Reviewer s report. Version: 0 Date: 28 Sep Reviewer: Richard Thomas Oster. Reviewer's report:

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Norah Campbell
6 years ago
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1 Reviewer s report Title: Do discrimination, residential school attendance and cultural disruption add to individuallevel diabetes risk among Aboriginal people in Canada? Version: 0 Date: 28 Sep 2015 Reviewer: Richard Thomas Oster Reviewer's report: I would like to truly thank the authors for their thorough revision of their manuscript. The exchange has been 'heated', which should not come as a surprise given the nature of the topic being discussed. I think the revised manuscript is better as a result. In their rebuttal, the authors make the point that the TRC highlights the individual impact of cultural disruption and residential schools, hence making the argument those factors can be measured at the individual level. Over a several year process the TRC painstakingly listened to individual people's stories, with thousands of hours of testimony. My argument is that it would be incredibly difficult to narrow those thousands of hours and individual stories down to questions on a questionnaire. I worry that the questionnaire does not do those stories justice (i.e. to truly determine if one has been affected by cultural disruption and residential school may require hours of interviewing as the TRC did, and may not be achievable in a questionnaire). Moreover, I think it plausible, given the inter-generational effects of cultural disruption and residential schools, that some Aboriginal people may be unaware of the impact it may have had in their own life, and again a questionnaire may not be able to capture the impact. So, I do wish that there had been some rigorous validation work done on the questionnaire beforehand, but also understand the difficulty in doing so. My worry comes from the 'weightiness' of the topic. This is a racially-charged, politically-charged, and emotionally-charged topic. Because of this, I disagree with the authors when they state in their rebuttal "we cannot see how anyone would interpret this as advocating for assimilation etc., or as suggesting a solution for those experiencing discrimination." Nowadays Aboriginal people are advocating more than ever (rightfully so) for cultural reclamation as a means of improving their communities (TRC and Idle No More movement are cases in point), and the responses from non-aboriginal Canadians are not always enthusiastic support (as we would hope). At the recent inaugural Indigenous Health Conference the "2014 Toronto Declaration" was made, where the conference delegates unanimously declared that that a genocide occurred by the government of Canada against

2 Indigenous peoples. Much of the conference highlighted this genocide at the root of the disparities we see today. Thus without being very clear in the manuscript, I think the findings could easily be taken out of their intended context. I did not find the first version of the manuscript very clear in terms of what points the authors were making about cultural disruption and residential schools and its links to diabetes, and found myself making my own inferences and assumptions as a result. Thus, considering the potential ramifications, I believe the 'story' of the manuscript must be crystal clear. The revised version makes their points clearer, and I am happy for it. However, I think the manuscript would be further strengthened if some of the points the authors made in their response to reviewer comments were included in the actual manuscript. The authors made excellent points in their rebuttal that certainly improved the clarity for me as a reader. Thus, I suggest the authors include the following from their rebuttal in the manuscript: - The justification of the CBPR approach used and the community engagement work done prior to the study should be further highlighted in the methods so readers understand the lengths the authors went to in making sure the research process was conducted in an appropriate and ethical manner. - The justification of the use of the Krieger scale. - The representativeness of the population (i.e. how the study population is comparable to the 2011 census). - The need for more research focusing on quantitative measurements for cultural disruption, residential school impact, and racism in Aboriginal people. The authors cite in their revised manuscript Oster et al, Int J Equity Health. This manuscript was not conducted and written by myself alone. There were four other authors, including two Aboriginal community members and two academics. The authors should change their description of the manuscript from "he" to "they", and from "Oster" to "Oster et al" where appropriate. Also I suggest the authors re-consider their interpretation of the Oster et al study. The authors state "had he looked at the within-community data (regardless of a particular community's prevalence of diabetes), it is quite likely that Oster would have also found a higher proportion of older individuals with diabetes, and it is quite possible that older diabetic individuals were more likely to speak an Indigenous language than their younger counterparts." To answer the author's question from the rebuttal, yes I agree in-part that it is plausible that older people who did not have diabetes were just as likely to have attended residential schools those who did have diabetes. But I do not think it is not as simple as whether or not a person attended residential school or not. For instance, I think it possible that some attendees were physically and sexually

