In search of a Healing Place: Aboriginal women in Vancouver's Downtown Eastside

Abstract

Research on general health service delivery in urban areas of Canada shows that Aboriginal people face formidable barriers in accessing culturally appropriate and timely care. Over the past decade, Urban Aboriginal Health Centres (UAHCs) have emerged to address the unmet health concerns of Aboriginal people living in metropolitan areas of the country. The purpose of this research was to address the gap in social science literature on how the health care concerns of Aboriginal women are being met by UAHCs. The research aimed to give voice to Aboriginal women by asking them whether the appropriate professional services and educational programs they need to address their health care needs were being provided in the inner city. A case-study approach was used whereby three separate focus groups were conducted with Aboriginal women who were clients of the Vancouver Native Health Society (VNHS), its sister organization, Sheway, or residents of Vancouver's Downtown Eastside (DTES). In addition, twenty-five semi-structured interviews were conducted with VNHS staff, health providers, government representatives, and community leaders in health care (total n=61). The findings indicate that despite efforts from various quarters to articulate the health and social concerns of the country's marginalized populations, such has not been the case for Aboriginal women living in one of Canada's most prosperous cities. Many Aboriginal women expressed a strong desire for a Healing Place, based on a model of care where their health concerns are addressed in an integrated manner, where they are respected and given the opportunity to shape and influence decision-making about services that impact their own healing.

Full text

Social Science & Medicine 56 (2003) 821–833
.
In search of a Healing Place: Aboriginal women in Vancouver’s
Downtown Eastside
Cecilia Benoit
a,
*, Dena Carroll
b
, Munaza Chaudhry
c
a
Department of Sociology, University of Victoria, P.O. Box 3050, Victoria, BC, Canada V8W 3P5
b
Aboriginal Health Consultant, 3627 Revelstoke Place, Victoria, BC, Canada V8P 3X5
c
Health Research Consultant, 1616 Prairie Street, Victoria, BC, Canada V8N 5X9
Abstract
Research on general health service delivery in urban areas of Canada shows that Aboriginal people face formidable
barriers in accessing culturally appropriate and timely care. Over the past decade, Urban Aboriginal Health Centres
(UAHCs) have emerged to address the unmet health concerns of Aboriginal people living in metropolitan areas of the
country. The purpose of this research was to address the gap in social science literature on how the health care concerns
of Aboriginal women are being met by UAHCs. The research aimed to give voice to Aboriginal women by asking them
whether the appropriate professional services and educational programs they need to address their health care needs
were being provided in the inner city. A case-study approach was used whereby three separate focus groups were
conducted with Aboriginal women who were clients of the Vancouver Native Health Society (VNHS), its sister
organization, Sheway, or residents of Vancouver’s Downtown Eastside (DTES). In addition, twenty-five semi-
structured interviews were conducted with VNHS staff, health providers, government representatives, and community
leaders in health care (total n¼61). The findings indicate that despite efforts from various quarters to articulate the
health and social concerns of the country’s marginalized populations, such has not been the case for Aboriginal women
living in one of Canada’s most prosperous cities. Many Aboriginal women expressed a strong desire for a Healing
Place, based on a model of care where their health concerns are addressed in an integrated manner, where they are
respected and given the opportunity to shape and influence decision-making about services that impact their own
healing. r2002 Elsevier Science Ltd. All rights reserved.
Keywords: Aboriginal women; Urban Aboriginal Health Centres; Healing Place; Canada
Introduction
About 1.1 million persons claimed some Aboriginal
ancestry in the 1996 census, up from 1 million in 1991.
1
Out of the general Aboriginal population in Canada,
there are approximately 408,100 Aboriginal women
(Statistics Canada, 2000; Dion Stout et al., 2001).
Aboriginal Canadians are more likely to live in
*Corresponding author. Tel.: +1-250-721-7578; fax: +1-250-721-6217.
E-mail address: cbenoit@uvic.ca (C. Benoit).
URL: http://web.uvic.ca/Bcbenoit/.
1
At the beginning of the 18th century there were about 10 Aboriginal people for every European settler in Canada; by 1881 there
were about 40 Europeans for every Aboriginal person (Jaffe, 1992). This was not primarily because of a natural increase of European
immigrants, however. Traders and later settlers to New France and British North America (later renamed Upper and Lower Canada)
brought with them not only trade items, but also racist attitudes toward the non-Christian ‘‘savages’’ who resided in the New World.
The Europeans were even prepared to use their superior military power to subdue any Aboriginal people unwilling to be colonized.
Europeans also brought with them deadly diseases. Smallpox and other epidemic diseases (including measles, influenza, tuberculosis)
had killed many Europeans in the previous centuries. However, for the Aboriginal people, these contagions were ‘‘virgin soil
epidemics,’’ ravaging hitherto unexposed populations without any built-up immunity to soften the impact. These ‘‘diseases of
0277-9536/03/$ - see front matter r2002 Elsevier Science Ltd. All rights reserved.
PII: S 0277-9536(02)00081-3

single-parent families and have higher rates of unem-
ployment and lower rates of high school completion than
the non-Aboriginal population (Hanselmann, 2001).
Their health status is likewise comparatively poor.
Research shows that the average life expectancy for
Aboriginal people is five or more years less than for other
Canadians (Canadian Institute for Health Information,
2000; Statistics Canada, 2000; Dion Stout et al., 2001).
More than half of Canada’s Aboriginal population
live in urban centres, and the two-thirds of Canada’s
urban Aboriginal population lives in Western Canada
(Hanselmann, 2001). Canada’s urban Aboriginal peo-
ple
2
today comprise a diverse, youthful and growing
population (Dion Stout et al., 2001). Despite their
growing numbers, urban Aboriginal people in Canada
continue to earn far below the median average income for
non-urban counterparts. Urban Aboriginal people also
tend to have comparatively higher rates of homelessness,
greater housing needs and higher rates of suicide and are
particularly at risk of substance abuse, contracting
tuberculosis, HIV/AIDS or developing diabetes (Health
Canada, 1999). These data indicate that many Aboriginal
people, especially those residing in urban areas, are in
danger of falling through the cracks of the Canadian
health care system and social security safety net.
