The colonial dynamics of health care: An ethnographic study in Vancouver's Downtown Eastside

This study examines how colonialism continues to be enacted in encounters between health care providers and people (‘residents’) who live with HIV and use illicit drugs in Vancouver’s Downtown Eastside, Canada. I extend critiques of colonialism to analyse the health care experiences of Indigenous and settler residents, based on two years of participant observation and interviews at a medical clinic and drop-in centre, in an organization known as Vancouver Native Health Society. I contend that colonialism continues to be enacted through multiple interacting hierarchies of power which accentuate the knowledge, agency and contributions of providers and the vulnerability, disorder and needs of residents. With particular attention to the political economy and moral dimensions of care, I conceptualize these hierarchies of power as ‘colonial dynamics’. The heightened importance of professional boundaries in this setting, I argue, is a response to the risks that relationships with residents were seen to present, and that elisions in conceptualizing these boundaries often caused providers to be unaware of harms they enacted in the delivery of care. Residents negotiated the asymmetries of power by engaging in covert strategies I refer to as ‘health work’. I argue that the negative impacts of colonial dynamics, combined with residents’ ongoing exposure to inequities and the broader regulation of their lives, could harm their sense of themselves as persons. I conceptualize this as moral violence. I suggest that the colonial dynamics of health care can also negatively impact providers by subordinating their personhood to the temporal and functional aspects of their roles and by exaggerating their responsibilities for residents’ lives and behaviors. I argue that the power of personhood in supportive relationships with providers temporarily mediates residents’ experiences of the asymmetries of power in health care and constitutes relational medicine which, for many, is important to their experiences and the efficacy of care.