3 abused whereas others were not, and I think it possible that some attendees were shamed into completely losing their Indigenous language whereas others were not. So, although some of the older people were potentially equally as likely to have attended residential school, they could have had very different experiences and their connection to their culture, language retention, and passing down of language and culture to younger people could have been entirely different later in life a result. So, I do not agree with the authors that older people who did not have diabetes were just as likely to speak Dene as those who did have diabetes. This again brings me back to my main worry that it may not be possible to accurately assess the impact of residential schools by a few questions on a questionnaire, and I re-iterate my suggestion that the authors mention lack of a validated questionnaire assessing cultural disruption and residential school impact among Aboriginal people in the limitations and suggest that research is needed so that a validated measuring tool can be developed. To answer the author's other question, yes I find it plausible that those spending significant time off-reserve, perhaps working in northern mines, might have had higher incomes (a social determinant of health), lower rates of diabetes and yes, have experienced more discrimination. But again, I would argue that it is not that simple, and in-fact it is a perplexing issue. I think it just a possible that those spending significant time off-reserve, and presumably experiencing more discrimination, are not necessarily working good jobs and are not necessarily financially better off. In Alberta we have found that so called 'apron communities', communities that are close to non-aboriginal urban areas, tend to have higher rates of diabetes. It may be that in many of these apron communities discrimination and racism are experienced more often due to more interaction with neighboring non-aboriginal communities, and thus mental and physical health may be compromised as a result. Is it implausible that those spending significant time offreserve, perhaps working menial low paying jobs in neighboring non-aboriginal communities in attempts to make ends meet, might have had lower incomes, higher rates of diabetes, and also experienced more discrimination and racism? I am a non-aboriginal person, so I've never experienced what racism and discrimination feels like in that way. I can only imagine how painful and debilitating that could be for some. I do know that racism towards Aboriginal people is 'alive and well' in Canada. I believe it to be our biggest 'black eye' as a country, and a topic that requires great care when being measured and discussed in research. Thus, as with cultural disruption, there is a need for a validated tool to accurately assess the impacts of racism in Aboriginal people as well. The authors make the point in their revised discussion that most of the literature has examined cultural continuity in relation to mental health, not physical health. I think it important to include a sentence or two discussing some of the research showing strong relationships between mental

4 health and physical health (including chronic diseases such as type 2 diabetes). For instance, the Adverse Childhood Experiences studies come to mind. This is very minor, but I still think the first reference needs to include also a more recent article as a reference alongside the Young et al reference (the author's own Dyck et al, CMAJ would fit nicely). The first sentence of the manuscript says Aboriginal people in Canada are experiencing an epidemic, which implies the epidemic is still happening now. The authors point out that our group used the same reference in our recent manuscript, which is true; although it was complemented with a more recent reference to show that the epidemic was happening in the 1990s and is still occurring years later. Are the methods appropriate and well described? If not, please specify what is required in your comments to the authors. Yes Does the work include the necessary controls? If not, please specify which controls are required in your comments to the authors. Yes Are the conclusions drawn adequately supported by the data shown? If not, please explain in your comments to the authors. Yes Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review? If an additional statistical review is recommended, please specify what aspects require further assessment in your comments to the editors. I am able to assess the statistics Quality of written English Please indicate the quality of language in the manuscript: Acceptable Declaration of competing interests Please complete a declaration of competing interests, considering the following questions:

5 1. Have you in the past five years received reimbursements, fees, funding, or salary from an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future? 2. Do you hold any stocks or shares in an organisation that may in any way gain or lose financially from the publication of this manuscript, either now or in the future? 3. Do you hold or are you currently applying for any patents relating to the content of the manuscript? 4. Have you received reimbursements, fees, funding, or salary from an organization that holds or has applied for patents relating to the content of the manuscript? 5. Do you have any other financial competing interests? 6. Do you have any non-financial competing interests in relation to this paper? If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your reply is yes to any, please give details below. I declare that I have no competing interests I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license ( I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published. I agree to the open peer review policy of the journal

6 6. Do you have any non-financial competing interests in relation to this paper? If you can answer no to all of the above, write 'I declare that I have no competing interests' below. If your reply is yes to any, please give details below. I declare that I have no competing interests I agree to the open peer review policy of the journal. I understand that my name will be included on my report to the authors and, if the manuscript is accepted for publication, my named report including any attachments I upload will be posted on the website along with the authors' responses. I agree for my report to be made available under an Open Access Creative Commons CC-BY license ( I understand that any comments which I do not wish to be included in my named report can be included as confidential comments to the editors, which will not be published. I agree to the open peer review policy of the journal

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