On a more positive note, Canada’s Aboriginal people
have recently reasserted control over their health and
social services and have assumed greater responsibility
over the design and delivery of programs. During the
last decade Urban Aboriginal Health Centres (UAHCs)
have also emerged across the country to address the
unmet health concerns of Aboriginal people living in
large metropolitan areas (Royal Commission on Abori-
ginal People, 1996; Waldram, Herring, & Young, 1997).
The best known of the UAHCs is Anishnawbe Health
Toronto (AHT), which was established in 1989 (Lowry,
1993). Some of the strategies of AHT and the other
UAHCs have included control and administration by a
qualified team of Aboriginal people, recruitment of
Aboriginal health professionals (including nurses, phy-
sicians, and social workers), and implementation of a
holistic philosophy of care that blends traditional
Aboriginal healing and Western medicine. The long-
range vision of the UAHCs has been to improve both
service delivery and health outcomes for urban Abori-
ginal people in Canada by increasing access to culturally
suitable and appropriate health care and social services.
In addition, the expectation has been that these UAHCs
would operate quite differently from mainstream med-
ical services in Canada, which are based primarily on a
fee-for-service physician model, in order to meet
previously unmet needs.
3
The purpose of this research was to address the gap in
social science literature on how effectively Aboriginal
women’s specific health concerns are being met by the
innovative UAHCs in particular. The few available
reports indicate that Aboriginal women have inadequate
access to reproductive care services, including access to
pap smears, mammogram screening and abortion
services (Hislop et al., 1996; BC Provincial Health
Officer, 1996; Clark, 1999; BC Women’s Health Bureau,
1998; Baxter, 1999; Poole, 2000; Dion Stout et al., 2001).
Our research focused on asking Aboriginal women
living in Vancouver’s Downtown Eastside (DTES)
whether the service delivery model employed at the
Vancouver Native Health Society (VNHS) provided
them with the appropriate professional services and
educational programs needed to take control of their
health and healing.
(footnote continued)
civilization,’’ along with the ill effects of adulterated whisky,
reduced the Aboriginal population of British Columbia, for
example, by nearly two-thirds before the end of the 1800s. So
marginalized were Canada’s Aboriginal people that they were
not entitled to vote alongside non-Aboriginal Canadian citizens
until 1960. The situation was arguably worst for Aboriginal
women. Prior to 1985, under the sexist provisions of the 1874
Indian Act, an Aboriginal woman who married a non-
Aboriginal man automatically lost her official designation as
Status Indian, including band membership, as did her children.
However, an Aboriginal man who married a non-Aboriginal
woman not only retained his Indian status, but also was able to
claim it for his wife. Under Canada’s federal Bill C-31, the
original Act was finally revised to grant official Indian status to
all Aboriginal women, irrespective of their marital status
(Benoit, 2000).
2
According to Canada’s 1982 Constitution Act, Aboriginal
people include Status and Non-Status Indians, M!
etis and Inuit
people. Each of these groups of people has a distinct history
and culture. Even within the groups, the cultures and histories
are not homogenous. The term Status Indian was first defined in
the Federal Government Indian Act of 1850 at which time an
‘Indian’ was defined as any person deemed to be: (1) Aboriginal
by birth; (2) any person belonging to a particular band or body
of Indians; or (3) any person who married an Indian or who
was adopted by Indians. Status Indians who voluntarily gave
up their status through enfranchisement or because they wanted
to work in particular occupations became non-Status Indians.
First Nations later replaced the term ‘Indian’ as the terminology
preferred by an Aboriginal person who identifies as being a
descendant of the first inhabitants of Canada, except in the
Arctic. The M!
etis are a distinct group of Aboriginal people of
mixed First Nations or Inuit and European ancestry. The Inuit
are also a unique population of Aboriginal people who mainly
reside in Northern Canada.
3
Community health centres and, more recently, Integrated
Delivery Systems, have also been introduced in non-Aboriginal
communities in Canada and countries abroad. Features have
included alternative modes of physician payment, integrated
service teams and emphasis on health promotion and preventive
health (Vohlonen, Pekurinen, & Saltman, 1989; Derber &
Thompson, 1992; Abelson & Hutchison, 1994; Leatt, Pink, &
Taylor, 1996).
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833822

After describing the study methods, we present
background information about the social-environmental
conditions of the DTES. This is followed by a general
profile of Aboriginal women living in the DTES. The
main body of the paper focuses on the care Aboriginal
women receive from three different types of services
provided at the VNHS: the Walk-In Medical Clinic, the
Positive Outlook Program (POP) and Sheway.
Research design and methods
An Ad Hoc Community Advisory Council comprising
Aboriginal and non-Aboriginal professionals was
formed to provide advice, direction and guidance
regarding our research goals, respondent recruitment
strategies, interviewing, and data analysis. Participant
observation, semi-structured interviews and focus
groups were our primary methods of determining
Aboriginal women’s perceptions of health care services
at VNHS. Three focus groups were conducted with
Aboriginal women who were clients of VNHS, clients of
its sister organization, Sheway, or non-affiliated Abori-
ginal women living in the DTES. Twelve different
women participated in each focus group and an
honorarium was made available to participants at the
end of their session. Despite some initial suspicions,
most participants were eager to share their experiences,
feelings and ideas. For many, this was the first time they
had ever been consulted about access to services in the
DTES.
In addition to the focus groups, twenty-five semi-
structured interviews were conducted with VNHS and
Sheway staff, health professionals connected to the
facility, provincial government health authorities and
community health workers knowledgeable about Abori-
ginal issues in the DTES (total n¼61). Our aim was to
get a wider view of the challenges to providing adequate
health care for urban Aboriginal women and to identify
approaches needed to address these needs.
Thematic analysis, which is widely used in social
science and health research, was chosen as the most
appropriate method for analyzing the data. According
to Luborsky (1994, p. 190), thematic analysis provides
‘‘direct representation of an individual’s own point of
view and descriptions of experiences, beliefs, and
perception.’’ By placing participants’ own perspectives
front and centre, thematic analysis gives voice to those
who are usually silenced. This analytical approach
involves a central goal of all qualitative research, which
is to present the lived experiences and meanings of those
who are the main focus of study. Themes were identified
by searching for the main points or central topics most
often repeated in and across the focus groups. Tran-
scriptions of the focus group data and the content of the
group discussion were summarized into several topics.
