Understanding papal documents from the 15th century and the nature and scope of their authority is important when working with Black, Indigenous, and people of color communities influenced by forces and structures of colonialism. Intergenerational trauma has deep roots, which require clinicians to understand historical and cultural context when working with vulnerable patients—in particular, young victims of child abuse and neglect.
Quiz Ref IDChild abuse and neglect remain a global crisis, and, as the articles in this special volume illustrate, health and social care professionals play a critical role in identifying, intervening on, reporting, and ultimately treating the biopsychosocial symptoms of neglect and abuse in their young patients. Clinicians recognize abuse in the clinical encounter, where the stakes are high for all the parties involved—in particular, for Black, Indigenous, and people of color (BIPOC) communities. Fortunately, our understanding of abuse and neglect has been transformed over the last several decades through trauma-informed theory and practices. More specifically, public health researchers have come to understand that historical traumas (eg, war, slavery, and genocide) can impact the current health status of living groups.1 Related to child abuse and neglect, ethnographic work by medical anthropologists has clearly shown how the legacy of forced removal of Aboriginal children to residential schools, as well as dispossession of First Nation and Inuit land, has caused significant intergenerational trauma for individuals and their families.2,3 Intergenerational trauma remains an important phenomenon for clinicians to understand and grapple with as they deal with day-to-day cases of abuse and neglect.4
Issued by Pope Alexander VI in 1493, the controversial Inter Caetara, or Doctrine of Discovery, was deployed by colonial powers as a fundamental and divinely authoritative set of instructions for the dispossession, exploitation, abuse, and ethnogenocide of Indigenous peoples. The document was translated into action and practice by European colonizers (eg, Spain, Portugal, France, and England) and the US government to subjugate non-Europeans and non-Christians throughout the so-called “New World.”5
Traumas of colonization began with words inscribed in the doctrine that provided what was called a divine decree and an authorization to conquer the “lands discovered by Columbus” in 1492.5 The doctrine begins with wishes of health and “apostolic benediction” (papal blessings) “to the illustrious sovereigns,” King Ferdinand and Queen Isabella of Spain. By the second sentence, Pope Alexander proclaims his hope that “the Catholic faith and the Christian religion be exalted and be everywhere increased and spread,” ensuring that “the health of souls be cared for and that barbarous nations be overthrown and brought to the faith itself.”5 Not coincidentally, 1492 was also the year that Christian Spain recovered the Kingdom of Granada from “the Saracens”—the Islamic Moors—who had inhabited and controlled much of the Iberian Peninsula for over 700 years.6 The papacy saw this reconquest of Spain and Columbus' encounters as divine signs to justify King Ferdinand's and Queen Isabella's “spread of the Christian rule to carry forward … [their] holy and praiseworthy purpose.”5 Spain had failed to convert the “infidels'' (the Moors), who chose to flee the country rather than convert. Nevertheless, the papacy also saw opportunities for mass conversion of Indigenous peoples, described as heathens at that time— some whose own spirituality recognized one God or Creator.
