism compared to those who had not tried to quit. This finding is possibly linked to encounters with health and substance use services where racism is deeply embedded [6]. Mental health and substance use provisions and policies are based on racist ideologies, removing Indigenous peoples’ agency and inflicting harm [42]. This is evident in “wellness checks,” a police response to mental health crisis, which recently led to the fatal shootings of Chantel Moore (Tlaoquiaht Nation) and Rodney Levi (Metepenagiag Nation), who needed help and care [43]. Criminalization of drug use, a policy measure rooted in racism [44], has also created disproportionate harm to Indigenous peoples [10, 45, 46]. During the first COVID-19 pandemic wave, Indigenous people died from overdoses at 5.6 times the rate of other BC residents, with Indigenous women dying at 8.7 times the rate of non-Indigenous women in 2019 [12]. Encounters with child ‘welfare’ likely contribute to the overdose crises experienced by Indigenous families. A recent study highlighted the devastating impact of child apprehension on Indigenous mothers, as they were more likely to experience a non-fatal overdose relative to non-Indigenous women [47]. Indigenous-led wholistic mental wellness and harm reduction services that support self-determination are essential [42]. Indigenous leaders and activists have called for structural interventions, including legislative changes to safe supply access, and reallocation of police funding to housing and mental health initiatives.

Health system

Thirty-four percent of participants reported they had experienced high levels of racism from health providers, and leaving ER without receiving treatment was associated with three times greater likelihood of experiencing high interpersonal racism. Encounters between Indigenous patients and non-Indigenous healthcare providers continue to be affected by deep-rooted racial bias, stereotypes, and racism that remain unaddressed [4, 48–50]. Resulting negative experiences can include instances when: concerns are discounted, assumptions are made about behaviour, someone is blamed or belittled, witnessing harm to loved ones, cultural health practices are diminished, and/or rights and agency are undermined [2, 6, 8, 51–53]. Impacts on access to health services perpetuate negative consequences of racism on health and wellbeing [6, 54]. This study’s findings affirm that Indigenous-specific racism is a health emergency. It is essential that the BC health system, at all levels, takes immediate and sustained action to implement the In Plain Sight recommendations [6].

Child apprehension system

Racism in interactions with government workers from the MCFD were reported by 37% of participants. Women who had a child apprehended were five times more likely to report experiencing high levels of racism. Cedar participants are deeply impacted by multigenerational state-enforced separation of children from families. More than half of participants had a parent who attended residential ‘schools’, and 65% had been through the foster system [55, 56]. Links between child apprehension and adverse health outcomes demonstrated in Cedar data include increased risk of HIV, HCV, and suicide, as well as reduced likelihood of success in HIV treatment [55, 57–60]. In January 2020, the federal government introduced Bill C-92 to reduce the number of Indigenous young people in state custody, affirm Indigenous jurisdiction over child and family services, establish national principles, and contribute to implementation of United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) [61]. However, Gitxsan activist Cindy Blackstock cautioned that lack of clarity around funding could render this legislation a ‘paper tiger’ and hinder meaningful implementation [62]. The Canadian Human Rights Tribunal (CHRT) has found Canada guilty of deliberately underfunding on-reserve child ‘welfare’ and ordered the federal government to pay $40,000 to each child apprehended–a decision contested by the Canadian government. Federal and provincial governments must uphold commitments to the Truth and Reconciliation Commission of Canada and UNDRIP by respecting and fully resourcing Indigenous self-determination related to child protection and ending inequity in public services for First Nations families [61, 63–66].

Language & culture

Having a traditional language spoken at home while growing up was associated with being nearly three times more likely to experience high interpersonal racism. This association was particularly pronounced among men. For many Cedar participants, resilience in the face of adversity is rooted in connections with land, culture, and family [67]. Yet, this study demonstrates that participants who grew up speaking their language are more likely to experience high levels of racism. This relationship has also been documented in research with urban Indigenous Australians–those who most strongly identify with their culture are at greater risk of experiencing racism [30, 68]. Singular focus on enhancing Indigenous resilience to fight oppressive systems without transformative systemic change that challenges the roots of oppression is insufficient. Indigenous self-determination needs to be prioritized across all siloes to transform institutions of risk into institutional wellness and risk environments into support environments.