The constant comparative method (Glaser & Strauss,
1967) was used to compare the thematic findings from
the focus group transcriptions with the central themes
emerging from the transcribed personal interview data.
All qualitative studies are limited in terms of making
generalizations about the entire population from a non-
random sample of respondents (Creswell, 1994; Denzin
& Lincoln, 1998). The self-selected sampling procedures
used to attract focus group participants and to find
interview respondents likely excluded the voices of
many, including other Aboriginal women in the DTES,
such as the elderly and women not in crisis, or those
living in other residential neighbourhoods of Vancouver.
In addition, only a small sample of service providers,
government spokespersons and community health work-
ers were interviewed, and may not represent the views of
their peers. Yet there are important benefits to case
studies that attempt to give agency to participants whose
needs are great and yet whose voices are seldom heard
(Rubin & Rubin, 1995; Maxwell, 1996; Berg, 1996;
Perry, 2000; Dion Stout et al., 2001).
The urban ghetto: DTES
Are we doing enough? I don’t think so. I just don’t
believe that I should have a family that comes in to
me here on a Friday afternoon saying, ‘we’ve had no
food in the house for the last four days’, or that ‘I
haven’t been able to feed my baby for the last couple
of days’.
-VNHS staff member
An estimated 28,000 Aboriginal people reside in the
city of Vancouver, representing 7 percent of the city’s
population (Joseph, 1999). Seventy percent of Vancou-
ver’s total Aboriginal population lives in the city’s
poorest neighbourhood, the Downtown Eastside, and
Aboriginal people make up nearly half (40 percent) of
the urban ghetto’s residents. A century ago this old
Vancouver community was an upper class enclave;
today it is infamous as Canada’s poorest neighborhood
(McColl, 1999; Joseph, 1999; TACCIT, 1999; Kazem-
piur & Halli, 2000). Three-quarters of its residents live at
the edge of poverty, with an annual income only one-
third that of other Vancouver residents (City of
Vancouver, 1998). Most DTES Aboriginal residents
have been displaced from other areas of the province or
have migrated from other parts of Canada (Currie,
1995). Housing for many DTES residents is a 12 9ft
slum hotel room, which can cost up to 65 percent of a
person’s monthly social assistance money. Slum hotels
tend to lack even the basic amenities, such as a
refrigerator, stove or private bathroom; security, privacy
and safety are also rare. Such hotels often serve as
shooting galleries for drug users, while ‘crack’ cocaine,
heroin, and prescription drugs are routinely sold and
used openly on the streets below the slum hotels.
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833 823

The DTES’ overcrowded hotels and poor living
conditions, in combination with a substantial part of
its population being dependent on addictive drugs and
practicing unprotected sex, have led to the highest rate
of HIV/AIDS transmission in the Western world
(TACCIT, 1999). A Canadian record of 365 drug
overdoses occurred in Vancouver in 1999, most of
which were in the DTES (Clark, 1999). In addition, the
urban ghetto is home to ‘superinfections’ of Hepatitis A
and C, and epidemic outbreaks of tuberculosis and
syphilis are commonplace (Kent, 1998). In 1997, the
Vancouver Richmond Health Board formally recog-
nized the severity of conditions in the DTES by
declaring a public health crisis (Vancouver Richmond
Health Board, 1997).
Aboriginal women in the DTES
Even though I’m a strong woman on the outside,
deep down I’m hurting and many of us women are
like that. But we don’t show it because we don’t want
people to look at us like we’re less than we are. It’s
just our way; we walk with our head high and proud.
-Aboriginal woman participant
The ratio of males to females in the DTES is estimated
at 3:1. Yet the urban ghettos’ Aboriginal population is
roughly balanced along gender lines (Joseph, 1999).
Estimates are that as many as 70 percent of DTES sex
workers are Aboriginal women, and that the average
Aboriginal sex worker is 26 years of age, has three or
more children, and is without a high school education
(Currie, 1995; Hanselmann, 2001). Inadequate access to
birth control, the rising incidence of drug use and the
growing problem of AIDS are all problems for
Aboriginal women in the DTES (Todd-Dennis, 1995).
Equally disturbing are that teen births, a large portion to
Aboriginal adolescents, are 13 times higher in the DTES
than in other regions of Vancouver; half of Aboriginal
families are headed by lone mothers; and as many as 80
percent of Aboriginal children in the urban ghetto live in
poverty (Joseph, 1999; Hanselmann, 2001).
Aboriginal women are also the fastest growing group
of HIV+ people in the DTES, and are three times more
likely to die of HIV/AIDS than other Vancouver women
(Joseph, 1999.) In general, unprotected sexual activity
and reliance on the street sex trade industry to garner a
living place Aboriginal women at a much higher risk of
having health problems than their non-Aboriginal
counterparts (Parry, 1997). Furthermore, Aboriginal
women are more likely than male counterparts to share
needles, to be ‘second on the needle’ and to associate
condom use or non-use with the important distinctions
between work and relational sex (Whynot, 1998; Garm,
1997). It is important to note as well that many
Aboriginal women with HIV/AIDS living in the DTES
have been displaced from their reserve communities and
extended families. Like most other residents of the
DTES, Aboriginal women migrants to the city tend to
find themselves isolated and without a strong social
support system or cultural base to access when in crisis.
Many keep to themselves and try to cope on their own
while others seek out frontline agencies for help and
support (Garm, 1997).
These statistics on Aboriginal women in the DTES are
presented to give a social environmental/health determi-
nant context to the daily challenges they face. Yet, as
other researchers have argued about marginalized
women elsewhere, homelessness is symptomatic of larger
problems, including substance abuse, mental health
issues, family breakdown, underemployment, low in-
come, and racism (Mohanty, Russo, & Torres, 1991;
Wojcicki & Malala, 2001; Hanselmann, 2001). However,
it would be shortsighted to see Aboriginal women in the
DTES merely as victims of larger structural forces,
without a sense of agency about how to change their
situation, improve their health and ensure a better life
for their children.
