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What BC Nurses Need to Know About "Death by a Million Paper Cuts"

by Sally Thorne, PhD, RN, DSc (Hon), FAAN, FCAHS


When the Canadian National Inquiry into Murdered and Missing Indigenous Women and Girls (MMIWG) released its Final Report in June 2019, it referenced Canadian Indigenous peoples as “victims of a race-based genocide empowered by colonial structures.” Immediately, as Indigenous Issues columnist Tanya Talaga reported in the Vancouver Star, various non-Indigenous persons and groups across the country took issue with the use of the term “genocide” in this context, claiming that it overstated the case in an unfair manner.

These critics seemed to reason that what was done by the Canadian government and societal structures to Indigenous persons did not amount to a mass slaughter such as may have been the case in other situations in which the term genocide has been widely used. Instead, what the report had documented as being directly associated with the MMIWG were such factors as colonial structures embedded in national legislation, the attempted assimilation of children through residential schools, and various breaches of human rights leading to conditions that increased rates of violence, death, and suicide among Indigenous communities. And these kinds of actions do quite reasonably align with the understanding of the author who coined the term “genocide” after the WWII Holocaust: “the destruction of essential foundations of the life of national groups, with the aim of annihilating the groups themselves” (Lemkin, 1944, p. 79). As Chief Commissioner Marion Buller clarified, this form of genocide may not have been enacted by direct physical violence alone, but rather could be seen as a form of “death by a million paper cuts.” The comparative morbidity and mortality rates for indigenous and non-indigenous Canadians clearly confirms that it was and remains deadly.

We can see, then, that the debate over whether the term genocide was fairly used became a complete distraction from the conclusive evidence in the report that Canadian society had been unacceptably slow to pay attention to the extraordinary number of cases in which indigenous women went missing or were murdered. It also deflected attention from the fact that this was entirely characteristic of the widespread indifference to the circumstances of indigenous persons and communities across this country throughout the entirety of Canadian history as a confederation. By using a term like “genocide,” the commissioners were asking mainstream Canadians to begin to recognize that the impact of repeated and systematic “micro-aggressions” over time and generations was every bit as lethal as the other atrocities for which we accept the use of the term without question. Dr. Margaret Moss, Director of UBC’s First Nations House of Learning and a faculty member at the UBC School of Nursing explained that this widespread debate over whether or not it was legitimate to characterize this particular systemic injustice in this manner revealed something of how painful it is to face difficult truths about the lives of “the other” in a society we choose to think of as just and fair.

Nursing has a great deal to account for in its part of the “death by a million paper cuts” described in the MMIWG Commission report. Although we don’t tend to mention this in our celebration of nursing’s history as a profession, it is telling that nurses have participated in many prior genocides, including “special task associated with forced sterilisation, killing of handicapped patients, work in concentration camps and human experimentation against Jewish people, gypsies, homosexuals and other “undesirables” in Nazi Germany (Benedict & Georges, 2006; Schweikardt, 2008). Sometimes this contribution was active and voluntary, sometimes indirect and/or involuntary. And in the widespread attempts to colonize various cultures that we have seen throughout nursing’s history, we have clearly been complicit in our attempts to bend cultural health and social practices to conform with those of the political colonizers (Aluwihare-Samaranayake & Paul, 2013; McGibbon, Mulaudzi, Didham, Barton & Sochan, 2014). In the Canadian context, we know that many nurses played an active part in the discriminatory practices of the Indian hospitals and field clinics that are part of our nation’s uncomfortable history (Pelley, 2018); and we know that many nurses continue to enact and reinforce the stereotypic attitudes and biases that prevent indigenous persons from feeling culturally safe in our care contexts today (Cameron, Carmargo Plazas, Salas, Bourque Bearskin & Hungler, 2014). Just as we are beginning to understand bullying as a deadly influence on the young people in our society today and take collective action to deal with it, and we are beginning to open up to the pervasiveness of sexual assault and our collective responsibilities in that regard through the “me too” movement, we are only now starting to step up collectively to do something about the powerful societal forces that have served as a systemic barrier to the health and wellbeing of indigenous persons, families and communities across our nation.

Many well-intended non-indigenous Canadian nurses prefer to position themselves as members of the most trusted profession – as among the heros within a system that has created injustice in the past. They may assume that as long as they are not the active aggressors, and they are not directly responsible for the historic and current aggressions, that they are off the hook. And they may not see the vitally important role that they can and should play – that we all should be playing – in ensuring that we build systems of care in which every indigenous member of our society can feel welcomed, safe and respected in seeking care.

Just as the solution to teen bullying requires a concerted and coherent effort on the part of all of us, not just the bullies, and just as dealing with sexual assault in our society requires a network of services, structures, attitudinal restructuring and specialized skillsets, finding a meaningful and effective way to change the current embedded racism within our society does require the coordinated effort of all of us. We non-indigenous nurses (also known as “settlers”, as a mechanism to emphasize our colonial heritage), have a special obligation to become as knowledgeable as possible about the concerns raised internationally by the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP) as well as the full scope of the Canadian Truth and Reconciliation Commission’s Call to Action. We need to build this historic critique and social justice commitment into our basic and continuing educational curricula, make viable spaces for nurses to engage, dialogue and learn how to mount collective action within their workspaces and the settings within which they deliver care, and we need to develop much stronger capability to notice, interpret, and manage the micro-aggressions when they occur around us in our everyday workplaces.

