When governments invite the public to participate in consultations to reform health care and other policies, they generally represent themselves as calling upon citizens to engage in a social, but apolitical process. This study questions this representation by rethinking how policy is formulated and enacted and by rethinking how Aboriginal women are regarded when they engage in the health care system. 

This report constitutes the second of two phases of research conducted in collaboration with a First Nation community in north central British Columbia. In the first phase of this study, we explored First Nations women’s encounters with mainstream health services, and the unequal power relations that shaped their experiences (Browne & Fiske, 2001; Browne, Fiske & Thomas, 2000). When we discussed the findings from Phase I with the research participants, several of whom were leaders in Aboriginal health, they proposed solutions to persistent inequities in health and health care, which they grounded in notions of health policy reforms. Underlying their policy recommendations was a call for a more representative and responsive health care system that would incorporate greater First Nations input into program design and system management. Critical reflection on the women’s recommendations led us to consider how and why their voices are erased in policy reform and how this might be changed. As we tracked the outcomes of Aboriginal women’s efforts to change health policies, we became aware of barriers to change that are inherent in policy practices themselves. This led to the second phase of our research, described here, which considers health care policy within the context of governmentsponsored policy “reform” consultations with citizens and within everyday encounters in health services where policy is implemented. We are specifically concerned with the paradox of positioning First Nations women as empowered citizens in dialogue with government while First Nations women are elsewhere represented as undeserving patients within health care services. We refer to the latter positioning as the construction of First Nations women as “discredited medical subjects.”

Critical discourse analysis provides the analytical framework for this paper. Such analysis primarily investigates how social power and inequality are produced, contested, and resisted in social and political arenas of society. Rather than “collecting data” from research participants, studies employing critical discourse analysis examine the meanings embedded in various discourses. In their examinations of health policy and calls for policy reforms, political arenas, government dialogues, and the media, researchers are directed to question what often gets taken for granted in communication and social relations. Drawing on critical discourse analysis in this report, we focus on Aboriginal women’s experiences as citizens engaged in policy consultation and how they come to be conceptualized in policy discourses, and in turn how this conceptualization is entangled in other political practices.

We have chosen several cases in order to illustrate concrete and detailed examples of public consultations and their outcomes related to First Nations women. The selected cases include: two Royal Commissions, the provincial referendum on treaty settlements, a recent consultation with Aboriginal governors who served on regional health boards, and a key recommendation made by the First Nations women in Phase I of our study, who expressed faith in policy as a mechanism through which to address their concerns related to health care. Analysis of these cases reveals that health care policies produce and are produced by a range of encompassing discourses that shape our suspicions and doubts about particular people or groups of people. By analyzing policy within the contexts of related public discourses, and the historical, economic, and social realities of Aboriginal women’s lives, we encounter a “doublespeak”—a paradox involving the construction of Aboriginal women as citizens in dialogue with government in health policy “reform” consultations, and their simultaneous construction as discredited medical subjects without legitimacy or power in health care services.

We conclude that health policy reform is and will continue to be constrained in effecting true social change unless it is accompanied by a significant shift in socio-economic power structures, critical awareness of the powers of discourse, and consciousness of the colonial legacy that underpins notions of reform and consultation. Without these interlocking transformations of power relations, many Aboriginal women, discredited as medical subjects, will find policy itself a barrier to their well-being. (Authors)