Vancouver Native Health Society
The VNHS, a provincially funded, non-profit society,
operates from a cramped, street-level storefront two
blocks from the main intersection in the DTES. The
Society’s core administrative funding comes from the
provincial government. Approximately 50 percent of
VNHS clients are of European descent, 40 percent are
Aboriginal, and the remaining clients are members of
one of Canada’s Visible Minority groups
4
. Few staff are
of Aboriginal background. This has been the case since
the VNHS’s inception nearly a decade ago, due, in part,
to the lack of qualified Aboriginal health professionals,
human rights hiring policies that make it difficult to
recruit Aboriginal people exclusively, and the high-risk
factors and crisis management focus associated with
employment in the DTES.
The original intent of the VNHS when it was
established in 1992 was to establish an Aboriginal-
administered, culturally focussed health centre exclu-
sively for Vancouver’s Aboriginal people in the DTES.
According to the VNHS administrative staff interviewed
for this study, however, the proposed on-site Aboriginal
Healing Centre (AHC) did not receive the economic
support it needed from government officials and local
health organizations. In addition, few traditional healers
were willing to work in a clinical setting, not only
because it was located in an urban ghetto, but also
because of problems regarding adequate remuneration,
government regulation of traditional practices, and
4
Canada’s Employment Equity Act defines Visible Minorities
as persons, other than Aboriginal people, who are non-
Caucasian in race or non-white in colour.
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833824

threat to traditional knowledge contents. Ultimately, for
these and other reasons, the proposed Healing Centre
notion was eventually abandoned and the commitment
to revitalizing and implementing traditional Aboriginal
healing and health practices as an integral part of the
VNHS was lost.
Whether the DTES Aboriginal population agrees or
not, the VNHS, like other UAHCs in BC and across
Canada, today practices an ‘open door’ policy, and the
majority of its staff adhere to the belief that the clinical
services and educational programs are open to non-
Aboriginals and Aboriginals alike. Indeed, the Director
and many of the staff maintain that it is important to
work with the entire DTES community and that health
care services must not ‘‘ghettoize’’ Aboriginal people or
‘‘encourage a system of apartheid’’, especially since the
overall needs in the area are so great.
Yet, as made clear by the focus group participants and
echoed below by a DTES community health worker,
some believe that the VNHS is not adequately meeting
its mandate to serve Aboriginal people,
If you’re going to do something for Native people, I
think you need to be like traditional and spiritual
‘cause that’s what Native people are about, you
know? Do they have elders in the VNHS? Do they
have Native healers? No, they have doctors! Gee,
that’s not my system, that’s not where I come from.
You know, for a First Nations organization, how
come there’s like, not a lot of Natives working? It’s
like the same White system with just a different name
on it.
Programs and services at the VNHS focus on main-
stream risk management models and include services
such as a Walk-In Medical Clinic, Positive Outlook (an
HIV/AIDS Home Health Care Program), The Sheway
Project, Pre-Recovery Empowerment Program, TBSA
Outreach Program (Tuberculosis Services to Aborigi-
nals), DTES Health Outreach Van Program, Youth Safe
House Project, and Inner City Foster Parents Project.
Traditional healing approaches, including Chinese
medicine and acupuncture, have recently been made
available through the POP. The Walk-In Medical Clinic
is the most public aspect of VNHS and the first point of
entry for most clients. The POP is popular among the
local population afflicted with HIV/AIDS and Sheway is
the only program specifically focussed on meeting some
of Aboriginal women’s health needs in the DTES.
Walk-In Medical Clinic
I use the Native Health Clinic. It’s a bit of a slow
process ‘cause you got to sit and wait. But that’s part
of the doctor thing. The doctors sit here and listen to
you, so I find that’s more helpful down here.
-Focus group participant
I see some doctors are great with women, but they
don’t have women-only services. [And] they need like
a women-only space. If you’re going to have a clinic
for everything, you don’t want to be sitting in the
waiting room with some guy, you know?
- Community health worker
The mission of the Walk-In Medical Clinic is to
provide free, non-judgmental primary care and health
promotion to all residents of the DTES community
(VNHS, 1998). According to one of the attending
physicians, ‘‘there is no discrimination in this Clinic. It
is remarkable that we will take anybody—whether they
are disheveled, whether they are inebriated, whatever!
Our function [is] to assist people in this area and we are
doing it.’’
Five male and four female doctors provide routine
medical treatment, HIV/AIDS care, methadone main-
tenance, STD counselling and follow-up professional
services. Currently, almost half of the visits to the Clinic
are by Aboriginal clients, and roughly half again are by
Aboriginal women; the majority of services are provided
to non-Aboriginal males who account for 36 percent of
the total caseload (for more detail, see Benoit & Carroll,
2001).
Plain-clothed security guards, indistinguishable from
the medical office assistants, provide security in the
small waiting area. As one Clinic health provider points
out, the clientele is not without its problems:
They’re difficult people, most of the people we see,
could quite easily get rejected in a standard practice,
you know, because of difficult behaviour. They’re
impatient, can’t wait very long, they can be
aggressive, they don’t dress normally, don’t necessa-
rily take baths, they can’t make appointments and
[often don’t] follow up. So you have to try to be more
tolerant of this sort or behaviour.
Another health provider noted: ‘‘on some level, we are
certainly functioning as a mini-emergency room. Below
that, depending on how many people are in the waiting
room, what the day is like, and what the time is like, I
always try to delve underneath the [initial] level to make
the connection and do more health, healing work.’’
However, due to the transient nature of the population,
high-risk lifestyle behaviours and difficulty in measuring
outcomes of services, it is not an easy task to know if the
services and support have any meaningful impact. In
addition, most of the people who received services had
little choice in the selection of service provider. In fact,
while waiting for the focus groups to begin, many
participants lined up just to ensure they could get an
appointment for a latter time.
Focus group participants had a number of positive
things to say about the Walk-In Clinic. Among other
things, they liked the fact that it is accessible in the
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833 825

evenings and on weekends, embraces an open-door
policy, and employs physicians who take time to listen
to their patients and help out in an emergency. A focus
group participant recalled,
I went to another downtown clinic and the doctor
that I had was giving me constantly the same pills all
the time when I was getting sick. I went over to the
Native Health and the doctor there, as soon as she
saw me, said, ‘Get to the hospital.’ And now she is
my doctor. She is somebody who cares and takes the
time to listen to me. Where, down at my other
doctor, it was in and out and bye.