These are not and cannot be the responsibility of our indigenous nursing colleagues. They have an important leadership role to play in many aspects of our collective societal response to indigenous health issues, and we have much to learn from their wisdom in that respect. However, we cannot expect them to solve the racism and bias within society – and within nursing – that continues to serve as a barrier to health for all.

In order to create a better Canada for the next generation of indigenous persons, nursing writ large requires a serious and sustained “decolonizing” approach. It needs to learn how to notice, resist and undo the forces of colonialism that still exist in our professional ideologies and practices, and to begin to understand the meaning of indigenous values, philosophies, and knowledge systems (Woolford & Benvenuto, 2015). This requires actively challenging the influences that have shaped the thinking of all of us and acknowledging the rightful power and place within society of indigenous persons.

Canadians have long prided themselves on holding equity and justice as core national values. Nursing has celebrated its history and tradition as a profession with a commitment to social justice. However, if we sustain the status quo, now that these “shameful secrets” have been brought to our attention in such a power manner, these become nothing but a convenient fiction. The time is long since past when “indigenous health” was a specialty concern of a small number of nurses; it is a pressing and shared concern that we must actively engage with because we are Canadians, and because we are nurses.

Those of us who are non-indigenous nurses in this country must find new ways to open our eyes and ears to the experiences of those who have been seriously harmed by the systemic injustices of our society, including those who are our fellow nurses and our patients. We need to hear and receive their painful truths without judgement or defensiveness, and to appreciate that we have been in a position of privilege that has allowed us to ignore their struggles. Aline LaFlamme – Metis grandmother, pipe carrier, drummer, Sundancer, traditional healer, and public advisor to the Canadian Nurses Association, as well as a long-time friend and advisor to the NNPBC – tells us that we have to force ourselves to “sit in battery acid” for a time as we listen to the gut-wrenching stories of those who have been harmed. But when we truly listen to their truths, we are taking an important step in gaining the cultural humility that will allow us to move forward with this work in partnership. Our moral outrage, combined with our nursing core values and code of ethics, is all we need to steer the course of our profession’s future as a force for good.

I am hopeful that, in challenging us through the use of the term “genocide,” the wise leaders who have constructed these recent Canadian reports can awaken the collective social conscience within all of BC nursing, and spur us into meaningful action. Injustices need not characterize the human condition, and Canada can find a way to rise above its colonial past in a manner that serves all members of our society. In this context, I see BC nursing as strongly positioned with the power and perspective to be a vital force for change across the health care sector and indeed across society. Lets do this important work together.


Aluwihare-Samaranayake, D. & Paul. P. (2013). The influence of gender, ethnicity, class, race, the women's and labour movements on the development of nursing in Sri Lanka. Nursing Inquiry, 20(2), 133-144. doi: 10.1111/j.1440-1800.2012.00600.x.

Benedict, S. & Georges, J.M. (2006). Nurses and the sterilization experiments of Auschwitz: A postmodernist perspective. Nursing Inquiry, 13(4), 277-288. doi: 10.1111/j.1440-1800.2006.00330.x

Cameron, B.L., Carmargo Plazas, M. P, Salas, A., S., Bourque Bearskin, R. L. & Hungler, K. (2014). Understanding inequalities in access to health care services for aboriginal people: A call for nursing action. Advances in Nursing Science, 37 (3), E1-E16.

Lemkin, R. (1944). Axis rule in occupied Europe: Laws of occupation, analysis of government, proposals for redress. Washington. DC: Carnegie Endowment for International Peace, Division of International Law. Retrieved from http://www.preventgenocide.org/lemkin/AxisRule1944-1.htm

McGibbon, E., Mulaudzi, F.M., Didham, P., Barton, S. & Sochan, A. (2014). Toward decolonizing nursing: the colonization of nursing and strategies for increasing the counter‐narrative. Nursing Inquiry, 21(3), 179-191. doi: 10.1111/nin.12042.

Pelley, L. (2018). Minister, indigenous advocates say “Indian hospital” class–action can't right all wrongs. CBC News, Jan 31, 2018. Retrieved from https://www.cbc.ca/news/canada/toronto/lawsuit-reaction-1.4511025

Schweikardt, C. (2008). The National Socialist Sisterhood: An instrument of National Socialist health policy. Nursing Inquiry, 16(2), 103-110. doi: 10.1111/j.1440-1800.2009.00442.x.

Woolford, A., & Benvenuto, J. (2015). Canada and colonial genocide. Journal of Genocide Research, 17(4), 373-390. doi: 10.1080/14623528.2015.1096580

About Sally Thorne

Sally Thorne, RN, PhD, is Professor at the University of British Columbia School of Nursing and a Board Director of Nurses and Nurse Practitioners of BC. She has a program of research in health and illness experience, including the intersection between health system structures and attitudes and the outcomes of those our systems serve. She is Editor-in-Chief of the scholarly nursing journal Nursing Inquiry, and has been the recipient of numerous national and international recognitions, including the Sigma Theta Tau International Nursing Research Hall of Fame, and the Canadian Nurses Association’s Jeanne Mance Award. An earlier version of these ideas was published as an editorial in volume 26(3) of Nursing Inquiry.

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