The Doctrine of Discovery plants seeds of early capitalism and reads in part as a territorial claim to the Western Hemisphere and as a prospector's guide to securing “gold, spices, and very many other precious things of divers kinds and qualities.”5 It notes that many Indigenous peoples at the time were living “in peace” but nonetheless required colonizers “to bring [them] under your sway … to the Catholic faith … to embrace the Christian religion.”5 It grants the Spanish sovereigns “full and free power, authority, and jurisdiction of every kind” as long as they insert God-fearing men throughout the colonies to “instruct … inhabitants and residents in the Catholic faith and train them in good morals.”5
Quiz Ref IDIt has been noted by journalists, scholars, and Indigenous communities that the Doctrine of Discovery, at the very least, provided the justification and motivation for Europeans' claiming new lands and early Catholic missionaries (eg, the Jesuits in New France, now Canada) expanding their conversion work.7- 9 The doctrine was also treated as a primary source by jurists and was cited in an 1823 Supreme Court case allowing the US government to dispossess Native people of their lands: “Discovery is the foundation of title, in European nations, and this overlooks all proprietary rights in the natives.”10 Perhaps more importantly, it has been argued that the doctrine inspired the later Monroe Doctrine (claiming US hegemony over the Western Hemisphere) and the US notion (and practice) of Manifest Destiny, which justified violent dominion over Native lands—from the Atlantic to the Pacific—by Euro-Americans.11
Quiz Ref IDPapal decrees, which helped to drive European colonial expansion and imbue early forms of capitalism with divine intent and authority, also affected other Indigenous peoples of that time— namely, Africans. The Romanus Pontifex of 1455 was specifically written for the Portuguese sovereign, whose armies had successfully explored and established colonial ports from North Africa (now Morocco) to West Africa (including part of modern-day Guinea).12 This doctrine laid the then-legal groundwork for early human trafficking between Africa and Europe and eventually between Africa and the Americas:
King Alfonso [may] invade, search out, capture, vanquish, and subdue all Saracens and pagans whatsoever, and other enemies of Christ wheresoever placed, and the kingdoms, dukedoms, principalities, dominions, possessions, and all movable and immovable goods whatsoever held and possessed by them and to reduce their persons to perpetual slavery, and to apply and to appropriate [them] to himself and his successors … and to convert them to his and their use and profit."12
By 1530, it is estimated that between 4000 to 5000 African slaves were being exported from the Kongo annually.13
Dispossession of Indigenous lands and the traumatic destruction of Native cultures continues today throughout the Americas. Brazil's conservative government continues to push legislation to cut federal funding to Amazonian tribes and “open up the Amazon” for mining and farming.14 There are also more subtle forms of dispossession of land when it is hijacked for commercial projects. For example, although President Biden ended the Keystone oil pipeline project in the United States, the Obama administration had previously approved replacing other pipelines that run through Native American communities in the upper Great Lakes region. These replacement lines often create new routes (rather than using the original pathways) and run over and under pristine waterways.15 The projects are described as “cultural genocide” by Native activists in these communities who argue they are also a violation of Native treaty rights.15
Quiz Ref IDHistorically, dispossession was combined with forced conversion, which took the form of so-called “civilizing projects.”16,17 In North America, religious institutions administered some Native American boarding schools and the Canadian residential school system, both of which were funded by government agencies.18 It can be hard to fathom that the last residential school in Canada closed in the mid-1990s.19 In Central America, similar projects arose in the 20th century in order to “modernize” Indigenous peoples, such as the Maya. In this case, the Maya, like other Indigenous groups, have been able to reclaim some of their lost lands as well as their cultural autonomy through political movements and structural reforms.20
A thread of traumatic dispossession of lands and other colonial practices can be pulled through the Doctrine of Discovery to our current times. My work within the Aboriginal community in Manitoba in the early 2000s demonstrated how a legacy of residential school abuses was perpetuated across generations through the stories, psyches, and bodies of First Nation Peoples.2 Clinicians who developed productive partnerships within the community took time to listen to these stories and to more fully understand colonial practices' traumatic legacy and their current embodiment.
In the United States, the recent and tragic discovery of mass graves at boarding schools has reconnected families with their traumatic past. National Public Radio's StoryCorps recently covered the case of an Oneida man from Wisconsin who traveled to the Carlisle school in Pennsylvania to see where his grandparents had been sent. He spent the next 2 years working to reclaim the remains of Oneida children buried on the grounds who had passed away while far from home. These children, including an orphan with the same last name as one of his relatives, have been reburied “at home” on the Oneida reserve, where they have been reconnected with their families.21 These kinds of intergenerational traumas run deep and are still being felt and lived through by Indigenous peoples throughout the world.
Scholars examining the historical roots of modern-day diagnostic forms and biopsychosocial outcomes of trauma often point to the industrialization of Europe in the 1860s (eg, urban train accidents both experienced and witnessed), as well as to soldiers who experienced various forms of “trauma neurosis” (eg, posttraumatic stress disorder) during World War I, as modern starting points.22 For BIPOC communities, the historical roots of trauma begin much earlier. Their modern-day traumas stem from the orders and practices believed (by some) to be divinely sanctioned by papal documents and that Europeans (and later Americans) ruthlessly carried out. Colonization, dispossession, forced conversion, and human trafficking were brought to bear on unsuspecting and often peaceful BIPOC communities.