However, some Aboriginal women expressed concern
that the practice style of a few Clinic physicians fell short
of the mark. One woman identified ‘‘there are a couple
of doctors who don’t belong here because they’re very
rude and there’s no compassion, there’s no caring,
there’s no nothing. We don’t need doctors like that
here.’’ Other research reports similar findings concerning
Aboriginal women’s reluctance to return for regular
check-ups, even when in extreme physical pain, due to
earlier disrespectful treatment by a physician (Todd-
Dennis, 1995).
Some of our participants also expressed a desire for
female physicians, due in part to the high rate of family
violence, physical and sexual abuse issues, and high-risk
behaviours in their earlier or present lives. One of the
community health workers interviewed stated that
Aboriginal women often have been or perhaps currently
are ‘‘in abusive relationships and they need to have that
trust foundation in place.’’ Fear of authority figures—
especially for residential school survivors—means that
many Aboriginal women on the streets were not getting
the basic medical and social treatment they need (Todd-
Dennis, 1995). Our focus group participants additionally
identified an urgent need for meaningful counselling and
emotional support. As one participant noted: ‘‘The reason
I quit coming to counselling here [at the VNHS] is because
the counselling is done very poorlyyI’m a First Nations
person, and I believe that a healing circle would help
because that is our spirituality, that’s how we help each
other.’’ There also was an identified gap in the availability
of mental health services for children and youth, as well as
for homeless urban Aboriginal women who suffer from
severe and often long-term mental illnesses.
Other features of the Clinic that some Aboriginal
women participants wished were different concerned the
waiting room space and lack of integration of traditional
models of healing with bio-medical models across all
programs and services. Many were uneasy about the
lack of Aboriginal staff and felt the need to have more
workers with similar cultural backgrounds and life
experiences as themselves (Todd-Dennis, 1995). The
desire to be cared for and supported by another
Aboriginal person in a more traditional way was very
real for many displaced persons in the DTES. As one
Aboriginal woman noted:
I prefer to be around First Nations people because
they’re the ones who understand where we come
from. When you go in there [the Clinic], a non-Native
person will look at you as a client. But a First
Nation’s person will look at you like a friend, but will
maintain her professionalism.
While cultural sensitivity workshops have been made
available to Clinic staff from time-to-time, there has
only ever been one Aboriginal doctor working at the
Clinic, along with one 6-month intern locum.
In their defense, VNHS staff noted that it is extremely
difficult to find qualified Aboriginal doctors, nurses and
other health professionals in BC and in Canada in
general. Furthermore, they noted traditional healers are
planned as part of future staff recruitment, though they
were unable to give an indication as to when such
appointments might take place, not least of all, as noted
above, because of difficulties recruiting traditional
healers/elders. In the meanwhile, VNHS staff have gone
some distance in integrating Aboriginal volunteers into
the Clinic’s and other programs. One physician saw this
development as a sign of success: ‘‘I think that the
success of Native Health [VNHS] has been that one way
or another, they’ve been able to recruit even volunteers
that are Aboriginal, even if the health practitioners may
not be. So when you walk in, you at least have the sense
that it’s an Aboriginal agency.’’
Our focus group participants additionally identified
that access to meaningful counselling was needed. As
one participant noted: ‘‘The reason I quit coming to
counselling here [at the VNHS] is because the counsel-
ling is done very poorlyyI’m a First Nations person,
and I believe that a healing circle would help because
that is our spirituality, that’s how we help each other.’’
Positive Outlook Program
At VNHS, the POP also provides medical care,
nursing services, methadone treatment outreach ser-
vices, and a drop-in for DTES residents who have HIV/
AIDS. The program was initially developed to reach
clients who, because of the stigma attached to their
medical condition and/or poor health record, tended not
to reach out for help.
The key to the POP’s success, according to its
coordinator, is its non-judgmental philosophy focussed
on treating the needs of the client and providing support
whenever requested. On this basis, the program has
developed a supervised treatment strategy whereby
clients’ medicines are stored at the drop-in and adminis-
tered when they come in on a daily basis. Other incentives
to drop-by include a food bank, meal program, free
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833826

access to a phone, showers, and a washer and dryer. If a
client fails to show up on any given day, an outreach
worker will actively search for him or her in the adjacent
neighbourhood. The program operates seven days a
week, with shorter operating hours on weekends.
Medical Clinic records indicate that Aboriginal
women are over-represented in the HIV/AIDS files.
Sixty-five percent of the Clinic’s female caseload is HIV/
AIDS related (Vancouver Native Health Society, 1998)
5
.
However, Aboriginal women comprise only 38 percent
of female clients at the POP HIV/AIDS drop-in
program located next door. Further, while the Clinic’s
HIV/AIDS caseload for Aboriginal clients was almost
equal across gender, Aboriginal women comprised only
29 percent of total Aboriginal visits to the POP in 1998
(Vancouver Native Health Society, 1998). These data
suggest that Aboriginal women are not frequenting the
program to the extent expected.
Some research participants identified the lack of
integration between program areas as a barrier to
restoring health and well-being to Aboriginal women.
As one provincial government representative stated: ‘‘I
don’t see Native Health [VNHS] services as being fully
integrated. They [are] more like a series of separate
programs within a health centre.’’ Yet service providers
interviewed maintained that networking between the
Medical Clinic and the POP was not a problem, as
informal processes and referrals were generally coordi-
nated and patients’ records shared across the two units.
The style of service delivery in the POP was offered as
an explanation for why participation by Aboriginal
women might be low. In particular, the women said they
wanted more traditional, spiritual healing such as
healing circles, access to traditional healers and more
support and compassion from staff. The lack of a
separate, private waiting room space for women to wait
for their appointments was a further concern.As one of
the Clinic physicians explained, Aboriginal women
‘‘tend to go to [all-women programs] as opposed to
mixed services. Well they, you know, they may see their
drug dealer in there right? They see them and maybe
they owe them something. Or maybe there’s a cop in
there and they’ve got warrants out for their arrest. Or
there may be some guy that they turned a trick with.’’
Safety also was a key issue as expressed by another
health provider, ‘‘I don’t think that women would
assume when they come into the downtown waiting area
that they are safe. There are only a few places in the
DTES that women do come and congregate, at women’s
centres and a few others. Not much thought had been
put into how you could really serve the needs of these
women whose health has been affected by violence.’’
This issue concerning the need for support services and
safety strategies for street-involved women has been
identified in other research (Currie, 1995).
According to our focus group participants, there are
very few places in the DTES where Aboriginal women
feel comfortable to go and sit with their children in a
safe environment. There are even fewer support systems
available for children to learn how to cope with the fact
that their mothers are seriously ill. There is also little
information available on basic health care and how to
manage chronic diseases. The Program is not alone in
this regard, as one focus group participant, herself
suffering from AIDS and with a child to care for, stated:
‘‘No AIDS places in Vancouver have support for our
children. It’s the year 2000 and I’ve been saying this for
the last ten years and nothing has being done. So how
can we look out for our future if we’re not? I think that
is what our AIDS organizations need to do, something
for our future.’’
Sheway
I think the unique feature of Sheway [is that] it helps
to make health and social services more available and
more accessible and more relevant to women, as well
as being a safe place.
-Sheway staff member
Sheway’s mandate is that when you have a baby
that’s eighteen months, you’re done your time here.
Sheway says it’s time to move on and that’s when you
need the most help, more support, more under-
standing. That’s when you need the next step.
-Focus group participant
Although a nextdoor neighbour and partner of
VNHS, Sheway, which is Aboriginal (Coast Salish) for
Growth, is a distinct program for substance-using
pregnant women in the DTES. Sheway appears to come
closer to our focus group participants’ vision of a safe
refuge and community program for themselves and their
children. It has earned a reputation in BC as a model
program focussed on improving infant, child and
maternal health in the urban ghetto. In 1999, Sheway
surpassed 100 open client files, of which 70 percent were
Aboriginal women. When the program opened in 1993,
40 percent of babies born in the DTES had FAS/NAS
syndrome; of these, 33 percent had low birth weights
and virtually all of these were apprehended by child
protection authorities (Loock, Kinnis, Robinson, Segal,
& Armstrong, 1993). By 1998, 86 percent of the
pregnant women who used Sheway services had infants
with birth weights of over 2500 g. Furthermore, child
custody was no longer a major concern for the majority
(58 percent) of the new mothers (Poole, 2000, p. 22).
5
These statistics coorelate with the Vancouver Injection Drug
User Survey. The Survey found that, given their relative
population size in the city, Aboriginal people were over-
represented in the HIV/AIDS category (see Currie, 1996-1998).
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833 827

Approximately 30–70 women, children and, less
frequently, male partners or other relatives drop in
daily at Sheway. On-site professionals include a multi-
disciplinary team of two part-time physicians, three
community health nurses, two social workers, one
outreach worker, a dietician, an infant development
program worker and an alcohol and drug counselor.
Through partnerships with other agencies, the services
of an occupational therapist, physiotherapist, pediatri-
cian, nurse clinician, and financial aid worker are also
made available. Other services include a daily nutritious
hot lunch, food hampers, vitamin supplements, bus
tickets, infant formula, baby supplies and other emer-
gency services. For many of the women interviewed,
poverty was a major issue and these services often meant
the difference between feeding and clothing their child or
not.
Sheway’s philosophy of care is based on harm
reduction in regard to use of alcohol and addictive
drugs as well as potentially risky sexual practices. As one
staff member pointed out:
We spend a lot of time talking about birth control
with a lot of women. I know the nurses will counsel
on safe sex; we all do. If we know that a woman is
practicing unsafe sex we are able to discuss [condom
use] as a form of prevention. We talk about
prevention in regard to safetiness for the women
working in the sex trade. We talk about looking out
for themselves, making sure they have a date list.
Our focus group participants had many positive
things to say about Sheway’s approach and the services
provided. Above all, they liked the fact that so many
things they needed were available on site, including
doctors and child development workers. A welcoming,
group-oriented approach to service delivery was also
noted as an important factor in determining their
comfort with accessing services. More than an ‘open
door’, this program practices a non-task-oriented
philosophy of care critical to getting women through
the front door—a first step in preventive health. Many
of the women taking part in this study said that they
initially approached Sheway for non-medical reasons,
including gaining access to wholesome food and availing
of the opportunity to socialize with other new mothers.
In time, once trust with staff had been developed, the
new arrivals began to address their specific health issues.
Were they required to reveal their personal histories and
health concerns upon first arrival, as is the norm in
medical offices, many of the women said that they would
not have entered the site in the first instance. As
expressed by one of our focus group participants, ‘‘many
[women] go in there for support or someone to talk to.
[The workers] need to listen, and not just say: ‘Well,
what is it you really want from us?’’’ The research
literature lends support to these findings (Tait, 1999;
Dion Stout et al., 2001).
In addition to social and emotional factors, the
overall staff–client structure at Sheway also influences
whether Aboriginal women perceive a facility to be
supportive. One research participant had this to say
about an administrator she liked: ‘‘I love the way she
handles all these clients, the way some of them are, you
know (laughs)yShe’s got good coordination and good
help behind her.’’ Other Sheway staff were also praised
for being easy to talk to and for meeting the women’s
diverse emotional and psychological needs. One focus
group participant said: ‘‘I like talking to the workers up
there and I find that it’s a good place for me right now,
where I’m at, to be around the people.’’
Our research participants identified the value of peer
support and appreciated the opportunity to meet with
other mothers who shared similar life situations. Sheway
provides a space for their children to socialize with other
children and to just ‘hang out’ in a non-judgmental
environment, something not available to them in the
adjacent Medical Clinic or the POP. For these women,
the program provides a safe, encouraging and suppor-
tive environment where women can learn problem-
solving skills, gain valuable experience in interpersonal
relationships, and enjoy role modelling and learning
from other women. Other women said that Sheway not
only drew them out of their isolated hotel room hovels,
but also offered them some sense of security from
abusive partners and the dangers of the street. As one
participant put it, ‘‘It’s [Sheway] a safe place; instead of
being out thereyI’m lucky this place is here, otherwise
I’d probably be six feet under long ago.’’
In addition to the positive features of Sheway noted
above, the focus group participants also appreciated the
hot lunches, nutritional snacks, vitamins, baby formula
and diapers, among other things. As expressed by one
woman, these provisions would not otherwise be
available: ‘‘ya big help is the milk and the food,
because a lot of times you don’t have money. Because
welfare [is] not enough money.’’ Sheway staff were also
praised for helping out in a crisis and for providing
support to the women: ‘‘When I had my second
daughter, I didn’t have a car seat and they [Sheway
staff] came to the hospital and gave me a car seat and
clothes and they took me home.’’