These somewhat obscure papal documents from the late 15th century had devastating consequences. Hierarchies and racialized structures were put into place that are being felt by BIPOC peoples and seen in clinical encounters today.23 Perhaps Canada remains the exemplar of working through this history, forming a Truth and Reconciliation Commission in 2008 for residential school survivors.24 Canada also is the first country to initiate the kind of structural reform that literally allowed for the sovereign return of a homeland to Indigenous people. In 1999, the Northwest Territories were divided to form Nunavut, which retains its own Tribal legal system as well as an autonomous government, run by the Inuit.25 The United States is behind Canada in terms of structural reforms and initiatives, but recent developments, including the US Department of the Interior Indian Boarding School Initiative, are encouraging.26
One very recent positive development has been a papal apology, the first of its kind, by Pope Francis after a contingent of First Nation Peoples visited the Vatican in March of 2022. The pope recognized Catholic complicity and stated: “Listening to your voices, I was able to enter into and be deeply grieved by the stories of the suffering, hardship, discrimination and various forms of abuse that some of you experienced, particularly in the residential schools.”27 One commentator understood the apology as part of the healing process: “This opens a door for us to continue on our healing journeys, and it opens a door for us to continue to fight for action.”28
Quiz Ref IDClinicians who work with BIPOC patients can be part of these healing journeys. In Winnipeg, where I conducted clinical ethnography between 2002 and 2004, the Aboriginal Healing Foundation (now defunct) supported healing circles for survivors, which also led many people to engage in sweat lodge and fasting ceremonies as forms of communal healing. Several clinicians I worked with understood cultural context and discussed these opportunities for healing with their patients and children suffering from trauma and abuse. The clinicians worked directly with local institutions, such as the Thunderbird House, to connect patients with Aboriginal-inspired resources, elders, and spiritual healers. Unfortunately, other clinicians I observed were not integrating this history and context into their treatment.29
Understanding traumatic histories is part of understanding patient context. Recent research assessing global health rotations for physician assistant students offers a valuable reminder about how understanding local and historical context can shape the clinical experience of both students and patients.30 These students specifically were part of a South African clinical rotation that focused on primary care. The student feedback was clear: students felt their futures as caregivers were going to be changed for the better by the work they did in South Africa. They were struck by how the lack of technology and diagnostic testing, which is central to the US system, was supplanted by a “three-stage assessment” that focused on “clinical, personal, and contextual characteristics” of their patients. This assessment involved talking, listening, and taking comprehensive notes. The author underscored what was “remarkable” to these students was the “deliberate clinician focus on patients' perspectives of their illness and treatment.”30
Clinicians throughout the world who engage in trauma-informed practices and work with victims of abuse and neglect understand that history is both remembered and felt. Many BIPOC communities have demonstrated incredible resilience during centuries of dispossession, exploitation, and trauma. Nevertheless, historical traumas remain a persistent threat to patient and community health. Clinicians' patient-centered approaches should incorporate sociocultural context, (deep) history and knowledge of colonial practices, and the patient's perspective in the diagnostic process.
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The AMA Journal of Ethics exists to help medical students, physicians and all health care professionals navigate ethical decisions in service to patients and society. The journal publishes cases and expert commentary, medical education articles, policy discussions, peer-reviewed articles for journal-based, video CME, audio CME, visuals, and more. Learn more
AMA Journal of Ethics
AMA J Ethics. 2023;25(2):E141-147.
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Michael J. Oldani, PhD is a professor of pharmaceutical sciences and administration as well as the director of the Interprofessional Practice and Education Certificate Program at Concordia University Wisconsin in Mequon. His medical anthropological work has focused on pharmaceutical sales, psychiatry, and the mental health of vulnerable/marginalized communities in Canada and the United States.
Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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