Yet not everything about Sheway gave comfort to the
women. Like the rest of the VNHS, the physical
space at Sheway is extremely cramped, consisting
of a walk-through street reception in front, a small
living and dining room area, miniature play area for
children that spans the hallway between Sheway and the
Medical Clinic, and a few offices off to the other side.
While some of the focus group participants expressed
fondness for the cozy fit of these tight quarters, others
expressed dismay at the overcrowded conditions of the
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833828

facility. One of the Sheway staff described the situation
like this:
A lot of women come back for second and third
pregnancies, so you don’t just have infants here, and
you have toddlers up to school age kids. If a woman
comes in and she’s having problems, you can’t take
her aside and talk about childcare, talk about
parenting, talk about discipline. There’s not even a
place for a woman to put her baby down.
Some focus group participants argued that Sheway
staff was partly to blame for the overcrowded conditions
because they were too lenient in providing access to
people who did not ‘qualify’, such as people who were
looking for meals or a ‘place to crash’. Because the
amount of food available daily was limited, concern is
expressed that non-pregnant women, as well as male
acquaintances, received meals before pregnant women
and their children. Others did not like their children
seeing clients who were ‘high’ or ‘passed out on the
couch’. One woman expressed her frustration in this
way, making note as well that she felt her privacy was
invaded:
Sheway is like Grand Central Station. I noticed like
fifteen people walking through here today that have
nothing to do with Sheway and they’re not pregnant
and we weren’t even notified. A few of us who got
really offended because we go there with the
confidence that it’s our privacy.
Another concern raised was in regard to the patient–
doctor relationship, especially for Sheway birthing
clients as they approach delivery time. Many commen-
ted that they never knew which doctor would be on duty
at the hospital’s maternity ward, or if they would have
an intern or student. Several participants spoke highly of
the midwifery services that were offered at Sheway
during 1996–1997 as a pilot project to VNHS. The
women felt midwives had more time for them and were
there for them during labour and delivery. However,
Sheway’s pilot midwifery project was terminated in
1997, at the same time that the midwifery profession was
granted legal standing and public funding in the
province (Benoit, 2000). To the authors’ knowledge,
none of the users of midwifery services at Sheway were
consulted about the elimination of the program. Despite
evidence of cost-effectiveness and lower risks of com-
plications in midwifery-assisted childbirth (Clarke,
2000), the service has yet to be replaced for Aboriginal
women living in Vancouver’s DTES. One participant
described what she missed with the elimination of the
Sheway midwives:
When they had midwives, it was just phenomenal.
Most of the women went through midwives and plus
the nurses and the doctors, so you got to know the
people before you went into labour. You knew who
was going to be there for you way before you got
pregnant. You knew who was going to be in there for
you and it made it so much more comfortable.
As the women see it, then, the Sheway model is more
akin to traditional Aboriginal health structures; it
includes a fluid and informal service delivery, a
collective, non-hierarchical staff structure, and horizon-
tal relationships between staff and clients, all of which
reflect the holistic values and structures of the more
communal, traditional Aboriginal societies. Yet others
are concerned that more could be done at Sheway to
promote traditional Aboriginal ways of healing and
practice. As one participant commented: ‘‘There’s lots of
Native women that come to Sheway, and I believe that’s
something that should be brought into their lives too.
Because that is our spirituality, that’s how we help each
other.’’ Similar to observations about the Medical Clinic
and POP, participants voiced complaints about the lack
of Aboriginal staff at Sheway and applauded the
promise of an Aboriginal nurse and outreach worker
whose position had just been funded at the time of
interview. Focus group participants also expressed
dismay that Sheway was not able to meet the needs of
older children, particularly those without any ‘identified
problems’. As expressed by one Aboriginal woman:
What we need to develop is a more structured core
program for kids. Sheway deals with young children;
Crabtree [a DTES childcare centre] deals with kids
up to age six. But where do kids go after that? I just
find that it’s really stressful, especially for someone
like myself, living with an illness and no support.
There needs to be a support program or a place for
my son to interact with other children and people
who are going through something similar.
Finally, women expressed a desire for greater access
to formal parenting skill training. Many admitted they
did not have family from whom to learn parenting skills
and many did not experience positive parenting them-
selves. As one focus group participant put it, ‘‘it would
be good to have someone come in and teach parents
about their children, discipline and all this stuff.’’
A Healing Place
When asked what they would like to see in a new
vision for programs for Aboriginal women in the DTES,
participants were unanimous about the urgent need for
something akin to a Healing Place.Their desire was to
build on the positive features of VNHS and especially
Sheway and at the same time provide a more holistic and
integrated system of health services specifically for
Aboriginal families across the life span. One of the
focus group participants stated that, ‘‘a Healing Place is
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833 829

not only for your health, physical health, but also for
your spiritual and mental health. It should be all
combined, not separated.’’ An Aboriginal community
health worker put it like this: ‘‘health is like mind, body,
spiritual and emotional, right? So, you got to have all
four in balance to be healthy. So my [vision] is a place
that looks after all four and you walk in balance. A
place that’s holistic and follows traditions as well.’’
It is somewhat ironic that while this research was in
process the Vancouver Regional Health Board had
discussions underway about whether or not to establish
an Aboriginal Healing Centre (AHC) in the city,
something that was also recommended by a federal
government royal commission on the nation’s Abori-
ginal people (Report on Aboriginal People, 1996). Most
of the women participating in our focus groups had not
heard about the proposed AHC, yet another indication
that they have little opportunity to give input in the
design of health services aimed at improving their health
and that of their children. And it was equally interesting
in this regard that all of those interviewed—VNHS staff,
health providers, government representatives and com-
munity health workers—had heard about the proposed
facility. While few opposed the concept, many wondered
what components it would include—a Medical Centre,
Social Centre, or Spiritual Centre or all combined?
Others had concerns around its possible geographical
location. Would it be in the DTES or in one of the more
privileged neighbourhoods of the city? And who would
be able to use the facility? Would it only be for
Aboriginal people? Would it be safe and welcoming
for Aboriginal women and their children?
Discussion
There is now a substantial body of research on
Aboriginal health showing that Aboriginal women face
formidable barriers in gaining access to the mainstream
health care system as well as related social welfare
services (Dion Stout et al., 2001). The study reported
here builds on this literature by examining the situation
of Aboriginal women in Vancouver’s urban ghetto, the
so-called Downtown Eastside. Analysis of data gathered
from focus groups with Aboriginal women residing in
the area and interviews with a sample of Vancouver
Native Health Centre staff, attending physicians, com-
munity health workers and government health officials,
indicates that Aboriginal women in the DTES are not
accessing services in the manner that would be predicted.
Regardless of their individual experiences in seeking
care, all of the Aboriginal women taking part in the
study were in search of culturally appropriate services
that (1) offered support and safe refuge from the
inhospitable urban ghetto around them; (2) provided
staff who understood Aboriginal women’s historical
wounds and were aware of the lingering racism and
sexism that continue to negatively affect their health,
language, identities and self-respect; (3) endorsed a
philosophy that promoted preventive health and in-
corporated traditional Aboriginal medicine into modern
health care practices; and (4) opened its doors to
Aboriginal women’s families, especially their children.
In brief, not only were there significant gaps identified
in the available services for DTES Aboriginal women,
but they also had to contend with discrimination and
racism in many of their encounters with the mainstream
system. Other research has shown this to be the case for
Aboriginal women in BC as well as other parts of
Canada (Aboriginal Nurses Association of Canada,
1996; Tait, 1999; Browne, Fiske, & Thomas, 2000).
Previous research in the DTES has likewise shown that
Aboriginal women are less likely to seek treatment for
substance abuse for fear their children will be appre-
hended and placed in adoptive homes or formal
arrangements of some kind (Parry, 1997; Poole & Isaac,
2001). Early work has indicated as well that women in
the DTES want more street outreach workers, as well as
more and/or better drug and alcohol services (Poole,
2000). In addition, as in this study, reports have shown
that Aboriginal women wish to be cared for by service
providers who have ‘been there’ to ensure a better
mutual understanding and trust between provider and
client (Core Women Care Report, 1995).
Currently, however, there are no specific policies or
strategies for addressing these concerns (Native Wo-
men’s Association of Canada, 1997; Dion Stout et al.,
2001; Browne, forthcoming). The need to integrate the
experiential knowledge gained from urban Aboriginal
women into our policies and programs is vital to
improving their health status in the long-term. Abori-
ginal women in the DTES are well aware of the strengths
and weaknesses of available health and social services
and are also willing to give voice to more innovative
ways of moving forward. In short, we agree with Dion
Stout et al. (2001, p. 30) that health research, but also
health and social policy, need to be ‘indigenized’ so that
both are truly reflective of Aboriginal women’s lives and
grounded in their personal experiences and life chal-
lenges.
Conclusion
This paper has attempted to give agency to Aboriginal
women in one of Canada’s most disadvantaged urban
neighbourhoods. In this respect, our study is not unlike
recent research on the health and well-being of women
in low-income countries who, despite the formidable
barriers they face daily, are not mere victims of others’
doing (Mohanty et al., 1991; Wojcicki et al., 2001).
Many of the Aboriginal women who took part in this
C. Benoit et al. / Social Science & Medicine 56 (2003) 821–833830

study were unable to direct major change in their lives.
Nevertheless they displayed an incredible inner strength
that has sustained them thus far. Many spoke of the
historical, cultural, socio-emotional and physical
wounds that have affected their health, language,
identities, self-respect and very survival as women. Each
woman is a warrior in her own right, fighting a losing
battle against poverty, disease, racism, sexism and
abandonment.
The DTES is not where Aboriginal women belong.
Many of them feel lost in the perils of a place that is so
far from their culture, offering them little by way of
tenderness, caring, or empowerment. Yet they remain
the main caretakers of their children, struggling to feed,
educate and comfort them, typically by putting off their
own health problems for another time in the future.
The VNHS was established over a decade ago with the
mandate to offer effective and culturally appropriate
health care based on a more holistic approach than had
previously not been available to Aboriginal people in the
DTES. Its initial vision of an AHC disappeared over the
years as the agency, and the facility, evolved to become a
frontline urban health service for the predominantly
male multi-ethnic marginalized population that resides
in the urban ghetto. While admirable in what it has
achieved to better the health situation of this population
living on the edge, the VNHS nevertheless is only partly
able to serve the needs of the Aboriginal women
interviewed for this study. Aboriginal women continue
to search for services that are gender-sensitive, culturally
appropriate and at the same time inclusive of their
children. The challenge ahead for the Centre is how to
better integrate and at the same time ensure balance
between Aboriginal and Western ways of healing
practice and holistic practices.
6
As Canadian governments create change in govern-
ance of health services there is concern that local
community governance structures may loose some of
their community-based authority and not be flexible
enough to meet emerging and current needs. In addition,
there is considerable evidence that existing services are
not getting at the root causes but instead remain focused
on symptoms of the problems or adopt medical oriented
strategies. If policy-makers are serious about affecting
real change, Aboriginal women, one of the most
marginalized groups of all inner city populations must
not be overlooked. The challenge will be how to address
the inequities and ghettoization that exists in the DTES
and at the same time work with urban Aboriginal
women to help them effectively reclaim control over
their health and social services. It is time we clearly
acknowledge that these women have a voice as well as a
vision about what kind of Healing Centre would best
meet their needs and effect positive change for
themselves and the next generation of Aboriginal
children in the DTES.
Acknowledgements
Foremost, we would like to thank the Aboriginal
women who participated in the focus groups and those
individuals who voluntarily participated in the inter-
views. Without their voices, this project would not have
been possible. In addition, our thanks go to the
following organizations and people: the Vancouver
Native Health Centre, especially Lou Demarais, Execu-
tive Director and Annette Garm, former Director of
Sheway, the Ad Hoc Advisory Committee for their
valuable expertise and advice, the National Network on
Environment and Women’s Health for their major
financial contribution, the Women’s Health Bureau in
Victoria for the additional financial support, Lisa Lawr
for her project co-ordination and research assistance
and Christina Zacharuk for her timely transcriptions of
the personal and focus group interviews. Finally, we
would like to extend gratitude to the University of
Victoria for its in-kind funding for this project, without
which it would have been difficult to bring to a final
conclusion.
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